Alexander F. Dagi

Complex orthopedic oncology cases require coordinated planning between tumor surgeons and reconstructive plastic surgeons, yet a technological disconnect exists. While orthopedic oncologists seek to achieve millimeter-level precision using three-dimensional-guided systems for bone tumor resection from computed tomography scan reformats, plastic surgeons rely on traditional two-dimensional imaging for reconstructive planning in the same cases. We conducted a systematic review of reviews examining three-dimensional technologies in orthopedic oncology and their relevance to soft tissue reconstructive planning. We searched PubMed, Embase, and Cochrane databases through November 2024, using terms combining "three-dimensional", "orthopedic oncology", and "bone tumor". Two independent reviewers performed dual screening with disagreements resolved by consensus. After reviewing 325 articles, we identified 16 reviews (three systematic, 13 narrative) published between 2009 and 2024. Despite comprehensive evaluation across these reviews encompassing hundreds of primary studies, no applications for soft tissue reconstruction planning were identified. Orthopedic teams demonstrated remarkable progress in precision with patient-specific instrumentation achieving superior negative margin rates (89% versus 68% for conventional methods) and cutting deviations of 0.3-4 mm, yet the same imaging data used for skeletal planning, containing nearly all information necessary for soft tissue reconstruction, remained unutilized for reconstructive purposes. Three-dimensional planning technologies have transformed orthopedic oncology but are typically absent from soft tissue reconstruction planning in the same cases. A significant opportunity exists for plastic surgeons to integrate into existing three-dimensional workflows through defect volume analysis, vessel mapping, flap design optimization, and coordinated reconstructive timing within navigation-guided resections.

While recent studies have characterized flap-based reconstruction in higher-acuity pediatric extremity tumor cases, the frequency and short-term outcomes of immediate soft-tissue reconstruction across the broader spectrum of pediatric limb-salvage extremity tumor surgery remain poorly defined. The ACS NSQIP-Pediatric database (2012 to 2023) was queried for pediatric upper extremity (UE) and lower extremity (LE) oncologic excisions using comprehensive CPT codes spanning all anatomic levels. We focused exclusively on tumors that required excision and were amenable to limb salvage. Immediate soft-tissue reconstruction was identified by concurrent reconstructive CPT codes. Primary outcomes were wound complications and overall morbidity. We identified 4500 limb-salvage cases (LE, 4295; UE, 205). Bone tumors comprised 94.8% of cases, with 87.7% undergoing simple excisions. Overall, 159/4500 (3.5%) underwent immediate reconstruction, including 134/4295 (3.1%) LE cases and 25/205 (12.2%) UE cases. Complications were more frequent in reconstructed than nonreconstructed cases (44/159, 27.7% vs. 104/4341, 2.4%; P OR =3.48, 95% CI: 1.56-7.75) and ASA III to IV classification ( OR =2.17, 95% CI: 1.18-3.98) were independently associated with 30-day complications. Immediate soft-tissue reconstruction is uncommon in pediatric limb-salvage extremity tumor surgery. In the lower extremity cohort, immediate reconstruction was associated with higher rates of short-term morbidity. However, reconstruction was preferentially used in anatomically and surgically complex cases, and the available data cannot fully account for differences in case complexity. Accordingly, this should not be interpreted as evidence that reconstruction itself increases postoperative risk. These findings provide benchmark data for case selection, perioperative counseling, and future orthoplastic outcomes research.

Case: A 4-year-old girl with bilateral arthrogrypotic clubfoot underwent posterior release with bilateral V-Y advancement flaps. At 4 months, the patient ambulated independently over moderate distances. One-year follow-up confirmed pain-free functional ambulation, although persistent toe-walking highlighted ongoing neuromuscular challenges and minor correction loss. Conclusion: V-Y advancement flaps provide effective soft tissue coverage after posterior release for arthrogrypotic clubfoot. Early multidisciplinary collaboration integrating orthopedic and plastic surgical planning is essential for optimizing outcomes.