Surgical options for reconstruction of the extensor mechanism of the knee after limb-sparing sarcoma surgery: an evidence-based review

Limb-salvage surgery remains current best practice for management of soft tissue and bony sarcomas about the knee, with the range of reconstructive options all providing reassuring levels of long-term survival and function. There is no current consensus as to the best method of reconstruction of the extensor mechanism of the knee (quadriceps-patellar complex), with a wide variety of options proposed. The techniques described in the literature include prosthetic reconstruction, soft tissue reconstruction (comprising reconstruction with pedicled muscle flaps or autogenous tendon grafts), and bony reconstructions (including vascularised fibula flaps). An evidence-based literature review assessing the available reconstructive options has not been undertaken. A thorough literature review was undertaken, evaluating the current evidence regarding the use of surgical techniques for reconstruction of the extensor mechanism of the knee following oncologic resection. The literature identified was critically evaluated based on the current Oxford Centre for Evidence-Based Medicine definitions. There are no randomised trials in the literature in this setting, and thus no level 1 or level 2A studies to support any given technique. As such, there are many favourable techniques for reconstruction that have been well described and have some evidence base to support their use. Overall, there is a trend towards improved outcomes with biological reconstructive options, with lower reported levels of failure, infection and amputation. Despite this, no single technique has adequately proven to be superior. Given the proposed difficulties in randomising patients, good evidence for the optimal reconstructive choices may be hard to establish.