Musculoskeletal Tumors 2023, Jan, 08 | 12:00 am

Quadriceps Resections

BACKGROUND

 

 

The quadriceps muscle group is the most common site for extremity soft tissue sarcomas.

 

The most common sarcomas at this site are liposarcomas, undifferentiated pleomorphic sarcomas, and leiomyosarcomas.

 

Although tumors of the anterior compartment of the thigh can be extremely large at presentation, it is possible to perform limb-sparing resections in most patients. By using induction chemotherapy and either preoperative or postoperative adjuvant radiation therapy to eradicate possible residual microscopic disease, resections of the anterior compartment of the thigh are often feasible and safe.

 

In addition, when resection necessitates en bloc removal of a considerable amount of muscle tissue, reconstruction of the extensor mechanism with the sartorius muscle, the hamstring muscles, or both produces good functional results.

 

The most common indications for amputation (ie, hip disarticulation or hemipelvectomy) are very large tumors with extracompartmental extension into the adductor and hamstring musculature, tumors with intrapelvic extension through the femoral triangle and inguinal ligament, large fungating tumors, and massive tumor contamination, with or without infection.

 

ANATOMY

 

The thigh consists of three distinct anatomic compartments, separated by thick fascial layers: the anterior compartment (quadriceps and sartorius muscle), the medial compartment (thigh adductor muscles), and the posterior compartment (the hamstring muscles).

 

The quadriceps muscle group consists of the vastus medialis, vastus lateralis, rectus femoris, and vastus intermedius muscles. The vastus medialis and lateralis arise from the proximal femur and intermuscular septum. The vastus intermedius arises from the surface of the femur and the linea aspera and covers the entire femoral shaft. The rectus femoris arises from the supra-acetabular tubercle at the superior part of the acetabulum. All four heads merge distally into the quadriceps tendon, which inserts onto the patella.

 

By covering the anterior aspect of the femur, the vastus intermedius protects the underlying femur from direct tumor extension by tumors of the other components of quadriceps muscle.

 

The fact that soft tissue sarcomas often remain localized to one muscle belly permits partial muscle group resection for many quadriceps sarcomas (FIG 1).

 

The medial and lateral intermuscular septum of the thigh separates the anterior thigh muscles from the medial and posterior compartments, respectively. However, the medial intermuscular septum “runs out” proximally, and quadriceps tumors may therefore extend into the posterior and medial compartments and complicate and sometimes obviate a limb-sparing resection. Likewise, tumors arising from the medial and posterior

compartments of the thigh may extend into the quadriceps group.

 

The femoral triangle is the key to resection of the quadriceps muscle group. It is formed by the adductor longus medially, the sartorius muscle laterally, and the inguinal ligament proximally. The pectineus muscle forms the floor of the triangle. A thick fascia covers the roof.

 

The superficial femoral artery and vein pass from below the inguinal ligament through the femoral triangle and into the sartorial canal at the apex. The femoral nerve enters the canal laterally and quickly branches to innervate the quadriceps muscle components. The superficial femoral artery and vein pass along the medial wall of the sartorial canal throughout the length of the thigh and are separated from the anterior group (vastus medialis) by a thick fascia, which often permits a safe resection.

 

This fascia forms a good border for quadriceps resections.

 

 

 

 

FIG 1 • Quadriceps resection types. Type A, resection of the vastus lateralis. Type B, resection of the vastus medialis. Type C, resection of the rectus femoris and vastus intermedius. Type D, subtotal resection of the quadriceps muscle. Type A and B resections often include the vastus intermedius as well.

 

 

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INDICATIONS

Almost all low-grade soft tissue sarcomas of the anterior thigh may be safely resected by a partial muscle group resection. The large majority of high-grade soft tissue sarcomas can be resected by partial or total

 

compartmental removal. The contraindications to limb-sparing resection are as follows:

 

Groin involvement: Tumors arising or involving the groin and femoral triangle often cannot be reliably resected and may require amputation.

 

Extracompartmental extension: In general, resection of a single muscle group permits a viable extremity. If two muscle groups have to be completely removed, the extremity may not be functionally salvageable. Large tumors of the anterior thigh may involve the adductor group as well as the posterior muscle group by passing through the linea aspera or the intermuscular septum. In this situation, amputation might be necessary.

 

Intrapelvic extension: On rare occasions, large tumors of the proximal thigh and groin extend below the inguinal ligament into the retroperitoneal space, necessitating amputation.

 

Recurrent tumors of the quadriceps, infection, extensive tumor hemorrhage, or extensive tumor contamination from previous surgical procedures may require amputation.

 

Neurovascular involvement of the tumor does not necessarily obviate limb salvage resections. Most tumors of the quadriceps muscle will displace but not invade the superficial femoral or common femoral arteries. If the surgical margins are positive for tumor cells or extremely close, resection of the involved artery and replacement with a vascular graft often allows limb salvage.

 

En bloc resection of the femoral nerve is also not a contraindication for limb-sparing resection; reconstruction techniques often provide patellar stabilization and allow limited knee extension, even when the entire quadriceps muscle is resected or paralyzed secondary to femoral nerve resection (Tables 1 and 2).

 

Table 1 Histopathologic Diagnoses of 15 Patients Treated with Soft Tissue Tumor Resection from the Anterior Compartment of the Thigh and Extensor Mechanism Reconstruction

Tumor Type

Number of

Patients

Malignant soft tissue tumors

Malignant fibrous histiocytoma

4

High-grade liposarcoma

3

Recurrent low-grade liposarcoma

1

Leiomyosarcoma

3

Malignant peripheral nerve sheath

tumor

2

Benign aggressive soft tissue

tumors

Recurrent aggressive fibromatosis

2

Total

15

 

 

Grade

Value

Movement

5

Normal

Able to extend knee against gravity with maximal resistance

4

Good

Able to extend knee against gravity with some (moderate) resistance

3

Fair

Able to extend knee against gravity

2

Poor

Able to extend knee when gravity eliminated

1

Trace

Evidence of slight contractility but no joint movement

0

Zero

No contraction palpated

 

Table 2 Grading System for Quadriceps Muscle Strength

Modified from Sapega AA. Muscle performance evaluation in orthopaedic practice. J Bone Joint

Surg Am 1990;72(10):1562-1574.

 

Unique Anatomic Considerations

 

An important criterion for the success of a muscle flap transfer (FIG 2A-D) is maintenance of a pattern of circulation that is consistent in location and resistant to the effect of radiation therapy and superficial trauma (FIG 2E).

 

The surgical manipulation of the muscle flap must not interrupt its circulation; therefore, a precise knowledge of the location and pattern of the vascular pedicles is required. The sartorius muscle is supplied by the superficial femoral artery and has a segmental vascular pattern (type IV vascular pattern

according to Mathes and Nahai6). Each pedicle provides circulation to a portion of the muscle, and division of more than three pedicles during the elevation of the flap may result in distal muscle necrosis. The hamstring muscles are supplied by branches of the profunda femoris artery and have proximal dominant vascular pedicles and distal minor pedicles (type II vascular pattern). Complete elevation of the muscles is possible when the dominant proximal vascular pedicles are preserved.

 

IMAGING AND OTHER STAGING STUDIES

Computed Tomography and Magnetic Resonance Imaging

 

Magnetic resonance imaging (MRI) and computed axial tomography (CAT) cross-sectional imaging are essential for determining the location and extent of the lesion and its relations to the femur and the neuromuscular bundle. Large tumors of the quadriceps muscle often displace the superficial and deep femoral vessels (FIG 3). It is important to determine the anatomic relations of these vessels to the tumor before resection. Large tumors of the proximal thigh may require ligation of the profundus femoris artery and vein; therefore, knowing before surgery whether the superficial artery is patent is essential. This is particularly true in the older patient in whom the superficial femoral artery may be occluded secondary to peripheral vascular disease. Displacement of the superficial femoral artery usually does not indicate direct tumor extension;

however, if the surgical margins are positive, the artery should be resected and replaced with a saphenous or artificial graft.

 

 

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FIG 2 • A. Muscle transfers for type A resection (vastus lateralis with or without vastus intermedius). The long head of the biceps femoris is transferred anteriorly and sutured to the patella, the quadriceps tendon, and the rectus femoris muscle. B. Muscle transfers for type B resection (vastus medialis with or without vastus intermedius). The sartorius muscle is transferred anteriorly but not detached from its distal insertion and is sutured to the patellar tendon, patella, quadriceps tendon, and rectus femoris muscle. C. Muscle transfers for type C resection (rectus femoris and vastus intermedius). The sartorius muscle is mobilized anteriorly and sutured to the patella and the remains of the quadriceps tendon. D. Muscle transfers for type D resection (subtotal resection). The biceps femoris laterally and the sartorius and semitendinosus medially are transferred anteriorly, tenodesed to each other, and sutured to the patella. E. Vascular anatomy of muscles. There are five patterns of vascular supply to muscles based on the distribution of major and minor vascular pedicles. The sartorius muscle has a type II vascular pattern, and the hamstring muscles have a type IV vascular pattern (represented by the gracilis muscle in the schematic).

 

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FIG 3 • Axial (A) and coronal (B) MR views of a large soft tissue sarcoma of the anterior compartment of thigh. The neurovascular bundle is compressed medially. The tumor, however, does not reach the anterior aspect of the femur and a plane of dissection exits.

 

 

Tumors may remain within one muscle belly or involve several components of the quadriceps muscle.

 

It is important to identify the relationship between the tumor and the underlying femur. Tumors that involve the vastus medialis very often involve the adjacent periosteum as well.

 

Bone Scanning

 

A three-phase bone scan is useful to determine the proximity of the tumor to the periosteum. Absence of periosteal uptake indicates a reactive border or a pseudocapsule. This does not make quadriceps tumors unresectable but indicates that the underlying periosteum must be removed during the surgical procedure. Rarely does tumor extend directly into the bone.

 

Biopsy

 

The biopsy site should be in line with the planned incision for resection and must be located over the most prominent portion of the tumor. The biopsy tract should preferably violate a single muscle and avoid the neurovascular bundle.

 

 

Computed tomography- and ultrasound-guided core needle biopsy has been shown to provide reliable pathologic diagnoses and is our preferred method. Multiple samples can be collected from the same puncture site.

 

SURGICAL MANAGEMENT

Positioning

 

The patient is placed in the supine position with a bolster underneath the ipsilateral buttock.

 

If the tumor is close to or involves the femoral artery, the contralateral leg should also be draped for

saphenous vein graft harvesting, in case the femoral artery needs to be resected (FIG 4).

 

 

 

 

FIG 4 • Position and incision marked for type A resection (vastus lateralis and vastus intermedius) and reconstruction with biceps femoris transfer for a large malignant soft tissue sarcoma in the lateral aspect of the anterior compartment of the thigh. Resection included the vastus lateralis and part of the vastus intermedius and rectus femoris. After completion of the resection, the lateral aspect of the femur was exposed. The long head of the biceps femoris was transferred anteriorly and sutured to the patella and the remains of the quadriceps tendon and rectus femoris.

 

 

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TECHNIQUES

  • Limited Resections of the Quadriceps Muscle

    Most tumors of the anterior compartment of the thigh are confined to one part of the quadriceps muscle and can be safely resected with negative margins without the need to sacrifice a considerable amount of muscle tissue.

    A longitudinal skin incision just above the tumor mass is made, encompassing the biopsy site. The tumor mass should be resected en bloc with 1 cm of surrounding healthy tissue.

    For tumors that involve the vastus medialis, vastus lateralis, or rectus femoris, the superficial margins are the skin and subcutaneous tissues and the deep margins may include part of the vastus intermedius. The superficial margins of tumors that involve the vastus intermedius may include part of one of the vasti or rectus femoris. If the deep surface of the tumor is close to the bone, the periosteum should be peeled off and resected and the superficial cortex removed with a high-speed burr (Midas).

  • Partial or Complete Quadriceps Resection

A long midline incision is made extending longitudinally from the anterior inferior iliac spine to the patella. It should be elliptical and should widely encompass the biopsy site (TECH FIG 1A).

 

Flaps composed of skin and subcutaneous tissue are made just superficial to the fascia lata. They extend to the adductor muscle group medially and to the greater trochanter and flexor muscles laterally. The saphenous vein is divided as it enters the fossa ovalis. The inguinal ligament and the femoral triangle are uncovered, exposing the common femoral artery and vein and the femoral nerve (TECH FIG 1B).

 

Lateral traction is placed on the quadriceps muscle group so that muscular branches coming from the superficial femoral artery and vein into the quadriceps muscle are exposed. Working from cranial to caudal, these vessels are clamped, divided, and ligated, including the profunda femoris artery and vein. In the area of the canal of Hunter, while strong lateral traction is placed on the sartorius muscle, muscular insertions from the adductor magnus muscle coursing over the superficial femoral artery are identified.

These muscular branches should be divided as they cross the superficial femoral artery (TECH FIG 1C,D).

 

A plane beneath the tensor fascia lata muscle and above the gluteus medius and minimus is identified. By electrocautery, the tensor fascia lata muscle is released from its origin on the wing of the ilium. Then the origin of the sartorius muscle on the anterior superior iliac spine is identified and divided. The origin of the rectus femoris muscle on the anterior inferior iliac spine is likewise identified and divided through its tendinous portion (TECH FIG 1E).

 

 

 

TECH FIG 1 • A. The incision extends longitudinally from the anterior inferior iliac spine to the patella. It should be elliptical and should widely encompass the biopsy site. If physical examination or tomography shows that the tumor encroaches on the patella, this bone and its tendon should also be excised. If this clinical situation arises, the incision should be continued over the knee to the tibial tubercle. B. Cross-sectional anatomy. (continued)

 

 

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TECH FIG 1 • (continued) C. Flaps composed of skin and subcutaneous tissue are made just superficial to the fascia lata. They extend to the abductor muscle group medially and to the greater trochanter and flexor muscles laterally. The saphenous vein is divided as it enters the fossa ovalis. The inguinal ligament and the femoral triangle are uncovered, exposing the common femoral artery and vein and the femoral nerve. D. Dissection of the superficial femoral vessels. Lateral traction is placed on the quadriceps muscle group so that muscular branches coming from the superficial femoral artery and vein into the quadriceps muscle are exposed. Working from cranial to caudal, these vessels are clamped, divided, and ligated, including the profunda femoris artery and vein. In the area of the canal of Hunter, when strong lateral traction is placed on the sartorius muscle, muscular insertions from the adductor magnus muscle coursing over the superficial femoral artery are identified. These muscle fibers should be divided as they cross the superficial femoral artery. E. Transection of muscle origins on the pelvis. A plane beneath the tensor fascia lata muscle and above the gluteus medius and minimus is identified. By electrocautery, the tensor fascia lata muscle is released from its origin on the wing of the ilium. Then the origin of the sartorius muscle on the anterior superior iliac spine is identified and divided. The origin of the rectus femoris muscle on the anterior inferior iliac spine is likewise identified and divided through its tendinous

portion. (continued)

 

 

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TECH FIG 1 • (continued) F. Resection includes the vastus lateralis and part of the vastus intermedius and rectus femoris. G. Transection of muscle origins on the femur. Origins of the vastus lateralis, vastus intermedius, and vastus medialis on the femur are transected from bone by using electrocautery. Strong upward traction on the muscle group facilitates this dissection. H. Transection of the muscle insertions of the quadriceps muscle. Using strong upward and medial traction on the specimen, the insertions of the vastus lateralis, vastus medialis, and rectus femoris into the patellar tendon are divided on the patella.

The insertion of the vastus medialis into the medial collateral ligament is likewise divided, and the specimen is then free. The dissection site is copiously irrigated, and any bleeding points are secured with ligatures or electrocautery. (continued)

 

 

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TECH FIG 1 • (continued) I. To facilitate rehabilitation by helping to provide stability to the knee, the gracilis muscle medially and the short head of the biceps muscle laterally are transected at their insertions on the medial and lateral collateral ligaments. This transection should be as far distal as possible so that a tendinous portion of the muscle is retained. Then, using heavy, nonabsorbable sutures, these two muscles are transplanted onto the patellar tendon. The prepatellar and quadriceps bursae are closed within these sutures. The muscles are approximated in the midline to cover the distal third of the femur. J. After completion of the resection, the lateral aspect of the femur is exposed. K. Suction catheters are placed beneath the skin flaps, and the subcutaneous tissue is approximated. The skin is closed, and the incision is covered with povidone-iodine ointment and a loose, dry sterile dressing. The patient may begin ambulation when the suction catheters have been removed and edema of the leg has resolved. Because the lymphatics along the superficial femoral artery and within the buttock remain intact, prolonged swelling is not usually a problem; serous drainage from transected muscle bundles does not occur in large amounts. The patient is ambulated initially with crutches and a touchdown gait.

 

 

The origins of the vastus lateralis, vastus intermedius, and vastus medialis on the femur are transected from the bone using electrocautery. Strong upward traction on the muscle group facilitates this dissection (TECH FIG 1F,G).

 

Using strong upward and medial traction on the specimen, the insertions of the vastus lateralis, vastus medialis, and rectus femoris into the patellar tendon are divided on the patella (TECH FIG 1H).

 

One cannot avoid transecting both the prepatellar and quadriceps (postpatellar) bursae. The insertion of the vastus medialis into the medial collateral ligament is likewise divided, and the specimen is then free. The dissection site is copiously irrigated, and any bleeding points are secured with ligatures or electrocautery.

 

If the tumor is close to the underlying femoral bone (TECH FIG 1I), the periosteum can be removed and the underlying bone exposed using a high-speed burr (Midas). Several millimeters of the outer cortex can

be removed; however, the outer cortex itself should not be removed en bloc.

 

Suction catheters are placed beneath the skin flaps, and the subcutaneous tissue is approximated with interrupted absorbable sutures. We recommend using 28-gauge chest tubes to drain the surgical space (TECH FIG 1K).

Fluid-Filled Masses

 

Occasionally, soft tissue sarcomas present as a large cystic mass, filled with necrotic and hemorrhagic fluid. These tumors are difficult to resect because they fill the affected compartment and neurovascular bundle is pressed and usually located at the base of the tumor and cannot be reached (TECH FIG 2A-C).

 

In these cases, we drain the fluid from the tumor before the resection (TECH FIG 2D-F). This maneuver results in a considerable reduction in the volume of the tumor and provides better visualization and easier manipulation of the contents of the compartment (TECH FIG 2G).

 

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TECH FIG 2 • Axial (A) and coronal (B) MR views of an extensive cystic soft tissue sarcoma of the anterior compartment of thigh. The tumor is filled with necrotic and hemorrhagic fluid. C. The tumor caused

considerable tension and associated discomfort in the anterior compartment. D. The tumor is exposed. The ballooning is the result of the large volume of fluid in its inner cavity. E. Through a purse-string suture, a large caliber drain is inserted into the tumor cavity. The fluid is drained, the tumor shrinks, and the opening in the tumoral wall is tightly sutured to prevent leakage. F. The drained fluid. G. The anterior compartment following tumor removal. The femur is exposed; periosteal stripping was done.

 

 

 

  • Soft Tissue Reconstruction of Residual Large Defects

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    If a significant amount of quadriceps muscle is resected or if the femoral nerve must be sacrificed, we routinely reconstruct the extensor mechanism to restore strength and balance patellar tracking. The long head of the biceps femoris muscle is used to reconstruct the lateral aspect of the quadriceps muscle (TECH FIG 3), and the sartorius muscle, the semitendinosus muscle, or both are used to reconstruct the medial aspect of the quadriceps muscle.

     

    Another technique that can be used to functionally reconstruct large defects (which is not within the scope of this textbook) is latissimus dorsi microvascular transplantation. We believe it should be used whenever muscle transfers cannot be performed.

     

     

     

    TECH FIG 3 • The long head of the biceps femoris is transferred anteriorly and sutured to the patella and the remains of the quadriceps tendon and rectus femoris (RF).

  • Biceps Femoris Transfer for Functional Reconstruction of Large Lateral Soft Tissue Defects

     

    After completion of the resection, the long head of the biceps is transected from its insertion on the head of the fibula. This transection should be as far distal as possible to retain a tendinous portion of the muscle.

     

    The muscle is transferred anteriorly to the midline so that it will have an almost direct line of pull.

     

    Only a few deep perforating branches need to be ligated during this procedure. Because of the type II vascular pattern of the hamstring muscles, ligation of distal branches does not jeopardize its vitality.

     

    Then, using heavy, nonabsorbable sutures, the muscle is transplanted onto the patella and the remains of the quadriceps tendon and rectus femoris.

  • Sartorius and Semitendinosus Muscle Transfer for Functional Reconstruction of Central and Medial Soft Tissue Defects

The sartorius, the semitendinosus, or both can be used to functionally reconstruct large medial defects. Large central defects are reconstructed with the sartorius muscle.

Semitendinosus Muscle Transfer

The muscle is transected as far distal as possible from its insertion to the proximal tibia and transferred anteriorly so that it will have an almost direct line of pull.

Because the semitendinosus has a type II vascular pattern, ligation of its distal vascular branches for its mobilization does not compromise the vitality of the muscle.

The muscle and its tendinous part are then sutured to the patella and the remains of the quadriceps.

Sartorius Muscle Transfer

After completion of the resection, the sartorius muscle is released, but not transected, from its distal insertion on the medial aspect of the proximal tibia. The aim is to transfer the muscle anteriorly to the midline to achieve a straight line of pull between its origin on the anterior superior iliac spine and the patella.

After ligating only two or three distal vascular branches, the sartorius can easily be transferred toward the midline and sutured to the patellar tendon, the patella, and the remains of the quadriceps tendon.

Because the sartorius muscle has a type IV vascular pattern, care should be taken not to ligate more than three vascular branches to prevent distal flap necrosis.

 

 

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PEARLS AND PITFALLS

Indications

  • Most tumors of the quadriceps arise within only one or two specific muscles (eg, vastus lateralis or medialis), so a partial

    resection of the quadriceps can often be done.

  • Tumors that are close to the groin or the origin of the quadriceps require a careful dissection of the femoral triangle.

  • The femoral triangle is rarely involved with quadriceps tumors.

  • Tumors that arise close to the insertion of the quadriceps muscles may require an intra-articular resection and removal of a portion of the adjacent knee capsule.

  • Tumors of the vastus intermedius may involve the underlying femur. The preoperative imaging studies must be carefully evaluated before an attempted resection.

  • Tumors that arise within the vastus medialis muscle may extend and displace the sartorial canal. This should be determined preoperatively and mandates exploration and mobilization of the superficial femoral vessels and contents of the canal.

Reconstruction ▪ Large defects after quadriceps resection can be reconstructed using various muscle transfers primarily. If radiation therapy is

planned postoperatively, it is best to postpone any transfers until the radiation is completed for optimal function of the transferred muscle.

 

 

POSTOPERATIVE CARE AND REHABILITATION

 

Continuous suction is required for 3 to 5 days and perioperative intravenous antibiotics are continued until the drainage tubes are removed. If muscle transfer reconstruction was performed, a knee extension brace is initially used and an intensive physical therapy program for muscle strengthening and knee range of motion is started 3 to 4 weeks postoperatively. Weaning off the brace proceeds gradually in accordance with the

patient's functional improvement.

 

No immobilization is required if only resection was carried out, and patients may gradually begin ambulation when the suction catheters have been removed. Because the lymphatics along the superficial femoral artery and within the buttock remain intact, prolonged swelling is not usually a problem.

 

 

OUTCOMES

Patients who undergo limited resections of the quadriceps muscle usually do not have any residual functional limitations. There are limited data regarding the functional outcomes of patients who undergo extensive resections of the quadriceps muscle with or without reconstruction.

Markhede and Stener5 evaluated the postoperative function in 17 patients who underwent quadriceps muscle resections. They found that the isometric strength of the muscle decreased by 22%, 33%, 55%, and 76% when one, two, three, or more components of the quadriceps muscle were resected, respectively.

Capanna et al1 reported on the functional effect of quadriceps resection combined with distal femoral resection and prosthetic reconstruction in patients with malignant bone tumors. They concluded that the degree of quadriceps resection has a strong impact on functional outcome.

Malawer4 performed a gait electromyographic analysis on a patient who underwent distal femoral resection, endoprosthetic replacement, and extensor mechanism reconstruction with the sartorius and biceps femoris muscles. Six months after the operation, both muscles were recruiting in phase with the rectus femoris of the same limb.

According to our experience, most patients who undergo muscle transfer functional reconstruction have good to excellent functional outcomes and satisfactory active range of motion.7 Reported results of latissimus dorsi functional transplantation are likewise encouraging.2,3,8

 

 

COMPLICATIONS

Wound dehiscence and infections may be associated with recent or ongoing postoperative radiation therapy and is easily managed by débridement, skin grafting, and vacuumassisted care.

Vascular injuries rarely occur.

Knee stiffness is the most common problem and is treated by physical therapy. Extensor mechanism weakness or dysfunction may result in falls and fractures.

Pathologic femur fractures due to radionecrosis of the femur is a rare and devastating late complication.

 

 

REFERENCES

  1. Capanna R, Ruggieri P, Biagino R, et al. The effect of quadriceps excision on functional results after distal femoral resection and prosthetic replacement of bone tumors. Clin Orthop Relat Res 1991;267:186.

     

     

  2. Hallock GG. Restoration of quadriceps femoris function with a dynamic microsurgical free latissimus dorsi transfer. Ann Plast Surg 2004;52:89-92.

     

     

  3. Ihara K, Shigetomi M, Kawai S, et al. Functioning muscle transplantation after wide excision of sarcomas in the extremity. Clin Orthop Relat Res 1999;358:140-148.

     

     

  4. Malawer MM. Distal femoral osteogenic sarcoma: principles of soft-tissue resection and reconstruction in conjunction with prosthetic replacement (adjuvant surgical procedures). In: Lane J, ed. Design and Application of Tumor Prostheses for Bone and Joint Reconstruction. New York: Thieme-Stratton, 1983:297.

     

     

  5. Markhede G, Stener B. Function after removal of various hip and thigh muscles for extirpation of tumors. Acta Orthop Scand 1981;52:373.

     

     

  6. Mathes SJ, Nahai F. Vascular anatomy of muscle: classification and application. In: Mathes SJ, Nahai F, eds. Clinical Applications for Muscle and Musculocutaneous Flaps. St. Louis: Mosby, 1982:16.

     

     

  7. Pritsch T, Malawer MM, Wu CC, et al. Functional reconstruction of the extensor mechanism following massive tumor resections from the anterior compartment of the thigh. Plast Reconstr Surg 2007;120:960-969.

     

     

  8. Willcox TM, Smith AA, Beauchamp C, et al. Functional free latissimus dorsi muscle flap to the proximal lower extremity. Clin Orthop Relat Res 2003;410:285-288.