Immediate reconstruction in lower extremity oncologic surgery: Patterns and outcomes from the National Surgical...

The frequency and patterns of immediate soft-tissue reconstruction across the full spectrum of limb-preserving adult lower extremity oncologic excisions remain undefined at the population level. The NSQIP database (2009-2022) was queried for adult lower extremity oncologic excisions using CPT codes, excluding amputations. Primary outcomes were 30-day wound complications and overall morbidity. Among 18,641 limb-salvage cases, 9.1% underwent immediate reconstruction. Soft tissue tumors (60.6% of cases) and radical excisions (29.8%) were the strongest predictors of reconstruction requirement (OR 2.96, 95% CI 2.54-3.45 and OR 2.22, 95% CI 1.92-2.56, respectively). Technique selection reflected anatomic location: proximal sites favored pedicled muscle flaps (pelvis/hip: 72.8%; thigh/knee: 47.8%), whereas distal sites utilized skin grafts and free tissue transfer (foot: 42.5% and 22.5%, respectively). Unadjusted complication rates were higher in reconstructed cases (30.5% vs. 15.7%, p<0.001). Multivariate analysis of the odds of complications among the entire cohort found that smoking independently predicted adverse outcomes (OR 1.34, 95% CI 1.18-1.52), whereas no reconstruction technique independently predicted complications. Among the reconstructed cases, pedicled muscle flap use was associated with increased odds of adverse events (OR 1.87, 95% CI 1.25-2.79). Immediate reconstruction was selectively utilized in 9.1% of adult lower extremity limb-salvage procedures, driven primarily by tumor type and excision complexity. These population-level benchmarks support resource allocation decisions and reinforce the importance of multidisciplinary reconstructive expertise in the subset of cases requiring complex soft-tissue management.