The figure showing the ulcerative pleomorphic sarcoma of the knee (a) with its MRI imaging (b). The patient underwent an intra-articular resection (c) and reconstruction with tibial and femoral mega-prosthesis and gemellus muscle flap with skin graft (d–f). Anteroposterior and latero-lateral postoperative X-ray of the leg (g, h)
Therefore primary amputations as the treatment choice in lower extremity sarcomas are now reduced to <5 % of all patients and <15 % among recurrences while demonstrating a comparable long-term survival. Primary amputation is however investable in extensive circumferential limb sarcoma, multicomponent proximal thigh tumors, extensive skeletal involvement, compromised general condition for a longer procedure, local unfavorable conditions like PVD, or technically difficult reconstructions [34, 35].
The surgical management of bone sarcomas is a real challenge to the orthopedic surgeon, owing to the diversity of sites in which tumors arise, combined with the extension of the tumor into adjacent soft tissues and their proximity, in many cases, to major neurovascular structures. The aim of treatment is local control and if possible the salvage of the limb and its function [32–35].
A wide (en bloc) resection entails removal of the tumor and its pseudocapsule, and a cuff of normal tissue peripheral to the tumor in all directions should be the objective. The adequate thickness of the normal tissue cuff is a controversy and it is generally believed to be a few centimeters, while an amputation is required when a wide resection is not possible .
The choice of the method of reconstruction should be individualized based upon many factors including the patient’s age, the extent and location of the tumor, the wishes of the patient, and the availability of surgical facilities and expertise, as well as the cost of the procedure. There’s a lot of choice including expandable and nonexpandable tumor prostheses, vascularized fibula, autograft, and allograft [37–40].
In the ulcerative sarcoma, performing a wide resection is needed lose skin and soft tissue, but an adequate soft tissue cover is cardinal in restoring function and should obliterate the dead space, tension-free skin closure, supporting the preserved skin with underneath muscle flaps and provide adequate cushion for exposed bony prominences or amputation stumps  (Fig. 25.2).
Figure showing a huge ulcerative synovial sarcoma of the pelvis with its MRI imaging (a, b) treated with an en bloc resection (c, d) VAC therapy and skin graft (e)
Standard procedures that are available include skin grafting for superficial defect closure, whereas vacuum-assisted closure therapy poses an option for temporary defect closure. Immediate coverage is the preferred choice, but it is not a must .
A wide variety of pedicled or free vascularized flaps are available for reconstruction in the whole musculoskeletal system. These include the lateral arm flap, scapula/parascapular flap, radial forearm flap, anterolateral thigh flap, free fibula flap, latissimus dorsi flap, rectus abdominis flap, gracilis flap, free filet flap, the medial femoral condyle periosteal bone flap, or various perforator flaps [42, 43]. Perforator or fasciocutaneous flaps are superior to skin grafts but inadequate to cover large defects, and donor site skin graft in the immediate vicinity is a disadvantage .
Unfortunately a patient with ulcerated sarcoma needs neoadjuvant and adjuvant chemotherapy and radiotherapy that can higher the rate of failure of the skin graft and flap because it reduces the vascularization and increases the fibrosis and inelasticity of the surrounding skin .
25.8.3 Treat Patient/Family Concerns
It is important for a right management of the pain, to value the impact on the patient and on his family of the pathology and to address psychological issues and coping strategies.
25.8.4 Treat the Wound
The aim of this treatment is to manage with primary dressing symptoms such as odor, bleeding, and pain and with secondary dressings to contain exudate. It is important for the right management of the ulcer that these medications are accessible and easy to use with a few dressing changes and an appropriate social support to decrease stress and anxiety at home [44–46].
Cleansing may be proposed in cancer wounds, as in any wound type, using water or physiological saline solution. Showering under tap water is also encouraged for the comfort of the patient and to decontaminate the wound and the surrounding skin. Low-pressure hydrojets may provide a more efficient cleansing, without causing pain or discomfort [47, 48].
25.8.6 Exudate Management
When exudates are moderate and the skin lesion is fresh (ulcerated nodules), the medication have the aim to prevent dressing adherence, bleeding, and crust formation or to hydrate skin which is fragile by the underlying tumor; nonadherent contact layers, amorphous hydrogels, sheet hydrogels, hydrocolloids, and semipermeable films may be useful . When exudates are more excessive, we must absorb and contain exudates to prevent dressing adherence; this can be obtained using hydrofiber or alginate dressings, foams, starch copolymers, gauze, soft cotton pads, or multilayer dressings to increase the absorption capacity . In the terminal phase, negative pressure therapy may be of interest, with a minimal pressure of 40–50 mmHg, in order to increase the drainage capacities and limit the number of dressing changes. Apart from this exceptional situation, negative-pressure therapy is contraindicated in tumor wounds as it has been reported to promote proliferation of tumor cells .
25.8.7 Bleeding Control
A slow capillary bleeding can be treated with alginates, silver nitrate, topical thrombin, gel foam, oxidized cellulose, collagen materials, tranexamic acid, sulfracrate paste, fibrinolytic inhibitors, or adrenalin diluted in saline (1:10) applied over the surface of the wound. When bleeding is provoked by dressing removal in spite of the gel formed by hydrofibers or alginate, Vaseline interface dressings or non-Vaseline interfaces, such as Mylar film, may be applied. If the lesion is associated to a major bleeding, then hemostatic radiotherapy, surgery cauterization or ligation, and embolization may be used. It is important to monitor hemoglobin to ensure anemia has not developed with persistent moderate to heavy bleeding [51, 52].
25.8.8 Infection and Odor Control
Infection and odor control is achieved by managing local bacterial colonization with an accurate wound cleansing and debridement, use of topical (efficacy only for superficial bacteria) and oral metronidazole or other antimicrobial agents, charcoal dressings placed above the primary dressing to adsorb the offensive volatile compounds, and Iodosorb gel . Topical preparations may be most effective due to the decreased perfusion and vasculature throughout malignant wounds which decreases the effectiveness of systemic therapy. The silver sulfadiazine is used to control pseudomonas infection. Avoid antiseptics such as hydrogen peroxide, povidone iodine, and sodium hypochlorite, as they may cause tissue damage and pain. Consider use of slow-release iodine products, i.e., Iodosorb. Consider use of specialized antimicrobial dressing to control infection at site [13, 54–56].
25.8.9 Perilesional Skin Care
25.8.10 Pain Control
Pain management cannot be limited to local treatments. Pain has to be managed with oral therapy such as morphine or hydromorphone. There is also limited evidence to support the use of topical opioids and other analgesics because peripheral opioid receptors should be present [12, 15].
Secondary pain has to be avoided during the dressing changes. Hypnoanalgesia, MEOPA (mélange équimolaire d’oxygène et de protoxyde d’azote), general anesthesia, and techniques of local anesthesia for dressing changes may be used .
Locally, combined lidocaine/prilocaine or lidocaine is used with limited effect, linked to the low penetration of the product. In clinical practice, morphine mixed with hydrogel at a dosage between 10 and 30 mg for 15 g of gel can be applied and has been reported to be beneficial [58–60].