Immediate Soft-Tissue Reconstruction in Pediatric Limb-Salvage Extremity Tumor Surgery

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 <0.001). In the LE multivariable analysis, immediate reconstruction ( 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.