Functional and oncological outcomes of limb-salvage surgery for foot and ankle tumors

Predictors of malignancy in surgically removed foot and ankle masses: a retrospective multi-center study

PURPOSE

Foot and ankle masses, though uncommon, are an important subset of musculoskeletal tumors, encompassing benign and malignant forms. Malignant tumors often necessitate aggressive treatment, including amputation, and unplanned resections can worsen outcomes by increasing recurrence risk. Identifying predictors of malignancy and functional deficits is vital for improving treatment strategies.

METHODS

A retrospective review of 120 tumors in 112 patients (2017-2024) assessed demographics, tumor characteristics, size, surgical approach, and outcomes. Interventions included excision, curettage, and amputation, with reconstruction when needed. Predictors of malignancy and functional outcomes were statistically analyzed.

RESULTS

Malignancy was observed in 9.8% of cases, with tumor size > 45 mm and age > 45 years identified as significant predictors. The majority of surgeries were excisions (83.9%), followed by curettage in 13.3% and amputation in 2.8%. Complete resection (R0) was achieved in 94.5% of cases. Early-term (0-180 days) wound complications occurred in 5.4%, while late-term recurrence (median 22 months) was observed in 4.5% CONCLUSION: Tumor size and patient age are key malignancy predictors. Complete resection improves outcomes, highlighting the importance of tailored surgical planning.

Intriguing tumor, synovial sarcoma: hard to diagnose, harder to treat

BACKGROUND

Synovial sarcoma (SS) is classified as an aggressive high-grade soft tissue sarcoma that predominantly affects the extremities. Despite its prevalence in the extremities (up to 80%), diagnostic and treatment challenges persist. This study aims to address these challenges by providing a comprehensive analysis of SS in extremities, focusing on diagnostic accuracy and treatment outcomes. The central questions of this study are: What are the diagnostic and treatment challenges associated with SS? How do tumor volume and histologic subtype influence prognosis? What role do immunohistochemistry and genetic markers play in SS diagnosis and management?

HYPOTHESIS

We hypothesize that larger tumor volume and poor histologic differentiation are associated with worse survival outcomes in patients with SS.

PATIENTS AND METHODS

This retrospective study analyzed data from 63 patients diagnosed with SS between 2005 and 2020 at a single center. Patients with complete records of pathology, radiology, and surgery, and a minimum follow-up of 12 months were included. Tumor characteristics, treatment modalities, and follow-up data were reviewed.

RESULTS

he study included 63 patients and 65 tumors. The mean age was 38 ± 17 years. There were 31 females (49%) and 32 males (51%). SS predominantly affected the extremities (n = 63, 97%), especially the lower limbs (n = 49, 75%). Tumor volume, with a mean of 110 ± 176 cm³, was a significant factor, with tumors >30 cm³ associated with higher rates of metastasis (p = 0,006) and reduced survival (p = 0,027). Histologically, 25 (38%) were monophasic, 24 (37%) were biphasic, and 16 (25%) were poorly differentiated, with poorer survival linked to poorly differentiated subtypes. Immunohistochemistry showed high positivity rates for Bcl-2 (89%, 17/19), EMA (88%, 52/59), and TLE1 (87%, 13/15). SS18-SSX fusion gene detected in 73% of cases (8/11). Metastasis occurred in 27 (42%) patients and recurrence in 24 (37%). 15 (23%) patients died from the disease.

DISCUSSION

Accurate diagnosis of SS is crucial for effective management. Clinicians should be aware of negative predictive factors, including tumor volume >30 cm³ and poor histologic differentiation, when making treatment decisions. The study highlights the importance of extended follow-up due to the risk of late recurrence.

LEVEL OF EVIDENCE

IV.

Ortho-oncoplastic surgery in foot and ankle: A narrative overview on reconstruction of soft-tissue defects after oncologic resections

INTRODUCTION

Malignant tumors of the foot are rare, and treatment strategies are challenging considering the complex anatomy of this area. In recent years, dramatic advances in technology and collaborations between different specialties (such as orthopedic, oncology, radiology, plastic, and vascular surgery) significantly changed the approach to complex malignant tumors without resorting to limb removal. The combination of the strengths of both orthopedic surgery and plastic surgery constitutes the modern definition of "orthoplasty." The aim of this review article is to provide treatment strategies that are available for reconstruction of foot and ankle in limb-salvage surgery after tumor resection, with a specific focus on microsurgical techniques in plastic surgery.

METHODS

We conducted a comprehensive search for relevant papers across PubMed, Scopus, Embase, and Web of Science. We included patient-based studies reporting on procedures for soft-tissue reconstruction with small and large soft tissue defects. Indications, pros and cons, and technique tips are discussed for each type of reconstructive technique.

RESULTS

The search was done using literature of the past 30 years (from 1990 to date), resulting in about 725 articles describing over 2000 cases. Cutaneous flaps included lateral supramalleolar flap, medial plantar flap, reverse sural neurocutaneous island flap, medial leg flap, and lateral leg flap. Free flaps included anterolateral thigh flap, radial forearm flap, latissimus dorsi flap, gracilis muscle flap, lateral arm flap, and rectus abdominis flap.

CONCLUSIONS

The orthoplastic approach in musculoskeletal oncology is a collaborative model of orthopedic and plastic surgeons working together, resulting in a higher rate of successful limb salvage in patients at risk for amputation. Protocols, biologic substitutes, and surgical techniques are largely improved in the last decades increasing the possibility of functional reconstruction. Microsurgical strategies represent the new frontiers in these demanding reconstructions.

Impact of Level of Surgery on the Functional Outcomes in Patients with Lower Extremity Bone Tumors Undergoing Amputation Versus Limb Salvage Surgery

Limb salvage surgery is the preferred treatment for bone tumors in the current surgical practice. The aim of this study was to compare the functional outcomes between amputation and limb salvage surgery based on the level of surgery at two levels: knee and hip. A single institutional analysis of 137 patients with lower extremity bone tumors was done between 2014 and 2020. Eighty-seven patients treated with amputation were compared with 50 patients treated with limb salvage surgery based on following variables: age, gender, histology, anatomic site, and MSTS score. The mean MSTS scores were fairly better in patients who underwent surgery at knee level compared to those who underwent surgery at hip level. The mean MSTS score at 1-year follow-up was 22.0 in amputation group compared to 22.4 in limb salvage group, whereas at 2-year follow-up was 24.1 in amputation group compared to 25.1 in limb salvage group. At knee level, functional outcomes were similar after amputation and limb salvage. At hip level, patients undergoing amputation had poorer MSTS scores compared to limb salvage surgery at 2-year follow-up (p = 0.04). The functional outcomes for patients undergoing surgery at knee level were similar irrespective of type of surgery. At longer follow-up, patients undergoing amputation at hip level had a poorer functional outcome compared to limb salvage surgery. Although limb salvage was associated with similar MSTS scores when compared with amputation, it produced a better functional outcome especially for proximally located tumors.

Reconstruction and Outcome of Foot Defects Following Oncological Resection-Experience from a Cancer Centre in North-East India

Solid tumours around the foot are rare and include soft tissue sarcomas, skin and bone malignancies. Extended soft tissue defects due to oncological resection result in the loss of shock-absorbing and friction resistant tissue, which leads to altered walking patterns and pain. Replacement of plantar tissue requires soft tissue resistant to weight, pressure and shear stress. The other important desired goal of foot reconstruction is short wound healing time in order to allow adjuvant therapy at stipulated time. This is a retrospective study from March 2016 to October 2019. A total of twenty-one (n = 21) patients were operated for foot malignancies during this period in our institute and the resulting defects were reconstructed using various methods. Different reconstructive surgeries were performed depending on tumour size, location and general health status of patients. The length of hospitalization and the presence of local postoperative complications were assessed. Functional outcomes were measured in terms of MSTS score. Average age of the series is 53.1 years. Sixty-six percent of the patients (n = 14) presented with tumour at the weight bearing areas and 33% patients (n = 7) at the non-weight bearing areas of the foot. Fifty-seven percent of patients (n = 12) presented with malignant melanoma of foot, squamous cell carcinoma was seen in 33% (n = 7) patients and 4% patients (n = 1 each) presented as osteosarcoma and malignant peripheral nerve sheath tumour respectively. The mean MSTS score in patients with weight bearing areas (location) is statistically significant (p = 0.031). There is a significant correlation between the surgical complications and follow up MSTS score (p = 0.046) which signifies that flap related complications result in lower MSTS score. The mean MSTS score was 22.71/30. Complications were observed in three cases which included partial flap necrosis, graft loss and foot stiffness. Simple skin grafts to local flaps maybe a viable option in a limited resource setting based on the location of defect. Free tissue transfer is the ideal choice in case of weight bearing areas to achieve acceptable outcomes.

Malignant Tumors of the Foot and Ankle

BACKGROUND

Surgical treatment is usually required for malignant foot and ankle tumors. In this study, we sought to review factors in treatment that may be associated with morbidity and mortality.

METHODS

All malignant foot and ankle tumors at our institution between April 1988 and April 2018 were retrospectively reviewed. The surgical modalities used and clinical outcomes of patients according to the anatomic location (Kirby zone) and clinical stage (Enneking system) of each tumor were described. Extent of surgical resection required, recurrence, and death rates were assessed.

RESULTS

Between April 1988 and April 2018, 80 patients with malignant tumors of the foot and ankle were treated at out institution. Mean age of patients was 42.6 (range, 3-89) years. Mean follow-up was 30.2 months (range, 24-120). Tumors were primary in 75 patients (94%) and metastatic from another organ in 5 patients (6%). Tumors originated from bone in 18 patients (22%) and from soft tissue in 63 patients (78%). Synovial sarcoma was the most common soft tissue tumor, and osteosarcoma was the most common osseous tumor.All patients had surgery to resect their tumor. Twenty-one (26%) had unplanned surgical procedures without initial biopsy at an outside institution prior to referral. Those patients were more likely to be treated with amputation or wide excison and free flap surgery (P < .01). The recurrence rate was 50% for the unplanned surgery group and 22% for the planned surgery group. Mortality rate was 10% for the unplanned group and 6% for the planned group. The recurrence and mortality rate was higher in the unplanned group (P = .03).

CONCLUSION

Our study suggests that unplanned initial surgeries are associated with higher recurrence and mortality rates and reinforces the notion that these patients should be referred for treatment at a center with specialized expertise in tumor management.

LEVEL OF EVIDENCE

Level, IV, retrospective case series.

Arthroscopic Management of Giant Cell Tumor of the Calcaneus

Giant cell tumor of the calcaneal bone is a very rare entity and generally seen in the 30 to 40 years age group. We report a case of a 17-year-old male with giant cell tumor of the calcaneus, presented with left heel pain without another obvious physical abnormality. Radiographs showed a lobulated, well-defined, lytic lesion of the calcaneus with narrow transitional zone without periosteal reaction, no extraosseal spread, and no lung metastases. Arthroscopic procedure was done directly for both diagnostic and curative procedures. All soft, grayish lesions were completely removed arthroscopically using direct lateral portals and the suspected reactive zones debrided using high-speed burr and injected with corticosteroid. Histopathology confirmed the suspected diagnosis. The postoperative clinical course was uneventful with immediate pain relief and full weight bearing and movement allowed soon. The patient had no recurrent pain as well as recurrent radiographic lesions, and normal joint mobility 9 months postoperatively. Considering the accessibility of the lesion, giant cell tumor of the calcaneal bone can be successfully treated arthroscopically using direct lateral approach.Levels of Evidence: Therapeutic, Level IV: Retrospective, case report.

Surgical outcomes of bone sarcoma of the foot

OBJECTIVE

Limb-salvage following resection of bone sarcomas of the foot are challenging due to the complicated anatomy, adjacent neurovascular structures and few durable reconstruction options.

METHODS

We retrospectively analysed 50 patients with primary malignant bone sarcoma of the foot who underwent surgery including chondrosarcoma (n = 23), Ewing's sarcoma (n = 14) and osteosarcoma (n = 13).

RESULTS

Median follow-up was 68 months. The primary sites were metatarsal (n = 18), phalanges (n = 15), calcaneus (n = 13) and others (n = 4). The 5-year disease-specific survivals were 100, 83 and 83% in chondrosarcoma, Ewing's sarcoma and osteosarcoma, respectively. Below knee amputation, ray/toe amputation, excision and curettage were performed in 21, 24, 2 and 3 patients, respectively. Below knee amputation was performed in 94% of mid/hindfoot tumours. Surgical margins were wide/radical, marginal and intralesional margin in 42, 5 and 3 patients. Three patients (6%) developed local recurrence, whereas, local recurrence was not observed in patients with wide/radical margins. Postoperative complications occurred in 3 patients (6%; surgical site infection n = 2 and delayed wound healing n = 1). Mean MSTS functional score was 26 points (range, 19-30).

CONCLUSIONS

Good local control was achieved with acceptable functional outcomes and post-operative complications; almost all mid/hindfoot tumours required below knee amputation achieving wide/radical margins without local recurrence.