Metatarsal Reconstruction with Use of Free Vascularized Osteomyocutaneous Fibular Grafts Following Resection of Malignant Tumors of the Midfoot

Use of Three-dimensional Titanium Trusses for Arthrodesis Procedures in Foot and Ankle Surgery: A Retrospective Case Series

Periarticular osseous defects pose a challenge when considering arthrodesis. Failure to restore the cubic content of bone can result in shortening and malalignment, as well as subsequent biomechanical issues. This study reports on 12 patients treated with patient-specific 3-D printed (7) and prefabricated titanium trusses (5). Twelve consecutive patients were treated for osseous defects of the forefoot, hindfoot, and ankle with patient-specific, 3D printed or prefabricated manufacturer titanium trusses. Seven were customized, patient-specific 3D printed trusses (4WEB, Frisco, Texas) and 5 were prefabricated manufacturer titanium trusses. All patients had a minimum of 6 months of clinical and radiographic follow-up. and no patients were lost to follow-up. Seven of the 12 patients had a computed tomography (CT) scan performed following surgery. Successful limb or ray salvage was achieved in 11 of 12 patients (91.7%). Six of 7 patients (85.7%) with a postoperative CT scan, went on to complete radiographic consolidation across all arthrodesis sites. The remaining 5 patients showed complete consolidation across the arthrodesis sites on plain film radiographs. Complications included one patient with a residual midfoot deformity that required a subsequent midfoot osteotomy in order to obtain a plantigrade foot following successful tibiotalocalcaneal (TTC) arthrodesis, and a below knee amputation in one patient who underwent revision TTC arthrodesis to salvage avascular necrosis of the talus that developed following the index procedure. Eleven of 12 patients undergoing arthrodesis demonstrated successful union with both customized, patient-specific 3D printed and prefabricated manufacturer titanium trusses on CT scans or radiographs. The average follow-up was 14 months. Reports on traditional methods of addressing periarticular defects in patients requiring arthrodesis show mixed results and relatively high complication rates. Custom, 3D printed and prefabricated titanium truss technology offers an alternative to traditional methods for large, periarticular osseous defects.

Adamantinoma-like Variant of Ewing Sarcoma in the Metatarsal Bone After Chemotherapy: Report of a Case Successfully Treated with Pedicled Osteocutaneous Fibular Transfer

Adamantinoma-like Ewing sarcoma is a rare variant of Ewing sarcoma with histologic and immunohistochemical evidence of squamous differentiation. This variant most commonly occurs in the head and neck region with a few cases reported in the long bones of the limbs. It may be associated with poorer clinical outcome and could pose a diagnostic challenge, particularly if it occurs in older patients or as a metastatic lesion. We present a case of Ewing sarcoma in the metatarsal of an 11-year-old boy that manifested adamantinoma-like morphology after neoadjuvant chemotherapy. Chemotherapy has been reported to induce neuronal maturation and rhabdoid morphology in cases of Ewing sarcoma, but no reports of treatment-induced squamous differentiation with P40/P63 expression have been demonstrated. This is also the first documented case treated with a pedicled osteocutaneous fibular transfer in a metatarsal malignancy, which is usually treated by either ray or below-knee amputation.

Midfoot Arthritis in Children: Is There Any Relation With Malignancy?

Background:

Musculoskeletal symptoms are a presenting manifestation in a number of lymphoproliferative disorders including leukemia, especially in children. Among these primary symptoms, midfoot arthritis seems to be an important alarm for malignancy in children. The aim of this study is evaluation association of midfoot arthritis with malignancy in children.

Method:

In this cross-sectional study, all medical records of patients with arthritis were identified and reviewed. All clinical and laboratory data were recorded in the information form and data were analyzed by SPSS 25 software.

Results:

A total of 557 cases of arthritis were evaluated, of which 18 (3.2%) cases have primary symptoms of midfoot arthritis. Four of 18 patients (22.2%) had B-cell precursor acute lymphoblastic leukemia, that midfoot arthritis was their first manifestation. Also, their laboratory findings confirmed that platelet, lactic acid dehydrogenesis, and uric acid values were significantly higher in these children. Based on statistical evaluation, there was no significant difference between age and sex in these patients.

Conclusion:

According to the findings of the present study, it can be concluded that “midfoot arthritis” may be the first manifestation of leukemia in children even with a near-normal hematologic values.

Malignant tumours of the foot and ankle

Tumours of the foot and ankle constitute about 4-5% of all musculoskeletal tumours with the majority of them being benign. Diagnosis of malignant soft tissue or bone tumours is frequently delayed because of the relatively low prevalence and uncommon presentation at the foot and ankle. Suspicious lesions or lumps should be subjected to CT, MRI and biopsy. Subfascial location, lump size more than 5 cm, increase in size, painful and recurrent tumours should raise the suspicion of malignancy and lead to patient referral to a designated tumour centre. Neoadjuvant and adjuvant systemic chemotherapy and/or radiation therapy, isolated limb perfusion (ILP) and hyperthermia for malignant tumours have to be discussed in a multidisciplinary tumour board. With the advances in local and free tissue transfer, limb-sparing techniques have increasingly replaced primary amputations thus preserving lower limb function as much as possible without compromising on the principles of oncologic resection.

Reconstruction of a Complex Foot Injury With Free Remodeled Fibular Osteocutaneous Flap: A Case Report and Literature Review

Management of complex foot injuries, which involve open fractures and severe trauma to soft tissues, represent a challenge to orthopedic clinicians. In the present case report, we treated a complex foot injury with a remodeled fibular osteocutaneous free flap to reconstruct the anterior and lateral areas of the foot. The flap survived completely. At the 9-month follow-up examination, bony union of the graft bone was identified by radiographic examination. The reconstructed foot could bear body weight, and the patient could maintain a bipedal gait without discomfort. The remodeled fibular osteocutaneous free flap provides an option for functional reconstruction of foot defects.

Malignant tumours of the foot and ankle

Most of tumours of the foot are tumour-like (synovial cyst, foreign body reactions and epidermal inclusion cyst) or benign conditions (tenosynovial giant cells tumours, planta fibromatosis). Malignant tumours of the soft-tissue and skeleton are very rare in the foot and their diagnosis is often delayed with referral to specialised teams after initial inappropriate procedures or unplanned excisions. The adverse effect of these misdiagnosed tumours is the increasing rate of amputation or local recurrences in the involved patients. In every lump, imaging should be discussed before any local treatment. Every lesion which is not an obvious synovial cyst or plantar fibromatosis should have a biopsy performed.

After the age of 40 years, chondrosarcoma is the most usual malignant tumour of the foot. In young patients bone tumours such as osteosarcoma or Ewing’s sarcoma, are very unusually located in the foot. Synovial sarcoma is the most frequent histological diagnosis in soft tissues. Epithelioid sarcoma or clear cell sarcoma, involve more frequently the foot and ankle than other sites. The classic local treatment of malignant conditions of the foot and ankle was below-knee amputation at different levels. Nowadays, with the development of adjuvant therapies, some patients may benefit from conservative surgery or partial amputation after multidisciplinary team discussions.

The prognosis of foot malignancy is not different from that at other locations, except perhaps in chondrosarcoma, which seems to be less aggressive in the foot. The anatomy of the foot is very complex with many bony and soft tissue structures in a relatively small space making large resections and conservative treatments difficult to achieve.

Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160078. Originally published online at www.efortopenreviews.org

Pedicled fibular flap for reconstruction of composite defects in foot

INTRODUCTION

Reconstruction of complex injuries involving bone and soft-tissue in foot remains a tough challenge for surgeons. The free fibular flap is a popular flap for treating these composite defects. However, complications caused by microvascular anastomoses are not uncommon. Herein, we designed a pedicled fibular flap elevated in the ipsilateral leg for reconstruction of multiple defects in foot.

METHODS

From July 2005 to April 2013, four patients with composite defects in foot were treated by pedicled fibular flaps. The defects were located in the first metatarsal bone and medial cuneiform bone in two patients, in the fourth metatarsal bone in one patient, and in the second to fourth metatarsal bones in one patient. The size of soft-tissue defects ranged from 10×7 cm to 15×7 cm, and the length of bone defects ranged from 6 to 8 cm.

RESULTS

The length of fibular grafts ranged from 7 to 8.5 cm, and the size of skin flaps ranged from 11×8 cm to 16×8 cm. All flaps survived completely. Complications occurred in two patients. One suffered moderate venous congestion and the flap survived without intervention. The other one sustained re-infection. Debridement was performed and the wound healed uneventfully. Follow-up ranged from 8 to 32 months. Bone union occurred at an average of 12 weeks, and the skin flaps showed good cosmetic results. No serous donor-site complications occurred.

CONCLUSION

The pedicled fibular flap transfer could avoid anastomosis complications and preserve healthy limb. It is a good option for reconstruction of complex defects in foot.

Vascularised or non-vascularised autologous fibular grafting for the reconstruction of a diaphyseal bone defect after resection of a musculoskeletal tumour

Resection of a primary sarcoma of the diaphysis of a long bone creates a large defect. The biological options for reconstruction include the use of a vascularised and non-vascularised fibular autograft. The purpose of the present study was to compare these methods of reconstruction. Between 1985 and 2007, 53 patients (26 male and 27 female) underwent biological reconstruction of a diaphyseal defect after resection of a primary sarcoma. Their mean age was 20.7 years (3.6 to 62.4). Of these, 26 (49 %) had a vascularised and 27 (51 %) a non-vascularised fibular autograft. Either method could have been used for any patient in the study. The mean follow-up was 52 months (12 to 259). Oncological, surgical and functional outcome were evaluated. Kaplan-Meier analysis was performed for graft survival with major complication as the end point. At final follow-up, eight patients had died of disease. Primary union was achieved in 40 patients (75%); 22 (42%) with a vascularised fibular autograft and 18 (34%) a non-vascularised (p = 0.167). A total of 32 patients (60%) required revision surgery. Kaplan-Meier analysis revealed a mean survival without complication of 36 months (0.06 to 107.3, sd 9) for the vascularised group and 88 months (0.33 to 163.9, sd 16) for the non-vascularised group (p = 0.035). Both groups seem to be reliable biological methods of reconstructing a diaphyseal bone defect. Vascularised autografts require more revisions mainly due to problems with wound healing in distal sites of tumour, such as the foot.

Foot salvage after loss of the first and second metatarsal rays with a free fibular osteocutaneous flap

Severely comminuted fractures of the metatarsal bones with significant bone and soft-tissue loss have commonly subjected patients to proximal amputation procedures. We describe two patients who experienced high-energy traumatic injuries to their limbs that resulted in significant destruction of their first and second metatarsal bones with overlying soft-tissue trauma not amenable to local coverage. In both cases, a vascularized free fibular osteocutaneous flap was used to reconstruct the metatarsal bone defect and traumatized soft tissues so that a proximal amputation was avoided. At an average of 14 months of follow-up, both patients had recovered well and regained independent ambulation, with one patient being able to play soccer. We show that the free fibular osteoseptocutaneous flap is useful in reconstructing significant metatarsal bone defects and in avoiding amputations in this patient population. The skin component of the flap may be used to fill soft-tissue losses, and the fibula bone may be osteotomized so that more than one ray may be reconstructed.