Soft-tissue tumors of the foot: value of MR imaging for specific diagnosis

Review of Soft Tissue Masses of the Foot and Ankle: Magnetic Resonance Imaging Features

A large number of soft tissue masses affect the foot and ankle, with the majority being benign. Benign and malignant soft tissue lesions usually present as lumps, and it is important to differentiate between them to allow for optimal management. Imaging, in particular magnetic resonance imaging (MRI), can contribute to narrow the differential diagnosis of soft tissue masses of the foot and ankle by describing its exact location, internal signal characteristics, presence of enhancement, and its relation to adjacent structures. In this review, we review the literature to describe the most common soft tissue masses around the foot and ankle, focusing on the MRI features of the lesions.

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.

Peroneus longus intra-tendinous ganglion cyst

Ganglion cysts arising from tendons are uncommon lesions with an unknown cause. We present a case report of a 38-year-old female was diagnosed with an intra-tendinous ganglion cyst of the peroneus longus. She complained of right ankle swelling for 1 year and associated with pain. MRI revealed a peroneus longus intra-tendinous ganglion below the lateral malleolus with a thin wall. The ganglion cyst was surgically excised while the structure of the peroneus longus tendon was preserved. The clinical and functional outcomes were satisfactory after 1 year without recurrence.

Solitary massive lipoma in the planter aspect of great toe presenting as two masses

Lipoma is rare in the planter aspect of the toes, and only few cases of massive lipoma have been reported in this site. The differential diagnosis of masses in the foot and toes is wide, and clinical diagnosis may be challenging. Access to magnetic resonance imaging, a standard diagnostic investigation for such soft tissue masses of the foot and toes, may be limited in some practice, requiring a reliance on clinical signs. We report a solitary massive lipoma in the planter aspect of the right great toe that appeared as two masses and with modification of typical clinical signs of lipoma.

Non-antiepileptic drugs for trigeminal neuralgia

BACKGROUND

Trigeminal neuralgia was defined by the International Association for the Study of Pain as a sudden, usually unilateral, severe, brief, stabbing recurrent pain in the distribution of one or more branches of the fifth cranial nerve. Standard treatment is with anti-epileptic drugs. Non-antiepileptic drugs have been used in the management of trigeminal neuralgia since the 1970s. This is an update of a review first published in 2006 and previously updated in 2011.

OBJECTIVES

To systematically review the efficacy and tolerability of non-antiepileptic drugs for trigeminal neuralgia.

SEARCH METHODS

On 20 May 2013, for this updated review, we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL (2013, Issue 4), MEDLINE (January 1966 to May 2013), EMBASE (January 1980 to May 2013), LILACS (January 1982 to May 2013) and the Chinese Biomedical Retrieval System (1978 to May 2013). We searched clinical trials registries for ongoing trials.

SELECTION CRITERIA

We included double-blind, randomised controlled trials in which the active drug was used either alone or in combination with other non-antiepileptic drugs for at least two weeks.

DATA COLLECTION AND ANALYSIS

Two authors decided which trials fitted the inclusion criteria and independently graded risk of bias. We assessed the quality of the evidence according to the GRADE criteria for this update.

MAIN RESULTS

In this 2013 update, we updated the searches, but identified only two new ongoing studies. The review includes four trials involving 139 participants. The primary outcome measure in each was pain relief. Three trials compared one of the oral non-antiepileptic drugs tizanidine, tocainide or pimozide with carbamazepine. The quality of evidence for all outcomes for which data were available was low. In a trial of tizanidine involving 12 participants (one dropped out due to unrelated disease), one of five participants treated with tizanidine and four of six treated with carbamazepine improved (risk ratio (RR) 0.30, 95% confidence interval (CI) 0.05 to 1.89). Few side effects were noted with tizanidine. For pimozide, there was evidence of greater efficacy than carbamazepine at six weeks. Up to 83% of participants reported adverse effects but these did not lead to withdrawal; the report did not provide comparable data for carbamazepine. Limited data meant that we could not assess the effects of tocainide; however, data from non-randomised studies (not included in this review) indicate that serious haematological adverse events can occur. A trial involving 47 participants compared 0.5% proparacaine hydrochloride eyedrops with placebo but did not show any significant benefits, again according to low-quality evidence. The report did not mention adverse events. The proparacaine trial was at low risk of bias; the other trials were at unclear risk of bias overall.

AUTHORS' CONCLUSIONS

There is low-quality evidence that the effect of tizanidine is not significantly different than that of carbamazepine in treating trigeminal neuralgia. Pimozide is more effective than carbamazepine, although the evidence is of low quality and the data did not allow comparison of adverse event rates. There is also low-quality evidence that 0.5% proparacaine hydrochloride eye drops have no benefit over placebo. Limitations in the data for tocainide prevent any conclusions being drawn. There is insufficient evidence from randomised controlled trials to show significant benefit from non-antiepileptic drugs in trigeminal neuralgia. More research is needed.

MR imaging of the paediatric foot and ankle

Radiography is the mainstay for initial evaluation of paediatric foot and ankle pathology. MRI is the preferred exam for further characterisation of the majority of these conditions. The modality features high sensitivity and specificity for this purpose with few exceptions. Findings on MRI will often dictate patient referral and further management, and are frequently required for surgical planning. This article will provide an overview of a variety of pathologies that afflict the foot and ankle in children. These include tarsal coalition, osteochondral lesions, osteonecrosis, osteochondroses, stress fractures, osteomyelitis, inflammatory arthritis, neoplasms of bone and soft tissue, and foreign bodies. Their respective imaging manifestations on MRI are the focus of the paper. Technical parameters and marrow signal variation are also discussed.

Clear cell sarcoma: a case report with radiological and pathological features of an atypical case

Clear cell sarcoma of soft tissue is a rare, aggressive soft tissue tumor, which is morphologically similar to malignant melanoma but has no precursor skin lesion and, instead, has a characteristic chromosomal translocation. It is critical, yet challenging, to recognize clear cell sarcoma of soft tissue because the outcome is very different to that of metastatic melanoma. We report a case of clear cell sarcoma of soft tissue arising in the left foot of a 35-year-old African-American woman.

Primary clear cell sarcoma of humerus: case report

We report a case of primary clear cell sarcoma occurring in the humerus. A 20 year old girl was referred to our hospital two years ago with painless swelling of the soft tissue surrounding the proximal right humerus. The conventional radiographic image showed an ill-defined, aggressive, osteolytic lesion associated with a partial cortical defect of the proximal right humerus. Magnetic resonance imaging found an irregularly shaped extraosseous mass extending from the proximal shaft of the right humerus, penetrating through the destroyed bone and invading the biceps brachii. After preoperative chemotherapy, a total tumor resection, internal fixation and bone cement implantation were performed. Histological studies of the resected tumor found that fibrous septa divided into well-defined nests and polygonal and fusiform cells with clear cytoplasm. Immunohistochemical studies demonstrated strong positive cytoplasmic staining with S-100 and scattered positivity with HMB-45. These findings led to a final, definitive diagnosis of clear cell sarcoma of the humerus. After routine postoperative chemotherapy, a 2-year follow-up showed no metastasis. Our findings in this report point out that primary clear cell sarcoma can originate from within the humerus and that limb salvage surgery can obtain a good result.

Arteriovenous hemangioma of the foot--a case report

We report a case of a 40-year-old woman who presented with a heel mass on her left foot. She underwent removal of the mass, which was found to be an arteriovenous hemangioma (AVH). Arteriovenous hemangioma is a rare tumours, especially in the foot which is extremely rare. This tumour should be considered in the differential diagnosis of a mass presenting in the foot.

The foot and ankle: MR imaging of uniquely pediatric disorders

MR imaging of the foot and ankle in children poses unique challenges, not only because of technical issues, but also because of the variations produced by age related changes. However, because of its excellent soft tissue contrast (especially helpful in delineating cartilage related abnormalities), MR imaging offers a distinct advantage over other imaging modalities. This article discusses MR imaging techniques for examining the pediatric foot and ankle, and reviews some common conditions encountered in a child's foot and ankle. This includes lesions such as osteochondritis dissecans; tarsal coalition; soft tissue and bony tumors of the foot and ankle; infection; and clubfoot.

Chopart's amputation for resection of clear cell sarcoma of the foot: a case report and review of the literature

Clear cell sarcoma (CCS) is a subset of soft tissue sarcoma that occurs mainly in young Caucasians. Although on initial presentation these growths might not appear to be malignant, CCS has a tendency to disseminate to regional lymph nodes and ultimately develop distant metastasis. We report a case of CCS from our institution, discussing the radiological and pathological findings, surgical treatments, and survival prognoses. To our knowledge, this is the first reported case of using a Chopart's amputation technique in the resection of CCS of the foot.

LEVEL OF CLINICAL EVIDENCE

4.

Tumors of the foot and ankle: experience with 153 cases

BACKGROUND

Both primary and metastatic tumors in the foot and ankle have been reported as rare. The purpose of this study was to describe 153 cases of foot and ankle tumors from a 20-year experience in a tertiary referral center specializing in orthopaedic oncology. It is the largest reported series of both bone and soft tissue tumors in the foot and ankle.

MATERIALS AND METHODS

Between 1986 and 2006, a retrospective chart review was performed of a total of 2,660 tumors surgically treated in all anatomic sites by a single surgeon at a musculoskeletal tumor referral center.

RESULTS

One hundred fifty-three patients (5.75%) with bone and/or soft tissue tumors of the foot and ankle were treated. There were 84 women and 69 men. The patients' ages ranged from 1 to 84, with a median age of 30 and mean of 33.2. The tissue types included 80 soft tissue and 73 bone tumors. Overall, 60 (39.2%) were malignant, and 93 (60.8%) were benign. The most common diagnosis was giant cell tumor. In addition, giant cell tumor was the most common bone tumor, while pigmented villonodular synovitis and giant cell tumor of the tendon sheath were the most common soft tissue tumors.

CONCLUSION

The incidence of tumors of the foot and ankle in this series of a single surgeon over a 20-year practice was 5.75%. The results of this study reaffirm that awareness, correctly diagnosing, and appropriately treating or referring to an orthopaedic oncologist may help with an improved outcome for patients.

Differentiating benign and malignant soft tissue masses by magnetic resonance imaging: role of tissue component analysis

BACKGROUND

There is a variable degree of accuracy in discriminating benign from malignant soft tissue masses based on signal intensity and morphologic characteristics by magnetic resonance imaging (MRI). The aim of this study was to determine the utility of detailed component pattern assessment, in addition to morphologic study, for differentiating benign from malignant soft tissue masses by MRI.

METHODS

The imaging features of 118 histologically proven soft tissue masses were analyzed according to: (1) signal characteristics: (a) high T1 matrix; (b) low T2 matrix; (c) fibrous tissue signal; (d) calcification; (e) myxoid signal tissue; (f) fatty signal tissue; (g) cystic signal; (h) necrotic signal; (i) septations; (j) vascular signal void signal; (k) fat rim; and (l) hemorrhage; and according to (2) morphologic assessment: (a) lesion size (maximal diameter) in centimeters (cm); (b) lesion depth in cm; (c) margins; (d) peritumoral edema; (e) bone involvement; (f) marginal capsule or pseudocapsule; and (g) neurovascular bundle involvement. Univariate and multivariate analyses followed by stepwise logistic regression of combination of imaging features were performed. The predictive value of each imaging feature and various combinations of imaging features were determined.

RESULTS

In univariate analysis, T2 low signal matrix, fibrous tissue, calcification, necrosis, septum, fat rim sign, peritumoral edema, and hemorrhage showed statistically significant differences between benign and malignant masses (p < 0.05). The positive predictive value of necrosis for malignancy was 84.8%, and its specificity was 90.9%. In multivariate analysis, the best model for predicting malignant masses was the combination of necrosis, maximal mass diameter, peritumoral edema, and absent fibrosis, absent calcification, and lack of fat rim. The combination of these parameters resulted in the most correct diagnoses of malignancy, with a sensitivity of 84.2%, specificity of 64.0%, and accuracy of 74.8%, whereas the accuracy of models consisting of component character and morphologic feature were 74.3% and 70.9%, respectively.

CONCLUSION

MRI is useful in determining whether a soft tissue mass is malignant or not. Traditional morphologic assessment was reinforced by detailed component characterization analysis. The parameters favoring malignancy were large lesion size, peritumoral edema, necrosis, and absent calcification, absent fibrosis, and lack of fat rim.

Sonographic diagnosis of fibromatosis

PURPOSE

To investigate the value of sonography in the diagnosis of fibromatosis.

METHOD

We retrospectively reviewed the sonographic findings, pathologic results, and other medical records of 42 patients with pathologically proven fibromatosis. The tumor's size and location were recorded. Echogenicity, margins, vascularity, and relationship with the adjacent tissue were analyzed.

RESULTS

A total of 42 patients with 44 lesions were included in the study. In 21 patients, the tumor was a primary tumor. In 7 of these patients, a preoperative diagnosis of fibromatosis was obtained via sonographically guided biopsy or surgical biopsy. In another 21 patients, the tumor was a recurrence (including 1 case of malignant transformation). Well-defined and regular margins were demonstrated in 26 lesions (59%), whereas poorly defined and irregular borders were seen in the other 18 lesions. On Doppler imaging, vascularity was absent in 66% (29/44) lesions, moderate in 23% (10/44), and marked in 11% (5/44). Infiltration into the adjacent skeletal muscles, cortical bone, or encasement vessels, nerves, or tendons was found in 21 (48%) lesions.

CONCLUSION

In patients with fibromatosis, sonography demonstrates a nonspecific hypoechoic solid mass and can guide the percutaneous needle biopsy.

Clear cell hidradenoma of the ankle

Clear cell hidradenoma is a relatively common, benign eccrine neoplasm with rare presentations in the foot and ankle. Variable clinical and histopathologic characteristics of the tumor warrant careful consideration over primary and recurrent malignancy, particularly eccrine carcinoma. The first known case of primary benign clear cell hidradenoma of the ankle is presented with imaging studies, surgical management, and clinicopathologic correlation, distinguishing the neoplasm from its malignant counterparts.

Soft-tissue masses

The purpose of this study was to show the qualitative and quantitative MRI characteristics of soft-tissue masses in differentiation of benign and malignant lesions. A total of 90 soft-tissue lesions were reviewed in this study. The scoring system presents a more objective diagnostic performance in the prediction of benign or malignant masses. With the use of this scoring system, unnecessary biopsy can be precluded in benign lesions.

MR appearance of clear cell sarcoma of tendons and aponeuroses (malignant melanoma of soft parts): radiologic-pathologic correlation

Clear cell sarcoma of tendons and aponeuroses (CCSTA) is a rare aggressive soft tissue tumor that frequently produces melanin. Its MR findings are rarely described in the literature. We report the case of a previously healthy 54-year-old man with clear cell sarcoma of the thigh who presented with a large painless mass of 1 year's duration. MR imaging showed the tumor to be of high signal intensity on fast spin-echo and STIR images. Both fine needle aspiration and excisional biopsy showed abundant melanin pigments. Histologic diagnosis was compatible with CCSTA.

Tumours and tumour-like lesions in the foot and ankle

We present a spectrum of tumour and tumour-like lesions in the foot and ankle in which a specific diagnosis can be made or strongly suggested on the basis of location, imaging features and the relevant clinical findings. Characteristic imaging appearances are emphasized.

Primary clear cell sarcoma of rib

Clear cell sarcoma (malignant melanoma of soft tissues) is a very rare soft tissue neoplasm. It generally arises in tendons and aponeuroses. Although metastasis of malignant melanoma to bone is not uncommon, primary clear cell sarcoma of bone is an extremely rare neoplasm. To our knowledge five cases have been reported in the English literature. We present a case of primary clear cell sarcoma of bone in a 28-year-old woman arising in the left ninth rib. We treated the patient with total excision of the mass and postoperative radiotherapy. The patient is alive and well without local recurrence or distant metastasis at 33 months after surgery.

Accuracy of MRI in characterization of soft tissue tumors and tumor-like lesions. A prospective study in 548 patients

The purpose of our study was to assess prospectively the value of MRI in characterization of soft tissue tumors (STT) and soft tissue tumor-like lesions in a multi-institutional setting by a group of experts. The material consisted of 548 untreated and proven STT or tumor-like lesions originating from a multi-institutional database of STT in which 930 consecutive patients with STT examined by MRI were registered between 1 January 2001 and 28 April 2003. Based on MRI findings, a suitably ordered differential diagnosis was made in consensus by two radiologists (J.L.M.A.G and A.M.D.S). MRI diagnoses were compared with histology results (455 cases, 83%) and/or 6-month follow-up (93 cases, 17%) as reference standards. The correlation between the MRI and histological diagnosis and between the radiological and histological phenotype were statistically determined. One hundred twenty-three patients presented with a malignant STT; 425 patients presented with a benign one. Concerning differentiation between malignant and benign lesions (dignity), a sensitivity of 93%, specificity of 82%, negative predictive value (NPV) of 98% and positive predictive value (PPV) of 60% with accuracy of 85% were obtained. Concerning phenotype characterization, if only the first MRI diagnosis was taken into account, a sensitivity of 67%, specificity of 98%, NPV of 98%, PPV of 70% and accuracy of 96% were obtained. For benign lesions, sensitivity of 75%, specificity of 98%, NPV of 98%, PPV of 76% and accuracy of 97% were obtained. The phenotype's definition of malignant STT had a sensitivity of 37%, a specificity of 96%, NPV of 96%, PPV of 40% and an accuracy of 92%. A correct diagnosis compared with histological assessment was proposed in 227(50%) of the 455 histologically confirmed cases. Despite non-quantified MR parameter evaluation, the results of our prospective study were better than those reported in previous studies and demonstrated the need for a centralized approach to such rare pathology.

Foot malignancies: a multidisciplinary approach

Malignant osseous and soft tissue tumors of the foot are rare and should be considered in patients who have foot-related symptoms. Most sarcomas affect patients who are older than 55 years; however, many young patients who are otherwise healthy, may present with malignant foot and ankle lesions. In addition to benign and malignant neoplasms, pseudotumorous conditions mimic neoplastic lesions and should be differentiated before any treatment is undertaken. Invasiveness is a characteristic of sarcomas. The foot is a terminal anatomic structure, with closed and tight compartments and well-vascularized tissues, that predispose it to hematogenous and lymphatic metastases. Patients who have a malignant foot tumor should be referred to an orthopedic oncologist for further evaluation and treatment. The goals of treatment include local tumor control, restoration of function and stability during standing and walking, long-term survival, and improved quality of life. In most cases, wide surgical margins require a ray, Syme, midtarsal, or below-the-knee amputation. Recent advances in chemotherapy and radiotherapy have allowed limb salvage procedures with wide tumor resections. Because overall survival is greatly improved in these patients, the reconstruction of skeletal defects needs to be more functional and durable. After tumor resection, reconstruction of the skeletal and soft tissue defects is possible by using bone allografts or vascularized autografts, arthrodesis, and free vascularized musculocutaneous flaps.

MR findings of clear cell sarcoma: two case reports

We report two patients with clear cell sarcomas arising from tendons in the ankle and knee. In the current cases, calcifications, fluid-fluid levels and the marked hypointense areas are not seen within the masses. In the differential diagnosis of the mass developing in the tendons and aponeuroses, when these signs are absent, the probability of clear cell sarcoma is higher.

Plantar fibromatosis: most common sonographic appearance and variations

PURPOSE

The aim of this study was to describe the most common sonographic appearances of plantar fibromatosis, thus enabling sonographic diagnosis of this benign, focally invasive fibrous neoplasm.

METHODS

The medical records, pathologic reports, and sonographic reports and images of 22 patients with palpable plantar masses were reviewed retrospectively. The sonographic findings were used to characterize those masses with respect to location, shape, size, and echogenicity. Sixteen patients were included in this study because of the proximity of their lesions to the plantar fascia; 6 patients were excluded because their lesions were metatarsophalangeal bursae or ganglia.

RESULTS

The 20 feet examined in the 16 patients studied contained 43 distinct lesions, all located on the surface of the plantar fascia. Thirty-seven (86%) of the 43 were 20 mm long or less. Thirty-seven (86%) of the 43 lesions were elongated; the remaining 6 (14%) were round or oval. Twenty-five (68%) of the 37 elongated lesions had tapered ends, and the other 12 (32%) had rounded ends. Thirty-one (72%) of the 43 lesions were hypoechoic; 25 (81%) of these 31 measured as long as 10 mm. Ten (83%) of the 12 lesions that had mixed echogenicity were longer than 10 mm.

CONCLUSIONS

The lesions of plantar fibromatosis were characteristically located on the surface of the plantar fascia, sagittally elongated, most often less than 20 mm long, fusiform, and hypoechoic. Lesions longer than 10 mm often exhibited mixed echogenicity. The superficial location and appearance should strongly suggest plantar fibromatosis, although careful examination is required to exclude other possibilities, such as sarcoma.

Imaging of musculoskeletal fibromatosis

The musculoskeletal fibromatoses comprise a wide range of lesions with a common histopathologic appearance. They can be divided into two major groups: superficial and deep. The superficial fibromatoses are typically small, slow-growing lesions and include palmar fibromatosis, plantar fibromatosis, juvenile aponeurotic fibroma, and infantile digital fibroma. The deep fibromatoses are commonly large, may grow rapidly, and are more aggressive. They include infantile myofibromatosis, fibromatosis colli, extraabdominal desmoid tumor, and aggressive infantile fibromatosis. Radiographs typically reveal a nonspecific soft-tissue mass, and calcification is common only in juvenile aponeurotic fibroma. Advanced imaging (ultrasonography, computed tomography, and magnetic resonance [MR] imaging) demonstrates lesion extent. Involvement of adjacent structures is common, reflecting the infiltrative growth pattern often seen in these lesions. MR imaging may show characteristic features of prominent low to intermediate signal intensity and bands of low signal intensity representing highly collagenized tissue. However, fibromatoses with less collagen and more cellularity may have nonspecific high signal intensity on T2-weighted images. Local recurrence is frequent after surgical resection due to the aggressive lesion growth. It is important for radiologists to recognize the imaging characteristics of musculoskeletal fibromatoses to help guide the often difficult and protracted therapy and management of these lesions.

Imaging of pediatric foot disorders

Imaging pediatric foot disorders is a challenging task. Optimally exposed and well-positioned radiographs can answer many questions. Because many bones may not be completely ossified, however, CT or MR imaging is often needed to provide additional information to assist in the management of congenital and acquired lesions in the foot.

Magnetic resonance imaging of musculoskeletal soft tissue masses

The role of MR imaging in the evaluation of children with large, deep, or infiltrative soft tissue masses is to characterize and determine the extent of the lesion for treatment planning. There are a small number of soft tissue tumors with MR imaging appearances characteristic enough to allow a specific diagnosis, obviating biopsy. In the remaining cases with nonspecific imaging appearances, MR imaging is used for anatomic staging, but tissue sampling is still required for determining histology and grading.

Cavernous hemangioma behaving like peroneal tenosynovitis

Hemangioma of the tendon sheath is rarely reported. In this case report, a 22-year-old man, who had been seen for peroneal tenosynovitis before (although symptoms remained) was reevaluated. A cavernous hemangioma was located in the peroneal muscle and the tendon. Complete excision was performed.

Foot and ankle sonography

Sonography of the foot and ankle offers many advantages. Currently, sonographic evaluation rivals or exceeds MR imaging for evaluation of tendons, joint and bursal pathology, and specific soft tissue pathology. The advantages of sonographic evaluation provide a strong impetus for applying this modality to imaging of foot and ankle pathology. Those who accept the challenge will have an expanded repertoire to offer in the pursuit of efficient and effective patient care.

Fibromatosis of the plantar fascia: diagnosis and indications for surgical treatment

Plantar fibromatosis is a rare, benign lesion involving the plantar aponeurosis. Eleven patients (13 feet) underwent 24 operations, including local excision, wide excision, or complete plantar fasciectomy. Clinical results were evaluated retrospectively. There were no differences among the subgroups in postoperative complications. Two primary fasciectomies did not recur. Three of six revised fasciectomies, seven of nine wide excisions, and six of seven local excisions recurred. Our results indicate that recurrence of plantar fibromatosis after surgical resection can be reduced by aggressive initial surgical resection.

Autogenous free dermal fat grafts in the surgical approach to plantar fibromatosis

Plantar fibromatosis is a benign disorder of the foot in which there is fibrous tissue infiltration of the plantar aponeurosis and in some cases the overlying skin. Treatment is indicated for pain and functional gait disturbance. Even with wide fascial resection, recurrence with spreading, scarring, and continued discomfort can be a frustrating and difficult problem. Various techniques to lessen recurrence have included split-thickness skin grafting and Marlex mesh placement. However, these procedures have documented problems, including recurrence, foreign-body reaction, scarring, and inadequate soft-tissue coverage. The authors introduce dermal fat grafting following primary excision as a means to minimize recurrence while maintaining the anatomic architecture of the foot and preserving a soft, supple weightbearing surface with minimal scar tissue formation.

Tumors of the foot and ankle: analysis of 196 cases

A retrospective assessment was performed on 196 tumors of the foot and ankle [out of 1786 bone and soft tissue tumor cases, (10.9%)] between March 1986 and March 1996 in the Ankara University Department of Orthopedics and Traumatology Tumor Section. Mean age was 28 years (range 3 to 75 years). Of the 196 foot and ankle tumor cases, 171 (87.2%) were benign, and 25 (12.8%) were malignant. One hundred ninety-four (98.9%) were primary tumors and 2 (1.1%) were metastatic tumors. One hundred thirty-six (69.4%) originated from bone, whereas 60 (30.6%) originated from soft tissue. The most frequent foot and ankle tumors were osteosarcoma among malignant osseous tumors, squamous cell carcinoma among malignant soft tissue lesions, solitary exostosis among benign osseous tumors, and xanthoma and giant cell tumor among benign soft tissue tumors. Mean follow-up time was 21.3 months (12 to 90 months). One hundred forty (71.4%) of the patients underwent various operations while the remaining 56 (28.6%) were treated conservatively. Of the 140 surgical cases, 13 (9.3%) had a recurrence, 3 (2.1%) died, and 124 (88.6%) had a clinical cure. For most of the patients who required surgery, nonaggressive procedures were sufficient while amputations were required for 14 patients.

MR imaging of the symptomatic ankle and foot

MR imaging can play a key role in the evaluation of soft tissues and marrow space of the symptomatic muscle and foot. Diagnostic efficacy is optimized by tailoring the examination to a given problem. Techniques for MR imaging of the foot and ankle are reviewed, the clinical use of MR imaging for examining the structures of the foot and ankle is discussed, and strategies for the integration of MR imaging into the work-up of selected clinical problems are presented.

Magnetic resonance imaging of the musculoskeletal system. II. The hip

Magnetic resonance (MR) imaging of the hip joint and adjacent structures can provide valuable information under many clinical circumstances. After plain radiography, MR imaging is arguably the modality of choice for the detection of osteonecrosis, occult fractures, primary and secondary neoplasms, and in the assessment of some soft tissue abnormalities. The accuracy of MR imaging is dependent on technical factors, such as magnet field strength, surface coils, and sequence selection. Low resolution MR images generally are satisfactory for screening for osteonecrosis and for the evaluation of large bone or soft tissue abnormalities. Tailoring an examination with high resolution images, specialized sequences, or contrast may add useful information, particularly if a detailed evaluation of the joint is desired. Tailoring of the examination by an experienced radiologist requires adequate clinical information, so communication between the referring physician and radiologist is crucial for optimal results. Finally, MR imaging and radiographs are complementary examinations; MR images of the hip should not be interpreted without having recent radiographs available for comparison.

Extraskeletal osteosarcoma: an unusual presentation as tarsal tunnel syndrome

Tarsal tunnel syndrome is a compressive neuropathy caused by intrinsic or extrinsic pressure on the posterior tibial nerve or one of its terminal branches. A mass in association with tarsal tunnel syndrome is most likely a benign tumor or tumor-like condition, although a more malignant tumor must be in the differential diagnosis. We report an unusual case of an extraskeletal osteosarcoma causing tarsal tunnel syndrome.