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Metatarsal Reconstruction with Use of Free Vascularized Osteomyocutaneous Fibular Grafts Following Resection of Malignant Tumors of the MidfootA Series of Six Cases
Cyril D. Toma, MD1; Martin Dominkus, MD1; Martin Pfeiffer, MD1; Pietro Giovanoli, MD2; Ojan Assadian, MD3; Rainer Kotz, MD1
1 Department of Orthopaedic Surgery, Medical University of Vienna, Währinger Gürtel 18-20, Vienna 1090, Austria. E-mail address for C.D. Toma: cyril.toma@meduniwien.ac.at
2 Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Währinger Gürtel 18-20, Vienna 1090, Austria
3 Department of Hygiene and Medical Microbiology, Medical University of Vienna, Währinger Gürtel 18-20, Vienna 1090, Austria
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Medical University of Vienna, Vienna, Austria

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2007 Jul 01;89(7):1553-1564. doi: 10.2106/JBJS.F.00659
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Background: Bone and soft-tissue sarcomas are uncommon, and their location in the foot is extremely rare. While limb salvage has become the standard of care in the treatment of sarcoma in an extremity, the unique anatomy of the foot presents challenges in reconstructing a viable and functional limb.

Methods: Between 1998 and 2005, we used free microvascularized osteomyocutaneous fibular grafts to reconstruct the defects created after extensive midfoot resection in six consecutive patients with a primary malignant tumor. In all but one patient, the extent of the resection involved at least two metatarsals. The mean age (and standard deviation) at the time of the operation was 30 ± 13 years. At the final follow-up examination, clinical and radiographic evaluations were performed on all patients, and functional outcome and quality of life were assessed with use of the Musculoskeletal Tumor Society score, the American Orthopaedic Foot and Ankle Society Score, and the Toronto Extremity Salvage Score.

Results: The median duration of follow-up was 52.2 months. Limb salvage was achieved in five patients. In the remaining patient, amputation was necessary because of flap failure. Revision surgery was necessary in all patients because of complications (skin ulcerations in three patients; hematoma in two patients; and infection, necrosis of the second toe, and flap necrosis in one patient each). At the time of final follow-up, five patients had satisfactory function and reported good quality of life. The average Musculoskeletal Tumor Society, American Orthopaedic Foot and Ankle Society, and Toronto Extremity Salvage scores were 82%, 75 points, and 92%, respectively. At the time of the final follow-up, five patients had no evidence of disease and one patient had disease.

Conclusions: Following the resection of a malignant tumor in the midfoot, the use of microvascularized osteomyocutaneous fibular grafts has proven to be a successful surgical technique, offering an alternative to ablative surgery with functional restoration of the salvaged limb.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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