The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 89, Issue 7

Scientific Articles | July 01, 2007

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

View Disclosures and Other Information

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

5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Article

Comments (0)

text A A A

Abstract

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.

Figures in this Article

Bone and soft-tissue tumors account for approximately 0.2% and 0.7%, respectively, of all estimated new cancer cases in the United States¹. The foot is an extremely rare location for these tumors, particularly malignant lesions, which in this location comprise <1% of all bone and soft-tissue sarcomas². While osteosarcoma and Ewing sarcoma are the most common malignant bone tumors of the foot^2,3, and arise most frequently in the calcaneus and metatarsal bones³, the most common malignant soft-tissue neoplasms of the foot are synovial sarcoma and Kaposi sarcoma, which predominantly occur on the dorsal aspect and in the digits³.

Limb salvage surgery has become an established alternative to amputation in the treatment of malignant bone and soft-tissue tumors of the extremities. However, the occurrence of these tumors in the distal aspects of the limb continues to be one of the most challenging areas of orthopaedic oncology. While small tumors with a superficial location are easily resected and reconstructed either primarily or with use of local flaps, those that are larger or deeply seated present a challenge for reconstruction. Because of the underlying anatomy of the foot, wide surgical margins in these latter cases will unavoidably be associated with the loss of skin as well as vital neurovascular, osseous, and tendinous structures. Additionally, the lack of locally available soft tissue for reconstruction and closure of the defect created further add to the difficulties of achieving a functionally viable limb. Therefore, amputation has been most commonly considered the only remaining option to achieve local tumor control and a good overall prognosis for the patient. In carefully selected patients, however, the use of free tissue transfer can compensate for the lack of available local tissues for reconstruction and wound closure; the type of flap depends on the nature of the defect created.

Since it was first described by Taylor et al. in 1975⁴, free vascularized fibular transfer has become a standard method used to reconstruct bone defects that result from tumor resection or trauma⁵. In patients with combined massive bone and soft-tissue defects, the free osteomyocutaneous fibular flap, as described by Yoshimura et al.⁶, allows simultaneous skeletal reconstruction and soft-tissue coverage. This procedure has been used successfully for the reconstruction of major defects following surgery for tumors of the mandible^7,8 and long bones^9-14. Likewise, several case reports have described good results after its use in patients with posttraumatic defects of the foot^15-19. To date, the cases of only three patients who had reconstruction with use of free vascularized osteomyocutaneous fibular grafts following resection of a tumor in the midfoot have been reported^20-22.

The goals of this study were to assess the long-term outcome (clinical, functional, and quality of life) and durability of free osteomyocutaneous fibular grafts for the reconstruction of large midfoot defects following wide resection of malignant bone and soft-tissue tumors in a consecutive series of patients for whom the only alternative would have been amputation.

Materials and Methods

Materials and Methods | Results | Discussion | Acknowledgements | References

Patients

Between October 1998 and January 2005, six patients (three male and three female) with primary malignant bone and soft-tissue tumors of the midfoot (five high-grade tumors and one intermediate-grade tumor) were prospectively enrolled in the study and underwent wide tumor resection and reconstruction with use of free vascularized osteomyocutaneous fibular grafts. Patients were included if, on the basis of our clinical judgment, any of the following situations applied: the tumor was too large to perform resection alone but smaller than what normally would require amputation; the first metatarsal alone was involved or more than one metatarsal was involved; or a major functional defect or lack of local tissue for reconstruction was expected following resection. The study was conducted in accordance to the Declaration of Helsinki, and all patients provided written informed consent. In all cases, data collection was performed by a physician (M.P.) who was not involved in the surgical procedure.

The baseline characteristics of the patients are shown in Table I. At the time of the procedure, five patients were skeletally mature and one was skeletally immature; the patients ranged in age from seventeen to fifty-two years (mean and standard deviation, 29 ± 13 years). The histopathological diagnosis was Ewing sarcoma in two patients (Cases 2 and 5), biphasic synovial sarcoma in two patients (Cases 1 and 6), alveolar rhabdomyosarcoma in one patient (Case 4), and intraosseous epithelioid hemangioendothelioma in one patient (Case 3). One patient with synovial sarcoma (Case 1) declined chemotherapy, and the second patient with synovial sarcoma (Case 6) received postoperative chemotherapy according to the soft-tissue sarcoma protocol²³. The patient with multifocal intraosseous epithelioid hemangioendothelioma (Case 3) only received adjuvant chemotherapy. The patient with rhabdomyosarcoma (Case 4) as well as the two patients with Ewing sarcoma (Cases 2 and 5) received neoadjuvant chemotherapy²⁴. None of the patients received preoperative radiation therapy; however, postoperatively, three patients (Cases 2, 3, and 4) received absorbed radiation doses of 30, 45, and 51 Gy, respectively.

View Larger

TABLE I Patient Characteristics and Preoperative Data

				Chemotherapy*
Case	Gender, Age (yr)	Histopathological Findings	Grade	Preop.	Postop.
1	M, 21	Biphasic synovial sarcoma	G2	No	No
2	F, 52	Ewing sarcoma	G3	Doxorubicin	EICESS; EVAIA 75%
3	M, 35	Intraosseous epithelioid hemangioendothelioma	G3	No	Taxane mono; CWSS
4	M, 21	Alveolar rhabdomyosarcoma	G3	CWS 96	CWS 96; HR B
5	F, 17	Ewing sarcoma	G3	Euro Ewing 99; 6× VIDE	Euro Ewing 99; 8× VAI
6	F, 30	Biphasic synovial sarcoma	G3	No

EICESS = European Intergroup Cooperative Ewing's Sarcoma Study; EVAIA = etoposide, vincristine, Adriamycin (doxorubicin), ifosfamide, and actinomycin D (dactinomycin); CWSS = Cooperative Weichteil-Sarkom Studie (Cooperative Soft-Tissue Sarcoma Study—Adult); CWS = Cooperative Weichteilsarkom Studie (German Paediatric Soft-Tissue Sarcoma Study Group); HR B = high-risk arm B of the study; VIDE = vincristine, ifosfamide, doxorubicin, and etoposide; VAI = vincristine, Adriamycin (doxorubicin), and ifosfamide; and Euro Ewing 99 = European Ewing Tumor Working Initiative of National Groups.

Add to My JBJS

TABLE I Patient Characteristics and Preoperative Data

				Chemotherapy*
Case	Gender, Age (yr)	Histopathological Findings	Grade	Preop.	Postop.
1	M, 21	Biphasic synovial sarcoma	G2	No	No
2	F, 52	Ewing sarcoma	G3	Doxorubicin	EICESS; EVAIA 75%
3	M, 35	Intraosseous epithelioid hemangioendothelioma	G3	No	Taxane mono; CWSS
4	M, 21	Alveolar rhabdomyosarcoma	G3	CWS 96	CWS 96; HR B
5	F, 17	Ewing sarcoma	G3	Euro Ewing 99; 6× VIDE	Euro Ewing 99; 8× VAI
6	F, 30	Biphasic synovial sarcoma	G3	No

The operative data for each of the six patients are described in Table II. Tumor resection involved only one metatarsal (the first metatarsal) in one patient (Case 2). In the remaining five patients, two or more metatarsals were resected. In all patients, total or partial resection of other midfoot or hindfoot bones became necessary to achieve wide surgical margins. All patients were subjected to a clinical and radiographic evaluation. The defect volume was estimated with use of the ellipsoid mass formula²⁵ (volume = [p/6] × height × width × depth) and was based on magnetic resonance images acquired immediately prior to surgery. After tumor resection, the resulting defect size was a mean (and standard deviation) of 112.6 ± 38.5 cm³ (range, 62.4 to 156.0 cm³) among the six patients. The mean length of the harvested fibula was 20.7 ± 3.3 cm (range, 15 to 24 cm), and the mean dimension of the skin island was 52.2 ± 7.9 cm² (range, 40 to 60 cm²). The ischemia time averaged 3 ± 1 hours (range, 1.5 to 4.5 hours), and operative time averaged 9 ± 2 hours (range, 6.0 to 11.5 hours). Generally, tourniquet release occurred after two hours; then, after a reperfusion time of thirty minutes, the tourniquet was reapplied, if necessary. All patients had transfusion of one to five units (mean, 3 ± 1.5 units) of whole blood.

View Larger

TABLE II Operative Data

Case	Side	Resection*	Margin	Tumor Volume (cm³)	Skin Paddle (cm²)	Fibular Length (cm)	Ischemia Time (min)	Operation Time (min)
1	R	1st and 2nd metatarsals	Wide	129.6	58	24	270	690
2	R	1st metatarsal	Wide	62.4	40	15	180	600
3	L	3rd and 4th metatarsals and calcaneus (partial)	Wide	143.0	55	23	150	420
4	L	3rd and 4th metatarsals	Wide	114.4	55	22	150	360
5	L	2nd, 3rd, and 4th metatarsals	Wide	70.2	45	19	210	495
6	L	3rd, 4th, and 5th metatarsals	Wide	156.0	60	21	90	585

All resections were performed en bloc.

Add to My JBJS

TABLE II Operative Data

Case	Side	Resection*	Margin	Tumor Volume (cm³)	Skin Paddle (cm²)	Fibular Length (cm)	Ischemia Time (min)	Operation Time (min)
1	R	1st and 2nd metatarsals	Wide	129.6	58	24	270	690
2	R	1st metatarsal	Wide	62.4	40	15	180	600
3	L	3rd and 4th metatarsals and calcaneus (partial)	Wide	143.0	55	23	150	420
4	L	3rd and 4th metatarsals	Wide	114.4	55	22	150	360
5	L	2nd, 3rd, and 4th metatarsals	Wide	70.2	45	19	210	495
6	L	3rd, 4th, and 5th metatarsals	Wide	156.0	60	21	90	585

All resections were performed en bloc.

Evaluation

Postoperatively, clinical and radiographic examinations were performed monthly for the first six months, bimonthly for the remainder of the first year, every three months for the second year, and then every six months thereafter. Functional outcome and quality of life were assessed at regular intervals in concert with oncologic follow-up examinations. Three measurements were used: the Musculoskeletal Tumor Society (MSTS) score, American Orthopaedic Foot and Ankle Society (AOFAS) score, and the Toronto Extremity Salvage (TESS) score. The MSTS score, a seven-item scale rated by the clinician, primarily evaluates clinical measures (pain, joint range of motion, strength, joint stability, joint deformity, overall function, and general acceptance of the treatment); the summary score ranges from 0 to 35 points²⁶, with a percentage rating calculated from the numerical score to allow for comparison of results. The AOFAS score rates pain, function, and alignment in four grading scales (ankle-hindfoot, midfoot, hallux metatarsophalangeal-interphalangeal, and lesser metatarsophalangeal-interphalangeal scales), each with 100 possible points²⁷. The TESS score, a measure of physical disability developed specifically for patients with extremity sarcomas, ranges from 0 to 100, and patients rate the difficulty they experience in performing routine daily activities²⁸.

Operative Technique

Following wide tumor resection, reconstruction was performed with use of a free osteomyocutaneous fibular graft. Graft preparation is performed with the patient placed in a supine position with the knee bent and medialized to facilitate access to the fibula. Dissection is carried out under tourniquet control with use of loop magnification and starts with a linear lateral incision over the fibula paralleling its posterior border. The skin paddle, positioned in the proximal part of the graft, is raised first with the dissection along the lateral intermuscular septum between the soleus and peroneus muscle proceeding to the posterolateral border of the fibula. The muscles of the lateral compartment are retracted anteromedially. The septum between the lateral and anterior compartments is then divided close to the fibula, and the anterior muscles are retracted anteromedially. The extensor hallucis longus and extensor digitorum longus are then separated from the fibula with use of electrocautery, leaving a 5-mm cuff of muscle around the fibula. Once the anterior tibial vessels and deep peroneal nerve have been identified, both structures are protected by retracting them medially. The interosseus membrane is then divided longitudinally close to the fibula to expose the tibialis posterior muscle.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 1-A and Fig. 1-B: Figs. 1-A, 1-B,1-C, 1-D,1-E, 1-F,1-G Case 1, a twenty-one-year-old man with biphasic synovial sarcoma. Fig. 1-A Axial T1-weighted magnetic resonance image shows contact of the tumor with the first and second metatarsals. Fig. 1-B Radiograph of the surgical specimen, depicting the extent of resection (partial resection of the first and second metatarsal bones and total resection of the medial and intermediate cuneiform bones).

The distal osteotomy is performed with an oscillation saw, usually 6 cm proximal to the lateral malleolus. The peroneal vessels are identified distally, ligated, and transected. The fibula is then retracted laterally and slightly posteriorly at the distal osteotomy site. With use of scissors, the fibula is dissected, to include the vascular pedicle and a small muscle cuff of flexor hallucis longus muscle. The proximal osteotomy is then performed, usually about 6 cm distal to the fibular head. The vascular pedicle is then separated from the tibialis posterior muscle, and the peroneal vessels are dissected up to the level of the posterior tibial vessels. Thus, the pedicle is skeletonized, the graft is harvested. The tourniquet is released, and hemostasis is achieved at the donor site.

After separation of the peroneal pedicle, and preceding the transfer of the graft to the recipient site, a transverse incision is performed at the midpoint of the fibula through the soft tissue and periosteum on the antimesenteric border. To expose the bone, the periosteum and soft tissues are swept distally and proximally with use of a periosteal elevator. A retractor is placed to protect the peroneal pedicle, and an osteotomy is performed with use of an oscillating saw under saline solution irrigation. The fibula is then folded to yield a double-barreled fibular graft vascularized by a single pedicle.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 1-C and Fig. 1-D: Figs. 1-C and 1-D Dorsoplantar (Fig. 1-C) and lateral (Fig. 1-D) radiographs made three months postoperatively.

Following transfer of the graft to the recipient site, graft fixation is achieved, depending on the nature of the recipient site, with use of screws, plates, or Kirschner wires. Care must be taken so that the placement of the graft allows a tension-free approximation of the vascular pedicles in order to perform the anastomosis. The return of microcirculation to the skin island is used as a monitor to assess successful circulation of the graft. Skin closure is performed with interrupted sutures.

Statistical Analysis

With the exception of the Anderson-Darling goodness-of-fit test (version 1.71, Analyse-it; Analyse-it Software, Leeds, United Kingdom), all results were calculated with use of Epi Info software (version 3.3, Epi Info 2000; Centers for Disease Control and Prevention, Atlanta, Georgia). Continuous variables were analyzed to evaluate normality of distribution with use of the Anderson-Darling goodness-of-fit test²⁹. When data were normally distributed, they were shown as the mean and standard deviation. When distribution was non-normal, variables were expressed as the median and percentile range (25th and 75th quartile). Discrete variables were expressed as numbers (percentages).

Results

Materials and Methods | Results | Discussion | Acknowledgements | References

Patient outcomes are described in Table III. The median follow-up time for the patients in whom limb salvage was achieved was 52.2 months (25th quartile = 40.3, 75th quartile = 64.7; range, 24.8 to 90.0 months). All but one graft survived. No donor-site morbidity, including peroneal nerve complications, occurred. Revision surgery was necessary in all patients because of complications that included skin ulceration in three patients, hematoma in two patients, and local superficial infection in one patient. The three patients with skin ulceration underwent delayed skin-grafting between the seventh and twelfth postoperative days. Hematoma evacuation was done on the first postoperative day in one patient and on the third postoperative day in the second patient. The local infection was treated with wound débridement and vacuum-assisted closure for seven days combined with antibiotic treatment to allow secondary closure. One patient also had necrosis of the second toe, which required amputation seventeen days after the initial procedure. A Boyd amputation (i.e., amputation of the foot with calcaneotibial arthrodesis)³⁰ was necessary in one patient because of flap necrosis one month after the initial operation. This patient had an anatomical variant with an absent posterior tibial artery and atypical vascular supply to the foot. In the remaining five patients, limb salvage was achieved. Postoperatively, the mean time to full weight-bearing was 5 ± 1.2 months.

View Larger

TABLE III Results*

						AOFAS Score†(Points)					Postoperative Range of Motion‡(deg)
Case	Complications	Revision	Duration of Follow-up (mo)	TESS Score (%)	MSTS Score (%)	A-H	MF	HMI	LTMI
1	Skin ulceration and hematoma	Skin-grafting and hematoma evacuation	90.0	99%	100%	95	80	77	82	10/40
2	Local infection	Débridement and vacuum-assisted sealing	64.7	81%	87%	100	92	95	95	20/45
3	Skin ulceration	Skin-grafting	41.1	95%	67%	78	56	69	74	20/40
4	Hematoma	Hematoma evacuation	40.3	100%	93%	88	83	80	80	20/50
5	Necrosis of 2nd toe and skin ulceration	Amputation of 2nd toe and skin-grafting	24.8	84%	65%	62	66	72	83	10/30
6	Flap necrosis	Boyd amputation	26.1	78%	50%	50	NA	NA	NA	NA

TESS = Toronto Extremity Salvage score, MSTS = Musculoskeletal Tumor Society score, and AOFAS = American Orthopaedic Foot and Ankle Society score. †A-H = ankle-hindfoot scale, MF = midfoot scale, HMI = hallux metatarsophalangeal-interphalangeal scale, and LTMI = lesser toe metatarsophalangeal-interphalangeal scale. ‡Range of motion of the ankle on the involved side given as dorsiflexion/plantar flexion. NA = not applicable.

Add to My JBJS

TABLE III Results*

						AOFAS Score†(Points)					Postoperative Range of Motion‡(deg)
Case	Complications	Revision	Duration of Follow-up (mo)	TESS Score (%)	MSTS Score (%)	A-H	MF	HMI	LTMI
1	Skin ulceration and hematoma	Skin-grafting and hematoma evacuation	90.0	99%	100%	95	80	77	82	10/40
2	Local infection	Débridement and vacuum-assisted sealing	64.7	81%	87%	100	92	95	95	20/45
3	Skin ulceration	Skin-grafting	41.1	95%	67%	78	56	69	74	20/40
4	Hematoma	Hematoma evacuation	40.3	100%	93%	88	83	80	80	20/50
5	Necrosis of 2nd toe and skin ulceration	Amputation of 2nd toe and skin-grafting	24.8	84%	65%	62	66	72	83	10/30
6	Flap necrosis	Boyd amputation	26.1	78%	50%	50	NA	NA	NA	NA

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 1-E and Fig. 1-F: Figs. 1-E and 1-F Dorsoplantar weight-bearing radiograph (Fig. 1-E) and lateral weight-bearing radiograph (Fig. 1-F) made ninety months postoperatively, following removal of osteosynthesis material.

At the end of the first postoperative year, all patients were either pain-free or had only mild discomfort that did not require treatment with analgesics. Additionally, except for some recreational restrictions, all but the one patient who had undergone the amputation had returned to their respective preoperative levels of activity. This patient experienced persistent problems with skin breakdown, leading to the inability to wear a prosthetic limb for prolonged periods of time. As a result, the patient had to discontinue her employment in a retail setting, which required her to be standing and walking most of the time. The average MSTS, AOFAS (midfoot scale), and TESS scores at the time of final follow-up for the patients in whom limb salvage was achieved were 82%, 75 points, and 92%, respectively. The results on all four AOFAS scales are shown in Table III. At the time of the final follow-up, all patients were alive, five with no evidence of disease and one with disease. Clinical examples of the reconstruction are shown in Figures 1-A and 1-B, 1-C and 1-D, 1-E and 1-F, 1-G, 2-A, 2-B, 2-C and 2-D, 2-E, 2-F.

Discussion

Materials and Methods | Results | Discussion | Acknowledgements | References

Limb salvage has become the standard of care in the treatment of extremity sarcomas. Bone and soft-tissue cancers are rare, accounting for <1% of all estimated new cases of cancer¹ and <1% of such malignancies occur in the foot². Because of this extremely low incidence in the foot, there is limited information about limb salvage in this location. This study represents what we believe is the largest series to date that specifically addresses the clinical outcome of vascularized fibular grafts in the foot following tumor resection.

Adequate local control is one of the most important factors in the treatment of primary malignant bone and soft-tissue tumors. Before the advent of sophisticated imaging techniques and adjuvant and neoadjuvant medical and radiotherapeutic treatment protocols, amputation was the most reliable method to achieve tumor-free margins and to prolong patient survival. Magnetic resonance imaging now permits a more accurate preoperative determination of tumor extent. In concert with improved surgical techniques, wide tumor resection and limb salvage have become the treatment of choice in tumors of the extremities. Although at least nine anatomic foot compartments have been described in the literature^31,32, true compartmentalization is not present in an oncologic sense, except for the metatarsal rays³³. Therefore, limb salvage for tumors of the foot is difficult to achieve and requires detailed preoperative assessment to determine the extent of the tumor. Depending on the size and location of the tumor in the foot, wide surgical margins can be achieved in the majority of patients by either ray resection or midtarsal amputation. Because these ablative procedures along with new treatment modalities have greatly improved patient survival, a fundamental goal of treatment is improved quality of life, including a functional and durable reconstruction of the musculoskeletal defect^34-36.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 1-G: Photograph of foot made at clinical examination ninety months postoperatively.

In patients with combined massive bone and soft-tissue defects, a vascularized free fibular graft with a monitoring flap allows simultaneous skeletal reconstruction and soft-tissue coverage. Wide surgical margins in the foot result in the loss of functionality because of the resection of substantial neurovascular, osseous, and tendinous structures as well as skin. Furthermore, the lack of locally available soft tissue for reconstruction adds to the complexity of attaining a functionally viable limb. In carefully selected patients, however, the use of free tissue transfer can compensate for the paucity of available local tissues for reconstruction and wound closure³⁷.

Prior to this report, only three separate case reports on patients who had reconstruction of metatarsal bones with use of free vascularized fibular grafts following a tumor resection had been published^20-22.

For over thirty years, composite flaps containing bone have been used successfully for major reconstruction following surgery for tumors of the mandible^7,8. However, their introduction into orthopaedic oncology evolved gradually^4,6,38-41. In 1973, Ueba and Fujikawa carried out the first free vascularized fibular graft transfer for reconstruction of major long-bone defects³⁸. However, because they did not report their results until 1983, Taylor et al.⁴, who reported on this procedure in 1975, are generally credited as being the first to have described this technique. It was only after the third report by Yoshimura et al.⁶, in 1983, describing the use of a free vascularized fibular graft with a myocutaneous monitoring flap that this method was successfully performed by other surgeons in patients with massive combined bone and soft-tissue defects following wide resection of long-bone tumors^5,9-14. In long bones, autogenous fibular grafts have been widely used to reconstruct osseous defects following tumor resection. Initially, nonvascularized strut grafts were used⁴². However, growth and adaptive changes were not possible because of the lack of viability of such grafts. To overcome this, vascularized pedicles were introduced. Subsequently, because of their success, vascularized pedicles became the preferred option, offering immediate restoration of blood supply, higher resistance to infection, rapid incorporation and osseous union, and progressive bone hypertrophy in response to loading.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 2-A: Figs. 2-A,2-B,2-C, 2-D, 2-E, 2-F Case 4. A twenty-one-year-old man with alveolar rhabdomyosarcoma of the left foot. Fig. 2-A Preoperative lateral radiograph.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 2-B: Preoperative T1-weighted magnetic resonance image.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 2-C and Fig. 2-D: Fig. 2-C Radiograph of the surgical specimen, depicting the extent of the resection (total resection of the third and fourth metatarsals and partial resection of the cuboid and cuneiform bone). Fig. 2-D Dorsoplantar radiograph made one day postoperatively.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 2-E: Figs. 2-E and2-F Radiographs made forty months postoperatively. Fig. 2-E Dorsoplantar weight-bearing radiographs of the involved (left) side (note osteosynthesis breakage and remodeling of the metatarsal heads) and noninvolved (right) side.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 2-F: Lateral weight-bearing radiograph of the involved (left) side and of the noninvolved (right) side.

Reconstructive options for midfoot resections include the use of bone allografts, vascularized autografts (such as the iliac crest or the fibula), and free vascularized musculocutaneous or septocutaneous flaps⁴³. The fibula, however, has distinct advantages compared with the iliac crest for the reconstruction of large defects in the midfoot because it is similar in shape and diameter to the metatarsals, it is easily accessible, and it has low donor-site morbidity. Also, because the fibula is highly vascularized and composed primarily of cortical bone, it can thicken to withstand and adapt to the stresses of weight-bearing, and yet it is thin enough to accommodate regular shoe wear, thus providing a functional reconstruction. Although radiation therapy and chemotherapy compromise autograft incorporation following oncologic resection, the vascularized fibula provides the potential for prompt bone-healing. Additionally, because it is a straight cortical bone, its length is generally sufficient to reconstruct large defects, and a skin island can also be transferred allowing for simultaneous reconstruction of soft-tissue defects^9,44. Unlike other donor bones, the fibula can be "folded." The folded or double-barreled fibula has been successfully used for femoral and humeral reconstruction^45-47 as well as mandibular reconstruction^48-50. Exner et al.²¹ and Mochizuki et al.²² were the first to use double-barreled vascularized osteomyocutaneous fibular grafts for foot salvage following resection of malignant midfoot tumors. In the foot, the advantage of the folded fibula is that two bones are formed out of one. The harvested free fibular graft is divided at its midpoint without dividing its vascular pedicle, thus producing two vascularized bones with one set of anastomoses⁴⁶. The folded fibula is ideal when reconstruction of two or more metatarsals is required.

Limb salvage is not an option for all malignant tumors of the foot. In our series, all tumors were located on the dorsal aspect of the foot. Because of the stress of weight-bearing, coverage after wide excision of a tumor localized to the plantar surface of the foot can be a problem⁵¹. Furthermore, intact sensation, especially on the plantar surface, is vital for foot function and skin integrity⁵². Therefore, we can only recommend the described operative technique in cases where the tumor has a dorsal extension. If reconstruction of the foot after wide resection does not ultimately allow for functionality, or continues to require an inordinate amount of medical care, then sparing the foot would be burdensome to the patient. In these cases, amputation followed by prosthetic fitting would be the optimal choice. A midfoot tumor that is small in size and/or restricted to bone and involves only one of the second through fifth metatarsals can generally be managed by ray resection alone. The first ray is a critical structure in the formation of the tripod of the foot enabling normal gait^53-55. During the stance and toe-off phases of the gait cycle, load-bearing focuses on the first ray⁵⁴. A total force of about 119% of body weight acts on the first metatarsal head⁵⁵, making it the most heavily loaded ray of the forefoot. Because of the importance of the first ray for weight-bearing and propulsion, resection of the first ray alone would alter the static and dynamic structure of the foot causing pathologic weight-bearing of the lesser metatarsals and leading to painful overuse syndromes, including transfer metatarsalgia and osteoarthritis of the tarsometatarsal joints⁵⁵. Therefore, our technique has valuable application for patients with tumor involvement of the first metatarsal alone.

One of our patients had flap failure, which was attributed to the absence of the posterior tibial artery and an atypical vascular supply to the foot. As a result, it would be tempting to conclude that preoperative angiograms should be performed on a routine basis to assess the presence of anatomical variations of the vessels at the donor and recipient sites. However, investigators evaluating large series of vascularized fibular grafts have come to different conclusions on this subject, with one group recommending preoperative angiograms⁵⁶ and another group recommending them only if pulses are not symmetrically palpable⁵⁷.

In summary, the occurrence of malignant bone or soft-tissue tumors in the midfoot should not be considered an absolute indication for amputation. Our results encourage the use of free vascularized osteomyocutaneous fibular grafts following midfoot resection in carefully selected patients with bone or soft-tissue tumors, offering an alternative to ablative surgery. The major advantage of this approach is simultaneous reconstruction of combined bone, soft-tissue, and skin defects, thereby providing a functional restoration of the salvaged limb. We believe this method deserves consideration as well for patients in whom posttraumatic or postinfectious foot defects may lead to amputation or loss of function in the salvaged limb. ?

Acknowledgements

Materials and Methods | Results | Discussion | Acknowledgements | References

Note: The authors thank Kazuo Mochizuki, MD, for his suggestion to perform the studied operative technique in our patients and for his review of the manuscript, Farshid Abdolvahab, MD, and Bernd Kubista, MD, for their assistance with data collection, and Lorraine R. Baer, PharmD, and Mag. Teresa Zettl for their assistance in the preparation of the manuscript.

References

Materials and Methods | Results | Discussion | Acknowledgements | References

American Cancer Society. Cancer facts and figures 2006. Atlanta: American Cancer Society; 2006. Available at: .
http://www.cancer.org/downloads/STT/CAFF2006PWSecured.pdf

Zeytoonjian T, Mankin HJ, Gebhardt MC, Hornicek FJ. Distal lower extremity sarcomas: frequency of occurrence and patient survival rate. Foot Ankle Int.2004;25: 325-30.25325 2004 [PubMed]

Bakotic B, Huvos AG. Tumors of the bones of the feet: the clinicopathologic features of 150 cases. J Foot Ankle Surg.2001;40: 277-86.40277 2001 [CrossRef]

Taylor GI, Miller GD, Ham FJ. The free vascularized bone graft. A clinical extension of microvascular techniques. Plast Reconstr Surg.1975;55: 533-44.55533 1975 [PubMed][CrossRef]

Han CS, Word MB, Bishop AT, Cooney WP 3rd. Vascularized bone transfer. J Bone Joint Surg Am.1992;74: 1441-9.741441 1992 [PubMed]

Yoshimura M, Shimamura K, Iwai Y, Yamauchi S, Ueno T. Free vascularized fibular transplant. A new method for monitoring circulation of the grafted fibula. J Bone Joint Surg Am.1983;65: 1295-301.651295 1983

Conley J. Use of composite flaps containing bone for major repairs in the head and neck. Plast Reconstr Surg.1972;49: 522-6.49522 1972 [CrossRef]

Ketchum LD, Masters FW, Robinson DW. Mandibular reconstruction using a composite island rib flap. Case report. Plast Reconstr Surg.1974;53: 471-6.53471 1974 [PubMed][CrossRef]

Minami A, Usui M, Ogino T, Minami M. Simultaneous reconstruction of bone and skin defects by a free fibular graft with a skin flap. Microsurgery.1986;7: 38-45.738 1986 [PubMed][CrossRef]

Jupiter JB, Bour CJ, May JW Jr. The reconstruction of defects in the femoral shaft with vascularized transfers of fibular bone. J Bone Joint Surg Am.1987;69: 365-74.69365 1987 [PubMed]

de Boer HH, Wood MB, Hermans J. Reconstruction of large skeletal defects by vascularized fibula transfer. Factors that influenced the outcome of union in 62 cases. Int Orthop.1990;14: 121-8.14121 1990

El-Gammal TA, El-Sayed A, Kotb MM. Microsurgical reconstruction of lower limb bone defects following tumor resection using vascularized fibula osteoseptocutaneous flap. Microsurgery.2002;22: 193-8.22193 2002 [PubMed][CrossRef]

El-Gammal TA, El-Sayed A, Kotb MM. Reconstruction of lower limb bone defects after sarcoma resection in children and adolescents using free vascularized fibular transfer. J Pediatr Orthop Br.2003;12: 233-43.12233 2003

Zaretski A, Amir A, Meller I, Leshem D, Kollender Y, Barnea Y, Bickels J, Shpitzer T, Ad-El D, Gur E. Free fibula long bone reconstruction in orthopedic oncology: a surgical algorithm for reconstructive options. Plast Reconstr Surg.2004;113: 1989-2000.1131989 2004 [PubMed][CrossRef]

Rajacic N, Ebrahim MK, Grgurinovic S, Starovic B. Foot reconstruction using vascularised fibula. Br J Plast Surg.1993;46: 317-21.46317 1993 [CrossRef]

Chung YK, Hong JP, Kang SY, Kim SW, Tark KC. A vascularized osteocutaneous fibular free flap for reconstruction of a complex injury of the foot. Ann Plast Surg.2000;45: 541-3.45541 2000 [PubMed][CrossRef]

Yazar S, Lin CH, Wei FC. One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities. Plast Reconstr Surg.2004;114: 1457-66.1141457 2004 [PubMed][CrossRef]

Celikoz B, Sengezer M, Isik S, Turegun M, Deveci M, Duman H, Acikel C, Nisanci M, Ozturk S. Subacute reconstruction of lower leg and foot defects due to high velocity-high energy injuries caused by gunshots, missiles, and land mines. Microsurgery.2005;25: 3-15.253 2005 [PubMed][CrossRef]

Santanelli F, Paolini G, Grippaudo FR. Microsurgical reconstruction of wide simple and compound foot defects. Minerva Chir.2002;57: 289-93.57289 2002 [PubMed]

Tomczak RL, Johnson RE, Hamilton J. The treatment of monostotic fibrous dysplasia of the first metatarsal with free vascularized fibular bone grafts. J Foot Ankle Surg.1993;32: 604-10.32604 1993 [PubMed]

Exner GU, Jacob HA, Middendorp J. Reconstruction on the first and second metatarsals with free microvascular fibular bone graft after resection of a Ewing sarcoma. J Pediatr Orthop B.1998;7: 239-42.7239 1998 [CrossRef]

Mochizuki K, Ishii Y, Yamaguchi H, Minabe T. Vascularized tissue transplantation in limb salvage procedures for musculoskeletal sarcoma. J Orthop Surg.1999;7: 23-32.723 1999

Koscielniak E, Harms D, Henze G, Jurgens H, Gadner H, Herbst M, Klingebiel T, Schmidt BF, Morgan M, Knietig R, Treuner J. Results of treatment for soft tissue sarcoma in childhood and adolescence: a final report of the German Cooperative Soft Tissue Sarcoma Study CWS-86. J Clin Oncol.1999;17: 3706-19.173706 1999 [PubMed]

Jürgens H, Exner U, Gadner H, Harms D, Michaelis J, Sauer R, Treuner J, Voûte T, Winkelmann W, Winkler K, Göbel U. Multidisciplinary treatment of primary Ewing's sarcoma of bone. A 6-year experience of a European Cooperative Trial. Cancer.1988;61: 23-32.6123 1988 [PubMed][CrossRef]

Bieling P, Rehan N, Winkler P, Helmke K, Maas R, Fuchs N, Bielack S, Heise U, Jürgens H, Treuner J, Romanowski R, Exner U, Kotz R, Winkler K. Tumor size and prognosis in aggressively treated osteosarcoma. J Clin Oncol.1996;14: 848-58.14848 1996 [PubMed]

Enneking WF. Modification of the system for functional evaluation of surgical management of musculoskeletal tumors. In: Enneking WF, editor. Limb salvage in musculoskeletal oncology. New York: Churchill Livingstone; 1987. p 626-39.626 1987

Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int.1994;15: 349-53.15349 1994

Davis AM, Wright JG, Williams JI, Bombardier C, Griffin A, Bell RS. Development of a measure of physical function for patients with bone and soft tissue sarcoma. Qual Life Res.1996;5: 508-16.5508 1996 [CrossRef]

Stephens MA. EDF statistics for goodness of fit and some comparisons. J Am Stat Assoc.1974;69: 730-7.69730 1974 [CrossRef]

Boyd HB. Amputation of the foot with calcaneotibial arthrodesis. J Bone Joint Surg.1939;21: 997-1000.21997 1939

Guyton GP, Shearman CM, Saltzman CL. The compartments of the foot revisited. Rethinking the validity of cadaver infusion experiments. J Bone Joint Surg Br.2001;83: 245-9.83245 2001 [PubMed][CrossRef]

Fulkerson E, Razi A, Tejwani N. Review: acute compartment syndrome of the foot. Foot Ankle Int.2003;24: 180-7.24180 2003 [PubMed]

Enneking WF. Musculoskeletal tumor surgery. New York: Churchill Livingstone; 1983. Foot and Ankle. p 719-41.719 1983

Pisters PW. Combined modality treatment of extremity soft tissue sarcomas. Ann Surg Oncol.1998;5: 464-72.5464 1998 [PubMed][CrossRef]

Papagelopoulos PJ, Mavrogenis AF, Badekas A, Sim FH. Foot malignancies: a multidisciplinary approach. Foot Ankle Clin.2003;8: 751-63.8751 2003 [PubMed][CrossRef]

Bach AD, Kopp J, Stark GB, Horch RE. The versatility of the free osteocutaneous fibula flap in the reconstruction of extremities after sarcoma resection. World J Surg Oncol.2004;2: 22.222 2004 [PubMed][CrossRef]

Langstein HN, Chang DW, Miller MJ, Evans GR, Reece GP, Kroll SS, Robb GL. Limb salvage for soft-tissue malignancies of the foot: an evaluation of free-tissue transfer. Plast Reconstr Surg.2002;109: 152-9.109152 2002 [CrossRef]

Ueba Y, Fujikawa S. Nine years follow-up of a vascularized fibula graft in neurofibromatosis: a case report and literature review. Jpn J Orthop Traumatol.1983;26: 595-600.26595 1983

Bruncke HJ, Furnas DW, Gordon L, Achauer BM. Free osteocutaneous flap from a rib to the tibia. Plast Reconstr Surg.1977;59: 799-804.59799 1977 [CrossRef]

Weiland AJ, Daniel RK. Microvascular anastomoses for bone grafts in the treatment of massive defects in bone. J Bone Joint Surg Am.1979;61: 98-104.6198 1979 [PubMed]

Pho RW. Free vascularised fibular transplant for replacement of the lower radius. J Bone Joint Surg Br.1979;61: 362-5.61362 1979

Mendicino SS. Giant cell tumor of the first metatarsal bone en bloc resection with autogenous middle fibular strut graft. J Foot Ankle Surg.1993;32: 405-10.32405 1993 [PubMed]

Smith DJ Jr, Loewenstein PW, Bennett JE. Surgical options in the repair of lower-extremity soft-tissue wounds. J Trauma.1982;22: 374-81.22374 1982 [CrossRef]

Harrison DH. The osteocutaneous free fibular graft. J Bone Joint Surg Br.1986;68: 804-7.68804 1986 [PubMed]

Jones NF, Swartz WM, Mears DC, Jupiter JB, Grossman A. The "double barrel" free vascularized fibular bone graft. Plast Reconstr Surg.1988:81: 378-85.81378 1988 [PubMed][CrossRef]

O'Brien BM, Gumley GJ, Dooley BJ, Pribaz JJ. Folded free vascularized fibula transfer. Plast Reconstr Surg.1988;82: 311-8.82311 1988 [CrossRef]

Muramatsu K, Ihara K, Shigetomi M, Kawai S. Femoral reconstruction by single, folded or double free vascularised fibular grafts. Br J Plast Surg.2004;57: 550-5.57550 2004 [PubMed][CrossRef]

Horiuchi K, Hattori A, Inada I, Kamibayashi T, Sugimura M, Yajima H, Tamai S. Mandibular reconstruction using the double barrel fibular graft. Microsurgery.1995;16: 450-4.16450 1995 [PubMed][CrossRef]

Bahr W, Stoll P, Wachter R. Use of the "double barrel" free vascularized fibula in mandibular reconstruction. J Oral Maxillofac Surg.1998;56: 38-44.5638 1998 [PubMed][CrossRef]

Munoz Guerra MF, Gias LN, Rodriguez Campo FJ, Diaz Gonzalez FJ. Vascularized free fibular flap for mandibular reconstruction: a report of 26 cases. J Oral Maxillofac Surg.2001;59: 140-4.59140 2001 [PubMed][CrossRef]

Fortin PT, Freiberg AA, Rees R, Sondak VK, Johnson TM. Malignant melanoma of the foot and ankle. J Bone Joint Surg Am.1995;77: 1396-403.771396 1995

Selch MT, Kopald KH, Ferreiro GA, Mirra JM, Parker RG, Eilber FR. Limb salvage therapy for soft tissue sarcomas of the foot. Int J Radiat Oncol Biol Phys.1990;19: 41-8.1941 1990 [PubMed][CrossRef]

Maskill JD, Bohay DR, Anderson JG. First ray injuries. Foot Ankle Clin.2006;11: 143-63, ix-x.11143 2006 [PubMed][CrossRef]

Lakin RC, DeGnore LT, Pienkowski D. Contact mechanics of normal tarsometatarsal joints. J Bone Joint Surg Am.2001;83: 520-8.83520 2001

Jacob HA. Forces acting in the forefoot during normal gait—an estimate. Clin Biomech (Bristol, Avon).2001;16: 783-92.16783 2001 [CrossRef]

Kessler P, Wiltfang J, Schultze-Mosgau S, Lethaus B, Greess H, Neukam FW. The role of angiography in the lower extremity using free vascularized fibular transplants for mandibular reconstruction. J Craniomaxillofac Surg.2001;29: 332-6.29332 2001 [PubMed]

Lutz BS, Wei FC, Ng SH, Chen IH, Chen SH. Routine donor leg angiography before vascularized free fibula transplantation is not necessary: a prospective study in 120 clinical cases. Plast Reconstr Surg.1999;103: 121-7.103121 1999 [PubMed][CrossRef]

Username

Password

Access for Patients

Forgot Password?

Have a subscription to the print edition?

Not a Subscriber?

Buy this Article

Get online access for 30 days for $35

New to JBJS?

Subscribe to the online edition for 30 days for $75

Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.

Have a subscription to the print edition?

Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.

Activate your online account now

Forgot your password?

Enter your username and email address. We'll send you a reminder to the email address on record.

Username:*

Email Address:*

Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
by your institution, please contact you librarian or administrator for username and password information. Institutional
administrators, to reset your institution's master username or password, please contact subs@jbjs.org

References

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.

CME Activities Associated with This Article

Submit a Comment

Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

* = Required Field

Comment Author(s) * (if multiple authors, separate names by comma)

Example: John Doe

Affiliation & Institution*

Comment Title*

Comment*

Cancel

Print
PDF
Email

Recipient(s) will receive an email with a link (good for 5 days) to 'Metatarsal Reconstruction with Use of Free Vascularized Osteomyocutaneous Fibular Grafts Following Resection of Malignant Tumors of the Midfoot: A Series of Six Cases'.
Your Name:*
Example: John Doe

Email Address:* CC Me:
Enter your valid email address. Example: jdoe@example.com

Recipient's Email Address:*

Separate multiple email address with semi-colons (up to 5).

Subject:* 's The Journal of Bone & Joint Surgery: 'Metatarsal Reconstruction with Use of Free Vascularized Osteomyocutaneous Fibular Grafts Following Resection of Malignant Tumors of the Midfoot: A Series of Six Cases'
Subject for your email.

Message:

(Optional, message will truncate at 1000 characters)

Processing your request... Please Wait...

Copyright © in the material you requested is held by The Journal of Bone & Joint Surgery, Inc. (unless otherwise noted). This email ability is provided as a courtesy, and by using it you agree that that you are requesting the material solely for personal, non-commercial use, and that it is subject to Journal of Bone & Joint Surgery, Inc.'s Terms of Use. The information provided in order to email this topic will not be used to send unsolicited email, nor will it be furnished to third parties. Please refer to The Journal of Bone & Joint Surgery Inc.'s Privacy Policy for further information.

Copyright © The Journal of Bone & Joint Surgery Inc. All rights reserved.
Share
Get Citation

Cyril D. Toma, Martin Dominkus, Martin Pfeiffer, Pietro Giovanoli, Ojan Assadian, Rainer Kotz; Metatarsal Reconstruction with Use of Free Vascularized Osteomyocutaneous Fibular Grafts Following Resection of Malignant Tumors of the MidfootA Series of Six Cases. The Journal of Bone & Joint Surgery. 2007 Jul;89(7):1553-1564.

Download citation file:

RIS (Zotero)

EndNote

BibTex

Medlars

ProCite

RefWorks

Reference Manager

Copyright © The Journal of Bone and Joint Surgery, Inc.
Rights & Permissions
Article Alerts

Processing your request... Please Wait.
Submit a Comment
Data Supplements

JBJS Case Connector