Metatarsal reconstruction with use of free vascularized osteomyocutaneous fibular grafts following resection of malignant tumors of the midfoot

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.