Tag Archives: Sarcoma

Malignant Fibrous Histiocytoma of the Ankle: A Case Report

by Katherine Neiderer, DPM, MPH1, Jodi Walters, DPM, James Dancho, DPM, FACFAS, Margaret Rennels, MD

The Foot and Ankle Online Journal 5 (3): 1

Malignant fibrous histiocytomas are a rare soft tissue sarcoma that present as indolent tumors in adults. Treatment consists of wide surgical excision. Local recurrence and metastasis is common and patients must be followed for such. We describe the case of a 49 year-old male that presented with a painless “lump” on the front of his ankle. Magnetic resonance imaging showed a 2.6 x 3.5 x 4.3 cm lesion that displayed high intensity on the T2 weighted image. The mass partially encased the tibialis anterior tendon along the medial aspect without invading the body of the tendon. The radiologist suspected a possible malignant neoplasm including synovial sarcoma or giant cell tumor of the tendon sheath. The patient underwent wide excision of the lesion and pathology diagnosed it as malignant fibrous histiocytoma at the anterior ankle. The patient underwent limb sparing surgery without adjuvant chemotherapy and after 2 years of follow-up he has had no recurrence or metastasis.

Key words: Ankle, histiocytoma, malignant fibrous, neoplasms, sarcoma

Accepted: February, 2012
Published: March, 2012

ISSN 1941-6806
doi: 10.3827/faoj.2012.0503.0001

Malignant fibrous histiocytomas (MFH) are the most common soft tissue sarcomas in adults.[1,2] MFH is a rare sarcoma that has no predilection for age and affects both genders equally. In a recent major review of 458 soft tissue sarcomas 11% were in the thigh (the most common location) while 3% were in a distal extremity, either distal to the knee or elbow.[3] Prognosis is correlated to tumor size, depth and location and has been discovered along with gouty tophi and internal fixation.[4-7]

MFH most commonly metastasizes to the lungs and patients should be followed with regular chest radiographs. Recurrence most commonly occurs within 2 years.[3] The treatment consists of primary resection with adjuvant chemotherapy depending on clear margins, depth and lymph node involvement.[8]

Case Report

A 49 year-old gentleman presented to our clinic with a complaint of a “bump” of the anterior medial ankle. The patient noted only minimal discomfort with high topped shoes or work type boots, as they would press directly on the lesion and cause irritation.

Figure 1 Magnetic resonance image of the soft tissue sarcoma. (A) Axial view (B) Longitudinal view.

The lesion had been present for at least one year, and was progressively growing over the past few months. No history of trauma to the area was noted and he had no previous treatment for the lesion.

The medical history was significant for hypertension, sleep apnea and chronic back pain. He had previous umbilical and inguinal hernia repair, a knee arthroscopy and mucocele removal. He denied any other lesions, similar to the one on his foot, anywhere on his body.

On physical examination, there was a round, mildly fluctuant, rubbery golf-ball sized lesion measuring approximately 3.5 cm in diameter along the lateral aspect of the tibialis anterior tendon. The lesion was fairly mobile underneath the skin and transillumination was not possible. It was fairly painless to palpation, leading to the suspicion that the mass was merely irritated by rubbing, or direct pressure from shoegear. There was no surrounding erythema, edema, ulceration or telangiectasias associated with the lesion.

Dorsalis pedis and posterior tibial pulses were palpable and capillary filling time was instantaneous to all digits bilaterally. Tinel’s sign was not elicited on percussion of the mass and sharp-dull, light touch and vibratory sensation were intact. Manual muscle testing was within normal limits and the lesion was noted to translocate with dorsiflexion and plantar flexion of the ankle.

Plain films revealed a large soft tissue rounded density anteriorly and medially overlying the right ankle without any definitive underlying bony abnormality. The patient was then sent for magnetic resonance imaging (MRI) to determine the characteristics of the lesion. The lesion measured 2.6 x 3.5 x 4.3cm and displayed high signal intensity and intense enhancement on the T2 weighted image. (Fig. 1) The mass partially encased the tibialis anterior tendon along the medial aspect without invading the body of the tendon. The radiologist suspected a possible malignant neoplasm due to the intense enhancement and size with differential diagnoses including synovial sarcoma or giant cell tumor of the tendon sheath.

Due to the suspicious nature of the lesion and for surgical planning a core needle biopsy was performed to obtain a clearer diagnosis.

It revealed a relatively cellular sample containing a few somewhat atypical cells with moderate mitotic activity and simple excision was performed. The patient was taken to the operating room and a linear incision was made over the underlying lesion. The lesion was dissected free of the surrounding soft tissue and appeared to be part of the medial branch of the superficial peroneal nerve. The lesion was a yellow/tan color and seemed well encapsulated. The tumor was easily separated from the surrounding tissues, but we were unable to remove it from the nerve, so the nerve had to be sacrificed. The final specimen measured 4.8 x 4.0 x 2.8cm. (Fig. 2)

Figure 2 Gross specimen of soft tissue sarcoma. Although it appeared to be encapsulated, it was not entirely circumscribed and included a transected margin with mitotically active pleomorphic cells.

Gross examination showed slight lobulation of the lesion with focal hemorrhage and no sign of necrosis. Sectioning the specimen revealed a soft, yellow/tan, vaguely lobulated mass with broad, fine, and indiscrete, fibrous septae. Microscopic examination noted an extremely cellular tumor with pleomorphic, mitotically active cells with a mitotic rate of 9 per high powered field with a histologic grade of 3. It was also noted at this time that despite the apparent encapsulation of the tumor, there was transection of the tumor margin and aggressive mitosis in the area that suggested a malignant fibrous histiocytoma of high grade malignancy. (Fig. 3)

Figure 3 Histological assessment reveals an area of pleomorphic tumor with bizarre giant cells and very high mitotic rate including abnormal mitoses (10x power/hematoxylin and eosin stain).

Due to the malignant finding and the incomplete margin a surgical oncologist was consulted. The patient returned to the operating room where a wide local excision of the area was performed. The resected tissue was examined, and no further remnants of the lesion were seen at the margins. A full thickness skin graft of the area was taken from the patient’s thigh and subsequently placed on the wound bed. The patient was kept non-weight bearing in an off-loading boot and subsequent local wound care was performed until complete healing was achieved.

Approximately 5 months later the patient developed a firm, well-demarcated lesion directly adjacent to the previous surgical margin. An MRI revealed a 5.1 x 4.5 x 4.0 mm mass just superficial but abutting the extensor digitorum longus tendons. This lesion was intermediate on T1 and increased on T2, showing a relatively homogenous enhancement. Due to its small nature it was difficult to differentiate between the vessels in the vicinity. Because of the patients’ history he was taken back to the operating room. A 5cm linear incision was made over the mass. The incision was deepened to the level of the superficial peroneal nerve where the mass was visualized within the nerve’s fibers.

It was traced proximally and distally and the entire nerve and lesion were removed in toto. Further inspection of the area revealed no additional lesions. Pathologic exam identified the 1.2 x 0.9 x 0.3cm specimen as a traumatic neuroma of the intermediate branch of the superficial peroneal nerve.

The patient is currently being followed for another pea-sized lesion that was discovered 3 months after his second surgery. It is approximately 2 mm in diameter, is movable and lies just proximal to the second surgical margin along the course of the superficial peroneal nerve. We are following him for any growth in this lesion and do not have any current plans for further surgical intervention.

Due to both of his surgeries the patient has numbness to the dorsum of his foot. He has no residual weakness to any of the muscle groups to his foot and has noticed no other lesions anywhere else on his body, with exception to the foot. The patient has also had serial chest radiographs that have shown no metastases.


Malignant fibrous histiocytoma (MFH), first described in the sixties, is the most common soft tissue sarcoma in adults. It occurs most often in the proximal portions of the extremities including the thigh and buttocks.1 The mean age is 55.8 with a range of 18 to 84 years and equally affects males and females. Most patients present with an asymptomatic tumor that they have noticed in less than a year.[3]

Initial diagnosis is frequently attained by biopsy and MRI is useful in surgical planning. This requires sampling from several areas of the tumor as the histological sample can vary from location to location. There is no specific immunohistochemical marker for MFH, so the diagnosis is usually one of exclusion.8 MFH are classified using immunohistochemical methods for type and grade according to the system of Enzinger and Weiss with the lower grades signifying level of differentiation.[2]

The histology of MFH is variable and several subtypes including storiform-pleomorphic, myxoid, giant cell and inflammatory exist with the storiform-pleomorphic being the most common.[9] All variants may be locally aggressive and surgical excision is required.

Resection achieving tumor-free margins of at least 1-1.5cm is the goal for every case and has been shown to be the strongest risk factor of local recurrence.[8] For patients without clear margins, further surgical resection is preferred before using other treatment modalities.10 Local recurrence has reported to range from 31-38%, with 73-100% occurring within 24 months.[3,8] Postoperative radiation therapy has been shown to decrease local recurrence rate although it has also been associated with increased morbidity due to difficulty in wound healing.[11-13]

Metastasis is a significant concern in patients diagnosed with MFH. Peiper, et al., found of 458 patients 29 developed metastases after a median of 12 months, with the most common, 80%, seeding to the lungs. Prognostic risk factors for distant metastases include tumor size, depth and grade (based on the classification of Enzinger and Weiss). The annual risk of distant metastases was 3.5 times higher in patients with higher grade tumors.[3]

Peiper, et al., recommends chemotherapy to those patients with synchronous pulmonary or regional lymph node metastases after resection of the primary tumor. After 6 courses of chemotherapy, resection of the pulmonary lesion was then performed. Even with aggressive resection and adjuvant chemotherapy, cumulative 5-year survival rates are 65%-80%.[8,14,15]

In conclusion, although MFH is the most common soft tissue sarcoma in adults, it is still a rare diagnosis especially in the distal extremity. In 24 months of follow-up our patient had an additional lesion diagnosed as a traumatic neuroma although approximately 30% of patients will have a second MFH.[3] He has had no evidence of metastasis to this date and is monitored every 3 months with a physical exam and chest radiograph.


1. Enjoji M, Hashimoto H, Tsuneyoshi M, Iwasaki H. Malignant fibrous histiocytoma. A clinicopathologic study of 130 cases. Acta Pathol Jpn 1980 30:727-741. [PubMed]
2. Enzinger F, Weiss S. Soft Tissue Tumors. 4th Ed St. Louis, Mosby, 2001. [Website]
3. Peiper M, Zurakowski D, Knoefel WT, Izbicki JR. Malignant fibrous histiocytoma of the extremities and trunk: An institutional review. Surgery 2004 135: 59-66. [PubMed]
4. Richter H, Vinh TN, Mizel MS, Temple HT. Malignant fibrous histiocytoma associated with remote internal fixation of an ankle fracture. Foot Ankle Int 2006 27: 375-379. [PubMed]
5. Carnero S, Teran P, Trillo E. Malignant fibrous histiocytoma arising in a gouty tophus at the second metacarpophalangeal joint. J Plast Reconstr Aesthet Surg 2006 59:775-778. [PubMed]
6. Gibbs JF, Huang PP, Lee RJ, et al. Malignant fibrous histiocytoma: an institutional review. Cancer Invest 19: 2003 23-27, 2001. [PubMed]
7. Le Doussal V, Coindre JM, Leroux AHacene K, Terrier P, Bui NB, Bonichon F, Collin F, Mandard AM, Contesso G. Prognostic factors for patients with localized primary malignant fibrous histiocytoma: a multicenter study of 216 patients with multivariate analysis. Cancer 1996 77:1823-1830. [PubMed]
8. Issakov J, Kollender Y, Soyfer V, Bickels J, Flusser G, Meller I, Merimsky O. A single-team experience of limb sparing approach in adults with high-grade malignant fibrous histiocytoma. Oncol Rep 2005 14:1071-1076. [PubMed]
9. Fletcher C, Unni, KK and Mertens, F. World Health Organization Classification of Tumours. Pathology and genetics of tumours of soft tissue and bone. Lyon, IARC Press, 2002.[Website]
10. Pezzi CM, Rawlings MS, Jr., Esgro JJ, Pollock RE, Romsdahl MM. Prognostic factors in 227 patients with malignant fibrous histiocytoma. Cancer 1992 69: 2098-2103. [PubMed]
11. Bujko K, Suit HD, Springfield DS, Convery K. Wound healing after preoperative radiation for sarcoma of soft tissues. Surg Gynecol Obstet 1993 176:124-134. [PubMed]
12. Sadoski C, Suit HD, Rosenberg A, Mankin H, Efird J. Preoperative radiation, surgical margins, and local control of extremity sarcomas of soft tissues. J Surg Oncol 1993 52: 223-230. [PubMed]
13. Spiro IJ, Rosenberg AE, Springfield D, Suit H. Combined surgery and radiation therapy for limb preservation in soft tissue sarcoma of the extremity: the Massachusetts General Hospital experience. Cancer Invest 1993 13: 86-95. [PubMed]
14. Bramwell VH. Current perspectives in the management of soft-tissue sarcoma. The role of chemotherapy in multimodality therapy. Can J Surg 1988 31: 390-396. [PubMed]
15. Engellau J. Prognostic factors in soft tissue sarcoma. Tissue microarray for immunostaining, the importance of whole-tumor sections and time-dependence. Acta Orthop Scand 2004 5(Suppl): 2 p preceding table of contents-52, backcover. [PubMed]

Address correspondence to: Katherine Neiderer, DPM,MPH
Email: Katherine.Neiderer@va.gov

1 Southern AZ VA Health Care System, 3601 S. 6th Ave. (2-112) Tucson, AZ  85723

© The Foot and Ankle Online Journal, 2012

Functional Outcomes of Reconstruction for Soft Tissue Sarcomas of the Foot and Ankle

by Emmanuel P. Estrella, MD1 , Edward HM Wang, MD1, MSc, Leo Daniel D. Caro, MD1, Vicente G. Castillo, MD2

The Foot and Ankle Online Journal 2 (3): 2

Objective: We present the functional outcome of six cases of soft tissue sarcomas of the foot and ankle area treated with limb-sparing surgery and soft tissue reconstruction.
Materials and Methods: Six patients with soft tissue sarcoma of the foot and ankle who were treated with limb-sparing surgery and soft tissue reconstructions from 1993 to 2007 were evaluated. On recent follow-up, patients function were scored using a Functional Evaluation Scoring System.
Results: There were three males and three females with an average age of 36.3 years (range, 11-56 years) at the time of surgery. The mean follow-up period was 49 months (range: 4-91 months). The average size of the soft tissue defect was 124.3 cm2 (range, 48-182 cm2). All flaps survived. As of final evaluation, three patients are alive without evidence of disease, two patients are alive with evidence of disease and one patient died of disease. The average Enneking Functional Score for the six patients was 92.8%.
Conclusion: Limb-sparing surgery and soft tissue reconstruction for foot and ankle sarcomas can provide good functional outcomes and will continue to play an important role in the management of these tumors.

Key Words: Sarcoma, foot and ankle, soft tissue reconstruction

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot and Ankle Online Journal (www.faoj.org)

Accepted: February, 2009
Published: March, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0203.0002

Soft tissue sarcomas of the foot and ankle continue to pose a limb and life-threatening disease. In the past, amputation was the resulting outcome when sarcomas of the limb were diagnosed. Advances in reconstructive and limb-sparing surgical techniques have given patients with soft tissue sarcomas of the extremity another option of treatment besides amputation.

The treatment combination of wide resection, adjuvant chemotherapy or radiotherapy and reconstructive surgery has been reported to not increase the incidence of local recurrence, metastasis, or mortality. [1,2, 3]

The foot and ankle is a common location where there is usually a soft tissue defect after sarcoma resection. This is an area difficult to reconstruct because of its unique anatomy and paucity of soft tissues. [4] Various soft tissue reconstructions are described to cover foot and ankle defects either due to trauma or tumor resection. [5-7,8,9,10]

Coverage of these defects should be able to withstand the mechanical stress of weight bearing, as well as to tolerate postoperative chemotherapy or radiotherapy. Local and systemic control and overall function of the individual should also be evaluated after sarcoma surgery.

The objective of this article is to present the functional outcome of six cases of soft tissue sarcoma of the foot and ankle treated with limb-sparing surgery and soft tissue reconstruction.

Patient and Methods

A retrospective review of all soft tissue sarcomas of the foot and ankle treated by limb-sparing surgery, chemotherapy or radiotherapy, and soft tissue reconstruction from 1993 to 2007 was undertaken at the Department of Orthopedics, University of the Philippines-College of Medicine, Philippine General Hospital, Manila, Philippines. Inclusion criteria included all patients with a histologic diagnosis of soft tissue malignant tumor of the foot and ankle area who had limb salvage surgery.

Tumor location, size of defect, reconstructive procedures, histological diagnosis and functional outcome were all critically evaluated. Each patient was contacted for follow-up and was evaluated using The Functional Evaluation of Reconstructive Procedures after Surgical Treatment of Tumors of the Musculoskeletal System for the upper and lower extremity. (Table 1) [11] Specific numerical values of 0 to 5 were assigned for each factor, based on established criteria and are equated with certain levels of achievement or performance. Each score was presented as a percentage of the total.

Table 1 The Revised Musculoskeletal Tumor Society Rating Scale. (Upper extremity-top, Lower extremity-bottom)

The Functional Evaluation of Reconstructive Procedures: Definition of Terms

Pain: The value for pain is determined by the amount and effect of pain on functional activities. Required information is the medication used by the patient for pain relief.

Function: The value for function is determined by the restriction in activities. The required data are the pretreatment occupation and the degree of occupational disability.

Emotional Acceptance: The value for emotional acceptance is determined by the patients’ emotional reaction to or perception of the functional result.

Support: The value for support is determined by the use of external support to compensate for weakness and instability as they affect standing or walking. The required data are the type of support and the frequency of use.

Walking Ability: The value for walking ability is determined by the limitations on walking imposed by the procedure. The required data are the walking distance and limitations in type (inside/outside, uphill, stairs, etc.).

Gait: The value for gait is determined by the presence or absence of gait alterations and its effect on restrictions or function. The required data are the type of gait abnormality and resultant restrictions or deformity.


From 2001 – 2007, we had a total of six patients with soft tissue sarcoma of the foot and ankle area requiring soft tissue reconstruction after tumor resection.

All six patients were treated with wide resection, soft tissue reconstruction and adjuvant chemotherapy or radiotherapy. There were three males and three females. The mean age was 36.3 years at the time of the surgery (range, 11 – 56 years). The mean follow-up period was 49 months (range, 4 – 91 months). All soft tissue reconstructions were done at the time of tumor resection. We had one free flap, four reverse pedicle flaps and one cross leg flap. All flaps survived. The cross leg flap was released after two weeks and was uneventful. All patients are now ambulating independently. The mean time from surgery to independent ambulation was 12.5 weeks (range, 2 – 24 weeks). Pertinent data for each patient is summarized in Table 2.

Table 2  Pertinent data on the six patients.

Three patients (patient no. 1, 4 and 6) had previous resections. As of latest follow-up, five patients are alive. Three are alive without evidence of disease, two are alive with evidence of disease, and one died from disease. There were no local recurrences in five patients. Two patients (no. 1 and 2) developed pulmonary nodules after tumor resection. Both are alive with evidence of disease and recieved chemotherapy with a decrease in the number of pulmonary nodules for both. Another patient (no. 3) had a recurrence on the same extremity where another wide resection was done and a soleus flap was used to cover the defect on the anterior leg. The patient died of disease at 60 months after sural flap.

Case Reports

Case #2

A 56 year-old male presented with an enlarging mass at the lateral aspect of the left heel. He was initially diagnosed to have gouty arthritis. Biopsy showed a high-grade liposarcoma. A wide resection was done and a free rectus abdominis flap was used to cover the soft tissue loss. Three months after the resection and reconstruction, computed tomography (CT) of the chest showed multiple metastatic lesions to the lungs. Patient underwent chemotherapy. The Enneking Functional Score was 29/30. Figure 1 illustrates the late post-operative view at 19 months. (Fig 1)

Figure 1  Case no. 2. This is a late post-operative view of a 56 year-old male after wide resection of a liposarcoma of the ankle region at 19 months after rectus abdominis free muscle flap. The flap remained stable. The patient underwent chemotherapy for pulmonary nodules with a decrease in the number of nodules.

Case #4

A 40 year-old female presented with a recurring mass over the medial, posterior and lateral aspect of the non weight-bearing heel. The mass had been resected previously on both the lateral and medial aspects of the ankle by a previous surgeon. Review of slides and repeat biopsy revealed a fibrosarcoma. Wide excision was done. The final defect was 12 cm x 13 cm (Fig 2A). A reverse sural artery flap was used to cover the defect. Post-operative radiotherapy was uneventful. Independent ambulation was started at 16 weeks. Enneking Functional Score was 27/30. Result at 24 months post-op. (Fig. 2B)


Figures 2A and 2B  Case no.4.  A 40 year-old female presented with a recurring mass over the ankle area.  After wide excision, the final defect was 12 x 13 cm. Histopathology showed a fibrosarcoma. (A)  The sural flap at 48 months after coverage. The flap remained stable. (B)

Case #5

A 43 year-old female with a fungating mass on the medial aspect of the left ankle was diagnosed to have synovial sarcoma on biopsy (Fig.3A). After a wide resection, a 12 x 15 cm soft tissue defect was made. (Fig.3B) The defect was covered with reverse sural flap with medial tibio-talar ligament reconstruction using a plantaris tendon graft. At 17 months follow-up, there was no recurrence of the mass. (Fig. 3C)


Figures 3A, 3B and 3C  Case no. 5.      A 43 year-old female presented with a fungating mass on the medial aspect of the right ankle. Biopsy showed a synovial sarcoma. (A)  After a wide resection, the medial tibio-talar ligament was excised together with the mass and a defect of 12 x 15 cm was evident. The ligament was reconstructed using a plantaris tendon free graft (black arrow). (B)  The reverse flap remained stable at 18 months and there was no recurrence of the tumor. (C)


We reviewed six cases of soft tissue sarcoma of the foot and ankle, treated by limb-sparing surgery and soft tissue reconstruction. The standard of treatment for soft tissue sarcoma of the extremity is limb-sparing surgery, soft tissue reconstruction, and chemotherapy or radiotherapy. Few studies on soft tissue reconstruction for foot and ankle soft tissue sarcoma have been reported. [7,9,12] Likewise, few studies have evaluated their results with an established functional measurement outcome scale. [12] In this small series of four patients with foot and ankle sarcoma treated with limb-sparing surgery and soft tissue reconstruction, we presented the functional outcome of these patients using a standardized outcome measurement scale.

Flap choices for soft tissue reconstruction after tumor ablation are mainly dependent on what is available, what is needed or on the experience of the reconstructive surgeon. Ideally, the same type of tissue should be replaced during reconstruction. Local tissues give the advantage of near tissue typing and avoidance of lengthy microvascular procedures. However, the limited size and arc of rotation precludes their practical use.

Distant flaps are more often required to overcome these limitations. [4] Langstein, et al., [7] reported that free flaps help facilitate limb salvage and that they help preserve meaningful limb function in patients who undergo resection of soft tissue malignancies of the foot. It is possible that the choice of flap is quite different between defects from tumor excision and from traumatic defects. This is because in the event that there would be a local recurrence, reverse pedicled flaps would have increased the contamination of the extremity.

In the case of a reverse sural artery flap, the next surgery that the patient will undergo would probably a below knee amputation in order to have a wider margin of resection.

This is one of the reasons why free flaps have become popular choices for foot and ankle coverage after tumor resection. [7,12] Reverse sural artery flaps are extremely useful and do not need microsurgical anastomosis of vessels. Among the disadvantages of this flap is donor site morbidity, paresthesias on the lateral aspect of the foot, painful neuromas if the sural nerve stump is not buried properly and in some cases, bulkiness of the flap. On the other hand, the sural flap is easier to harvest, has a shorter operative time and can cover a relatively mid-sized defect.

These studies, however, used only independent ambulation as a measure of the functional outcome of their reconstructions. Serletti, et al., [12] evaluated their results with a standard outcome measure.

The present study made use of a standardized functional outcome measurement scale to evaluate reconstructive procedures done on the foot and ankle area after tumor resection. Although the overall scores of our patients are high, the only complaint was the deformity due to early physeal closure and the skin graft donor site of the reconstructive procedure. Serletti, et al., [12] had a similar Functional Outcome Measurement scale and found no difference between pedicled and free flaps in soft tissue reconstruction after tumor excision. However, they tend to favor free flaps to avoid further dissection of the recipient site, and to add vascularity on the already compromised recipient bed.

In summary, successful tumor excision with subsequent reconstructive surgery of foot and ankle sarcomas continues to challenge both the tumor and the reconstructive surgeon.

Careful planning of reconstructive options from the most simple to the more complex should be within the armamentarium of the reconstructive surgeons expertise. We believe that the simplest reconstructive method is still the best technique that will likely produce the best outcome. There will always be instances where a more complex reconstruction will be needed, and with the advances in microsurgery, we are now able to reconstruct larger defects and able to restore function after tumor ablation. By using a standardized functional outcomes assessment for evaluation, we can now redefine our reconstructive options that will best suit our patients in order to produce the best possible results.


1. Lindberg RD, Martin RG, Romsdahl MM, Barkley HT, Jr. Conservative surgery and postoperative radiotherapy in 300 adults with soft tissue sarcomas. Cancer. 47(10): 2391 – 2397, 1981
2. Talbert ML, Zagars GK, Sherman NE, Romsdahl MM. Conservative surgery and radiation therapy for soft tissue sarcoma of the wrist, hand, ankle, and foot. Cancer 66 (12): 2482 – 2491. 1990
3. Wexler AM, Eilber FR, Miller TA. Therapeutic and functional results of limb salvage to treat sarcomas of the forearm and hand. J. Hand Surg. 13A: 292 – 296, 1988.
4. Clark N, Sherman R. Soft-tissue Reconstruction of the Foot and Ankle. Orthopedic Clinics of North America. 24 (3): 489 – 503, 1993.
5. Goldberg JA, Adkins RN, Tsai TM. Microvascular reconstruction of the foot: Weight-bearing patterns, gait analysis, and long-term follow-up. Plast. Reconstr. Surg 92 (5): 904 – 910, 1993.
6. Hidalgo DA, Disa JJ, Cordiero PG, Hu QY. A Review of 716 consecutive free flaps for oncologic surgical defects: Refinement in donor-site selection and technique. Plast. Reconstr. Surg 102 (3): 722 – 732, 1998.
7. 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 109 (1): 152 – 159, 2002.
8. Potparić Z and Rajačić N. Long-term results of weight-bearing foot reconstruction with non-innervated and innervated free flaps. Br J Plast Surg 50: 176 – 181, 1997.
9. Reath DB, Taylor JW. The segmental rectus abdominis free flap for ankle and foot reconstruction. Plast Reconstr Surg 88 (5): 824 – 828, 1991.
10. Weinzweig N, Davies BW. Foot and ankle reconstruction using the radial forearm flap: A review of 25 cases. Plast Reconstr Surg 102 (6): 1999 – 2005, 1998.
11. Enneking F, Dunham W, Gebhardt MC. A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system. Clin. Orthop 286: 241 – 246, 1993.
12. Serletti, JM, Carras AJ, O’Keefe, RJ, Rosier RN. Functional Outcome after soft-tissue reconstruction for limb salvage after sarcoma surgery. Plast Reconstr Surg 102 (5): 1576 – 1583, 1998.

Corresponding Author: Emmanuel P. Estrella, MD
Department of Orthopedics, University of the Philippines-College of Medicine, Philippine General Hospital, Manila Philippines 1000.
Tel. No. (632) 5242203
Fax No. (632) 5260149
Email Add: estee96@yahoo.com

Consultant, Department of Orthopedics, University of the Philippines-College of Medicine, Philippine General Hospital, Manila, Philippines
Consultant, Department of Surgery, University of the Philippines-College of Medicine, Philippine General Hospital, Manila, Philippines

© The Foot and Ankle Online Journal, 2009