J. David Pitcher

Metastatic Skeletal Disease of the Foot: Case Reports and Literature Review

Background: Metastatic disease of the skeleton occurs in at least 20% to 30% of patients with malignancy, but metastasis to the foot and hand (acrometastasis) is extremely rare (0.007% to 0.3%). Metastases to the feet are even rarer and have been reported in half to one-third the rate for hand metastases. Failure to recognize these lesions has led to delayed diagnosis and/or inappropriate treatment. The purpose of this report is to highlight the clinical and radiologic features that aid in the diagnosis and potential treatment of this condition along with a pertinent review of the literature. Materials and Methods: In a retrospective review of 694 patients with histologically proven metastatic skeletal disease (January 1988 to January 2007), 14 cases of metastatic lesions to the foot were identified. Results: The most frequent primary site was in the genito-urinary system in eight patients and the most common bones involved were the calcaneus and the talus in six patients each. All patients died after a mean survival of 14.8 (range, 1 to 54) months after diagnosis of metastases. Conclusion: Although metastatic disease of the foot is rare, it should be considered in the diagnosis of a painful foot, especially if suspicious radiographic changes are present in an older patient. The common primary sites are the genito-urinary, lungs, breast, and the colo-rectum. Treatment is usually palliative to reduce pain and maintain function.

Soft tissue sarcomas of the foot and ankle: impact of unplanned excision, limb salvage, and multimodality therapy.

Background: Foot and ankle sarcomas have historically been treated with amputation because of the difficulty in achieving local disease control and maintaining a functional foot. Potential opportunities for limb salvage may be further compromised by unplanned excisions. Materials and Methods: We reviewed 52 consecutive patients with soft tissue sarcomas of the foot and ankle and analyzed the impact of planned versus unplanned initial excision, limb salvage, and multimodality therapy on treatment and outcomes. Results: Unplanned excisions had been performed in 29 (55.8%) patients. Limb salvage was performed in 38 patients, with 14 requiring free soft tissue transfers. At an average followup of 99 (range, 24 to 216) months, the 5-year overall survival estimate was 76.3%. Although not statistically significant, we noted clinically relevant potential differences in local recurrence-free, disease-free, and oncologic survival between the planned and unplanned excision groups. Seven patients (13.5%) had a local recurrence, five of these following an unplanned excision. Functional scores averaged 83.2% for all patients which were similar between planned versus unplanned and amputation versus limb salvage groups. Significantly more patients with unplanned excisions required free flaps for limb salvage (p = 0.017) and received adjuvant radiotherapy (p = 0.0004). Conclusion: Unplanned surgery for soft tissue sarcomas of the foot and ankle often results in the need for more aggressive surgery and/or adjuvant radiotherapy and may impact oncologic outcomes, but does not necessarily portend worse functional outcomes. Multi-modal therapy and judicious use of soft tissue flap reconstruction allows limb salvage in most patients with favorable outcomes.

Salvage of failed massive allograft reconstruction with endoprosthesis.

A subset of osteoarticular allograft reconstructions after tumor resection ultimately will fail in patients achieving long-term survival. There are several alternative surgical approaches to revising these reconstructions. We retrospectively evaluated the outcome of 20 patients who had allograft reconstruction with a modular endoprosthesis. All patients had a failed massive allograft (average length, 15.7 cm) after tumor resection about the shoulder and knee. The reasons for original allograft failure were fracture (14 patients), infection (five patients), and both (one patient). Followup of the patients averaged 159.7 months (range, 63-293 months) after allograft reconstruction and 77 months (range, 24-234 months) after endoprosthetic revision. The average number of operative procedures each patient had was 4.1 (range, 2-15 procedures). Two patients had amputations for resistant periprosthetic infections. A successful revision procedure was accomplished in 80% of the patients, and 90% of the patients retained functional limbs at recent followup. The predicted 5-, 10-, and 15-year survivals were 92%, 55% and 28% respectively. Musculoskeletal Tumor Society scores averaged 76% (range, 60-93.3%). When used to salvage massive allograft failure from infection and fractures, endoprosthetic revision preserves limb function with minimal complications. Level of Evidence: Therapeutic study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Squamous cell carcinoma of the foot.

Background: Squamous cell carcinomas (SCC) of the foot are relatively common, but have been infrequently reported in the orthopaedic literature. Materials and Methods: Twelve patients with SCC of the foot treated at a single institution from 1998 to 2005 were studied retrospectively with regard to risk factors for the disease, treatment, and functional and oncologic outcomes. The mean duration of postoperative followup was 43 (range, 24 to 105) months. Results: Eight of the 12 patients had identifiable risk factors for SCC. Inadequate or inappropriate procedures had been previously performed in eight of the 12 cases, requiring more aggressive definitive treatment in at least four cases. Definitive operative treatment consisted of wide excision (4 patients), partial or complete toe amputation (4), partial foot amputation (3), and transtibial amputation (1). Two patients developed local recurrence of disease, and both ultimately required Syme amputations for local control. One patient with local recurrence died of metastatic disease and the other 11 patients are alive without evident disease. Musculoskeletal Tumor Society functional scores averaged 90 and were good or excellent in nine of the 11 surviving patients. Conclusion: Squamous cell carcinomas of the foot are likely underreported and frequently subject to inappropriate initial treatment. Most patients have identifiable risk factors for SCC that can aid in formulating an appropriate differential diagnosis. Despite frequent suboptimal initial treatment, most patients are candidates for complete or partial limb salvage, with generally good oncologic and functional outcomes expected.

Cystic hygroma of the arm: a case report and review of the literature.

Abstract Cystic hygromas arising outside of the cervicofacial, thoracic, and abdominal areas are extremely rare. Detailed descriptions of this lesion, along with its MRI findings, in the extremities are lacking in the literature. The following case report describes such a lesion occurring in the arm.

Ganglioneuromas of the sacrum–a report of two cases with radiologic–pathologic correlation

Ganglioneuromas are rare, benign, well-differentiated, slow-growing tumors, composed of ganglion cells and Schwann cells. Ganglioneuromas are derived from the neural crest cells and can arise anywhere from the base of the skull to the pelvis. We present and discuss the clinicopathologic and radiographic features of two patients with ganglioneuroma arising from the sacrum, a rare anatomic location.

Accessory Soleus Presenting as a Posterior Ankle Mass: A Case Report and Literature Review

The accessory soleus muscle is a rare anatomic variant that may present as a mass in the posterior-medial aspect of the ankle in young adults. The presence of such a mass may result in pain and difficulty with running. We present a case of accessory soleus muscle in a 21-year-old soldier and review the literature. We present the first magnetic resonance imaging studies in the American literature, to our knowledge, of this unusual anomaly.

Benign multicystic peritoneal mesothelioma in a cesarean-section scar presenting as a fungating mass

We report a case of a benign multicystic mesothelioma, which presented as a fungating mass through the anterior abdominal wall and arose in a cesarean-section scar without direct peritoneal involvement. A wide local excision was done and the diagnosis was confirmed by histopathology and immunohistochemistry. The postoperative course was uneventful and the patient is asymptomatic at 3 years’ follow-up. Although a history of previous abdominal surgery has been reported in a patient with benign multicystic mesothelioma, to the best of our knowledge, there is no report of a benign multicystic mesothelioma arising in a cesarean-section scar or presentation as a fungating skin mass. This unusual presentation may point to a traumatic or inflammatory etiology, although seeding of the wound during the previous surgeries is a more likely postulate. A pertinent review of the literature on benign multicystic mesothelioma is also presented.

Low-grade central osteosarcoma of the foot and ankle: Radiographic and pathologic features in two patients: Case report and literature review

Low-grade central osteosarcoma (LGCOS), an uncommon form of osteosarcoma, rarely occurs in the foot and ankle and generally is difficult to distinguish from benign bone lesions. The differential diagnosis of LGCOS includes fibrous dysplasia, desmoplastic fibroma, nonossifying fibroma, chondrosarcoma, chondromyxoid fibroma, simple bone cyst, and subacute osteomyelitis. Its radiographic differentiation from benign lytic bone lesions is based on its often subtle but almost invariably present findings of aggressiveness, such as cortical invasion, periosteal new bone formation, or the presence of osseous matrix. Accurate diagnosis is important because of its high rate of recurrence, often as a higher grade sarcoma, if it is not excised widely. We reviewed the radiographic studies, the pathologic material, and the clinical history of two patients. This study has been submitted for Instituional Review Board Approval.

The Radiographic Morphology of Foot Deformities in Patients with Fibrodysplasia Ossificans Progressiva

Background: The most consistent deformities that allow early diagnosis of fibrodysplasia ossificans progressiva are the presence of bilateral short first rays and hallux valgus. The purpose of this study was to describe the radiographic features observed in the feet of patients with fibrodysplasia ossificans progressiva. Methods: The radiographs of 26 feet (15 patients with fibrodysplasia ossificans progressiva) were reviewed to evaluate the radiographic changes that occur in the first ray. Variables analyzed were the hallux valgus (HV) angle, the distal metatarsal articular (DMA) angle, the proximal phalangeal articular (PPA) angle, the intermetatarsal (IM) angle, ratio of the lengths of the first and second metatarsal lengths (MT1:MT2), and the first and second ray length ratio. The length ratios were then subtracted from similar ratios in radiographs of age- and gender-matched normal patients previously reported. Results: The proximal phalanx was consistently shortened but morphologically dissimilar from subject to subject. Asymmetry was noted in some patients with bilateral radiographs. The mean HV angle was 28 degrees, and the mean IM angle was 10 degrees. The mean DMA angle was 33 degrees, and the mean PPA angle was 14 degrees. The MT1:MT2 ratio was 0.89, and the mean first ray to second ray length ratio was 0.87. The mean of the differences in the MT1:MT2 and first and second ray length ratios in patients with fibrodysplasia ossificans progressiva compared to the normal controls were 0.05 and 0.01, respectively. Fusion occurred between the abnormal tibial epiphysis of the proximal phalanx and metatarsal head with advancing age, and 68% of the metatarsal heads were fused with the abnormal proximal phalangeal epiphysis. Conclusions: Foot pathology in patients with fibrodysplasia ossificans progressiva is variable but consistently involves an abnormality of the tibial aspect of the proximal phalangeal epiphysis of the hallux. This results in the clinical observation of hallux valgus in these patients. The first metatarsal is consistently shortened, and fusion between the epiphysis of the abnormal proximal phalanx and the shortened first metatarsal head occurs with advancing age.