Ankle and Foot Bone Tumors



Ankle and Foot Bone Tumors


Robert J. Steffner

Raffi S. Avedian

Sahitya K. Denduluri





ANATOMY



  • There is minimal soft tissue coverage in the ankle and foot. Surgical resections requiring skin excision and/or placement of bulk cortical allograft should consider the need for soft tissue coverage to minimize the risk of infection and nonunion.


  • When functional deficit and donor site morbidity for free tissue transfer are anticipated, consideration should be given to below-knee amputation. Patients may recover faster and have better long-term function with a prosthesis.1


PATIENT HISTORY AND PHYSICAL FINDINGS



  • It is important to ask patients about prior trauma and infections at the site of concern.


  • A clinical history focusing on the duration of symptoms, presence of night pain, and systemic symptoms can help delineate benign from malignant etiologies.


  • Physical exam focuses on the presence of prior incisions, skin mobility over the tumor, and neurovascular status distal to the site of tumor involvement.


IMAGING



  • Obtain plain radiographs of the involved site.


  • Perform an MRI scan with and without contrast to assess the extent of tumor and involvement of critical structures such as tendons, nerves, and vessels. Also perform a whole bone MRI to demonstrate the extent of intramedullary involvement of tumor and look for skip lesions.


  • Make every effort to obtain any prior imaging for comparison.


  • Quality of imaging and the interpretation of imaging are vital for surgical planning.


  • Upon diagnosis of a primary bone malignancy, staging studies are performed to assess for regional or distant metastatic disease. This generally requires a chest CT and whole body bone scan.




NONOPERATIVE MANAGEMENT



  • Benign-appearing lesions that are not causing symptoms can be followed with serial imaging. Stable appearance on serial imaging studies supports nonsurgical management.


SURGICAL MANAGEMENT



  • Symptomatic benign bone tumors and benign but active bone tumors are most often treated with intralesional curettage or marginal excision.


  • Malignant bone tumors may require multidisciplinary management with the possible need for chemotherapy and/or radiation in addition to surgery.


  • In nonmetastatic or oligometastatic primary bone cancer, the goal of surgery is resection with negative margins.


Preoperative Planning



  • If needed, size-matched fresh-frozen allografts should be coordinated from an appropriate vendor well ahead of time. The surgeon should assure that the graft has been delivered to the hospital. It is wise to have a back-up allograft available.


  • Bone cuts are planned off T1-sequences from the first MRI scan. It is important to appreciate any soft tissue extensions and to look for fat planes around neurovascular structures to make sure they are free from tumor. Determination of appropriate margins is based on the specific diagnosis and the type of tissue at the level of resection.


Positioning



  • Positioning depends on tumor location. Please see the “Techniques” section below.


Approach



  • An oncologic approach allows for a limited tissue biopsy while maintaining the possibility of wide resection in the setting of a malignant diagnosis. If oncologic principles are followed, the majority of patients will be eligible for limb salvage.2


Nov 24, 2019 | Posted by in Aesthetic plastic surgery | Comments Off on Ankle and Foot Bone Tumors
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