Minimally Invasive Reconstructive Surgery for Complex Oncologic Foot Defects in Children

Abstract

Sir: Recently Iorio et al.1 and previously Lee et al.2 evaluated the clinical results of the lower extremity reconstruction by using Integra, a bioengineered dermal matrix, in diabetic patients and burn injury, respectively. Iorio reviewed the use in 121 wounds and concluded that Integra is a viable option for reconstruction in diabetic patient at low risk for amputation.1 Analyzing nine complex burn injuries, Lee et al. observed Integra to be a stable wound coverage that should be considered as part of the lower extremity wound coverage algorithm.2 These authors' experience in the therapeutic challenge for the preservation of functional limb length showed that Integra provides durable coverage of vital lower extremity structures. We believe this is also a key reconstructive option in pediatric oncology patients, in which this matrix allows salvage of extremities that might be amputated or require prolonged staged procedures. We would like to report our experience with a plantar rhabdomyosarcoma in a child in which the use of Integra has allowed us to improve young patient care, with a minimally invasive reconstruction after extensive demolition in the same operative session.3 A left plantar massive neoplasm (10 × 3.7 cm) involving the flexor digitorum brevis was determined by biopsy to be alveolar rhabdomyosarcoma. Surgical resection of the tumor with total exeresis of the flexor digitorum brevis, plantar aponeurosis, and skin by en bloc radical soft-tissue excision was performed, with exposition of the flexor hallucis longus tendon, the flexor digitorum longus tendons, and the quadratus plantar muscle (Fig. 1). The wide and deep defect was reconstructed by using a single layer of Integra measuring 12.5 × 10 cm that we folded to obtain a width of 5 cm and greater thickness. By using Integra, we protect the exposed muscle-tendon structures and provide immediate wound closure, and the heel was reconstructed by suture plans. Sixteen days postoperatively, Integra was biodegraded and in its place was neodermis with full restoration of the thickness and complete preservation of the exposed structures (Fig. 2). Skin grafting restored epidermal coverage after definitive histologic assessment determined it to be tumor-free. The morphologic functional recovery of the salvaged limb was complete, with restoration of the internal longitudinal arch and normal plantar and finger flexion. At 36-month follow-up, the patient had no evidence of disease; he had regained satisfactory function and reported good quality of life, no functional limitations, and normal walking and gait. (See Video, Supplemental Digital Content 1, which demonstrates that walking is unhindered and gait is normal, https://links.lww.com/PRS/A367.)Fig. 1.: En bloc radical soft-tissue excision of 12.5 × 5 × 3 cm and exposition of the flexor hallucis longus tendon, the flexor digitorum longus tendons, and the quadratus plantar muscle (structures responsible for plantar and finger flexion).Fig. 2.: Neodermis induced by Integra.Video.: Supplemental Digital Content 1 demonstrates that walking is unhindered and gait is normal, https://links.lww.com/PRS/A367.Rhabdomyosarcoma is a highly malignant tumor and the most common soft-tissue sarcoma in children. Localization in the foot is rare. The unique anatomy of the foot presents challenges in reconstructing a viable and functional limb.4 Reconstructive surgery in children with cancer is complex and often requires multiple procedures. Free flap surgery is the most common reconstruction5 and usually results in excellent outcomes. Drawbacks are longer operative time, invasiveness and complexity of the procedure, large skin incisions, donor-site morbidity, possible flap loss or necrosis of the distal portion with delayed healing, cosmetic problems, and patient intolerance. An exclusion criterion can be situations of specific risk, such as very aggressive histologic subtypes (i.e., alveolar), where the final reconstruction should be deferred pending definitive histologic assessment. Reconstruction using Integra has allowed us to override the above-mentioned drawbacks with complete recovery. Thus, Integra following resection of a malignant plantar tumor has proven to be a successful technique, offering an important alternative to the traditional reconstructive choices. The technique is easy and minimally invasive, with operative time reduced. It avoids major complications and wide donor-site scarring. It is ideal for immediate wound closure pending final histologic assessment, simplifying wound care and improving patient tolerance, with good healing and rapid recovery. DISCLOSURE The authors have no financial interests to declare in relation to the content of this communication. No outside funding was received. Maria Giuseppina Onesti, M.D. Maria Ida Rizzo, M.D. Anna Maria Spagnoli, M.D. Nicolò Scuderi, M.D. Department of Plastic Surgery La Sapienza University of Rome Rome, Italy