Introduction

The arch of the foot has been described as a truss where the plantar fascia (PF) acts as the tensile element. Its role in maintaining the arch has likely been underestimated because it only rarely torn in patients with progressive collapsing foot deformity (PCFD). We hypothesized that elongation of the plantar fascia would be a necessary and sufficient precursor of arch collapse.

Purpose: To review all cases of soft tissue sarcoma of the foot and ankle treated in a specialized musculoskeletal oncology practice over a 15 year period. This was done to gain insight into the presentation, treatments, and outcomes for this rare disease.

Method: 16 patients (mean age at presentation 43, range 15–79, 9 female) were identified from our database of nearly 1000 cases of musculoskeletal tumors (1.6%). 8 were referred following unplanned excision and 3 after local recurrence. The pathologic diagnoses included synovial sarcoma (n=7), clear cell sarcoma (n=2), fibrosarcoma (n=2), and other diagnosis (n=6). AJCC stages were: Ia – 2, IIb – 7, IIc – 1, III – 4, and IV – 2. The tumors were mostly located on the medial (n=7) or dorsal (n=6) aspects of the foot. They were equally distributed among the hindfoot, midfoot, and forefoot.

Results: Treatment consisted of resection in 10, resection and arthrodesis in 3, and amputation in 4 patients. The resections were intralesional in 4 patients, marginal in 7 and wide in 6. Among the 13 limb salvage patients, one needed skin grafting and 9 required free tissue transfers. Radiation therapy was used preoperatively in 5 and post-operatively in 7 cases. Neoadjuvant chemotherapy was given to 2 patients. Followup averaged 6 years (range 2–15). Local recurrence occurred in 2 patients (17%). One was treated with re-excision and one with amputation. Lung metastases occurred in 4 patients. At last followup: 11 of the 17 patients were alive without disease, 2 with disease, and 4 had died of their disease. No local recurrence in primarily treated tumor led to metastasis. Postoperative MSTS 1987 and TESS scores averaged 28 and 90% respectively.

Conclusion: Soft tissue sarcoma of the foot is rare. Surgical treatment is challenging due to the complex anatomy and limited soft tissues. Limb salvage often required accepting intralesional or marginal resections and using free tissue transfer. The addition of radiation therapy yielded an acceptable local control rate and very good functional outcomes. However, the impact this limb salvage approach on mortality is not clear.