Functional Outcome in Limb-Salvage Surgery for Soft Tissue Tumours of the Foot and Ankle

Purpose. This paper describes the functional and oncologic outcome of 30 cases (in 29 patients) treated with limb-salvage surgery for localized soft tissue sarcoma (STS) or fibromatosis of the foot and ankle. Subjects. Patients were eligible for the study if they had a STS or fibromatosis in the distal one-third of the tibia or the foot such that ablative surgery would require a below-knee amputation; had no metastatic disease at presentation; and had a minimum of 2 years of follow-up. Methods. Function was prospectively evaluated using the modified Enneking functional rating scale (MSTS) at 3, 6, 12 months and at most recent follow-up. Premorbid work status and change following surgery, lower leg oedema, and the use of orthotics and ambulatory aids were consecutively assessed. Tumour characteristics were recorded and patients were followed for systemic and local recurrence. Results. Thirty-six consecutive cases were managed by a multi-disciplinary sarcoma team. Six patients underwent below-knee amputation due to extensive local disease, while 30 cases were treated with limb-salvage surgery. Of the patients treated with limb salvage, there were 19 high-grade sarcomas, five low-grade sarcomas and six cases of fibromatosis. Microscopically negative margins were achieved in 26 of 30 cases. Ten cases required bone excision, and eight patients needed free vascularized tissue flaps. Twenty-five patients received adjuvant radiotherapy. Seven patients had post-operative complications. At mean follow-up of 52 months (range 24–109 months), four patients had developed systemic recurrence. There was one local recurrence in a patient with fibromatosis, while another patient with fibromatosis developed recurrence a considerable distance from the surgical and radiation field. Mean scores on the MSTS were 27.5 (range 11–35), 29.9 (range 13–35), 31.4 (range 17–35) and 31.0 (range 13–35) at 3, 6, 12 months and at most recent follow-up, respectively. Eighty-five per cent of the patients scored good to excellent at their last visit. Twelve patients reported persistent pain with two continuing to require occasional narcotics. Six had persistent mild oedema. Four required shoe modifications and three continue to use a cane. Six patients were unable to return to their premorbid employment with the majority of these previously employed in jobs requiring physical labour or long periods of either standing or walking. Discussion. Thirty of 36 patients (83%) presenting with foot and ankle STS or fibromatosis were candidates for limb preservation. With excellent local control and good functional outcome demonstrated in this study, limb salvage should be a primary goal in the management of selected patients with STS and fibromatosis of the foot and ankle.


Introduction
T he treatment of soft tissue sarcom a (STS) in the extremity has changed m arkedly in the past 30 years. H istorically, surgical excision by am putation w as the m ainstay of m anagement of STS of the extremities. Subsequently, Sim on and Enneking showed that achieving local control at the prim ary site by surgical m eans alone required radical local resection or am putation. 1 Although im provem ents in local recurrence rates w ere observed with radical surgery, the extent of resection often dram atically altered lim b function. More recently, advances in radiological im aging and the addition of irradiation as adjuvant therapy following local excision have resulted in acceptable rates of both local recurrence and extremity function. 2± 9 C om bined m anagement with irradiation and surgery has therefore becom e the treatm ent of choice in resectable extremity STS. 2± 6,9 . Correspondence to: R. S. Bell Aggressive ® bromatosis is a non-encapsulated benign m esenchym al neoplastic process that exhibits local tumour spread and invasio n w ithout respect for tissue planes. Both the disease and its treatm ent can lead to signi® cant functional m orbidity. Although ® brom atosis does not m etastasize, the invasiveness of this tum our is sim ilar to the local behaviour of STS 10± l2 and there is a high risk of recurrence following surgical excision alone. T he optim al therapy for ® brom atosis is controversial and treatment recom m endations vary from a radical surgical resection to observation. W hen eradication of the ® brom atosis is warranted due to the functional m orbidity of the local disease, com bined wide surgical excision and adjuvant radiotherapy offers the best chance of success. 10± 12 In this situation, the surgical m anagement parallels that of extrem ity ST S.
The goal of achieving both com plete surgical excision of a ST S or ® brom atosis while m aintaining adequate lim b function is particularly dif® cult in the foot and ankle region. Soft tissue tum ours of the foot and ankle are rare and the m ajority of soft tissue lesions in this location are benign, accounting for the high rate of initial sim ple excision of unsuspected sarcom as and a delay in referral to a sarcom a centre. l3± l5 The weight-bearing dem ands of the distal lower extremity, the lim itations of soft tissue coverage and the complexity of underlying vital structures are factors that com plicate the planning of lim bsalvage surgery. W hile the literature emphasizes the oncologic outcom e in the m anagem ent of tumours of the foot, there is little inform ation describing the functional and psychological outcom e, or the im pact of com plications, following lim b salvage of the foot and ankle. 3,4,6,7,l6± 18 . These functional issues are especially im portant in the m anagement of foot and ankle ST S, 19± 20 since below-knee amputation and prosthetic ® tting provides excellent function and versatility in daily activities as well as the capacity to engage in recreational activities. 21,22 The functional im pact of lim b-salva ge surgery versus am putation was ® rst addressed by Sugarbaker. 20 D espite a variety of m ethodological problems w ith that study, it was apparent that both oncological and functional outcom e need to be addressed to evaluate lim b preservation in the m anagement of soft tissue tumours. T he purpose of this study is to describe the m anagement strategy that w e employed in a group of patients with localized ST S or ® brom atosis in the foot and ankle, and to em phasize the functional status of the patients who underwent lim b salvage.

S ubjects and m ethods
F rom 1987 to 1994, 36 consecutive cases m eeting the following inclusion criteria were m anaged by a m ulti-disciplinary sarcom a group: (1) histologically con® rm ed STS or ® brom atosis prior to de® nitive m anagem ent; (2) location of the lesion in the distal one-third of the tibia or the foot such that ablative surgery w ould require a below -knee am putation; (3) no m etastatic disease on pre-operative system ic staging; (4) m inim um prospective follow -up of 24 m onths.
Patients with both de novo and locally recurrent disease were included.
Initial patient w ork-up included chest radiography, chest computed tom ography (CT ), technetium bone scan w hen indicated, plain ® lm s of the distal low er extrem ity, and axial im aging of the lesion with either CT or m agnetic resonance im aging (M RI). Local staging of the extent of the disease identi® ed patients eligible for limb-salvag e surgery, while cases that were deemed unresectable were offered below-knee am putation. C riteria used to assess resectability included clinical and radiological assessm ent of tum our extent and invasion of vital structures, previous surgical incisions and prior m anagem ent. All pathological diagnosis and assessm ent of surgical margins were perform ed by experienced m usculoskeletal oncological pathologists. T he surgical m argin w as assessed using both the operative note and pathology report. H istological evidence of disease at the inked surface of the specimen was considered to be a positive m argin. 2,3 The decision for adjuvant chem otherapy or radiotherapy was m ade by the m ulti-disciplinary team.
Adjuvant radiotherapy w as adm inistered using either pre-operative or post-operative protocols. Pre-operative treatment entailed 50 Gy in 25 fractions over 5 weeks. In the early period of the study, m ost patients received a post-operative boost of 16 Gy in eight fractions com mencing after wound healing. However, in the later stages the boost w as restricted to those cases in which the m argins of the resected specimen were m icroscopically positive at the time of surgery. A full course of post-operative radiotherapy consisted of 66 Gy in 33 fractions com mencing after wound healing. T his technique has been described in previous publications. 5,23 Of the 36 cases (in 35 patients) presenting with STS or ® brom atosis in the distal one-third of the leg or foot, four were unresectable and underwent below -knee am putation. T he rem aining 32 cases were initially deemed appropriate for lim bsalvage surgery, but tw o patients were found at the time of surgery to be unresectable with adequate margins. F ollowing further discussion, these two patients were treated w ith below -knee am putation.
D ata collected included: patient demographics and sym ptom s; work status; pre-operative functional status; neurovascular involvem ent; and tum our location, size, histological type and grade. Sarcoma histological grade was designated as low -or highgrade m alignancy 24 to allow consistency for comparison betw een other studies. 2,3,7 . Chemotherapy and radiotherapy treatment and surgical procedures and reconstruction characteristics were recorded. O ncologic outcom e with respect to local and system ic recurrence, as well as survival, were docum ented. The 30 cases (in 29 patients) treated w ith lim b preservation were followed prospectively and functional outcom e was docum ented by a single physiotherapist at 3, 6, 12 m onths post-operatively, and at m ost recent visit to evaluate sym ptom s, w ork status, oedema, 25 use of w alking aids and the param eters necessary to score the m odi® ed M usculoskeletal T um our Society (M STS) functional rating scale. 26 . T he m axim um score is 35 and the seven items included are: pain, range of m otion, strength, stability, deform ity, functional activity and emotional acceptance of their treatment. W ork demands were classi® ed into three groups: (1) a job requiring heavy physical activity was de® ned as requiring the m ajority of time standing or w alking with perform ance of strenuous activities, e.g. lifting, clim bing; (2) dom estic work that also required spending a large proportion of time standing but did not require strenuous physical activities; (3) a non-p hysical occupation encom passed jobs requiring less than 50% total time standing or walking, e.g. desk work.
D ue to the sm all num ber of patients, descriptive analysis was used for dem ographic and tum ourrelated variables. Repeated m easures analysis of varian ce was used to analyze functional status as m easured by the M ST S.

Limb-salvage group
Patient characteristics. Twenty-nine patients underwent lim b-salva ge surgery, with one patient having bilateral extensive ® brom atosis and requiring surgery on each foot. Sixteen patients were fem ales and 13 patients were m ales, w ith a m ean age of 51 years (range 15± 78, SD 5 18.5). M ean follow-up was 52 m onths (range 24± 109, SD 5 23.2).
At the time of presentation, 20 patients (67%) had undergone either an excisional biopsy or had a local recurrence. Only three patients (10% ) were de novo presentations, of which two were ® brom atosis and the rem aining seven w ere seen following incisional biopsy perform ed elsewhere. In the m ajority of patients referred following an excisional biopsy the diagnosis of STS w as unsuspected at the time of initial surgery.
Two patients were treated w ith chem otherapy prior to referral to the m ulti-disciplinary sarcom a group. O ne patient had an em bryonal rhabdom yosarcom a with m etastatic disease at presentation and underwent thoracotom y following chem otherapy. She w as free of system ic disease 2 years later and underwent lim b salvage with curative intent. She rem ains alive with no evidence of disease (AN ED ) 85 months after lim b salvage. T he second patient received one course of chem otherapy prior to referral but locally progressed.
Tum our characteristics. There w ere 19 high-grade sarcom as, ® ve low-grade sarcomas and six ® brom atoses. Histological types are shown in T able 1, with m alignant ® brous histiocytoma (M FH ) m ost frequent in our series (23% ), followed by ® brosarcom a in four patients (13% ). Synovial sarcom a was seen in only one of the limb-salvag e patients. T he m ean tum our size was 6.4 cm and 17 of the lesions (57%) were greater than 5 cm in m axim um diameter. Four lesions were larger than 10 cm com prising tw o ® brom atoses, an M F H and a sclerosing liposarcoma.
Thirteen of the lesions were situated around the ankle, nine tumours were located on the dorsum of the foot and seven lesions w ere on the plantar aspect of the foot; one sarcom a involved the great toe. Four of the ® brom atoses were on the plantar aspect of the foot with the remaining two involving the lateral ankle. Lesions w ere classi® ed as sub-fascial if they w ere initially subcutaneous but at time of presentation had gross sub-fasc ial disease or de® nite evidence of sub-fascial extension from previous surgery. T wenty-eight (93% ) of the lesions were sub-fasc ial at time of presentation and seventeen w ere invasive , with direct involvem ent of bone (present in 10 cases), nerve or vessel (present in nine cases).
Limb-salvage procedure and adjuvant radiotherapy. Lim b salvage was performed by en bloc surgery with rem oval of a cuff of norm al tissue around the lesion in 29 cases. In one case of ® brom atosis, an intralesional resection was perform ed. The m ean resection specimen size was 11.3 cm and bone resection was required in 10 patients. Reconstruction with a structural bone graft was carried out in three patients. D orsalis pedis or posterior tibialis vessel resection w as performed in seven patients and the super® cial peroneal nerve was sacri® ced in four. F ree m usclē ap reconstruction utilized the rectus in ® ve patients, the latissim us dorsi in tw o patients and the gracilis in one. Split thickness skin graft (STSG) alone w as used in seven patients.
Tw enty-® ve patients received adjuvant radiotherapy consisting of pre-operative treatm ent in eight patients, pre-operative plus post-operative boost in ® ve cases, and post-operative treatment only in 12 cases. In the eight patients treated w ith free¯ap reconstructions, adjuvant radiotherapy was used pre-operatively in two patients, pre-operatively plus post-operative boost in three patients, and postoperatively only in three. Twenty-six patients had negative m icroscopic m argins, of whom 21 patients received adjuvant radiotherapy. Each of the three patients with m icroscopically positive resection m argins and the one patient with ® brom atosis treated by intralesional surgery received adjuvant radiotherapy.
Post-op erative complications. Post-operative com plications com prised four m ajor wound problem s, two m inor wound infections and one pulm onary em bolus. T he four m ajor wound infections required debridem ent and healed by secondary intention. One of these w as in a patient w ith a foot lesion who received post-operative radiotherapy to an STSG w hich becam e secondarily infected.
Five patients suffered fractures within the high-dose irradiation ® eld 4± 19 m onths follow ing surgery. Three of these patients had required partial bone resection. There were tw o patients requiring partial resections of the anterior tibia with ankle arthrodesis, one w ith resection of the anterior talus, and one patient who underwent partial resection of the ® bula en bloc w ith the tum our. T he ® fth patient with a fracture had a drill hole passed through the ® rst m etatarsal as part of her reconstructive procedure. The fractures healed in all but one patient who suffered a fracture through the anterior tibial bony defect. T his patient went on to chronic nonunion despite bone grafting and ultimately required below-knee am putation.
Functional outcom e. C om plete functional results were available on 27 of the 30 consecutive cases (90% ) that underw ent lim b-salva ge surgery ( Table  2). The rem aining three patients do not live close to our centre and are followed near their hom e. Six patients were unable to return to their prem orbid em ployment. Three of six patients previously employed as labourers were unable to return to w ork. This contrasts with the less physicallydemanding occupations in w hich 88% were able to return to their premorbid level of activity. N o patients rem aining off work at one year after surgery were able to return to their original employm ent.
After one year, no patient had an im provem ent in their overall functional rating, or im provem ent in the clinical m easurem ents of the M ST S functional evaluation (motion, stability, deform ity and strength). Tw o patients, however, reported an improvem ent in their functional activity at most recent follow-up which m ay suggest an adaptation to physical disab ility. O nly three patients required an am bulatory aid at m ost recent assessm ent com pared to nine patients at 3 m onths after surgery. T wo patients continue to use an orthosis, and tw o use a rocker bottom sole on their footwear. At 3 months after lim b-salva ge surgery, 56% of patients had som e degree of lower lim b oedema. At m ost recent assessm ent, six patients (22%)  continued to have m ild leg oedem a ( Table 2). T hirteen patients reported persistent pain, with the m ajority having m ild pain without need for narcotic agents but two patients continued to require occasional narcotic use for severe pain.
Oncologic outcom e. At m ean follow-up of 52 m onths (24± 109 m onths), there were four system ic recurrences in patients with high-grade tumours, one local recurrence in a patient with ® brom atosis and one regional recurrence in a second patient with ® bromatosis ( Table 3). The single patient experiencing local recurrence had undergone lim b salvage for a sm all ( , 5 cm ), de novo sym ptom atic ® bromatosis on the plantar asp ect of the foot. T he lesion w as resected with w ide m argins and no adjuvant radiotherapy was used; recurrent ® brom atosis developed 14 m onths after treatment. T his patient has had no further intervention and clinically is stable w ith a good functional result. T he patient w ho developed regional recurrence had undergone below-knee am putation for com plications of lim b salvage and subsequently developed recurrence in her stum p. T his recurrence w as far rem oved from the original lesion and m ore than 10 cm outside the radiation ® eld used 3 years before. She is currently disease free follow ing above-knee am putation and functioning w ith a prosthesis. Three patients are dead of disease and one patient is alive with pulm onary m etastasis. All four patients had high-grade lesions and developed system ic recurrence less than one year following surgery (m ean 7 m onths). T hree of the lesions showed invasive properties, either encasing neurovascular structures or eroding into adjacent bone. In total, 24 (80%) patients rem ain disease free and 25 patients are currently alive with no evidence of disease.

Amputation group
Six patients (four m ales and two fem ales) with a m ean age of 52 years had below-knee am putations for local disease; they had no m etastatic disease on pre-operative staging. Four patients were preoperatively considered unresectable due to the extensive involvem ent of local vital structures, while the other two were found at the time of surgery to be unresectable and underwent am putation shortly thereafter. This group consisted of ® ve high-grade lesions and one low-grade ST S (Table 1). T wo sarcom as presented de novo, one follow ing incisional biopsy, and three after attem pted excisional biopsy and tum our contam ination throughout the foot. T hree lesions originated around the ankle, two lesions involved the dorsal foot and one was situated on the plantar aspect of the foot. W ith a m ean follow-up time of 26 m onths for the am putated patients, three continue to be disease free. T wo patients are dead of disease and a third is alive with system ic disease.

D iscussion
ST S sarcom a of the foot and ankle poses a dif® cult challenge for lim b preservation. W ith the success of com bined m odality therapy in proxim al extrem ity ST S, sim ilar principles are being app lied to achieve lim b salvage of the distal low er lim b. 7,9,13,18,27 T his paper presents 36 consecutive cases of STS or aggressive ® brom atosis treated by m ulti-m odality therapy by our sarcom a group. Patients with aggressive ® bromatosis requiring resection w ere included in the study since the treatm ent of this disease often requires com bined m anagem ent with both surgery and adjuvant radiotherapy. Since the therapeutic approach to both ST S and ® brom atosis was sim ilar in our hands, we grouped these patients together in order to gain a better understanding of the functional results of treatment. T hirty cases underw ent lim b salvage (83%) employing a consistently applied protocol of wide local en bloc resection plus adjuvant radiotherapy to supplement close surgical m argins. Since the ultimate goal in these patients is overall survival and preservation of m axim um limb function, a concurrent analysis of both outcom es is appropriate.
Sugarbaker et al., 20 in a landm ark pap er on quality of life and functional assessm ent, did not substantiate an im proved function in lim b salvage versus am putation for STS of the upper and lower extremity. Patients were randomized to am putation or lim b salvage, with quality of life assessm ent at one point in time. In their paper, Sugarbaker et al. questioned the results of the study due to the generalizability and sensitivity of the outcomes adm inistered. Currently, when possible, lim b preservation is preferred over amputation, even in the absence of sound evidence in the literature. 7,9,13,18,27,28 T his study provides objective results on the functional bene® t of limb-salvag e surgery in patients with localized soft tissue tumours of the foot and ankle.
W hile the M ST S 26 does not m eet the current standards of evaluating function from the patient' s perspective, 29 we chose to evaluate function for this study using the M ST S, 1987 version, as it w as the only m easure available speci® c to the tum our lim bsalvage population at the time that prospective functional data collection was begun. W hile it is recognized that the M STS includes m any items related to clinical param eters, e.g. range of m otion, strength, joint stability and joint deform ity, this scale does provide data that can be com pared to other published studies. Furtherm ore, we have added an evaluation of w ork status in relation to job dem ands as an indicator of function.
Eighty-® ve per cent of the patients had a good or excellent functional outcome at m ost recent visit. Sixteen patients had no functional lim itations and all patients were satis® ed with the result of their treatment. The only exception was the patient who required am putation for com plication of treatment.
Fifty-two per cent had no pain and only two patients required occasional narcotic use. The M STS functional evaluation rating scale showed a progressive im provem ent in function with time and a plateau of function after one year. This correlates with the ® nding that patients returned to work up to one year following treatment but not beyond that time. This inform ation has im plications with respect to patient and physician expectations over time and the planning of post-operative physiotherapy.
Chou and Malaw er 13 review ed 33 patients with an assortm ent of bone or soft tissue lesions of the foot and ankle. Surgical m anagement varied from simple curettage to am putation. They reported that 82% of patients had a good to excellent functional outcom e according to the M ST S functional evaluation criteria and 55% were able to bear full weight and had unlim ited activity. 14 Supporting docum entation was not provided and it is not certain whether any patients received radiotherapy. N onetheless, their population was con® ned to the foot and ankle and provides one of the few pap ers in which a com parison of the functional outcom e can be m ade with our study.
Ow ens et al., in a retrospective study of 50 patients with stage M 0 ST S of the hand and foot, em phasized that while local recurrence had an om inous effect on prognosis, an im provem ent in local control did not translate into an im proved survival. Approximately half of their patients had am putation and the rem ainder had various com binations of com bined m odality lim b salvage. 7 A 5-year survival of 68% with either am putation (no local recurrence) or conservative surgery (32% local recurrence) was reported, a ® nding shared by other authors. 2± 4,7,17,28 In our group of lim b-salva ge patients, no sarcom a recurred locally although there was one local and one regional recurrence of ® brom atosis (7% ). T here was a 20% systemic recurrence rate at a m ean time of 7 m onths from presentation in patients with ST S. H eise et al., in an extensive review of extremity ST S, show ed a median time to recurrence of 9.7 m onths for local and system ic recurrence combined. 30 T he presence of occult m etastatic disease at time of presentation continues to be a challenge, especially since no therapeutic interventions have thus far been show n to im prove prognosis. 31 Talbert et al. reported on 78 patients with conservative surgery and irradiation of the hand and foot. 18 N ine patients had de® nite residual gross disease and no further surgery, while 46 patients with piecemeal or simple local excision had no further surgery. All patients were treated with a com bination of adjuvant radiotherapy and chem otherapy. T here w as a 19% local recurrence rate and the com plication rate was 56% in the low er extremity versus 28% in the upper extremity. Thirteen per cent of the low er extrem ity cases required am putation for com plication of their treatm ent. Fiftythree per cent of the distal low er extrem ity patients had norm al function or m ild to m oderate functional lim itation. T he use of radiotherapy to control local disease w hen there is histological or gross evidence of residual disease m ay not be prudent and the larger dose required m ay lead to increased functional m orbidity. 2,5,7,8,31 Stinson et al. described both the frequent longterm functional com plications of radiotherapy and m ethods to reduce their incidence. 33 T hey reported a third of their patients had a m oderate to severe decrease in range of m otion and a 19% rate of oedema greater than 2 1 . T wenty-two per cent of our patients had m ild (1 1 ) or m oderate (2 1 ) oedema using the criteria of Stern 25 at last visit. Except in two patients, delayed local toxic effects of adjuvant radiotherapy did not translate into a deterioration of function with time as shown in other studies. 18,32,34 O ne patient had increasing pain in the foot one year following radiotherapy. The second patient required am putation for pathological fracture and non-union 2 years after lim b salvage. Improvem ent in radiotherapy technique has enabled m ore accurate dosage to speci® c anatom ical regions, the sparing of part of the lim b circum ference and the use of a m ore standardized, better tolerated dose, reducing the risk of com plications following irradiation. 5,23 The com bination of poor soft tissue coverage following resection in a distal extremity that also receives adjuvant radiotherapy can represent a m ajor challenge to the reconstructive surgeon. The use of vascularized tissue transfer from distant sites brings both soft tissue coverage and new blood supply to the area. A review of wound healing com plications after extremity STS surgery and adjuvant radiotherapy by Peat et al. showed an 11% m ajor wound com plication rate with the use of vascularized tissue transfers versus a 30% rate of com plications with direct wound closure. 23 In our series, tw o of eight tissue transfers had m ajor problem s but only one w as not salvageable. Six of the vascularized¯aps received post-operative radiotherapy of w hich one developed partial¯ap necrosis. The residual¯ap survived but the patient ultimately required am putation for a pathological fracture and non-union. T he successful use of a vascularized tissue transfer in seven out of eight otherw ise unreconstructable lim b-salva ge patients supports the bene® t of this technique in lim b preservation surgery of the foot and ankle.
A pathological fracture in the high-dose irradiation ® eld (as experienced by ® ve patients in this series) presents potentially devastating consequences for lim b function as demonstrated by the one patient who required below-knee am putation for chronic non-union. T he two patients w ith the anterior tibia cortical defects w ere part of a series of patients in w hom it w as dem onstrated that open segm ental cortical defects with adjuvant irradiation increase the risk for pathological fracture. 3,5 Our current practice w hen treating such patients is to stabilize prophylatically the weakened bone with an intram edullary rod, plate or bone graft. T hese fractures m ay have been prevented using our current m anagem ent protocol.
M ost published studies reporting outcom e in foot and ankle sarcom a have concentrated on oncologic outcom e with only a m inor emphasis on functional issues. T he m odi® ed M ST S functional evaluation rating scale provides a m eans of assessing function in the extremity. Com bined w ith the excellent local control achieved in this study the functional results provide support for lim b salvage as a primary goal in the m anagem ent of selected patients with ST S of the foot and ankle. C oncurrent m easurem ent of function and oncologic outcom e will better enable us to assess future treatm ent interventions in the m anagem ent of ST S of the extremities.