Abstract
Purpose
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Primary bone tumors of the fibula are rare. Distal fibular resection has a significant impact on ankle biomechanics and gait, possibly leading to complications such as ankle instability, valgus deformity, and degenerative changes. Question: Is there a need for reconstructive surgery after distal fibular resection, and what reconstructive procedures are available?
Materials and methods
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The review is registered with the PROSPERO International Register of Systematic Reviews. Inclusion criteria consisted of all levels of evidence, human studies, patients of all ages and genders, publication in English, and resection of the distal portion of the fibula due to tumor pathology. The reviewers defined four different categories of interest by method of treatment. Additional articles of interest during full-text review were also added.
Results
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The initial search resulted with a total of 2958 records. After screening, a total of 50 articles were included in the study. Articles were divided into ‘No reconstruction’, ‘Soft tissue reconstruction’, ‘Bone and soft tissue reconstruction’, and ‘Arthrodesis, arthroplasty or other reconstruction options’ groups.
Conclusion
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Limb salvage surgery should be followed by reconstruction in order to avoid complications. Soft tissue reconstructions should always be considered to stabilize the joint after fibular resection. Bone reconstruction with reversed vascularized fibula is the preferred technique in young patients and in cases of bone defects more than 3 cm, while arthrodesis should be considered in adult patients. Whenever possible for oncologic reason, if a residual peroneal malleolus could be preserved, we prefer augmentation with a sliding ipsilateral fibular graft.
Introduction
Primary bone tumors (PBTs) of the fibula are rare (1, 2, 3). A study showed that 4.08% of PBTs occur in the fibula, with around 20% of them being malignant (4). Approximately one-quarter of these PBTs involve the distal fibula (4). Historically, below-the-knee amputation was the treatment of choice, with the goal to either obtaining local control of the malignancy or addressing the pain and functional loss due to locally aggressive benign tumors (5, 6, 7). However, a study showed that the survival rate for patients with malignant tumors in the distal lower extremity is greater than for those occurring elsewhere in the body (8). Moreover, advancements in chemotherapy and radiotherapy allowed limb salvage surgery to become a feasible treatment option in a larger number of patients (9, 10). Li et al. reported no survival benefits of amputation in comparison to limb salvage surgery for osteosarcomas (11). Therefore, distal fibular resection became the most commonly used procedure for malignant and locally aggressive PBTs of the distal fibula (12, 13, 14). This surgical procedure has a significant impact on the ankle biomechanics and gait, possibly leading to complications such as ankle instability, valgus deformity, and degenerative changes (5, 15, 16, 17). Resection of the distal fibula without reconstruction can result in functional deficits in the ankle joint, as the fibula plays an important role in ankle stability and movement. The fibula is one of the bones that make up the ankle joint and is an important stabilizer of the joint. Without the fibula, the ankle joint may be unstable, resulting in difficulty with weight-bearing and walking, and an increased risk of ankle sprains and injuries. A question arises: Is there a need for reconstructive surgery after distal fibular resection, and what reconstructive procedures are available?
Materials and methods
We conducted an online systematic literature search in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The review has been registered on the International Prospective Register of Systematic Reviews (PROSPERO). Two reviewers (MP, IB) performed a literature search independently on 30 May 2022 and searched PubMed/Medline and Scopus using predefined key terms (Fig. 1). Inclusion criteria comprised all levels of evidence, human studies, patients of all ages and genders, English language of publication, and resection of the distal portion of the fibula due to tumor pathology. Exclusion criteria included studies not including resection of the distal portion of the fibula due to tumor pathology (i.e. resection after trauma or infection, cadaveric studies, conservative treatment, curettage and grafting, review articles), or studies not reporting on functional outcomes after surgery. The reviewers independently screened titles and abstracts of all identified studies. Studies were further included in the full-text review process if one of the two authors agreed on inclusion. Finally, all the studies that were included by one of the two the full-text review process were discussed between two reviewers, and a final list of included articles was made after the reviewers agreed on their decision on all articles. The reviewers defined four different categories of interest by method of treatment and separated the cases from articles into adequate categories. Additional articles of interest found as references during the full-text review of selected articles were also added to the manuscript. Because of the heterogeneity of identified studies, meta-analysis was not possible; thus, a qualitative assessment was performed.
Literature search parameters on PubMed/Medline and Scopus using predefined key terms.
Citation: EFORT Open Reviews 9, 6; 10.1530/EOR-23-0159
Results
The initial search resulted in a total of 2958 records (Fig. 2). After title and abstract screening, a total of 2816 records were removed, leaving 142 articles for further full-text assessment. Of those 142, 42 were duplicates, while six were unavailable in full-text form online. Therefore, 94 articles went through full-text screening, resulting in 50 articles that were included in the study. One additional article was identified from the references in one of the screened articles and was included in the study. The reviewers had no disagreements throughout all stages of the review. The articles were divided into ‘Resection of the distal fibula with no reconstruction’, ‘Resection of the distal fibula and soft tissue reconstruction’, ‘Resection of the distal fibula and bone reconstruction’, and ‘Resection of the distal fibula and reconstruction with arthrodesis, arthroplasty, or other options’ groups.
Flow diagram of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) process.
Citation: EFORT Open Reviews 9, 6; 10.1530/EOR-23-0159
Discussion
Even if ‘no reconstruction’ should be considered an option after distal fibular resection due to bone tumors, there are several reconstructive surgical strategies that can be used. Some common strategies include soft tissue reconstructive strategies, massive bone grafting, autografting, free vascularized fibular graft, prosthetic replacement, arthrodesis, and others. It is important to note that each of these techniques has its own risks and benefits, and the choice of technique will depend on the specific needs and circumstances of the patient.
Resection of distal fibula with no reconstruction
A summary of patients treated with resection of the distal fibula without reconstruction is presented in Table 1 (5, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27). In cases where the distal fibula is resected without reconstruction, the patient may experience a decrease in ankle range of motion and strength, as well as difficulty with balance and stability. In some cases, the ankle joint may become more pronated (turned inward) or supinated (turned outward), which can also lead to further instability and decreased function. Mohler and Cunningham (24) state that reconstruction or ankle arthrodesis is not needed in initial tumor management, as these procedures may result in an increased rate of wound complications, as well as violate the anatomy of regions unaffected by the tumor. Norman-Taylor et al. reported that resection of the distal fibula can be performed with a minor loss of function in the ankle, thus advocating there is no need for ankle reconstruction (5). Other authors report good outcomes after resection of the distal fibula with no reconstruction as well (19, 24, 26, 28, 29). Caso Martínez et al. (26) presume that the formation of scar tissue provides ankle stability after resection. Furthermore, Mohler and Cunningham (24) believe that both scar formation and proprioception combined with dynamic forces produced by muscles and tendons provide ankle stability. However, our literature review shows that a complication of treatment was reported in more than two-thirds of patients classified in this group, and valgus deformity of the ankle was the most commonly reported one. Around 70% of reported cases were children. The peculiarity of children is their growth potential, making them a difficult group to definitively treat by reconstruction. In some cases, patients may be able to compensate for the loss of the distal fibula with physical therapy and rehabilitation and may achieve a good level of function without reconstruction. Some authors suggest reconstruction can be done if the patient survives the disease or if the ankle becomes symptomatic in terms of instability or degenerative changes (24, 26). Therefore, this expectative management approach may be beneficial for children as it gives time for growth cessation, allowing reconstructive surgery to be both a definitive and successful treatment option. It is important to note that the decision to forego reconstruction of the distal fibula should be made carefully, taking into consideration the potential functional deficits and the impact on the patient's quality of life.
Summary of patients treated with resection of the distal fibula with no reconstruction.
| Study | Age | Sex | Diagnosis | Resection | Adjuvant therapy | FU (months) | Complications | Treatment | Oncologic, functional outcome |
|---|---|---|---|---|---|---|---|---|---|
| (18) | |||||||||
| 14 | F | ES | DF (remnant of LM fixed to tibia) | CT | 116 | Peroneal nerve palsy, pain | NED, MSTS score 27 | ||
| 17 | M | ES | DF (remnant of LM fixed to tibia) | CT, RT | 44 | – | DOD, na | ||
| 10 | M | ES | DF (remnant of LM fixed to tibia) | CT | 69 | Flatfoot | NED, MSTS score 25 | ||
| (19) | 67 | M | LMS | DF (15 cm) | – | 80 | – | NED, good motion | |
| (20) | 5 | M | ES | DF | na | 84 | Severe deformity | * | NED, AOFAS score 30 |
| (21) | 31 | M | CS | DF (wide resection) | na | 564 | – | NED (dead) | |
| (22) | |||||||||
| 4 | F | ES | DF (with talus and partial tibia) | CT | 120 | Severe deformity | ** | NED, ISOLS score 27 | |
| 8 | M | ES | DF (wide resection) | CT, RT | 84 | Severe deformity | *** | NED, amputation | |
| 14 | F | OS | DF (with talus and partial tibia) | – | 288 | Instability | Arthrodesis | NED, ISOLS score 24 | |
| 4 | M | OS | DF (with talus and partial tibia) | CT | 96 | OS metastases | AWD, ISOLS score 21 | ||
| 35 | M | ADA | DF (wide resection) | – | 264 | LR | Amputation | NED, amputation | |
| 38 | M | CS | DF (wide resection) | – | 360 | LR | Amputation | NED (dead) | |
| (23) | 13 | na | OO | DF (5 cm) | – | 48 | – | na | |
| (24) | 17 | M | ADA | DF (16 cm) | CT | 36 | Lung metastases | AWD, good motion | |
| (25) | |||||||||
| 19 | M | ES | DF (including peroneal nerve) | CT, RT | 34 | Drop foot | NED, Poor function | ||
| 15 | F | ES | DF (inadequate margins) | CT, RT | 25 | LR | Amputation | na, amputation | |
| (5) | 8–13 | 4F | |||||||
| ES | DF | CT, RT | 184 | Deformity | Arthrodesis | NED, ISOLS score 23 | |||
| ES | DF (entire fibula) | CT, RT | 125 | Severe deformity | NED, ISOLS score 26 | ||||
| ES | DF | CT, RT | 88 | Stable metastatic disease | AWD, ISOLS score 26 | ||||
| ES | DF | CT | 69 | – | NED, ISOLS score 28 | ||||
| ES | DF | CT | 17 | – | NED, ISOLS score 28 | ||||
| (26) | 21 | F | ABC | DF (marginal resection) | – | 30 | – | NED, good motion | |
| (27) | 37 | M | GCT | En bloc excision | – | 60 | – | NED, na |
*Complex reconstructive procedure was performed in this case that is reported in Table 3.
**Revised with posterior tibial tendon transfer (2 years) and corrective cuboid and medial cuneiform osteotomy (4 years).
***Corrective distal tibial osteotomy (4 years) resulting in infected nonunion and chronic osteomyelitis → below knee amputation (6 years).
ABC, aneurysmal bone cyst; ADA, adamantinoma; CS, chondrosarcoma; CT, chemotherapy; DF, distal fibula; DOD, died of disease; ES, Ewing’s sarcoma; FU, follow-up; F, female; ISOLS, International Society of Limb Salvage; LM, lateral malleolus; LMS, leiomyosarcoma; M, male; MSTS, Musculoskeletal Tumor Society; na, not available; NED, no evidence of disease; ROM, range of motion; RT, radiotherapy; OS, osteosarcoma; OO, osteoid osteoma.
Resection of distal fibula and soft tissue reconstruction
A summary of patients treated with resection of the distal fibula and soft tissue reconstruction is presented in Table 2 (6, 7, 12, 30, 31, 32, 33, 34, 35, 36). The tibialis posterior tendon can be harvested from its insertion and sutured to the remaining distal part of the peroneus brevis after mobilization under the tibia through the interosseous membrane (Fig. 3). Vaseenon et al. state that the main advantage of using this reconstruction approach is avoidance of autograft and allograft implantation, thus there is no risk of non-union, and there is no donor site morbidity (7). Bone fusion or healing is further compromised if patients undergo radiotherapy or chemotherapy, supporting the choice of soft tissue reconstruction only (12, 35). Some authors reports that adequate realignment and immobilization will finally result in fibrosis of the soft tissue that will become strong enough to maintain ankle stability (36), and others address that radiotherapy may contribute to ankle stability due to local soft tissue fibrosis (35). Capanna et al. reported in their series that joint mobility and stability were reduced in comparison to preoperative state, but the function was still satisfying (35). The meshplasty is another technique that exploits the properties of a folded polypropylene mesh in determining intense fibrosis in surrounding tissue and providing adequate strength to stabilize the joint (Fig. 4A) (17, 37). Prajapat et al. describe the technique as easy, reproducible, and with minimal complications (17). Moreover, it does not affect postoperative rehabilitation when radiotherapy is indicated, as is the case when using bone grafts (17). Also, the thromboembolic risk is low when consistent and careful prophylaxis with low-molecular-weight heparin is prolonged until the time of complete weight-bearing (38). The reported results seem good, however, there is a limited number of cases available in the literature. A vast majority of reported cases use peroneal tendons for reconstruction in various fashion (33). They may preserve ankle motion but are not recommended in children to avoid valgus deformity due to the growth of the tibia and medial malleolus (10). When peroneal tendons are not available, a transfer of the posterior tibialis tendon and tendon allografts are used (7, 32, 33). Tibiotalar bone–tendon allografts directed to counteract inversion forces (Fig. 4B and C) or a patellar bone and tendon graft (Fig. 4D) have been described as salvage techniques (32, 33). Talar shift and valgus deformity were reported in some cases; however, the incidence is significantly lower than in the no reconstruction group (Table 2). Nevertheless, most reported cases present good functional outcomes (39). Isolated reconstruction of soft tissue reconstruction after resection of the distal fibula has several advantages and is, therefore, a viable treatment option in carefully selected patients.
Artistic drawing realized by AA show the technique of tibialis posterior transfer to peroneus brevis.
Citation: EFORT Open Reviews 9, 6; 10.1530/EOR-23-0159
Artistic drawing realized by AA shows three techniques of soft tissue reconstruction: (A) meshplasty; (B, C) anterolateral and lateral view of tibial tunnel and allograft placement. (D) anterolateral view of the reconstruction with a patellar tendon bone allograft (black arrow) fixed with screws in tibia and calcaneus, and quadriceps tendon (white arrow) attached to remaining tissues.
Citation: EFORT Open Reviews 9, 6; 10.1530/EOR-23-0159
Summary of patients treated with resection of the distal fibula and soft tissue reconstruction.
| Study | Age (years) | Sex | Diagnosis | Resection | Reconstruction | Adjuvant therapy | FU (months) | Complications | Treatment | Oncologic, functional outcome |
|---|---|---|---|---|---|---|---|---|---|---|
| (30) | ||||||||||
| 23 | F | OS | DF (with partial tibia) | PB tendon transfer | CT | 96 | – | NED, good motion | ||
| 19 | F | ES | DF | PB tendon transfer | CT, RT | 15 | – | NED, good motion | ||
| (7) | 30 | F | OS | DF | TP tendon transfer | CT | 84 | – | NED, good motion | |
| (6) | 11 | M | OS | DF (15 cm) | Soft tissue | CT | 60 | Valgus deformity | NED, good motion | |
| (12) | ||||||||||
| 24 | F | GCT | DF | Suture anchors* | – | 48 | Metatarsal fracture | NED, good motion | ||
| 41 | M | ES | DF | Suture anchors* | CT | 114 | Painful bursae | Bursectomy | NED, good motion | |
| 16 | F | ES | DF | Suture anchors* | CT | 14 | – | NED, good motion | ||
| (31) | 64 | M | Metastasis | DF (8 cm) | Peroneal tendon reconstruction | – | 30 | – | NED, MSTS score 93% | |
| (32) | 67 | M | Metastasis | DF (wide resection) | Patellar allograft | – | 12 | No | NED, AOFAS 100 | |
| (33) | 29 | F | Multiple OC | DF (9 cm) | PB tendon transfer | – | 3 | Failure after trauma | ** | NED, instability |
| Patellar allograft | – | 168 | – | NED, stable ankle | ||||||
| (34) | 7 | M | OC | DF (mainly LM) | Soft tissue | – | 30 | – | NED, excellent function | |
| (35) | ||||||||||
| 16 | M | ES | DF (marginal) | Peroneal tendon reconstruction | CT, RT | 48 | Radionecrosis | NED, stable ankle | ||
| 9 | F | ES | DF | Peroneal tendon reconstruction | CT | 24 | Ankle subluxation | NED, good function | ||
| 6 | F | ES | DF (marginal) | Peroneal tendon reconstruction | CT, RT | 12 | – | NED, stable ankle | ||
| (36) | ||||||||||
| 43 | M | GCT | DF (with partial tibia) | Soft tissue | – | 24 | – | NED, stable ankle | ||
| 12 | F | GCT | DF (mainly LM) | Soft tissue | – | 24 | – | NED, stable ankle |
*Transection of PB tendon, suturing to calcaneofibular and anterior talofibular ligaments with tendon fixation to the lateral distal tibia with suture anchors and staple.
**Revision surgery done in the patient is reported in the row below.
ABC, aneurysmal bone cyst; AOFAS, The American Orthopaedic Foot & Ankle Society; Adam., Adamantinoma; CT, chemotherapy; CS, chondrosarcoma; DOD, died of disease; DF, distal fibula; ES, Ewing’s sarcoma; F, female; ISOLS, International Society of Limb Salvage; LM, lateral malleolus; LMS, leiomyosarcoma; M, male; MSTS, Musculoskeletal Tumor Society; na: not available; NED, no evidence of disease; OS, osteosarcoma; OC, osteochondroma; PB, peroneus brevis; RT, radiotherapy; ROM, range of motion; TP, tibialis posterior.
Resection of distal fibula and bone reconstruction
A summary of patients treated with resection of the distal fibula and bone and soft tissue reconstruction is presented in Table 3 (9, 10, 13, 18, 20, 31, 35, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58). Resection of the distal fibula alters foot and ankle biomechanics (20, 53). If the resection is 15–20 mm above the distal tibiofibular articulation or at least 5 mm above the growth plate in children, ankle function may be preserved (18, 35). Resection below 6–8 cm from the tip of lateral malleolus results in damaged syndesmotic ligaments and interosseous membrane, causing rotation of the lateral malleolus, translational instability, increased stress, and cartilage degeneration of the ankle (35, 43, 54, 59). Therefore, according to the oncologic concept of surgical margin, the goal is to preserve as much of the lateral malleolus as possible, preserving the lateral ligamentous attachments intact (43, 60). Augmentation of the remnant of the fibula was widely described with a sliding ipsilateral fibular graft (Fig. 5A) (43, 61). Leibner et al. suggest preserving as much native fibula as possible to lengthen the lateral malleolus remnant by bone grafting, as well as performing a subperiosteal resection when needed, in order to preserve the ligaments (Fig. 5B) (53). Other papers reported reconstructions with sliding of half-fibular autograft plus banked bone graft (Fig. 5C) (62), vascularized ipsilateral osteocutaneous fibular flap (10), rotational ipsilateral fibula transposition (Fig. 5D and E) (18, 46), tricortical iliac crest autograft, and cortical allografts (45, 49, 63), with more or less satisfying results (35).
Artistic drawing realized by AA shows techniques of fibular graft harvesting to stabilize distal fibular malleolus. (A) simple distalization and plate/screws fixation; (B) a 10 cm length of fibula is resected subperiosteally to serve as a split double-barreled bone graft; (C) sliding of half-fibular autograft plus banked bone graft; (D) rotational ipsilateral fibula transposition fixed to the lateral malleolus using cable and wires; and (E) reversed fibula fixed to the tibia with screws.
Citation: EFORT Open Reviews 9, 6; 10.1530/EOR-23-0159
Summary of patients treated with resection of the distal fibula and bone reconstruction.
| Study | Age (years) | Sex | Diagnosis | Resection | Reconstruction | Adjuvant therapy | FU (months) | Complications | Treatment | Functional outcome |
|---|---|---|---|---|---|---|---|---|---|---|
| (40) | 9 | M | ES | DF (wide resection) | VPFG | CT | 48 | Foot drop | NED, Kofoed 100 | |
| (10) | 68 | M | MFS | DF (remnant of LM) | VPFG | CT, RT | 36 | – | NED, AOFAS 87 | |
| (18) | ||||||||||
| 27 | F | ES | DF (remnant of LM) | VPFG | CT, RT | 111 | Nerve palsy | NED, MSTS 30 | ||
| 19 | F | ES | DF (11 cm) | Autograft (fibula) | CT | 18 | Chronic pain | NED, MSTS 29 | ||
| 12 | M | ES | DF (16.5 cm, intralesional) | Autograft (fibula) | CT, RT | 13 | No | DOD, MSTS 21 | ||
| 37 | F | OS | DF (4 cm) | Allograft (4 cm fibula) | – | 48 | No | NED, MSTS 28 | ||
| (41) | 21 | M | GCT | DF (wide resection) | VPFG | – | 12 | No | NED, AOFAS 88 | |
| (42) | 12 | F | GCT | DF (wide resection) | Autograft (fibula) | – | 57 | LR (3 months) | * | NED, na |
| (43) | 20 | M | GCT | DF (remnant of LM) | Autograft (fibula) | – | 24 | No | NED, AOFAS 97 | |
| (44) | ||||||||||
| 12 | M | OS | DF | VPFG | CT | 104.7 | No | NED, MSTS 30 | ||
| 21 | M | OS | DF | VPFG | CT | 87.9 | Lung metastasis | AWD, MSTS 30 | ||
| 37 | M | OS | DF | VPFG | CT | 204.1 | No | NED, MSTS 30 | ||
| (45) | 18 | F | GCT | DF (remnant of LM) | Autograft (iliac crest) | – | 18 | No | NED, good motion | |
| (46) | 12 | M | FD | DF (remnant of LM) | VPFG | – | 63 | No | NED, AOFAS 100 | |
| (13) | 17 | F | GCT | DF | VPFG | – | 12 | No | NED, good motion | |
| (47) | 16 | M | CMF | DF (8 cm) | Autograft (iliac crest) | – | 14 | No | NED, good motion | |
| (48) | ||||||||||
| 12 | M | OS | DF (15 cm) | Allograft (fibula) | CT | 108 | Valgus deformity | NED, good motion | ||
| 31 | M | ES | DF (18 cm) | Allograft (fibula) | CT | 60 | Screw breakage | NED, good motion | ||
| 25 | M | ES | DF (16 cm) | Allograft (fibula) | CT | 36 | No | NED, good motion | ||
| 30 | F | GCT | DF (7 cm) | Allograft (fibula) | – | 27 | No | NED, good motion | ||
| (20) | 12 | M | ES | DF (7 years before) | Autograft (fibula) | – | 48 | Discrepancy 1.5 cm | NED, AOFAS 93 | |
| (31) | 15 | M | ES | DF (15 cm) | Autograft (fibula) | CT, RT | 155 | Positive margins | Amputation | NED, na |
| (9) | 4 | M | ES | DF | Allograft | CT, RT | 216 | No | NED, AOFAS 100 | |
| (49) | ||||||||||
| 8 | NR | ABC | DF | Autograft (cortical strut) | – | 102 | Deformity | NED, AOFAS 100 | ||
| 10 | NR | ABC | DF | Autograft (cortical strut) | – | 330 | No | NED, AOFAS 100 | ||
| 12 | NR | ABC | DF | Allograft (homologous) | – | 37 | Screw breakage | NED, AOFAS 96 | ||
| (50) | 31 | F | GCT | DF | Autograft (fibula) | CT, RT | 8 | Bony metastases | DOD, na | |
| (51) | 27 | F | HE | DF | VPFG | – | 21 | No | NED, good motion | |
| (52) | 17 | M | OS | DF (wide resection) | VPFG | – | 3 | No | NED, good motion | |
| (53) | 15 | M | ES | DF (remnant of LM) | Autograft (fibula) | CT | 60 | No | NED, good motion | |
| (54) | 23 | F | GCT | DF (wide resection) | Autograft (iliac crest) | No | 180 | Graft failure | Graft revision | NED, Free ROM |
| (55) | 13 | M | OS | DF | VPFG | CT | 30 | No | NED, good motion | |
| (25) | ||||||||||
| 7 | F | ES | DF (25 cm) | Cement → Autograft | CT, RT | 114 | Fatigue fracture | NED, good motion | ||
| 14 | M | ES | DF (13 cm) | Autograft (fibula) | CT | 43 | Positive margins | Amputation | NED, poor | |
| (56) | 28 | F | GCT | DF | VPFG | – | 24 | – | NED, good motion | |
| (35) | ||||||||||
| 18 | M | ABC | DF (remnant of LM) | Allograft (cortical graft) | – | 12 | – | NED, excellent | ||
| 26 | M | DFib | DF (remnant of LM) | Allograft (cortical graft) | – | 18 | – | NED, excellent | ||
| 16 | M | ABC | DF (remnant of LM) | Allograft (cortical graft) | – | 6 | – | NED, excellent | ||
| 39 | F | CS | DF | VPFG | – | 24 | – | NED, excellent | ||
| 15 | F | ES | DF | VPFG | CT | 6 | – | NED, good motion | ||
| (57) | 36 | M | CS | DF | VPFG | – | 30 | – | NED, excellent | |
| (58) | ||||||||||
| 45 | F | GCT | DF | VPFG | – | na | – | na | ||
| 6 | F | ES | DF | VPFG | RT | 24 | Leg length discrepancy (2 cm) | NED, excellent |
*LR removal. New recurrence in fibular graft (15 months) leading to implant removal and segmental resection.
ABC, aneurysmal bone cyst; AOFAS, The American Orthopaedic Foot & Ankle Society; Adam., adamantinoma; CT, chemotherapy; CS, chondrosarcoma; CMF, chondromyxoid fibroma; DF, distal fibula; DOD, died of disease; DFib, desmoplastic fibroma; ES, Ewing’s sarcoma; F, female; FD, fibrous dysplasia; GCT, giant cell tumor; HE, hemangioendothelioma; ISOLS, International Society of Limb Salvage; LM, lateral malleolus; M, male; MFS, myxofibrosarcoma; MSTS, Musculoskeletal Tumor Society; na: not available; NED, no evidence of disease; OC, osteochondroma; OS, osteosarcoma; PB, peroneus brevis; RT, radiotherapy; VPFG, vascularized proximal fibular graft.
Preserving part of the lateral malleolus is not always possible. In such cases, the use of reversed vascularized ipsilateral proximal fibula (Fig. 6) (13, 35, 40, 44, 51, 52, 55), contralateral non-vascularized fibula transposition (18), sliding fibular graft (50), long bone graft from the iliac crest with periosteal flap for lateral ligaments reconstruction (54), fibula allograft (47, 48, 60), and homologous cortical grafts (49) were described. All these methods seem to have more or less satisfying functional outcomes. However, several aspects need to be taken into consideration. Chemotherapy and radiotherapy may cause wound healing complications, increasing the rate of wound infections and compromising the incorporation of used grafts (35, 44). Kiyokawa et al. report that the success of reconstruction and bone incorporation lies in the early recovery of blood supply to the bone (52). They advocate for coverage of the graft with soft tissue, thus facilitating the vascularization and filling of the dead space around the graft that may promote infection (52). Leibner et al. believe soft tissue plays a critical role in successful reconstruction and should therefore always be addressed (53). When using autografts, donor site morbidity may become an issue (31, 46). As the proximal fibula is the most commonly used autograft, care has to be taken to prevent common peroneal nerve or knee lateral collateral ligament injuries, especially when harvesting a proximal fibula with fibular head (18, 43, 53). Allografts avoid the morbidity of the donor site, but they are associated with a higher chance of graft incorporation failure and risk of infection (52). Grafts are usually not congruent with the articular surface on the talus, and some authors advocate osteotomy of the graft to achieve a better fit (55, 56), even if the shape of the graft changes gradually with joint movement (52). An additional consideration arises when treating children, due to the growth potential of the open distal tibial epiphysis, that may result in valgus deformity of the ankle (53). The pedicled vascularized ipsilateral proximal fibula is the most appropriate graft for the restoration of longitudinal growth capacity when reconstructing the distal fibula (40, 46, 55). Alternatively, distal tibial epiphysiodesis may be performed, resulting in a stable and aligned ankle, but with a discrepancy in leg length (53). All things considered, reconstruction of bone and soft tissue after distal fibula resection seems to achieve good functional results and should be taken into consideration when deciding on the treatment option.
Artistic drawing realized by AA shows the technique of reverse vascularized proximal fibular graft. The proximal fibula is reversed with the head of fibula incorporating into the ankle mortise and fixed to the remaining fibula using a plate and screws in two different settings (A, B) or stabilized directly to the tibia with two screws (C).
Citation: EFORT Open Reviews 9, 6; 10.1530/EOR-23-0159
Resection of distal fibula and reconstruction with arthrodesis, arthroplasty, or other options
A summary of patients treated with resection of the distal fibula and reconstruction modalities such as arthrodesis, arthroplasty, and other reconstruction options is presented in Table 4 (17, 18, 22, 31, 37, 44, 64, 65, 66, 68, 69). Mansour and Ghanem (66) reported on a two-staged procedure described as a variant of the Masquelet technique (Fig. 7). Few cases are available in the literature, and the authors believe this technique is a reasonable alternative for using vascularized fibular grafts when dealing with significant bone loss, as it is less demanding and not so prone to graft failure (25, 66, 68, 70). A custom-made ankle prosthesis was used in one case only treated for osteosarcoma of the distal fibula (both distal fibula and tibia were resected), reporting satisfying functional outcomes at mid-term follow-up (69).
Artistic drawing realized by AA shows a variant of the Masquelet technique after fibular resection. Bone cement (asterisk) is used to fill the fibular defect in the first stage and then is replaced by autologous cancellous bone.
Citation: EFORT Open Reviews 9, 6; 10.1530/EOR-23-0159
Summary of operatively treated patients due to tumor of the distal fibula using modalities such as arthrodesis, arthroplasty, and other reconstruction options.
| Study | Age (years) | Sex | Diagnosis | Resection | Reconstruction | Adjuvant therapy | FU (months) | Complications | Treatment | Functional outcome |
|---|---|---|---|---|---|---|---|---|---|---|
| (37) | 28 | M | GCT | DF (wide resection) | Meshplasty | – | 12 | – | NED, good motion | |
| (18) | ||||||||||
| 71 | F | OS | DF + partial tibia (7.5 cm) | Arthrodesis with allograft | – | 23 | – | NED, MSTS 27 | ||
| 47 | M | OS | DF + partial tibia (11 cm) | Arthrodesis with autograft | CT | 26 | Infection | * | DOD, na | |
| 19 | M | ES | DF + partial tibia (12 cm) | Arthrodesis with grafts | CT, RT | 71 | – | DOD, na | ||
| (17) | ||||||||||
| 43 | F | PNET | DF (13 cm) | Meshplasty | CT, RT | 161 | – | NED, MSTS 29 | ||
| 35 | M | ANG | DF (12 cm) | Meshplasty | RT | 103 | – | NED, MSTS 28 | ||
| 19 | M | PNET | DF (13 cm) | Meshplasty | CT | 71 | – | NED, MSTS 29 | ||
| 13 | M | OS | DF (10 cm) | Meshplasty | CT | 55 | Valgus deformity | NED, MSTS 28 | ||
| 36 | M | GCT | DF (9 cm) | Meshplasty | – | 37 | LR | Excision | NED, MSTS 28 | |
| 25 | M | PNET | DF (16 cm) | Meshplasty | CT, RT | 34 | – | NED, MSTS 24 | ||
| 17 | M | PNET | DF (14 cm) | Meshplasty | CT, RT | 88 | – | NED, MSTS 27 | ||
| 13 | M | PNET | DF (20 cm) | Meshplasty | CT | 15 | Metastases | Died of the disease | ||
| 26 | M | OS | DF (13 cm) | Meshplasty | CT | 12 | Metastases, LR | Died of the disease | ||
| (64) | 47 | F | AD | DF + tibia | Arthrodesis (graft + nail) | – | 24 | Neuropathic pain | NED, MSTS 77% | |
| (44) | ||||||||||
| 47 | M | OS | DF + partial tibia | Arthrodesis (graft + plate) | CT | 56.4 | – | NED, MSTS 30 | ||
| 10 | M | OS | DF + partial tibia | Arthrodesis (graft + plate) | CT | 53.3 | – | NED, MSTS 30 | ||
| 18 | M | OS | DF + partial tibia | Arthrodesis (graft + plate) | CT | 144.1 | LR | Amputation | NED, good motion | |
| (65) | 38 | F | AD | DF (wide resection) | Arthrodesis (nail) | – | 84 | – | NED, good motion | |
| (66) | 11 | F | OS | DF (6 cm) | Masquelet technique | CT | 24 | Plate exposure | NED, na | |
| (67) | 41 | M | HE | DF + partial curettage | Arthrodesis (nail) | – | 66 | – | NED, good motion | |
| (68) | 14 | M | ES | DF (16.5 cm) | Masquelet technique | CT | 21 | – | NED, MSTS 30 | |
| (31) | ||||||||||
| 15 | M | ES | DF (13 cm) | Arthrodesis (graft, screws) | CT, RT | 81 | – | NED, MSTS 93% | ||
| 38 | M | OS | DF (12 cm) | Arthrodesis (screws) | CT | 84 | Wound problem§ | AWD, MSTS 80% | ||
| 32 | M | ES | DF (20 cm) | Arthrodesis (screws) | CT, RT | 48 | Metastases | AWD, MSTS 93% | ||
| 15 | M | ES | DF (17 cm) | Arthrodesis (screws) | CT | 16 | – | NED, MSTS 100% | ||
| 18 | M | OS | DF (19 cm) | Arthrodesis (screws) | CT | 49 | Pseudoarthrosis, deep infection# | NED, na | ||
| 15 | F | OS | DF (13 cm) | Arthrodesis (nail) | CT | 14 | Implant removal | NED, MSTS 90% | ||
| 16 | M | ES | DF (19 cm) | Arthrodesis (nail) | CT, RT | 22 | Tibia fracture | NED, MSTS 93% | ||
| 12 | M | OS | DF (21 cm) | Arthrodesis (nail) | CT | 18 | – | NED, MSTS 76% | ||
| 12 | F | ES | DF (21 cm) | Arthrodesis (nail) | CT, RT | 27 | Wound problems | NED, MSTS 93% | ||
| (22) | ||||||||||
| 23 | F | OS | DF + partial tibia | Arthrodesis (graft, screws) | – | 276 | Flap necrosis | NED, ISOLS 28 | ||
| 22 | M | OS | DF + partial tibia | Arthrodesis (graft, screws) | CT | 36 | Infection | Additional fibular resection | NED, ISOLS 28 | |
| 67 | F | CS | DF + partial tibia | Arthrodesis (graft, screws) | No | 168 | No | NED, ISOLS 29 | ||
| 68 | F | CS | DF + partial tibia | Arthrodesis (graft, screws) | No | 36 | No | NED, ISOLS 29 | ||
| (69) | 36 | F | OS | DF + partial tibia | Ankle prosthesis | CT | 68 | No | NED, ISOLS 28 |
*Removal of osteosynthetic material; §→ muscle flap, lung metastasis → resection; #→ stabilized with external fixateur, revised pseudoarthrosis → amputation.
ABC, aneurysmal bone cyst; AD., adamantinoma; ANG, angioscarc; AOFAS, The American Orthopaedic Foot & Ankle Society; CMF, chondromyxoid fibroma; CS, chondrosarcoma; CT, chemotherapy; DF, distal fibula; DFib, desmoplastic fibroma; DOD, died of disease; ES, Ewing’s sarcoma; F, female; FD, fibrous dysplasia; GCT, giant cell tumor; HE, hemangioendothelioma; ISOLS, International Society of Limb Salvage; LM, lateral malleolus; M, male; MFS, myxofibrosarcoma; MSTS, Musculoskeletal Tumor Society; na, not available; NED, no evidence of disease; OS, osteosarcoma; OC, osteochondroma; PB, peroneus brevis; preop, preoperative; PNET, primary neuroectodermal tumor; RT, radiotherapy; TP, tibialis posterior; VPFG, vascularized proximal fibular graft.
Ankle arthrodesis is one of the most frequently used treatment options in cases of distal fibula resection. In this technique, the remaining bones in the ankle joint are fused together to create a stable and functional joint. This is typically only done in cases where the patient is not expected to have a lot of activity or weight-bearing needs after surgery (13, 52). However, Papagelopoulos et al. state that ankle arthrodesis achieves the most reliable results in adults, especially when significant soft tissue removal is needed (22). Complications may occur, such as ankle instability due to resection of ligaments around the ankle (44), pseudarthrosis, or intraoperative distal tibial fracture (31). The quality of bone needs to be assessed, as well as other factors compromising bone union, such as postoperative chemotherapy or radiotherapy (31). They further suggest the use of retrograde nail for tibiotalocalcaneal arthrodesis as a more reliable option (Fig. 8A), stating that subtalar arthrodesis does not affect the functional result because the motion in the subtalar joint is usually severely limited after isolated ankle arthrodesis (31, 64, 67). In other reported cases, bone grafting was used to further promote bone fusion (Fig. 8B, C and D). Reconstruction of the ankle mortise is necessary for children to avoid late ankle deformity or instability, and these patients may be candidates for arthrodesis later in life (31). However, if the lateral malleolus has a residual of less than 3 cm, bone and soft tissue reconstruction should be preferred, also in young patients (18).
Artistic drawing realized by AA shows techniques of ankle arthrodesis: (A) retrograde nail for tibiotalocalcaneal arthrodesis; (B) ankle arthrodesis with fibular graft fixed with plate and screws; (C) ankle arthrodesis with hemifibular allograft fixed with screws; and (D) ankle arthrodesis with allograft in case of fibular resection together with distal tibiofibular joint and lateral cortex of the distal tibia.
Citation: EFORT Open Reviews 9, 6; 10.1530/EOR-23-0159
Conclusion
Limb salvage surgery appears to be a viable option for addressing tumors in the distal fibula. However, to mitigate potential complications affecting ankle function, post-surgical reconstruction is usually considered. Considering that there are certainly not enough numbers to reach any conclusion about risk/benefit ratio, our recommendations stem from a combination of our clinical experiences and a review of available literature. We advocate for soft tissue reconstructions as a standard practice to enhance joint stability post-fibular resection. In cases where bone reconstruction is necessary, our preference for utilizing the reversed vascularized fibula technique in younger patients and those with bone defects exceeding 3 cm is based on considerations of potential benefits and outcomes. Similarly, we suggest considering arthrodesis in adult patients. Additionally, when feasible for oncological reasons, preserving the residual peroneal malleolus and employing augmentation with sliding ipsilateral fibular graft is favored in our practice. While these recommendations align with our professional judgment, we acknowledge that individual circumstances may vary, and other approaches may also warrant consideration.
ICMJE Conflict of Interest Statement
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the study reported.
Funding Statement
The authors received no funding for the research. Open access fee was funded by Department of Surgery, Oncology and Gastroenterology (DISCOG) of University of Padova.
Author contribution statement
Conceptualization, project administration: AA, IB; data curation and formal analysis: IB, MP, CB, MC; supervision: AA, PR; writing – original draft: IB, MP; writing – review and editing: AA, GT, DRG; drawings: AA. All authors read and agreed to the final version of the manuscript.
Acknowledgements
The original artistic works are available after direct contact with the author (AA) at andrea.angelini@unipd.it.
References
- 1↑
Ruggieri P, Angelini A, Jorge FD, Maraldi M, & Giannini S. Review of foot tumors seen in a university tumor institute. Journal of Foot and Ankle Surgery 2014 53 282–285. (https://doi.org/10.1053/j.jfas.2014.01.015)
- 2↑
Murai NO, Teniola O, Wang WL, & Amini B. Bone and soft tissue tumors about the foot and ankle. Radiologic Clinics of North America 2018 56 917–934. (https://doi.org/10.1016/j.rcl.2018.06.010)
- 3↑
Unni KK, & Inwards CY. Dahlin’s Bone Tumors: General Aspects and Data on 10,165 Cases. Philadelphia: Lippincott Williams & Wilkins 2010.
- 4↑
Arikan Y, Misir A, Ozer D, Kizkapan TB, Yildiz KI, Saygili MS, Incesoy MA, Dincel YM, Gursu SS, & Sahin V. The incidence and distribution of primary fibula tumors and tumor-like lesions: a 35-year experience. Journal of Orthopaedic Surgery 2018 26 2309499018798180. (https://doi.org/10.1177/2309499018798180)
- 5↑
Norman-Taylor FH, Sweetnam DI, & Fixsen JA. Distal fibulectomy for Ewing’s sarcoma. Journal of Bone and Joint Surgery 1994 76 559–562. (https://doi.org/10.1302/0301-620X.76B4.8027140)
- 6↑
Saadon I, Amit B, Zolquarnian A, & Muhamad F. Primary osteosarcoma of the distal fibula treated with distal fibulectomy with a five-year follow-up: a case report. Malaysian Orthopaedic Journal 2017 11 64–67. (https://doi.org/10.5704/MOJ.1707.010)
- 7↑
Vaseenon T, Saengsin J, Kaminta A, Pattamapaspong N, Settakorn J, & Pruksakorn D. Ankle ligament reconstruction after wide resection of the osteosarcoma of the distal fibula: a case report. BMC Research Notes 2017 10 769. (https://doi.org/10.1186/s13104-017-3097-4)
- 8↑
Zeytoonjian T, Mankin HJ, Gebhardt MC, & Hornicek FJ. Distal lower extremity sarcomas: frequency of occurrence and patient survival rate. Foot and Ankle International 2004 25 325–330. (https://doi.org/10.1177/107110070402500509)
- 9↑
San-Julian M, Duart J, de Rada PD, & Sierrasesumaga L. Limb salvage in Ewing’s sarcoma of the distal lower extremity. Foot and Ankle International 2008 29 22–28. (https://doi.org/10.3113/FAI.2008.0022)
- 10↑
Nunez-Villaveiran T, Zamora P, Masia J, & Fernández-Garrido M. Ankle joint salvage surgery with an ipsilateral mid-fibula osteocutaneous free flap and contralateral anterolateral thigh free flap: a case report and literature review. Microsurgery 2022 42 490–499. (https://doi.org/10.1002/micr.30864)
- 11↑
Li X, Zhang Y, Wan S, Li H, Li D, Xia J, Yuan Z, Ren M, Yu S, Li S, et al.A comparative study between limb-salvage and amputation for treating osteosarcoma. Journal of Bone Oncology 2016 5 15–21. (https://doi.org/10.1016/j.jbo.2016.01.001)
- 12↑
Monson DK, Vojdani S, Dean TJ, & Louis-Ugbo J. Lateral ankle stabilization after distal fibular resection using a novel approach: a surgical technique. Clinical Orthopaedics and Related Research 2014 472 1262–1270. (https://doi.org/10.1007/s11999-013-3408-6)
- 13↑
Nadkarni S, Punit AS, & Nair RV. Giant cell tumour of distal fibula managed by en block resection and reconstruction with ipsilateral proximal fibula. Journal of Orthopaedic Case Reports 2015 5 52–54. (https://doi.org/10.13107/jocr.2250-0685.255)
- 14↑
Angelini A, Biz C, Cerchiaro M, Longhi V, & Ruggieri P. Malignant bone and soft tissue lesions of the foot. Journal of Clinical Medicine 2023 12 3038. (https://doi.org/10.3390/jcm12083038)
- 15↑
Jones RB, Ishikawa SN, Richardson EG, & Murphy GA. Effect of distal fibular resection on ankle laxity. Foot and Ankle International 2001 22 590–593. (https://doi.org/10.1177/107110070102200711)
- 16↑
Bozkurt M, Yavuzer G, Tönük E, & Kentel B. Dynamic function of the fibula. Gait analysis evaluation of three different parts of the shank after fibulectomy: proximal, middle and distal. Archives of Orthopaedic and Trauma Surgery 2005 125 713–720. (https://doi.org/10.1007/s00402-005-0054-9)
- 17↑
Prajapati A, Gulia A, Hegde P, & Puri A. Is minimal reconstruction (meshplasty) adequate to restore ankle function after excision of distal fibula tumors? Journal of Clinical Orthopaedics and Trauma 2020 11 467–470. (https://doi.org/10.1016/j.jcot.2020.03.023)
- 18↑
Khal AA, Zucchini R, Giannini C, Sambri A, Donati DM, & De Paolis M. Distal fibula reconstruction in primary malignant tumours. Current Oncology 2021 28 3463–3473. (https://doi.org/10.3390/curroncol28050299)
- 19↑
Hanafy M, Schwonzen M, Kuhnen C, Schley B, & Wilke A. Primary leiomyosarcoma of the distal fibula: a case report and review of the literature. Orthopedic Reviews 2017 9 7236. (https://doi.org/10.4081/or.2017.7236)
- 20↑
Jung ST, Park HW, & Chung JY. Treatment of a severe neglected valgus deformity after excision of the distal fibula for Ewing’s sarcoma. Journal of Bone and Joint Surgery 2012 94 138–140. (https://doi.org/10.1302/0301-620X.94B1.27784)
- 21↑
Papagelopoulos PJ, Galanis EC, Mavrogenis AF, Savvidou OD, Bond JR, Unni KK, & Sim FH. Survivorship analysis in patients with periosteal chondrosarcoma. Clinical Orthopaedics and Related Research 2006 448 199–207. (https://doi.org/10.1097/01.blo.0000194684.40624.a8)
- 22↑
Papagelopoulos PJ, Savvidou OD, Mavrogenis AF, Galanis EC, Shaughnessy WJ, Unni KK, & Sim FH. Lateral malleolus en bloc resection and ankle reconstruction for malignant tumors. Clinical Orthopaedics and Related Research 2005 437 209–218. (https://doi.org/10.1097/01.blo.0000164356.99795.a2)
- 23↑
González-Herranz P, del Río A, Burgos J, López-Mondejar JA, & Rapariz JM. Valgus deformity after fibular resection in children. Journal of Pediatric Orthopedics 2003 23 55–59. (https://doi.org/10.1097/01241398-200301000-00011)
- 24↑
Mohler DG, & Cunningham DC. Adamantinoma arising in the distal fibula treated with distal fibulectomy: a case report and review of the literature. Foot and Ankle International 1997 18 746–751. (https://doi.org/10.1177/107110079701801112)
- 25↑
Ozaki T, Hillmann A, Lindner N, & Winkelmann W. Surgical treatment of bone sarcomas of the fibula. Analysis of 19 cases. Archives of Orthopaedic and Trauma Surgery 1997 116 475–479. (https://doi.org/10.1007/BF00387580)
- 26↑
Caso Martínez J, Gonzalez Acha J, Gonzalez Galarraga JI, & Sarobe Andueza JM. En-bloc resection of the distal fibula for aneurysmal bone cyst. Acta Orthopaedica Belgica 1993 59 87–89.
- 27↑
Fain JS, Unni KK, Beabout JW, & Rock MG. Nonepiphyseal giant cell tumor of the long bones. Clinical, radiologic, and pathologic study. Cancer 1993 71 3514–3519. (https://doi.org/10.1002/1097-0142(19930601)71:11<3514::aid-cncr2820711109>3.0.co;2-a)
- 28↑
Uhl RL, Segalman KA, Fetto J, & Present D. Malignant fibrous histiocytoma of the distal fibula: a case report. Bulletin of the Hospital for Joint Diseases Orthopaedic Institute 1990 50 183–188.
- 29↑
Shoji H, Koshino T, Marcove RC, & Thompson TC. Subperiosteal resection of the distal portion of the fibula for aneurysmal bone cyst. Report of two cases. Journal of Bone and Joint Surgery. American Volume 1970 52 1472–1476. (https://doi.org/10.2106/00004623-197052070-00026)
- 30↑
Lamb A, Mueller J, Levy E, Hobbs JL, & Brien E. Distal fibular excision: a review of the literature and presentation of our reconstruction technique case series. International Journal of Surgery Case Reports 2021 80 105611. (https://doi.org/10.1016/j.ijscr.2021.01.105)
- 31↑
Dieckmann R, Ahrens H, Streitbürger A, Budny TB, Henrichs MP, Vieth V, Gebert C, & Hardes J. Reconstruction after wide resection of the entire distal fibula in malignant bone tumours. International Orthopaedics 2011 35 87–92. (https://doi.org/10.1007/s00264-009-0931-x)
- 32↑
Schuurman W, & Willems WJ. Lateral ankle reconstruction using a patellar tendon graft: a case report. Journal of Foot and Ankle Surgery 2009 48 353–357. (https://doi.org/10.1053/j.jfas.2009.02.002)
- 33↑
Su EP, & Healey JH. Salvage reconstruction for lateral ankle instability using a tendon allograft. Clinical Orthopaedics and Related Research 2003 (415) 232–238. (https://doi.org/10.1097/01.blo.0000092976.12414.b0)
- 34↑
Durak K, Bilgen O, Kaleli T, & Aydinli U. Distal fibula resection in osteochondroma. Journal of International Medical Research 1996 24 381–386. (https://doi.org/10.1177/030006059602400411)
- 35↑
Capanna R, van Horn JR, Biagini R, Ruggieri P, Bettelli G, & Campanacci M. Reconstruction after resection of the distal fibula for bone tumor. Acta Orthopaedica Scandinavica 1986 57 290–294. (https://doi.org/10.3109/17453678608994394)
- 36↑
Yadav SS. Ankle stability after resection of the distal third of the fibula for giant-cell lesions: report of two cases. Clinical Orthopaedics and Related Research 1981 155 105–107. (https://doi.org/10.1097/00003086-198103000-00019)
- 37↑
Rangaswamy N, Kumar VS, Banjara R, Majeed A, Goyal D, & Khan SA. Limb salvage surgery in fungating giant cell tumors: a report of three cases. Journal of Orthopaedic Case Reports 2021 11 19–23. (https://doi.org/10.13107/jocr.2021.v11.i02.2008)
- 38↑
Ruggieri P, Montalti M, Pala E, Angelini A, Calabrò T, Errani C, & Mercuri M. Clinically significant thromboembolic disease in orthopedic oncology: an analysis of 986 patients treated with low-molecular-weight heparin. Journal of Surgical Oncology 2010 102 375–379. (https://doi.org/10.1002/jso.21645)
- 39↑
Angelini A, Tiengo C, Sonda R, Berizzi A, Bassetto F, & Ruggieri P. One-stage soft tissue reconstruction following sarcoma excision: a personalized multidisciplinary approach called “orthoplasty”. Journal of Personalized Medicine 2020 10 278. (https://doi.org/10.3390/jpm10040278)
- 40↑
Long ZY, Lu Y, Chen G, Li M, Huang M, Xiao X, Wang Z, & Li J. Lateral malleolus reconstruction after tumor resection in children: a case report and literature review. Orthopaedic Surgery 2022 14 782–786. (https://doi.org/10.1111/os.13205)
- 41↑
Karmakar A, Mondal K, Chatterjee A, Ray U, & Chakraborty S. Management of lateral malleolus giant cell tumor using A reverse proximal fibular graft-A case report. Journal of Orthopaedic Case Reports 2021 11 92–95. (https://doi.org/10.13107/jocr.2021.v11.i12.2584)
- 42↑
Wadia F, Chaudhary K, Anchan C, George S, & Dhawale A. Metachronous multicentric giant cell tumour of bone in a 12-year-old girl: a case report and review of literature. Journal of Orthopaedics, Trauma and Rehabilitation 2021 28. (https://doi.org/10.1177/22104917211021102)
- 43↑
Bhowmick K, & Boopalan PRJVC. Saving the ankle in distal fibular giant cell tumour - A case report. Journal of Clinical Orthopaedics and Trauma 2019 10 1054–1058. (https://doi.org/10.1016/j.jcot.2019.03.010) Erratum in: Journal of Clinical Orthopaedics and Trauma. 2021 11 101570.
- 44↑
Wang J, Du Z, Yang R, Tang X, & Guo W. Lateral malleolus en bloc resection for the distal fibula osteosarcoma based on a new classification and proposed reconstruction choice: analysis of 6 cases prognosis and literature review. Foot and Ankle Surgery 2020 26 855–863. (https://doi.org/10.1016/j.fas.2019.11.003)
- 45↑
Vaishya R, Kapoor C, Golwala P, Agarwal AK, & Vijay V. A rare giant cell tumor of the distal fibula and its management. Cureus 2016 8 e666. (https://doi.org/10.7759/cureus.666)
- 46↑
Gao YS, Zhang CQ, & Sheng JG. Reverse transfer of the proximal vascularized fibula to reconstruct the lateral malleolus: a case report and literature review. Journal of Foot and Ankle Surgery 2016 55 397–400. (https://doi.org/10.1053/j.jfas.2015.02.004)
- 47↑
Tomazini ACC, Carniel JP, & da Cunha LAM. Chondromyxoid fibroma of the distal fibula in a pediatric patient: a case report. Revista Brasileira de Ortopedia 2013 48 563–566. (https://doi.org/10.1016/j.rboe.2013.12.005)
- 48↑
Jamshidi K, Mazhar FN, & Masdari Z. Reconstruction of distal fibula with osteoarticular allograft after tumor resection. Foot and Ankle Surgery 2013 19 31–35. (https://doi.org/10.1016/j.fas.2012.09.001)
- 49↑
Lampasi M, Magnani M, & Donzelli O. Aneurysmal bone cysts of the distal fibula in children: long-term results of curettage and resection in nine patients. Journal of Bone and Joint Surgery 2007 89 1356–1362. (https://doi.org/10.1302/0301-620X.89B10.19375)
- 50↑
Leichtle CI, Leichtle UG, Gärtner V, Schimmel H, Hartmann JT, & Rudert M. Multiple skeletal metastases from a giant cell tumour of the distal fibula with fatal outcome. Journal of Bone and Joint Surgery 2006 88 396–399. (https://doi.org/10.1302/0301-620X.88B3.16606)
- 51↑
Shah ZK, Peh WCG, Shek TWH, Wong JWK, & Chien EP. Hemangioendothelioma with an epithelioid phenotype arising in hemangioma of the fibula. Skeletal Radiology 2005 34 750–754. (https://doi.org/10.1007/s00256-005-0912-0)
- 52↑
Kiyokawa K, Tanaka S, Kiduka Y, Inoue Y, Yamauchi T, & Tai Y. Reconstruction of the form and function of lateral malleolus and ankle joint. Journal of Reconstructive Microsurgery 2005 21 371–376. (https://doi.org/10.1055/s-2005-915204)
- 53↑
Leibner ED, Ad-El D, Liebergall M, Ofiram E, London E, & Peyser A. Lateral malleolar reconstruction after distal fibular resection: a case report. Journal of Bone and Joint Surgery 2005 87 878–882. (https://doi.org/10.2106/JBJS.D.02539)
- 54↑
Eger W, Schörle C, & Zeiler G. Giant cell tumor of the distal fibula: fifteen-year result after en bloc resection and fibula reconstruction. Archives of Orthopaedic and Trauma Surgery 2004 124 56–59. (https://doi.org/10.1007/s00402-003-0562-4)
- 55↑
de Gauzy JS, Kany J, & Cahuzac JP. Distal fibular reconstruction with pedicled vascularized fibular head graft: a case report. Journal of Pediatric Orthopedics. Part B 2002 11 176–180. (https://doi.org/10.1097/00009957-200204000-00017)
- 56↑
Dogra AS, Kulkarni SS, & Bhosale PB. Distal fibular giant cell tumour. Journal of Postgraduate Medicine 1995 41 83–84.
- 57↑
Persson BM, & Rydholm A. Excisional biopsy for bone tumours. Archives of Orthopaedic and Traumatic Surgery 1979 94 71–74. (https://doi.org/10.1007/BF00448097)
- 58↑
Carrel WB. Transplantation of the fibula in the same leg. Journal of Bone and Joint Surgery 1938 20 627–634.
- 59↑
Panagopoulos GN, Mavrogenis AF, Mauffrey C, Lesenský J, Angelini A, Megaloikonomos PD, Igoumenou VG, Papanastassiou J, Savvidou O, Ruggieri P, et al.Intercalary reconstructions after bone tumor resections: a review of treatments. European Journal of Orthopaedic Surgery & Traumatology 2017 27 737–746. (https://doi.org/10.1007/s00590-017-1985-x)
- 60↑
Gümüştaş SA, Çevik HB, & Kayahan S. An epidemiological study of primary bone tumors of the fibula. Archives of Bone and Joint Surgery 2021 9 548–553. (https://doi.org/10.22038/abjs.2020.47057.2299)
- 61↑
Perisano C, Marzetti E, Spinelli MS, Graci C, Fabbriciani C, Maffulli N, & Maccauro G. Clinical management and surgical treatment of distal fibular tumours: a case series and review of the literature. International Orthopaedics 2012 36 1907–1913. (https://doi.org/10.1007/s00264-012-1536-3)
- 62↑
Rizzo M, Scully SP, & Harrelson JM. Ipsilateral fibular slide grafts in the management of distal fibula lesions. Foot and Ankle International 1999 20 135–136. (https://doi.org/10.1177/107110079902000212)
- 63↑
Appy-Fedida B, Krief E, Deroussen F, Plancq MC, Collet LM, Klein C, & Gouron R. Mitigating risk of ankle valgus from ankle osteochondroma resection using a transfibular approach: a retrospective study with six years of follow-up. Journal of Foot and Ankle Surgery 2017 56 564–567. (https://doi.org/10.1053/j.jfas.2017.01.029)
- 64↑
Callan AK, Singleterry S, Czerniak BA, Selber JC, & Satcher RL. Total tibial allograft reconstruction for adamantinoma: a case report with 2-year follow-up. JBJS Case Connector 2020 10 e20.00046. (https://doi.org/10.2106/JBJS.CC.20.00046)
- 65↑
Yoshida S, Murakami T, Suzuki K, Itou S, Watanuki M, Hosaka M, & Hagiwara Y. Adamantinoma arising in the distal end of the fibula. Rare Tumors 2017 9 6823. (https://doi.org/10.4081/rt.2017.6823)
- 66↑
Mansour TM, & Ghanem IB. Preliminary results of the induced membrane technique for the reconstruction of large bone defects. Journal of Pediatric Orthopedics 2017 37 e67–e74. (https://doi.org/10.1097/BPO.0000000000000663)
- 67↑
Bisbinas I, Karabouta Z, Georgiannos D, Lampridis V, & Badekas A. Multifocal epithelioid hemangioendothelioma of the foot and ankle: a case report. Journal of Orthopaedic Surgery 2014 22 122–125. (https://doi.org/10.1177/230949901402200130)
- 68↑
Chotel F, Nguiabanda L, Braillon P, Kohler R, Bérard J, & Abelin-Genevois K. Induced membrane technique for reconstruction after bone tumor resection in children: a preliminary study. Orthopaedics & Traumatology, Surgery & Research 2012 98 301–308. (https://doi.org/10.1016/j.otsr.2011.11.008)
- 69↑
Lee SH, Kim HS, Park YB, Rhie TY, & Lee HK. Prosthetic reconstruction for tumours of the distal tibia and fibula. Journal of Bone and Joint Surgery 1999 81 803–807. (https://doi.org/10.1302/0301-620x.81b5.9588)
- 70↑
Abuhassan FO, & Shannak AO. Subperiosteal resection of aneurysmal bone cysts of the distal fibula. Journal of Bone and Joint Surgery 2009 91 1227–1231. (https://doi.org/10.1302/0301-620X.91B9.22395)
