Fibulectomy for Primary Proximal Fibular Bone Tumors

Abstract

Background:Primary benign and malignant tumors of the proximal fibula are not very common. Upper fibula being an expendable bone; the majority of the primary bone tumors at this site are usually treated with en bloc proximal fibulectomy. There is scarce literature on functional results, difficulties faced during dissection when to preserve or sacrifice common peroneal nerve and importance of lateral collateral ligament repair after proximal fibulectomy. The present study attempts at assessing these variables.Materials and Methods:This retrospective study included 46 patients; 30 males and 16 females with age ranging from 12 to 44 years (average: 26 years) operated between 2003 and 2014. There were 34 benign and 12 malignant tumors. All were treated with proximal en bloc fibulectomy as indicated and decided by the operating surgeon keeping in view its extent on magnetic resonance imaging. Peroneal nerve sacrifice or preservation was decided as per the type (benign/malignant), its involvement by the tumor and the extent of the tumor. In 14 (for 12 malignant and two benign giant cell tumors [GCTs]) patients, the peroneal nerve required resection for the margins. Partial upper tibial resection was performed in cases of malignant tumors and three GCTs. The followup ranged between 24 and 120 months (median: 48 months).Results:Patients with peroneal nerve resection had inferior functional outcome than those without peroneal nerve resection. There was no higher risk of tibia fracture in patients with partial tibial resection. Lateral collateral reconstruction yielded better results and should be performed in all cases. Functional outcome was significantly better in patients with benign tumors than in patients with malignant tumors as these required neither resection of the peroneal nerve nor large amount of muscle excision. The functional results were evaluated using Musculoskeletal Tumor Society (MSTS) score, and clinical outcomes were evaluated using knee and ankle movements and stability. The overall average MSTS score was 26.50.Conclusions:With good reconstruction of lateral ligament we can achieve good results after proximal fibulectomy for benign as well as malignant tumor without much instability. With partial upper tibial resection (i.e., the extra-articular resection of proximal tibiofibular joint) adequate margins are feasible even in malignant tumors.

Surgical Management of Benign Tumors of the Proximal Fibula

“…The proximal fibula is surrounded by neurovascular and anatomical structures, which necessitate careful surgical attention. 10 The peroneal nerve passes over the fibular neck before dividing into the superficial and deep branches, respectively. Damage to the peroneal nerve may result in sensation deficits over the lateral lower leg with a resultant weakness of foot dorsiflexion and eversion.…”

“… 26 , 38 - 40 Although nonsurgical interventions are a viable initial treatment for select latent lesions, surgical interventions serve the primary role in definitive tumor management in some cases of the proximal fibula. 1 , 10 , 41 …”

“…The surgeon must account for tumor type, size, probability of recurrence, and postoperative functional outcomes (including potential peroneal nerve palsy and ligamentous instability). 7 , 9 , 10 , 12 …”

“… 45 46 47 48 Given the low reported recurrence rates, intralesional and marginal excisions provide the added benefit of decreased risk of iatrogenic neurovascular and anatomical compromise in this sensitive region. 10 En bloc type I resections have been described for benign nonaggressive tumors of the proximal fibula but are typically reserved for rapidly growing, locally destructive lesions with potential for malignant transformation. 7 , 10 , 31 , 54…”

“… 8 , 9 As a result, establishing local tumor control and minimizing joint disturbance can pose a challenge for the orthopaedic surgeon. 10 The ideal surgical outcome maximizes postoperative limb functionality and minimizes the risk of tumor recurrence. Classic thinking has favored minimally invasive excisions over wide resections in the fibula for this purpose, although categorical indications for deciding among procedures have not been established because of a paucity of large-scale comparisons.…”