Effect of distal fibular resection on ankle laxity

Case report: Individualized 3D-printed uncemented distal fibular prosthesis preserving the lateral malleolus for repair of distal fibular defects

Background

Involvement of the distal fibula by alveolar soft-part sarcoma is rare. Extensive resection or amputation may be needed; however, distal fibula resection can disrupt foot and ankle biomechanics, leading to ankle joint instability. Reports on joint preservation for maintaining optimal ankle joint function are scarce. Computer-aided design and individualized three-dimensional (3D)-printed uncemented implants represent an evolving solution for reconstructing the distal fibula.

Case presentation

A 34-year-old woman was diagnosed with alveolar soft-part sarcoma in the right lower leg involving the cortical bone of the fibula. After anlotinib treatment, the tumor size decreased, and the tumor response rate was a partial response (PR); however, the patient continued to experience adverse reactions. With multiple disciplinary team discussions, surgical resection was deemed appropriate. Due to the extensive defect and ankle joint instability after resection, a custom-made 3D-printed prosthesis was designed and fabricated to reconstruct the defect, preserving the lateral malleolus. During the follow-up, the patient achieved favorable ankle function, and no prosthesis-related complications were observed.

Conclusion

3D-printed personalized uncemented implants constitute a novel approach and method for addressing the reconstruction issues of the distal fibula and ankle joint. Through the personalized design of 3D-printed prostheses, the lateral malleolus can be preserved, ensuring the normal anatomical structure of the ankle joint. They achieve a well-integrated interface between the prosthesis and bone, ensuring satisfactory postoperative function. Additionally, they offer valuable insights for reconstructing distal bone defects near joints in the extremities. However, confirming these findings requires extensive cohort studies.

Distal Fibular Reconstruction Using Iliac Grafting and Emslie-Vidal's Ligamentoplasty after Exeresis of Single Renal Carcinoma Metastasis

Introduction. Restoring lateral ankle stability following distal resection of the fibula is a difficult procedure for which several surgical techniques have been proposed. Each of these techniques has potential drawbacks. This report presents a new option for fibular reconstruction. Case Study. We report the case of a 68-year-old male with evolving pain in the left ankle throughout the past 3 months. Three years prior to consultation, he underwent left nephrectomy for clear-cell adenocarcinoma. A swelling on the external side of the left ankle was noticed upon clinical examination, with no signs of inflammation. The ankle was stable with normal mobility. Radiographic examination revealed a 4 cm lytic lesion on the lateral malleolus with internal and external cortical damages as well as invasion of the soft tissues. Neither lower peroneotibial nor tibiotarsial joints were invaded. Needle biopsy confirmed the presence of metastatic renal clear-cell adenocarcinoma. Consequently, large exeresis of this single metastasis was indicated while preserving functional integrity of the ankle. Following block resection of the distal fibula including the lower tibioperoneal joint, a bicortical autograft was positioned to abut against the external side of the talus. Emslie-Vidal's ligamentoplasty procedure was performed with half of the short peroneal passed under the pedal flexor, then in the bone abutment, and finally through a calcaneal bone tunnel. Peroneus muscles were stabilized using a fragment sampled from the Achilles tendon. Pain decreased in 3 months, and the ankle was stable with normal functionality at a 5-year follow-up. Discussion. Reconstruction of the lateral ankle following fibular resection is possible by reconstructing the external facet of the malleolus using an autograft associated with Emslie-Vidal's ligamentoplasty procedure, hence stabilizing both tibiotalar and subtalar joints. This surgical procedure allowed the patient to return to his daily activities with neither instability nor evolution towards short-term tibiotalar arthrosis.

Is minimal reconstruction (meshplasty) adequate to restore ankle function after excision of distal fibula tumors?

BACKGROUND

Reconstruction modalities described after distal fibula resection varies from no reconstruction to size matched allograft or reconstruction with ipsilateral proximal fibula. Every procedure has their own limitation. We used Prolene mesh to reconstruct lateral restraint (Meshplasty) after distal fibulectomy.

QUESTION

Is a minimal reconstruction using prolene mesh (meshplasty) adequate to restore ankle stability and function post distal fibula resection?

METHOD

This retrospective analysis was performed in patients who underwent distal fibulectomy at the tertiary cancer hospital in India, between 01/01/2006 and 31/12/2016. Distal fibulectomy was performed through standard lateral approach. A prolene mesh was anchored to distal tibia and talus using screws or Ethibond sutures. Rehabilitation protocol included below knee cast for 6 weeks followed by gradual full weight bearing mobilization and ankle range of motion. Total 9 patients with mean age of 25 years (range: 13-43) got operated for distal fibulectomy during this period. Mean resection length was 13.3 cm (range: 9-20).

RESULTS

Seven patients were available for final assessment at a median follow-up duration of 78 months (range: 34-161 months). Two patients developed local recurrence. Two patients developed distant recurrence both died of disease. One patient of GCT developed local recurrence in soft tissue at 30months, which was excised. Another patient of OGS developed local recurrence after 8 months along with distant recurrence. One patient of PNET developed distant recurrence at 3 months. One patient had a valgus deformity at 55 months follow up without any restriction of activity while the others had a stable ankle without any deformity. The mean MSTS score was 28 (24-29).

CONCLUSION

"Meshplasty" after distal fibulectomy is an easy, reproducible, time and cost effective reconstruction modality with minimal complications. It adequately restores ankle function while providing results comparable to other procedures.

LEVEL OF EVIDENCE

IV.

Arthroscopic ankle fusion to manage sequel of loss of lateral malleoli in compound crushed ankle injury

Defect in the lateral malleolus along with lateral ligamentous injury of ankle is rare. It occurs mainly due to resection of distal fibula tumors and severe trauma leading to loss of lateral malleolus. Lateral malleoli has the major contribution in weight transmission to foot and ankle stability. To avoid persistent pain and gait abnormality due to ankle instability, reconstruction of bony defect is inevitable. Methods to address these defects are iliac crest bone grafting, vascular and nonvascular proximal fibula transfer, patella tendon bone graft and allograft. Donor site morbidity, allograft related problems are not rare. Arthrodesis of ankle gives painless stable joint. Arthrodesis can be performed by open and arthroscopic methods. Open method has more soft tissue dissection and too difficult in scenario with previous skin grafting with adherent skin to bone. We managed a case of compound ankle injury with loss of lateral malleolus with loss of lateral ligament in stages, first management of compound crushed ankle followed by arthroscopic ankle arthrodesis. Even after 6 year of follow patient has stable pain less ankle with satisfactory gait.

Adamantinoma Arising in the Distal End of the Fibula

Adamantinoma is a rare, low-grade, malignant bone tumor. It frequently occurs in the tibia but rarely arise in the distal end of the fibula. This study reported a case of adamantinoma arising in the distal end of the fibula, resulting in good prognosis. A 38-year old female felt left ankle pain, and was suspected as having a bone tumor at the distal end of the fibula by X-ray. She was diagnosed as the classical adamantinoma of the fibula by open biopsy. En bloc wide resection of the tumor, primary arthrodesis of the ankle was performed. During the follow-up period of 7 years after the surgery, she has lived without any metastasis and local recurrence. A wide resection and arthrodesis of the ankle joint can provide a good outcome for adamantinoma arising in the end of the fibula.

Giant Cell Tumour of Distal Fibula Managed by En Block Resection and Reconstruction with Ipsilateral Proximal Fibula

Introduction:

Giant cell tumour is the commonest benign bone tumour arising at the epiphyseometaphyseal regions of long bones. Around the knee is commonest site followed by distal radius. A giant cell tumour of the distal fibula is extremely rare. We report here a case of giant cell tumour of distal fibula. There are very few similar cases reported worldwide and it is the purpose of this report to describe the management of such a case.

Case Report:

A 17 year old girl presented with swelling of ankle and pain while walking for six months. Radiographs were suggestive of a giant cell tumour, computerised tomography revealed cortical break, en block resection was done with ipsilateral proximal fibula used in reconstruction of ankle mortise.

Conclusion:

Giant cell tumour of long bones are common but those involving the distal fibula are exceedingly rare. The management of such tumours with high recurrence rates can be easily accomplished by en block resection and reconstruction of the ankle mortise with proximal fibula ensuring good range of motion of the joint post operatively.

Lateral ankle stabilization after distal fibular resection using a novel approach: a surgical technique

BACKGROUND

After tumor resection involving the distal fibula, the method for recreating stability of the lateral ankle remains controversial. Many reconstructive options exist, including allograft reconstruction and arthrodesis; however, each of these approaches has significant potential disadvantages.

DESCRIPTION OF TECHNIQUE

The distal fibula is resected as necessary to obtain negative margins for local control of the neoplasm. Reconstruction of the lateral ankle ligamentous complex is performed using the peroneus brevis tendon to reestablish lateral and anterior stability of the tibiotalar joint. The peroneus brevis tendon is transected proximally at it myotendinous junction and then sutured to the calcaneofibular and anterior talofibular ligaments in sequence and then tenodesed to the lateral distal tibia with suture anchors and a staple.

METHODS

We present three patients who underwent distal fibulectomy for tumors originating in the distal fibula. All patients who have undergone the reconstruction being described are included within this cohort study. The patients were assessed clinically and radiographically at a range of 14 months to 9.5 years (average, 4.8 years) for functional recovery, return of range of motion, stability of the ankle, and imaging evidence of arthrosis and instability.

RESULTS

There were no episodes of instability or early progression to arthrosis. In addition, all patients obtained excellent ankle stability and range of motion on examination, but two had complications. One sustained a traumatic fracture to the base of the fifth metatarsal that healed with nonsurgical treatment and another who underwent further fibular shortening and bursectomy at the tip of the residual fibula with complete relief of his symptoms.

CONCLUSIONS

Reconstruction of the lateral ankle after distal fibular resection is possible using the peroneus brevis tenodesed to the distal tibia and sutured to the remnants of the calcaneofibular and anterior talofibular ligaments as described in this surgical technique. In this small group, we found that patients were able to return to normal daily activities without instability or progression to tibiotalar arthrosis at short term; however, longer followup and larger series of patients are called for to confirm these findings.

Reconstruction of distal fibula with osteoarticular allograft after tumor resection

BACKGROUND

Involvement of distal fibula by benign aggressive and malignant tumors usually necessitates resection of the involved segment of fibula. Numerous techniques have been proposed to reconstruct the ankle joint after this procedure, which can result in complications. We introduce reconstruction of ankle joint by fibular osteoarticular allograft.

METHODS

Reconstruction of the distal fibula after wide resection of tumor was carried out in four patients. There were two cases of Ewing sarcoma, one case of osteosarcoma and one giant cell tumor. After wide resection of tumor, we reconstructed the lateral side of the ankle joint by osteoarticular fibular allograft, which was applied and internally fixed with semitubular plate and screws. In the follow up period, we did assessment of complications, pain and ankle joint instability.

RESULTS

The mean age of our patients was 24.2 years (12-31). The mean follow-up was 3.2 years (1.5-6.7). In follow up visits there were no signs of infection or wound healing problems. Union was achieved in all patients.

CONCLUSION

In cases of benign aggressive and malignant tumors involving the distal fibula, we can recommend resection of the distal fibula and reconstruction of the ankle with osteoarticular allograft of the distal fibula.

LEVEL OF EVIDENCE

Case series level IV.

Clinical management and surgical treatment of distal fibular tumours: a case series and review of the literature

PURPOSE

Study reports clinical and functional outcomes of surgical treatment in a case series of nine patients with distal fibular tumours.

METHODS

Nine patients with distal fibular tumours were observed between 2005 and 2010. A PubMed search was performed using the terms "fibula", "lower limb tumour [cancer]", "sarcoma", "Ewing", "peroneal", "fibular metastasis", and "limb-salvage surgery".

RESULTS

In all our patients, lesions were unilateral. All patients complained of pain; limping was present in 5 of 9 tumours. Patients were managed surgically, except one who underwent local radiotherapy. In six patients, a benign or tumor-like lesion was detected. Malignancies consisted of metastatic lung adenocarcinoma (two cases) or multifocal mesenchymal cancer (one case). Non-malignant lesions were treated by curettage and filling, followed by internal fixation when needed. In malignant or locally aggressive lesions, metadiaphyseal fibular resection was performed. The literature search retrieved either case reports or small case series, reflecting the rarity of distal fibular tumours. Surgical treatment was successful in all patients with benign lesions, whereas the rate of success was 40-100 % in case of malignancies.

CONCLUSIONS

Given the low incidence of distal fibular tumours, controversies exist about the optimal surgical management. Clinical observation and imaging should be reserved to asymptomatic benign lesions. In non-malignant tumours causing pain, limping, and pathological fractures; in malignancies, surgery is recommended. Finally, in patients with asymptomatic lesions of uncertain nature, biopsy and histological examination should be performed to plan appropriate management.

Treatment of a severe neglected valgus deformity after excision of the distal fibula for Ewing's sarcoma

In distal fibular resection without reconstruction, the stabilising effect of the lateral malleolus is lost. Thus, the ankle may collapse into valgus and may be unstable in varus. Here, we describe a child who underwent successful staged surgical correction of a severe neglected valgus deformity after excision of the distal fibula for a Ewing's sarcoma.

Reconstruction after wide resection of the entire distal fibula in malignant bone tumours

In this study we present a series of patients (n = 11) with resection of the entire distal fibula in the case of sarcoma or metastasis. Moreover, we describe a new method to restore ankle stability with a tibiotalocalcaneal arthrodesis using a retrograde hindfoot nail (n = 4) in contrast to tibiotalar arthrodesis with screws (n = 5). The screw fixation failed in two patients due to osteopoenic bone. The crucial benefits of an arthrodesis with a retrograde nail are a stable arthrodesis, intramedullary stabilisation of the tibia and avoidance of extrinsic material in the wound area. An arthrodesis with a retrograde nail is a good alternative for reconstruction after a wide distal fibula resection. The additional arthrodesis of the subtalar joint was not associated with worse functional results in the MSTS and TESS scores.

Anatomic factors and biomechanics in ankle instability

Ankle sprains are common in both sport and leisure activities. Despite the high success rates of conservative management, approximately 10% to 30% patients develop chronic instability. Surgery yields high success rates, but clinical problems such as functional and mechanical instability, persistent talar tilt, range of motions limitations, and pain may persist despite surgery.

Distal fibular length needed for ankle stability

BACKGROUND

The fibula is commonly used for bone grafts. Previous clinical and biomechanical studies have suggested that the length of the residual portion of the distal part of the fibula has an important effect on the long-term stability of the ankle joint. However, we cannot find clear-cut guidelines for the amount of bone that can be harvested safely.

METHODS

Using six normal fresh-frozen cadaver legs, motions of the tibia, talus and calcaneus were measured. The fibula was cut sequentially 3 cm from the proximal tip of the fibula and distally 10 cm, 6 cm, and 4 cm from the distal tip of the lateral malleolus. The angular motion of each bone was measured while a medial and lateral traction force of 19.6 N was applied to the proximal tibia. Angles of the tibia, talus, and calcaneus were measured.

RESULTS

Sequential resection of the fibula increased the inversion angles of the ankle joint. The proximal 3-cm cut increased the inversion angle from 42.1 +/- 6.2 degrees to 49.6 +/- 3.6 degrees, and the distal 4-cm cut increased the angle from 57.6 +/- 6.6 degrees to 67.4 +/- 5.9 degrees. The rotational angles were almost constant with sequential resections of the fibula; however, the distal 4-cm cut increased the rotational angle from 11.3 +/- 25.1 degrees to 78.7 +/- 37.5 degrees.

CONCLUSIONS

The whole fibula including the head is essential for the stability of the ankle joint complex, and the distal fibula is responsible for stabilizing the ankle mortise during external rotation and inversion. We recommend fixation of the syndesmosis or bracing to prevent ankle joint instability with rotation of the talus in the mortise, especially when the distal fibula is shortened 6 cm or more.

[Distal fibula reconstruction using a frozen allograft: a case report]

We report the case of a 25-year-old woman who developed recurrent chondromyxoid fibroma involving the distal portion of the right fibula. This patient had been treated two years earlier with curettage without grafting. The treatment associated en bloc resection of the distal 12 cm of the fibula and reconstruction with a cryopreserved allograft fixed with a lateral plate and pin associated with a syndesmodesis screw for six weeks. The lateral collateral ligament and the tibiofibular ligaments were also repaired. At two years, the patient has no sign of recurrence and the ankle motion is satisfactory. The ankle is stable and pain free with an esthetic aspect similar to the healthy side. Allograft reconstruction is a novel alternative for reconstruction of the distal fibula. We have found only one other case reported in the literature.

Lateral malleolus en bloc resection and ankle reconstruction for malignant tumors

Four children and six adults required en bloc resection of the lateral malleolus for malignant tumors. There were four osteosarcomas, three chondrosarcomas, two Ewing's sarcomas, and one adamantinoma. Surgical margins were wide in seven patients, marginal in two, and intralesional in one. A primary ankle arthrodesis was done in four adults and bracing without any reconstruction was done in four children and two adults. During a mean followup of 14.5 years (range, 3-30 years), there were two local recurrences (two of 10 patients) after a marginal excision and an intralesional excision. One patient had reoperation for a skip osteosarcoma lesion in the proximal fibula. Other complications included chronic osteomyelitis, a lateral talus subluxation and cavovarus deformity, and recurrent ankle instability and degenerative changes of the ankle. At the latest followup, all 10 patients showed no evidence of disease. Five patients who had primary or late ankle arthrodesis had a Musculoskeletal Tumor Society and International Society of Limb Salvage functional score of 28 points (92%), and two adolescents who had postoperative bracing alone had a functional score of 24 points (80%). The three remaining patients had a salvage amputation.

LEVEL OF EVIDENCE

Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

Salvage reconstruction for lateral ankle instability using a tendon allograft

Lateral ligamentous instability may result after an inversion injury to the ankle. Although it generally responds well to nonsurgical treatment, recurrent cases may warrant surgical intervention. There is extensive literature detailing various procedures designed to restore lateral ankle stability. We describe a case in which a patient had a distal fibulectomy for multiple symptomatic osteochondromas, with reconstruction of the lateral ligament complex using peroneus brevis tendon. The patient subsequently disrupted this surgical construct with a severe inversion injury and had recurrent lateral ankle instability. The lateral ligament complex then was reconstructed using a tibiotalar bone-tendon allograft directed to counteract inversion forces. Fourteen years after the procedure, the patient remains satisfied with a painless, stable ankle. The described technique provides a salvage reconstruction of the lateral ligament complex using allograft tissue, in the unique setting of an absent fibula and deficient peroneus brevis tendon.