Fibular Resections



Fibular Resections


Jacob Bickels

Kristen Kellar-Graney

Martin M. Malawer



BACKGROUND



  • The fibula is a rare anatomic location for both primary and metastatic bone tumors.1 When tumor does occur, it most commonly involves the proximal fibula, followed by the fibular diaphysis and the distal fibula.


  • Chondrosarcoma, osteosarcoma, and benign aggressive cysts constitute the most common histologic subtypes of fibular tumors (Table 1).


  • Primary bone sarcomas of the fibula have traditionally been treated with above-knee amputations. Increased use of limbsparing procedures stimulated an interest in the surgical anatomy in this area and the possibility that tumors of the fibula might be safely resected.2,3,4,5,6,7


ANATOMY


Proximal Fibula



  • The proximal fibula is the attachment site for the lateral collateral ligament (LCL) and biceps femoris tendon and therefore has a role in determining lateral knee joint stability.


  • The peroneal nerve turns around the base of the fibular head to enter the peroneus longus tunnel (FIG 1).


Fibular Diaphysis



  • The fibular diaphysis is circumferentially surrounded by muscle origins at all aspects and anatomic levels.


Distal Fibula



  • The distal fibula is a subcutaneous structure with minimal soft tissue coverage.








    Table 1 Tumors of the Proximal Fibula by Histologic Subtype, 1990-2014

































    Tumor

    No.


    Benign aggressive cysts (GCTs and ABCs)

    18


    Chondrosarcoma

    16


    Osteosarcoma

    5


    Ewing sarcoma

    7


    Osteochondroma

    11


    Enchondroma

    9


    Other

    10


    Metastatic carcinomas to bone

    2


    Total

    78



  • It is the attachment site for the tibiofibular and calcaneofibular ligaments and therefore has a role in determining lateral ankle joint stability.




INDICATIONS



  • Benign aggressive tumors


  • Primary sarcomas of bone






    FIG 1 • A. The LCL and biceps femoris tendon attach to the fibular head, and the peroneal nerve turns around the base of the fibula to enter the peroneus longus tunnel. B. Intraoperative photograph showing the peroneal nerve (N) as it enters the peroneus longus tunnel (open arrow). This tunnel has been opened to show the course of the nerve around the base of the fibular head. The biceps tendon (Bi) inserts on the fibular head away from the peroneal nerve. Vessel loops on the peroneal nerve are used to provide gentle traction for the dissection of the nerve branches.







    FIG 2 • A. Computed axial tomography of the proximal fibula shows an intermediate-grade fibrosarcoma with cortical breakthrough and extraosseous extension. B,C. Coronal and axial magnetic resonance images of the proximal fibula, respectively, showing a high-grade osteosarcoma with cortical breakthrough and extension to the anterior and lateral compartments of the leg. (Courtesy of Martin M. Malawer.)


  • Metastatic lesions of the fibula are usually treated with radiation therapy and rarely require surgery. This is because the fibula is not a major weight-bearing structure and bone destruction at that site does not compromise the mechanical stability of the lower extremity.


  • Above-knee amputation is considered when a malignant tumor grossly invades the tibia or there is extensive multicompartmental involvement, especially the posterior deep compartment.


IMAGING AND OTHER STAGING STUDIES



  • In staging fibular tumors, emphasis is placed on the extent of bone destruction, intramedullary involvement, and soft tissue extension. Special attention is also given to the relation of the tumor to the peroneal nerve, blood vessels, and tibia.


  • Plain radiographs and computed tomography are required to assess the extent of bone involvement and cortical destruction. These data are completed by magnetic resonance imaging (MRI), which shows the extent of medullary and extraosseous extension (FIG 2).


SURGICAL MANAGEMENT


Positioning



  • A semisupine position (45-degree elevation of the operated side) is used to permit easy access to the anterior and lateral compartments and allow dissection of the popliteal space. The entire extremity, from the inguinal ligament to the foot, is included in the sterile field to allow evaluation of the distal foot pulses and execution of an above-knee amputation, if indicated.


  • The utilitarian fibular incision, which allows exposure and resection of tumors at all levels of the fibula, extends from the biceps above the knee joint, over the midportion of the fibula, anteriorly to the crest of the tibia, and then curves posteriorly and distally to the ankle. This permits the development of large anterior and posterior fasciocutaneous flaps.


  • The anterior compartment, the lateral compartment (peroneal musculature), and the superficial posterior compartment consisting of the lateral gastrocnemius and soleus muscle are exposed, and the popliteal space and trifurcation can be explored through this incision. The biopsy site is removed en bloc with the tumor mass (FIG 3).






FIG 3 • A. The utilitarian fibular incision extends from the biceps above the knee joint, over the midportion of the fibula, and anteriorly to the crest of the tibia, and then curves posteriorly and distally to the ankle. A component of the incision is used according to the level of resection: The proximal third is used for resection of the proximal fibula (B) and the proximal two-thirds are used for intercalary resection (C). (A: From Malawer MM. Surgical management of aggressive and malignant tumors of the proximal fibula. Clin Orthop Relat Res 1984;186:172-181.) (continued)







FIG 3 • (continued)




TECHNIQUES


▪ Proximal Fibula Resection

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Jul 22, 2016 | Posted by in ONCOLOGY | Comments Off on Fibular Resections

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