Ankle joint salvage surgery with an ipsilateral mid‐fibula osteocutaneous free flap and contralateral anterolateral thigh free flap: A case report and literature review

Abstract

The tibiofibular joint can be reconstructed after distal fibular sarcoma salvage surgery to maintain ankle stability and achieve early gait. Classical reconstructive options include ligamentoplasties, arthrodesis, prosthetic replacement, bone grafts, and pedicled ipsilateral or free contralateral fibular bone flaps. We present a novel strategy for reconstruction of the ankle in an elderly patient and a literature review. A 68-year-old man presented with a high-grade myxofibrosarcoma to his distal fibula.Wide resection of the tumor and adjacent structures left a 12 Â 12 Â 8 cm defect including the distal fibula (10 cm), a 2 cm fragment of the lateral cortex of the tibia, the lateral anterior and superficial posterior compartments, and the lateral compartment. A 3 cm distal fibula remnant was left in the ankle mortice. Reconstruction was performed using a free ipsilateral 13-cm diaphyseal osteocutaneous fibular flap telescoped into the distal fibula remnant and anastomosed to the anterior tibial artery. A pre-bent L-shaped locking plate was used to reconstruct a syndesmotic joint. A 21 Â 13 cm suprafascial ALT flap was anastomosed to the proximal stump of the peroneal artery to cover the soft tissue defect. The patient had no complications and was ambulating with full weight bearing by postoperative week 11. He received postoperative chemo and radiotherapy. Three years postoperatively, he is tumor free, has complete ankle ROM and stability, and ambulates with no restrictions. Limb sparing surgery with a functional tibiofibular joint reconstruction should be considered to attain an early functional recovery after distal fibula sarcomas resection.

Reconstructive surgery after distal fibular resection due to bone tumors: a technical report on surgical strategies and results from the PROSPERO international register of systematic reviews

“…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 ).…”

“…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 ).…”

“…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 ).…”

“…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).…”

“…(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).…”