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

Abstract

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.

Ipsilateral Nonvascularized Autograft and Periosteal Repair for the Treatment of Pediatric Tumors of the Distal Fibula

“…The fibula is affected in only 2.4% of primary bone tumors. 12 Tumors most commonly affecting the fibula include giant cell tumor of bone (GCT) and Ewing's sarcoma, which have an incidence of 1% and 8%, respectively. 12 Occurrence of fibular osteosarcoma has also been reported (2%-5.6%); its occurrence specifically in the distal fibula is extremely low at 0.47%.…”

“…12 Tumors most commonly affecting the fibula include giant cell tumor of bone (GCT) and Ewing's sarcoma, which have an incidence of 1% and 8%, respectively. 12 Occurrence of fibular osteosarcoma has also been reported (2%-5.6%); its occurrence specifically in the distal fibula is extremely low at 0.47%. 9,13 Because the fibula is a dispensable bone, wide resection is considered easier to achieve when compared with other locations.…”

“…14 Resections in the middle portion are not technically demanding and do not require reconstruction. 12 In contrast, management of proximal and distal fibular tumors is more difficult. 5,6 Resections in the proximal fibula are challenging due to the proximity of the common peroneal nerve and the anterior tibial artery.…”

Clinical, Radiological and Surgical Pitfalls in Fibular Tumors

“…Distal fibula tumors are rare and when compared with the proximal zone, its surgical resection is easier and its prognosis is better due to its being far from neurovascular structures (24). However, it should be protected due to its importance in ankle instability (3). If the fibula distal can be protected less than 3-5 cm., it should be secured with syndesmosis screws.…”

“…In distal fibula, ligament reconstruction or arthrodesis methods are applied to increase ankle stability (3,4). However, since fibula tumors are rare and since it is not possible to get ideal resection all the time, it may cause some complications such as instability in joints and local relapse in tumor.…”