Free Fibula Reconstruction of Distal Tibial Defects After Sarcoma Surgery

Abstract

Distal tibial tumor ablation results in combined soft tissue and bone defect that involves the ankle joint. This area is unique and problematic because it combines low caliber limb size, relatively soft tissue deficiency, suboptimal bone and soft tissue healing ability, and the need to sustain increased mechanical loads. The management is difficult, controversial, and traditionally was treated by primary amputation. We present our experience with a limb sparing surgery using biological reconstruction.Between 2004 and 2007, 5 patients with malignant bone tumors of the distal tibia underwent tumor resection and reconstruction with free vascularized osteoseptocutaneous fibula flap. The average age was 33.2 years (range, 11-62 years). In all cases, a skin island was harvested and used for wound closure. Arthrodesis of the ankle joint was preformed in all patients. Double fixation system was used to provide stability and avoid flap rotation.All flaps survived. There were no major complications. One patient had partial loss of the skin paddle that was treated conservatively. Callous formation was documented after an average time of 4 months, partial weight bearing after an average time of 4 months, and full weight bearing after an average time of 11.5 months. All patients regained almost normal ambulation within a year.

Limb Salvage for Primary Malignant Bone Tumors of the Distal Leg in Skeletally Immature Patients: Ankle Arthrodesis Using Vascularized Ipsilateral or Contralateral Fibular Flap

“…19,20 The Capanna's technique, combining allograft and vascularized fibula, has been described for reconstruction of several long-bone defects but, to our knowledge, it has not been used for ankle arthrodesis. 21 This may be related to the fact that the reconstruction is too bulky for the ankle as suggested by Scaglioni et al 14 Moore et al published their results on ankle arthrodesis using allograft in nine tumor patients. 12 Six of nine patients required additional surgery including two cases of graft fracture that were managed by iliac crest bone grafting and revision of fixation.…”

“…Fractures of large segment structural bone grafts are major concern in musculoskeletal reconstructions and vascularized grafts have the advantage over allografts for the ability to heal spontaneously. 19 Several authors preferred the technique of centralization of the ipsilateral fibular graft into tibial defect 7, 15,16 while Scaglioni et al 14 published their results on the use of contralateral free vascularized fibular flap. Although we used both techni-ques, the small number of patients in both groups does not allow for a statistical comparison of the outcome.…”

Limb saving surgery for Ewing’s sarcoma of the distal tibia: a case report

“…Furthermore, the presence of nerves and blood vessels at this site makes securing safe surgical margins difficult. Thus, amputation or radiotherapy may be the only curative treatment for patients with tumors of the distal tibia [ 3 , 4 ].…”

Is Limb Salvage With Microwave-induced Hyperthermia Better Than Amputation for Osteosarcoma of the Distal Tibia?

“…Amputation has long been regarded as the standard surgical treatment for these tumors, with satisfactory functional results when an appropriate prosthesis is used [25]. With the advances in chemotherapy and surgical techniques, limb salvage has become the preferred treatment when possible.…”

“…While survivorship of patients who undergo amputation for distal tibia osteosarcoma generally is high [26] and complications are disconcertingly frequent [4], function as measured by the Musculoskeletal Tumor Society (MSTS) [6] score after amputation is generally low [15]. Small series of patients undergoing limb salvage for osteosarcoma in this location are not always dramatically better in terms of function [20], complications are likewise common [25], and survivorship seems even worse [18]. For this reason, we believe the best surgical option for patients who have osteosarcoma of the distal tibia is unclear.…”