Lateral Malleolar Reconstruction After Distal Fibular Resection

878 COPYRIGHT © 2005 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED LATERAL MALLEOLAR RECONSTRUCTION AFTER DISTAL FIBULAR RESECTION A CASE REPORT BY EFRAIM D. LEIBNER, MD, PHD, DEAN AD-EL, MD, MEIR LIEBERGALL, MD, ELISHA OFIRAM, MD, ELI LONDON, D P M , MSC, AND AMOS PEYSER, MD Investigation performed at the Department of Orthopedic Surgery, Hadassah-^ Hebrew University Medical Center, Jerusalem, Israel T umors of the distal part of the fibula necessitating resection pose a problem because of the need to reconstruct a stable ankie joint and to obtain coverage of this area. Standard textbook solutions include simple resection of the distal aspect of the fibula including the iaterai malleolus, as described by Carnesale' and later by Norman-Taylor et al.', and resection of the distal part of the fibula with reconstruction of the lateral malleolus with use of the fibular head, as described by Carreli \ Herring et al.', and de Gauzy et al.\ An allograft reconstruction has also been descrihed\ as has reconstruction with an iliac crest bone graft'. Other possible techniques, albeit less desirable, are ankle arthrodesis and amputation. Although the textbook techniques are considered to be classics, not many reports have detailed their use and results''•'". These methods, at least theoretically, have a number of drawbacks. In distal fibular resection without reconstruction, the stabilizing effect of the lateral malleolus is lost. Soft-tissue reinforcement, even when it is possible, cannot fully compensate for the loss of stability''. Thus, the ankle may collapse into valgus and may be unstable in varus. Conversely, when the mortise is reconstructed with use of a proximal fibular (head) graft, the lateral collateral ligament of the knee is affected and the peroneal nerve is endangered'^'. Additionally, the fibular head is not totally congruent with the lateral articular surface of the talus and provides no stabilizing ligament attachments. Ankle arthrodesis might solve the problems of instability, but it limits the ability to walk. Amputation is reserved as a last resort for patients in whom limb-sparing is not feasible. We describe a method of reconstructing the ankle mortise with use of the distal fihular remnant^the epiphysislateral malleolus—^to which a bone graft fi-om the fihula, proximal to the resection margin, was attached. Stability was achieved with arthrodesis of the distal aspect of the tibia to the reconstructed distal part of the fibula, and coverage was obtained with a vascularized free latissimus dorsi fiap. The patient was informed that data concerning the case would be submitted for publication. Case Report fifteen-year-old boy presented to another hospital because of pain and swelling in the distal aspect of the left calf. Radiographs demonstrated an expansile lesion in the distal aspect of the fibular shafi (Fig. I ], and a bone scan demon- A Fig, i Anteropostertor radiograph of the left ankle, demonstrating the lesion in the distal aspect of the fibula. Note that the distal growth piate and the area immediately superior to it appear unaffected. 879 T H E JOURNAL OF BONE & I O I N T SuRctRY • iins.oRci VOLUME 8 7 - A • NUMBER 4 • APRIL 2005 TL-weighted magnetic resonance imaging scan of the distal aspect of the fibula, demonstrating the lesion and its boundaries. Note the ring 0' normal bone superior to the growth plate. Figs. 3-A and 3-B Reconstruction technique. Fig. 3-A Schematic representation. LATERAL MALLEOLAR RECONSTRUCTION AFTER DISTAL FIBULAR RESECTION strated increased uptake at the site. An open biopsy was performed, and the lesion was diagnosed as Ewing sarcoma. Staging with computerized tomography and magnetic resonance imaging studies demonstrated that the lesion was localized, with no evidence of metastasis, and the patient was referred to our service. Treatment was initiated with chemotherapy. Repeat computerized tomography and magnetic resonanct' imaging studies for staging confirmed the localized nature of the lesion, defined the anatomical boundaries of the tumor (Fig. 2), and demonstrated lliat ihe growth plate was free of tumor. A wide resection was undertaken, and the distal aspect of the fibula was resected down to the growth plate. The soft-tissue envelope, including the portion of the peroneal muscles adjacent to the resected fibuhi, the anterior tibial artery, and the open biopsy scar, was resected. Proximal to the resection area hut distal to the fibular neck, a 10-cm length of fibula was resected subperiosteally to serve as a bone graft. The graft was split into two parts longitudinally, and both were attached as a double-barreled graft to the distal fibular remnant and to the abraded lateral surface of the distal aspect of the tibia with a buttress plate and screws to create a stable ankle morlise (Figs. 3-A and 3-B). The peroneal tendon stumps were sutured to the graft. Soft-tissue coverage was obtained with use of a vascularized free latissimus dorsi flap, which was anastomosed to the anterior tihial artery stump. Split-thickness skin was grafted from the ipsilateral thigh. Chemotherapy was instituted at six weeks. The patient was managed with ininiobili/ation of the leg in a short cast for twelve weeks. Weight-bearing was permitted in the cast after eight weeks, and then use of an air-cast was recommended for an additional twelve weeks. At one year, the patient was pain-free and had full use of 88o THE JOURNAL OF BONE & IOINT SURGERY • IBIS.ORC VOLUME 87-A • NUMBER 4 • APRIL 2005 LATERAL MALLEOLAR RECONSTRUCTION AFTER DISTAL FIBULAR RESECTION Fig. 4-A Fig. 3-B Radiograph made six months postoperatively. Note the new bone formation at the area of subperiosteal resection. the extremity, without a limp or instability. At five years, the patient wa.s pain-free and physically active with no limitations. He lived and worked in an agricultural setting, walked at least 5 km daily, and played recreatiotial soccer, all without a brace or support. On examination, he had no limp and no ankle deformity or deformity of the foot. The ankle range of motion was comparable with that of the contralateral side (Figs. 4-A and 4-B). The patient reported no instability ofthe ankle. No evidence of local tumor recurrence or metastasis was present on examination or imaging studies. Radiographs made at one year and five years demotistrated ftill incorporation of the graft (Fig. 5). Fig. 4 B Figs. 4-A and 4-B Clinical photographs made one year postoperatively. demonstrating ankle plantar flexion and dorsiflexton (note the toe extension on dorsiflexion}. 88i THE JOURNAL OF BONE & JOINT SURGERY • IBIS.ORG VOLUME 87-A • NUMBER 4 • APRIL 2 0 0 5 Anteroposterior radiograph made five years postoperatively. Note the graft incorporation on the lateral aspect ofthe tibia. Discussion esection ofthe distal aspect ofthe fibula is not a common procedure and has not been widely reported in the medical literature. Most reports describe one or two patients, with the largest series by tar consisting of eleven palients in a report from the Rizzoli Orthopedic lnstitute^ The patient with the longest duration of follow-up was described by Carnesale'. He reported that, thirty-nine years after resection of the distal third of the tlbula because of osteosarcoma, the ankle was cosmetically and functionally normal although there had been no osseous reconstruction. Shoji Lt al."\ Yadnv", Norman-Taylor et al.', and Uhl et al.'" also described good results after distal fibular resection without osseous reconstruction. In the report by Shoji et al., the distal .lspect of the fibula was resected in a subperiosteal manner (leaving the osseous tip ofthe lateral malleolus in one palient), thus leaving the ligamentous attachments intact. Yadav described two patients in whom the lateral ankle ligaments \vcre reattached to the periarticular soft tissue. At two years, both patients were asymptomatic, with good ankle motion .ind no evidence of instability on stress radiographs. NormanTaylor et al. de.scribed five patients who had distal fibular re- R LATERAL MALLEOLAR RECONSTRUCTION ArTF.R DISTAL FIBULAR RESECTION sections for the treatment of Hwing sarcoma. Three patients had a substantial valgus deformity develop, and two also had limitation of motion. Carreir, in I93S, described two patients in whom the distal part ofthe fibula was resected and the proximal a.spect ofthe fibula was used to reconstruct the ankle mortise. Information regarding postoperative knee and ankle fiinction was not available for one patient, but function in ihe second patient was reported to be good at two years. Herring et al.* also described a patient in whom a distal fibular defect, which was due tt) trauma, was reconstructed with the fibttlar head five years after the injury because of lateral shifting of the talus. At a follow-up evaluation twenty-seven years after surgery, the ankle was stable and painless with a good range of motion. However, degenerative changes were evident on radiographs, de Gauzy et al. used a vascularized fibular head graft to reconstruct the lateral malleolus after resection for the treatment of osteogenic sarcoma and reported good results at 2.5 years postoperatively'. Lubliner et al.'' described a patient who had resection of the distal aspect ofthe fibula and allograft reconstruction for the treatment of an anetirysmal bone cyst. At two and a half years postoperatively, the patient was asymptomatic, with union ofthe allograft. In a case report by Hger et al., a patient with a giant-cell tumor liad a good result after distal fibitlar resection and reconstruction with an iliac crest bone graft. Capanna et al.", in the most comprehensive series to date, reported the cases of eleven patients at the Rizzoli Orthopedic Institute who had resection of the distal aspect of the fibula. Various techniques were used, depending upon the location and type of lesion. Intercalary resection of a portion ofthe distal part ofthe fibttla leaving the lateral malleolus and the distal diaphysis ititact was performed in three patients—two with synostosis and one without. Intercalary resection with the distal cut at the level of the tibiotalar joint and curettage ofthe lateral malleolus, with replacement with bone graft, was performed in three patients with low-grade tumors. Total resection ofthe distal aspect ofthe fibula with reconstruction ofthe lateral malleolus with use ofa proximal fibuiar graft (the Carrell technique) was performed in two patients, and total resection of the distal part of the fibula with soft-tissue reconstruction was performed in three patients, (lood restilts were described for most of them. Patients who did not undergo osseous reconstruction had a reduction in ankle motion, with lateral instability of the ankle in one. Babhulkar et al.'" studied the effect of Hbular resection on ankle stability. Various symptoms and tiiulings were described with resection at different levels. All patients in whom resection was <6.5 cm from the tip ofthe lateral malleolus (six patients) had ankle instability develop, lones et al." investigated the effect of distal fibular resection in cadavera and found that resection ofthe distal part ofthe fibula caused ankle instability despite tendon reconstruction. The small number of reported cases, nnd their variety, precludes the possibility of providing unequivocal recommendations with regard to reconstruction, and each case must be 882 T H E JOURNAL OF BONE & JOINT SURGERY • IBIS.ORG VOLUME 87-A • NUMBER 4 • APRIL 2005 approached on its own merits. However, on the basis ofthe results mentioned above, we believe that the following seven guidelines can be followed. (I) Preserve as much of the native fibula as deemed safe. Magnetic resonance imaging is a reliable too! in assessing the extent of tumor, as reported by Hoffer et al.' for osteosarcoma, and as demonstrated by the case of our patient who had Ewing sarcoma. (2) In patients in whom <6.5 cm ofthe distal aspect ofthe fibula is left, it is probably prudent to try to achieve distal tibiofibular synostosis with or without bone-grafting to prevent rotation of the distal fragment, as recommended by Capanna et al.", and to prevent the development of a valgus instability, as described by Babhulkar et a\."\ In patients in whom the distal part ofthe fibula is resected at the level of the ankle joint or distal to it, proximal lengthening ofthe distal fibular remnant by bonegrafting is necessary to allow synostosis, as was done in our patient. (3) When resection ofthe entire lateral malleolus is required, subperiosteal resection is preferred when possible, leaving the ankle ligaments intact. If subperiosteal resection is not possible, reconstruction ofthe osseous mortise with use ofthe fibular head or an allograft is a reasonable solution. (4) In younger patients, the growth potential of the distal tibial physis must be taken into consideration when planning the reconstruction to prevent an imbalance between the lateral and medial sides of the ankle. One may place the graft distalty in anticipation of further distal tibial growth, attach the graft distal to the tibial growth plate, or use a reversed fibular head graft with an intact physis'. Alternatively, distal tibial epiphysiodesis produces a stable, well-aligned but shortened ankle. (5) Soft-tissue handling plays a critical role in the more extensive reconstructions. The ankle ligatnents should be reattached or reinforced when violated. If peroneal tendon resection is nec- LATERAL MALLEOLAR RECONSTRUCTION AFTER DISTAL FIBULAR RESECTION essary, the tendon stumps should be attached to the lateral ankle structures, which, together with local scarring, provide some static stability for the hindfoot. (6) When a fibular head graft is used, the peronea! nerve should be meticulously protected and the lateral collateral ligament and the biceps femoris tendon should be reattached to the proximal part of the tibia. Patients should always be forewarned about the possibility of damage to the peroneal nerve. (7} (Obtaining coverage with a soft-tissue fiap was required in our patient because of the extensive soft-tissue resection, and it is probably prudent to use such a fiap in all patients who have a wide resection. • Efi-aim D. Leibner, MD, PhD Meir Liebergall, MD F.lishaOtlram, MD Eli London. DPM, MSc Amos Peyser, MD Department of Orthopedic Surgery. Hadassah-Hebrew University Medical Center, RO.B. 12000, lerusaleni, 91 120, Israel. E-mail address for E.D. Leibner; [email protected] Dean Ad-H1,MD Department of Plastic Surgery and Burns, Beilinson Medical Center, Rabin Campus, Jabotinski Street, Petah-Tikvah, 49100 Israel The authors did not receive grants or outside funding in support of" their researcb or preparation of this manuscript. Tbey did not receive payments or otber benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with wbich tbe authors are affiliated or associated. doi:10.2106/IBIS.D.02539 References 1 . Carnesale PG. General principals of tumors. In; Canate ST, editor. Campbell's operative orthopaedics. 9th ed. St. Louis: Mosby: 1998. p 647-a. 2. Norman-Taylor FH, Sweetnam Di. Fixsen JA. 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