Proximal fibular resections for primary bone tumours: oncological and functional results of a case series

Background: Resection of aggressive benign or malignant tumours of the proximal fibula are difficult due to the high number of surrounding anatomical compartments and close association with many important neurovascular and functional structures. For the same reasons malignant tumours behave differently in this area. Before the 1980s results were poor. With the introduction of neoadjuvant chemotherapy and limb salvage surgery, Malawer described a technique of local en bloc resection. This study presents the oncological and functional results of a case series using this technique. Patients and methods: A retrospective folder review of 14 patients was done. Six patients with a large active, an aggressive benign or a low-grade malignant tumour had a Malawer type I marginal resection, and eight patients with a stage IIB malignant sarcoma had a Malawer type II wide intracompartmental resection sacrificing the common peroneal nerve. The follow-up at a median of 38 months included the imaging, histology and a functional MSTS score.  Results: The median age of the type I resections was 42.5 years; giant cell tumour was the commonest tumour (50%); and the median functional MSTS score at follow-up was 29. The median age of the type II resections was 12 years; osteoblastic osteosarcoma was the commonest tumour (75%); and the median functional MSTS score was 26. All type II resections achieved clear margins at the initial surgery and there were no recurrences or metastases in either group. There were no wound complications and no vascular complications in spite of sacrificing the tibialis anterior artery in some type I and all type II resections, and the peroneal artery in type II resections. No patient complained of knee instability. The main functional impairment was due to loss of common peroneal function which required an AFO in some patients and a tibialis posterior tendon transfer in one patient. Conclusions: Resection of benign and malignant tumours of the proximal fibula achieved good cure rates and functional results, despite the sacrifice of the common peroneal nerve. Level of evidence: Level 4