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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 158-162

Intraoperative difficulties during management of proximal fibular tumors: A case series


1 Department of Orthopaedics, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
2 Department of Orthopaedics, AIIMS, Bhubaneshwar, Odisha, India

Date of Submission31-Oct-2020
Date of Acceptance16-May-2021
Date of Web Publication27-Dec-2021

Correspondence Address:
Dr. Ritesh Runu
Indira Gandhi Institute of Medical Sciences, Patna - 800 014, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_78_20

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  Abstract 


Proximal fibular tumors are treated by en bloc excision and lateral collateral ligament (LCL) repair. Intraoperative injury to the popliteal artery or its trifurcation, common peroneal nerve, and LCL can occur. Three cases of giant cell tumor and one case of exostosis of proximal fibula were analyzed. Apart from routine tests, preoperative computed tomography angiography (CTA) was done in two cases. Vascular injury was seen in two cases where CTA was not done, while in others, it was safe. Foot drop was seen in one case due to peroneal nerve resection. None of the patients developed varus instability even without LCL repair. Authors suggest preoperative CTA in all tumors of proximal fibula for preoperative planning, counseling of patients, vascular consultation, and to prevent complications.

Keywords: Computed tomography angiography, exostosis, giant cell tumor, popliteal artery, proximal fibula


How to cite this article:
Subhash A, Kashyap N, Runu R, Jain M. Intraoperative difficulties during management of proximal fibular tumors: A case series. J Orthop Traumatol Rehabil 2021;13:158-62

How to cite this URL:
Subhash A, Kashyap N, Runu R, Jain M. Intraoperative difficulties during management of proximal fibular tumors: A case series. J Orthop Traumatol Rehabil [serial online] 2021 [cited 2022 Jan 26];13:158-62. Available from: https://www.jotr.in/text.asp?2021/13/2/158/333570




  Introduction Top


Proximal fibular tumors count for 2.5% of all bone tumors.[1] The commonly reported tumors in this area are osteosarcoma, giant cell tumor (GCT), enchondroma, aneurysmal bone cyst, and osteochondroma.[2],[3],[4],[5].These are usually managed by en bloc resection and lateral collateral ligament (LCL) repair.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13].During procedure, common peroneal nerve (CPN), popliteal artery, and its trifurcation and LCL injury can occur.[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13] We want to highlight the intraoperative problems faced by us with these cases.


  Case Report Top


Four cases with proximal fibular lesions were reported with painful lesions over the posterolateral aspect of knee joint along with difficulty in squatting and intact neurovascular status [Table 1]. As per tumor protocol, all were investigated. Along with hemogram, X-ray, magnetic resonance imaging (MRI), and fine-needle aspiration cytology were done. Histologically, three were GCTs (Cases 1, 2, and 3) and one was exostosis (Case 4) arising from fibular head. Preoperative computed tomography angiography (CTA) was done in the third (GCT) and fourth (exostosis) case. Preoperative vascular surgeon consultation is done in Case 2, 3, and 4. They were operated after anesthesia clearance and informed consent.
Table 1: Case details

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Surgical technique

Position

All the patients were operated in a lateral position with a sandbag under the ipsilateral gluteal region and tourniquet in the upper thigh. Case 2 was operated in prone position without tourniquet. This led to severe bleeding and prolonged surgical time.

Incision

A posterolateral incision was used in three cases except in the Case 2. Through this approach, the exposure was adequate. However, identification of the popliteal artery and anterior tibial artery was difficult [Figure 1].
Figure 1: Posterolateral incision

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In case 2, posterior midline S incision was taken to identify popliteal artery and its branches first. Due to proximal and medial extension of tumor, the identification of anterior tibial artery was difficult. However, the anterior extension of tumor to interosseous membrane was better approached with this incision.

Common peroneal nerve dissection

  1. Stretching of nerve over the tumor led to flattening and difficult identification. Hence, it was traced from biceps tendon proximally [Figure 2]
  2. Thickening of fascial sheath over the fibular head reduced the mobility of nerves. It was released, and nerve was traced to the interosseous membrane distally. Complete exposure led to mobilization of nerves and prevented any injury
  3. In case 2, for vascular exploration, posterior midline incision was taken which led to difficulty in nerve exploration. Finally, CPN was decompressed by increasing the distal limb of incision. Due to nerve entrapment in tumor, it was sacrificed, and foot drop splint was used postoperatively
  4. A branch of the CPN was found supplying the tumor in all cases, and it was sacrificed to increase mobility of CPN.
Figure 2: Common peroneal nerve

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Popliteal and anterior tibial artery dissection

  1. The popliteal artery was found in close contact of tumor medially in all cases. The sheath of vessel was adhered with GCT, while it was separated by a thin slimy layer of tissues in exostosis. Hence, dissection in exostosis was comparatively easy
  2. In Case 1, the tumor expansion was beyond midline, the vessel was compressed, and sheath adhered with tumor. Adherence of arterial sheath with the tumor made dissection more difficult after tourniquet inflation [Figure 3]. This caused an arterial injury which was identified after tourniquet deflation and repaired
  3. In case 2, GCT, the popliteal artery was lying anterior to tumor proximally [Figure 4]. We explored the popliteal artery from proximal to distal end through posterior midline incision. The anterior tibial artery was found hooked over the tumor proximally. Then, anterior tibial artery and the feeder vessels were ligated, and a popliteal artery was mobilized to develop a plane from the tumor. This helped in saving the artery from any injury
  4. In case 3, the popliteal artery was lying anterior to tumor in proximity. Due to preoperative CTA, the popliteal artery was dissected on medial aspect first then whole tumor was excised without risk [Figure 5]
  5. In case 4, the popliteal artery was lying over the exostosis anteriorly [Figure 6]. Through posterolateral incision, after retracting CPN, the knee was flexed and lateral gastrocnemius was relaxed. Due to slimy layer between the tumor and vessel, the exostosis was exposed and excised by blunt dissection [Figure 7].
Figure 3: Popliteal artery adhered to tumor

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Figure 4: Case 2 computed tomography angiography

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Figure 5: Case 3 computed tomography angiography

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Figure 6: Case 4 computed tomography angiography

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Figure 7: Excision of exostosis

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After excision of lesion, the vascular status was checked by deflating the tourniquet. Hemostasis secured. LCL was not repaired in any cases. Postoperatively, limb was supported in long leg plaster of Paris slab for 2 weeks till stitch removal. Then, patients were mobilized in the knee brace and exercises started. None of the patients reported varus instability or fear of fall postoperatively.


  Discussion Top


Tumors of proximal fibula are 2.5% of all bone tumors. [1],[6] These tumors usually present with pain, palpable mass, and peroneal nerve lesions (3Ps). [2],[5],[7],[8] Increased skin temperature was an unusual presentation as noted by Sun et al.[7] In our cases, tender palpable mass and difficulty in squatting were the most common presentation. None of the patients presented with peroneal palsy. The average gap between disease and presentation is 10.3 months as described by Sun et al.[7] and we had similar findings.

Complete preoperative workup is vital for diagnosis and management. X-ray and MRI of the knee with leg along with computed tomography of the chest, bone scan, and histopathological examinations are also done.[2],[3],[4],[5],[6],[8],[9],[10],[11],[12] Open biopsy is done for suspected malignancy.[9] Nerve conduction studies are done in cases with peroneal nerve symptoms.[11] Preoperative CTA has not been discussed in literature for surgical planning. We introduced it in our protocol after facing intraoperative problems. Preoperative CTA shows the proximity of popliteal artery and anterior tibial artery with the tumor. It also shows any abnormal branches to tumor which needs ligation during surgery.

During surgical excision, CPN is the first and most superficial structure encountered. Sometimes, the nerve may be adhered to the aggressive tumor sheath or engulfed by tumor mass. Faezypour et al. had described the intraoperative difficulties of neurolysis of peroneal nerve.[10] Abdel et al. found that peroneal nerve palsy is 8% in Malawar Type I resection (resection of tumor with 2 cm of diaphysis with muscle cuff), while the nerve is resected in Malawar Type II resection (wide intracompartmental resection).[2] In malignant tumors, if the nerve is in contact with the tumor or infiltrated, then epineurectomy or nerve resection can be done.[3] Their preservation can lead to the recurrence of tumor as we saw in our case 2[9],10].[Figure 8]. Postoperative foot drop can be managed by foot drop splint or tendon transfer.
Figure 8: Case 2 recurrence

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Intraoperative dissection of tumor and preservation of popliteal vessels and its branches is a challenge to surgical team. In the proximal part of the leg, medial and lateral inferior genicular artery branches out from popliteal artery. Then, anterior tibial artery arises from posterior tibial artery just medial to the neck of fibula and crosses the interosseous membrane. Due to tumor mass, the vascular mobility is reduced, and chances of injury are high. Hence, anterior tibial artery and several branches supplying the tumor are ligated and resected. [9],[10] It reduces the bleeding, mobilizes the posterior tibial artery and en bloc tumor removal becomes easy. [2],[4] Dieckmann et al. described invasion of vessel and its resection and vascular repair in one of their case. However, the repair was not successful and the patient had to undergo Chopart amputation for forefoot necrosis.[3] Kundu et al.[12] explored the origin of trifurcation of popliteal artery along the tibial nerve, traced the anterior tibial artery, and ligated it where tumor mobilization was difficult. They also encountered injury to trifurcation of popliteal artery which was repaired with saphenous graft. We also found tethering of trifurcation with the tumor (case 1), which was damaged and repaired with saphenous graft.

Preservation of LCL and its repair or reconstruction is debatable. LCL reconstruction is suggested by several authors to maintain knee stability.[2],[5],[10],[13] On the other side, Einoder and Choong found insignificant instability of knee joint after resection of fibular head.[4]

CTA explains the relation of vessels to tumor which helps in surgical planning. This investigation also helps in deciding the incision – lateral, posterolateral, or midline.[12] In case of popliteal artery lying separate from tumor posterolateral incision works, but in case of entrapped vessel posterior incision is better. In this era of increasing medicolegal disputes, CTA helps in comprehensive planning, counseling, and vascular consultation preoperatively.


  Conclusion Top


CTA is an essential preoperative investigation for proximal fibular lesions which reduces intraoperative difficulties and postoperative complications. Peroneal nerve should not be saved at the cost of complete tumor excision.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Unni KK. Dahlin's Bone Tumours: General aspects and Data on 11067 cases. Philadelphia: Lippincott – Raven; 1996. p. 1-9.  Back to cited text no. 1
    
2.
Abdel MP, Papagelopoulos PJ, Morrey ME, Wenger DE, Rose PS, Sim FH. Surgical management of 121 benign proximal fibula tumors. Clin Orthop Relat Res 2010;468:3056-62.  Back to cited text no. 2
    
3.
Dieckmann R, Gebert C, Streitbürger A, Henrichs MP, Dirksen U, Rödl R, et al. Proximal fibula resection in the treatment of bone tumours. Int Orthop 2011;35:1689-94.  Back to cited text no. 3
    
4.
Einoder PA, Choong PF. Tumors of the head of the fibula: Good function after resection without ligament reconstruction in 6 patients. Acta Orthop Scand 2002;73:663-6.  Back to cited text no. 4
    
5.
Inatani H, Yamamoto N, Hayashi K, Kimura H, Takeuchi A, Miwa S, et al. Surgical management of proximal fibular tumors: A report of 12 cases. J Bone Oncol 2016;5:163-6.  Back to cited text no. 5
    
6.
Malawer MM. Surgical management of aggressive and malignant tumours of proximal fibula. Clin Ortho Rel Res 1984;186:172-81.  Back to cited text no. 6
    
7.
Sun T, Wang L, Guo C, Zhang G, Hu W. Symptoms and signs associated with benign and malignant proximal fibula tumours: A clinico pathological analysis of 52 cases. World J Surg Oncol 2017;15:92.  Back to cited text no. 7
    
8.
Sakamoto A, Okamoto T, Matsuda S. A posterior approach for curettage in giant cell tumour of bone in the proximal fibula. J Surg Case Rep 2019;9:1-3.  Back to cited text no. 8
    
9.
Guo C, Zhang X, Gao F, Wang L, Sun T. Surgical management of proximal fibular tumors: Risk factors for recurrence and complications. J Int Med Res 2018;46:1884-92.  Back to cited text no. 9
    
10.
Faezypour H, Davis AM, Griffin AM, Bell RS. Giant cell tumor of the proximal fibula: Surgical management. J Surg Oncol 1996;61:34-7.  Back to cited text no. 10
    
11.
Kushwaha SS, Goyal A, Verma A, Khan YA, Mohammed F. Giant Osteochondroma of the proximal fibula: A rare case. Int J Clin Skill 2017;11:47-50.  Back to cited text no. 11
    
12.
Kundu ZS, Tanwar M, Rana P, Sen R. Fibulectomy for primary proximal fibular tumours: A functional and clinical outcome in 46 patients. Ind J Orthop 2018;52:3-9.  Back to cited text no. 12
    
13.
Arikan Y, Misir A, Gur V, Kizkapan TB, Dincel YM, Akman YE. Clinical and radiologic outcomes following resection of primary proximal fibula tumors: Proximal fibula resection outcomes. J Orthop Surg (Hong Kong) 2019;27:1-7.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1]



 

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