Kundu Zile Singh, Tanwar Milind, Rana Parveen, Sen Rajeev
Department of Orthopaedics, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India.
Department of Pathology, BPS-GMC, Sonepat, Haryana, India.
Indian J Orthop. 2018 Jan-Feb;52(1):3-9. doi: 10.4103/ortho.IJOrtho_323_16.
Primary benign and malignant tumors of the proximal fibula are not very common. Upper fibula being an expendable bone; the majority of the primary bone tumors at this site are usually treated with proximal fibulectomy. There is scarce literature on functional results, difficulties faced during dissection when to preserve or sacrifice common peroneal nerve and importance of lateral collateral ligament repair after proximal fibulectomy. The present study attempts at assessing these variables.
This retrospective study included 46 patients; 30 males and 16 females with age ranging from 12 to 44 years (average: 26 years) operated between 2003 and 2014. There were 34 benign and 12 malignant tumors. All were treated with proximal fibulectomy as indicated and decided by the operating surgeon keeping in view its extent on magnetic resonance imaging. Peroneal nerve sacrifice or preservation was decided as per the type (benign/malignant), its involvement by the tumor and the extent of the tumor. In 14 (for 12 malignant and two benign giant cell tumors [GCTs]) patients, the peroneal nerve required resection for the margins. Partial upper tibial resection was performed in cases of malignant tumors and three GCTs. The followup ranged between 24 and 120 months (median: 48 months).
Patients with peroneal nerve resection had inferior functional outcome than those without peroneal nerve resection. There was no higher risk of tibia fracture in patients with partial tibial resection. Lateral collateral reconstruction yielded better results and should be performed in all cases. Functional outcome was significantly better in patients with benign tumors than in patients with malignant tumors as these required neither resection of the peroneal nerve nor large amount of muscle excision. The functional results were evaluated using Musculoskeletal Tumor Society (MSTS) score, and clinical outcomes were evaluated using knee and ankle movements and stability. The overall average MSTS score was 26.50.
With good reconstruction of lateral ligament we can achieve good results after proximal fibulectomy for benign as well as malignant tumor without much instability. With partial upper tibial resection (i.e., the extra-articular resection of proximal tibiofibular joint) adequate margins are feasible even in malignant tumors.
腓骨近端的原发性良性和恶性肿瘤并不常见。腓骨上部为可牺牲骨；该部位的大多数原发性骨肿瘤通常采用腓骨近端切除术治疗。关于功能结果、解剖过程中在保留或牺牲腓总神经时面临的困难以及腓骨近端切除术后外侧副韧带修复的重要性，相关文献较少。本研究旨在评估这些变量。
这项回顾性研究纳入了46例患者；30例男性和16例女性，年龄在12至44岁之间（平均26岁），于2003年至2014年接受手术。其中有34例良性肿瘤和12例恶性肿瘤。所有患者均根据手术医生的指示并结合磁共振成像上肿瘤的范围决定接受腓骨近端切除术。根据肿瘤类型（良性/恶性）、肿瘤对其的累及情况以及肿瘤范围决定是否牺牲或保留腓总神经。在14例患者（12例恶性肿瘤和2例良性骨巨细胞瘤[GCT]）中，为保证切缘需要切除腓总神经。对于恶性肿瘤和3例GCT患者进行了部分胫骨上段切除。随访时间为24至120个月（中位数：48个月）。
腓总神经切除的患者功能结局比未切除腓总神经的患者差。部分胫骨切除的患者发生胫骨骨折的风险并不更高。外侧副韧带重建效果更好，所有病例均应进行。良性肿瘤患者的功能结局明显优于恶性肿瘤患者，因为良性肿瘤既不需要切除腓总神经也不需要大量切除肌肉。使用肌肉骨骼肿瘤学会（MSTS）评分评估功能结果，使用膝关节和踝关节活动度及稳定性评估临床结局。总体平均MSTS评分为26.50。
通过良好地重建外侧韧带，腓骨近端切除术后无论是良性还是恶性肿瘤都能取得较好的效果，且不会出现明显不稳定。对于恶性肿瘤，即使进行部分胫骨上段切除（即近端胫腓关节的关节外切除）也能获得足够的切缘。
