Giant Cell Tumor of the Lateral Malleolus Treated by Tumor Excision and Reconstruction using A 180° Rotated Proximal Fibular Autograft – A Rare Case Report

Introduction

Giant cell tumor (GCT) of bone is a benign but locally aggressive neoplasm and is among the most frequently encountered benign bone tumors in orthopedic practice. The most commonly affected anatomical sites, in descending order of frequency, include the distal femur, proximal tibia, distal radius, and proximal humerus. Involvement of the small bones of the hand and foot is relatively rare, with reported incidences of approximately 2.4% in the hand and 1.2–1.8% in the foot ^[1]. The occurrence of GCT in the distal fibula is exceptionally uncommon, constituting <1% of all reported cases.

Several surgical options have been proposed for the management of GCT of the lateral malleolus, ranging from extended intralesional curettage with adjuvant therapies to en bloc resection of the distal fibula followed by ankle reconstruction. Reconstructive techniques described in the literature include inter tibio-fibular or tibiotalar arthrodesis, 180° rotation of the proximal fibula ^[3–8], cortical or strut graft reconstruction of the remaining fibula, fibular allograft reconstruction, repair of the lateral ligamentous complex of the ankle, and utilization of the distal peroneal tendons to re-establish ankle stability.

Case Report

A 26-year-old male patient presented with pain in the left ankle region and difficulty in walking for a period of 6 months. On examination, a vertically ovoid swelling was present on the lateral aspect of the ankle with restriction of ankle movement. Radiograph of the left ankle showed an eccentric, expansile lytic lesion with a soap-bubble appearance, 6.5 cm in size at the epiphyseo-metaphyseal part of the distal fibula. Magnetic resonance imaging showed that the lesion was compressing the peroneal muscles and tendons and the talar bone (Fig. 1, 2, 3).

Discussion

GCT of the lateral malleolus is an uncommon clinical entity ^[9], and the management of aggressive lesions at this location remains particularly challenging. Owing to its rarity, there are no established treatment guidelines, and the available literature is limited to isolated case reports and small case series. The distal 10 cm of the fibula plays a vital role in maintaining the stability of the ankle mortise. Therefore, reconstruction of the distal fourth of the fibula following tumor excision is essential to preserve ankle stability. Lesions occurring in this region require meticulous planning, especially in young and active individuals, to maintain ankle function and prevent long-term disability.

Furthermore, deformities involving the ankle can significantly impair gait and functional mobility, adversely affecting a patient’s daily activities, social interactions, and occupational performance. Patients with GCT of the lateral malleolus commonly present with pain, swelling, and restricted ankle movements. Previous studies have demonstrated that ankle stability depends not only on the integrity of the distal fibula but also on the preservation of its ligamentous attachments. During weight-bearing, the fibula contributes to deepening the ankle mortise and transmits approximately 7.1% of the body’s weight. Complete excision of the distal fibula without appropriate reconstruction may result in valgus instability of the ankle and subsequent degenerative arthritic changes ^[5].

Capanna et al. ^[2] described six different methods of fibular excision and reconstruction based on the location of the distal fibular lesion. These techniques include reconstruction using a proximally harvested fibula rotated through 180°, cortical grafting, and augmentation of ankle stability with the peroneal tendons ^[10]. Additional reconstructive options aimed at preserving ankle joint congruity include the use of tricortical iliac crest grafts and fibular allografts stabilized with dynamic compression plates. Although each technique offers distinct advantages, they are also associated with specific limitations. Moreover, harvesting the proximal fibula carries the potential risk of injury to the common peroneal nerve and the lateral collateral ligament complex.

Leibner et al. ^[10] proposed seven principles for distal fibular reconstruction, emphasizing preservation of the native fibula whenever oncologically feasible. In the present case, the patient had a Grade II lesion and expressed a strong desire to retain normal ankle function. Consequently, our treatment strategy focused on complete tumor excision while restoring the integrity of the ankle mortise. Resection of the fibula at a level 6–8 cm proximal to the distal tip can disrupt the syndesmotic ligaments and interosseous membrane, thereby increasing inversion and rotational stresses across the ankle joint. Clinically, this may manifest as deep muscular pain, weakness, and difficulty with running and other strenuous activities. Therefore, reconstruction and stabilization of the syndesmosis are recommended. In our patient, the tumor was excised completely, followed by reconstruction using a 180° rotated proximal fibular graft, syndesmotic repair, and fixation with a reconstruction plate.

Conclusion

GCTs of the lateral malleolus are extremely rare and pose challenges in their management. Thus, we recommend that all aggressive and large GCTs of the lateral malleolus must be excised adequately, and the bony defect should be reconstructed using autogenous bone graft with internal fixation. It is mandatory to preserve the ankle mortise during reconstructive surgery to achieve a good functional outcome.

Clinical Message

Giant cell tumor of the lateral malleolus poses a challenge in management; therefore, proper excision and reconstruction of the ankle mortise are essential for a good functional outcome.

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About the Authors

• 

  N Ebel Raj

• 

  G S Mukharjee

• 

  P S Amal