This text is a general description of a proximal fibula resection. Focus is on anatomic structures and muscle resection. Before fibula resection, a good pre-operative imaging is needed as well as pre-operative planning.
Based on tumor biology (biopsy first!) tumor resection is determined. Which level? Which structure can be saved? Nerve involvement (commun fibular nerve) and it’s consequences should be anticipated and discussed with the patient first. Intraarticular involvement of proximal tibio-fibular joint is determined based on MRI. Accordingly an intra or extraarticular resection is planned. Tibialis anterior and peroneal vessel involvement should be determined preoperatively and resection planed accordingly. Reconstruction is not necessary for proximal fibular resection, but lateral collateral ligament +/- biceps femoris must be reinserted or reconstructed. Lateral knee stability depends on this structure.
Malawer described two different types of proximal resection based on tumor biology and extension (The enneking classification is useful). In a type II resection, large “en bloc” resection is done with sacrifice of common peroneal nerve, tibialis anterior artery as well as fibular artery. The origin of proximal muscles are also sacrified (fibularis longus, soleus origin, EDC origin). This type of resection is mandatory for Enneikin stage IIB (high grade extracompartmental tumor).
Type I resection is more conservative. It is performed for benign, low grade or intracompartmental tumors. Nerve is dissected and spared. Tibialis anterior is generally spared. Muscle resection is also more conservative than in type II resection.
For a proximal fibular resection, many anatomic structures should be anticipated. Normal anatomy localizations should be known to avoid nerve or vessels damage. All above structures must be known as well as their anatomic course.