En bloc resection of proximal fibular giant cell tumour in skeletally immature patients with common peroneal nerve neuropraxia: a retrospective case series of 20 patients with one-year follow-up

INTRODUCTION

Giant cell tumour of bone (GCTB) typically affects skeletally mature adults, but up to 10% may occur in skeletally immature patients.¹ The proximal fibula is an uncommon site, accounting for 2.5–5% of GCTB.^1,2 Surgery in this region is challenging due to proximity of the common peroneal nerve (CPN) and stabilising structures (LCL, biceps femoris).³

While en bloc resection reduces recurrence risk compared to curettage, it carries potential complications of peroneal palsy and lateral knee instability.^1,2 These issues are particularly relevant in skeletally immature patients presenting with preoperative CPN neuropraxia.⁴ This study evaluates outcomes of 20 skeletally immature patients with proximal fibular GCT and preoperative CPN neuropraxia treated by en bloc resection, with a minimum one-year follow-up.

CASE SERIES

A case series of consecutive 20 patients who were skeletally immature (≤18 years or open physes), presented with weakness in ankle dorsiflexion (CPN neuropraxia) with palpable swelling over lateral aspect of proximal leg treated between September 2023 and August 2024 at New Medical College and Hospital, Kota, Rajasthan.

Inclusion criteria

Inclusion criteria included skeletally immature (≤18 years or open physes), histologically confirmed proximal fibular GCT, presence of preoperative CPN neuropraxia, and treatment by en bloc resection.

Exclusion criteria

Exclusion criteria included individuals with prior surgery, metastatic disease, inadequate follow-up (<12 months).

Preoperative assessment

All patients had documented CPN involvement. Preoperative ankle dorsiflexion (ADF) power was graded using the medical research council (MRC) scale.

Management

All patients underwent Malawer type I extra-periosteal proximal fibulectomy.^6,7 The CPN was identified and preserved. LCL and biceps femoris were reattached to the lateral tibia using transosseous tunnels or suture anchors.³ Margins were negative in all cases.

Outcomes assessed

Primary

CPN recovery (complete, partial, persistent; time to recovery), local recurrence.

Secondary

MSTS score, knee stability (clinical varus stress test), final ADF power, return to school/sport, complications.

Statistical analysis

Descriptive statistics were used.

Baseline characteristics

At presentation, mean age was 16.35 years (range 14–18); 8 were male and 12 females. Laterality was 9 right and 11 left. Campanacci grade II was most common (16/20, 80%), grade III in 4 (20%).

Median symptom duration was 7 months (range 5–8). Preoperative ADF power was grade 1 in 4 (20%), grade 2 in 12 (60%), and grade 3 in 4 (20%) (Table 1).

Operative details

All 20 patients underwent Malawer type I resection. LCL and biceps femoris were reattached in all. Margins were negative. Mean operative time was 72 minutes (range 60–88); blood loss was not significant (Table 2).

Outcomes at 12 months

At one year, 17 patients (85%) regained complete CPN recovery at a mean of 9 months (range 6–10); 3 (15%) had partial recovery; none had persistent palsy. All patients achieved functional ADF: 17 (85%) improved to grade 5, 3 (15%) to grade 4.

No recurrences were recorded.¹³ Mean MSTS score was 28.6±1.87. Knee stability was preserved in 17 (85%) patients, with grade I varus laxity in 3 (15%).³ Median return to school was 28 weeks; return to sports 32 weeks (Table 3).

Complications

Superficial infection occurred in 2 cases, and 1 required wound debridement with closure. No permanent palsy or major complications occurred (Table 4). Comparison of preoperative and 12-month postoperative ankle dorsiflexion power (Medical Research Council grading) in 20 skeletally immature patients undergoing en bloc resection of proximal fibular giant cell tumour with preoperative common peroneal nerve neuropraxia. Preoperatively, most patients presented with grade 2 weakness, whereas at 12 months all improved to grade 4 or 5, with 85% regaining full strength (grade 5) (Figure 1). Figure 2 shows pre-op and post-op X-ray, respectively. Intra-op photos showing en-bloc resection of fibular head (Figure 3).

DISCUSSION

This series demonstrates that en bloc (Malawer type I) resection of proximal fibular GCT in skeletally immature patients with preoperative CPN neuropraxia is oncologically safe and functionally effective. Complete or partial CPN recovery occurred in all patients, with no persistent palsy. Previous studies report peroneal palsy rates from 3–57% after proximal fibula resection, highlighting the value of nerve-preserving techniques.^1,2,11

Importantly, all patients regained at least grade 4 ADF power, with 85% recovering fully to grade 5. This reinforces that preoperative neuropraxia is reversible when the CPN is preserved.^2,4 The absence of recurrence aligns with published evidence favouring en bloc resection at this site.¹³ Knee stability was maintained in 85% with only mild laxity in 15%, consistent with the protective effect of LCL and biceps femoris reattachment.^3,12

Strengths include uniform surgical technique and systematic follow-up; limitations are retrospective design, single-centre data, and relatively short follow-up.

CONCLUSION

En bloc resection of proximal fibular GCT in skeletally immature patients with preoperative CPN neuropraxia provides excellent local control, high rates of nerve recovery, functional restoration of dorsiflexion, and stable knees at one year.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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