Reconstruction après résection des tumeurs malignes de l’extrémité inférieure du fibula chez l’enfant

Reconstruction après résection des tumeurs malignes de l’extrémité inférieure du fibula chez l’enfant

A propos

Introduction

Les tumeurs malignes de l’extrémité inférieure du fibula posent un double problème de résection et de reconstruction.Différentes techniques de reconstruction ont été proposées dans la littérature allant de l’absence de reconstruction(1,2) ou la simple suture des parties molles adjacentes(3), jusqu’à l’arthrodèse de cheville(1) ou même l’amputation(4), en passant par les autogreffes par la tête du fibula(5,6) et la greffe corticospongieuse de la crête iliaque(1,7). 

Les auteurs rapportent un cas de sarcome d’Ewing de l’extrémité inférieure du fibula chez un enfant en exposant la technique de résection utilisée et la reconstruction par lambeau périosté et plastie des tendons fibulaires.

II-Observation

A.F,garçon de 10 ans, nous a été adressé pour complément de prise en charged’une ostéomyélite de l’extrémité inférieure du fibula évoluant depuis 2 mois et qui n’a pas évolué favorablement sous antibiothérapie prolongée. Il a été adressé avec une radiographie de la cheville montrant une lésion ostéolytique mal limitée de l’extrémité inférieure du fibula et un scanner de la cheville qui été en faveur d’un abcès sous périosté de la métaphyse distale du fibula.Devant cet aspect radiologique, les douleurs persistantes à l’examen clinique et un bilan biologique encore perturbé malgré une antibiothérapie prolongée, une étiologie tumorale a été suspectée, mais sans pouvoir éliminer l’ostéomyélite. Une IRM a été alors demandé et a montré une lésion métaphyso-diaphysaire de l’extrémité inférieure du fibula avec atteinte des parties molles. Sur les coupes axiales, la lésion s’étendait dans toute la loge postéro-latérale de la jambe et arrivait au contact de la face postéro-latérale du tibia. Elle envahissait aussi l’articulation tibio-fibulaire inférieure . Cette lésion prenait le produit de contraste de façon intense. Une biopsie par voie externe a été réalisé. En peropératoire, il y avait du pus avec un décollement périosté étendu. Le prélèvement bactériologique était négatif et la biopsie a conclu à un sarcome d’Ewing. Le bilan d’extension comprenanat une scintigraphie osseuse et un scanner thoracique, était négatif. Une chimiothérapie néoadjuvante a été alors démarrée (photos 1). L’évolution radiologique a été marquée par une minéralisation et une reconstruction de l’extrémité inférieure du fibula, témoignant d’une bonne réponse à la chimuiothérapie.L’IRM de controile a montré une nette regression de la masse tumorale évaluée à 75% avec absence de signe d’atteinte de l’articulation tibio-fibulaire inférieure. (photos 2). Devant cette bonne réponse à la chimiothérapie , nous avons opté pour une résection en conservant la mobilité de la cheville.

Le fibula a été coupé en haut en zone saine sans toucher la membrane interosseuse., on a enlevé une baguette osseuse emportant la face postérolatérale du tibia et l’articulation tibio-fibulaire inférieure. Les tendons fibulaires ont été coupés en bas. Pour la reconstruction  de l’articulation de la cheville, nous avons complété l’exposition du périoste tibial en haut qu’on a prélevé afin de le retourner sur la face externe de la cheville, permettant la reconstitution de deux faisceaux fixés par agrafes au niveau du calcanéum pour recouvrir la face externe de l’articulation de la cheville.Les tendons fibulaires ont été allongés par dédoublement de bas en haut, pour venir renforcer la face externe de la cheville et ont été fixés par une agrafe sur le tibia.L’analyse de la pièce opératoire a montré des limites saines  avec une nécrose tumorale évaluée à 100%.

En post-opératoire , l’enfant a porté une attelle de marche et une autre de nuit permettant de stabiliser la cheville pendant une année. Au recul de 3 ans, l’enfant avait une marche normale, avec une cheville stable et de mobilité normale. (photos3)

III-Discussion:

Chez l’enfant le problème de reconstruction est plus difficile que chez l’adulte, puisqu’il existe un risque important d’instabilité et de déviation en valgus avec la croissance. Plusoieurs auteurs ont décrit de bons résultats après résection distale du fibula sans reconstruction. Mais il existait toujoures un risque  de dégradation des résultats  avec le temps  avec apparition d’instabilité ou déviation en valgus de la cheville avec subluxation du talus.

La reconstruction par du périoste prélevé de la diaphyse tibiale adjacente associée à la plastie de ligaments fibulaires a permis dans notre cas une reconstruction adéquate du plan ligamentaire externe et un bon résultat anatomique et fonctionnel à un recul de 3 ans.La constatation ultérieure d’un valgus de la cheville pourra nécessiter une arthrodèse après la fin de croissance.

  1. Références

1.Papagelopoulos PJ et al.lateral malleolus en bloc resection and ankle reconstruction for malignant tumors.clin Orthop Rel Res 2005;347:209-18

2.Norman-Taylor F.H et al.Distal fibulectomy for Ewing’s sarcoma.J Bone Joint Surg 1994;76B:559-62

3.Yadav SS et al.Ankle stability after resction of the distal third of the fibula for giant-cell lesions:report of two cases.Clin Orthop Rel Res 1981;155:105-7

  1. Ozaki et al. Surgical treatment of bone sarcomas of the fibula.Arch Orthop Trauma Surg 1997;116:457-9
  2. Herring CL et al. Replacement of the lateral malleolus of the ankle joint with a reversed proximal fibular bone graft. Foot Ankle Int 1997; 116:475-9

6-De Gauzy J.S et al.Distal fibular reconstruction with a pedicled vascularised fibular head graft.J Pediatr Orthop  2002;11B:18:317-23

  1. Eger W et al. Giant cell tumor of the distal fibula.Arch Orthop Traum Surg 2004;124:56-9
  2. Goh J.C.H et al. Biomechanical study on the load-bearing characteristics of the fibula and the effects of fibular resction. Clin Orthop 1992; 279:223-8

9- Leibner E.D et al.Lateral malleolar reconstruction after distal fibular resection.J Bone  Joint Surg 2005; 87A:878-82

  1. Shoji H et al. Subperiosteal resection of the distal portion of the fibula for aneurysmal bone cyst. J Boint Joint Surg 1970;52A:1472-6
  2. Jones R.B et al. Effect of distal fibular resection on ankle laxity.Foot Ankle Int 2001; 22: 590-3

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