Successful Resection of Ewing Sarcoma Involving the Whole Fibula in a Pediatric Patient with Long Vascular Bypass and Reconstruction of Knee and Ankle Ligaments: A Case Report and Literature Review

Abstract

Introduction: Ewing sarcoma is the second most prevalent primary malignant bone tumor affecting pediatric and adolescent patients. Ewing sarcoma can affect any bone, but it primarily affects bones in the lower limb and pelvis. The femur is the most commonly affected bone. Approximately 8% of primary Ewing sarcoma originates from the fibula, and involvement of the entire fibula is a rare presentation. The standard treatment of Ewing sarcoma involves neo-adjuvant multimodal chemotherapy followed by local treatment using wide local resection (with or without radiation) and adjuvant chemotherapy.

Case Presentation: A nine-year-old male patient, who is medically free, presented to the orthopedic oncology clinic complaining of left leg pain and swelling, accompanied by nighttime pain and weight loss. Clinical examination revealed swelling and tenderness in the entire leg, particularly the lateral aspect, and distal neurovascular examination was normal. Radiographic assessment, including plain X-rays and whole leg MRI with contrast, suggested the presence of a potentially malignant lesion affecting the entire fibula. CT-guided biopsy and histopathology confirmed the diagnosis of Ewing Sarcoma of bone. CT Angiogram of the left lower limb was performed to assess vascular involvement, which revealed the anterior tibial artery and peroneal artery were found be encased by the tumor. Following neo adjuvant chemotherapy, the patient underwent total fibular resection, long vascular bypass and reconstruction of the ankle and knee ligaments. Postoperative follow-up and recovery yielded maintained ankle and knee stability, resulting in a satisfactory functional outcome.

Conclusion: Ewing sarcoma involving the entire fibula is exceptionally rare, with limited experience reported in the literature. In the present pediatric case, complete tumor resection, long segment vascular bypass, and concurrent reconstruction of the ankle and knee ligaments were performed, resulting in durable stability of both joints. This experience underscores that, when guided by a multidisciplinary team, total fibular resection can offer an effective and function-preserving procedure in pediatric bone sarcoma.