VIMS Journal: July 2017

Case Report

Limb Salvage in Ewing Sarcoma with Fibular Graft and Ilizarov Fixator: A Case Report

Dr. D. K. Jha, Dr. P. K. Pujari, Dr. B. Gayen

Abstract :
Ewing sarcoma can be treated with multidrug chemotherapy and limb salvage surgery. This article describes a case of Ewing sarcoma treated with limb salvage surgery with fibular allograft and Ilizarov ring fixator with excellent functional result and without any recurrence in long term follow up.

Keywords :
Ewings Sarcoma, limb salvage, fibular graft, Ilizarov.

Introduction :
Ewing sarcoma mostly occur in 5 to 25 years age group. Metaphyses of long bones (often extending into the diaphyses) is the most common location[1]. Prior to use of multidrug chemotherapy, long term survival was < 10%. The development of multidrug chemotherapy, radiation therapy and surgery increased long term survival rate >50%[2]. Limb salvage surgery can be performed in place of amputation without compromising survival rates.
Current treatment of Ewing sarcoma includes neoadjuvant or adjuvant chemotherapy or both and local procedures where possible limb salvage surgery[3]. After wide resection of the sarcoma large bone defect should be reconstructed to restore the function of the limb. The options are allograft, autograft or endoprosthesic reconstruction.

Presentation of Case :
A 13 years old male patient presented with pain and mild swelling proximal part of right leg. There was a history of occasional fever. On examination there was firm, tender sweeling over proximal one third of right tibia. X-Ray was done and it was radiologically diagnosed as Ewing Sarcoma of proximal tibia.

Diagnosis was confirmed by biopsy. Bone scan and chest CT was done which revealed no pulmonary and skeletal metastasis.
Patient was initiated with seven cycles of multidrug chemotherapy. After that limb salvage surgery was planned and MRI was done to know the bony and soft-tissue extent of sarcoma.

First limb was stabilised with Ilizarov ring fixator. Then wide excision of the sarcoma was done.

Then fibula was harvested from left leg, then the defect was reconstructed with the fibular graft.

Initially patient was kept non weight bearing, only passive and active exercises were allowed. After radiographic evidence of union, weight bearing was allowed and after fracture consolidation, fixator was removed, a long leg guard was applied and patient was allowed full weight bearing.
Following surgery another cycle of chemotherapy was given. After 1 year follow up, there was no evidence of recurrence.

Discussion :
With early diagnosis and neo-adjuvant chemotherapy limb salvage in Ewing sarcoma is possible with better functional outcome. We have discussed one of the limb salvage methods which resulted in excellent outcome without any complications.

References
  1. JOA Musculoskeletal Tumor Committee: The Incidence of Bone Tumours in Japan, 2003. Tokyo, Japan: National Cancer Institute;2003.

  2. Bacci G, Ferrari S, Bertoni F, Rimondini S, Longhi A, Bacchini P, et al. Prognostic factors in nonmetastatic Ewing sarcoma of bone treated with adjuvant chemotherapy: analysis of 359 patients at the Intituto Orthopedico Rizzoli. J Clin Oncol 2000;18:4-11.

  3. Bacci C, Ferrari S, Longhi A, et al: Local and systemic control in Ewing's sarcoma of the femur treated with chemotherapy, and locally by radiotherapy and/or surgery. J Bone Joint Surg 2003; 85B:107.

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