Response to: “Letter Regarding: Modified Sliding Fibular Graft for Aneurysmal Bone Cyst of the Lateral Malleolus: Technique and Two-Case Series”

Dear Editor,

The recent publication “Modified Sliding Fibular Graft for Aneurysmal Bone Cyst of the Lateral Malleolus: Technique and Two-Case Series” ¹ was intended to describe an alternative reconstructive technique for benign bone tumors of distal fibula. From the outset, the title clearly states that this is a surgical technique description illustrated by 2 cases, thereby explicitly acknowledging the limited number of patients.

We fully recognize the value of larger series and longer follow-up to validate any surgical technique. However, aneurysmal bone cysts (ABCs) of the distal fibula represent a rare pathology in an infrequent anatomical location. Surgeons experienced in bone tumor management understand that accumulating a large series of ABCs at this site, in a single institution, would likely require 5-10 years. Although a randomized clinical trial with alternative reconstructions and long-term follow-up would be ideal, such a study design is not realistically feasible for this specific condition.

Regarding oncologic management, the current standard treatment for ABCs is curettage, with reconstruction typically performed using bone graft. Extended curettage aims to remove residual tumor cells, to mitigate the risk of recurrence. Often, the procedure is combined with adjuvant treatment, as high-speed burring, electrocautery, phenol, or liquid nitrogen. This approach is well established across multiple anatomical sites, including long bones, spine, and pelvis.

The surgical technique for curettage typically involves creating a cortical window while preserving 1 or more cortices, followed by thorough curettage of the lesion and adjuvant treatment of the remaining internal cortical surface. As correctly described by Yigit et al, ² a reference cited by the letter’s author, “An oval-shaped cortical section. . .” is created and “the cyst walls were meticulously cleaned using a high-speed burr and electrocautery.” This is the same standard technique employed and described in our manuscript. Therefore, the oncologic approach presented in our study does not differ from widely accepted surgical practice for ABCs.

If wide en bloc resection were to be advocated for all ABCs, we would respectfully disagree. As reported by Döring et al, ³ another reference cited in the letter, 93% of the patients underwent curettage. Our group follows the classic indications for confirmed ABCs, incorporating adjuvant therapies prior to reconstruction, which are discussed in detail in the manuscript.

Concerning functional outcomes, both the Musculoskeletal Tumor Society score (MSTS) and American Orthopaedic Foot & Ankle Society (AOFAS) score are well- established tools for evaluating outcomes after lower limb tumor surgeries and foot and ankle surgeries. These instruments incorporate both objective and subjective parameters, combining patient-reported outcome components, as suggested by the letter’s author. Although recent systematic review ⁴ highlight improvements in pathology-specific PROMs over the past decade, their use remains inconsistent. In contrast, AOFAS has been widely used for many years and continues to appear in contemporary studies. A tumor-specific foot and ankle outcome tool would certainly be desirable in the future.

Finally, we emphasize that this manuscript presents an alternative reconstructive technique, not an outcome study of ABC recurrence. Tumor resection was performed using an intralesional approach, consistent with standard treatment for ABCs. The proposed technique highlights a biological, autologous, low-cost reconstruction that preserves limb length and alignment. The 2 reported cases demonstrated favorable results on validated functional outcomes tools. Although the series is small and follow-up is midterm, this study was designed as a surgical technique description, which is not intended to address long-term functional outcomes.

We thank the author of the letter for the thoughtful comments and the opportunity to further clarify the rationale, indications, and scope of the work. Scholarly discussion of surgical techniques for rare conditions is essential to advancing care, and we appreciate the engagement with our manuscript.

Supplemental Material

sj-pdf-1-fao-10.1177_24730114261435584 – Supplemental material for Response to: “Letter Regarding: Modified Sliding Fibular Graft for Aneurysmal Bone Cyst of the Lateral Malleolus: Technique and Two-Case Series”

Supplemental material, sj-pdf-1-fao-10.1177_24730114261435584 for Response to: “Letter Regarding: Modified Sliding Fibular Graft for Aneurysmal Bone Cyst of the Lateral Malleolus: Technique and Two-Case Series” by Filipe Marques de Oliveira, Mariana Vendramin Mateussi, Jairo Greco Garcia, Marcelo de Toledo Petrilli, Dan Carai Maia Viola and Reynaldo Jesus-Garcia Filho in Foot & Ankle Orthopaedics

Filipe Marques de Oliveira, MD Department of Orthopaedics and Traumatology, Universidade Federal de São Paulo – Escola Paulista de Medicina (UNIFESP/EPM), São Paulo, Brazil Email: [e-mail] Mariana Vendramin Mateussi, MD, Jairo Greco Garcia, MD, MSc, Marcelo de Toledo Petrilli, MD, PhD, Dan Carai Maia Viola, MD, PhD and Reynaldo Jesus-Garcia Filho, MD, PhDDepartment of Orthopaedics and Traumatology, Universidade Federal de São Paulo – Escola Paulista de Medicina (UNIFESP/EPM), São Paulo, Brazil