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

To the Editor,

The article titled “Modified Sliding Fibular Graft for Aneurysmal Bone Cyst of the Lateral Malleolus: Technique and Two-Case Series” by Marques de Oliveira et al ¹ presents a careful technical improvement for reconstructing the distal fibula after intralesional resection of an aneurysmal bone cyst. The authors’ focus on maintaining the medial cortex in order to preserve fibular length and alignment addresses a clinically difficult balance between biomechanical integrity and oncologic control, particularly in younger patients.

Even though this change is conceptually appealing, there are some restrictions that should be taken into account before these results influence general clinical practice. A notable limitation of the study is the inclusion of only 2 cases and the relatively short follow-up period. Recurrence rates for aneurysmal bone cysts are known to vary, with larger surgical series indicating that recurrence may occur after brief follow-up periods and differ significantly depending on the treatment modality. ² In the absence of larger cohorts and longer surveillance, it is uncertain whether the observed lack of recurrence reflects maintained local control rather than early follow-up alone.

Furthermore, there is no evidence to support the oncologic safety of preserving the medial cortex without an accurate margin evaluation. The absence of histologic margin confirmation or safe cortex preservation criteria, considering the authors’ description of electrocautery of the retained cortex, raises concerns, particularly in view of the possibility of locally aggressive behavior in aneurysmal bone cysts. ³ Clarifying whether cortical involvement was ruled out intraoperatively or preoperatively would increase confidence in the suggested method.

Lastly, the lack of verified patient-reported outcome measures restricts the interpretation of patient-centered benefits, although functional scores like the AOFAS and MSTS are shown. Recent study data have highlighted the significance of merging patient-reported tools with clinician-rated ratings to accurately assess functional results in foot and ankle reconstructions, particularly because the AOFAS score has acknowledged limits in psychometric validity.^4,5 The claims of biomechanical preservation would be strengthened if objective radiographic alignment measurements corresponded with these findings.

Notwithstanding these drawbacks, the authors deserve appreciation for presenting an intriguing reconstructive idea that might be particularly helpful in situations where an allograft is not an option. Their method extends the continuous endeavor to enhance functional preservation while maintaining disease control. Future research should include larger cohorts, specific oncologic margin analysis, longer follow-up, and standardized patient-centered outcome measures in order to confirm and enhance these findings.

Respectfully,

Supplemental Material

sj-pdf-1-fao-10.1177_24730114261435585 – Supplemental material for 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_24730114261435585 for Letter Regarding: Modified Sliding Fibular Graft for Aneurysmal Bone Cyst of the Lateral Malleolus: Technique and Two-Case Series by Mahad Ahmad, FNU Mehrish and Imran Maheen in Foot & Ankle Orthopaedics

Mahad Ahmad, MBBS Islamic International Medical College, Rawalpindi, Pakistan Email: [e-mail] FNU Mehrish, MBBS Islamic International Medical College, Rawalpindi, Pakistan Maheen Imran, MBBSIslamic International Medical College, Rawalpindi, Pakistan