The distal tibia is a rare site for primary malignant bone tumors. A review of 1,754 consecutive patients from our unit with osteosarcoma or Ewing sarcoma revealed that only 40 tumors were located in the distal tibia representing just over 2% of primary malignant bone tumors. When bone sarcomas do occur in the distal tibia, they present a particular challenge with regard to limb salvage surgery.

These challenges include:

The lack of soft tissue cover anteriorly. The tibia is in a subcutaneous position and, although, a fascio cutaneous flap can be turned down from the calf or, alternatively, a free flap can be applied, skin and soft tissue cover is a significant challenge particularly where there is soft tissue extension of the tumor. The talus is a relatively small bone, and hence a difficult site to obtain secure bony fixation for the distal component of an endoprosthesis particularly as the implant usually has to provide a greater degree of ankle joint’s stability than might be required from, for example, a total ankle replacement for arthritis, where the soft tissues are intact.

It is common knowledge from celebrities and media coverage of disabled athletes that function can be remarkably good following below knee amputation and therefore a limb salvage procedure that saves the limb but provides relatively poor function may not be regarded as an overall success. In most cases, there will, therefore, be a trade-off between body image and function when performing limb salvage surgery at this site in particular.

The salvage procedure from a failed distal tibial prosthetic replacement will in most cases be inferior to the result that would have been obtained had a primary below knee amputation been performed. The amputation level will be elevated to gain clearance from the previous surgical zone particularly if there has been infection or local recurrence of tumor. It may even be necessary to perform a through knee or above knee amputation under these circumstances.