LIMB SALVAGE IN EWING SARCOMA

WITH FIBULAR GRAFT AND ILIZAROV

FIXATOR: A CASE REPORT.

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.

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
location1. 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
surgery3. 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.