Advances in Surgical Management of Malignant Tumors of the Distal Tibia.

Opinion statement: Malignant tumors of the distal tibia are rare and pose unique reconstructive challenges due to the region's complex anatomical and biomechanical characteristics. Contemporary treatment has progressively shifted from amputation to limb salvage. We believe that a favorable histologic response to neoadjuvant chemotherapy and the absence of major neurovascular involvement are key prerequisites for successful limb salvage. Amputation is generally considered a salvage option when limb salvage fails. In adults, we typically favor biological reconstruction combined with ankle arthrodesis as the first-line approach. For smaller defects, either allograft or distraction osteogenesis is recommended. For larger defects, we advocate for the use of recycled tumor-bearing autograft combined with fibular grafting. Non-biological reconstruction may be appropriate for patients who require immediate stability and early weight-bearing, but it is not recommended for patients with a life expectancy of several decades due to rising complication rates and progressive functional deterioration. For end-stage patients, the focus shifts to improving quality of life. We prefer simpler surgical procedures combined with nonsurgical oncologic care. In pediatric patients, preservation of the growth plate and joint is prioritized whenever oncologically safe. If preservation is not possible, a conventional non-expandable prosthesis is appropriate when the predicted limb-length discrepancy at skeletal maturity is less than 2 cm. Physeal distraction or an expandable prosthesis is preferred when the discrepancy is larger. Preoperatively, MRI and PET-CT are used for precise evaluation, along with multidisciplinary fracture risk prediction methods for fracture risk stratification. Intraoperatively, fluorescence guidance and computer assistance can enhance resection and reconstruction accuracy. However, several of these adjuncts remain under investigation. Ultimately, we individualize the surgical plan according to the patient's preferences while respecting local regulations and cultural or religious considerations.