Resection of a primary sarcoma of the diaphysis
of a long bone creates a large defect. The biological options for reconstruction
include the use of a vascularised and non-vascularised fibular autograft. The purpose of the present study was to compare these methods
of reconstruction. Between 1985 and 2007, 53 patients (26 male and 27 female) underwent
biological reconstruction of a diaphyseal defect after resection
of a primary sarcoma. Their mean age was 20.7 years (3.6 to 62.4).
Of these, 26 (49 %) had a vascularised and 27 (51 %) a non-vascularised
fibular autograft. Either method could have been used for any patient in
the study. The mean follow-up was 52 months (12 to 259). Oncological,
surgical and functional outcome were evaluated. Kaplan–Meier analysis
was performed for graft survival with major complication as the
end point. At final follow-up, eight patients had died of disease. Primary
union was achieved in 40 patients (75%); 22 (42%) with a vascularised
fibular autograft and 18 (34%) a non-vascularised (p = 0.167). A
total of 32 patients (60%) required revision surgery. Kaplan–Meier
analysis revealed a mean survival without complication of 36 months
(0.06 to 107.3, . sd. 9) for the vascularised group and 88
months (0.33 to 163.9, . sd. 16) for the non-vascularised
group (p = 0.035). . Both groups seem to be reliable biological methods of reconstructing
a diaphyseal bone defect.
Various kinds of bone have been used as a donor for vascularised bone grafts (VGF) to the upper extremities; among them the fibula has been widely used because of its structural characteristics and low donor site morbidity.
The results and complications of 104 vascularised fibular grafts in 102 patients are presented. Bony union was ultimately achieved in 97 patients, with primary union in 84 (84%). The mean time to union was 15.5 weeks (8 to 40). In 13 patients, primary union was achieved at one end of the fibula and secondary union at the other end. In these patients, the mean time to union was 31.1 weeks (24 to 40). Five patients failed to achieve union, with a resultant pseudarthrosis (3 patients) or amputation (2 patients). There were various complications. Immediate thrombosis occurred in 14 cases. In two of 23 patients with osteomyelitis, infection recurred at two and six months after surgery, respectively. Both patients had active osteomyelitis less than one month before the operation. Bony infection occurred in a patient with a synovial sarcoma of the forearm one year after surgery. In 15 patients, 19 fractures of the fibular graft occurred after bony union, all except one within one year after union. In patients in whom an external fixator had been used, fracture occurred soon after its removal. Union was difficult to achieve in cases of congenital pseudarthrosis of the tibia. Appropriate alignment of the fibular graft is an important factor in preventing stress fracture. The vascularised fibula should be protected during the first year after union. Postoperative complications at the donor site included transient palsy of the superficial peroneal nerve in three patients, contracture of flexor hallucis longus in two and valgus deformity of the ankle in three.
We describe our experience with vascularised bone grafting for the treatment of fibrous dysplasia of the upper limb in eight patients, five men and three women, aged between 17 and 36 years. The site was in the humerus in six and the radius in two. Persistent pain, progression of the lesion and pathological fracture with delayed union were the indications for surgical intervention. We used a vascularised fibular graft after curettage of the lesion. Function and radiological progress were serially monitored. Early radiological union of the graft occurred at periods ranging from 8 to 14 weeks. The mean period for reconstitution of the diameter of the bone was 14 months (12 to 18) predominantly through inductive formation of bone around the vascularised graft, which was a prominent feature in all patients. There were no recurrences and none of the grafts sustained a fracture or failed to unite. After operation function was excellent in three patients and good in five.
In our practice sequestration of the shafts of long bones in children because of acute osteomyelitis continues to be a problem. Conventional procedures for bone grafting are likely to fail.
Five children with congenital pseudarthrosis of the tibia treated by free vascularised fibular grafts were followed up until skeletal maturity. The ipsilateral fibula was used in four cases, the contralateral fibula in one. All our cases achieved bone union, but leg length discrepancy, atrophy of the foot and ankle stiffness were frequent complications, due perhaps to the many previous operations.
Purpose: Therapeutic options for shaft reconstruction are allografts, shaft prosthesis, and autografts, which may be vascularised or not. The purpose of this work was to assess mid-term results and complications after upper limb reconstructions using a vascularised fibula in children and adolescents undergoing surgery for tumour resection. Material and methods: A vascularised fibular graft was used for reconstruction in ten patients who underwent surgery for resection of upper limb tumours between 1994 and 2000. The patients were seven boys and three girls, aged seven to seventeen years. the vascularised fibula was used for reconstruction after tumour resection in the same operation for eight patients and to salvage a proximal humeral prosthesis in two patients. The eight single-procedure reconstructions concerned four resections of the humeral shaft and four resections of the radius. Tumour histology was: classical osteosarcoma (n=7), low-grade osteosarcoma (n=1), Ewing tumour (n= 1) and aggressive enchondroma (n=1). Six patients were on chemotherapy at the time of the fibular transfer. Graft lengths varied from nine to 21 cm (mean 14 cm). Plate fixation was used in most cases. All patients wore a cast for six to twelve weeks after surgery. Results: Results were analysed retrospectively after 3.9 years follow-up (range 1 – 7 years). Mean time to bone healing was three months (range 1.5 – 5 months). Five of the six humeral shaft reconstructions fractured due to trauma, requiring revision surgery in four cases. All patients who were reoperated achieved bone healing rapidly. One radius had to be revised to add supplementary bone. The mean functional score (MSTS) was 25.5/30 (range 21 – 30). One patient died from lung metastasis and the others exhibited complete tumour remission. Discussion:
Purpose: To describe our experience with vascularised fibulas used in sarcoma limb salvage surgery using standardized patient outcome measures. Methods: All vascularised fibulas and osteochondral allografts performed in the Capital District Health authority were assessed. A complete chart review and current functional assessment of the patients using the Toronto Extremity Salvage score (TESS) and the Musculosketal Tumour Society (MSTS) score were performed. Results: Nineteen patients with 19 tumors were recorded. The tumors range from 11 osteosarcomas, 4 Ewing’s sarcoma, 3 Malignant Fibrous Histiocytoma’s and 1 Chondrosarcoma. Average age was 23. The patient demographics are 75% male, 42% smokers, 86% femoral lesions and 13 % presented with pathological fracture. There were 9 hip fusions, 3 knee fusions, 6 intercalary grafts and one osteochondral graft. There was 21 % mortality with 21% lung mets, 20% local recurrence, 15.7% rates of amputation or infection or and non union. Allograft fracture rates of 10% were noted. Two patients underwent numerous operations (18) due to non-compliance. Rate of surgical failures defined as patients requiring re-operation after 2 years is 21%. Of 19 patients 10 are working, 4 are unable and 4 are deceased and 1 lost to follow up. Average follow up is 9.8 years (range of 4–18). Our functional results include TESS averaging 57.5 with a range of 30–105 and MSTS scores of average of 16.8 with a range of 3–28 and a percent score average of 55.8. The average score on the subjective assessment question was 4 equaling a response of accept it and would do it again. The Halifax outcome and functional data corresponds well with that in the literature. Conclusions: The biological repair of a combination of large Allografts with
Purpose: Reconstruction using a revascularised fibula has advantages in terms of remodelling the transplant to the stress forces and of better resistance against infections. Osteosynthesis offers mechanical advantages (stabilisaton facilitating primary and stress fracture healing) but with the risk of preventing hypertrophy of the fibula which is not exposed to the stress forces. Material and methods: Our series of 25 vascularised fibular transfers (maximum follow-up 15 years) concerned post-trauma tissue loss (11 cases) and tumour resections (14 cases). For this study of remodelling, we retained only oncological reconstructions because in the event of trauma sequelae, many factors can interfer (infection, preservation of the homolateral fibula with tibial tissue loss). None of the patients were lost to follow-up and remodelling was assessed at two years or more. Results: There was one failure requiring leg amputation (infected nonunion of the distal tibia on a radiated osteo-sarcoma). All the other fibulae healed. Three metaphyseal resections of the distal femur were assembled with a lateral plate using the fibula as a medial strut under compression. This type of assembly favours remodelling and excellent results were obtained in three cases. Five arthrodeses of the knee were performed using a fibula with a femorotibial nail. Healing was slow and the fibula thickened little, particularly when it was simply apposed on the tutor (three cases) rather than encased under compression (two cases). For five proximal humeri, use of a thin plate in three cases (forearm plate) was sufficient to allow healing without inhibiting remodelling. Discussion: For the lower limb, good remodelling is obtained with an assembly allowing compression of the fibula placed medially to the shaft alignment. For metaphyseal loss, we advise a lateral plate with a fibular strut medially. For arthrodesis, a nail is probably more prudent. The position of the lateral tutor decreases the stress on the fibula and is recommended less than the medial strut position. For the humerus, synthesis is required but may be minimal to allow optimal remodelling. Conclusion:
Fibula autograft reconstruction, both vascularised (v) and non-vascularised (nv), has been established as a standard method in limb salvage surgery of bone and soft tissue tumours of the extremities. This study retrospectively analyses the results of fibula autograft procedures in general and in relation to vascular reconstruction or simple bone grafting. Since the implementation of the Vienna Tumour Registry in 1969, 26 vascularised and 27 non-vascularised fibula transfers have been performed at our institution in 53 patients, 26 males and 27 females with an average age of 21 years (range 4 to 62 years). Indications included osteosarcoma in 18, Ewing’s Sarcoma in 15, adamantinoma in 5, leiomyosarcoma in 3 and others in 12. Thirty patients were operated for reconstruction of the tibia (8v/22 nv), 7 for the femur (6v/1nv), 7 for defects of the forearm (4v/3nv), 5 for metarsal defects (all v), 3 for the humerus (1v/2nv) and one patient was treated for a pelvic defect (nv). Average follow-up was 63 months (range 2 to 259 months). 43 patients showed successful primary bony union of the autograft. In 12 cases pseudarthrosis indicated further surgical revision, 9 of these patients were primarily reconstructed by use of a nv autograft. 4 patients, 2 with v and 2 with nv reconstruction, suffered a fracture of the transplant and were operated for secondary osteosynthesis. 10 patients with v bone graft developed wound healing disturbances which led to surgery, 2 patients with nv grafts suffered such complications. In 2 patients recurrent infection of a nv and a v fibula transfer led to the implantation of a modular tumour prostheses or amputation, retrospectively. Function of all patients with primary bone healing was rated satisfactory. The use of fibula autograft in limb-salvage surgery under oncological conditions allows biological reconstruction with good functional outcome, especially when primary bone healing is achieved.
To determine union rate in complicated nonunions of the scaphoid treated with a vascularised bone graft.
Autografts produced by recycling of tumor-bearing bone have been used for bridging intercalary bone defects but they are known to act as massive allografts after recycling procedures due to devitalisation. Recycled bone is superior to massive allografts since it allows anatomical reconstruction.
The management of osteonecrosis of the femoral head ranges from symptomatic therapy to total hip replacement. Conservative treatment is effective only in small, early-stage lesions. Free vascularised fibular grafting has provided more consistently successful results than any other joint-preserving method. It supports the collapsing subchondral plate by primary callus formation, reduces intra-osseous pressure, removes and replaces the necrotic segment, and adds viable cortical bone graft plus fresh cancellous graft, which has osseoinductive and osseoconductive potential. Factors predisposing to success are the aetiology, stage and size of the lesion. Furthermore, it is a hip-salvaging procedure in early pre-collapse stages, and a time-buying one when the femoral head has collapsed.
Segmental bone defects following osteomyelitis in pediatric age group may require specifically designed surgical options. Clinical and radiographic elements dictate the option. Different elements play a role on the surgeon's choice. Among them, the size of the defect, the size and the quality of the bone stock available, the status of the skin envelope, the involvement of the adjacent joint. When conditions occur, vascularized fibula flap may represent a solution in managing defects of the long bones even during the early years of life. A retrospective study, covering the period between October 2013 and September 2015, was done. Fourteen patients, nine males, five females, aged 2–13 years, with mean skeletal defect of 8.6 cm (range, 5 to 14 cm), were treated; the mean graft length was of 8.3 cm. The bones involved were femur (4), radius (4), tibia (3) and humerus (3). In 5 cases fibula with its epiphysis was used, in 5 cases the flap was osteocutaneous and in the remaining 4 cases only fibula shaft was utilized. After an average time of 8 months from eradication of infection, the procedure was carried out and the flap was stabilized with external fixators, Kirschner's wires or mini-plate. No graft augmentation was used.Aim
Method
Infected non-union after severe open fracture or unsuitable fracture operation is frequently associated with bone defect and its treatment has been controversial. We have used microsurgical vascularised composite graft for these problematic cases. Fifty one patients aged 17∼70 year old (43.6 years old in average), including 41 men and 10 women. Follow-up has been more than 6 months. The vascularised composite graft included a free fibular osteocutaneous flap in 41 cases, a vascular pedicled fibular osteocutaneous flap in 2 cases, a free iliac osteocutaneous flap in 5 cases, a vascularised cutaneous flap in 2 cases and other in one case. All infected non-unions were united without trouble and co-existing infection was successfully eradicated. This method also enables the patients rapid bone union and subsequent early functional recovery. This success was attributed to greater transport of oxygen and good antibiotic perfusion in presence of good blood supply. We conclude that microsurgical vascularised composite graft for infected non-union is an extremely useful method with early bone union and subsidence of infection.
From 1979 to 1990 we treated 20 patients with large bone defects or established nonunion of the femur by vascularised fibular grafts. There were 18 men and two women with an average age at operation of 36.6 years (16 to 69). Ten patients had infected nonunion, three had post-traumatic nonunion or a bone defect without infection, four had a defect after tumour resection, and three had other lesions. The mean length of the fibular grafts was 18.1 cm. Postoperative circulatory disturbances needed revision surgery in five patients, including three with circulatory problems in the monitoring flap, but not at their anastomoses. The outcome was successful in 19 of the 20 patients with bone union at means of 6.1 months at the proximal site and 6.6 months at the distal site. Three patients had fractures of the fibular grafts but all these united in two to three months after cast immobilisation.
The results of vascularised rib graft transfers are analysed in 25 patients followed up for more than two years (average 34 months). Radiographs showed early and rapid incorporation of the grafts in 4 to 16 weeks (average 8.5 weeks); external immobilisation averaged 11 weeks (range 5 to 24 weeks). The technique seems a useful alternative to allografts or homografts employing an avascular rib or fibula since it promotes rapid healing without needing microsurgical techniques.
The aims of this study were to analyse the long-term outcome
of vascularised fibular graft (VFG) reconstruction after tumour
resection and to evaluate the usefulness of the method. We retrospectively reviewed 49 patients who had undergone resection
of a sarcoma and reconstruction using a VFG between 1988 and 2015.
Their mean follow-up was 98 months (5 to 317). Reconstruction was
with an osteochondral graft (n = 13), intercalary graft (n = 12),
inlay graft (n = 4), or resection arthrodesis (n = 20). We analysed
the oncological and functional outcome, and the rate of bony union
and complications.Aims
Patients and Methods
Scaphoid non-unions can result in debilitating wrist problems. This study compared treatment of scaphoid non-unions using either a non vascularised (NVBG) or a vascularised bone graft (VBG). Twenty one cases of scaphoid non-unions were treated by two surgeons between 2005 and 2008 using either a NVBG from the iliac crest or a VBG from the radius based on a 1,2 intercompartmental supraretinacular artery pedicle.Purpose
Method
A second stage reconstruction was performed after 4–6 weeks, using a free vascularised fibular graft, fixed using internal and/or external fixation.
Patients gained an average of 46° forearm rotation (range 0–105°) with wrist or elbow motion significantly improved in 3 patients. At last review, all patients had a pain-free stable forearm with unhindered hand functions of grasp, hook and pinch. SF-36 assessment showed varied results, although mean values for the physical components of the survey were lower than general population values, while mental/emotional scores were as good.
Free, vascularised fibular grafting is well described in limb salvage surgery. The mechanical properties of the fibula make it ideal for replacement of bony defects after tumour resection and it can be sacrificed with minimal morbidity. We review the outcome of a consecutive series of 24 patients. Between 1993 and 2002 we performed free vascularised fibular grafts in 24 patients as part of a limb salvage procedure following tumour excision. Pre-operatively patients were staged using the Musculoskeletal Tumour Society (MSTS) system. Post-operatively patients were followed up with radiographs and clinical examination. From the radiographs graft hypertrophy and time to bony union was documented. Functional outcome was assessed using the MSTS scoring system. Complications were recorded. There were 15 women and 9 men with a mean age of 26 years (6–52). Mean follow up was 51 months (12–106). There were 19 malignant tumours, all stage 2b, and 5 giant cell tumours. The mean length of graft was 12.5 cm. (4.5–25). 16 grafts were used in the upper limb and 8 in the lower limb. Arthrodesis was performed in 8 cases and intercalary reconstruction in 16 cases. Fixation of grafts was achieved with a plate and screws in 21, a blade plate in 2 and an IM nail in 1. In 6 cases the resected tumour bone was reinserted as autograft after extracorporeal irradiation. In all but one patient the tumour margins were clear. Primary bony union was achieved in 22 patients (92%) at a mean of 35 weeks (12–78). Graft hypertrophy was seen in 7/29 cases (24%). Complications included 2 wound breakdowns, 3 stress fractures, 1 muscle contracture, 1 malunion and 1 painful plate. Overall 8 patients (33%) required second operation. 2 patients died of recurrent disease and one has metastases. The mean MSTS functional score was 87% (80–93). Free vascularised fibula grafts offer a reliable method of reconstruction after excision of bone tumours. The complication rate appears high and some patients require a revision procedure. However, the problems are relatively easy to correct, bony union is achieved in the majority and functional outcome is good.
A vascularised fibular strut graft was used for anterior spinal fusion in 16 patients with spinal kyphosis. The procedure was abandoned in three because of difficulty in establishing a vascular anastomosis and in one because the grafted fibula dislodged two days after operation. One patient died after five days. Of the 11 remaining patients, there were seven males and four females. Their ages at the time of operation averaged 30.9 years (12 to 71). The number of vertebrae fused averaged 6.7 (5 to 9) and the length of fibula grafted averaged 10.9 cm (6.5 to 18). Average follow-up was 54 months (27 to 84). Bone union occurred at both ends of the grafted fibula in all 11 patients, with an average time to union of 5.5 months (3 to 8). We did not see a fracture of the grafted fibula. Two patients had postoperative complications; the graft dislodged in one and laryngeal oedema occurred two days after operation in the other. A vascularised fibular strut graft provides a biomechanically stable and long-standing support in spinal fusion because the weak phase of creeping substitution does not take place in the graft.
We assessed the usefulness of vascularized bone transfer for treatment of aggressive musculoskeletal tumours. Classification by reconstruction method with vascularized bone transfer of our 33 patients was made into five types: 1) intercalary type in 6 cases, 2) arthrodesis type in 5 cases, 3) arthroplasty type using fibular head in 8 cases, 4) hybrid type with recycling autograft as heat treated bone or irradiated bone in 4 cases, and 5) inlay type after curettage of benign tumour chiefly for femoral head and/or neck in 10 cases. From October 1975 to December 1999, 33 patients composed of 18 males and 15 females with age ranging from 9 to 69 years (average of 30 years) received vascularized bone transfer. There were 28 cases of bone tumour and 5 cases of soft tissue tumour. In 31 cases we grafted the fibula of 8 to 20 cm in size and in 2 cases the ileum of 8 cm in size. Postoperative follow-up period ranged from 10 months to 15 years with average of 65 months. Primary union was achieved in 31 cases postoperatively between 1.5 month and 4 months with average of 3 months. As complication, we observed fracture of the graft in 4 cases and local recurrence in 3 cases. Postoperative functional evaluation ranged from 33.3% to 96.7% with average of 76.7%. As for oncological therapeutic results, continuous disease free cases accounted for 27, case of no evidence of disease for 1, case alive with disease for 1, and cases of death of disease for 4. Intercalary transfer of vascularized bone is best indicated for defect of long bone. Arthrodesis was performed in only one knee joint where reconstruction with prosthesis is usually indicated. In arthroplasty type, remodeling of fibular head was observed. In hybrid type, rapid bone union and low complication rate can be expected when compared to recycling autograft alone. In inlay type, femoral head necrosis even after wide curettage can be prevented.
We have reviewed 30 patients at a mean of 36 months after free vascularised fibular transfer to reconstruct massive skeletal defects after resection of primary bone tumours. There were 23 malignant and 7 benign neoplasms, half in the lower limb and half in the upper. Arthrodesis was performed in 15 and intercalary bone replacement in 15. The mean fibular graft length was 189 mm. Union was achieved in 27 (90%) at an average of 7.6 months, and the 3-year survival was 89%. There was a high complication rate (50%), but most resolved without greatly influencing the final outcome. There was local recurrence in two (6.7%), but 16 of the 24 assessed patients (67%) had satisfactory functional results. This is a reasonably effective means of reconstruction for limb salvage after resection of tumours.
We did a retrospective comparative analysis of twenty five patients treated with Ilizarov bone transport [IBT] and twenty one patients treated with vascularised fibular graft [VFG] from 1994 to 2003 in one institution, for post traumatic tibial bone defects of more than six centimetres. The aim of the study was to find out if there were any differences in achieving radiological end points, bone and functional score and return to work (final outcome), hospital stay and operating time (logistic factors) and complication rates. The mean defect size in the IBT group was 11.9 centimetres and in the VFG group 14.6 centimetres. Twenty one and sixteen patients in the IBT and VFG group respectively achieved the radiological end point that is union of the defect and graft hypertrophy [p 0.5]. Nineteen patients in the IBT group and fifteen in the VFG group returned to productive work [p 0.72]. Bone and functional results were analyzed by Paley's evaluation system and there were no significant differences in the two groups of patients [bone result p 0.97 and functional result p 0.1]. The logistic factors were significantly less of IBT group [p < 0.05]. Two patients in the IBT group and one patient in the VFG group had amputation and one patient in VFG group died. Three cases in the VFG group had flap loss. Stress fracture of the graft occurred in eight patients in the VFG group [p 0.0007]. The final outcome was same in both groups. Hospital stay, operating time and refractures were significantly less in IBT group.
Surgical treatment of infected bones with vascularised bone grafts is well established as an efficient strategy since several years. Nevertheless orthopaedic and trauma surgeons seem to apply vascularised bone grafts as the last treatment option only. Two strategies exist for treatment of chronically infected bones with vascularised bone grafts. First: Complete resection of the infected, often non-united part of the bones and reconstruction with large vascularised bone grafts, mostly fibular grafts. Second: Augmentation of the kept and intact parts of the bones with vascularised bone grafts. Two small series of patients are presented to illustrate both techniques and to show the results and outcome. Resection of big parts of the tibia and reconstruction with mostly ipsilateral fibular grafts – single barrel in children and double barrel in adults – led to uneventful healing in all cases. Augmentation of radius, femur and calcaneus with vascularised grafts from the iliac crest or the scapula was followed by primary healing, too. All patients were disburdened from infection up to now and regained full extremity function. The presented vascularized bone grafts did not only salvage the extremities but also could maintain their functionality. The procedure is demanding, but reliable and safe at a low rate of complications. Thus vascularised bone grafts should not only be used as ultimative salvage procedures, but as early as possible whenever standard treatments for osteomyelitis fail.
The Authors report their experience in the treatment of scaphoid non-union recurring to the vascularised bone graft technique as described by Zeidemberg. The patients have been treated between the 1999 and 2004. The authors report 22 cases (21 males and 1 female) with an average age of 31 years (from 17 to 42). 10 cases the involved wrist was the right one and in the other 12 cases was the left one. 18 patients presented an avascular necrosis of the proximal fragment of the scaphoid, recognised by the MNR. Two patients have been previously treated by the traditional bone graft technique as described by Matti-Russe, using a cannulated screw for the stabilization of the graft. 16 patients have been controlled at the follow-up (mean 23 months, from 3 to 65). The authors, looking at the good results obtained at the follow-up, feel that this technique might be a very useful one in the treatment of the established scaphoid non-union, mainly in presence of an avascular necrosis of the proximal third of the scaphoid. This technique might also be useful in the treatment of the failure of the classic bone graft technique.
In order to investigate the efficacy of free vascularised fibular graft (VFG) after bone intercalary tumour resection in tibia, we present our results with a minimum follow-up of 2 years. From 1988 to 2001, 47 patients affected by high-grade tibial sarcoma in 31 cases (66%), and low-grade diesease in 16 cases (34%) were treated in our department. Average age was 19 years (range 5–60 years), with a male/female ratio of 1.35. The average length of tibial resection was 15 cm, while the average length of the fibular graft was 19 cm. In 11 cases (21%) VFG was assembled alone, while in 36 cases (79%) a massive bone allograft was associated to the fibula. Three patients developed a deep infection, treated by amputation in two cases and by graft removal and an Ilizarov device in one case. Minor complications occurred in 28 cases (55%) (stress fractures, wound slough, osteosynthesis breakage), all healed by minor surgery or conservative treatment. At an average follow-up of 108 months (range 24 to 185 months), four patients had died of disease and three were lost to follow-up. Regarding the overall results, the combined group of fibula plus massive allograft showed to be more effective than the group of fibula alone in terms of early weight bearing (6 versus 12 months), while VFG showed intrinsic efficacy in achieving early bony fusion at the osteotomy lines and hypertrophy of the graft in both groups. Furthermore, using the combined assembly the articular surface could be spared in all the trans-epiphyseal resections, while VFG alone appeared to be electively indicated for infected or irradiated fields. In conclusion, despite the demanding surgical technique, VFG appears to be a long-lasting and definitive biological reconstruction procedure after intercalary tibial resection.
The reconstruction of a skeletal defect after resection of a bone tumour represents a challenge for the orthopaedic surgeon. Age, site of the lesion and extension of the disease often limit the choice of surgical technique for a conservative procedure, but several options are available, mainly modular, composite or custom prostheses, massive bone allografts with or without autologous vascularised fibular grafts (AVF), and arthrodeses. An interesting reconstructive technique uses the AVF graft, with microsurgical technique, alone or associated with a massive allograft. The association of a fibular transplant with an allograft increases the mechanical strength of the reconstruction, also promoting more rapid integration. The fibula is a cortical bone and it may provide mechanical strength in the reconstruction of a large segmental bony defect if employed as a viable biological rod. In the present paper the authors discuss their experience with 17 patients treated at the Oncological Orthopaedic Unit of the G.Pini Orthopaedic Institute, for bone tumour resection and reconstruction using AVF graft, almost always combined with a bone allograft. No treatments were performed as augmentation in osteoarticular massive allografts. Subjects’ ages ranged from 7 to 66 years (mean 25.2 years). Most of the patients were referred for a diagnosis of malignancy (15 of 17 cases) and in only two patients were the tumours not aggressive. In 11 patients the AVF was transplanted immediately after tumour resection, while in the others it was used after problems of previous reconstruction. The authors report two cases of deep infection and four mechanical fractures (all healed after a period of cast immobilisation with or without bone bridging). All the AVF survived and healed with a good functional result for the patients except for two recurrences that required an amputation.
A vascularised bone-graft procedure from the base of the second metacarpal was performed in 14 patients with nonunion of the scaphoid. There were 11 men and three women with a mean age of 22 years. In eight patients, who had dorsiflexed intercalated segment instability (DISI), an open wedge was formed at the site of nonunion, and the vascular pedicle was grafted from the volar side. In the six patients without DISI, transplantation was carried out through the same dorsal skin incision. Complete bony union was obtained in all patients after a mean post-operative period of 10.2 weeks, and DISI was corrected in all affected patients. According to Cooney’s clinical scoring system, the results were excellent in five, good in six, and fair in three patients. Because of its technical simplicity and the limited dissection needed, the procedure should be considered for the primary surgical treatment of patients with nonunion of the scaphoid.
Vascularized bone grafts (VFG) have brought great benefits in the field of reconstruction of the lower extremity. However, complications such as fracture of the grafted fibula and delayed union are sometimes seen. Not only to prevent these complications but also for stability after fracture of the grafted fibula, the Ilizarov external fixator is a very useful option. We report here the clinical results of cases treated by VFG combined with Ilizarov external fixator for reconstruction of the lower extremity. We have performed 53 vascularized fibula transfers to reconstruct lower extremities. An Ilizarov external fixator was used for the initial immobilization in 7 (2 femur, 5 tibia) and for delayed union or fracture of the grafted fibula in 2 cases of congenital pseudoarthrosis of the tibia. All patients achieved good bone reconstruction. All are able to walk without a brace except for one congenital case. The average period to achieve bony fusion was 13 months in femur cases, 6 months in adult tibia cases and 2 months in congenital cases. The average periods to walk without a brace were 14 months, 8 months and 10 months respectively. However, it took 9 months and 28 months to achieve bony union in the cases with delayed union or fracture of the grafted fibula. In the reconstruction of the lower extremities using VFG, the determining factor in method selection is whether sufficient mechanical support is available. An Ilizarov external fixator for immobilization permits the patient to walk as soon as possible. Dynamization from this semi-rigid external fixator causes bone hypertrophy and improved incorporation of the graft.
It has long been recognised that the periosteal membrane has osteogenic capability and experimental studies have concluded that periosteum transplanted to a distant site could also be osteogenic. This ability of periosteum to generate new bone at distant sites may have clinical application. In the laboratory setting however periosteal flaps in animals have demonstrated variable results. Little clinical work using the technique of periosteal transfer has been reported, with only individual case reports in the literature. A clinical review of a series of three fracture patients in whom vascularised periosteal transfer has been used is presented. Cases involved a primary bony defect at the fracture site (first metatarsal), established non-union (tibia) or post-traumatic AVN (talar dome). The technique is described and clinical follow-up of the patients is presented. In each instance evidence of lasting new bone formation was demonstrated clinically and radiologically. The efficacy of this technique in forming new bone is demonstrated. The technique may have utility alongside other techniques in cases where new bone is required.
Gap defects in the tibial shaft can arise as a consequence of auto-sequestrectomy in chronic osteomyelitis. Whilst bone transport techniques can be utilised to treat defects, the skills and equipment necessary for such procedures are seldom available in the developing world. An alternative, and more freely available method of reconstruction is to use ipsilateral vascularised fibular transfer. Approach to the fibula is postero-lateral. Muscle attachments to the lateral and antero-medial surfaces of the bone are released but care is taken to maintain the posterior proximal vascular pedicle, arising from the peroneal artery and to keep the periosteum intact. The fibula is then osteotomised proximally and distally and then transposed, by translation and rotation into a pre-prepared graft bed spanning the tibial defect. Some form of fixation and stabilisation may then be required and cancellous bone graft applied. Over the past 12 months 5 cases of ipsilateral vas-cularised fibular transfer have been performed. Mean age of the patients was 6.4. In three cases stabilisation was by a trans-calcaneal, intramedullary K-wire. In the remainder interfragmentary screws were used at the proximal and distal ends of the graft, supplemented by external fixation. Cancellous bone grafting was only performed in those cases also undergoing external fixation. In all cases the graft united satisfactorily at both the proximal and distal ends. No further procedures were necessary to effect this union. Particularly in the younger patients compensatory hypertrophy of the fibula, in response to the increased weight-bearing demand, was both marked and rapid. All five cases have completed treatment and need no mobility aids when walking. In conclusion we feel that the ipsilateral vascular-ised fibular graft is a useful method for treating tibial gap defects of osteomyelitic origin. Few specialised resources are required and thus it is a suitable technique for the developing world.
For decades the treatment of chronic post-traumatic osteomyelitis associated with bone exposure has been one of the most serious problems in the field of orthopaedic surgery. “Sterilisation” of the osteomyelitic site, that is radical débridement of all infected tissue, is the basic requirement of the treatment; in the past, the remaining defect of the débrided area was closed with skin grafts, which were removed in a further stage when the infection had cleared; then the defect was filled with muscle flap and bone graft of various types. Both soft tissue and osseous reconstruction took a relatively long period of time, requiring several-stage treatment. Over the years, introduction of microsurgery led to free muscle flaps and skin graft in one reconstruction setting in the 1970s and thin fascio-cutaneous flap reconstruction in the 1980s, allowing a shorter period of hospitalisation and an improvement in patients’ lifestyle. We performed a retrospective study of 22 patients treated for chronic osteomyelitis (middle or distal 1/3 of the leg, n=10; tarsus, n=6; forearm, n=6) by means of free vascularised bone graft or composite grafts between 1992 and 2003. In most of them a two-stage treatment was performed (resection and sterilisation in the first stage and bone transfer in the second one); in others a one-stage treatment was performed. In 78.5% of cases the infection was cured without requiring secondary procedures; revision of the flap was carried out in 12.3% of cases. In only one case leg amputation under the knee was necessary. In spite of advanced treatment protocols, persisting infection and residual functional deficit is not rare. Over the years the approach has changed. The application of microsurgical tissue transfers for reconstruction of the extremities allows repair of significant bone and soft-tissue defects. A wide variety of free flaps offers the potential to reconstruct nearly any defect of the limbs. The total array of flaps and their indications is beyond the scope of a single discussion, but this paper focuses on a few flaps that have found application for coverage and functional restoration of the limbs. Microsurgical transfers allow more radical débridement of the area affected by osteomyelitis with low peri-operative morbidity, reducing the number of procedures required to obtain bony union and subsequently effect a quick “return to work”. In management of chronic, post-traumatic osteomyelitis with soft-tissue loss, we prefer a well-vascularised muscle flap rather than a fascio-cutaneous flap (its important vascular supply helps reduce bacterial contamination).
We developed a 3D vascularized bone remodeling model embedding human osteoblast and osteoclast precursors and endothelial cells in a mineralized matrix. All the cells included in the model exerted their function, resulting in a vascularized system undergoing mineralized matrix remodeling. Bone remodeling is a dynamic process relying on the balance between the activity of osteoblasts and osteoclasts which are responsible for bone formation and resorption, respectively. This process is also characterized by a tight coupling between osteogenesis and angiogenesis, indicating the existence of a complex cross-talk between endothelial cells and bone cells. We have recently developed microscale in vitro hydrogel-based models, namely the 3D MiniTissue models, to obtain bone-mimicking microenvironments including a 3D microvascular network formed by endothelial cell self-assembly [1–2]. Here, we generated a vascularized 3D MiniTissue bone remodeling model through the coculture of primary human cells in a 3D collagen/fibrin (Col/Fib) matrix enriched with CaP nanoparticles (CaPn) to mimic bone mineralized matrix. Human umbilical vein endothelial cells (HUVECs), bone marrow mesenchymal stem cells (BMSCs), osteoblast (OBs) and osteoclast (OCs) precursors were cocultured in plain and CaPn-enriched Col/Fib according to the following experimental conditions: a) HUVECs-BMSCs; b) OBs-OCs; c) HUVECs-BMSCs-OBs-OCs. Undifferentiated BMSCs were used to support HUVECs in microvascular network formation. BMSCs and peripheral blood mononuclear cells were respectively pre-differentiated into OB and OC precursors through 7 days of culture in osteogenic or osteoclastogenic medium. Needle-shaped CaPn (Ø ∼20 nm, length ∼80 nm) were added to a collagen/fibrinogen solution. Cells were resuspended in a thrombin solution and then mixed with plain or CaPn-enriched collagen/fibrinogen. The cell-laden mix was injected in U-shaped PMMA masks and let to polymerize to generate constructs of 2×2×5 mm3. Samples were cultured for 10 days. Microvascular network formation was evaluated by confocal microscopy. OB differentiation was analyzed by quantification of Alkaline Phosphatase (ALP) and cell-mediated mineralization. OC differentiation was assessed by Tartrate-Resistant Acid Phosphatase (TRAP) and cell-mediated phosphate release quantification. HUVECs developed a robust 3D microvascular network and BMSCs differentiated into mural cells supporting vasculogenesis. The presence of CaPn enhanced OB and OC differentiation, as demonstrated by the significantly higher ALP and TRAP levels and by the superior cell-mediated mineralization and phosphate release measured in CaPn-enriched than in plain Col/Fib. The coculture of OBs and OCs with HUVECs and BMSCs further enhanced ALP and TRAP levels, indicating that the presence of HUVECs and BMSCs positively contributed to OB and OC differentiation. Remarkably, higher values of ALP and TRAP activity were measured in the tetraculture in CaPn-enriched Col/Fib compared to plain Col/Fib, indicating that also in the tetraculture the mineralized matrix stimulated OB and OC differentiation. The 3D MiniTissue bone remodeling model developed in this study is a promising platform to investigate bone cell and endothelial cell cross-talk. This system allows to minimize the use of cells and reagents and is characterized by a superior ease of use compared to other microscale systems, such as microfluidic models. Finally, it represents a suitable platform to test drugs for bone diseases and can be easily personalized with patient-derived cells further increasing its relevance as drug screening platform.
We are presenting the outcome of a young adult with extensive epithelioid hemangioendothelioma of the femur treated with wide excision and vascularised fibular graft. An 18-year-old builder was referred with an aggressive primary bone tumor of the right femur. Initial staging showed no evidence of distant disease but tumor confined to a 26.5cm diaphyseal segment of the femoral shaft. The patient’s pre-operative Oxford knee score was 28 and the AKSS scores were 74 (observational) and 65 (functional). True cut open biopsy confirmed low grade angiosarcoma. The patient underwent a wide excision of the lesion through a lateral approach leaving a generous cuff of bone and muscle tissue around the tumor. Clear resection margins were assessed intraoperatively. Histologically, the tumor was found to be epithelioid hemangioendothelioma. The 29.5cm defect was filled with a vascularised bone graft of the ipsilateral fibula. The graft was secured with a 22-hole DCS bridging plate and screws at both ends. Intraoperative knee range of motion was from 0 to 125 degrees without recurvatum and graft movement. The patient had an unremarkable recovery. At the latest follow-up, one year after his operation, the patient had made an excellent functional recovery with non-symptomatic full weight bearing and had also returned to his work as a builder. He demonstrated a knee range of motion of 0 to 115 with a slight genu varum. The patient’s post-operative Oxford knee score was 40 and the AKSS scores were 70 (observational) and 90 (functional). Radiographs showed excellent union at the distal aspect of the graft and a healing stress fracture of the fibula graft at the proximal aspect. Vascularized fibular graft with plating is a safe reconstruction limb salvage option for defects of long bones after tumor resection.
The aetiology, pathogenesis and clinical staging of osteonecrosis of the femoral head have been the subject of considerable discussion. The same is true regarding the treatment of such conditions, which could be non-operative (shockwaves, no traction, PEMFs) or operative (conservative methods or prosthetic substitution), depending on the age of the patient and the degree of compromise of the femoral head. During the period between 1972 and 2003 at the CTO Hospital of Turin, Italy, 54 patients underwent surgery. We used core decompression (forage biopsy) in 39 cases and in the other 15 cases free vascularised fibular grafting (microsurgical techniques). All the patients were at the initial stages of the condition (Steinberg I–IIIa), stages in which subchondral collapse had not yet occurred. Follow up average 125.6 months. The results were estimated according to the Harris Hip Score, which allows for a score in relation to pain upon motional, functional and clinical deformity. In light of our data, we can confirm that the advantage of the result is secondary to the appropriate use of surgical techniques in relation to the clinical staging of the pathology. We have, in fact, established a treatment protocol that calls for core decompression at stage 0 – IA and free vascularised fibular grafting at the more advanced stages that go from IB to IIIA.
Autologous bone grafting is a standard procedure for the clinical repair of skeletal defects, and good results have been obtained. Autologous vascularized bone grafting is currently the procedure of choice because of high osteogenic potential and resistance against reabsorption. Disadvantages of this procedure include limited availability of donor sites, clinical difficulty in handling, and a failure rate exceeding 10%. Allografts are often used for massive bone loss, but since only the marginal portion is newly vascularized after the implantation non healing fractures are often reported, along with a graft reabsorption. To overcome these problems, some studies in literature tried to conjugate bone graft and vascular supply, with encouraging results. On the other side, several studies in literature reported the ability of bone marrow derived cells to promote neo-vascularization. In fact, bone marrow contains not only hematopoietic stem cells (HSCs) and MSCs as a source for regenerating tissues but also accessory cells that support angiogenesis and vasculogenesis by producing several growth factors. In this scenario a new procedure was developed, consisting in an allogenic bone graft transplantation in a critical size defect in rabbit radius, plus a deviation at its inside of the median artery and vein with a supplement of autologous bone marrow concentrate on a collagen scaffold. Twenty-four New Zealand male white rabbits (2500–3000 g) were divided into 2 groups, each consisting of 12 animals. Surgeries were performed as follow:
Group 1 (#12): allogenic bone graft (left radius) / allogenic bone graft + vascular pedicle + autologous bone marrow concentrate (right radius) Group 2 (#12): sham operated (left radius)/ allogenic bone graft + vascular pedicle (right radius) For each group, 3 experimental time: 8, 4 and 2 weeks (4 animals for each time). The bone used as graft was previously collected from an uncorrelated study. An in vitro evaluation of bone marrow concentrate was performed in all cases, and at the time of sacrifice histological and histomorphometrical assessment were performed with immunohistochemical assays for VEGF, CD31 e CD146 to highlight the presence of vessels and endothelial cells. Micro-CT Analysis with quantitative bone evaluation was performed in all cases. The bone marrow concentrate showed a marked capability to differentiate into osteogenic, chondrogenic and agipogenic lineages. No complications such as infection or intolerance to the procedure were reported. The bone grafts showed only a partial integration, mainly at the extremities in the group with vascular and bone marrow concentrate supplement, with a good and healthy residual bone. immunohistochemistry showed an interesting higher VEGF expression in the same group. Micro CT analysis showed a higher remodeling activities in the groups treated with vascular supplement, with an area of integration at the extremities increasing with the extension of the sacrifice time. The present study suggests that the vascular and marrow cells supplement may positively influence the neoangiogenesis and the neovascularization of the homologous bone graft. A longer time of follow up and improvement of the surgical technique are required to validate the procedure.
The twenty-two patients who achieved primary bone healing developed a hypertrophic graft (mean 61%, range 22 – 190%). Graft hypertrophy was not observed in the five cases requiring a secondary graft after the scintigram demonstrated lack of vascularisation. Hypertrophy of the vascularised fibular graft was more marked for lower limb reconstructions than for upper limb reconstructions.. Functional outcome was satisfactory in all cases. On the 30-point Enneking scale as modified, our patients achieved a mean 26 points (range 19 – 30).
Retrospective comparative analysis of twenty five patients treated with Ilizarov bone transport [IBT] and twenty one patients treated with vascularised fibular graft [VFG] from 1994 to 2003 in one institution, for post traumatic tibial bone defects of more than six centimeters. The aim of the study was to find out if there were any differences in achieving radiological end points, bone and functional score and return to work (final outcome), hospital stay and operating time (logistic factors) and complication rates. The mean defect size in the IBT group was 11.9 centimeters and in the VFG group 14.6 centimeters. Twenty one and sixteen patients in the IBT and VFG group respectively achieved the radiological end point that is union of the defect and graft hypertrophy [p 0.5]. Nineteen patients in the IBT group and fifteen in the VFG group returned to productive work [p 0.72]. Bone and functional results were analyzed by Paley’s evaluation system and there were no significant differences in the two groups of patients [bone result p 0.97 and functional result p 0.1]. The logistic factors were significantly less of IBT group [p <
0.05]. Two patients in the IBT group and one patient in the VFG group had amputation and one patient in VFG group died. Three cases in the VFG group had flap loss. Stress fracture of the graft occurred in eight patients in the VFG group [p 0.0007]. The final outcome was same in both groups. Hospital stay, operating time and refractures were significantly less in IBT group.
Following a laboratory rat study where iliac crest was removed, the femoral vessels were placed as a pedicle through the centre of the graft which was wrapped in silastic sheeting and transplanted to the subcutaneous abdominal wall, which showed in all cases bone revascularisation and viability within three weeks. A human study followed in two patients with chronic complex scaphoid non unions where iliac crest was placed in the anterior interosseous pedicle in the proximal forearm. The pedicle was ligated proximally. Four months later, the graft was dissected on its pedicle distally to the scaphoid. In both cases, the scaphoid united and in both cases the bone was viable at biopsy. Rather than this tedious two stage procedure, Russe and Fisk grafts are routinely pedicled with the superficial radial vessels flowing retrograde at scaphoid bone grafting. At the same time of our rat study, Zaidemberg published his dorso-radial radius vascularised pedicled bone graft on the “irrigating artery”. The details were scant as they were at the oral presentation three years later. The irrigating artery was subsequently beautifully demonstrated in Zancolli’s Atlas of Hand Surgery and this and other dorsal pedicled bone grafts of the radius have been well described by Bishop and colleagues at the Mayo Clinic. The technique of 1-2 SRA (Zaidemberg) pedicled bone grafting is described in detail together with the indications for prefabrication and vascularised pedicled bone grafting and the necessary pre operative imaging information to plan and select the correct procedure.
In oncological resections there is a higher risk of infection around the foot and ankle. An infection here can be difficult to treat and easily lead to an amputation due to the limited amount of soft tissue coverage of the region. In three patients an infection developed after resection of a bone tumour in the foot and ankle. In the first case, female 34 years, an epitheloid hemangioepithelioma was excised from the anterior part of the calcaneus, cuboid and lateral os cuneiform. An iliac crest graft was initially used to fill the defect, but got infected. The antibiotic loaded bone cement spacer cured the infection and filled the dead space but was painful. A free vascularised fibula with skin-flap was used successfully to fill the defect and take away the pain. At three-year follow-up there is no pain and full weight bearing, with a nice hypertrophy of the graft. In the second case, a 14-year old girl, there was an Aneu-rismal Bone Cyst (ABC) of the distal tibia with a deep infection after ethibloc injection. The vacuum assisted closure cleaned the wound but a defect resulted. It was successfully filled with an ipsilateral free vascularised fibula with skin-flap. Follow-up shows full function and nice hypertrophy at 24 months. In the third case, male 65 years, a chondrosarcoma grade one (after biopsy) in the cuboid was curetted out. It proved grade two in the definitive histology and furthermore it got infected. The cuboid was excised and a cement spacer was placed. The soft tissues were insufficient to close it properly. A free vascularised fibula with skin-flap was used. The vascularity of the graft was insufficient and the skin-flap did not survive. A vacuum assisted closure was done. He can bear weight and has no pain. The fibula graft is shows some hypertrophy and a fistula persists for 18 months now. We conclude that vascularised free fibula with skinflap can successfully prevent amputation in case of infection in oncological resection of foot and ankle. The fibula reconstructs the bone defect and the skin-flap the soft tissue defect.
Several methods have been used for proximal humeral reconstruction following tumour resection. None of these modalities allow the patient to regain his normal shoulder range of motion. Moreover, every modality has its advantages and disadvantages. The aim of this study was to compare the functional outcome of 2 reconstructive modalities that we are using in our institution for proximal humeral reconstruction; endoprosthesis and shoulder arthrodesis using a vascularised autograft This study included 48 patients diagnosed with malignant or benign aggressive tumours that required resection of their proximal humerus. They were divided into 2 groups according to the method of reconstruction. Group 1 included 22 patients with an average age of 20 years were reconstructed by shoulder arthrodesis using a free vascularised fibular graft (6) or a pedicled scapular crest graft (16). Group 2 included 26 patients with an average age of 26 years were reconstructed with an endoprosthesis. In group 1 the average follow up period was 88 months (range 12 to 184 months). The average functional outcome (according to the MSTS scoring system) was 25 points (range 19 – 28). The average abduction and forward flexion range of motion (scapulothoracic) was 40 degrees (range 20 -60). Complications included failed fixation (2), non union (1), infection (1) and temporary radial nerve palsy (2). In group 2 the average follow up period was 36 months (range 12 – 110). The average functional outcome was 24 points (range 20 – 27). The average abduction and forward flexion range of motion was 40 (range 30 –70). Complications included sublaxation (2), loosening (1) and infection (1). Reconstruction of the proximal humerus by arthrodesis or endoprosthesis yield similar functional outcome. Although endoprosthesis is a much more expensive modality, it does not provide any superior functional outcome over shoulder arthrodesis.
The objective of our study is to identify the causes for recurrence and to evaluate the results of our technique. We retrospectively analysed 18 patients (12 females; 6 males) who had both clinical and electrophysiological confirmation (7 focal entrapments; 11 severe entrapments) of recurrent carpal tunnel syndrome. In all the patients, after releasing the nerve a vascularised fat pad flap was mobilised from hypothenar region and sutured to the lateral cut end of flexor retinaculum. All the patients were assessed post-operatively for relief of pain, recovery of sensory and motor dysfunction.Aims
Material and Methods
This is a prospective study assessing the results of patients receiving large fragment allograft and a vascularised fibular graft following primary malignant tumour resections around the hip and the knee. 18 patients underwent tumor resection followed by reconstruction with large fragment allograft and vascularised fibular graft. Eight patients underwent resection arthrodesis of the hip, four underwent resection arthrodesis of the knee and six underwent intercalary resections. Following tumour resection with adequate margins, an appropriate sized allograft fragment was internally fixed with either a plate or an intramedullary nail. A vascularised fibular graft was used to span the gap between the remaining host bones. Osteosarcoma was the commonest diagnosis. The patients were clinically assessed by MSTS functional scoring system and radiologically assessed at regular intervals. The mean age was 26 years (range12–70) and majority of the patients was men. 11 patients received preoperative chemotherapy. Mean follow-up was 85 months (range 8–153). Six patients have died of metastatic disease at a mean of 33 months. Complications included local recurrence in two, deep infection in one and stress fracture of the fibula in two cases. One patient with local recurrence and the other with deep infection underwent an amputation. Majority of the patients had good or excellent MSTS scores at final follow-up and 75% of the patients are engaged in physically active occupations. Graft hypertrophy was evident in majority of the patients. Our experience clearly indicates that reconstruction with large fragment allograft and vascularised fibular graft is a useful limb salvage procedure with the fibula hypertrophying slowly with time. The eventual fracture of the allograft or failure of the allograft-plate composite is to be expected but is not deleterious due to the physiological response of the vascularised fibula to the weight bearing stresses over time. We feel that this biological solution is likely to demonstrate superior long-term results compared to a prosthetic reconstruction.
All traumatic cases happened almost 2 weeks before operation except three which caused between 2 and 6 months earlier. In the 2 diabetic cases the lesion appeared between 3 and 5 month ago. We have performed: 9 sural flaps, 5 perforator-posterior tibial artery flap, 1 medial plantar, 4 based on distal perforators of the peroneal artery, 1 Saphenous, 2 muscular flaps. All patients were between 17 and 81 years all and the follow up between 8 month and 2 years. Everywhere before the flap we performed surgical debridement. As supplementary combined reconstructive technique we performed: 1. Mega papineau technique, 2. Bone filling, 3. Distraction osteogennesis, with spatial Taylor frame.
These flaps are better tolerated by the patient than the traditional techniques and safer, less demanding and faster to perform than the free tissue transfers.
A defect following resection of Giant Cell Tumour of the distal radius (GCT-DR) is reconstructed by either vascularised free fibular transfer (VFF) or non-vascularised structural iliac crest transfer (NIC). The purpose of this study was to compare these procedures. Twenty-seven patients at two centres were identified, 14 underwent VFF and 13 NIC. The two groups were comparable for age, sex, and tumour grade. Functional outcomes were assessed with TESS, MSTS, and DASH. In the VFF group, ankle joint morbidity was assessed with the Ankle Osteoarthritis Scale. In the NIC group, iliac crest morbidity was assessed with a short questionnaire.Objectives
Methods
Aims. This retrospective cohort study compared the results of vascularised
and non-vascularised anterior sliding tibial grafts for the treatment
of osteoarthritis (OA)of the ankle secondary to osteonecrosis of
the talus. . Patients and Methods. We reviewed the clinical and radiological outcomes of 27 patients
who underwent arthrodesis with either vascularised or non-vascularised
(conventional) grafts, comparing the outcomes (clinical scores,
proportion with successful union and time to union) between the
two groups. The clinical outcome was assessed using the Mazur and
American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot
scores. The mean follow-up was 35 months (24 to 68). Results. The mean outcome scores increased significantly in both groups.
In the vascularised graft group, the mean Mazur score improved from
36.9 to 74.6 and the mean AOFAS scale improved from 49.6 to 80.1. . In the conventional arthrodesis group, the mean Mazur score improved
from 35.5 to 65 and the mean AOFAS scale from 49.2 to 67.6. . Complete fusion was achieved in 13 patients (76%) in the vascularised
group, but only four (40%) in the conventional group. The clinical
outcomes and proportion achieving union were significantly better
in the vascularised group compared with the conventional arthrodesis
group, although time to union was similar in the two groups. Take home message:
The management of chronic osteomyelitis requires the excision of necrotic and infected material followed by the prolonged administration of antibiotics. Sequestrectomy may be required before an involucrum has formed, resulting in a longitudinal bone defect. This can be difficult to fill.
Purpose. We retrospectively evaluated the outcome of fibula grafts in upper limb post infectious diaphyseal gap nonunions and assessed the following modifiers: age, site, vascularised/ nonvascularised, and length of the graft on time to union, graft incorporation, complication rate and reoperation rate. Methods. Thirty seven paediatric upper limb segmental defects treated over a period of 10 years were identified. Twenty two post septic defects in 21 children were treated with intramedullary fixation and vascularised/ nonvascularised fibula grafting. Union time was assessed from records and radiographs. Graft incorporation was assessed using Pixel value ratio (Hazra et al). Complications were defined as nonunion, delayed union, implant failure, refractures, graft loss and infection. Results. Twenty one children with 22 nonunions, 9 boys and 12 girls, mean age 6.5 years were followed up for a mean of 24 months. Defects (humerus-8, radius-8, ulna-6) ranged from 10 mm to 85 mm before surgery. Seven vascularised grafts(mean length = 69.9 mm) 3 in ulna and 4 in radius and 14 nonvascularised (48.8 mm) were 8 in humerus, 4 in radius, 3 in ulna. Primary union was 81% at a mean of 4.7 months. Mean pixel value for graft incorporation was 1.3 (SD = 0.2) on immediate postoperative radiograph and 1.08 (SD 0.16) at mean of 2 years. Complications included nonunion requiring surgery in 4, delayed union in 6, wire migration in 6, refractures in 4, infection reactivation in 2 with loss of graft in 1. Time to union was 5.5 (SD 2.9) months in nonvascularised and 3.1 (SD 0.6) in vascualrised group (P = 0.04). Complication rate was 1.2 and 0.2 in nonvascularised and vascularised grafts(p = 0.04). Bone, age and the graft length did not significantly affect union time, graft incorporation, complication and reoperation rate. The complication rate was significantly higher in children ≤8 year; however other outcomes were not significantly different. Conclusion.
The aim of the study was to compare measures of the quality of
life (QOL) after resection of a chordoma of the mobile spine with
the national averages in the United States and to assess which factors
influenced the QOL, symptoms of anxiety and depression, and coping
with pain post-operatively in these patients. A total of 48 consecutive patients who underwent resection of
a primary or recurrent chordoma of the mobile spine between 2000
and 2015 were included. A total of 34 patients completed a survey
at least 12 months post-operatively. The primary outcome was the
EuroQol-5 Dimensions (EQ-5D-3L) questionnaire. Secondary outcomes were
the Patient-Reported Outcome Measurement Information System (PROMIS)
anxiety, depression and pain interference questionnaires. Data which
were recorded included the indication for surgery, the region of
the tumour, the number of levels resected, the status of the surgical
margins, re-operations, complications, neurological deficit, length
of stay in hospital and rate of re-admission.Aims
Patients and Methods
A new method of vascularised tibial grafting
has been developed for the treatment of avascular necrosis (AVN)
of the talus and secondary osteoarthritis (OA) of the ankle. We
used 40 cadavers to identify the vascular anatomy of the distal
tibia in order to establish how to elevate a vascularised tibial
graft safely. Between 2008 and 2012, eight patients (three male,
five female, mean age 50 years; 26 to 68) with isolated AVN of the
talus and 12 patients (four male, eight female, mean age 58 years;
23 to 76) with secondary OA underwent vascularised bone grafting
from the distal tibia either to revascularise the talus or for arthrodesis.
The radiological and clinical outcomes were evaluated at a mean
follow-up of 31 months (24 to 62). The peri-malleolar arterial arch
was confirmed in the cadaveric study. A vascularised bone graft
could be elevated safely using the peri-malleolar pedicle. The clinical
outcomes for the group with AVN of the talus assessed with the mean
Mazur ankle grading scores, improved significantly from 39 points
(21 to 48) pre-operatively to 81 points (73 to 90) at the final
follow-up (p = 0.01). In all eight revascularisations, bone healing
was obtained without progression to talar collapse, and union was
established in 11 of 12 vascularised arthrodeses at a mean follow-up
of 34 months (24 to 58). MRI showed revascularisation of the talus
in all patients. We conclude that a vascularised tibial graft can be used both
for revascularisation of the talus and for the arthrodesis of the
ankle in patients with OA secondary to AVN of the talus. Cite this article:
Non-traumatic osteonecrosis of the femoral head
is a potentially devastating condition, the prevalence of which
is increasing. Many joint-preserving forms of treatment, both medical
and surgical, have been developed in an attempt to slow or reverse
its progression, as it usually affects young patients. However, it is important to evaluate the best evidence that is
available for the many forms of treatment considering the variation
in the demographics of the patients, the methodology and the outcomes
in the studies that have been published, so that it can be used
effectively. The purpose of this review, therefore, was to provide an up-to-date,
evidence-based guide to the management, both non-operative and operative,
of non-traumatic osteonecrosis of the femoral head. Cite this article:
We retrospectively reviewed 101 consecutive patients
with 114 femoral tumours treated by massive bone allograft at our
institution between 1986 and 2005. There were 49 females and 52
males with a mean age of 20 years (4 to 74). At a median follow-up
of 9.3 years (2 to 19.8), 36 reconstructions (31.5%) had failed.
The allograft itself failed in 27 reconstructions (24%). Mechanical complications such as delayed union, fracture and
failure of fixation were studied. The most adverse factor on the
outcome was the use of intramedullary nails, followed by post-operative
chemotherapy, resection length >
17 cm and age >
18 years at the
time of intervention. The simultaneous use of a vascularised fibular
graft to protect the allograft from mechanical complications improved
the outcome, but the use of intramedullary cementing was not as
successful. In order to improve the strength of the reconstruction and to
advance the biology of host–graft integration, we suggest avoiding
the use of intramedullary nails and titanium plates, but instead
using stainless steel plates, as these gave better results. The
use of a supplementary vascularised fibular graft should be strongly
considered in adult patients with resection >
17 cm and in those
who require post-operative chemotherapy.
Chronic conditions of the wrist may be difficult to manage because
pain and psychiatric conditions are correlated with abnormal function
of the hand. Additionally, intra-articular inflammatory cytokines
may cause pain. We aimed to validate the measurement of inflammatory cytokines
in these conditions and identify features associated with symptoms. The study included 38 patients (18 men, 20 women, mean age 43
years) with a chronic condition of the wrist who underwent arthroscopy.
Before surgery, the Self-Rating Depression Scale (SDS), Hand20 questionnaire
and a visual analogue scale (VAS) for pain were used. Cytokine and
chemokine levels in the synovial fluid of the wrist were measured
using enzyme-linked immunosorbent assays and correlations between
the levels with pain were analysed. Gene expression profiles of
the synovial membranes were assessed using quantitative polymerase
chain reaction.Aims
Patients and Methods
We report the results of limb salvage for non-metastatic osteosarcoma of the distal tibia using resection arthrodesis, autogenous fibular graft and fixation by an Ilizarov external fixator. In six patients with primary osteosarcoma of the distal tibia who refused amputation, treatment with wide In five patients sound fusion occurred at a mean of 13.2 months (8 to 20) with no evidence of local recurrence or deep infection at final follow-up. The mean post-operative functional score was 70% (63% to 73%) according to the Musculoskeletal Tumour Society scoring system. All five patients showed graft hypertrophy. Union of the graft was faster in cases reconstructed by vascularised fibular grafts. One patient who had a poor response to pre-operative chemotherapy developed local tumour recurrence at one year post-operatively and required subsequent amputation.
The December 2014 Oncology Roundup360 looks at: metaphyseal and diaphyseal osteosarcoma subtly different beasts; sports and endoprosthetic reconstruction of the knee; is curettage without tissue diagnosis sensible in cartilaginous tumours?; autoclaved autograft in bone tumour reconstruction; vascularised graft a step too far in bone defects?; interdigitated neoadjuvant chemoradiotherapy in high-grade sarcoma; predicting life expectancy in patients with painful metastasis; and osteolytic lesions of the hands and feet.
This preliminary study evaluates a combination
of bone morphogenetic protein (BMP)-7 and non-vascularised autologous
fibular grafting (AFG) for the treatment of osteonecrosis of the
femoral head. BMP-7/AFG combination was applied in seven pre-collapse femoral
heads (five Steinberg stage II, two stage III) in six patients.
Pre- and post-operative evaluation included clinical (Harris hip
score (HHS), visual analogue scale (VAS) for pain) and radiological
assessment (radiographs, quantitative CT) at a mean follow-up of
4 years (2 to 5.5). A marked improvement of function (mean HHS increase of 49.2)
and decrease of pain level (mean VAS decrease of 5) as well as retention
of the sphericity of the femoral head was noted in five hips at
the latest follow-up, while signs of consolidation were apparent
from the third post-operative month. One patient (two hips) required
bilateral total hip replacement at one year post-operatively. In
the series as a whole, quantitative-CT evaluation revealed similar densities
between affected and normal bone. Heterotopic ossification was observed
in four hips, without compromise of the clinical outcome. In this limited series AFG/BMP-7 combination proved a safe and
effective method for the treatment of femoral head osteonecrosis,
leading to early consolidation of the AFG and preventing collapse
in five of seven hips, while the operative time and post-operative
rehabilitation period were much shorter compared with free vascularised fibular
grafts. Cite this article:
We report our experience of treating 17 patients with benign lesions of the proximal femur with non-vascularised, autologous fibular strut grafts, without osteosynthesis. The mean age of the patients at presentation was 16.5 years (5 to 33) and they were followed up for a mean of 2.9 years (0.4 to 19.5). Histological diagnoses included simple bone cyst, fibrous dysplasia, aneurysmal bone cysts and giant cell tumour. Local recurrence occurred in two patients (11.7%) and superficial wound infection, chronic hip pain and deep venous thrombosis occurred in three. Pathological fracture did not occur in any patient following the procedure. We conclude that non-vascularised fibular strut grafts are a safe and satisfactory method of treating benign lesions of the proximal femur.
We describe a series of 20 patients with ununited fractures of the femoral neck following neglected trauma or failed primary internal fixation who were seen at a mean of 7.5 months (2 to 18) following injury. Open reduction and internal fixation of the fracture was performed in all patients, together with a myoperiosteal flap on the quadratus femoris muscle pedicle. Union occurred at a mean of 4.9 months (2 to 10) in all patients. The mean follow-up was for 70 months (14 to 144). There was no further progression in six of seven patients with pre-operative radiological evidence of osteonecrosis of the femoral head. One patient had delayed collapse and flattening of the femoral head ten years after union of the fracture, but remained asymptomatic. This study demonstrates the orthopaedic application of myoperiosteal grafting for inducing osteogenesis in a difficult clinical situation.
The June 2013 Hip &
Pelvis Roundup360 looks at: failure in metal-on-metal arthroplasty; minimal hip approaches; whether bisphosphonates improve femoral bone stock following arthroplasty; whether more fat means more operative time; surgical infection; vascularised fibular graft for osteonecrosis; subclinical SUFE; and dentists, hips and antibiotics.
We evaluated 31 patients who were treated with a non-vascularised fibular graft after resection of primary musculoskeletal tumours, with a median follow-up of 5.6 years (3 to 26.7 years). Primary union was achieved in 89% (41 of 46) of the grafts in a median period of 24 weeks. All 25 grafts in 18 patients without additional chemotheraphy and/or radiotherapy achieved primary union, compared with 16 of the 21 grafts (76%; 13 patients) with additional therapy (p = 0.017). Radiographs showed an increase in diameter in 70% (59) of the grafts. There were seven fatigue fractures in six patients, but only two needed treatment. Non-vascularised fibular transfer is a simpler, less expensive and a shorter procedure than the use of vascularised grafts and allows remodelling of the fibula at the donor site. It is a biological reconstruction with good long-term results, and a relatively low donor site complication rate of 16%.
Congenital pseudarthrosis of the tibia (CPT)
is a rare but well recognised condition. Obtaining union of the pseudarthrosis
in these children is often difficult and may require several surgical
procedures. The treatment has changed significantly since the review
by Hardinge in 1972, but controversies continue as to the best form
of surgical treatment. This paper reviews these controversies. Cite this article:
The October 2012 Oncology Roundup360 looks at: the causes of primary bone tumours; adjuvant chemotherapy in the longer term; vascularised fibular grafts to salvage massive femoral allografts; a new look at old risks; reconstruction with excised irradiated bone; predicting chemosensitivity in osteosarcoma ; and chemotherapy, osteoporosis and the risk of fracture.
The June 2012 Children’s orthopaedics Roundup360 looks at; open reduction for DDH; growing rod instrumentation for scoliosis; acute patellar dislocation; management of the relapsed clubfoot; clubfoot in Iran; laughing gas and fracture manipulation; vascularised periosteal fibular grafting for nonunion; slipped upper femoral epiphysis; intramedullary leg lengthening and orthopaedic imaging and defensive medicine.
Congenital pseudarthrosis of the tibia remains one of the most difficult orthopaedic problems. We describe early excision and the use of the Masquelet technique to reconstruct the bone defect in a child aged 14 months. Consolidation sufficient for complete weight-bearing was achieved by seven weeks. After two and a half years, the child was asymptomatic with a fully reconstructed tibia and no leg-length discrepancy.
Between 1997 and 2007, 68 consecutive patients underwent replacement of the proximal humerus for tumour using a fixed-fulcrum massive endoprosthesis. Their mean age was 46 years (7 to 87). Ten patients were lost to follow-up and 16 patients died. The 42 surviving patients were assessed using the Musculoskeletal Tumor Society (MSTS) Score and the Toronto Extremity Salvage Score (TESS) at a mean follow-up of five years and 11 months (one year to ten years and nine months). The mean MSTS score was 72.3% (53.3% to 100%) and the mean TESS was 77.2% (58.6% to 100%). Four of 42 patients received a new constrained humeral liner to reduce the risk of dislocation. This subgroup had a mean MSTS score of 77.7% and a mean TESS of 80.0%. The dislocation rate for the original prosthesis was 25.9; none of the patients with the new liner had a dislocation at a mean of 14.5 months (12 to 18). Endoprosthetic replacement for tumours of the proximal humerus using this prosthesis is a reliable operation yielding good results without the documented problems of unconstrained prostheses. The performance of this prosthesis is expected to improve further with a new constrained humeral liner, which reduces the risk of dislocation.
We describe a retrospective review of 38 cases of reconstruction following resection of the metaphysiodiaphysis of the lower limb for malignant bone tumours using free vascularised fibular grafts. The mean follow-up was for 7.6 years (0.4 to 18.4). The mean Musculoskeletal Tumor Society score was 27.2 (20 to 30). The score was significantly higher when the graft was carried out in a one-stage procedure after resection of the tumour rather than in two stages. Bony union was achieved in 89% of the cases. The overall mean time to union was 1.7 years (0.2 to 10.3). Free vascularised fibular transfer is a major operation with frequent, but preventable, complications which allows salvage of the limb with satisfactory functional results.
We describe the use of a vascularised periosteal patch onlay graft based on the 1,2 intercompartmental supraretinacular artery in the management of 11 patients (ten men, one woman) with chronic nonunion involving the proximal third of the scaphoid. The mean age of the patients was 31 years (21 to 45) with the dominant hand affected in eight. Six of the patients were smokers and three had undergone previous surgery to the scaphoid. All of the proximal fragments were avascular. The presence of union was assessed using longitudinal axis CT. Only three patients progressed to union of the scaphoid and four required a salvage operation for a symptomatic nonunion. The remaining four patients with a persistent nonunion are asymptomatic with low pain scores, good grip strength and a functional range of wrist movement. Although this technique has potential technical advantages over vascularised pedicled bone grafting, the rate of union has been disappointing and we do not recommend it as a method of treatment.
We describe the management of nonunion combined with limb-length discrepancy following vascularised fibular grafting for the reconstruction of long-bone defects in the lower limb after resection of a tumour in skeletally immature patients. We operated on nine patients with a mean age of 13.1 years (10.5 to 14.5) who presented with a mean limb-length discrepancy of 7 cm (4 to 9) and nonunion at one end of a vascularised fibular graft, which had been performed previously, to reconstruct a bone defect after resection of an osteosarcoma. Reconstruction was carried out using a ring fixator secured with correction by half pins of any malalignment, compression of the site of nonunion and lengthening through a metaphyseal parafocal osteotomy without bone grafting. The expected limb-length discrepancy at maturity was calculated using the arithmetic method. Solid union and the intended leg length were achieved in all the patients. Excessive scarring and the distorted anatomy from previous surgery in these patients required other procedures to be performed with minimal exposures and dissection in order to avoid further compromise to the vascularity of the graft or damage to neurovascular structures. The methods which we chose were simple and effective in addressing these complex problems.
We present the results of ankle fusion using the Ilizarov technique for bone loss around the ankle in 20 patients. All except one had sustained post-traumatic bone loss. Infection was present in 17. The mean age was 33.1 years (7 to 71). The mean size of the defect was 3.98 cm (1.5 to 12) and associated limb shortening before the index procedure varied from 1 cm to 5 cm. The mean time in the external fixator was 335 days (42 to 870). Tibiotalar fusion was performed in 19 patients and tibiocalcaneal fusion in one. Associated problems included diabetes in one patient, pelvic and urethral injury in one, visual injury in one patient and ipsilateral tibial fracture in five. At the final mean follow-up of 51.55 months (24 to 121) fusion had been achieved in 19 of 20 patients. A total of 16 patients were able to return to work. The results were graded as good in 11 patients, fair in six and poor in three. The mean external fixation index was 8.8 days/mm (0 to 30). One patient with diabetes developed severe infection which required early removal of the fixator. Refractures occurred in three patients, two of which were at the site of fusion and one at a previous tibial shaft fracture site. Equinus deformity of the ankle fusion occurred after a further fracture in one patient. There were two patients with residual forefoot equinus, and one developed late valgus at the fusion site. Poor consolidation of the regenerated bone in two patients was treated by bone grafting in one and by bone and fibular strut grafting in the other. Residual soft-tissue infection was still present in two patients.
We report the use of a free vascularised iliac bone graft in the treatment of 21 patients (19 men and 2 women) with an avascular nonunion of the scaphoid in which conventional bone grafting had previously failed. The mean age of the patients was 32 years (23 to 46) and the dominant wrist was affected in 14. The mean interval from fracture to the vascularised bone grafting was 39 months (9 to 62). Pre-operative MRI showed no contrast enhancement in the proximal fragment in any patient. Fracture union was assessed radiologically or with CT scans if the radiological appearances were inconclusive. At a mean follow-up of 5.6 years (2 to 11) union was obtained in 16 patients. The remaining five patients with a persistent nonunion continued to experience pain, reduced grip strength and limited range of wrist movement. In the successfully treated patients the grip strength and range of movement did not recover to match the uninjured side. Prevention of progressive carpal collapse, the absence of donor site morbidity, good subjective results and pain relief, justifies this procedure in the treatment of recalcitrant nonunion of the scaphoid.
We studied the safety of external fixation during post-operative chemotherapy in 28 patients who had undergone distraction osteogenesis (17, group A) or vascularised fibular grafting (11, group B) after resection of a tumour. Four cycles of multi-agent post-operative chemotherapy were administered over a mean period of 14 weeks (6 to 27). The mean duration of external fixation for all patients was 350 days (91 to 828). In total 204 wires and 240 half pins were used. During the period of post-operative chemotherapy, 14 patients (11 in group A, 3 in group B) developed wire- and pin-track infection. A total of ten wires (4.9%) and 11 half pins (4.6%) became infected. Seven of the ten infected wires were in periarticular locations. External fixation during post-operative chemotherapy was used safely and successfully for fixation of a vascularised fibular graft and distraction osteogenesis in 27 of 28 patients. Post-operative chemotherapy for malignant bone tumours did not adversely affect the ability to achieve union or cause hypertrophy of the vascularised fibular graft and had a minimal effect on distraction osteogenesis. Only one patient developed osteomyelitis which required further surgery.
The use of a navigation system in musculoskeletal tumour surgery enables the integration of pre-operative CT and MRI images to generate a precise three-dimensional anatomical model of the site and the extent of the tumour. We carried out six consecutive resections of musculoskeletal tumour in five patients using an existing commercial computer navigation system. There were three women and two men with a mean age of 41 years (24 to 47). Reconstruction was performed using a tumour prosthesis in three lesions and a vascularised fibular graft in one. No reconstruction was needed in two cases. The mean follow-up was 6.9 months (3.5 to 10). The mean duration of surgery was 28 minutes (13 to 50). Examination of the resected specimens showed clear margins in all the tumour lesions and a resection that was exactly as planned.
We present a retrospective study of patients suffering from a variety of benign tumours in whom external fixators were used to treat deformity and limb-length discrepancy, and for the reconstruction of bone defects. A total of 43 limbs in 31 patients (12 male and 19 female) with a mean age of 14 years (2 to 54) were treated. The diagnosis was Ollier’s disease in 12 limbs, fibrous dysplasia in 11, osteochondroma in eight, giant cell tumour in five, osteofibrous dysplasia in five and non-ossifying fibroma in two. The lesions were treated in the tibia in 19 limbs, in the femur in 16, and in the forearm in eight. The Ilizarov frame was used in 25 limbs, the Taylor Spatial Frame in seven, the Orthofix fixator in six, the Monotube in four and the Heidelberg fixator in one. The mean follow-up was 72 months (22 to 221). The mean external fixation period was 168 days (71 to 352). The mean external fixation index was 42 days/cm (22.2 to 102.0) in the 22 patients who required limb lengthening. The mean correction angle for those with angular deformity was 23° (7° to 45°). At final follow-up all patients had returned to normal activities. Four patients required a second operation for recurrent deformity of further limb lengthening. Local recurrence occurred in one patient, requiring further surgery.
Custom-made intercalary endoprostheses may be used for the reconstruction of diaphyseal defects following the resection of bone tumours. The aim of this study was to determine the survival of intercalary endoprostheses with a lap joint design, and to evaluate the clinical results, complications and functional outcome. We retrospectively reviewed six consecutive patients, three of whom underwent limb salvage with intercalary endoprostheses of the tibia, two of the femur, and one of the humerus. Their mean age was 42 years (28 to 64). The mean follow-up was 21.6 months (9 to 58). The humeral prosthesis required revision at 14 months owing to aseptic loosening. There were no implant-related failures. Musculoskeletal Tumour Society functional outcome scores indicated that patients achieved 90% of premorbid function. Custom intercalary endoprostheses result in reconstructions comparable with, if not better than, those of allografts. Using this design of implant reduces the incidence of early complications and difficulties experienced with previous versions.
Arthritis of the hip in the young adult can be a disabling condition. Recent years have witnessed extensive research related to the management of this condition. This article reviews the current status with regard to aetiology, diagnosis and treatment of arthritis of the hip in the young adult.
Between 1996 and 2003, 16 patients (nine female, seven male) were treated for a primary bone sarcoma of the femur by wide local excision of the tumour, extracorporeal irradiation and re-implantation. An additional vascularised fibular graft was used in 13 patients (81%). All patients were free from disease when reviewed at a minimum of two years postoperatively (mean 49.7 months (24 to 96). There were no cases of infection. Primary union was achieved after a median of nine months (interquartile range 7 to 11). Five host-donor junctions (16%) united only after a second procedure. Primary union recurred faster at metaphyseal junctions (94% (15) at a median of 7.5 months (interquartile range 4 to 12)) than at diaphyseal junctions (75% (12) at a median of 11.1 months (interquartile range 5 to 18)). Post-operatively, the median Musculoskeletal Tumour Society score was 85% (interquartile range 75 to 96) and the median Toronto Extremity Salvage score 94% (interquartile range 82 to 99). The Mankin score gave a good or excellent result in 14 patients (88%). The range of movement of the knee was significantly worse when the extracorporeally irradiated autografts were fixed by plates rather than by nails (p = 0.035). A total of 16 (62%) of the junctions of the vascularised fibular grafts underwent hypertrophy, indicating union and loading. Extracorporeal irradiation autografting with supplementary vascularised fibular grafting is a promising biological alternative for intercalary reconstruction after wide resection of malignant bone tumours of the femur.
We reviewed 29 patients who had undergone intercalary resection for malignant tumours. Of these, 14 had received segmental allograft reconstruction and 15 extracorporeally-irradiated autograft. At a mean follow-up of 71 months (24 to 132), 20 were free from disease, five had died and four were alive with pulmonary metastases. Two patients, one with an allograft and one with an irradiated autograft, had a local recurrence. Reconstruction with extracorporeally-irradiated autograft has a significantly lower rate of nonunion (7% Extracorporeally-irradiated autograft could be an acceptable alternative for reconstruction after intercalary resection, especially in countries where it is difficult to obtain allografts.