Free vascularized bone transfers for nonunions, segmental gaps, and following tumor resection

Free vascularized bone transfer is recognized as a valuable technique for skeletal reconstruction and salvage with certain nonunions, skeletal defects, and following tumor resection. This procedure is most often indicated for reconstruction of lengthy skeletal defects or under circumstances where conventional bone grafting techniques are unlikely to succeed. Factors affecting selection of donor bone and technical peculiarities relative to the recipient sites are discussed. The results of 49 cases at the Mayo Clinic for management of nonunion, segmental gaps or following tumor resection suggest a union rate of 82%. The most consistent rate of success was found for reconstruction of defects affecting the tibia, mandible or forearm bones.     

Clinical applications of vascularized bone autografts

Our experience with microvascular transfer of fibular grafts and composite osteocutaneous iliac flaps has shown that massive autogenous bone grafting with an intact vascular pedicle decreases the time to bony union and the duration of immobilization required for functional reconstruction of an extremity. The technique has proven reliable (87 per cent success rate) in the reconstruction of bone defects of greater than 6 to 8 cm following tumor resection or defects existing in a fibrotic, avascular bed. More importantly, these techniques have been applied for limb salvage in patients with tumors or with severely traumatized extremities that were not candidates for more traditional methods of bone grafting. In many cases, amputation would have been the only alternative.     

Upper limb salvage with microvascular bone transfer for major long-bone segmental tumor resections

A series of 14 young, active patients who underwent vascularized bone graft reconstructions of large (9-15 cm) segmental skeletal defects of the upper extremity resulting from resection of a variety of bony tumors is presented. Eight defects involved the proximal humerus and required shoulder joint reconstruction, two were mid humeral and four involved the distal radius. Surgical techniques for both distal radius reconstruction with vascularized iliac crest and vascularized fibular head and glenohumeral reconstruction using the vascularized fibula are described. Several cases are discussed in detail, including achievement of bony union, postoperative range of motion and pain, and each patient's ability to resume activities. The literature is reviewed, and other reconstructive options for large bony defects of the upper extremity after tumor resection are discussed: nonvascularized bone grafts, allograft transfer, and custom prosthetic devices. The authors think that vascularized bone grafting offers the most favorable method of upper extremity salvage with preservation of joint function, especially at the shoulder.     

腓骨移植治疗肢体侵袭性骨肿瘤和恶性骨肿瘤

目的：比较游离腓骨或吻合血管腓骨移植治疗切除四肢侵袭性骨肿瘤或恶性骨肿瘤后引起的长段骨缺损的临床疗效。方法：对１８例吻合血管移植及４例游离腓骨移植术的病例术后，采用ＥＣＴ、彩色多普勒血管超声检查、Ｘ线照片检查及随访，时间为术后２～１２年，移植骨最长达２６ｃｍ。结果：侵袭性骨肿瘤和恶性骨肿瘤１８例，肿瘤切除后用吻合血管腓骨移植重建缺损，１５例桡骨远端骨巨细胞瘤患者作游离腓骨移植重建缺损，结果前者愈合良好，移植骨片与受骨接合牢固，游离腓骨移植则愈合较差。结论：吻合血管腓骨移植可一期重建因骨肿瘤或骨恶性肿瘤广泛切除后造成的６ｃｍ以上的骨缺损，其优越性远远超过游离腓骨移植。     

Case Report: Reconstruction of the Distal Tibia with Porous Tantalum Spacer after Resection for Giant Cell Tumor

Treatment options for giant cell tumors of the distal tibia include curettage and cement packing, curettage and bone grafting, or resection and reconstruction for aggressive tumors. Curettage of aggressive tumors often leads to severe bone loss requiring reconstruction. Allograft and autograft may be effective options for reconstruction, but each is associated with drawbacks including the possibility of infection and collapse. We present a case of giant cell tumor of the distal tibia treated with curettage and arthrodesis using a porous tantalum spacer. Complete removal of the tumor and successful arthrodesis of the ankle were accomplished using the spacer. The patient returned to pain-free walking along with eradication of the giant cell tumor. We believe porous tantalum spacers are a reasonable option for reconstructing the distal tibia after curettage of a giant cell tumor with extensive bone loss.     

Operative technique of distal radius resection and wrist fusion with iliac crest bone graft

Malignant lesions of distal radius and appropriately selected cases of benign aggressive lesions (giant cell tumor) of distal radius require resection for limb salvage. Post resection, reconstruction of that defect can be accomplished by either arthrodesis or arthroplasty both having their own pros and cons. In cases undergoing arthrodesis as modality of reconstruction, small defects (≤6 cm) can be reconstructed using autologous iliac crest bone graft which results in good cosmetic appearance and functional outcome. We have described in detail, the preoperative planning, surgical steps and rehabilitation of wrist fusion with iliac crest bone grafting post distal radius resection.     

The effect of multidrug chemotherapy on bone graft augmented prosthesis fixation.

Use of combination adjuvant chemotherapies have improved the disease free survival rate of tumor patients significantly. However, studies have shown that chemotherapeutic agents have negative effects on bone graft incorporation and fixation of porous-coated prostheses needed for reconstruction of bone defects after wide resection of malignant tumors. Unilateral resection of a 6-cm segment of the femoral diaphysis and reconstruction with a porous-coated segmental prosthesis was performed in eight mixed-breed dogs under perioperative chemotherapy with doxorubicin, cisplatin, and ifosfamide. Eight strips of autogenous cortical bone were evenly placed around the junctions between the femur and the prosthetic surface. Autogenous cancellous bone was placed under and between the strips of cortical bone. Two cycles of the chemotherapy were given preoperatively, and three cycles postoperatively. The animals were followed for 12 weeks, with sequential assessments of weight-bearing and radiographic evaluation. Biomechanical, histological, and microradiographic analyses of the retrieved specimens were performed. Doxorubicin, cisplatin, and ifosfamide combination chemotherapy showed a significant effect on new bone formation as seen in reduced callus size and lower ultimate strength of extracortical fixation. However, the onlay corticocancellous grafting method provided better biologic fixation of the prosthesis compared with fixation without any bone grafting under non-chemotherapy condition in a previous study. Extracortical bone grafting is an effective modality for implant fixation even under intensive chemotherapy.     

The use of vascularized fibular grafts for the reconstruction of spinal and sacral defects

Background: Large segmental defects of the spine may result from tumor resection as well as infection. The surrounding soft tissue in these situations is often compromised due to radiation exposure or infection. In these situations, in which conventional bone grafting has often failed, we have found vascularized fibular grafts an effective method of achieving bony union. The purpose of this study was to review the results of vascularized bone grafting for complex spinal reconstruction using free fibular transfer. Methods: We performed a retrospective chart review of all patients who underwent multisegmental spinal reconstruction and pelvic reconstruction using posterior instrumentation and free fibula vascularized bone transfer. Results: Twelve patients underwent 14 free fibula transfers (7 anterior and 5 posteriorly placed) for reconstruction of lumbosacral spinal defects. Preoperative diagnoses included tumor, osteomyelitis, and nonunion. Average number of vertebral body resections was four and posterior instrumentation was used for all arthrodeses. Average duration of follow up was 45 months. Two flaps failed (14%), one resulting in nonunion and the other required salvage with an external hemipelvectomy. All remaining flaps healed at a mean time of 4.5 months (range, 3–10 months). Conclusion: Free fibula transfer for complex spinal reconstruction is a reliable means of obtaining bony union for complex lumbar or sacral resections where traditional bone grafting techniques may not be technically feasible. © 2009 Wiley‐Liss, Inc. Microsurgery, 2009.     

Intercalary tibial allografts following tumor resection: the role of fibular centralization

Options to reconstruct intercalary tibial defects include allografts, vascularized bone transfers, autogenous cortical grafts, endoprostheses, and Ilizarov bone transport. Five patients underwent intercalary bulk allograft reconstruction following en bloc resection of tibial sarcomas. Two patients underwent immediate fibular centralization and iliac crest bone grafting in addition to the allograft. Two patients who underwent fibular centralization during primary reconstruction united uneventfully. The remaining three patients developed nonunion, of which one was successfully salvaged by fibular centralization. A combined allograft transplant and fibular centralization with iliac crest bone grafting is an effective procedure to reconstruct the tibial diaphysis, as well as a salvage procedure for allograft nonunion.     

肱骨近端恶性肿瘤的保肢治疗

目的 探讨肱骨近端恶性肿瘤切除术后的重建方法。方法 36例肱骨近端恶性肿瘤,其中骨肉瘤 11例、软骨肉瘤 6例、皮质旁骨肉瘤及纤维肉瘤各 3例、原始神经外胚层瘤及恶性纤维组织细胞瘤各 2例、转移性骨肿瘤 5例、恶性骨巨细胞瘤 4例。骨肉瘤、原始神经外胚层瘤与恶性纤维组织细胞瘤患者均接受了新辅助化疗。肿瘤关节内切除 33例,关节外切除 3例。 21例采用异体半关节移植, 4例采用人工假体置换, 6例行游离锁骨移植, 5例行带骨膜血管蒂锁骨移植。结果 随访 6～ 118个月,平均 62.7个月。死亡 11例,局部复发 3例。按 Enneking功能评价标准, 21例采用异体半关节移植的患者,平均得分 24分; 4例人工假体置换的患者,平均得分 26分; 11例采用同侧锁骨重建肱骨近端的患者,平均得分 23分。结论 肱骨近端恶性肿瘤保肢手术的重建以人工假体置换和异体半关节移植为首选,儿童的保肢可选用同侧锁骨移植。保肢术后的功能与肩袖和肩外展肌的修复密切相关。     

人工节段型骨干假体重建治疗肱骨骨干肿瘤

目的探讨人工节段型骨干假体重建治疗肱骨骨干肿瘤的可行性、手术方法以及疗效评估。方法回顾性分析2008年4月至2012年6月期间我院采用肿瘤广泛切除和节段型骨干假体重建术治疗6例肱骨骨干肿瘤患者的手术方案及疗效。6例患者中男性2例,女性4例,年龄为19~74岁,平均50．8岁;其中肱骨干单纯性骨囊肿2例、肺癌单发肱骨干转移瘤2例、肱骨干动脉瘤样骨囊肿1例及肱骨干富含巨细胞纤维性病变1例。结果术后随访8～58个月,平均29．5个月。截至末次随访,5例患者存活,1例患者于术后2（）个月死亡。存活患者肿瘤无局部复发、假体松动等并发症,末次随访时患肢功能状态良好,国际骨与软组织肿瘤协会（MSTS）肢体功能评分平均为24．8分（19~28分）。结论长骨骨干肿瘤大段广泛切除和节段型骨干假体保肢重建是治疗骨干肿瘤的有效手术方案之一。设计定制假体能够确保手术切除至安全外科边界,降低术后局部复发率,并保留正常关节及周围软组织,使患者术后即可负重锻炼,提高了术后生活质量。     

Case report: Reconstruction of an intercalary defect with bone transport after resection of Ewing's sarcoma

We report a 13-year-old girl with Ewing's sarcoma of the tibia who was treated with multiagent chemotherapy, followed by local control tumor surgery consisting of wide resection of the tumor and bone transport with distraction osteogenesis for reconstruction. The bone defect created by resection was 13 cm long and was replaced by bone transport using a monolateral external fixator. Evaluation of the resected specimen revealed wide tumor-free margins with 100% chemonecrosis. A planned Harmon-type autogenous bone grafting between the middle and proximal segments of the tibia (docking site) was done primarily after docking occurred, and a solid union was obtained by 23 months after resection. The bone healing index (treatment index) was 54 days/1 cm distraction, which is indicative of slow healing. Clinical evaluation of the affected extremity using the Musculoskeletal Tumor Society rating system revealed 80% normal functional capability. Indications for bone transport in reconstruction of bone defects created by wide resection of bone sarcomas are discussed. In retrospect, we have concerns regarding the suitability of this technique in the setting of diaphyseal sarcoma reconstruction in patients with Ewing's sarcoma who require aggressive and intense multiagent chemotherapy.     

Elbow reconstruction after excision of proximal ulna tumors: Challenges and solutions

Most malignant bone tumors are treated with surgical excision, adhering to oncologic principles, followed by reconstruction to preserve form and function whenever feasible. Primary bone tumors around the elbow are rare accounting for <1% of all skeletal tumors. They pose a reconstructive challenge, due to the complex interplay between the osseous & capsulo-ligamentous structures which is essential for elbow stability and function. Tumors affecting the proximal ulna are rare and reconstruction of the defects following these tumors is extremely challenging. Various reconstruction options like arthrodesis, autogenous bone grafts, allografts, re-implantation of sterilized tumor bone, pseudoarthrosis, and endoprosthesis have been tried with variable success. However, due to lack of standardization and the rarity of the site, surgeons are often in a dilemma to choose the correct option. This can lead to suboptimal functional outcomes and long-term failures. In this article, we reviewed the published literature on proximal ulnar tumors and noted the pros and cons of various reconstructive procedures. We have also attempted to formulate reconstruction recommendations based on the level of resection of proximal ulna.     

人工间置型假体置换治疗长骨骨干恶性肿瘤（附4例报告）

目的探讨人工间置型假体置换治疗长骨骨干恶性肿瘤的手术方法与疗效。方法 2008年6月-2010年6月,4例长骨骨干恶性肿瘤患者于我院接受骨干瘤段切除人工间置型假体置换手术。4例均为男性,年龄24～60岁,平均41岁。其中股骨干恶性纤维组织细胞瘤1例,肺癌单发股骨干转移瘤1例,软组织腺泡状肉瘤胫骨干转移瘤1例,肾癌单发肱骨干转移瘤1例。结果获得随访16～40个月。截止末次随访时,4例患者患肢功能良好,MSTS评分平均为28.3分（27～30分）。均无局部复发。其中3例无瘤生存;1例胫骨干转移瘤患者术前已有肺转移,术后9个月出现脑转移,目前带瘤存活。结论肿瘤瘤段截除人工间置型假体置换术是治疗长骨骨干恶性肿瘤的有效术式之一,该术式能够达到安全的外科边界,降低局部复发率,并保留良好的肢体功能。     

Die extrakorporale Bestrahlung

Background

Malignant bone tumors themselves and the wide resection required because of them may cause huge bone defects in the bone segment involved. Autologous bone grafts are a reliable option to cover these defects in many cases but their availability is limited. Besides common alternative reconstruction methods, including the use of allografts and/or prostheses, especially extracoroporeal irradiation (ECI) and reimplantation of the bone segment involved is attracting increasingly more attention nowadays.

Discussion

In the following, we report on indications/contraindications, details of the operative technique, as well as the recommended rehabilitation regime of ECI. Furthermore, we compare our own results with those published in the recent literature. Especially the advantages and disadvantages of this method, the risks and the complications are illustrated and critically discussed.

Conclusion

Extracorporeal irradiation of a tumor bearing bone segment is a valuable alternative reconstruction technique following tumor resections of the pelvis, femur and tibia, with encouraging results with respect to local control, complication risks and functional outcome.

     

Primary reconstruction with digital ray transposition after resection of malignant tumor

Introduction  Hand reconstruction after wide resection of digital malignant tumors is still very challenging. The technique of adjacent digital ray transposition has been used for digital defects arising from trauma, but few papers have focused on reconstruction following resection of malignant tumors of the finger. The indications, complications and functional outcomes with this approach are discussed. Patients and methods  Four patients underwent primary reconstruction with adjacent digital ray transposition after tumor resection. Two were men and two were women and the median age was 62 years. The malignant tumors were low-grade chondrosarcomas of the metacarpal bone in two cases, epithelioid sarcoma at the fingertip in one case and synovial sarcoma at the base of the thumb in the fourth case. Results  Metacarpal osteotomies were rigidly stabilized with a plate and screws and with an intramedullary bone peg graft. Digit length and rotation were satisfactory and there were no non-unions. Local recurrence was not observed at the final follow-up. The mean musculoskeletal tumor society (MTS) score was 60% (range 48–80%). The results of the disabilities of the arm, shoulder and hand score were similar to the MTS score, with a mean score of 35 points (range 22.5–63.5). The worst result was for index-to-thumb transposition and the best was for index-to-middle. All patients experienced emotional difficulty with acceptance of a three-finger hand. Conclusion  Primary reconstruction with digital ray transposition produces acceptable functional outcomes after resection of malignant tumor. This procedure is best indicated for central single ray amputation but sometimes is associated with esthetical problems.     

Intraoperative extracorporeal autogenous irradiated bone grafts in tumor surgery

There are several procedures for reconstruction of bony defects after resection of malignant musculoskeletal tumors. The clinical results of intraoperative extracorporeal autogenous irradiated bone grafts in 20 patients with musculoskeletal tumors are discussed. The authors' method of treatment consists of: (1) wide en bloc resection of the tumor with involved bone; (2) curettage of the tumor from the resected bone; (3) extracorporeal irradiation with 50 Gy as a bolus single dose to the isolated bone; and (4) reimplantation of the irradiated bone into the host with fixation devices. Twelve bone sarcomas and eight soft tissue sarcomas with bone involvement were treated surgically with this reconstruction method after wide resection of the tumors. The irradiated bone was used as an intercalary graft in seven cases, as an osteoarticular graft in 11 cases, and as a hemicortical graft in two cases. The theoretical advantages of this method are certain sterilization of tumor cells with radiation, easy availability and good adaptation of size and shape, no risk of disease transmission, preservation of bone stock and ligamentous tissue, and no immunologic reaction. Radiologically, bony union occurred in 23 of 29 (79%) osteotomy sites. The overall radiographic evaluation rating was 74% and the functional rating was 73% according to the International Society of Limb Salvage rating system. Nonunion (20%) and infection (15%) were the two major complications. Preservation of the tendon insertions and ligamentous structures of the irradiated bone seemed to restore excellent joint function. No local recurrence was detected from the irradiated bones during the mean followup of 45 months. These results indicate intraoperative extracorporeal irradiated bone graft can be a widely applicable method for reconstruction in tumor surgery.     

Craniofacial reconstruction after tumor resections using vascularized outer table calvarial bone flaps

The outer table of calvarium is a useful donor site for facial reconstruction after resection of tumors. Large defects, especially when associated with multiple operations and radiotherapy, are poor recipient beds for nonvascularized bone grafts. A technique for the transfer of vascularized outer table has been developed and used in 11 patients for reconstruction of tumor defects. Satisfactory correction of both functional and esthetic problems has been achieved with satisfactory long-term stability and low morbidity.     

同种异体骨复合人工关节置换治疗骨肿瘤

目的：探讨分析同种异体同关节复合人工假体移植治疗骨肿瘤的临床应用及疗效。方法：对应用同种异体骨关节复合人工假体移植治疗骨肿瘤12例进行临床回顾分析。其中髋关节周围7例，膝关节周围3例，肩关节周围（肱骨近端）2例，病变性质；骨巨细胞瘤6例，皮质旁骨肉瘤2例，软骨肉瘤2例，转移性腺癌2例，均行肿瘤切除及异体骨关节复合人工假体移植。结果：本组12例病人手术均顺利，肿瘤获彻底切除，平均随访时间2．5年（1－5年），伤口均一期愈合无1例感染，关节功能按Mankin标准评定，优良率为91．6％，结论：同种异体骨关节复合人工假体移植是修复骨肿瘤的有效手段。     

Free vascularized fibula in traumatic long bone defects and in limb salvaging following tumor resection: Comparative study

In this retrospective analysis, we present our experience with two groups of patients who had long bone defects secondary to trauma or tumor resection and who were treated with a free vascularized fibular graft for skeletal reconstruction. Both groups were comparable in number and average age of patients, length of bone defect, and mean follow-up (average 3 years both groups). The number of surgical procedures prior to microvascular grafting was significantly higher for the traumatic defects. Primary bone union in a mean period of 6 months occurred at a higher rate in the tumor patients; the trauma patients had a significantly higher nonunion rate, which required multiple additional surgical procedures. The latter did not, significantly, improve the rate of success in the trauma group. Residual limb shortening was present in one-half of the patients with traumatic defects. On the basis of this review, it appears that the scarred and relatively avascular soft tissues surrounding the long bone defects secondary to trauma affect the course and the final outcome of the microvascular fibular grafting. A similar procedure applied for limb salvaging after tumor resection is better. © 1993 Wiley-Liss Inc.