Biological reconstruction after resection of bone tumors of the proximal tibia using allograft shell and intramedullary free vascularized fibular graft: Long‐term results

Reconstruction after excision of bone tumor of the proximal tibia is a challenging issue for the reconstructive surgeon. The combined use of a free fibular flap and allograft can provide a reliable reconstructive option in this location. This article describes the authors' long‐term follow‐up using this technique. Twenty‐seven patients that had resection of proximal tibia bone tumors underwent reconstruction using this technique. Only 21 patients that had primary reconstruction were included in this study. All patients had their surgeries performed at least 24 months before the end of the study. The average age at time of operation was 18.1 years. The average follow‐up time was 139.3 months. Limb salvage was 82.7%. The average length of the resected tibial segment was 15.3 cm and that of the residual proximal tibia remaining after resection was 2.7 cm. The average time of union of fibula was 5.4 months and for union of allograft was 19.1 months. Primary union of the allograft was achieved in 90.5% of cases. Full weight‐bearing was achieved at an average of 21.6 months. Ten patients (47.6%) had 14 local complications. The (MTSRS) average score at final follow‐up was 27.3. Local recurrences occurred in two patients (9.5%). Distant metastasis to the lung occurred in three patients (14.3%). One patient died of disease. This technique provides good long‐term results in reconstruction of proximal tibia. The viability of the fibula is a cornerstone in both success of reconstruction as well as successful management of complications. © 2009 Wiley‐Liss, Inc. Microsurgery, 2009.     

Revision total hip arthroplasty: The use of solid allograft

Intract solid allografts was used to augment severe bone loss in 8 acetabula and 15 femora in 22 patients who underwent revision total hip arthroplasty with noncemented implants. The average follow-up period was 4 years. The average time to radiographic union of whole acetabular allografts was 11 months. Superior migration of the allografts occurred in four patients. Varus tilt of the acetabular component within the allografts was noted in three patients. Eleven patients underwent entire proximal femoral allograft reconstruction, and four patients had femoral head allograft reconstruction. Nine patients with entire proximal femoral allografts achieved radiographic union at an average of 13 months and two failed by nonunion. Only one of the four patients with femoral head, allograft reconstruction achieved union. Femoral component subsidence was noted in seven whole proximal femoral allografts (64%). Entire proximal femoral allograft reconstruction was complicated by at least one episode of postoperative dislocation in 6 of 11 procedures. The authors recommend that femoral head allografts should be used with caution to reconstruct proximal femoral deficiencies in which structural, support is required for stability of the implant. Successful use of acetabular allografts requires that the majority of the allograft be contiguous to host bone and not to soft tissue. With entire proximal femoral reconstruction, the tip of the femoral, component should not reside at the host-graft junction. All components should be cemented into allograft bone; and revision surgery should be performed before osteolytic destruction of bone advances to the point where allograft reconstruction is required.     

Ipsilateral pedicle vascularized fibula grafts for reconstruction of tibial defects and non-unions

Between October 1983 and August 1998, 31 patients with non-union or bone defect of the tibia have undergone 32 vascularized fibula transfers to reconstruct lower legs. Of these 32 vascularized fibula transfers, there were 19 pedicle transfers from the ipsilateral leg. There were 17 males and two females. The average patient age was 53 (21 to 84) years old. All patients achieved good bone reconstruction. All patients are currently able to walk without a brace, except for one. As to major complications, three of these 19 had delayed union, with only one postoperative fracture. In the cases with delayed union or fractured grafted fibulas, the periods to walking without a brace were longer than in the cases without such major complications. From the results, the ipsilateral pedicle vascularized fibula graft appears to be a useful option for reconstruction of tibial defects.     

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。     

桡骨远端瘤段切除后单纯自体腓骨移植与吻合血管腓骨移植重建桡腕关节疗效比较

目的分析单纯自体腓骨移植与吻合血管腓骨移植在桡骨远端瘤段切除后修复桡骨远端缺损和重建桡腕关节远期效果.方法 1979年1月～2002年9月对15例桡骨远端肿瘤患者行瘤段切除后,6例行单纯自体腓骨移植,9例行吻合血管腓骨移植重建桡腕关节.随访1年,参照Enneking系统及国际肢体修复讨论会所制定的同种/带血管蒂骨移植的影像学评价方法,进行肢体功能、影像学及供区的功能评价.结果 8例吻合血管腓骨移植恢复肢体功能的80%,6个月内完成骨愈合;6例单纯自体腓骨移植恢复肢体功能的67%,其中4例移植骨在5 cm以内术后6个月骨愈合可,2例骨移植超过12 cm者愈合延迟,分别为13个月和16个月;1例术后2个月行肘下截肢术.结论应用腓骨头替代桡骨远端重建腕关节是合适的;吻合血管腓骨移植重建桡腕关节不受骨缺损长度影响,且植骨愈合率高、时间短,无骨吸收.可作为桡骨远端肿瘤手术治疗的一种有效手段.     

A modified induced membrane 2-stage technique using a thoracodorsal artery perforator free flap followed by vascularized or non-vascularized free fibular transfer for the treatment of complex bone infection with concomitant severe soft tissue lesion–A case series of 9 cases

Treatment of post-traumatic complex bone infection is very challenging. The two principal bone reconstruction approaches are the single-stage vascularized bone graft technique and the two-stage induced membrane technique (IMT). Here we introduce a modified 2-stage induced membrane technique (MIMT) for complex long bone infection with a major bone defect and a concomitant severe soft tissue lesion. The 2-stage procedure consists of bone debridement, placement of a PMMA spacer and soft tissue reconstruction with a thoracodorsal artery perforator free flap (“Tdap”) at stage 1. At stage 2, the thoracodorsal artery perforator flap is elevated and a fibular strut graft (either vascularized of non-vascularized) is placed for bone reconstruction.We retrospectively analyzed the extents of lower extremity, long bone, post-traumatic bone infection treated via MIMT from 2008 to 2020. There were nine such cases (eight males) of mean age 59.8 (range 31 to 79) years. The osteomyelitis durations ranged from 3 to 360 months (mean 53 months). The cortical bone defect sizes was ranged from 9 to 14 cm (mean10.7 cm). All skin resurfacing employed Tdap. Vascularized fibular grafts were placed in six patients and non-vascularized grafts were placed in three. The fibular graft size ranged from 12.5 to 19 cm (mean 16.2 cm). Non-vascularized iliac bone grafts served as the fibula docking sites.Unfortunately, all patients suffered complications before bone union was achieved. One case of plate stress fracture and one case of screw fracture required plate and screw change. In three cases of cellulitis, one resolved by use of intravenous antibiotics, others required plate and screw removal. Wound disruption required re-suture and distal skin flap partial necrosis was covered by perforator-based island flap. One case of fibular stress fracture needed cast for 4 weeks. A peroneal nerve palsy patient recovered spontaneously. Bone union was achieved after 6 months in five patients and after 8 months in three (mean 6.9 months). All patients were able to walk unaided. The follow-up period ranged from 2 to 14 years (mean 6.2 years).MIMT saves the limbs in cases with difficult post-traumatic bone infection. It is valid treatment option for complex bone infections with severe soft tissue lesions. However, even with this technique potential complication must be considered.     

Vascularized bone segment transfers for management of chronic osteomyelitis

Vascularized bone segment transfer procedures appear to be of value for select cases of chronic osteomyelitis. They are particularly indicated for reconstruction in those patients who require an extensive bone resection for an adequate debridement. In the authors' series, apparent control of sepsis was achieved in approximately 85 per cent of patients with this procedure. Secondary surgical procedures were necessary in about half of the group to achieve bony union and complete healing.     

Microvascular composite tissue transfer for the management of type IIIB and IIIC fractures of the distal leg and compound foot fractures

Patients who sustain high-energy, compound fractures with severe contamination and soft tissue loss, face high rates of delayed union, nonunion, infection and, in some instances, amputation. The authors reviewed 18 patients with compound foot fractures and IIIB and IIIC tibial fractures. All patients were treated by early free-flap coverage and simultaneous bone reconstruction. Corticocancellous bone grafting, composite osteocutaneous free flaps, or bone transport techniques were utilized, as required. Bony union was achieved in all cases; rehabilitation and return to work occurred within 12 to 18 months, with no major complications. The authors believe that the reconstruction ladder usually followed should be altered in certain cases in which severe periosteal stripping and soft-tissue contamination necessitate distant free composite tissue transfer, particularly those cases involving the distal third of the leg and foot. Simultaneous reconstruction is superior to other methods of wound management in providing early coverage of extensive wounds, a barrier against bacterial contamination, prevention of osteomyelitis, and enhanced union of the fractures.     

Pedicle bone grafting in treatment of bone union disorders after femoral neck fracture]

Clinical and radiological assessment of 8 patients operated because of femoral neck pseudoarthrosis or delayed union proved the pedicle bone grafting to be very useful method, especially in young patients. Surgical reconstruction of femoral neck with the use of pedicular graft (Judet--Chacha) resulted in all the patients in absence of pain; satisfactory range of movement has been restored in operated hip. Bone union has been achieved in 7 from the 8 operated patients that is in all the cases of posttraumatic union disorders. However, we failed in total reconstruction of anatomy and the radiographs revealed osteoarthritis of the joint.     

Free vascularised fibular graft for reconstruction of defects of the lower limb after resection of tumour

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.     

Is delayed reconstruction using the latissimus dorsi free flap a worthy option in the management of open IIIB tibial fractures?

Early reconstruction of severe open fractures, performed within 7 days of the injury, has a better outcome than closure after 7 days. However, the uncertain demarcation of damaged tissue often results in delayed reconstruction. In this article, we report our surgical outcomes of delayed reconstruction using latissimus dorsi free flap with internal fixation. Twenty‐three patients with Gustilo type IIIB open tibial fractures Between March 2009 and May 2012 were included in this study. There were 16 cases of distal 1/3 fracture of the tibia, 4 of midshaft fracture, 1 of proximal 1/3 fracture, and 2 of segmental fracture. Serial debridement with application of negative pressure wound therapy (NPWT) was performed before the final operation. All patients underwent internal fixation of the bone and reconstruction of soft tissue defect using latissimus dorsi free flap. The number of serial debridements, excluding those performed during emergency and finial operation, ranged from 1 to 5 (mean 2.69) times. Mean time from injury to final operation was 10.65 (range, 7–22) days. All flaps survived without complications. Three cases (13%) were infected, and three cases required further bone graft surgery to facilitate bone union (13%). Bone union was achieved after a mean 6.3 (range, 3–12) months. Mean follow‐up period was 16.34 (range, 12–26) months. During follow‐up, all patients were able to ambulate without use of an aid. In cases of severe open fracture, treatment should emphasize soft tissue coverage rather than rushing to achieve definitive fixation in the setting of poor surrounding tissues. When delayed reconstruction is inevitable, radical debridement is performed first, then NPWT is used as bridging therapy, and free flap could be considered for definite soft tissues coverage. © 2015 Wiley Periodicals, Inc. Microsurgery 36:453–459, 2016.     

Intercalary femoral reconstruction with extracorporeal irradiated autogenous bone graft in limb-salvage surgery

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.     

跟骨钢板及骨移植在跟骨塌陷骨折治疗中的应用

目的探讨应用跟骨重建钢板及自体骨移植，在重建跟骨塌陷骨折距下关节面完整和稳定性中的作用。方法应用跟骨重建钢板及自体骨移植治疗跟骨塌陷性骨折25例，临床随访6个月～2a，平均1年2个月。结果25例跟骨塌陷骨折全部骨性愈合。按Kerr百分评分系统进行疗效评定，优10例，良12例，一般2例，差1例，优良率88％。结论应用跟骨重建钢板及自体骨移植重建跟骨塌陷骨折距下关节面完整和稳定性，固定坚强可靠，可早期功能锻炼，重建跟骨体高度及Boehler角，防止并发症发生。     

Outcome of limb reconstruction system in open tibial diaphyseal fractures

Background:Management of open tibial diaphyseal fractures with bone loss is a matter of debate. The treatment options range from external fixators, nailing, ring fixators or grafting with or without plastic reconstruction. All the procedures have their own set of complications, like acute docking problems, shortening, difficulty in soft tissue management, chronic infection, increased morbidity, multiple surgeries, longer hospital stay, mal union, nonunion and higher patient dissatisfaction. We evaluated the outcome of the limb reconstruction system (LRS) in the treatment of open fractures of tibial diaphysis with bone loss as a definative mode of treatment to achieve union, as well as limb lengthening, simultaneously.Results:Mean followup period was 15 months. The mean bone loss was 5.5 cm (range 4-9 cm). The mean duration of bone transport was 13 weeks (range 8-30 weeks) with a mean time for LRS in place was 44 weeks (range 24-51 weeks). The mean implant index was 56.4 days/cm. Mean union time was 52 weeks (range 31-60 weeks) with mean union index of 74.5 days/cm. Bony results as per the ASAMI scoring were excellent in 76% (19/25), good in 12% (3/25) and fair in 4% (1/25) with union in all except 2 patients, which showed poor results (8%) with only 2 patients having leg length discrepancy more than 2.5 cm. Functional results were excellent in 84% (21/25), good in 8% (2/25), fair in 8% (2/25). Pin tract infection was seen in 5 cases, out of which 4 being superficial, which healed to dressings and antibiotics. One patient had a deep infection which required frame removal.Conclusion:Limb reconstruction system proved to be an effective modality of treatment in cases of open fractures of the tibia with bone loss as definite modality of treatment for damage control as well as for achieving union and lengthening, simultaneously, with the advantage of early union with attainment of limb length, simple surgical technique, minimal invasive, high patient compliance, easy wound management, lesser hospitalization and the lower rate of complications like infection, deformity or shortening.     

Locking Compression Plate in Musculoskeletal Oncology 'a Friend in Need'

Background

We are presenting our experience in the use of locking compression plate (LCP) after juxta-articular oncological resections in addition to its use in pathologic fracture.

Methods

A retrospective audit of skeletal reconstruction using LCP in 25 cases of long bone tumors was performed from 2008 to 2010. Reconstruction following limb salvage surgery was done in 17 patients and internal fixation of pathological fracture was done in 8 patients. All patients were available for > 12 months of follow-up, and thus assessed for union at the resected ends.

Results

There were 8 males and 17 females in the study. The average age at the time of surgery was 30 years (range, 9 to 66 years). The minimum follow-up was 12 months (range, 12 to 32 months). All patients except three went on to heal successfully. Complications occurred in those three patients: wound infection in one, nonunion in another, and periprosthetic fracture in the other patient. In the remaining patients, union was achieved at an average of 6.5 months after reconstruction in curative resection and 4.75 months after fixation of pathological fractures.

Conclusions

Joint sparing limb salvage surgery was made successfully possible after sekeletal reconstruction with LCP. Its use was also quite effective in pathological fractures with poor bone quality. Use of locking plates for musculoskeletal oncological reconstruction resulted in a good and predictable rate of union.     

Two stage reconstruction of septic non-union of the humerus with the use of circular external fixation

Achieving quiescence in chronic osteomyelitis remains challenging. Wide resection of all infected and necrotic tissues improves the chances of achieving remission of the disease. Extensive debridement however decreases the already compromised bone stock that increases the complexity of reconstruction. We report on the outcome of eight patients with Cierny and Mader stage IV chronic osteomyelitis of the humerus who underwent debridement followed by bone graft and circular fixator application as a second stage procedure. Resolution of infection and humeral shaft union was achieved in all patients. Our study finds that two-stage reconstruction of stage IV chronic osteomyelitis with the use of circular external fixation is effective in achieving infection control and union in these complex cases.     

Free vascularized osteocutaneous fibular graft to the tibia in 51 consecutive cases

The authors reviewed retrospectively the clinical results of 51 consecutive cases of vascularized osteocutaneous fibular graft to the tibia for the reconstruction of extensive tibial bone and soft-tissue defects. The mean duration of follow-up was 31 months (range: 13 to 76 months). In the 51 procedures of free vascularized osteocutaneous fibula graft from the contralateral side, bony union was achieved in 48 cases at an average of 3.74 months after the operation, except for two cases of non-union and two cases of delayed union. Forty-eight cutaneous flaps survived, and three cutaneous flaps failed due to deep infection and venous thrombosis. All united fibulae hypertrophied during the follow-up periods. Stress fracture of the grafted fibula was the most common complication (16 cases), and it was treated with above-the-knee cast immobilization or internal fixation with a conventional cancellous bone graft. The free vascularized osteocutaneous fibular graft is recommended as a useful treatment modality for the reconstruction of extensive tibial defects combined with soft tissue injury.     

Pedicle versus free frozen autograft for reconstruction in malignant bone and soft tissue tumors of the lower extremities

Background

Of the biological reconstruction methods for malignant bone and soft tissue tumors, reconstruction with liquid nitrogen has the advantage of maintaining continuity on the distal side of the tumor bone site (pedicle freezing procedure; PFP). This method is expected to result in early blood flow recovery, with early union and low complication rate. The purpose of this study was to compare the outcomes of the PFP and free freezing procedure (FFP) in the lower extremities.

Methods

The study included 20 patients (12 men and 8 women) with frozen autografts (FFP, 13 cases; PFP, 7 cases). The mean age of the subjects was 36.3 years (range 11–79 years), and the mean follow-up period was 56.4 months (range 12–142 months).

Results

Final bone union occurred in 11 patients in the FFP group (84.6 %) and in 7 patients in the PFP group (100 %). The mean union period in patients who did not need additional surgery was 9.8 months (range 4–21 months) in the FFP group and 4.8 months (range 2–7 months) in the PFP group. Postoperative complications occurred in 8 cases: infection in 3 cases, fracture in 3 cases, and joint destruction in 2 cases. Six FFP patients, and 2 PFP patients (two cases of fracture), developed postoperative complications.

Conclusions

The union period was shorter and the rate of postoperative complications was lower with the PFP than with the FFP. We considered that early blood flow recovery might have led to the above results in the PFP.     

Management of proximal scaphoid bone pseudarthroses and fractures with the mini-Herbert screw via a dorsal approach

32 patients, aged 16 to 49 years, were treated by osteosynthesis using the Herbert mini screw. The indications were five fractures (type B3, Herbert classification), two delayed unions (type C) and 25 nonunions (type D1 to D3, Filan and Herbert classification). Six patients received no bone grafts, 19 received cancellous bone graft from the radius. An interpositional iliac crest bone graft was used in four, and a vascularized bone graft from the distal radius in three cases respectively. The average postoperative immobilisation in a forearm splint was nine weeks. 26 patients could be recruited for clinical follow-up at an average of 14,5 months. The radiological results were assessed in 30 cases (94%). Bony consolidation was achieved in 26 cases (100% of the fractures, 84% of the nonunions). In three cases a loosening of the screw, and in three further cases a dislocation into the radiocarpal joint were observed. A humpback deformity was present in four cases. Three patients showed a persisting nonunion, one patient a fibrous union. Early degenerative changes of the radiocarpal joint were observed in six cases. The clinical follow up examination showed an average grip strength of 91% (JAMAR II), 94% for the three finger, and 95% for the pinch grip compared to the contralateral side. The mean postoperative pain score on the visual analog scale was one for resting conditions, eleven for motion and 33 under stress. The range of motion was 79% of the opposite side for extension/flexion and 83% for radial/ulnar deviation. The average DASH-score reached 15 points. The Herbert mini screw has proven to be a reliable implant for reconstruction of proximal pole fractures and nonunions of the scaphoid.     

Induced membrane technique for the reconstruction of bone defects in upper limb. A prospective single center study of nine cases

Introduction

Bone defect in the upper limb remain infrequent with few reported in the literature. Their reconstruction raises the problem of bone union of non weight-bearing segments as well as the function of adjacent joints. We report a monocentric continuous series of nine patients treated with the induced membrane technique (Masquelet technique).

Patients and methods

Nine patients with a mean age of 39.2 years (17–69) presented with a bone defect of the humerus (six cases) or one of two bones (three cases). Diaphyseal (six cases) or metaphyseal (three cases) defects were secondary to trauma in three patients, to non-union in four others and following tumors for the other two. The mean defect was 5.1 cm (2.5–9). Reconstruction was done by initial filling using a spacer in cement, followed by a cancellous bone graft within the induced membrane. BMP's growth factor was used in two cases.

Results

Bone union was achieved in eight out of nine cases with a follow-up of 23 months (8–52) after the first stage, and 17 months (6–49) following filling by the graft. One patient did not want the second stage done before one year. The failure was in a very non-compliant patient who had a bone substitute associated with aBMP. Two septic non-unions were cured. Shoulder and elbow functional outcomes were comparable to the controlateral side for humeral defects; pronosupination decreased by 17% for the cases of reconstruction of two bones.

Discussion

The technique of the induced membrane allows filling of a large bone defect, while avoiding vascularised bone autografts and their morbidity. It requires two procedures but can be used in emergency or after failure of other interventions. It is a reliable, and reproducible technique where the only limit is the cancellous bone stock. Following the series of Masquelet, Apard and Stafford in the lower limb, and the series of Flamans in the hand, this is the first report of reconstruction of defect in the upper limb using this technique.