Donor site morbidity following resection of the fibula

Ten adults were studied two to seven years after resection of a fibula for use as a free vascularised bone graft. Six had no symptoms in the donor leg, four had some aching, weakness or paraesthesia and three had definite weakness of the long toe flexors and extensors. All knees and ankles were clinically and radiologically stable, but the distal fibular remnant was osteoporotic in nine patients. Gait analysis of the donor leg and the contralateral normal leg showed definite differences, which could be attributed to weakness of the deep muscles caused by loss of their normal origin and to the change in load transmission through the fibula.     

Reconstruction of distal fibula with osteoarticular allograft after tumor resection

BackgroundInvolvement of distal fibula by benign aggressive and malignant tumors usually necessitates resection of the involved segment of fibula. Numerous techniques have been proposed to reconstruct the ankle joint after this procedure, which can result in complications. We introduce reconstruction of ankle joint by fibular osteoarticular allograft.MethodsReconstruction of the distal fibula after wide resection of tumor was carried out in four patients. There were two cases of Ewing sarcoma, one case of osteosarcoma and one giant cell tumor. After wide resection of tumor, we reconstructed the lateral side of the ankle joint by osteoarticular fibular allograft, which was applied and internally fixed with semitubular plate and screws. In the follow up period, we did assessment of complications, pain and ankle joint instability.ResultsThe mean age of our patients was 24.2 years (12–31). The mean follow-up was 3.2 years (1.5–6.7). In follow up visits there were no signs of infection or wound healing problems. Union was achieved in all patients.ConclusionIn cases of benign aggressive and malignant tumors involving the distal fibula, we can recommend resection of the distal fibula and reconstruction of the ankle with osteoarticular allograft of the distal fibula.Level of evidenceCase series level IV.     

Reconstruction after resection of the distal fibula for bone tumor

We have reviewed 11 patients after distal fibular resection for benign or malignant tumors with different techniques of reconstruction. Seven patients had normal function and four had reduced mobility, one of whom had a lateral subluxation of the talus. All the patients were without pain. After resection of the lateral malleolus without replacement the soft tissues should be reinforced.     

Reconstruction after resection of the distal fibula for bone tumor

We have reviewed 11 patients after distal fibular resection for benign or malignant tumors with different techniques of reconstruction. Seven patients had normal function and four had reduced mobility, one of whom had a lateral subluxation of the talus. All the patients were without pain. After resection of the lateral malleolus without replacement the soft tissues should be reinforced.     

Ankle fusion with centralisation of the fibula after distal tibia bone tumour resection

Background

Management of distal tibial tumours with limb salvage surgery poses a challenge for the orthopaedic surgeon. This study was done to evaluate the results of fibular centralisation as a technique to reconstruct defects that occurred after resection at this site.

Materials and methods

Nine patients with a mean age of 23.2 years (range 17–34) with diagnosis of osteosarcoma in four patients, Ewing’s sarcoma in two, giant cell tumour in two and chondrosarcoma in one patient underwent surgical treatment for tumour in the distal tibia. All patients had wide resection of the tumour and ankle arthrodesis with centralisation of the fibula. Patients were assessed clinico-radiologically for bone union, infection and complications. The final functional outcome was estimated according to Musculoskeletal Tumor Society (MSTS) scores.

Results

The mean age at the time of surgery was 23.2 years (17–34). There were five females and four males. The mean follow-up was 37 months (range 28–54 months). One of the patients with osteosarcoma had a recurrence a year after limb salvage surgery, underwent above-knee amputation, and died 18 months later due to metastasis. One patient developed leg length discrepancy. The mean MSTS score was 22.75 (range 17–27).

Conclusion

Fibular centralisation is a durable reconstruction tool for defects of the distal tibial metaphysis with an acceptable functional outcome. It is an inexpensive and simple procedure, with a low rate of late complications, and reproducible results.

Level of evidence

IV Retrospective case series.     

桡骨远端切除游离腓骨重建腕关节

当桡骨远端由于外伤或肿瘤遭到破坏波及关节面时，常需行桡骨远端切除重建。以往的方法均不理想，目前较好的方法是：游离腓骨，取用带血管的腓骨头移植替代桡骨远端重建腕关节。     

Blumgart anastomosis for pancreaticojejunostomy minimizes severe complications after pancreatic head resection

Background:

Leakage from the pancreaticojejunostomy is the major cause of septic complications after partial pancreaticoduodenectomy. This study evaluated a new transpancreatic ‐suture technique (Blumgart anastomosis, BA), which aims to avoid shear forces during knot‐tying.

Methods:

Using a before–after study design, BA was compared with a modified Cattell–Warren anastomosis (CWA). Two patient cohorts (CWA, 90; BA, 92), which were similar with respect to primary diagnosis, age, sex and American Society of Anesthesiologists score, were compared retrospectively. Dependent variables were surgical and overall morbidity and mortality after partial pancreaticoduodenectomy.

Results:

Duration of operation (354 versus 328 min for CWA versus BA; P = 0·002), pancreatic leakage rate (13 versus 4 per cent; P = 0·032), postoperative haemorrhage (11 versus 3 per cent; P = 0·040), total surgical complications (31 versus 15 per cent; P = 0·011), general complications (36 versus 17 per cent; P = 0·005) and length of intensive care unit stay (median 5·4 versus 2·8 days; P = 0·015) were significantly reduced after BA. These effects were not related merely to an improvement over time.

Conclusion:

BA appears to be a fast, simple and safe technique for pancreaticojejunostomy. It might reduce leakage rates and surgical complications after partial pancreaticoduodenectomy. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Tibia fracture after fibula resection for distal peroneal bypass

The lateral approach to the distal peroneal artery has been used by vascular surgeons for 25 years. No complications specifically related to this approach have previously been reported. We reviewed 18 cases of peroneal bypass for limb salvage using the lateral approach with fibula resection and found that two of these cases had ipsilateral tibia fractures within 1 year of the bypass. Eight out of 18 cases were women, and two of these eight had tibia fracture. Both women suffered from osteoporosis. We conclude that tibia fracture is a possible complication of this approach, especially in elderly women with osteoporosis.     

A quantitative analysis of donor site morbidity after vascularized fibula transfer

Eleven patients with free vascularized fibula graft transplants to the upper extremity were studied for donor-side morbidity effects. Based on their surgical follow-up times, the patients were divided into either group 1 (5 +/- 2 months) or group 2 (21 +/- 8 months) to examine the effects of surgical trauma more closely. Gait evaluation was performed using two walkways containing different ground conditions. Knee and ankle-foot motion was measured using a three-dimensional electrogoniometer. Basic temporodistance factors and ground reactions were obtained from foot switches, instrumented floor mats, and a force plate. A modified Cybex II isokinetic dynamometer was used to quantitate ankle-foot strengths. Moderate knee and ankle-foot motion changes were seen while walking on the level, sideslope, and ramp in patients evaluated less than 10 months after their surgical procedure. Minimal joint motion effects were discovered in patients with follow-up times longer than 10 months. Muscle strengths were significantly impaired in both groups, especially foot inversion and eversion. An inverse relationship existed between the length of resected fibula and ankle evertor muscle strength. Donor side morbidity does not appear to be caused by surgical soft-tissue trauma exclusively. These patients need to be studied for several more years to determine the long-term functional effects of free vascularized fibular graft transfer.     

Giant cell tumor of the distal fibula: fifteen-year result after en bloc resection and fibula reconstruction

Introduction Giant cell tumor of the distal fibula is a very rare condition. The treatment of advanced tumors at this location can be challenging and has been described in the literature only in single cases.Materials and methods We report on a patient with a stage III giant cell tumor, according to the classification of Campanacci, of the distal fibula after en bloc resection and distal fibula reconstruction with a long bone graft from the iliac crest in a second procedure. The syndesmosis was reconstructed with a periosteal flap, the capsule and ligaments with local scar tissue.Results Fifteen years after the initial treatment the patient is free of local recurrence and demonstrates an excellent clinical outcome without any signs of instability, loss of function or osteoarthritis of the ankle joint.Conclusion We suggest the method to be worthwhile for treatment of this uncommon lesion in terms of recurrence and functional outcome.     

Repair and regeneration of vertebral body after antero-lateral partial vertebrectomy using beta-tricalcium phosphate

Antero-lateral partial vertebrectomy (ALPV) was used for decompression in 91 patients with multilevel cervical disorders. The high-speed drill was used to excise about 1/3 of the vertebral body for relief of anterior compression of the cord and nerve roots under the operating microscope. The key point was opening of the medial wall of the foramen of transverse process at the beginning of the ALPV, allowing the determination of the lateral borders of the ALPVs. To repair and regenerate the vertebral body, a beta-tricalcium phosphate (beta-TCP) block was trimmed into a cuneiform shape and implanted into the sites of the ALPV excluding the upper and lowermost vertebral bodies. Postoperative computed tomography confirmed that beta-TCP was gradually replaced by newly formed bone from the surface towards the center of the block, and that the affected vertebral body was remodeled by 6 to 12 months after the implantation of beta-TCP. The cortical bone borders on the bone marrow at the site of the regeneration. The pedicles on the side of the ALPVs were rebuilt during regeneration of the affected vertebrae. Thus, the vertebral foramen of the cervical spine was widened in the anterior direction at the levels of the ALPVs, resulting in restoration of the physiological size of the cervical cord. The cervical curvature remained unchanged and a certain degree of cervical mobility (mean 86%) was preserved in this series.     

腓骨近端肿瘤切除术后膝关节稳定性重建的临床研究

目的探讨腓骨近端肿瘤切除术后重建膝关节稳定性的方法及临床疗效。方法回顾分析2008年1月-2009年12月行近端腓骨切除并重建腓侧副韧带和股二头肌肌腱骨性止点的16例腓骨近端肿瘤患者(试验组)临床资料,与同期5例未行韧带骨性重建患者(对照组)进行比较。两组患者性别、年龄、病程、肿瘤发生部位等一般资料比较,差异无统计学意义(P>0.05),具有可比性。术后行膝外侧方应力试验;摄X线片测量关节间隙,与健侧比较间隙增大程度并分级;参照美国骨与软组织肿瘤协会(MSTS)功能评分标准对关节功能进行评分。结果术后两组切口均Ⅰ期愈合。两组采用MalawerⅡ型手术切除者均发生医源性完全腓神经功能丧失。患者术后均获随访,随访时间12～36个月,平均30个月。试验组中1例纤维母细胞性骨肉瘤患者发生局部复发,12个月后死于肺部及全身转移;其余患者肿瘤均无复发。末次随访时,试验组膝外侧方应力试验均为阴性,关节间隙增大分级为A级;对照组应力试验均为阳性,分级为D级。试验组MSTS评分为(97.5±3.5)分,对照组为(87.5±3.5)分,两组比较差异有统计学意义(t=2.85,P=0.01)。结论腓骨近端肿瘤切除术后重建腓骨近端腓侧副韧带及股二头肌肌腱的骨性附着点,恢复了膝关节稳定性,利于关节功能重建。     

A modern analysis of morbidity after pancreatic resection

Complications after pancreatic resection remain prevalent. Procedure-related morbidity has previously focused on prevention of pancreatic and biliary fistulas (PFs and BFs) with other complications receiving less attention. We examined morbidity and its impact on reoperation, length of stay (LOS), and mortality following pancreatic resection. We retrospectively reviewed patients having elective pancreatectomy at the University of Tennessee affiliated hospitals during a recent 5-year time period. Factors examined included morbidity, mortality, and the need for reoperation. Patient deaths were analyzed with a focus on antecedent complications. Comparisons were made using Student's t test and chi2 analysis where appropriated. From 1997 to 2003, 125 patients had pancreatic resections: 93 Whipple procedures, 27 distal, and 5 total pancreatectomies. Twenty-nine patients (23%) did not have intraperitoneal drainage (IPD). Resections were performed for cancer in 75 per cent. Seventy complications occurred in 55 patients (44%). Morbidity related to an intra-abdominal process resulted in 16 reoperations and 4/6 deaths in this series (overall mortality, 4.8%). There were no BFs. Of 10 patients with PFs (8%), none required reoperation, and there was no PF-related mortality. No patient without IPD developed a PF. The presence of a PF significantly increased LOS when compared to those without (30.9 +/- 13.1 vs 17.4 +/- 12.2 days, P < 0.01). Forty-four per cent of all complications were related to either intra-abdominal abscess (IAA), hemorrhage, or feeding tube placement (18, 8, and 5, respectively). Management of IAA included percutaneous drainage in 16 and reoperation in 2 with 1 associated death. Hemorrhage necessitated reoperation in 6, resulted in 1 patient death, and was followed by IAA in 2. Of 5 jejunostomy tube complications, 4 required reoperation and 2 patients died. LOS was significantly greater in these 28 patients when compared to all others (28.1 +/- 16.9 vs 15.8 +/- 9.9 days, P < 0.001). Following pancreatectomy, 1) BFs should be a rare event; 2) PFs remain important but are most often managed nonoperatively with few sequelae; 3) in this series, IAA and hemorrhage were more common than PF, frequently mandated reoperation, prolonged hospitalization, and were associated with procedure related mortality; 4) feeding tube complications, though rare, are often catastrophic; 5) future efforts should focus on factors that could reduce abscess formation and a reduction in overall complications--many of which are potentially preventable.     

Free fibula donor-site morbidity: the Mayo experience with 100 consecutive harvests

A retrospective analysis of 100 consecutive patients undergoing free fibula harvest at the Mayo Clinic is presented. Every patient was analyzed by reviewing postoperative physical examination data. All patients were evaluated and followed in the early postoperative course by the physical medicine and rehabilitation services. Patients were followed from 3 to 60 months, with an average follow up of 17.42 months. In the patient group, 72 flaps were osseous and 28 osteocutaneous. Thirty-six complications at the donor site were observed in 30 patients. An additional 19 patients required prolonged pharmacologic pain control beyond the first 6 postoperative weeks, with no donor-site complications clinically detectable. Hammertoe was observed in six patients and wound dehiscence in seven patients. Tendon exposure was observed in five patients; partial split-thickness skin graft loss was observed in eight. Numbness of the foot was reported in 10 patients. Fifteen patient had limited maximum ambulatory distance to less than 1000 m. An additional six patients reported difficulty walking stairs. Attention to details and meticulous wound care are required to further reduce wound-healing complications. Immediate postoperative involvement of the physical medicine and rehabilitation services was beneficial in early patient mobilization and achievement of preoperative ambulation levels. After a short rehabilitation period, the majority of patients were able to engage in all daily activities.     

Postoperative morbidity and long-term survival after pancreaticoduodenectomy with superior mesenterico-portal vein resection

The role of superior mesenteric-portal vein resection (SM-PVR) for vein invasion or tumor adherence during pancreatoduodenectomy (PD) is still under debate. We investigated morbidity, mortality, and long-term survival in patients who underwent PD with or without SM-PVR. Between July 1994 and December 2004, 222 PD (78% pylorus preserving, 19% Whipple, and 3% total pancreatectomy) were performed for malignant disease. Fifty-three patients (24%) had PD with SM-PVR. Sixty-eight percent of the venous resections were performed as wedge excisions and 32% as segmental resections. Long-term survival was analyzed in 165 patients with pancreatic (n=110), ampullary (n=33), or distal bile (n=22) duct cancer using univariate (log-rank) and multivariate (Cox regression) methods. In patients undergoing PD with SM-PVR and conclusive histologic examination of the resected vein specimen (n=42), 60% had true tumor involvement of the venous wall, whereas 40% had no proven tumor infiltration. In the complete study group, negative resection margins were obtained in 69% of patients with SM-PVR and in 79% of patients without SM-PVR (P=0.09). Median duration of surgery was 500 minutes (SM-PVR) versus 440 minutes (no SM-PVR; P<0.001). Volume of intraoperatively transfused blood was 600 ml (median) in both groups. Postoperative surgical complications/mortality occurred in 23%/3.8% (SM-PVR) versus 35%/4.1% (no SM-PVR); P=0.09/0.9. Analysis of long-term survival in all 165 patients included 41 with SM-PVR. Five-year survival rates were 15% in cancer of the pancreatic head, 22% in ampullary cancer, and 24% in distal bile duct cancer (P=0.02). Long-term survival was not influenced by the need for SM-PVR in any of the different tumor entities. In multivariate analysis, a positive resection margin (P<0.01, relative risk [RR]: 1.8, 95% confidence interval [CI]: 1.2–2.7), a histologically undifferentiated tumor (P=0.01, RR: 1.7, 95% CI: 1.1–2.5), and the tumor entity (P<0.01) were significant predictors of survival. Univariate survival analysis of the 110 patients with cancer of the pancreatic head revealed that a histologically undifferentiated tumor (P=0.05) and positive resection margins (P=0.02) were associated with a poorer survival. In multivariate analysis, the resection margin (P=0.02, RR: 5.1, 95% CI: 1.1–2.8) and a histologically undifferentiated tumor (P=0.05, RR: 3.8, 95% CI: 1.0–2.5) significantly influenced survival. After PD, perioperative morbidity and long-term survival in patients with SM-PVR were similar to those of patients without vein resection. In case of tumor adherence or infiltration, combined resection of the pancreatic head and the vein should always be considered in the absence of other contraindications for resection. Initial results were presented at the Forty-Fourth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Florida, May 18–21, 2003 (poster).     

Use of purified beta-tricalcium phosphate for filling defects after curettage of benign bone tumours

Fifty-three patients with benign bone tumours were treated with curettage and filling with a purified beta-tricalcium phosphate (β-TCP). Recurrences occurred in two cases. There was neither a postoperative infection nor adverse reaction due to the material. Postoperative fractures did not occur in any patients. Radiographically, complete resorption of the material and bone remodelling were achieved in 23 cases (43%). Of these 23 cases, there was a statistical correlation between the filling volume and the time taken for complete resorption (p<0.05). We concluded that purified β-TCP was an ideal bone graft substitute for the treatment of benign bone tumours because of its good biocompatibility and resorption characteristics.

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Résumé 53 patients présentant une tumeur bénigne des os ont été traités par curetage et greffe par du beta-tricalcium phosphate (β-TCP) pur. La récidive de la tumeur n’a été observée que dans deux cas. Il n’y a eu aucune infection et aucune réaction négative dues au matériel. Nous n’avons pas constaté de fractures post-opératoires. Sur le plan radiographique, nous avons assisté à une résorption complète de la tumeur et remodelage osseux chez 23 patients (43%). Pour ces 23 patients, il existe une corrélation statistique non significative entre le volume du substitut et le temps pour sa complète résorption (p<0.05). Nous pouvons en conclure que le β-TCP est un substitut osseux idéal pour le traitement des tumeurs osseuses bénignes qu’il présente une bonne bio compatibilité et des caractéristiques satisfaisantes en terme de résorption.

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No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.     

Reconstruction after wide resection of the entire distal fibula in malignant bone tumours

In this study we present a series of patients (n = 11) with resection of the entire distal fibula in the case of sarcoma or metastasis. Moreover, we describe a new method to restore ankle stability with a tibiotalocalcaneal arthrodesis using a retrograde hindfoot nail (n = 4) in contrast to tibiotalar arthrodesis with screws (n = 5). The screw fixation failed in two patients due to osteopoenic bone. The crucial benefits of an arthrodesis with a retrograde nail are a stable arthrodesis, intramedullary stabilisation of the tibia and avoidance of extrinsic material in the wound area. An arthrodesis with a retrograde nail is a good alternative for reconstruction after a wide distal fibula resection. The additional arthrodesis of the subtalar joint was not associated with worse functional results in the MSTS and TESS scores.     

Tissue-engineered approach for the treatment of steroid-induced osteonecrosis of the femoral head: transplantation of autologous mesenchymal stem cells cultured with beta-tricalcium phosphate ceramics and free vascularized fibula

Autologous mesenchymal stem cells (MSCs) cultured with beta-tricalcium phosphate (beta-TCP) ceramics and with a free vascularized fibula were transplanted into three patients with steroid-induced osteonecrosis of the femoral head. The average follow-up period was 34 months and the average patient age at the time of surgery was 28 years old. Fifteen milliliters of bone marrow was obtained from the patients 4 weeks before surgery, and was used for in vitro proliferation of MSCs. beta-TCP granules were immersed in the MSC suspension and the cells were further cultured for 2 weeks. Cultured MSCs/beta-TCP composite granules were implanted into the cavity that remained after curettage of necrotic bone; and finally, a free vascularized fibula was grafted. All hips showed preoperative collapse and radiographic progression was observed in two hips postoperatively. Osteonecrosis did not progress any further and early bone regeneration was observed. This tissue-engineered approach has potentials for the treatment of osteonecrosis. However, our results suggested that the present procedure could not be used for cases with severe preoperative collapse.     

Donor site morbidity after free fibula flap. Report of 42 consecutive cases

Donor site morbidity after free fibula flap was assessed in 42 patients, 37 of whom had undergone mandibular reconstruction and five proximal humerus. Lower limb reconstructions were excluded. The study comprised functional assessment with two international orthopaedic scales (Karlsson and Kitaoka); comparative lower limb clinical and X-ray assessment. Mean Karlsson score was 90.4/100 with 52% of excellent, 36% of good, and 12% of medium results. Mean Kitaoka score was 93.7/100 with 64% of excellent, and 36% of good results. Fifty-two percent of patients were pain free, 29% had pain on walking on uneven terrain, and 19% occasionally; 7% experienced instability. For 76%, physical activity was unrestricted. Clinical examination found no alteration in hindfoot axis, no joint laxity, mild and acceptable reduction in hallux plantar flexion power in 76% cases, and superficial fibular nerve hypoesthesia in 5% of cases. Methodology and results are detailed and compared to the literature. In conclusion, we found only slight morbidity and free fibula flap remains our first choice as bone flap.