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Chand BB, Rajbhandari A, Banskota AK, Banskota B. Open segmental tibial bone defects treated with Ilizarov frame: a radiological and functional outcome study with average ten year follow-up. INTERNATIONAL ORTHOPAEDICS 2024; 48:2519-2523. [PMID: 39198329 DOI: 10.1007/s00264-024-06277-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Accepted: 08/09/2024] [Indexed: 09/01/2024]
Abstract
PURPOSE Surgical reconstruction of large post-traumatic tibial bone and soft tissue defects following high-energy trauma presents a significant challenge for orthopaedic surgeons. This study aimed to evaluate the functional and radiological outcomes of large post-traumatic tibial bone and soft tissue defects managed by single or double-level bone transport using the Ilizarov technique. MATERIAL & METHODS 13 patients who underwent treatment for large tibial bone defects (Gustillo IIIa, IIIb, IIIc) along with soft tissue defects with Ilizarov from 2010 to 2020 A.D were included. ASAMI functional and radiological outcomes were assessed at the final follow-up to report the outcome. RESULTS The mean age was 27.38 (18-48). An average bone defect was 7.69 cm (5-13 cm). Based upon the Gustillo-Anderson classification (GA), 2 (15%) of them were GA - 3 A, 7 (54%) were GA - 3B, and 4 (31%) were GA - 3 C. The average time of distraction was 11.76 weeks (8-16). The average time for the union was 37 weeks (27-48 weeks). The average bone lengthening was 7.69 cm (5-13 cm). The mean final leg length discrepancy (LLD) at the final follow-up was 1.96 cm (0-4 cm). The primary union was achieved in eight cases, and five required bone grafting at the docking site. Using the ASAMI (Association for the Study of the Method of Ilizarov) scoring system, the functional results were excellent in six and good in seven cases, while the bony results were excellent in eight, good in four and fair in one case. CONCLUSION Good to excellent functional and radiological scores (ASAMI) can be expected when using the Ilizarov frame for simultaneous treatment of the large tibial bone and soft tissue defect when this method is applied with correct principles.
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Sambri A, Zunarelli R, Morante L, Paganelli C, Parisi SC, Bortoli M, Montanari A, Fiore M, Scollo C, Bruschi A, De Paolis M. Graft Infections in Biologic Reconstructions in the Oncologic Setting: A Systematic Review of the Literature. J Clin Med 2024; 13:4656. [PMID: 39200798 PMCID: PMC11354657 DOI: 10.3390/jcm13164656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2024] [Revised: 08/03/2024] [Accepted: 08/06/2024] [Indexed: 09/02/2024] Open
Abstract
Background: Biologic graft infection (BGI) is one of the main complications in graft reconstructions. However, very little evidence exists regarding the epidemiology of BGI, as most of the data come from sparse reports. Moreover, most of the series did not detail the treatment and outcome of graft infections. The aim of this systematic review of the literature is to provide a comprehensive data collection on BGI after oncologic resections. Methods: Three different databases (PubMed, Scopus, and Web of Science) were searched for relevant articles, and further references were obtained by cross-referencing. Results: 139 studies met the inclusion criteria. A total of 9824 grafts were retrieved. Among these, 684 (6.9%) were in the humerus, 365 (3.7%) in the pelvis, 2041 (20.7%) in the femur and 1660 (16.8%) in the tibia. Most grafts were osteoarticular (2481, 26.7%) and intercalary 2112 (22.7%) allografts. In 461 (5.0%), vascularized fibula grafts (VFGs) were used in combination with recycled autografts. Recycled grafts were reported in 1573 (16.9%) of the cases, and allograft-prosthetic composites in 1673 (18.0%). The pelvis and the tibia had the highest incidence of BGI (20.4% and 11.0%, respectively). The most reported first treatment was debridement and implant retention (DAIR) in 187 (42.8%) cases and two-stage revision with graft removal in 152 (34.8%). Very little data are reported on the final outcome specified by site or type of graft. Conclusions: This systematic review of the literature confirms a high incidence of infections in biologic reconstructions after resections of primary bone tumors. Despite DAIR being a viable attempt, in most cases, a two-stage approach with graft removal and reconstruction with endoprosthesis presented the highest chance to overcome infection, guaranteeing a reconstruction. We emphasize the need for future multicentric studies to focus on the management of infections after biological reconstructions in bone sarcomas.
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Affiliation(s)
- Andrea Sambri
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (R.Z.); (L.M.); (C.P.); (S.C.P.); (M.B.); (A.M.); (M.F.); (C.S.); (A.B.); (M.D.P.)
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Opyrchał J, Bula D, Dowgierd K, Pachuta B, Krakowczyk D, Raciborska A, Krakowczyk Ł. Case Series: Fibula Free Flap with Bone Allograft as the Gold Standard in Lower Limb-Salvage Surgery for Adolescent Patients with Primary Bone Tumors Located within Tibial Diaphysis: Technical Modifications and Short-Term Follow-Up. J Clin Med 2024; 13:4217. [PMID: 39064257 PMCID: PMC11277773 DOI: 10.3390/jcm13144217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 07/16/2024] [Accepted: 07/17/2024] [Indexed: 07/28/2024] Open
Abstract
Background: Primary malignant bone tumors are most commonly associated with mutilating surgical procedures that can significantly disturb the motor development of a young patient and are frequently affiliated with major postoperative complications. Unfortunately, despite available autologous tissue donor sites, artificial materials are still most commonly used for the reconstruction of post-resection defects. Reconstructive microsurgery is increasingly recognized as an effective method of functional reconstruction, creating the possibility of performing limb-sparing surgery (LSS) with significant limitation of major postoperative complications at the same time. Methods: The study group consisted of 9 pediatric patients diagnosed with primary malignant bone tumor in the limb location. In order to perform microvascular reconstruction, 9 free fibula flaps were used in combination with a bone allograft (Capanna method). The functional outcome of the reconstruction was assessed on the basis of the MSTS (Musculoskeletal Tumor Society Scoring System) scale. Results: The presented analysis proves the effectiveness of this reconstructive procedure and the possibility of performing LSS with reasonable functional outcomes after appropriate patient qualification. In this study, all limbs included were spared. In all cases, the R0 surgical margins were achieved and no reports of local recurrences were reported during the follow-up. The average score on the MSTS scale was 27/30 points. Conclusions: Microvascular reconstructive surgery is an individually personalized and highly effective method of treating patients with primary bone tumors in the limb location and provides satisfactory functional outcomes.
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Affiliation(s)
- Jakub Opyrchał
- Department of Oncology and Surgical Oncology for Children and Youth, Institute of Mother and Child, 01-211 Warsaw, Poland
- 1st Department of Oncologic Surgery, Maria Sklodowska Curie Memorial National Cancer Center, 44-100 Gliwice, Poland
| | - Daniel Bula
- 1st Department of Oncologic Surgery, Maria Sklodowska Curie Memorial National Cancer Center, 44-100 Gliwice, Poland
| | - Krzysztof Dowgierd
- Department of Clinical Pediatrics, Head and Neck Surgery Clinic for Children and Young Adults, University of Warmia and Mazury, 10-709 Olsztyn, Poland
| | - Bartosz Pachuta
- Department of Oncology and Surgical Oncology for Children and Youth, Institute of Mother and Child, 01-211 Warsaw, Poland
| | - Dominika Krakowczyk
- Pediatric Surgery and Urological Department, Upper Silesian Child Health Center in Katowice, Silesian University of Medicine, 40-052 Katowice, Poland
| | - Anna Raciborska
- Department of Oncology and Surgical Oncology for Children and Youth, Institute of Mother and Child, 01-211 Warsaw, Poland
| | - Łukasz Krakowczyk
- Department of Oncology and Surgical Oncology for Children and Youth, Institute of Mother and Child, 01-211 Warsaw, Poland
- 1st Department of Oncologic Surgery, Maria Sklodowska Curie Memorial National Cancer Center, 44-100 Gliwice, Poland
- Department of Clinical Pediatrics, Head and Neck Surgery Clinic for Children and Young Adults, University of Warmia and Mazury, 10-709 Olsztyn, Poland
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Cheng X, Yao Y, Liu K, Wu L, Yang W. Free iliac crest grafting technology for the management of critical-sized tibial bone defect. BMC Musculoskelet Disord 2024; 25:201. [PMID: 38454383 PMCID: PMC10918920 DOI: 10.1186/s12891-024-07335-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/05/2024] [Indexed: 03/09/2024] Open
Abstract
OBJECTIVE To introduce the method and experience of treating critical-sized tibial bone defect by taking large iliac crest bone graft. METHODS From January 2020 to January 2022, iliac crest bone grafting was performed in 20 patients (10 men and 10 women) with critical-sized tibial bone defect. The mean length of bone defect was 13.59 ± 3.41. Bilateral iliac crest grafts were harvested, including the inner and outer plates of the iliac crest and iliac spine. The cortical bone screw was used to integrate two iliac bone blocks into one complex. Locking plate was used to fix the graft-host complex, supplemented with reconstruction plate to increase stability when necessary. Bone healing was evaluated by cortical bone fusion on radiographs at follow-up, iliac pain was assessed by VAS score, and lower limb function was assessed by ODI score. Complications were also taken into consideration. RESULTS The average follow-up time was 27.4 ± 5.6 (Range 24-33 months), the mean VAS score was 8.8 ± 1.9, the mean ODI score was 11.1 ± 1.8, and the number of cortical bone fusion in the bone graft area was 3.5 ± 0.5. Satisfactory fusion was obtained in all cases of iliac bone transplant-host site. No nonunion, shift or fracture was found in all cases. No infection and bone resorption were observed that need secondary surgery. One patient had dorsiflexion weakness of the great toe. Hypoesthesia of the dorsal foot was observed in 2 patients. Ankle stiffness and edema occurred in 3 patients. Complications were significantly improved by physical therapy and rehabilitation training. CONCLUSION For the cases of critical-sized tibial bone defect, the treatment methods are various. In this paper, we have obtained satisfactory results by using large iliac bone graft to treat bone defect. This approach can not only restore the integrity of the tibia, but also obtain good stability with internal fixation, and operation skills are more acceptable for surgeons. Therefore, it provides an alternative surgical method for clinicians.
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Affiliation(s)
- Xiaoqiang Cheng
- Department of Orthopaedics, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210000, China
| | - Yilun Yao
- Department of Orthopaedics, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210000, China
| | - Kang Liu
- Department of Orthopaedics, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210000, China
| | - Lei Wu
- Department of Orthopaedics, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210000, China
| | - Wengbo Yang
- Department of Orthopaedics, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210000, China.
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Kim MB, Kim KW, Lee SH, Lee YH. Use of Three-Column Reconstruction and Free Vascularized Fibular Grafts for the Repair of Large Tibial Defects after Tumor Resection. Clin Orthop Surg 2023; 15:1029-1035. [PMID: 38045591 PMCID: PMC10689222 DOI: 10.4055/cios22298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 06/09/2023] [Accepted: 06/09/2023] [Indexed: 12/05/2023] Open
Abstract
Background This study aimed to evaluate the clinical outcomes of three-column reconstruction of the lower leg using a single-barrel contralateral vascularized fibular graft (VFG), medial locking plate, and the ipsilateral fibula for the repair of large tibial defects after tumor resection. Methods In this retrospective study, we reviewed 12 patients who underwent three-column reconstruction using a single-barrel contralateral VFG, medial locking plate, and the ipsilateral fibula between June 1996 and May 2020. These patients had large tibial bone defects following tumor resection. The mean age of the patients was 26.3 years (range, 11-63 years), and 7 of them were women. The mean follow-up period was 104.8 months (range, 26-284 months). The mean size of the tibial bone defect after tumor resection was 17.8 cm (range, 11-26.8 cm). The clinical and radiological outcomes were evaluated at the final follow-up. Results All patients survived beyond the final follow-up without recurrence of the primary bone tumor. The mean time from reconstruction to bony union at both host-graft junctions was 12.9 months (range, 4-36 months). The mean Musculoskeletal Tumor Society score was 82.3% (range, 60%-97%). All tibial defects were reconstructed with adequate bone healing. There were 4 cases of stress fracture and graft failure; these were resolved by using longer plates and more screws. All patients were ambulatory without assistance and showed no permanent complications. Conclusions Large tibial defects that occur after tumoral resection can be effectively reconstructed by three-column reconstruction using a medial locking plate, an inlay single-barrel VFG harvested from the contralateral side, and the intact ipsilateral fibula. This technique permits early weight-bearing before fibular hypertrophy and bony union.
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Affiliation(s)
- Min Bom Kim
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung Wook Kim
- Department of Orthopaedic Surgery, Dankook University Hospital, Cheonan, Korea
| | - Seung Hoo Lee
- Department of Orthopaedic Surgery, Chungnam National University Sejong Hospital, Chungnam National University College of Medicine, Sejong, Korea
| | - Young Ho Lee
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Xie L, Huang Y, Zhang L, Si S, Yu Y. Ilizarov method and its combined methods in the treatment of long bone defects of the lower extremity: systematic review and meta-analysis. BMC Musculoskelet Disord 2023; 24:891. [PMID: 37968675 PMCID: PMC10652567 DOI: 10.1186/s12891-023-07001-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 10/30/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Ilizarov method has become one of primary methods for treating bone defects. Currently, there is growing trend in the application of modified Ilizarov methods (e.g., applying unilateral external fixators or with flap tissue) and its combined methods (e.g., Ilizarov method with antibiotic spacer or internal fixation) to manage bone defects. However, there is a lack of studies with systematical evaluation of the clinical effects of these evolving methods. This study aimed to conduct a systematic review and meta-analysis for overall evaluating the clinical effects on long bone defects of lower extremity in Ilizarov methods and its combined methods. METHODS Studies were identified in three electronic databases (Pubmed, Embase and Cochrane Library) from the earliest indexing year through November 01, 2022, and relevant data were extracted subsequently. The total number of participants, number of participants with bone unions, bone result or functional result, and related complications including pin infection, pin loosening, pain, refracture, limb discrepancy, malalignment, joint stiffness, recurrent infection, and amputation were extracted in this study. Then, union rate (defined as the proportion of patients who achieved bone unions) and specific complication incidence rate (defined as the proportion of patients who experienced specific complication) were pooled estimated respectively. Relative risk (RR) was used for comparing the clinical effects among various Ilizarov technique. RESULTS Sixty-eight case series studies, 29 comparative studies, and 3 randomized clinical trials were finally included. The union rate of Ilizarov methods was 99.29% (95% CI: 98.67% ~ 99.86%) in tibial defects and 98.81% (95% CI: 98.81% ~ 100.00%) in femoral defects. The union rate of Ilizarov method with antibiotic spacer and intramedullary nail in tibial defects was 99.58% (95% CI: 98.05% ~ 100.00%) and 95.02% (95% CI: 87.28% ~ 100.00%), respectively. Compared to the Ilizarov methods, the union rate of the Ilizarov method with antibiotic spacer in tibial defects increased slightly (RR = 1.02, 95% CI: 1.01 ~ 1.04). Meanwhile, compared to Ilizarov methods, we found lower excellent rate in bone result in Ilizarov method with antibiotic spacer, with the moderate to high heterogeneity. Compared to the Ilizarov method, lower rate of pin infection, higher rate of recurrent infection and amputation were observed in Ilizarov method with intramedullary nail, however, the findings about the comparison of pin infection and recurrent infection between the two groups were presented with high degree of statistical heterogeneity. CONCLUSION Our study confirmed the reliable treatment of Ilizarov methods and its combined technique on long bone defects, and founded there were significant differences on some complications rate between Ilizarov methods and its combined technique. However, the findings need to be confirmed by further studies.
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Affiliation(s)
- Lijun Xie
- Department of Orthopedic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, P. R. China
- Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, P. R. China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, P. R. China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou City, Zhejiang Province, P. R. China
| | - Ye Huang
- Department of Public Health, and Department of Anesthesiology, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, P. R. China
- Department of Epidemiology & Health Statistics, School of Public Health, School of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, P. R. China
| | - Libi Zhang
- Department of Public Health, and Department of Anesthesiology, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, P. R. China
- Department of Epidemiology & Health Statistics, School of Public Health, School of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, P. R. China
| | - Shuting Si
- Department of Public Health, and Department of Anesthesiology, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, P. R. China
- Department of Epidemiology & Health Statistics, School of Public Health, School of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, P. R. China
| | - Yunxian Yu
- Department of Public Health, and Department of Anesthesiology, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, P. R. China.
- Department of Epidemiology & Health Statistics, School of Public Health, School of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, P. R. China.
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Singh S, Toci GR, Kapadia K, Colon A, Greenberg P, Iyer H, Katt B, Shah A. Vascularized Bone Grafting Versus the 2-Stage Masquelet Technique for Upper-Extremity Bone Reconstruction: A Meta-Analysis. J Hand Surg Am 2023; 48:984-992. [PMID: 37542493 DOI: 10.1016/j.jhsa.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 05/15/2023] [Accepted: 06/23/2023] [Indexed: 08/07/2023]
Abstract
PURPOSE Vascularized bone grafting (VBG) has been described as the technique of choice for larger bone defects in bone reconstruction, yielding excellent results at the traditional threshold of 6 cm as described in the literature. However, we hypothesize that the 2-stage Masquelet technique provides equivalent union rates for upper-extremity bone defects regardless of size, while having no increase in the rate of patient complications. METHODS A systematic literature review was conducted using PubMed and Scopus for outcomes after VBG and the Masquelet technique for upper-extremity bone defects of the humerus, radius, ulna, metacarpal, or phalanx (carpal defects were excluded). A meta-analysis was performed to compare outcomes following VBG and the Masquelet technique at varying defect sizes. RESULTS There were 77 VBG (295 patients) and 25 Masquelet (119 patients) studies that met inclusion criteria. Patients undergoing the Masquelet technique had defect sizes ranging from 0-15 cm (average 4.5 cm), while patients undergoing VBG had defect sizes ranging from 0-24 cm (average 5.9 cm). The union rate for Masquelet patients was 94.1% with an average time to union of 5.8 months, compared to 94.9% and 4.4 months, respectively, for VBG patients. We did not identify a defect size threshold at which VBG demonstrated a significantly higher union rate. No statistically significant difference was found in union rates between techniques when using multivariable logistic regression analysis. CONCLUSION There was no statistically significant difference in union rates between VBG and the Masquelet technique in upper-extremity bone defects regardless of defect size. Surgeons may consider the Masquelet technique as an alternative to VBG in large bone defects of the upper extremity. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
| | - Gregory R Toci
- Rothman Orthopaedics at Thomas Jefferson University Hospital, Philadelphia, PA
| | | | | | | | - Hari Iyer
- The Center for Hand and Upper Extremity Surgery, Hackensack, NJ
| | - Brian Katt
- Rutgers Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Ajul Shah
- The Center for Hand and Upper Extremity Surgery, Hackensack, NJ
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Lavía KF, Izquierdo Ó, Boccolini HS, Hernández R, Pérez G, Andrés M, Panadero M. Treatment of a case of septic tibial nonunion by the Capanna technique. Trauma Case Rep 2023; 47:100912. [PMID: 37637455 PMCID: PMC10458955 DOI: 10.1016/j.tcr.2023.100912] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2023] [Indexed: 08/29/2023] Open
Abstract
This report presents the case of a 25-year-old male with an infected tibial diaphyseal nonunion caused by a bone transport procedure carried out to treat an open fracture the patient had sustained 10 years before referral to our hospital. After an initial radical debridement, a bone defect was created, which was subsequently obliterated by placement of an antibiotic-impregnated cement spacer and Stimulan beads and covered by an anterolateral thigh flap. As the patient refused to wear an external fixator and his osseous biology was not amenable to a Masquelet procedure, a decision was made to apply the Capanna technique as soon as the infection healed. The second debridement resulted in a 12-cm-long bone defect that was filled with a tibial allograft and a vascularized fibular graft. At six months, the patient had regained full knee function and was able to bear his full weight, without pain or the need of support equipment. At one year, the bone had healed completely, the infection had subsided and the patient was able to resume his everyday activities. Although the Capanna technique was initially developed to reinforce reconstructions at risk of fracture or nonunion as a result of chemotherapy, its use in post-traumatic cases has been shown to be successful in a selected group of patents. Our study demonstrated that increasing the stability of a reconstruction with an allograft can accelerate the time to heal, and that using a vascularized fibular graft can enhance incorporation of the whole construct. It can be concluded that the Capanna technique is a valid treatment option for managing infected segmental bone defects in selected patients.
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Tsuchiya R, Kobayashi E, Fukushima S, Arikawa M, Ogura K, Iwata S, Akazawa S, Kawai A. Outcomes of Sling Procedure Using a Free Vascularized Fibular Graft After Resection of the Proximal Humerus. JB JS Open Access 2023; 8:e23.00044. [PMID: 37900324 PMCID: PMC10602540 DOI: 10.2106/jbjs.oa.23.00044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2023] Open
Abstract
Background The proximal humerus is a common site for both primary and metastatic bone tumors. Although various methods have been developed for reconstruction following resection of the proximal humerus, a consensus on which technique is best has not been established. We focused on the sling procedure using a free vascularized fibular graft (FVFG) and conducted what we believe to be the largest retrospective study of patients to undergo this surgery to date. Methods We retrospectively reviewed the data of 19 patients who underwent the sling procedure with use of an FVFG at our hospital between 1998 and 2022. The median age was 20 years, and the median follow-up duration was 63.1 months. Surgical data, oncological outcomes, the postoperative course, complications, and functional outcomes as measured with use of the Musculoskeletal Tumor Society (MSTS) score were thoroughly reviewed. Results The median operative duration was 555 minutes, and the median blood loss was 374 mL. The median length of the bone defect was 17.0 cm, and the median length of the graft was 20.0 cm. With respect to oncological outcomes, 9 patients were continuously disease-free, 9 patients had no evidence of disease, and 1 patient was alive with disease. Bone union was present in 13 of the 17 patients for whom it was evaluable. The median time to bone union was 4 months. Graft growth was observed in 2 pediatric patients. Postoperative fracture was a major complication at the recipient site. The incidence of pseudarthrosis significantly increased when the FVFG could not be inserted into the remaining humeral bone or was split in half (p = 0.002). Although a few patients demonstrated peroneal nerve palsy at the donor site, the symptom was temporary. The overall functional outcome was favorable, with an average MSTS score of 66.9%. Conclusions The sling procedure demonstrated a low complication rate and a favorable functional outcome overall. Therefore, we believe that this procedure is a useful reconstruction method for patients in a broad age range who have a wide defect of the proximal humerus. Level of Evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ryuto Tsuchiya
- Department of Musculoskeletal Oncology and Rehabilitation, National Cancer Center Hospital, Tokyo, Japan
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Eisuke Kobayashi
- Department of Musculoskeletal Oncology and Rehabilitation, National Cancer Center Hospital, Tokyo, Japan
| | - Suguru Fukushima
- Department of Musculoskeletal Oncology and Rehabilitation, National Cancer Center Hospital, Tokyo, Japan
| | - Masaki Arikawa
- Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Koichi Ogura
- Department of Musculoskeletal Oncology and Rehabilitation, National Cancer Center Hospital, Tokyo, Japan
| | - Shintaro Iwata
- Department of Musculoskeletal Oncology and Rehabilitation, National Cancer Center Hospital, Tokyo, Japan
| | - Satoshi Akazawa
- Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Akira Kawai
- Department of Musculoskeletal Oncology and Rehabilitation, National Cancer Center Hospital, Tokyo, Japan
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Feltri P, Solaro L, Errani C, Schiavon G, Candrian C, Filardo G. Vascularized fibular grafts for the treatment of long bone defects: pros and cons. A systematic review and meta-analysis. Arch Orthop Trauma Surg 2023; 143:29-48. [PMID: 34110477 DOI: 10.1007/s00402-021-03962-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 05/16/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To quantify union rate, complication rate, reintervention rate, as well as functional outcome after vascularized fibular bone grafts (VFGs) for the treatment of long-bone defects. METHODS A comprehensive search was performed in the PubMed, Web of Science, and Cochrane databases up to August 18, 2020. Randomized controlled trials, comparative studies, and case series describing the various techniques available involving VFGs for the reconstruction of segmental long-bone defects were included. A meta-analysis was performed on union results, complications, and reinterventions. Assessment of risk of bias and quality of evidence was performed with the Downs and Black's "Checklist for Measuring Quality". RESULTS After full-text assessment, 110 articles on 2226 patients were included. Among the retrieved studies, 4 were classified as poor, 83 as fair, and 23 as good. Overall, good functional results were documented and a union rate of 80.1% (CI 74.1-86.2%) was found, with a 39.4% (CI 34.4-44.4%) complication rate, the most common being fractures, non-unions and delayed unions, infections, and thrombosis. Donor site morbidity represented 10.7% of the total complications. A 24.6% reintervention rate was documented (CI 21.0-28.1%), and 2.8% of the patients underwent amputation. CONCLUSIONS This systematic review and meta-analysis documented good long-term outcomes both in the upper and lower limb. However, VFG is a complex and demanding technique; this complexity means an average high number of complications, especially fractures, non-unions, and vascular problems. Both potential and limitations of VFG should be considered when choosing the most suitable approach for the treatment of long-bone defects.
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Affiliation(s)
- Pietro Feltri
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, 6900, Lugano, Switzerland
| | - Luca Solaro
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli, 1/10, 40136, Bologna, Italy.
| | - Costantino Errani
- Orthopaedic Service, Musculoskeletal Oncology Department, IRCCS Istituto Ortopedico Rizzoli, 40136, Bologna, Italy
| | - Guglielmo Schiavon
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, 6900, Lugano, Switzerland
| | - Christian Candrian
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, 6900, Lugano, Switzerland.,Facoltà Di Scienze Biomediche, Università della Svizzera Italiana, Via Buffi 13, 6900, Lugano, Switzerland
| | - Giuseppe Filardo
- Applied and Translational Research Center, IRCCS Istituto Ortopedico Rizzoli, 40136, Bologna, Italy.,Facoltà Di Scienze Biomediche, Università della Svizzera Italiana, Via Buffi 13, 6900, Lugano, Switzerland
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11
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Long-Term Follow-Up of Biological Reconstruction with Free Fibular Graft after Resection of Extremity Diaphyseal Bone Tumors. J Clin Med 2022; 11:jcm11237225. [PMID: 36498798 PMCID: PMC9741265 DOI: 10.3390/jcm11237225] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022] Open
Abstract
This study aimed to evaluate the clinical outcomes and complications of reconstruction with a composite free fibula inside other biological grafts. We retrospectively reviewed 26 patients who underwent reconstruction after bone tumor resection of the diaphysis of the long bone. Surgical data, time to bony union, functional outcomes, and complications were evaluated in all cases. The median follow-up was 72.5 months. The limb salvage rate was 100%. Primary osseous union was achieved in 90.4% of the junctions. The union rates at the metaphyseal and diaphyseal junctions were 100% and 85.7%, respectively (p = 0.255). The mean time of bony union in the upper (87.5%) and lower (91.7%) extremity was 4.6 ± 1.6 months and 6.9 ± 2 months, respectively. The mean MSTS score was 27.2 ± 3.2, with a mean MSTS rating of 90.7%. Complications occurred in 15.4% of the cases. The administration of vascularized or non-vascularized grafts did not significantly influence the union time (p = 0.875), functional outcome (p = 0.501), or blood loss (p = 0.189), but showed differences in operation time (p = 0.012) in lower extremity reconstruction. A composite free fibula inside other biological grafts provides a reasonable and durable option for osseous oncologic reconstruction of the long bone diaphysis of the extremities with an acceptable rate of complications. A higher union rate was achieved after secondary bone grafting. In lower-extremity reconstruction, two plates may be considered a better option for internal fixation. Vascularizing the fibula did not significantly affect the union time.
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12
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Mayfield CK, Ayad M, Lechtholz-Zey E, Chen Y, Lieberman JR. 3D-Printing for Critical Sized Bone Defects: Current Concepts and Future Directions. Bioengineering (Basel) 2022; 9:680. [PMID: 36421080 PMCID: PMC9687148 DOI: 10.3390/bioengineering9110680] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 11/04/2022] [Accepted: 11/08/2022] [Indexed: 11/15/2023] Open
Abstract
The management and definitive treatment of segmental bone defects in the setting of acute trauma, fracture non-union, revision joint arthroplasty, and tumor surgery are challenging clinical problems with no consistently satisfactory solution. Orthopaedic surgeons are developing novel strategies to treat these problems, including three-dimensional (3D) printing combined with growth factors and/or cells. This article reviews the current strategies for management of segmental bone loss in orthopaedic surgery, including graft selection, bone graft substitutes, and operative techniques. Furthermore, we highlight 3D printing as a technology that may serve a major role in the management of segmental defects. The optimization of a 3D-printed scaffold design through printing technique, material selection, and scaffold geometry, as well as biologic additives to enhance bone regeneration and incorporation could change the treatment paradigm for these difficult bone repair problems.
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Affiliation(s)
- Cory K. Mayfield
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA 90033, USA
| | - Mina Ayad
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA 90033, USA
| | - Elizabeth Lechtholz-Zey
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA 90033, USA
| | - Yong Chen
- Department of Aerospace and Mechanical Engineering, Viterbi School of Engineering, University of Southern California, Los Angleles, CA 90089, USA
| | - Jay R. Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA 90033, USA
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13
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Kaneuchi Y, Yoshida S, Fujiwara T, Evans S, Abudu A. Limb salvage surgery has a higher complication rate than amputation but is still beneficial for patients younger than 10 years old with osteosarcoma of an extremity. J Pediatr Surg 2022; 57:702-709. [PMID: 35490054 DOI: 10.1016/j.jpedsurg.2022.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 02/19/2022] [Accepted: 04/03/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND/PURPOSE Limb preserving surgery for the treatment of patients with osteosarcoma younger than 10 years old is challenging and some authors have advocated amputation to reduce the risk of complications. The aim of this study was to compare the clinical outcomes and surgical complications of patients with osteosarcoma of the extremity aged <10 years old who were treated with limb salvage and amputation. PATIENTS AND METHODS Retrospective review of patients aged <10 years old who were treated for primary osteosarcoma of bone between 2000 and 2018. RESULTS We analyzed 82 consecutive patients (32 males, 50 females; median age 8, range 3-9 yrs). Limb-salvage surgery (LSS; n = 65, 79%) and amputation (n = 17, 21%) were performed. Fourteen patients had metastasis at surgery. In patients without metastasis at surgery, the metastasis-free and overall survival rates at 5 years following LSS vs. amputation were 75% vs. 58% (p = 0.162) and 71% vs. 55% (p = 0.516), respectively. The 2-year and 5-year OS rates of the LSS and amputation groups of patients with metastasis at surgery were 88% versus 83% and 50% versus 0%, respectively (p = 0.180). The overall complication rates were 46% post-LSS with 31% requiring re-operation versus 12% post-amputation, with 6% requiring re-operation (p = 0.010). CONCLUSION The prognosis of patients with localized osteosarcoma aged <10 years undergoing LSS is similar to those treated with amputation, but LSS is associated with a higher risk of complications and subsequent re-operation. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Yoichi Kaneuchi
- Department of Oncology, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK; Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan.
| | - Shinichirou Yoshida
- Department of Oncology, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Tomohiro Fujiwara
- Department of Oncology, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Scott Evans
- Department of Oncology, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Adesegun Abudu
- Department of Oncology, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
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14
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Cao Z, Zhang Y, Lipa K, Qing L, Wu P, Tang J. Ilizarov Bone Transfer for Treatment of Large Tibial Bone Defects: Clinical Results and Management of Complications. J Pers Med 2022; 12:jpm12111774. [PMID: 36579496 PMCID: PMC9692871 DOI: 10.3390/jpm12111774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 10/12/2022] [Accepted: 10/20/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUNDS The purpose of this study is to present our clinical experience using the Ilizarov bone transfer technique and free-flap technique in the reconstruction of large tibial bone and soft tissue defects, including an evaluation of both the management of postoperative complications and long-term outcomes. METHODS From January 2010 to May 2020, 72 patients with tibia bone and soft tissue defects were retrospectively evaluated. Either an anterolateral thigh perforator flaps (ALTP) or latissimus dorsi musculocutaneous flaps (LD), solely or in combination, were used to cover soft tissue defects. Once the flap was stabilized, an Ilizarov external fixator was applied to the limb. Follow-up was postoperatively performed at 1, 3, 6, 9, and 12 months. RESULTS Postoperatively, there were two cases of total and five of partial flap necrosis, and two cases of subcutaneous ulcers, which were caused by vascular crisis, infection, and hematoma, respectively. All the patients underwent Ilizarov external fixator surgery after flap recovery. A total of 16 complications occurred, including 3 cases of simple needle tract infection (antibiotic treatment) and 13 cases of complications requiring reoperation. A correlation factor analysis revealed that the main factors affecting the healing time were the defect length and operative complications. All patients with complications treated with the vascularized iliac flap eventually healed completely. CONCLUSIONS The Ilizarov method used together with an ALTP, LD, or a combination thereof yields good clinical results for repairing large bone and soft tissue defects of the tibia, thus reducing the incidence of amputations. However, longer treatment times may be involved, and postoperative complications can occur. The vascularized iliac flap may be a suitable choice for the treatment of postoperative complications of this type of Ilizarov bone transport.
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Affiliation(s)
- Zheming Cao
- Department of Orthopedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, China
| | - Yiqian Zhang
- Department of Orthopedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, China
| | - Katelyn Lipa
- Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA 15260, USA
| | - Liming Qing
- Department of Orthopedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, China
| | - Panfeng Wu
- Department of Orthopedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, China
| | - Juyu Tang
- Department of Orthopedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, China
- Correspondence:
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15
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Mughal M, Rose V, Sindali K, Farhadi J, Havard H, Pollock R, Roblin P. Dual pedicle epiphyseal transfer for paediatric bony sarcoma reconstruction: Technique and review of outcomes. J Plast Reconstr Aesthet Surg 2022; 75:2466-2473. [PMID: 35504788 DOI: 10.1016/j.bjps.2021.08.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 05/14/2021] [Accepted: 08/26/2021] [Indexed: 11/30/2022]
Abstract
Skeletal reconstruction after tumour resection in paediatric patients is challenging. The resultant reconstruction needs to meet the demands of graft incorporation as well as the potential for growth. The vascularised fibular epiphyseal transfer (VFET) offers the potential for both. We retrospectively reviewed eight paediatric patients treated with VFET after bony tumour resection. All patients underwent a dual pedicle transfer with the peroneal artery for the diaphyseal blood supply and the recurrent branch of the anterior tibial artery for the physis. This is the largest series in literature for dual pedicle transfers for bony reconstruction. We present our surgical technique and outcomes in terms of functional limb salvage and growth.
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Affiliation(s)
- Maleeha Mughal
- Department of Plastic Surgery, Guy's & St. Thomas Hospital, London, UK; Department of Plastic Surgery, University Health Network, Toronto, ON, CA.
| | - Victoria Rose
- Department of Plastic Surgery, Guy's & St. Thomas Hospital, London, UK
| | - Katia Sindali
- Department of Plastic Surgery, Guy's & St. Thomas Hospital, London, UK
| | - Jian Farhadi
- Department of Plastic Surgery, Guy's & St. Thomas Hospital, London, UK
| | - Heledd Havard
- Department of Orthopaedics, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Robin Pollock
- Department of Orthopaedics, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Paul Roblin
- Department of Plastic Surgery, Guy's & St. Thomas Hospital, London, UK
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16
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Hartnett DA, Milner JD, Salameh M, Got CJ, Blankenhorn BD. Traumatic Fibular Loss Managed with a Free Vascularized Fibular Graft: A Case Report. JBJS Case Connect 2022; 12:01709767-202203000-00065. [PMID: 35263306 DOI: 10.2106/jbjs.cc.21.00792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 25-year-old man involved in a jet skiing accident experienced a traumatic excision of his distal fibula in conjunction with other lower extremity injuries. He subsequently underwent a reconstruction of his lateral malleolus using an ipsilateral free vascularized fibular graft (FVFG) from his proximal fibular shaft, resulting in a preserved and stabilized ankle joint at 1 year. CONCLUSION Traumatic distal fibular excision is a rare injury that can be successfully managed using an FVFG, with fusion of the distal syndesmosis and a symmetric ankle mortise observed at the 1-year follow-up.
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Affiliation(s)
- Davis A Hartnett
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
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17
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Yang YP, Gadomski BC, Bruyas A, Easley J, Labus KM, Nelson B, Palmer RH, Stewart H, McGilvray K, Puttlitz CM, Regan D, Stahl A, Lui E, Li J, Moeinzadeh S, Kim S, Maloney W, Gardner MJ. Investigation of a Prevascularized Bone Graft for Large Defects in the Ovine Tibia. Tissue Eng Part A 2021; 27:1458-1469. [PMID: 33858216 DOI: 10.1089/ten.tea.2020.0347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
In vivo bioreactors are a promising approach for engineering vascularized autologous bone grafts to repair large bone defects. In this pilot parametric study, we first developed a three-dimensional (3D) printed scaffold uniquely designed to accommodate inclusion of a vascular bundle and facilitate growth factor delivery for accelerated vascular invasion and ectopic bone formation. Second, we established a new sheep deep circumflex iliac artery (DCIA) model as an in vivo bioreactor for engineering a vascularized bone graft and evaluated the effect of implantation duration on ectopic bone formation. Third, after 8 weeks of implantation around the DCIA, we transplanted the prevascularized bone graft to a 5 cm segmental bone defect in the sheep tibia, using the custom 3D printed bone morphogenic protein 2 (BMP-2) loaded scaffold without prior in vivo bioreactor maturation as a control. Analysis by micro-computed tomography and histomorphometry found ectopic bone formation in BMP-2 loaded scaffolds implanted for 8 and 12 weeks in the iliac pouch, with greater bone formation occurring after 12 weeks. Grafts transplanted to the tibial defect supported bone growth, mainly on the periphery of the graft, but greater bone growth and less soft tissue invasion was observed in the avascular BMP-2 loaded scaffold implanted directly into the tibia without prior in vivo maturation. Histopathological evaluation noted considerably greater vascularity in the bone grafts that underwent in vivo maturation with an inserted vascular bundle compared with the avascular BMP-2 loaded graft. Our findings indicate that the use of an initial DCIA in vivo bioreactor maturation step is a promising approach to developing vascularized autologous bone grafts, although scaffolds with greater osteoinductivity should be further studied. Impact statement This translational pilot study aims at combining a tissue engineering scaffold strategy, in vivo prevascularization, and a modified transplantation technique to accelerate large segmental bone defect repair. First, we three-dimensional (3D) printed a 5 cm scaffold with a unique design to facilitate vascular bundle inclusion and osteoinductive growth factor delivery. Second, we established a new sheep deep circumflex iliac artery model as an in vivo bioreactor for prevascularizing the novel 3D printed osteoinductive scaffold. Subsequently, we transplanted the prevascularized bone graft to a clinically relevant 5 cm segmental bone defect in the sheep tibia for bone regeneration.
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Affiliation(s)
- Yunzhi Peter Yang
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA.,Department of Material Science and Engineering, Stanford University, Stanford, California, USA.,Department of Bioengineering, Stanford University, Stanford, California, USA
| | - Benjamin C Gadomski
- Department of Mechanical Engineering and School of Biomedical Engineering, Immunology, and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - Arnaud Bruyas
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Jeremiah Easley
- Department of Clinical Sciences, and Immunology, and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - Kevin M Labus
- Department of Mechanical Engineering and School of Biomedical Engineering, Immunology, and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - Brad Nelson
- Department of Clinical Sciences, and Immunology, and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - Ross H Palmer
- Department of Clinical Sciences, and Immunology, and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - Holly Stewart
- Department of Clinical Sciences, and Immunology, and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - Kirk McGilvray
- Department of Mechanical Engineering and School of Biomedical Engineering, Immunology, and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - Christian M Puttlitz
- Department of Mechanical Engineering and School of Biomedical Engineering, Immunology, and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - Dan Regan
- Department of Microbiology, Immunology, and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - Alexander Stahl
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA.,Department of Chemistry and Stanford University, Stanford, California, USA
| | - Elaine Lui
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA.,Department of Mechanical Engineering, Stanford University, Stanford, California, USA
| | - Jiannan Li
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Seyedsina Moeinzadeh
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Sungwoo Kim
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - William Maloney
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
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18
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Pinto D, Mehta R, Agashe M. Lengthening After Nonvascularized Fibula Grafting for Large Postinfective Bone Defect: A Case Report with Long Follow-up. JBJS Case Connect 2021; 11:01709767-202106000-00027. [PMID: 33979828 DOI: 10.2106/jbjs.cc.20.00749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We describe a case of lengthening of the tibial regenerate after nonvascularized fibula grafting, for postinfective tibial gap nonunion in a child. A large tibial defect secondary to osteomyelitis in a 10-month-old boy was reconstructed using a 5-cm fibula autograft. Concomitant distal tibial physeal arrest led to progressive shortening. Distraction osteogenesis was performed, through the grafted segment, on 2 occasions-at the ages of 3.5 and 8 years-to achieve total lengthening of 9 cm and good functional recovery at 11.5 years of age. CONCLUSION The tibial regenerate after nonvascularized fibula grafting in children has good potential for distraction osteogenesis.
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Affiliation(s)
- Deepika Pinto
- Department of Pediatric Orthopaedics, Bai Jerbai Wadia Hospital for Children, Mumbai, India
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19
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D'Arienzo A, Ipponi E, Ruinato AD, De Franco S, Colangeli S, Andreani L, Capanna R. Proximal Humerus Reconstruction after Tumor Resection: An Overview of Surgical Management. Adv Orthop 2021; 2021:5559377. [PMID: 33828866 PMCID: PMC8004366 DOI: 10.1155/2021/5559377] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/10/2021] [Indexed: 02/07/2023] Open
Abstract
Proximal humerus is one of the anatomical sites that are most frequently involved by bone and soft tissue malignant tumors. Alone or in association with adjuvant treatments, surgery represents the main therapeutic option to treat and eradicate these diseases. Once the first-line option, in the last decades, amputation lost its role as treatment of choice for the large majority of cases in favor of the modern limb sparing surgery that promises to preserve anatomy and-as much as possible-upper limb functionality. Currently, the main approaches used to replace proximal humerus after a wide resection in oncologic surgery can be summarized in biological reconstructions (allografts and autografts), prosthetic reconstructions (anatomic endoprostheses, total reverse shoulder prostheses), and graft-prosthetic composite reconstructions. The purpose of this overview is to present nowadays surgical options for proximal humerus reconstruction in oncological patients, with their respective advantages and disadvantages.
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Affiliation(s)
- Antonio D'Arienzo
- Department of Orthopaedic and Trauma Surgery, University of Pisa, Pisa, Italy
| | - Edoardo Ipponi
- Department of Orthopaedic and Trauma Surgery, University of Pisa, Pisa, Italy
| | | | - Silvia De Franco
- Department of Orthopaedic and Trauma Surgery, University of Pisa, Pisa, Italy
| | - Simone Colangeli
- Department of Orthopaedic and Trauma Surgery, University of Pisa, Pisa, Italy
| | - Lorenzo Andreani
- Department of Orthopaedic and Trauma Surgery, University of Pisa, Pisa, Italy
| | - Rodolfo Capanna
- Department of Orthopaedic and Trauma Surgery, University of Pisa, Pisa, Italy
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20
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Structural Iliac Crest Autograft for Segmental Reconstruction After Metastatic Renal Cell Tumor Resection of the Radial Shaft. Tech Orthop 2021. [DOI: 10.1097/bto.0000000000000543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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21
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Surgical Advances in Osteosarcoma. Cancers (Basel) 2021; 13:cancers13030388. [PMID: 33494243 PMCID: PMC7864509 DOI: 10.3390/cancers13030388] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/17/2021] [Accepted: 01/18/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Osteosarcoma (OS) is the most common bone cancer in children. OS most commonly arises in the legs, but can arise in any bone, including the spine, head or neck. Along with chemotherapy, surgery is a mainstay of OS treatment and in the 1990s, surgeons began to shift from amputation to limb-preserving surgery. Since then, improvements in imaging, surgical techniques and implant design have led to improvements in functional outcomes without compromising on the cancer outcomes for these patients. This paper summarises these advances, along with a brief discussion of future technologies currently in development. Abstract Osteosarcoma (OS) is the most common primary bone cancer in children and, unfortunately, is associated with poor survival rates. OS most commonly arises around the knee joint, and was traditionally treated with amputation until surgeons began to favour limb-preserving surgery in the 1990s. Whilst improving functional outcomes, this was not without problems, such as implant failure and limb length discrepancies. OS can also arise in areas such as the pelvis, spine, head, and neck, which creates additional technical difficulty given the anatomical complexity of the areas. We reviewed the literature and summarised the recent advances in OS surgery. Improvements have been made in many areas; developments in pre-operative imaging technology have allowed improved planning, whilst the ongoing development of intraoperative imaging techniques, such as fluorescent dyes, offer the possibility of improved surgical margins. Technological developments, such as computer navigation, patient specific instruments, and improved implant design similarly provide the opportunity to improve patient outcomes. Going forward, there are a number of promising avenues currently being pursued, such as targeted fluorescent dyes, robotics, and augmented reality, which bring the prospect of improving these outcomes further.
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22
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Kim Y, Jang WY, Park JW, Park YK, Cho HS, Han I, Kim HS. Transepiphyseal resection for osteosarcoma in patients with open physes using MRI assessment. Bone Joint J 2020; 102-B:772-778. [PMID: 32475249 DOI: 10.1302/0301-620x.102b6.bjj-2019-1141.r2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS For paediatric and adolescent patients with growth potential, preservation of the physiological joint by transepiphyseal resection (TER) of the femur confers definite advantages over arthroplasty procedures. We hypothesized that the extent of the tumour and changes in its extent after neoadjuvant chemotherapy are essential factors in the selection of this procedure, and can be assessed with MRI. The oncological and functional outcomes of the procedure were reviewed to confirm its safety and efficacy. METHODS We retrospectively reviewed 16 patients (seven male and nine female, mean age 12.2 years (7 to 16)) with osteosarcoma of the knee who had been treated by TER. We evaluated the MRI scans before and after neoadjuvant chemotherapy for all patients to assess the extent of the disease and the response to treatment. RESULTS The mean follow-up period was 64.3 months (25 to 148) after surgery and no patients were lost to follow-up. On MRI evaluation, 13 tumours were near but not in contact with the physes and three tumours were partially in contact with the physes before neoadjuvant chemotherapy. Bone oedema in the epiphysis was observed in eight patients. After neoadjuvant chemotherapy, bone oedema in the epiphysis disappeared in all patients. In total, 11 tumours were not in contact and five tumours were in partial contact with the physes. The postoperative pathological margin was negative in all patients. At the last follow-up, 12 patients were continuously disease-free and three had no evidence of disease. One patient died due to the disease. Functionally, the patients with retained allograft or recycled autograft had a mean knee range of flexion of 126° (90° to 150°). The mean Musculoskeletal Tumor Society functional score was 27.6 (23 to 30). CONCLUSION TER is an effective limb-salvage technique for treating malignant metaphyseal bone tumours in paediatric and young osteosarcoma patients with open physes when a good response to chemotherapy and no progression of the tumour to the epiphysis have been confirmed by MRI. Cite this article: Bone Joint J 2020;102-B(6):772-778.
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Affiliation(s)
- Yongsung Kim
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Woo Young Jang
- Department of Orthopaedic Surgery, Korea University Anam Hospital, Seoul, South Korea
| | - Jong Woong Park
- Orthopaedic Oncology Clinic, National Cancer Center, Goyang-si, Gyeonggi-do, South Korea
| | - Yeong Kyoon Park
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Hwan Seong Cho
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Ilkyu Han
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Han-Soo Kim
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
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23
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Takeuchi A, Yamamoto N, Hayashi K, Matsubara H, Miwa S, Igarashi K, Tsuchiya H. Joint-preservation surgery for pediatric osteosarcoma of the knee joint. Cancer Metastasis Rev 2020; 38:709-722. [PMID: 31807972 DOI: 10.1007/s10555-019-09835-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The multi-disciplinary approach involving imaging, multi-agent chemotherapy, meticulous surgical procedures, and careful postoperative care has facilitated an increase in the use of limb-sparing surgery for pediatric osteosarcoma. Osteosarcoma usually occurs around the metaphysis of the distal femur or proximal tibia and needs wide excision with the adjacent joint and replacement by a megaprosthesis. The recent advancement in imaging modalities and surgical techniques supports joint-preservation surgery (JPS), involving the preservation of the adjacent epiphysis, for select patients following careful assessment of the tumor margins and precise tumor excision. An advantage of this surgery is that it maintains the adjacent joint and preserves the growth of the residual epiphysis, which provides excellent limb function. Various reconstruction options are available, including allograft, tumor-devitalized autograft, vascularized fibula graft, distraction osteogenesis, and custom-made implants. However, several complications are inevitable with these options, such as loosening, non-union at the host-graft junction, infection, fracture, implant loosening, breakage, deformity, limb-length discrepancy related to the reconstruction methods, or patient growth in pediatric osteosarcoma. Surgeons should fully understand the advantages and disadvantages of this procedure. In this review, we discuss the concept of JPS, types of reconstruction methods, and current treatment outcomes. It is our opinion that the further analysis by multi-institutional setting is necessary to clarify long-term outcomes and establish global guidelines on the indications and surgical procedure for JPS.
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Affiliation(s)
- Akihiko Takeuchi
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, 920-8641, Japan.
| | - Norio Yamamoto
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Katsuhiro Hayashi
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Hidenori Matsubara
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Shinji Miwa
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Kentaro Igarashi
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
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Shankhdhar VK, Yadav PS, Puri A, Kasat A, Dushyant J, Narayan Raghu RB, Gulia A. Free fibula flap for lower limb salvage after tumour resection. Indian J Plast Surg 2019; 51:274-282. [PMID: 30983726 PMCID: PMC6440356 DOI: 10.4103/ijps.ijps_113_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Context: Post-tumour resection lower limb salvage. Aim/Introduction: Resection of tumours of the femur and tibia around the knee and ankle joints results in large bony defects. Often arthrodesis is an alternative; in case, adequate functional motors cannot be preserved or due to economic constraints. Thus, in an immunocompromised patient, the vascularised fibula is the best form of reconstruction. The vascularised fibular flap (pedicled/free) can be used in combination with an allograft. We refer to such a combination reconstruction as ‘allocombo’. The vascularised fibular graft hypertrophies in due course of time, and till that period, the allograft provides the required mechanical strength to allow early ambulation. Subjects and Methods: A retrospective study of 24 cases of vascularised fibular graft for lower limb reconstruction was conducted from February 2003 to March 2014. The average defect size was 15.5 cm and the average length of fibula harvested was 24.35 cm. A total of 19 free fibular flaps and 5 pedicled fibula were done. Mean age was 26 years. Fibula was nestled in the allograft obtained from the tissue bank. Results: The mean follow-up time was 52 months. Free flap success rate was 96%. Successful healing was achieved at 45 ends (97.8%). Radiological evidence of union at osteotomy sites occurred at an average of 6.8 months. Eight patients eventually succumbed to disease. At the final follow-up, the mean Musculoskeletal Tumour Society functional score of the evaluable patients was 26 (range 20–30). Conclusions: Pedicled fibula is a good option if the defect is within 14 cm of the knee joint at the femoral end. The vessels have to curve around the fibular head, thus its removal improves the reach of the pedicle. The flap is easy to harvest with predictable vascular anatomy and it can provide a large amount of vascularised bone and skin paddle. It results in early ambulation, rehabilitation and reduced morbidity. We realised that fixation is easier and chances of vascular injury are less in free as compared to pedicled fibula.
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Affiliation(s)
| | | | - Ajay Puri
- Tata Memorial Centre, Mumbai, Maharastra, India
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Tan L, Xing Z, Ji T, Guo W. [Effectiveness of free vascularized fibular graft for bone defect after resection of lower limb malignant tumor]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:850-853. [PMID: 31298002 DOI: 10.7507/1002-1892.201810118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To analyze the effectiveness of free vascularized fibula grafts (FVFG) for extensive bone defects after resection of lower limb malignant bone tumors. Methods Between November 2015 and July 2018, 15 cases of lower limb malignant bone tumors were treated. There were 12 males and 3 females with an average age of 12.3 years (range, 9-21 years). There were 11 cases of osteosarcoma and 4 cases of Ewing's sarcoma. The tumor located at middle femur in 8 cases, lower femur in 4 cases, and middle tibia in 3 cases. The disease duration was 2-6 months (mean, 3.2 months). The tumor was completely removed, and the length of the bone defect was 8-23 cm (mean, 17.7 cm). The bone defect was repaired by FVFG, and combined inactivated tumor bone was used in 8 cases of femoral bone defect. Results The average operation time was 280 minutes (range, 180-390 minutes). The average blood loss was 310 mL (range, 200-480 mL). All incisions healed by first intention. All patients were followed up 2-24 months with an average of 14.5 months. Bone healing achieved in all patients at 9-18 months (mean, 12.3 months) after operation except 1 patient which was followed up only 2 months. The fibula grafts had active metabolism and the average bone metabolism score was 184 (range, 111-257) in effected side and 193 (range, 127-259) in contralateral side. There was no difference between bilateral sides. The average Enneking score was 24.6 (range, 20-30) at last follow-up. No ankle instability or paralysis of common peroneal nerve occurred. Conclusion FVFG appeared very efficient in repair of extensive bone defect after resection of lower limb malignant bone tumor.
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Affiliation(s)
- Lei Tan
- Department of Orthopedics, Peking University International Hospital, Beijing, 102206, P.R.China
| | - Zhili Xing
- Department of Orthopedics, Peking University International Hospital, Beijing, 102206,
| | - Tao Ji
- Department of Musculoskeletal Tumor, Peking University People's Hospital, Beijing, 100044, P.R.China
| | - Wei Guo
- Department of Musculoskeletal Tumor, Peking University People's Hospital, Beijing, 100044, P.R.China
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Chen H, Zhang J, Li X, Liu L, Zhang X, Ren D, Ma C, Zhang L, Fei Z, Xu T. Multi-level customized 3D printing for autogenous implants in skull tissue engineering. Biofabrication 2019; 11:045007. [DOI: 10.1088/1758-5090/ab1400] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Zhang C, Zeng B, Zhu K, Zhang L, Hu J. Limb salvage for malignant bone tumours of distal tibia with dual ipsilateral vascularized autogenous fibular graft in a trapezoid-shaped array with ankle arthrodesis and preserving subtalar joint. Foot Ankle Surg 2019; 25:278-285. [PMID: 29409179 DOI: 10.1016/j.fas.2017.11.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 11/15/2017] [Accepted: 11/29/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND The treatment of malignant tumours of the distal tibia is a challenging surgical problem due to the scarce soft tissue coverage and the instability of the ankle joint that often occurs after resection. However, there is no consensus on the ideal treatment for malignant tumours of the distal tibia. METHODS We report a new reconstruction for five patients with high-grade osteosarcoma of distal tibia, using dual ipsilateral vascularized autogenous fibular graft in a trapezoid-shaped array and external fixator, with ankle arthrodesis and preserving subtalar joints. The patients were examined clinically and radiographically. RESULTS The average follow-up duration was 88 months. The mean wound healing time was 14 days. Bone healing was achieved for all the five patients at an average time of 7 months. There were no complications of mal-union, skin necrosis, post-operative infection, loss of internal fixation, peroneal nerve injury. One patient had a local recurrence, which required amputation 15 months postoperatively. The remaining four patients were able to walk with an average functional score of 81.25% according to MSTS. CONCLUSIONS Our study shows that this technique is safe and effective to perform implantation of dual ipsilateral vascularized autogenous fibular graft in a trapezoid-shaped array and preserving subtalar joints in terms of the distal tibial reconstruction for malignant bone tumour of the distal tibia. This reconstruction represents a biological alternative protocol for limb salvage in cases of malignant bone tumour of the distal tibia, with encouraging results and with the advantages of lower complications and accelerating recovery. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Chunlin Zhang
- Department of Orthopaedic Surgery, Shanghai Tenth People's Hospital Affiliated To Tongji University, 301 YanChang Zhong Road, Shanghai 200072, China.
| | - Bingfang Zeng
- Department of Orthopaedics, The Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, 600 Yishan Road, Shanghai 200233, China
| | - Kunpeng Zhu
- Department of Orthopaedic Surgery, Shanghai Tenth People's Hospital Affiliated To Tongji University, 301 YanChang Zhong Road, Shanghai 200072, China
| | - Lei Zhang
- Department of Orthopaedic Surgery, Shanghai Tenth People's Hospital Affiliated To Tongji University, 301 YanChang Zhong Road, Shanghai 200072, China
| | - Jianping Hu
- Department of Orthopaedic Surgery, Shanghai Tenth People's Hospital Affiliated To Tongji University, 301 YanChang Zhong Road, Shanghai 200072, China
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Abstract
Various methods for reconstructing large femur bone defects after tumor resection have been introduced. In this study, we reviewed the clinical outcomes of using a 1-barrel free vascularized fibular graft (FVFG) protected by a lateral locking plate for large femoral defects not involving the knee joint.Between August 2007 and August 2013, we treated 7 patients with large femoral bone defects after tumor resection. The mean age of the patients was 19 years (range, 12-36 years), and 3 were women. All defects were free of infection before the procedure. Femoral bone defects were reconstructed using a 1-barrel FVFG protected by a lateral locking plate. The mean bone defect size was 10.5 cm (range, 6-16 cm). We reviewed clinical outcomes at the last follow-up.All patients survived beyond the last follow-up; the mean follow-up period was 54 months (range, 26-100 months). Two patients sustained stress fractures of the FVFG, but the lateral locking plate protected the fractured graft until in situ bone healing obtained. Mean time to bone union of both host-graft junctions was 24 months (range, 18-31 months). The mean Musculoskeletal Tumor Society score (%) was 85.8% (range, 80-95%).A 1-barrel FVFG protected by a lateral locking plate maintained a stable graft-host bone construct, successfully leading to bone healing, even in cases of stress fractures of the graft, and appears to be a good option for large femur bone defects.
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Zhang X, Zhang T, Liu T, Li Z, Zhang X. Lengthening of free fibular grafts for reconstruction of the residual leg length discrepancy. BMC Musculoskelet Disord 2019; 20:66. [PMID: 30736769 PMCID: PMC6368813 DOI: 10.1186/s12891-019-2445-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 01/30/2019] [Indexed: 12/02/2022] Open
Abstract
Background We evaluated our results of lengthening of free vascularized fibular grafts using a unilateral external fixator in patients with residual leg length discrepancy after free vascularized fibular graft for lower limb reconstruction. Cases presentation Two patients were administrated to our hospital with residual tibial length discrepancy after vascularized free fibular graft surgery. Lengthening of the free vascularized fibular graft with a unilateral external fixator was performed to correct the leg length discrepancy. Both patients recovered well with no difficult in activities of daily living at the last follow-up. Conclusions This study shows that lengthening of free vascularized fibular grafts with an external fixator is an effective treatment for massive residual leg shortening after vascularized free fibular graft surgery.
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Affiliation(s)
- Xianghong Zhang
- Department of Orthopedics, The Second Xiangya Hospital of Central South University, 139# Middle Renmin Road, Changsha, Hunan, 410011, People's Republic of China.,Department of Orthopedics, Liuzhou General Hospital, Guangxi University of Science and Technology, Liuzhou, 545006, Guangxi, China
| | - Tingting Zhang
- Department of Obstetrics and Gynecology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Tang Liu
- Department of Orthopedics, The Second Xiangya Hospital of Central South University, 139# Middle Renmin Road, Changsha, Hunan, 410011, People's Republic of China.
| | - Zhihong Li
- Department of Orthopedics, The Second Xiangya Hospital of Central South University, 139# Middle Renmin Road, Changsha, Hunan, 410011, People's Republic of China
| | - Xiangsheng Zhang
- Department of Orthopedics, The Second Xiangya Hospital of Central South University, 139# Middle Renmin Road, Changsha, Hunan, 410011, People's Republic of China
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Kontogeorgakos VA, Eward WC, Brigman BE. Microsurgery in musculoskeletal oncology. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 29:271-278. [PMID: 30623252 DOI: 10.1007/s00590-019-02373-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 01/04/2019] [Indexed: 12/22/2022]
Abstract
Sarcomas are rare mesenchymal bone and soft tissue tumors of the musculoskeletal system. In the past, the primary treatment modality was amputation of the involved limb and the 5-year survival was very low for high-grade tumors. During the last three decades, limb salvage has become the rule rather than the exception and the use of neoadjuvant and adjuvant therapies (radiation and chemotherapy) has dramatically increased disease-free survival. Reconstruction of large bone and soft tissue defects, though, still remains a significant challenge in sarcoma patients. In particular, vascularized tissue transfer has proved extremely helpful in dealing with complex bone and soft tissue or functional defects that are frequently encountered as a result of the tumor or as a complication of surgery and adjuvant therapies. The principles, indications and results of microsurgical reconstruction differ from trauma patients and are directly related not only to the underlying disease process, but also to the local and systemic therapeutic modalities applied to the individual patient. Although plastic reconstruction in the oncological patients is not free of complications, usually these complications are manageable and do not jeopardize oncological outcome. The overall treatment strategy should be tailored to the patient's and sarcoma profile.
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Affiliation(s)
- Vasileios A Kontogeorgakos
- Department of Orthopaedics, National and Kapodistrian University of Athens, Rimini 1, Xaidari, Athens, Greece.
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Wiratnaya IGE. Wide margin excision followed by tibialisation of fibula and ankle arthrodesis as novel surgical technique in giant cell tumor patient. J Clin Orthop Trauma 2019; 10:1004-1007. [PMID: 31528085 PMCID: PMC6739288 DOI: 10.1016/j.jcot.2018.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 05/17/2018] [Indexed: 10/16/2022] Open
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Luo S, Jiang T, Yang X, Yang Y, Zhao J. Treatment of tumor-like lesions in the femoral neck using free nonvascularized fibular autografts in pediatric patients before epiphyseal closure. J Int Med Res 2018; 47:823-835. [PMID: 30556444 PMCID: PMC6381492 DOI: 10.1177/0300060518813510] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Objectives Surgical resection of benign bone tumors and tumor-like lesions at the
femoral neck presents a difficult reconstructive challenge. However, the
safety and efficacy of free nonvascularized fibular autografts (FNFAs) in
the treatment of femoral neck tumor-like lesions before epiphyseal closure
in young patients remain unknown. Methods Sixteen pediatric patients who had not yet undergone epiphyseal closure were
treated with FNFAs after resection of tumor-like lesions in the femoral neck
from August 2012 to September 2016. All patients underwent supplementary
skeletal traction through the supracondylar femur for 4 to 6 weeks after
resection. Demographic data were recorded and clinical and radiological
outcomes were evaluated during the follow-up. Results All patients could walk with partial weight bearing 4 weeks postoperative,
and full weight bearing was permitted after a mean of 8 weeks. Graft union
was attained in all 16 patients at a mean of 2 months. The donor site of the
fibular cortical strut showed good regeneration in all patients. The Harris
hip score significantly improved from 65% to 95%. Conclusions Application of an FNFA is a feasible method in the treatment of tumor-like
lesions in the femoral neck before epiphyseal closure in pediatric
patients. Level of Evidence Level IV.
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Affiliation(s)
- Shanchao Luo
- Yulin Orthopedics Hospital of Chinese and Western Medicine,
Yulin, China
- Postdoctoral Innovation Practice Base, The Ninth Affiliated
Hospital of Guangxi Medical University, Beihai, China
- Guangxi Engineering Center in Biomedical Materials for Tissue
and Organ Regeneration & Guangxi Collaborative Innovation Center for
Biomedicine, Life Sciences Institute, Guangxi Medical University, Nanning,
China
- *These authors contributed equally to this
work
| | - Tongmeng Jiang
- Guangxi Engineering Center in Biomedical Materials for Tissue
and Organ Regeneration & Guangxi Collaborative Innovation Center for
Biomedicine, Life Sciences Institute, Guangxi Medical University, Nanning,
China
- Department of Orthopaedics & Guangxi Key Laboratory of
Regenerative Medicine, International Joint Laboratory on Regeneration of Bone
and Soft Tissue, The First Affiliated Hospital of Guangxi Medical University,
Nanning, China
- School of Materials Science and Engineering, Zhejiang
University, Hangzhou, China
- *These authors contributed equally to this
work
| | - Xiaoping Yang
- Yulin Orthopedics Hospital of Chinese and Western Medicine,
Yulin, China
| | - Yingnian Yang
- Yulin Orthopedics Hospital of Chinese and Western Medicine,
Yulin, China
| | - Jinmin Zhao
- Postdoctoral Innovation Practice Base, The Ninth Affiliated
Hospital of Guangxi Medical University, Beihai, China
- Guangxi Engineering Center in Biomedical Materials for Tissue
and Organ Regeneration & Guangxi Collaborative Innovation Center for
Biomedicine, Life Sciences Institute, Guangxi Medical University, Nanning,
China
- Department of Orthopaedics & Guangxi Key Laboratory of
Regenerative Medicine, International Joint Laboratory on Regeneration of Bone
and Soft Tissue, The First Affiliated Hospital of Guangxi Medical University,
Nanning, China
- Jinmin Zhao, Department of Orthopaedics
& Guangxi Key Laboratory of Regenerative Medicine, International Joint
Laboratory on Regeneration of Bone and Soft Tissue, The First Affiliated
Hospital of Guangxi Medical University, Shuangyong Road #22, Nanning 530021,
China.
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McEwan JK, Tribe HC, Jacobs N, Hancock N, Qureshi AA, Dunlop DG, Oreffo RO. Regenerative medicine in lower limb reconstruction. Regen Med 2018; 13:477-490. [PMID: 29985779 DOI: 10.2217/rme-2018-0011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Bone is a highly specialized connective tissue and has a rare quality as one of the few tissues that can repair without a scar to regain pre-injury structure and function. Despite the excellent healing capacity of bone, tumor, infection, trauma and surgery can lead to significant bone loss requiring skeletal augmentation. Bone loss in the lower limb poses a complex clinical problem, requiring reconstructive techniques to restore form and function. In the past, amputation may have been the only option; however, there is now an array of reconstructive possibilities and cellular therapies available to salvage a limb. In this review, we will evaluate current applications of bone tissue engineering techniques in limb reconstruction and identify potential strategies for future work.
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Affiliation(s)
- Josephine K McEwan
- Bone & Joint Research Group, Centre for Human Development, Stem Cell & Regeneration, Institute of Developmental Sciences, University of Southampton, Tremona Road, Southampton SO16 6YD, UK
| | - Howard C Tribe
- Bone & Joint Research Group, Centre for Human Development, Stem Cell & Regeneration, Institute of Developmental Sciences, University of Southampton, Tremona Road, Southampton SO16 6YD, UK
| | - Neal Jacobs
- Salisbury NHS Foundation Trust, Salisbury, Wiltshire, UK
| | - Nicholas Hancock
- Trauma & Orthopaedic Department, University Hospital Southampton, Southampton, UK
| | - Amir A Qureshi
- Trauma & Orthopaedic Department, University Hospital Southampton, Southampton, UK
| | - Douglas G Dunlop
- Trauma & Orthopaedic Department, University Hospital Southampton, Southampton, UK
| | - Richard Oc Oreffo
- Bone & Joint Research Group, Centre for Human Development, Stem Cell & Regeneration, Institute of Developmental Sciences, University of Southampton, Tremona Road, Southampton SO16 6YD, UK
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Abstract
The use of fibular graft for the reconstruction of bone defects has been demonstrated to be a reliable method. The aim of this study was to assess the clinical outcome of graft union, functional outcome (hypertrophy of the graft bones) and complications of both non-vascularized and vascularized grafts.From 1981 to 2015, 10 patients were treated using non-vascularized fibular graft or free vascularized fibular graft. The outcomes were bony union time, graft hypertrophy and complications based on radiograph and functional outcomes according to the Musculoskeletal Tumor Society (MSTS) score. Mobility of the ankle at the donor site was evaluated using the Kofoed ankle score system.This study included 10 patients with an average follow-up of 6.8 years. The union rate for all patients was 100%. The mean union time was 21.3 weeks for vascularized fibular grafts and 30.5 weeks for non-vascularized fibular grafts (P = .310). There was a significant difference between the upper limbs and the lower limbs regarding hypertrophy of the grafts in 5 patients (P = .003). The mean MSTS score in 10 patients was 84% (range 53%-97%). Stress fracture of the graft occurred in 1 patient. Donor site complications, including valgus deformity and length discrepancy, between 2 legs occurred in 2 patients who were under 18 years of age at the time of operation (P = .114). The mean Kofoed score was 96.8 (range 88-100).A greater increase in hypertrophy of grafts was observed with reconstruction in the lower limbs. There was no difference in MSTS score between these 2 types of grafts. Children were more likely to experience the valgus deformity at the donor site after harvesting the fibula. Keeping at least the distal 1/4 of the fibula intact during the surgery is a valid means of ensuring ankle stability at the donor site, and children should be considered for prophylactic distal tibiofibular synostosis creation to prevent the valgus deformity of the ankle at the donor site.
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Affiliation(s)
- Siyi Liu
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuchang District, Wuhan City
| | - Shengxiang Tao
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuchang District, Wuhan City
| | - Jinhai Tan
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuchang District, Wuhan City
| | - Xiang Hu
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuchang District, Wuhan City
| | - Huiyi Liu
- Department of Surgery, 3rd Hospital of Ezhou, Ezhou city, Hubei Province, China
| | - Zonghuan Li
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuchang District, Wuhan City
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Campanacci DA, Totti F, Puccini S, Beltrami G, Scoccianti G, Delcroix L, Innocenti M, Capanna R. Intercalary reconstruction of femur after tumour resection: is a vascularized fibular autograft plus allograft a long-lasting solution? Bone Joint J 2018; 100-B:378-386. [PMID: 29589494 DOI: 10.1302/0301-620x.100b3.bjj-2017-0283.r2] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims After intercalary resection of a bone tumour from the femur, reconstruction with a vascularized fibular graft (VFG) and massive allograft is considered a reliable method of treatment. However, little is known about the long-term outcome of this procedure. The aims of this study were to determine whether the morbidity of this procedure was comparable to that of other reconstructive techniques, if it was possible to achieve a satisfactory functional result, and whether biological reconstruction with a VFG and massive allograft could achieve a durable, long-lasting reconstruction. Patients and Methods A total of 23 patients with a mean age of 16 years (five to 40) who had undergone resection of an intercalary bone tumour of the femur and reconstruction with a VFG and allograft were reviewed clinically and radiologically. The mean follow-up was 141 months (24 to 313). The mean length of the fibular graft was 18 cm (12 to 29). Full weight-bearing without a brace was allowed after a mean of 13 months (seven to 26). Results At final follow-up, the mean Musculoskeletal Tumor Society Score of 22 evaluable patients was 94% (73 to 100). Eight major complications, five fractures (21.7%), and three nonunions (13%) were seen in seven patients (30.4%). Revision-free survival was 72.3% at five, ten, and 15 years, with fracture and nonunion needing surgery as failure endpoints. Overall survival, with removal of allograft or amputation as failure endpoints, was 94.4% at five, ten, and 15 years. Discussion There were no complications needing surgical revision after five years had elapsed from surgery, suggesting that the mechanical strength of the implant improves with time, thereby decreasing the risk of complications. In young patients with an intercalary bone tumour of the femur, combining a VFG and massive allograft may result in a reconstruction that lasts a lifetime. Cite this article: Bone Joint J 2018;100-B:378-86.
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Affiliation(s)
- D A Campanacci
- Department of Orthopaedic Oncology and Reconstructive Surgery, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - F Totti
- Department of Orthopaedic Oncology and Reconstructive Surgery, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - S Puccini
- Department of Orthopaedic Oncology and Reconstructive Surgery, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - G Beltrami
- Department of Paediatric Orthopaedic Oncology, Azienda Ospedaliera Universitaria Careggi
| | - G Scoccianti
- Department of Orthopaedic Oncology and Reconstructive Surgery, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - L Delcroix
- Department of Plastic Surgery and Microsurgery, Azienda Ospedaliera Universitaria Careggi
| | - M Innocenti
- Department of Plastic Surgery and Microsurgery, Azienda Ospedaliera Universitaria Careggi
| | - R Capanna
- Department of Orthopaedic and Trauma Surgery, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
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Stevenson JD, Doxey R, Abudu A, Parry M, Evans S, Peart F, Jeys L. Vascularized fibular epiphyseal transfer for proximal humeral reconstruction in children with a primary sarcoma of bone. Bone Joint J 2018; 100-B:535-541. [DOI: 10.1302/0301-620x.100b4.bjj-2017-0830.r1] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Aims Preserving growth following limb-salvage surgery of the upper limb in children remains a challenge. Vascularized autografts may provide rapid biological incorporation with the potential for growth and longevity. In this study, we aimed to describe the outcomes following proximal humeral reconstruction with a vascularized fibular epiphyseal transfer in children with a primary sarcoma of bone. We also aimed to quantify the hypertrophy of the graft and the annual growth, and to determine the functional outcomes of the neoglenofibular joint. Patients and Methods We retrospectively analyzed 11 patients who underwent this procedure for a primary bone tumour of the proximal humerus between 2004 and 2015. Six had Ewing’s sarcoma and five had osteosarcoma. Their mean age at the time of surgery was five years (two to eight). The mean follow-up was 5.2 years (1 to 12.2). Results The overall survival at five and ten years was 91% (confidence interval (CI) 95% 75% to 100%). At the time of the final review, ten patients were alive. One with local recurrence and metastasis died one-year post-operatively. Complications included seven fractures, four transient nerve palsies, and two patients developed avascular necrosis of the graft. All the fractures presented within the first postoperative year and united with conservative management. One patient had two further operations for a slipped fibular epiphysis of the autograft, and a hemi-epiphysiodesis for lateral tibial physeal arrest. Hypertrophy and axial growth were evident in nine patients who did not have avascular necrosis of the graft. The mean hypertrophy index was 65% (55% to 82%), and the mean growth was 4.6 mm per annum (2.4 to 7.6) in these nine grafts. At final follow-up, the mean modified functional Musculoskeletal Tumour Society score was 77% (63% to 83%) and the mean Toronto Extremity Salvage Score (TESS) was 84% (65% to 94%). Conclusion Vascularized fibular epiphyseal transfer preserves function and growth in young children following excision of the proximal humerus for a malignant bone tumour. Function compares favourably to other limb-salvage procedures in children. Longer term analysis is required to determine if this technique proves to be durable into adulthood. Cite this article: Bone Joint J 2018;100-B:535–41.
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Affiliation(s)
- J. D. Stevenson
- Royal Orthopaedic Hospital, The Woodlands,
Birmingham, Aston University Medical School, Aston
Express Way, Birmingham, B4
7ET, UK
| | - R. Doxey
- University of Birmingham Medical School, Birmingham, UK
| | - A. Abudu
- Royal Orthopaedic Hospital, The
Woodlands, Bristol Road South, Birmingham
B31 2AP, UK
| | - M. Parry
- Royal Orthopaedic Hospital, The Woodlands,
Birmingham, Aston University Medical School, Aston
Express Way, Birmingham, B4
7ET, UK
| | - S. Evans
- Royal Orthopaedic Hospital, The
Woodlands, Bristol Road South, Birmingham
B31 2AP, UK
| | - F. Peart
- Royal Orthopaedic Hospital, The
Woodlands, Bristol Road South, Birmingham
B31 2AP, UK
| | - L. Jeys
- Royal Orthopaedic Hospital, The Woodlands,
Bristol Road South, Birmingham, University
of Aston, Aston Expressway, Birmingham, B4
7ET, UK
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Landau MJ, Badash I, Yin C, Alluri RK, Patel KM. Free vascularized fibula grafting in the operative treatment of malignant bone tumors of the upper extremity: A systematic review of outcomes and complications. J Surg Oncol 2018. [PMID: 29513891 DOI: 10.1002/jso.25032] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVES Vascularized bone grafting after tumor resection can be an important component in the treatment of bony neoplasms of the upper extremity. The purpose of this study was to determine the outcomes of free vascularized fibula grafting (FVFG) in the treatment of upper extremity sarcomas. METHODS A systematic review of the literature of FVFG used in the treatment of upper extremity sarcomas was performed. RESULTS A total of 56 studies were included in final analysis. The most common diagnosis was osteosarcoma (35.1%) and the most common recipient site was the humerus (57.3%). FVFG had a median union rate of 93.3%, with the median time to union being 5.0 months. The most common complications were fracture (11.7%), nerve injury (7.5%), infection (5.7%), and hammer toe deformity (3.3%). The reoperation rate was 34.5%. The most commonly reported standardized assessment of clinical outcomes following treatment was the Musculoskeletal Tumor Society Score, which had a median of 80% postoperatively. CONCLUSIONS FVFG in the treatment of malignant bony neoplasms of the upper extremity has a high rate of union and good overall outcomes; however, postoperative complication rates are high. A greater degree of standardization is needed in the reporting of patient-centered outcomes to facilitate future comparative studies.
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Affiliation(s)
- Mark J Landau
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, Los Angeles, California
| | - Ido Badash
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, Los Angeles, California
| | - Christine Yin
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, Los Angeles, California
| | - Ram K Alluri
- Department of Orthopedic Surgery, Keck Medical Center of the University of Southern California, Los Angeles, California
| | - Ketan M Patel
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, Los Angeles, California
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Santanelli di Pompeo F, Selvaggi G, Longo B, Laporta R, Amorosi V, Sorotos M. Double-barrel vascularized dual fibula transfer with epiphyseal growth plate for hip reconstruction: A case report. Microsurgery 2018; 38:572-575. [PMID: 29418008 DOI: 10.1002/micr.30303] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 01/21/2018] [Accepted: 01/24/2018] [Indexed: 11/06/2022]
Abstract
We present a case report of a 10-year-old girl diagnosed with Ewing sarcoma treated with intra-articular wide resection of the right femur and reconstruction with a series-connected double-barrel bilateral vascularized fibula graft (db-BVFG), including fibular head for articulation with the acetabulum of the pelvic bone and preservation of the epiphyseal growth plates for eventual limb growth. No postoperative complications were observed and bone union was achieved with fibular graft hypertrophy, allowing for full weight bearing. Neither local recurrence nor metastasis was observed at 17-year follow-up. Range of motion degrees at last follow up: hip flexion 90 degree, extension 12 degree, abduction 31 degree, rotation 25 degree. Right versus left limb discrepancy was 60 mm. Db-BVFG may be an option for reconstruction of long femoral defects and hip joint restoration following tumor resection and inclusion of epiphysis within the graft is a viable option in pediatric patients to restore longitudinal growth of the reconstructed long bone.
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Affiliation(s)
- Fabio Santanelli di Pompeo
- Plastic Surgery Department, Sant'Andrea Hospital, School of Medicine and Psychology, "Sapienza" University of Rome, Rome, Italy
| | - Gennaro Selvaggi
- Department of Plastic and Reconstructive Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Benedetto Longo
- Plastic Surgery Department, Sant'Andrea Hospital, School of Medicine and Psychology, "Sapienza" University of Rome, Rome, Italy
| | - Rosaria Laporta
- Plastic Surgery Department, Sant'Andrea Hospital, School of Medicine and Psychology, "Sapienza" University of Rome, Rome, Italy
| | - Vittoria Amorosi
- Plastic Surgery Department, Sant'Andrea Hospital, School of Medicine and Psychology, "Sapienza" University of Rome, Rome, Italy
| | - Michail Sorotos
- Plastic Surgery Department, Sant'Andrea Hospital, School of Medicine and Psychology, "Sapienza" University of Rome, Rome, Italy
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Treatment of critical-sized bone defects: clinical and tissue engineering perspectives. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 28:351-362. [PMID: 29080923 DOI: 10.1007/s00590-017-2063-0] [Citation(s) in RCA: 220] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 10/08/2017] [Indexed: 12/11/2022]
Abstract
Critical-sized bone defects are defined as those that will not heal spontaneously within a patient's lifetime. Current treatment options include vascularized bone grafts, distraction osteogenesis, and the induced membrane technique. The induced membrane technique is an increasingly utilized method with favorable results including high rates of union. Tissue engineering holds promise in the treatment of large bone defects due to advancement of stem cell biology, novel biomaterials, and 3D bioprinting. In this review, we provide an overview of the current operative treatment strategies of critical-sized bone defects as well as the current state of tissue engineering for such defects.
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San-Julian M, Vazquez-Garcia B. Biological Reconstruction in Bone Sarcomas: Lessons from Three Decades of Experience. Orthop Surg 2017; 8:111-21. [PMID: 27384719 DOI: 10.1111/os.12243] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 02/13/2016] [Indexed: 11/29/2022] Open
Affiliation(s)
- Mikel San-Julian
- Orthopaedic Surgery and Traumatology Unit, Clinica University of Navarra, Pamplona, Spain
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Parag S, Yogesh P, Rathod J, Nikhil P, Amit J. Limb salvage with microvascular free fibula following primary bone sarcoma resection. Indian J Plast Surg 2017; 49:370-377. [PMID: 28216818 PMCID: PMC5288913 DOI: 10.4103/0970-0358.197244] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: Extremity sarcomas are challenging to manage. Total eradication of tumour has to be balanced with restoration of limb function to prevent mortality and morbidity. Disease-free survival with maximum limb function is the ultimate goal in these patients. Materials and Methods: We present a series of ten cases of extremity malignancies, where limb salvage was attempted with microvascular free fibula for limb reconstruction from the period of 2008 to 2015. Results: Of the ten cases in the study, there were two females and eight males. There were nine patients with lower limb malignancies and one patient with upper limb malignancy. There were four patients with Ewing's sarcoma of femur, five patients with osteosarcoma of femur and one patient with chondrosarcoma of the humerus. The follow-up period ranged from 1.2 to 6.2 years with mean follow-up of 3.1 years. There were two deaths during follow-up, both were due to distant metastasis. The assessment of the function was done on the basis of Musculoskeletal Tumour Society functional score. Maximum score was 30 and minimum score was 24, the average score being 26. Of the eight surviving patients, three patients had full weightbearing, four patients had partial weightbearing at end of 2 years and one patient of upper limb reconstruction had complete upper limb function. None of the patients had to undergo limb amputation. Conclusion: Limb salvage with vascularised fibula graft offers good functional outcome along with good disease-free survival rates.
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Affiliation(s)
- Sahasrabudhe Parag
- Department of Plastic Surgery, B.J. Government Medical College and Sassoon General Hospitals, Pune, Maharashtra, India
| | - Panchwagh Yogesh
- Department of Plastic Surgery, Deenanath Hospital, Pune, Maharashtra, India
| | - Jesal Rathod
- Department of Plastic Surgery, Deenanath Hospital, Pune, Maharashtra, India
| | - Panse Nikhil
- Department of Plastic Surgery, B.J. Government Medical College and Sassoon General Hospitals, Pune, Maharashtra, India
| | - Jadhav Amit
- Department of Plastic Surgery, Deenanath Hospital, Pune, Maharashtra, India
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Complications and Long-Term Outcomes of Free Fibula Reconstruction following Resection of a Malignant Tumor in the Extremities. Plast Reconstr Surg 2017; 139:510e-519e. [DOI: 10.1097/prs.0000000000003004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Jiang Y, Guo YF, Meng YK, Zhu L, Chen AM. A report of a novel technique: The comprehensive fibular autograft with double metal locking plate fixation (cFALP) for refractory post-operative diaphyseal femur fracture non-union treatment. Injury 2016; 47:2307-2311. [PMID: 27469400 DOI: 10.1016/j.injury.2016.07.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 07/06/2016] [Accepted: 07/19/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The refractory post-operative diaphyseal femur fracture (DFF) non-union is extremely difficult to treat and remains severe challenges for orthopedists. Although several traditional internal fixations and novel biomedical techniques have been used in managing this complication, its treatment is still fraught with severe challenges. PATIENTS AND METHODS Starting from 1999, 5 patients after three previous internal fixation operations showing refractory DFF non-union underwent the comprehensive fibular autograft with double metal locking plates fixation (cFALP) surgery. The autogenous fibular was first harvested and non-evenly split into two halves in a longitudinal manner. After retracting all previous internal fixation(s), the larger half strut fibula was hammered into the femur canal while the smaller half was fragmented into small pieces and filled surrounding the DFF site. Two locking compression plate were fixed on the lateral and anterior (or antero-lateral) side of the femur, respectively. RESULTS The follow-up ranged from 60 to 96 weeks. All cases (100%) achieved bony union without severe complications. The mean time to union was 36±14.7 weeks (range 24-60 weeks). CONCLUSION The cFALP is a promising surgical modality for DFF non-union treatment. However, because fibular harvest may cause severe complications, the cFLAP should only be considered in refractory DFF non-union cases.
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Affiliation(s)
- Ying Jiang
- Department of Medicine, New Jersey Medical School Affiliated to Rutgers University, Newark, NJ 07103, United States; Department of Neurosurgery, Shanghai Chang Zheng Hospital Affiliated to China Second Military Medical University, 415 Feng Yang Rd., 200003, Shanghai, PR China.
| | - Yong-Fei Guo
- Department of Orthopedic, Shanghai Chang Zheng Hospital Affiliated to China Second Military Medical University, 415 Feng Yang Rd., 200003, Shanghai, PR China.
| | - Ya-Ke Meng
- Department of Orthopedic, Shanghai Chang Zheng Hospital Affiliated to China Second Military Medical University, 415 Feng Yang Rd., 200003, Shanghai, PR China.
| | - Lei Zhu
- Department of Orthopedic, Shanghai Chang Zheng Hospital Affiliated to China Second Military Medical University, 415 Feng Yang Rd., 200003, Shanghai, PR China.
| | - Ai-Ming Chen
- Department of Orthopedic, Shanghai Chang Zheng Hospital Affiliated to China Second Military Medical University, 415 Feng Yang Rd., 200003, Shanghai, PR China.
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Qi Y, Sun HT, Fan YG, Li FM, Lin ZS. Do stress fractures induce hypertrophy of the grafted fibula? A report of three cases received free vascularized fibular graft treatment for tibial defects. Chin J Traumatol 2016; 19:179-81. [PMID: 27321302 PMCID: PMC4908233 DOI: 10.1016/j.cjtee.2016.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The presence of large segmental defects of the diaphyseal bone is challenging for orthopedic surgeons. Free vascularized fibular grafting (FVFG) is considered to be a reliable reconstructive procedure. Stress fractures are a common complication following this surgery, and hypertrophy is the main physiological change of the grafted fibula. The exact mechanism of hypertrophy is not completely known. To the best of our knowledge, no studies have examined the possible relationship between stress fractures and hypertrophy. We herein report three cases of patients underwent FVFG. Two of them developed stress fractures and significant hypertrophy, while the remaining patient developed neither stress fractures nor significant hypertrophy. This phenomenon indicates that a relationship may exist between stress fractures and hypertrophy of the grafted fibula, specifically, that the presence of a stress fracture may initiate the process of hypertrophy.
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Affiliation(s)
- Yong Qi
- Department of Orthopaedics, Guangdong Second People's Hospital, Guangzhou 510317, China,Guangzhou University of Traditional Chinese Medicine, Guangzhou 510405, China,Corresponding author. Department of Orthopaedics, Guangdong Second People’s Hospital, Guangzhou 510317, China.Department of OrthopaedicsGuangdong Second People’s HospitalGuangzhou510317China
| | - Hong-Tao Sun
- Department of Orthopaedics, Guangdong Second People's Hospital, Guangzhou 510317, China
| | - Yue-Guang Fan
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou 510405, China
| | - Fei-Meng Li
- Department of Orthopaedics, Guangdong Second People's Hospital, Guangzhou 510317, China
| | - Zhou-Sheng Lin
- Department of Orthopaedics, Guangdong Second People's Hospital, Guangzhou 510317, China
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46
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Hara H, Kawamoto T, Onishi Y, Fujioka H, Nishida K, Kuroda R, Kurosaka M, Akisue T. Reconstruction of the Midfoot Using a Free Vascularized Fibular Graft After En Bloc Excision for Giant Cell Tumor of the Tarsal Bones: A Case Report. J Foot Ankle Surg 2015. [PMID: 26213165 DOI: 10.1053/j.jfas.2015.04.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We report the case of a 32-year-old Japanese female with a giant cell tumor of bone involving multiple midfoot bones. Giant cell tumors of bone account for approximately 5% of all primary bone tumors and most often arise at the ends of long bones. The small bones, such as those of the hands and feet, are rare sites for giant cell tumors. Giant cell tumors of the small bones tend to exhibit more aggressive clinical behavior than those of the long bones. The present patient underwent en bloc tumor excision involving multiple tarsals and metatarsals. We reconstructed the longitudinal arch of the foot with a free vascularized fibular graft. At the 2-year follow-up visit, bony union had been achieved, with no tumor recurrence.
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Affiliation(s)
- Hitomi Hara
- Research Associate, Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan.
| | - Teruya Kawamoto
- Research Associate, Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yasuo Onishi
- Orthopedist, Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroyuki Fujioka
- Professor, Hyogo University of Health Sciences School of Rehabilitation, Kobe, Japan
| | - Kotaro Nishida
- Lecturer, Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ryosuke Kuroda
- Associate Professor, Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masahiro Kurosaka
- Professor, Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Toshihiro Akisue
- Professor, Department of Rehabilitation Science, Kobe University Graduate School of Medicine, Kobe, Japan
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Ma L, Zhou Y, Zhang Y, Zhou X, Yao Z, Huang W, Qiao G, Xia H. Biomechanical evaluation with finite element analysis of the reconstruction of femoral tumor defects by using a double-barrel free vascularized fibular graft combined with a locking plate. Int J Clin Exp Med 2014; 7:2425-2434. [PMID: 25356094 PMCID: PMC4211744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 07/27/2014] [Indexed: 06/04/2023]
Abstract
The repair of large distal femoral tumor defects can be challenging for orthopedic surgeons. The combination of a double-barrel free vascularized fibular graft (DFVFG) with a locking plate is a viable option. However, the biomechanical influence of the fibular bone length on the locking plate attachment is unclear. We aimed to evaluate the stability of the distal femoral defect after reconstruction with fibular grafts of different lengths. A three-dimensional model of a healthy volunteer was developed using computed tomography images. A locking plate and bicortical screws were constructed and registered with CAD. Four models were defined (6 cm, 8 cm, 10 cm, and 12 cm bone grafts). The models were imported into finite element analysis software. Boundary-constrained and load conditions were applied. The model stress distribution and displacement were statistically analyzed. The Von Mises stress distributions were similar between the 6 cm, 8 cm, and 10 cm bone grafts and locking plate within each of those bone defect models (P > 0.05), while the Von Mises stress distribution was significantly higher in the 12 cm model than the other 3 lengths for both the bone graft and locking plate (P < 0.05). Significantly greater Von Mises stress was observed at the 12 cm bone graft and locking plate than with the shorter bone grafts. Therefore, we recommend that, to avoid complications, the bone graft should not exceed 12 cm when using FVFG in combination with a locking plate while treating a distal femoral tumor defect.
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Affiliation(s)
- Limin Ma
- Hospital of Orthopedics, Guangzhou General Hospital of Guangzhou Military Command111 Liuhua Road, Guangzhou 510010, China
| | - Ye Zhou
- Department of Medical Research, General Hospital of Guangzhou Military CommandChina
| | - Yu Zhang
- Hospital of Orthopedics, Guangzhou General Hospital of Guangzhou Military Command111 Liuhua Road, Guangzhou 510010, China
| | - Xia Zhou
- Department of Medical Research, General Hospital of Guangzhou Military CommandChina
| | - Zilong Yao
- Hospital of Orthopedics, Guangzhou General Hospital of Guangzhou Military Command111 Liuhua Road, Guangzhou 510010, China
| | - Wenhan Huang
- Hospital of Orthopedics, Guangzhou General Hospital of Guangzhou Military Command111 Liuhua Road, Guangzhou 510010, China
| | - Guoqing Qiao
- Department of Radiology, General Hospital of Guangzhou Military CommandChina
| | - Hong Xia
- Hospital of Orthopedics, Guangzhou General Hospital of Guangzhou Military Command111 Liuhua Road, Guangzhou 510010, China
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Noailles T, Tanaka C, Lintz F, Collon S, Bargoin K, Gouin F. Acetabular reconstruction using a free fibular autograft in total hip arthroplasty revisions. INTERNATIONAL ORTHOPAEDICS 2014; 38:2447-53. [PMID: 25038971 DOI: 10.1007/s00264-014-2439-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 05/25/2014] [Indexed: 11/26/2022]
Abstract
PURPOSE Acetabular reconstruction for segmentary bone loss aims for primary stability and long-lasting integration. The use of a fibular autograft has been described after tumour resection and in traumatology. The hypothesis of this study is that it offers a mechanically reliable solution with good functional results and acceptable morbidity. METHODS This is a two center retrospective study of 26 operated hips. Indication was mechanical loosening in every case. The operative technique included fibular grafting of a segmental bone loss associated with an acetabular metal reinforcement. RESULTS Mean follow up was 88 months (three to 165). The PMA score increased from 8.5 (five to 12) to 15 (six to 18) (p <0.001). Acetabular migration was 2 mm (0-4) vertically and 1 mm (0-2) medially. Three graft failures were observed. No major morbidity was observed. CONCLUSION Fibular autograft after mechanical loosening and segmentary bone loss in total hip arthroplasty revisions offers a mechanically reliable solution for acetabular reconstruction. The results seem to be at least equivalent to other techniques.
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Bumbasirevic M, Stevanovic M, Bumbasirevic V, Lesic A, Atkinson HDE. Free vascularised fibular grafts in orthopaedics. INTERNATIONAL ORTHOPAEDICS 2014; 38:1277-82. [PMID: 24562850 DOI: 10.1007/s00264-014-2281-6] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 01/09/2014] [Indexed: 12/14/2022]
Abstract
Bony defects caused by trauma, tumors, infection or congenital anomalies can present a significant surgical challenge. Free vascularised fibular bone grafts (FVFGs) have proven to be extremely effective in managing larger defects (longer than 6 cm) where other conventional grafts have failed. FVFGs also have a role in the treatment of avascular necrosis (AVN) of the femoral head, failed spinal fusions and complex arthrodeses. Due to the fact that they have their own blood supply, FVFGs are effective even in cases where there is poor vascularity at the recipient site, such as in infection and following radiotherapy. This article discusses the versatility of the FVFG and its successful application to a variety of different pathologies. It also covers the applied anatomy, indications, operative techniques, complications and donor-site morbidity. Though technically challenging and demanding, the FVFG is an extremely useful salvage option and can facilitate limb reconstruction in the most complex of cases.
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Affiliation(s)
- Marko Bumbasirevic
- School of Medicine, Clinic of Orthopaedic Surgery and Traumatology, Clinical Centre, University of Belgrade, Visegradska 26, 11000, Belgrade, Serbia,
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Campanacci DA, Puccini S, Caff G, Beltrami G, Piccioli A, Innocenti M, Capanna R. Vascularised fibular grafts as a salvage procedure in failed intercalary reconstructions after bone tumour resection of the femur. Injury 2014; 45:399-404. [PMID: 24183391 DOI: 10.1016/j.injury.2013.10.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2013] [Indexed: 02/02/2023]
Abstract
Vascularised fibular grafts (VFGs) are widely used for primary reconstruction of long bones after bone tumour resections. The biological properties of VFGs are such that they can be a useful option even in failed intercalary reconstructions. The purpose of the current study was to investigate the results and the morbidity of VFGs as a salvage procedure in failed previous reconstructions after intercalary bone tumour resection of the femur. Our series included 12 patients, treated from April 1989 to March 2005, with an average age of 23 years (range 10-43 years) at presentation. The initial diagnosis was osteosarcoma in 10 cases and Ewing's sarcoma in two cases. All patients received chemotherapy and none received radiation therapy. Seven patients received VFG as biologic augmentation in intercalary allograft non-union and in the other five patients, a combination of allograft and VFG was used to replace a cement spacer with hardware failure (four patients) and a failed intercalary prosthesis (one patient). Three patients died during follow-up, in all cases because of metastatic disease. At an average follow-up of 147 months (range 11-260 months), the remaining nine patients were continuously disease-free. Complete healing of the osteotomy of both allograft and VFG was observed in 10 patients at final follow-up. Two major complications were observed that required surgical revision, eventually healing in one case and leading to a poor functional outcome in one case. Significant hypertrophy of the VFG was detected in seven of nine evaluable patients. At final follow-up the mean Musculoskeletal Tumour Society (MSTS)'93 functional score of the nine evaluable patients was 90% (range 66-100%). These results indicate that VFG is a valid salvage procedure in failed intercalary reconstructions of the femur after bone resection.
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Affiliation(s)
- Domenico Andrea Campanacci
- Department of Orthopaedic Oncology and Reconstructive Surgery, Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla 3, 50134 Firenze, Italy.
| | - Serena Puccini
- Department of Orthopaedic Oncology and Reconstructive Surgery, Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla 3, 50134 Firenze, Italy
| | - Giuseppe Caff
- Department of Orthopaedic Oncology and Reconstructive Surgery, Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla 3, 50134 Firenze, Italy
| | - Giovanni Beltrami
- Department of Orthopaedic Oncology and Reconstructive Surgery, Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla 3, 50134 Firenze, Italy
| | - Andrea Piccioli
- Orthopaedic Oncology Unit "Palazzo Baleani", Cancer Center, Policlinico Umberto I, Roma, Italy
| | - Marco Innocenti
- Department of Microsurgery, Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla 3, 50134 Firenze, Italy
| | - Rodolfo Capanna
- Department of Orthopaedic Oncology and Reconstructive Surgery, Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla 3, 50134 Firenze, Italy
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