Vascularized fibula grafts for reconstruction of bone defects after resection of bone sarcomas

Abstract

We evaluated the results of limb-sparing surgery and reconstruction of bone defects with vascularized fibula grafts in 8 consecutive patients (mean age at operation 13.6 years (range 4.1-24.2 years), female/male = 6/2) with bone sarcomas (BS) (osteosarcoma/Ewing's sarcoma/chondrosarcoma= 4/3/1) operated on form 2000 to 2006. The bone defects reconstructed were proximal femoral diaphysis and epiphysis (n = 2), humeral diaphysis (n = 2), humeral proximal diaphysis and epiphysis (n = 1), femoral diaphysis (n = 1), ulnar diaphysis (n = 1), and tibial diaphysis (n = 1). One patient with Ewing's sarcoma had an early hip disarticulation, developed multiple metastases, and died 9 months after the operation. The remaining patients (n = 7) are all alive 50 months (range 26-75 months) after surgery. During the follow-up the following major complications were seen: 1-2 fractures (n = 4), pseudarthrosis (n = 2), and hip dislocation (n = 1). Limb-sparing surgery with reconstruction of bone defects using vascularized fibular grafts in BS cases is feasible with acceptable clinical results, but fractures should be expected in many patients.

Figure 1

Resection of the proximal part of the tibial diaphysis performed because of an osteosarcoma and reconstruction of the bone defect with a double-barrelled pedicle vascularized fibula graft (patient 7). X-rays taken 9 days postoperatively (a), after 16.5 months when weight bearing without external fixation (fixation pins left until the effect of weight bearing was evaluated) had been started 3 weeks earlier (b), and status 53 months postoperatively (c).

Figure 2

Status after resection of the ulnar diaphysis (patient 1) because of a low grade osteosarcoma (a), and reconstruction with a vascularized fibula graft 3 weeks later (b). A pseudathrosis developed at the proximal junction (c), and it was treated by bone grafting and plate osteosynthesis (d). The final result 2 years after reconstruction (e).

Figure 3

Resection of the proximal part of the femur because of Ewing's sarcoma and reconstruction with a vascularized fibula graft including the proximal epiphysis (patient 2). X-rays taken 2 weeks postoperatively (a), with follow-up after 7 months when weight-bearing was started (b), after 12 months when full weight-bearing had been allowed for 3 months (c), and finally a bone scan performed 12 months postoperatively (d).

Figure 4

Resection of the proximal part of the femur because of Ewing's sarcoma and reconstruction with a vascularized fibula graft including the proximal epiphysis (patient 2). X-rays taken 13.5 months postoperatively after the patient had sustained a fracture from falling while doing gymnastics at school (a), and with follow-up 2 months after the fracture (b). X-ray 3 years after insertion of the fibula graft; a proximal osteotomy has been performed because the fracture healed in an unfavourable position leading to an unstable hip joint (c).

Figure 5

Resection of the proximal part of the humerus because of an osteosarcoma and reconstruction with a vascularized fibula graft including the proximal epiphysis (patient 5). X-rays taken 1 month postoperatively (a), and after 8 months when the junction was healed but the patient had just sustained a fracture of the graft (b) treated by plate ostesynthesis (c). 29 months after insertion of the graft, where the patient has had one more fracture just above the plate healed on conservative treatment; X-ray (d) and clinical photos showing active abduction (e) and extension (f) of the shoulder joint just before removal of the plate.