Free Vascularized Fibular Grafting ForMalignant Bone and Soft Tissue Tumor:Ragiological , Clinical and Functional Outcome

Kaya M, Wada T, Nagoya S, Sasaki M, Matsumura T and Yamashita T

Dept. of Orthop. Surg. Sapporo Medical University

CTOS 14th Annual Meeting, November 15, 2008London, UK

Reconstructive options after bone and soft tissue tumor removal

•Tumor Megaprosthesis•Treated Bone pasteurized autologous bone

liquid nitrogen treated boneextracorponeal irradiated bone

•Allograft•Vascularized Fibula•Distractive osteogenesis

Reconstructive options after bone and soft tissue tumor removal

•Tumor Megaprosthesis•Treated Bone pasteurized autologous bone

liquid nitrogen treated boneextracorponeal irradiated bone

•Allograft•Vascularized Fibula•Distractive osteogenesis

Purpose

To analyze the clinical results of free vascularized fibula graft (FVFG) reconstruction after the removal of malignant bone and soft tissue tumor.

Knee Arthrodesis

Indications

•Malignant bone tumor of distal femur and proximal tibia

•Possible to preserve of popleteal vessels and nerves

Distal FemurProximal Tibia

Reconstruction Methods

12 patients who were followed more than 5 years

were enrolled.

Follow up periods Ave. 95 months

Histology

OS 11 Pts.

MFH 1

Clinical Results

Limb sparing 83.3 ％ （ 10/12 Pts. ）

skip metastasis 1 Pt

　　　　　　　 Infection 1

Union 　 83.3 ％（ 10/12 Pts. ）

Time to the Union 　 6 Mo.

Complications

•Stress fracture 　 7 Pts.

•Peroneal nerve palsy 5

•Delayed-union 2

　　　

Pain Function Emotional External Walking Gait Total

acceptance support ability

100 97.2 87.5 100 95 60 86.3

MSTS functional score ( mean, %)

Sling procedure

Malawar’s

Indications

IA VB

Biceps femoris tendon

Fibular head

Humerus

Peroneal a.

Commitant v.

Transient wire

Posterior circum. hemeral a. Basilic v.

J Bone Joint Surg Br, 1999

Reconstruction Methods

9 patients were reconstructed

with this methods

Follow up periods Ave. 95 months

Histology

OS 11 Pts.

CS 3

MFH 1

Case Age Histology Union FU Results（ M ）

1. 43 CS + 90 CDF2. 20 OS + 30 DOD3. 10 OS + 91 CDF4. 17 OS + 191 CDF5. 30 OS + 196 CDF6. 34 MFH + 164 CDF7. 14 OS + 150 CDF8. 47 CS + 32 CDF9. 20 CS + 12 CDF

Clinical Results

Complications

# of case# of case Additional TreatmentAdditional Treatment

•Fibula Head 55 　　 NoneNone

Absorption

•Fracture Fracture 1 1 ORIF+bone graftORIF+bone graft

•Delayed Union Delayed Union 11 Bone graftBone graft

•InfectionInfection 1 1 DebridementDebridement

pain function emotion hand manual liftposition

dexiterityability

97.7 92.5 73.3 73.3 100 66.6

MSTS Functional Score (mean, %)

Hip Arthrodesis

II

IIII

IIIIIIEnneking & DunhamEnneking & Dunham

Indications

•Malignant bone tumor

arised in pelvic bone

•Possible to preserve of femoral

vessels and sciatic nerve

6 patients were reconstructed

with this methods

Follow up periods Ave. 7.1 yrs. (0.7-12)

Histology

CS 3 pts.

OS 2

pleomorphic adenomapleomorphic adenoma 1

Reconstruction Methods

Type II 1

Type II+III 3

Type I+II+III 2

Clinical Results

# # Histology Histology Relapse Relapse 　　 GraftGraft FU(Y) FU(Y) MetastasisMetastasis RResultsesults

11 OSOS ＋　＋　 N/A N/A 0.7 0.7 lunglung DDOD OD

22 CSCS - - union union 12 12 - - CDF CDF

3 3 CSCS - - union union 12 12 - - CDF CDF

4 4 CSCS - - union union 11 11 - - CDF CDF

5 5 AdenoAdeno - - non-union 3.5non-union 3.5 - - CDF CDF

6 6 OSOS - - union 3.5union 3.5 lung,spinelung,spine DODDOD

Clinical Results

# # Histology Histology Relapse Relapse 　　 GraftGraft FU(Y) FU(Y) MetastasisMetastasis RResultsesults

11 OSOS ＋　＋　 N/A N/A 0.7 0.7 lunglung DDODOD

22 CSCS - - union union 12 12 - - CDF CDF

3 3 CSCS - - union union 12 12 - - CDF CDF

4 4 CSCS - - union union 11 11 - - CDF CDF

5 5 AdenoAdeno - - non-union 3.5non-union 3.5 - - CDF CDF

6 6 OSOS - - union 3.5union 3.5 lung,spinelung,spine DODDOD

Complications

# of case# of case additional treatmentadditional treatment

•InfectionInfection 22 　　 debridement debridement

•fracture fracture 1 1 ORIFORIF

•Delayed union Delayed union 22 bone graftbone graft

•Wound troubleWound trouble 1 1 debridementdebridement

•Non unionNon union 22 　　 ORIF+bone graftORIF+bone graft

MSTS functional evaluation

Case Pain Function Emotional External Walking Gait Total

acceptance support ability

1 N/A N/A N/A N/.A N/A N/AN/A

2 5 5 5 5 5 5 30

3 5 5 5 5 4 4 28

4 5 3 3 4 3 4 26

5 2 1 1 0 0 0 4

6 N/A N/A N/A N/.A N/A N/AN/A

MSTS functional evaluation

Case Pain Function Emotional External Walking Gait Total

acceptance support ability

1 N/A N/A N/A N/.A N/A N/AN/A

2 5 5 5 5 5 5 30

3 5 5 5 5 4 4 28

4 5 3 3 4 3 4 26

5 2 1 1 0 0 0 4

6 N/A N/A N/A N/.A N/A N/AN/A

Free Vascularized Fibula Graft

Advantage•Biological reconstruction•Durability

Disadvatage•Complicated methods•High risk of complication

Knee Athrodesis

•Long durability

•Excellent pain relief and support

•Poor in emotional acceptance and gait ability

•Social acceptance??

Golden standard = Tumor Megaprosthesis

Proximal humerus reconstruction

•Tumor Megaprosthesis•Clavicula Pro Humero Reconstruction•Sling Procedure

Proximal humerus reconstruction

•Tumor Megaprosthesis•Clavicula Pro Humero Reconstruction•Sling Procedure

•Biological spacer

•Even in case with glenoid resection

•Maximize the elbow and hand function

by reconstructing the mobile shoulder

Hip Arthrodesis

•Low grade tumor ; good indication for this procedure•High grade tumor; its use cannot be recommended•Good durability and function•Severe functional loss in case with non union or infection

Summary

•We evaluated the clinical results of FVFG reconstruction

•We evaluated advantage and disadvantage of this method

•Careful patients selection and accurate surgical technique determine the clinical results

Thank you for your attention.