The two-stage ipsilateral ® bular transfer for tibial...

Sarcoma (2000) 4, 27± 30

ORIGINAL ARTICLE

The two-stage ipsilateral ® bular transfer for tibial defect followingtumour excision

MASAHITO HATORI, KHALID S. AYOUB, ROBERT J. GRIMER, SIMON R. CARTER &ROGER M.TILLMAN

The Royal Orthopaedic Hospital Oncology Service,The Royal Orthopaedic Hospital, Birmingham, UK

AbstractMethod. We performed a two-stage vascularized ipsilateral ® bular graft transfer for segmental tibial defect following exci-sion of malignant bone tumours.Results. We report 10 patients who had this procedure with an average follow-up of 116 months.The graft was transposedmedialy on its vascular pedicle by two-stage surgery. Full weight bearing was achieved in six patients at 8± 43 months post-operatively, but every patient had a signi® cant complication.Discussion. The use of this method in isolation is not recommended for reconstruction of the tibia following tumour exci-sion.

Key words: ® bulograft, sarcoma, bone graft

Introduction

One of the most difficult problems confronting theorthopaedic surgeon is the reconstruction of largebone defects following resection of tumours,particularly arising in the tibial shaft. One of thecommon ways of reconstruction is autogenous corticalbone graft.1± 3The majority of osteocytes of this graftundergo necrosis requiring the eventual replacementof the dead bone by creeping substitution.4 Othermethods of reconstruction including autoclaved bone5

and allograft6 have been used but frequently result incomplications such as non-union and/or infection.7,8

With the development of microvascular technique,free vascularized ® bular grafts have been contributedfollowed by ipsilateral vascularized transfer.4,9± 11

However, such kinds of reconstructive proceduresare extensive and time-consuming, requiringexpensive equipment.3 We report our experience ofusing two-stage ipsilateral ® bular graft transfer as amethod of tibial reconstruction following wide exci-sion of malignant tumours arising in the shaft.

Patients and methods

We have undertaken a retrospective review. Tenpatients have undergone two-stage ipsilateral vascu-larized ® bular transfer to reconstruct defects of thetibia. There are six males and four females.The ages

range from 5 to 22 years with an average of 14 years.The mean follow-up is 116 months (range 19± 175months). The primary tumours of the affected tibiawere: three osteosarcomas, three Ewing’s sarcomas,two adamantinomas, one malignant ® brous histiocy-toma, and one chondrosarcoma. The tumour loca-tions in the tibial diaphysis are: one proximal tibial,six mid-tibial, and three distal tibial diaphysis. Pre-and post-operative chemotherapy was used for oste-osarcoma and Ewing’s sarcoma. The length of bonedefect ranged from 8 to 20 cm with the average of 15cm (Table 1).

Operative technique

The ® rst stage procedure

Curved anterior incision was made, taking an ellipseof skin with the biopsy site. Dissection was continuedmedialy and laterally with care taken not to exposethe tumour. Proximal and distal tibial osteotomieswere performed excising the preoperatively-decidedlength of the tibia. The ® bula was transected 1 cmbeyond the level of distal tibial resection, mobilizedand inserted into the medullary canal of the tibia(Fig. 1, left). If necessary, Kirschner wires or Stein-mann pins were used for the stabilization of the fibula.Any remaining gap between the tibia and the ® bulawas ® lled with cancellous bone harvested from the

Correspondence to: Mr R.J. Grimer, Consultant Orthopaedic Oncologist, Royal Orthopaedic Hospital Oncology Service, The RoyalOrthopaedic Hospital NHS Trust, Bristol Road South, North® eld, Birmingham B31 2AP, UK.Tel.: 0121-6854150; Fax: 0121-6854146.

1357-714Xprint/1369-1643online/00/010027-04 ½ 2000Taylor & Francis Ltd

osteotomized tibial edges.The wound was closed inlayers.The operating time was less than 90 min. Post-operative casting was applied.

The second stage procedure

The second stage surgery was performed at 2± 4months, with the average of 3 months, after the ® rstprocedure.The ® bula was divided 1± 2 cm above thelevel of the tibia (Fig. 1, right).A window was createdin the cortex of the tibia and the ® bula was slotted inand packed with bone graft taken from the proximaltibial segment. Union was assessed clinically andradiographicaly at regular intervals. If there wasevidence of non-union,the site was surgically exposedand plated with autogenous cancellous bones. Stressfractures were treated by plaster casting.

Results

Out of 10 patients included in this study, wide surgicalexcision of the tumour was achieved in nine. Onepatient had an intra-lesional excision of the primarytumour at the ® rst stage procedure and was treatedwith a below-knee amputation. Local recurrenceoccurred in two patients, both treated with below-knee amputations. Metastasis developed in threepatients, two of them died as a result.The remainingeight patients are still alive and free of disease.

Bone union between the ® bular graft and the tibiaoccurred in ® ve patients with an average time tounion of 6 months (range 2± 12 months). Threepatients developed non-union.These were treated byinternal ® xation (plating) and secondary bone graftingresulting to full union and incorporation of the graftwith the tibia.The other two patients had early below-knee amputations (one local recurrence and oneresidual tumour) before reaching the stage of completeunion. Five fractures (four stress fractures and onetraumatic) of the ® bular strut were diagnosed in fourpatients at 10, 13, 13, 19 and 24 months after thesecond stage procedure.These developed during therehabilitation period with increasing weight bearingon the operated leg.The stress fractures were treatedby conservative (non-operative) methods, and thetraumatic fracture by external ® xation with bonegrafting. All resulted in complete union and gavegood results. Full and unprotected (i.e. no splintage)weight-bearing on the operated leg, with or withoutwalking aids, was achieved at an average time of 21months (range 8± 43 months).We found that the maincauses for this rather prolonged period until full weightbearing were stress fractures and non-union.

Radiographically, hypertrophy of the grafted fibulawas observed in all the patients (Fig. 2).

The range of knee and ankle movements were

Table 1. Details of 10 patients with ® bular graft

Patient

Gender,age

(years)

Lengthof tibialdefect(cm) Complications Treatment

Time tounion

(months)

Time tofull weight

bearing(months)

Follow-up(months)

Status at latestfollow-up

LH F, 5 10 Local recurrence Below-kneeamputation

19 Died of lungmetastasis

LW M, 6 10 Stress fracture Non-operative 2 19 137 No evidence ofdisease

SI M, 8 16 Non-union,valgus deformity,mild pininfection

Two operationsof bone grafting

21 24 108 No evidence ofdisease

PL M, 13 15 2.5 cmshortening

Notavailable

Notavailable

169 No evidence ofdisease

MN M, 15 14 Varus deformity 3 8 116 No evidence ofdisease

JW F, 17 20 Stress fracture,equinus, 2 cmshortening

Non-operativetreatment forstress fracture


MB F, 18 18 Non-union,stress fracture

Two operationsof bone grafting


PS M, 19 18 Residual tumour,lung metastasis

Below-kneeamputation

89 No evidence ofdisease

MG F, 20 8 (a) Traumaticfracture(b) Stressfracture

(a) Ex. ® xation +bone grafting(b) Non-operative


DW M, 22 13 (a) Non union(b) Stressfracture(c) Localrecurrence

(a) Threeoperation ofbone grafting(b) Non-operative(c) Below-kneeamputation

32 Neveroccurred

175 Died of lungmetastasis

28 M. Hatori et al.

normal in seven and ® ve patients, respectively. In twopatients the range of ankle motion was impaired dueto mild equinus deformity. The axial alignment wasnormal in ® ve patients. Asymptomatic valgus andvarus deformities were observed in one patient each.Two centimetres of leg shortening was found in twopatients. Mild pin infection was observed in onepatient. No other local or systemic complications haveoccurred (Table 1).

Discussion

Wide excision of a lesion in the tibia presents a difficultreconstructive problem in that it produces an interca-lary gap in a major weight-bearing bone. The maingoal is restoration of the skeletal anatomy and func-tion of the extremity. With the development of newtechnology, the surgeon has a wide selection of avail-able methods with which to bridge the massive bonedefects that are created by the radical resection oflarge tumours of bone.3

The ® bula was used as a substitute for a missingsegment of tibia or to reinforce a weakened sectionusing different methods.Transplantation of the upper

end of the ® bula into the tibia to replace loss of tibialsubstance was ® rst conceived by Hahn in 1884.12

Huntington took the procedure one stage further andtransferred the lower end of the ® bula into the tibia.13

Wilson in 1941 published his experience in two-stage® bular transplantation for use in cases of complicatedand congenital pseudoarthrosis of the tibia. Hestressed that the operation is best performed in twostages because this method has the advantages oflessening the risk of dislodging the end of the ® bulafrom its connection with the tibia, of shortening thetime of the operation, and of reducing the severity ofthe postoperative reaction.14

The shaft of the ® bula is strong and could providea free vascularized graft from the contralateral sideusing a microvascular technique (Taylor, Miller andHam). Many authors have reported the usefulness ofthe free vascularized ® bula graft.9,15 However, thistechnique is highly specialized and may not be avail-able even in major centres.16 A high complicationrate has been reported.17 It also means operating onthe non-affected leg and sacri® cing the contralateral® bula, and that should be performed before tumourexcision in order to minimize the possibility of tumourcells seeding.

The development of techniques for harvestingmicrovascular ® bular transplants indicated the

Fig. 1. Anteroposterior view of postoperative radiographs of15-year-old boy who had a malignant ® brous histiocytoma inthe mid-shaft left tibia. Left: Two months after the ® rst stageprocedure showing 14 cm tibial bone defect following tumourresection, and the distal ® bular osteotomy and transfer into thecanal of distal tibial segment.Right: One month after the secondstage procedure showing the proximal ® bular osteotomy and

transfer into the canal of proximal tibial segment.

Fig. 2. Anteroposterior and lateral radiographs for the samepatient in Fig. 1, almost 8 years following the second stageprocedure. It shows complete incorporation of the graft with thetibia, as well as hypertrophy of the graft itself acquiring the size

and shape of the tibia.

Fibular transfer 29

potential use of the ipsilateral ® bula, retaining theperiosteal and endosteal circulation.10,16 Chacha etal. carried out the dissection and transposition of the® bula, preserving its vascular supply in 11 patients.He was successful in obtaining good results.The useof the ipsilateral ® bula with an intact blood supplythrough its musculoperiosteal vessels provides a largeliving graft which can be ® xed to the tibia. Theexperimental and the clinical studies have providedgood evidence of the viability of such a graft.16 Otherauthors also reported the usefulness of this methodfor the treatment of massive bone defect of the tibia,mainly due to trauma.10,11,18Although this procedurehas many merits, it is thought to be time-consuming,technically demanding and one-stage ® bula transferis not always possible in terms of its vascular preserva-tion. Other options for reconstructing the tibia needto be considered. These include the option of bonetransport, allograft, and the combined option of ipsi-lateral vascularized ® bular graft with allograft.19

On the basis of our experience we do not recom-mend an ipsilateral ® bular graft as a good option forlimb reconstruction in isolation in the tibia. In ourexperience no patient avoided a signi® cant complica-tion, and also underwent the uncertainty of aprolonged period of partial or non-weight bearingwith consequent diminished function.

Having reviewed the literature on this subject wefeel that the most encouraging results have been witha combination of vascularized ® bular graft with anallograft, and we have currently used this in severalpatients with promising results. For short segmentbone resection we have used bone transport. Ingeneral there is no `best option’ and the techniqueused will depend on the availability of allograft, theavailability of appropriate external ® xator skills andthe possibility of micro-vascular reconstruction.

References

1 Enneking WF, Eady JL, Burchardt H. Autogenouscortical bone grafts in the reconstruction of segmentalskeletal defects. J Bone Joint Surg 1980; 62A:1039± 58.

2 Swierstra BA, Rijnberg WJ, van Linge B. Reconstruc-tion of the tibia by dual grafting. 3 cases of tumourresection. Acta Orthop Scand 1990; 61:266± 8.

3 Yadav SS. Dual-® bular grafting for massive bone gapsin the lower extremity. J Bone Joint Surg 1990;72A:486± 94.

4 Takami H,Takahashi S, Ando M, Masuda A. Vascular-ized ® bular grafts for the resonstruction of segmentaltibial bone defects. Acta Orthop Trauma Surg 1997;116:404± 7.

5 Sijbrandij S. Resection and reconstruction for bonetumours. Acta Orthop Scand 1978; 49:249± 54.

6 Gebhardt MC, Lord FC, Rosenberg AE, Mankin HJ.The treatment of adamantinoma of the tibia by wideresection and allograft bone transplantation. J BoneJoint Surg 1987; 69A:1177± 88.

7 Mankin HJ, Doppelt S,Tomford W. Clinical experiencewith allograft implantation. The ® rst ten years. ClinOrthop 1983; 174:69± 86.

8 Ortiz-Cruz E, Gebhardt MC, Jennings LC, SpringfieldDS, Mankin HJ.The results of transplantation of inter-calary allografts after resection of tumors. J Bone JointSurg 1997; 79A:97± 106.

9 Taylor GI, Miller GD, Ham FJ. The free vascularizedbone graft: a clinical extension of microvasculartechniques. Plast Recontr Surg 1975; 55:533± 44.

10 Hertel R, Pisan M, Jakob RP. Use of the ipsilateralvascularized ® bula for tibial reconstruction. J Bone JointSurg (Br) 1955;77B:914± 19.

11 Shapiro MS, Endrizzi DP, Cannon RM, Dick HM.Treatment of tibial defects and nonunion using ipsilat-eral vascularized ® bular transposition. Clin Orthop 1993;296:207± 12.

12 Hahn Eugen. Eine Methode, Pseudarthrosen der Tibiamit grossem Knochendefekt zur Heilung zu bingen.Zentralbl f Chir 1884; 11:337± 41

13 Huntington TW. Case of bone transference. Use of asegment of ® bula to supply a defect in the tibia. AnnSurg 1905; 41:249± 51.

14 Wilson PD. A simple method of two-stage transplanta-tion of the ® bula for use in cases of complicated andcongenital pseudoarthrosis of the tibia. J Bone JointSurg 1941; 23:639± 75.

15 Weiland AJ, Daniel RK. Microvascular anastomosesfor bone grafts in the treatment of massive defects inbone. J Bone Joint Surg 1989; 61A:98± 104.

16 Chacha PB, Ahmed M, Daruwalla JS. Vascular pediclegraft of the ipsilateral ® bula for non± union of the tibiawith a large defect: an experimental and clinical study.J Bone Joint Surg (Br) 1981; 63B:244± 53.

17 Hsu RW-W,Wood MB, Sim FH, Chao ES. Free vascu-larized ® bular grafting for reconstruction after tumourresection. J Bone Joint Surg 1997; 79B:36± 42.

18 Coleman SS, Coleman DA. Congenital pseudoar-throsis of the tibia: treatment by transfer of the ipsilat-eral ® bula with vascular pedicle. J Pediatr Orthop 1994;14:156± 60.

19 Ozaki A, Hillmann A, Wuisman P, Winkelmann W.Reconstruction of tibia by ipsilateral vascularized fibulaand allograft. 12 cases with malignant bone tumors.Acta Orthop Scand (Norway) 1997;68:298± 301.

30 M. Hatori et al.

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