Reconstruction with ipsilateral fibula transfer with pasteurized bone after excision of bone sarcoma of the tibia

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1 Srcom, June/Septemer 2004, VOL. 8, NO. 2/3, TECHNICAL NOTE Reconstruction with ipsilterl fiul trnsfer with psteurized one fter excision of one srcom of the tii TOSHIFUMI OZAKI 1, KAZUO FUJIWARA 1, TOSHIYUKI KUNISADA 1, TATSUO ITO 1, AKIRA KAWAI 2, HAJIME INOUE 1 1 Deprtment of Orthopedic Surgery, Okym University Hospitl, Shikt-cho, Okym , Jpn 2 Deprtment of Orthopedic Surgery, Ntionl Cncer Center Hospitl, Tsukiji, Chuo-ku, Tokyo , Jpn Astrct We report technique of implnttion of the ipsilterl vsculrized fiul with psteurized recycled one fter excision of tii srcom in two cses. Plte nd screws were used for osteosynthesis of the tii or tlus, vsculrized fiul, nd psteurized one. Microsurgery is not necessry for this reconstruction technique. Two ptients who underwent this technique hve otined good functionl results without tumor relpse 5 nd 6 yers fter opertion. The technique produced excellent results with regrd to tiil reconstruction in these cses. We found it to e simple, speedy, sfe, nd low cost technique y use of recycled one. Introduction Tumor re in one nd its extrskeletl involvement cn currently e clerly recognized with creful preopertive rdiologicl evlution, including mgnetic resonnce (MR) imging. 1 Improved imging techniques 2 nd preopertive chemotherpy 3,24 permit lim-spring surgeries to e crried out sfely in ptients with one nd soft tissue tumors. Good long-term functionl results hve een reported fter reconstruction of lrge one defects using vsculrized fiulr grfts fter tumor resection. 5 The one union rte in one report ws 81% (130 of 160 ptients) t n verge of 42 months fter vsculrized one trnsfer. 6 However, lower extremity reconstructed with only vsculrized fiul pprently is too wek to withstnd the mechnicl stresses of full weight ering efore union or thickening of the grfted fiul. When psteurized one shell is implnted round vsculrized fiul, the recycled one cn strengthen the fiul nd one junction, nd protect the fiul from mechnicl filure. Moreover, if ipsilterl vsculrized fiul from the ffected site is ville, the opertive invsion cn e limited to only one leg. We report technique of such reconstruction of the tiil defects fter tumor excision of the tii in two cses. The ipsilterl vsculrized fiul ws trnsferred centro-medilly, nd psteurized tiil one ws implnted s n utogrft shell with plte nd screws. The procedure is modifiction of technique originlly descried y Cpnn et l. 7 nd Wuismn et l. 8 Opertive technique The tiil tumor is excised with wide mrgin. The ttched soft tissue of the resected one including the tumor is removed. Tumor resection nd grft preprtion procedures must e done on tles other thn the instrumenttion or opertion tle to prevent tumor contmintion. A mssive psteurized one grft is prepred from the resected tiil portion y tretment in physiologicl sline with povidone iodine (concentrtion, 3000 mg/1000 ml) t 60 C for 30 min. 10 The psteurized one then is remed. One-third of the circumference of the psteurized one is excised longitudinlly to llow implnttion of the vsculrized fiul in the cvity of the shell. Two-thirds of the tii is retined for externl support of the vsculrized fiul. The ipsilterl fiul, which is usully cut 4 5 cm longer thn the resection, is hrvested with its periostel cuff nd peronel vessels. The ends of Correspondence to: Toshifumi Ozki, Deprtment of Orthopedic Surgery, Okym University Hospitl, Shikt-cho, Okym , Jpn. Tel.: þ ; Fx: þ ; E-mil: tozki@md.okym-u.c.jp X print/ online ß 2004 Tylor & Frncis Ltd DOI: /

2 98 T. Ozki et l. the vsculrized fiul re inserted few centimeters into the medullry cnl of the residul tii, nd 5 mm into the tlus. The met-diphysel interclry psteurized one is implnted round the fiul with the vsculr pedicle emerging from the split side of the psteurized one. The fiulr lood flow is confirmed y the leeding t the end of the one efore osteosynthesis. Cse report Cse 1 A 45-yer-old mn hd sudden onset of left lower leg pin while he ws plying sell. A rdiogrph of the left lower leg reveled pthologicl frcture of the tii nd he ws referred to the uthors hospitl. The ptient s medicl history nd fmily history were unremrkle. The ptient presented with swelling nd tenderness of the left lower leg. Plin rdiogrphs reveled n osteolytic shdow nd frcture t the distl metphysis of the left tii (Fig. 1). Bone scn showed n norml uptke from the shft to the distl tii. A digitl sutrction ngiogrph showed incresed vsculrity of the vessels in the lesion. MR imges showed low-signl intensity tumor with n extrskeletl tumor projection on T1-weighted imges (Fig. 2) nd high-signl intensity on T2-weighted imges. Gdolinium-diethylenetriminepentcetic cid (DTPA)-enhnced T1-weighted imges showed imhomogeneous enhncement of the tumor (Fig. 2). Open iopsy ws performed; the dignosis ws leiomyosrcom. Two cycles of preopertive chemotherpy ifosphmide, doxoruicin, nd dcruzine (MAID) 9 were dministered. Preopertive intr-rteril dministrtion of cispltin (150 mg) ws done twice. Preopertive MR imges mde fter chemotherpy showed tumor limited to the tii. The tumor ws excised with wide mrgin. The resected one ws removed for psteuriztion. The fiul ws cut 5 cm longer thn the resected tii. After dividing the introsseous memrne, the peronel vessels were identified. The fiul ws not relesed, ut with the muscles, it ws moved nteromedilly. The proximl end ws inserted in the residul tii nd the distl end ws inserted in the tlus. The psteurized one ws implnted round the fiul. A long plte with seven screws ws used for osteosynthesis. The one union ws rpid, nd prtil weight ering egn 12 weeks fter opertion. At 6 months, full weight ering ws permitted. Twelve months fter opertion, the junction etween the recycled one nd host one hd lmost heled. The ptient, postmn, hd resumed his work, which included riding motor ike. At 5 yers fter the opertion, the junction ws completely heled (Fig. 3). The leg length discrepncy ws 3 cm. Evlution scores t lst follow-up, ccording to the method of Enneking et l., 11 were 5 in pin, 4 in function, 4 Fig. 1. Cse 1. Plin rdiogrph shows rdiolucent re with pthologicl frcture in the distl tii. () Antero-posterior view; () lterl view.

3 Reconstruction with ipsilterl fiul trnsfer 99 Fig. 2. Cse 1. () T1-weighted mgnetic resonnce (MR) imging showed low-signl intensity tumor with extr-skeletl projection. ( ) Gdolinium-diethylenetriminepentcetic cid (DTPA)-enhnced T1-weighted imges showed n inhomogeneously enhnced tumor. emotionl cceptnce, 5 support, 5 for wlking, 4 for git; 27 (90%) in totl. Cse 2 A 12-yer-old oy hd right lower leg pin without trum. His medicl history indicted tht he hd hd red cell plsi 1 month fter irth nd hd received steroid therpy. His fmily history indicted tht his mother hd colon cncer. The ptient s lower leg pin incresed grdully, nd night pin developed. Anorml findings were identified on plin rdiogrphs, nd he ws referred to the uthors institute where he presented with tenderness on the proximl prt of the right lower leg. Plin rdiogrphs showed periostel rection of the posterior diphysis nd sclerotic shdow in the met-diphysis of the right tii (Fig. 4). MR imges showed low signl intensity re of 15 cm on T1-weighted imges (Fig. 4) nd high signl intensity re on T2-weighted imges in the diphysis of the right tii. A one scn showed n norml high-uptke in the right met-diphysis of the tii. Histologicl dignosis indicted high suspicion of enign tumor with smll possiility of osteosrcom. There ws no extr-skeletl tumor protrusion, nd the dignosis ws uncler. Tumor excision with wide surgicl mrgin without preopertive chemotherpy ws performed in this ptient. The residul epiphysel one segment mesured 2 cm in thickness. After tumor excision, the vsculrized fiul, which ws 4 cm longer thn the tii defect, ws trnsferred ntero-medilly. The vsculrized fiul ws inserted in the psteurized resected tii (Fig 4c), nd oth ends of the fiul were inserted in the residul tii. Osteosynthesis ws y mens of metl pltes with screws. Histologicl dignosis fter exmintion of the resected specimen ws low-grde osteosrcom. Postopertive chemotherpy ws dministered ccording to the modified NECO95J protocol. 4 Prtil weight ering ws strted 11 weeks fter opertion. Full weight ering ws permitted from 3 months fter opertion. To dte, the ptient hs survived more thn 5 yers without relpse fter the opertion. He cn wlk without externl support (Fig. 5). The one union is excellent (Fig. 5). The leg length discrepncy ws 3 cm. Evlution

4 100 T. Ozki et l. Fig. 3. Cse 1. Rdiogrph tken t 5 yers fter opertion. The junction site of one heled completely. () Antero-posterior view; ( ) lterl view. c Fig. 4. Cse 2. () Rdiogrph showed periostel rection of the posterior proximl met-diphysis of the tii nd sclerotic shdow in the proximl met-diphysis of the right tii. ( ) Mgnetic resonnce imges showed low signl intensity re (T1-weighted imges). (c) The fiul end protrudes from the psteurized tii.

5 Reconstruction with ipsilterl fiul trnsfer 101 c Fig. 5. Cse 2. Five yers fter opertion. () The ptient, high-school student t ge 17 yers, is shown using the knee rce. However, he cn wlk without further externl supports. ( ) Anterior-posterior view of plin rdiogrph. (c) Lterl view of plin rdiogrph. scores t lst follow-up, ccording to the method of Enneking et l., 11 were 5 for pin, 3 for function, 4 for emotionl cceptnce, 4 for support, 4 for wlking, 4 for git; 24 (80%) in totl. Discussion Cppn et l., in 1991, reported tht contrlterl vsculrized fiul nstomosis ws performed fter excision of the tiil srcom. 7 Their reconstruction procedure ws chrcterized y comintion of n externl llogrft with n inner, vsculrized free fiulr flp. 7,12 In 1996, Wuismn et l. reported ipsilterl vsculrized fiul trnsfer with implnttion of llogrft fter excision of tiil srcom. 8 The uthor of the current report pulished the results of ipsilterl vsculrized fiul nd implnttion of llogrft shell in 12 cses. 13 The susequent dete on the reltive usefulness of the ipsilterl fiul grft versus the contrlterl fiul grft continues. Ipsilterl fiul trnsfer is n esy technique tht cn e completed in reltively short opertion time, nd does not require vessel nstomosis. Volume reduction of the lower leg due to ntero-medil shift of the fiul fcilittes skin closure fter tumor excision. However, creful control of lignment t the opertive site is necessry to prevent mllignment of the lower leg. In cses of vsculrized fiul trnsfer, vlgus deformity of the donor site nkle is known to occur fter fiulectomy, 14,15 especilly in children younger thn yers. 16,17 A tiiofiulr syndesmotic screw efficiently prevents nkle vlgus. 5 We think tht the fiul lone is indequte to withstnd compression nd torsion stresses of weight ering. And it is thought tht shell implnt with plte nd screws is resonle structurl supplement for the fiul. Internl plte fixtion is preferle to externl fixtion for osteosynthesis. In previous report, 13 ptients with fixtion y screws or Kirschner wire hd frcture or deformity of the junction, ut ptients with plte fixtion hd no such complictions t the junction. A long plte with severl screws is etter thn miniml osteosynthesis using smll frgment screws. 12 The risk of infection my e incresed ecuse ptients usully receive postopertive chemotherpy nd the psteurized one is not s strong s ginst infection. However, psteurized one, in generl, hs fewer complictions nd fster one union thn llogrft one does. 10,13 Both cses in the current report illustrte reconstruction of the tii with vsculrized fiul trnsfer nd psteurized one. The uthors consider the method to e excellent for tiil reconstruction ecuse it is simple, speedy, nd sfe technique with n economicl use of recycled one. References 1. Spin V, Torricelli P, Montnri N, Mnfrini M, Picci P, Sngiorgi L, et l. The epiphysel involvement of metphysel one srcoms in ptients with fertile growth pltes. A mgnetic resonnce ssessment. Rdiol Med (Torino) 1994; 88(3):

6 102 T. Ozki et l. 2. Ozki T, Inoue H, Tguchi K, Sugihr S. Gdolinium-DTPA enhnced mgnetic resonnce imging of one nd soft tissue srcoms in comprison with pthologicl findings. Act Med Okym 1992; 46(6): Bielck S, Kempf-Bielck B, Schwenzer D, Birkfellner T, Delling G, Ewereck V, et l. [Neodjuvnt therpy for loclized osteosrcom of extremities. Results from the Coopertive osteosrcom study group COSS of 925 ptients.] Klin Pditr 1999; 211(4): Isu K, Ymwki S, Beppu Y, Umed T, Kwguchi T, Ttezki S, et l. Prognostic results from multiinstitute study of djuvnt chemotherpy for osteogenic srcom. J Jpn Orthop Assoc 1999; 73(Suppl): Frgniere B, Wicrt P, Mscrd E, Duousset J. Prevention of nkle vlgus fter vsculrized fiulr grfts in children. Clin Orthop 2003; 408: Hn CS, Wood MB, Bishop AT, Cooney WP, 3rd. Vsculrized one trnsfer. J Bone Joint Surg Am 1992; 74(10): Cpnn R, Buflini C, Cmpncci M. A new technique for reconstructions of lrge metdiphysel one defects. A comined grft (llogrft shell plus vsculrized fiul). Orthop Trumtol 1993; 2: Wusimn P, Gruenert J, Lnger M. Ipsilterl, pedicled fiul trnsfer in the tretment of mlignnt tii tumor. Op Orthop Trumtol 1996; 8(2): Kwi A, Nito N, Sugihr S, Ozki T, Morimoto Y, Inoue H. Mesn, drimycin, iifosphmide, dcrzine (MAID) chemotherpy for high grde soft tissue srcoms. Orthop Surg 2000; 51(5): Mne J, Kwguchi N, Mtsumoto S. Psteurized utogenous one grft for reconstruction fter resection of mlignnt one nd soft tissue tumors: imging fetures. Semin Musculoskelet Rdiol 2001; 5(2): Enneking WF, Dunhm W, Gehrdt MC, Mlwr M, Pritchrd DJ. A system for the functionl evlution of reconstructive procedures fter surgicl tretment of tumors of the musculoskeletl system. Clin Orthop 1993; 286: Mnfrini M, Gsrrini A, Mlguti C, Ceruso M, Innocenti M, Bini S, et l. Intrepiphysel resection of the proximl tii nd its impct on lower lim growth. Clin Orthop 1999; 358: Ozki T, Hillmnn A, Wuismn P, Winkelmnn W. Reconstruction of tii y ipsilterl vsculrized fiul nd llogrft. 12 cses with mlignnt one tumors. Act Orthop Scnd 1997; 68(3): Weilnd AJ, Moore JR, Dniel RK. Vsculrized one utogrfts. Experience with 41 cses. Clin Orthop 1983; 174: Weilnd AJ, Weiss AP, Moore JR, Tolo VT. Vsculrized fiulr grfts in the tretment of congenitl pseudrthrosis of the tii. J Bone Joint Surg Am 1990; 72(5): Omokw S, Tmi S, Tkkur Y, Yjim H, Kwnishi K. A long-term study of the donor-site nkle fter vsculrized fiul grfts in children. Microsurgery 1996; 17(3): Den GS, Kime RC, Fitch RD, Gunneson E, Urnik JR. Tretment of osteonecrosis in the hip of peditric ptients y free vsculrized fiulr grft. Clin Orthop 2001; 386: