JBJS | Growth of the Proximal Fibular Physis and Remodeling of the Epiphysis after Microvascular Transfer. A Case Report*

The Journal of Bone & Joint Surgery, Volume 79, Issue 4

Articles | April 01, 1997

Growth of the Proximal Fibular Physis and Remodeling of the Epiphysis after Microvascular Transfer. A Case Report*

KEVIN G. SHEA, M.D.†; SHERMAN S. COLEMAN, M.D.†; DON A. COLEMAN, M.D.†, SALT LAKE CITY, UTAH

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Investigation performed at the Department of Orthopaedics, University of Utah School of Medicine, Salt Lake City

The Journal of Bone & Joint Surgery. 1997; 79:583-6

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Introduction

Introduction | Case Report | Discussion | References

The advantages of use of vascularized grafts as compared with use of non-vascularized grafts have been demonstrated experimentally and clinically in skeletally mature individuals. These advantages include skeletal healing without creeping substitution²² of the graft from the surrounding host bone^8,29; more rapid incorporation and union⁹; lower rates of fracture, infection, resorption, and non-union^3,12,31; the option of using the grafts for the treatment of established infections^8,15 and segmental defects larger than five centimeters^3,8; greater initial strength^8,18,25; remodeling in a manner similar to that of viable bone^8,16,18,25; the ability to respond to biomechanical loading physiologically^9,13,18,25; increased hypertrophy⁷; and a decreased duration of immobilization after implantation¹¹.

Another, theoretical advantage of use of a microvascularized fibular graft is the potential for growth of the graft through the open physis. Continued growth of the physis after vascularized bone transfer was demonstrated by Weiland in a dog model as reported by Burwell et al.⁴. Microvascular transfer of the combined physis and epiphysis after digital amputation has resulted in longitudinal growth in children²⁰.

We describe the case of a patient who had excision of an osteosarcoma of the proximal part of the humerus. The skeletal defect was treated with insertion of a microvascularized free fibular graft, including the proximal physis and epiphysis, into the glenohumeral joint. The proximal physis remained open and demonstrated continued growth and remodeling four years after the transfer.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Department of Orthopaedics, University of Utah School of Medicine, 50 North Medical Drive, Salt Lake City, Utah 84132.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Department of Orthopaedics, University of Utah School of Medicine, 50 North Medical Drive, Salt Lake City, Utah 84132.

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Fig. 1: Radiograph made when the patient was eight years old, showing an osteosarcoma of the proximal part of the humerus (arrowhead).

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Fig. 2: Radiograph made three days after excision of the tumor and reconstruction of the skeletal defect with a vascularized fibular graft.

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Fig. 3: Radiograph made seventeen months postoperatively, showing the fracture that was sustained when the patient was thrown from a horse. There is proliferative formation of callus about the vascularized fibular graft and some shortening of the graft.

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Fig. 4: Radiograph made forty-nine months postoperatively. The fibular physis of the vascularized graft remains open and the graft has hypertrophied. The fibular head has grown and remodeled to a more spherical shape, but the diaphyseal component has not remodeled completely.

Case Report

Introduction | Case Report | Discussion | References

An eight-year-old girl was seen because she had had pain in the right shoulder for three months. There was no history of trauma. The findings on the neurological examination and the range of motion of the right upper limb were normal. The motor strength was grade 5 of 5. No mass was detected on palpation. Radiographs revealed a lesion in the proximal part of the humerus that was consistent with the appearance of an osteosarcoma (Fig. 1). A bone scan showed no other osseous lesions, and a computerized tomography scan of the chest was negative for evidence of metastatic disease.

An incisional biopsy was performed. Histological examination of the specimen demonstrated osteoid formation within a pleomorphic, anaplastic cellular background. The pathological diagnosis was that of a high-grade osteosarcoma. A preoperative chemotherapy protocol, which included Adriamycin (doxorubicin; sixty milligrams per square meter of skin), cisplatin (180 milligrams per square meter of skin), and methotrexate (twelve grams per square meter of skin), was initiated.

After the preoperative chemotherapy had been completed, a wide excision of the lesion that included the proximal part of the humerus, the rotator cuff, and part of the deltoid was performed. The radial nerve was preserved. A fibular graft was obtained from the right leg, with the distal twelve centimeters of the fibula left intact. Because the ankle mortise was left intact, no reconstruction of the donor site was done. The wound was closed in layers over a drain. The length of the fibular graft was matched to that of the excised portion of the humerus. The graft, including the entire proximal part of the fibula and its epiphysis, was placed into the glenohumeral joint. The graft was then secured to the humeral diaphysis with a plate and screws, and the fibular head was stabilized in the glenohumeral joint with a Kirschner pin (Fig. 2). The anastomosis of the fibular vessels was to the brachial artery and vein. The total operative time was six hours, and the estimated loss of blood was 500 milliliters.

Clinically, the arms appeared equal in length after the operation. A bone scan made on the fifth postoperative day demonstrated perfusion of the fibular graft. The Kirschner pin was removed three weeks postoperatively.

The pathology report described a margin that was free of tumor, but the specimen showed 30 per cent tumor viability. Therefore, the postoperative chemotherapy regimen was changed to VP-16 (etoposide; 100 milligrams per square meter of skin for six days) and ifosfamide (1800 milligrams per square meter of skin for six days).

The postoperative course was uncomplicated. Three weeks after the operation, progressive passive range-of-motion exercises were initiated. The patient had very little pain with these exercises. At six weeks, gentle active range-of-motion exercises were begun. Full range-of-motion exercises were not started for approximately three months, in order to protect the site of osteosynthesis. Although the passive range of motion was normal, the active range of motion remained limited because of limited function of the deltoid after the operation.

Six months postoperatively, the physical examination showed a full passive range for forward flexion, abduction, and internal and external rotation. Active abduction and forward flexion were to 70 degrees each. Motor strength was grade 4 of 5.

Seventeen months after the operation, the patient returned to our clinic. Four weeks earlier, she had been thrown from a horse and had sustained a fracture of the fibular graft. Radiographs demonstrated some fracture-shortening, which was estimated to be four or five millimeters (Fig. 3). The graft showed proliferative formation of callus. The clinical examination revealed little pain with motion. The fracture healed eight weeks after the injury.

Radiographs made thirty-seven months after the operation showed that the physis of the vascularized fibular graft was open and the graft had hypertrophied. The fibular head demonstrated continued growth and remodeling to a more spherical shape. The diaphyseal portion of the graft had not completely remodeled, and some of the shortening may have occurred at the time of the fracture. The actual length of the graft had increased by approximately four millimeters. These measurements were made with use of the constant length of the plate to adjust for radiographic magnification.

Forty-nine months after the operation (Fig. 4), the right upper limb was two centimeters shorter than the left upper limb. The passive range of motion of the right shoulder was abduction to 160 degrees, forward flexion to 150 degrees, internal rotation to the level of the sixth thoracic vertebra, and external rotation to 70 degrees. The active range of motion was abduction to 60 degrees, forward flexion to 80 degrees, internal rotation to the level of the twelfth thoracic vertebra, and external rotation to 45 degrees. Although active motion was limited, the patient was able to comb her hair with the right hand.

The patient was evaluated with use of two clinical scoring systems for assessment of the outcome of limb-salvage procedures. According to the functional evaluation system of the Musculoskeletal Tumor Society¹⁰, she had a score of 25 points. This was 83 per cent of the possible total of 30 points, with the score having been downgraded 2 points for loss of function, 1 point for limitation with regard to positioning of the hand, and 2 points for limited lifting ability. With use of the system of Mankin et al.¹⁷, in which the result is classified as excellent, good, fair, or a failure, she was given a rating of good. This indicated that she had no evidence of disease and, although the function of the shoulder was reduced, she did not need a brace or other support to return to most daily activities.

The site from which the fibular graft had been obtained was assessed clinically. The patient reported no pain, weakness, paresthesias, or instability of the ankle. There was no evidence of a limb-length discrepancy or a valgus deformity²¹. The range of motion and the stability of the ankle were comparable with those on the contralateral side. Radiographs made thirty-seven months after the operation showed a normal ankle joint.

Discussion

Introduction | Case Report | Discussion | References

In 1975, Taylor et al.²⁷ described the technique for reconstruction of a large tibial defect with a free vascularized fibular graft in two patients. Since then, numerous studies have demonstrated that microvascularized transfer of bone can be effective for the reconstruction of large skeletal defects, including those due to trauma^5,15,34, resection of a tumor^{1,2,11,12,14,19,23,28,30,31,33}, infection^5,30,34, and congenital tibial pseudarthrosis^6,24,26,32.

Jupiter et al.¹⁶ demonstrated that, after secondary reconstruction procedures, mature vascularized fibular grafts respond in a manner similar to normal cortical bone. The patient described in the current report sustained a fracture of the vascularized fibular transplant seventeen months after the operation. The fracture healed within eight weeks with abundant formation of callus, which suggests that this autogenous graft functioned in a manner similar to normal vascularized bone. Unlike normal vascularized bone, the graft did not completely remodel, as there was still some deformity in the diaphyseal component. Although the fibular epiphysis remodeled and expanded, there was little over-all increase in axial length. This may have been related to the shortening that occurred at the time of the fracture.

In summary, our skeletally immature patient who had a wide excision of the proximal part of the humerus for the treatment of an osteosarcoma and replacement with a microvascularized free fibular graft, including the proximal physis and the epiphysis, had continued growth of the epiphysis, and the fibular head remodeled to a more spherical shape within the glenoid. Therefore, we believe that our patient benefited from the use of a microvascularized fibular graft with the proximal physis left intact.

References

Introduction | Case Report | Discussion | References

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