Proximal tibial reconstruction with auto transplantation of the fibular growth plate: two case reports, describing the surgical technique
© Baptista et al. 2016
Received: 20 May 2015
Accepted: 23 March 2016
Published: 20 April 2016
Tumors of the proximal tibia, in children, can affect the growth plate and pose a challenge to further reconstruction of the bone defects resulting from tumor resection. Reconstruction methods do not always compensate the potential for bone growth in this segment. We present a new surgical technique of bone reconstruction, based on the transposition of the ipsilateral fibula with its growth plate and the use of an internal sliding fixation device, without need for microsurgical technique.
We report two patients with osteosarcoma of the proximal tibia affecting the growth cartilage who were treated with the new technique.
Discussion and Evaluation
In both cases, bone healing, hypertrophy and longitudinal growth of the transposed fibula were documented.
This new technique preserves the blood supply of the auto-transplanted bone segment, maintaining physeal growth potential, with no need for microsurgery. The implant allows longitudinal bone growth, which was radiographically confirmed.
Level of evidence
Case report, Level IV.
KeywordsGrowth Sliding Device Fibula Physis Fixation Sarcoma Tibialization Transplant
In young patients, reconstruction of bone defects resulting from tumor resection of this segment with traditional methods may show poor results after skeletal growth (Boyer et al. 1994). Some of this current methods include the replacement of the bone segment by megaprothesis, callotasis and the use of bone autograft or allograft (Saghieg et al. 2010). None of these techniques can replace the injured growth plate. Although callotasis allows bone lengthening, it may be impractical due to the need of multiple interventions for limb equalization in young children and the prolonged use of an external fixator device, which may favour infection in immunosuppressed oncological patients.
The advance of vascularized fibula autograft by microsurgical technique has allowed its use with the functioning physis in distant locations from its anatomical site (Agiza 1981; Langenskiöld 1983; Taylor et al. 1975). This has enabled the reconstruction of bone defects while keeping its growth potential (Pho et al. 1988). This technique, however, is costly and has potential complications.
In this study we describe a new surgical technique for reconstruction of bone lesions that compromise the proximal tibia and its growth plate in children and report two cases successfully treated with this technique. The patients, or their family, gave their consent for the use of their personal and medical information for the publication of this case report.
A 12 year old male patient with osteosarcoma of the proximal right tibia underwent wide tumor resection, with preservation of the proximal tibial epiphysis. The proximal fibula was medially transferred with its physis to the tibial epiphysis, preserving its blood supply, and osteosynthesis was performed with an extendable internal fixation device. After surgery, the limb was kept in an orthesis.
In the fourth postoperative month, radiographic evidence of consolidation was observed and load bearing was initiated with crutches. Full weight bearing started when fibular hypertrophy was radiographically evidenced, which occured at 14 months pos operatively. During follow up the patient returned to his full activities.
Load bearing was initiated in the third postoperative month. The patient continued on adjuvant chemotherapy and, in the fourth month, resumed walking without orthesis. During the first 8 months of follow up, approximately 0.3 cm growth of the transposed fibula was observed. Distal bone healing and initial fibular hypertrophy were radiographically confirmed (Fig. 9c, d). Non bone healing has occurred in the proximal fibula with the remnant epiphysis. Even though, full weight bearing occurred at 9 months after surgery (Additional file 5: Video 4), demonstrating the stability promoted by the Baptista’s extendable internal fixation device. After that period the patient died due to chemotherapy related complications.
Reconstruction of bone defects resulting from resection of tumors compromising the growth cartilage of the proximal tibia in children represents a challenge to the orthopedist. Due to the low frequency of these lesions, this is a rare situation, in which our technique is for a specific indication: Proximal tíbia tumors resections when the growth line must be removed for oncological reason, but the epiphysis can be preserved, in children with remnant limb growth potential.
Yoshida et al. (2010), has compared multiple reconstruction alternatives at the knee level after tumor resection. They demonstrated that when epiphyseal maintenance is feasible, the vascularized fibular graft or callotasis techniques offers the highest score in the MSTS rating system (Enneking et al. 1993).
Distraction osteogenesis with external fixator eliminates the need of graft and allows padding of the bone defects created by tumor resection through callostasis. It requires, however, long periods with an external fixator device, which increases the risk of infection in patients potentially immunosuppressed by adjuvant oncological treatment (Kapukaya et al. 2000).
Bone grafts have been used for reconstruction of proximal tibial resections, especially in cases where the tibial epiphysis can be preserved (Honoki et al. 2008), which occurs in up to 20 % of cases (Norton et al. 1991; Simon and Bos 1980). When the graft is not vascularized, the technique presents high rates of fracture or non-union, and it does not prevent further limb discrepancy (Muscolo et al. 2004). Weitao et al. (2012) reported the use of allograft in the proximal tibia in 5 patients after tumor resection preserving the epiphysis. Delayed bone healing in Allograft-host junction were seen in all cases.
Transposition of the fibula shows advantages over the allograft in the bone healing process. Since it is a bone-muscle flap with natural vascularization, bone turnover is preserved and actively participates in the process of bone healing, while the growth potential of the physis is maintained. As seen in Figs. 7 and 9, the fibula undergoes progressive hypertrophy and strengthening, in contrast to allograft, which may fail even years after integration (Date et al. 1996; Hriscu et al. 2006).
The transfer of the fibula with its growth plate as a reconstruction method requires long term rehabilitation and late resuming of loadbearing ambulation, until bone healing of the tibia and the transposed fibula occurs. Hypertrophy of the fibula, which was reported in our two cases, evidences that the bone has achieved enough resistance required for loadbearing. Since this is a biological reconstruction method, once consolidation and hypertrophy occur, it can be considered a definitive solution, carried out with a single surgical procedure. The preservation of the proximal epiphysis of the tibia while maintaining the articular surface of the knee by trans epiphyseal osteotomy represents a mechanical advantage. It is also a necessary condition to use a fibular transposition. The maintenance of longitudinal growth of the transposed fibular segment, as documented in our two patients, is of major importance, since it can prevent or minimize the final discrepancy of the lower limbs length after growth.
Capanna et al. (2007) presented a original solution for long bones intercalary defects reconstruction associating massive allograft with vascularized fibular autograft. Good results were presented in 57 patients with proximal tibia reconstruction, nevertheless this technique does not address final limb discrepancy. The authors developed a good alternative to reconstructions of bone defect of the proximal tibia, but require microsurgery technique, which increases the cost of the procedure and the availability of bone allograft compatible in size with the patient, which is not widely available in some countries.
Our technique has the advantage to waive any method of vascular reconstruction of the fibular segment, since vessels are preserved. Fibular hypertrophy and longitudinal growth of the transplanted bone segments were observed in the two reported cases. Distal bone healing was succeeded in both cases. Proximally, there was a non union in the second case, due to the non resection of the proximal fibular articular cartilage which is essential for bone healing. This patient was schedule to a second procedure to resect the articular cartilage of the proximal fibula, but he had a clinical complication, from chemotherapy, which led to death. During the first 8 months after surgery, however, growth of at least 0.3 cm of the transposed fibula was documented, suggesting preservation of the growth potential (Fig. 9).
The first patient developed a valgus deformity of the right knee in the immediate postoperative period, which was corrected within the first post-operative year, after bone growth and correction of slope of the screws (Fig. 7). Long term resolution of the tibial reconstruction defect was observed in this patient, as documented by the equal length and normal function of lower limbs in adulthood. In spite of the restricted indication, we believe that our technique can positively affect the long term outcome of young patients undergoing reconstruction of proximal tibial defects.
Reconstruction of the proximal tibia with a megaprosthesis represents a therapeutic option when epiphysis must be resected. It allows limb preservation and early ambulation but High rates of complications have been reported such as infection, aseptic loosening, mechanical failure, and limitation to physical activities (Saghieg et al. 2010; Gosheger et al. 2006; Campanacci et al. 2010; Fang et al. 2013). This method requires multiple surgical procedures for revisions, reaching 42 % implant failures in 10 years follow up (Jeys et al. 2008). When epiphyseal maintenance is feasible, megaprosthesis has fewer indications. When early ambulation is priority for low expectation of life patients.
The authors believe the excellent longterm results in the first case and the ability to restore limb growth potential in both cases, avoiding further salvage surgical procedures, justify the application of this meticulous technique. The extensible internal fixation device stabilizes the reconstruction with the ipsilateral fibula and allows bone growth through sliding of the plates.
The purpose technique is indicated in intercalary proximal tibial resection, when the growth plate is removed for oncological purpose, in young children. Especially with high growth potential. The technique is not indicated in cases of low expectation of life due to the time required to initiate ambulation. In these situations a megaprosthesis might be preferred. More patients should be included on future studies to validate the reproducibility of this new technique.
PB: Operated the two patients described with the technique proposed by him and conceived the work. Made the images and videos record of the cases described and edited those. Reviewed all the versions of this paper. CB: Participated in the second patient surgery and his post-operative care. He wrote the first summary of the work in the original language and reviewed all the others. FB: He collected data from medical records and reviewed the first patient in the ambulatory. Contributed to the bibliographic survey. DB: Updated the bibliographic survey, reviewed the medical record information, wrote the steps until final version of the work, including it, and translated into English. All authors read and approved the final manuscript.
Work performed in the Department of Orthopedics and Traumatology, of the Faculty of Medical Sciences of Santa Casa de São Paulo.
The present work were approved by the Ethical review committee of the Santa Casa de Misericordia de São Paulo.
The authors declare that they have no competing interests.
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