Biological reconstruction after resection of bone tumors of the proximal tibia using allograft shell and intramedullary free vascularized fibular graft: Long‐term results

Abstract

Reconstruction after excision of bone tumor of the proximal tibia is a challenging issue for the reconstructive surgeon. The combined use of a free fibular flap and allograft can provide a reliable reconstructive option in this location. This article describes the authors' long-term follow-up using this technique. Twenty-seven patients that had resection of proximal tibia bone tumors underwent reconstruction using this technique. Only 21 patients that had primary reconstruction were included in this study. All patients had their surgeries performed at least 24 months before the end of the study. The average age at time of operation was 18.1 years. The average follow-up time was 139.3 months. Limb salvage was 82.7%. The average length of the resected tibial segment was 15.3 cm and that of the residual proximal tibia remaining after resection was 2.7 cm. The average time of union of fibula was 5.4 months and for union of allograft was 19.1 months. Primary union of the allograft was achieved in 90.5% of cases. Full weight-bearing was achieved at an average of 21.6 months. Ten patients (47.6%) had 14 local complications. The (MTSRS) average score at final follow-up was 27.3. Local recurrences occurred in two patients (9.5%). Distant metastasis to the lung occurred in three patients (14.3%). One patient died of disease. This technique provides good long-term results in reconstruction of proximal tibia. The viability of the fibula is a cornerstone in both success of reconstruction as well as successful management of complications.

What Is the Outcome of Allograft and Intramedullary Free Fibula (Capanna Technique) in Pediatric and Adolescent Patients With Bone Tumors?

“…As a result of this, we feel children can be counseled that a return to some athletic activity is possible after limb salvage. This appears to be a higher percentage of patients achieving this level of function than has been previously reported after the Capanna technique or with the use of massive allografts alone where good to excellent Mankin scores were only seen in 49% to 74% of patients [2,6,17,21]. Although initially structurally superior to fibular grafts, the use of large cortical intercalary allografts for lower extremity limb salvage has been reported to have a high rate of complications as a result of the avascular nature of the graft including nonunion, infection, and fracture [5,17,29,33,34,36,43].…”

“…Although a majority of our patients in our series were undergoing chemotherapy, which has been shown to increase the risk of infection [11], we did not have any postoperative infectious complications. This is a lower rate of postoperative infection than has previously been shown for the Capanna technique, which has ranged from 4% to 33% [1,11,21,37]. Late donor site complications were minimal and no patient developed ankle instability.…”

“…The preservation of the articular cartilage is thought to provide joint stability, longevity of the joint, and, if the growth plate can be preserved and not hampered by fixation devices, limb growth may be unimpeded [34]. Because the Capanna technique allows for the preservation of these structures along with augmenting bony union, it provides a satisfactory biological reconstruction technique for pediatric patients [21].…”

“…The combination of the osteogenic potential of the vascularized free fibula and the structural support of the cortical allograft make the use of these grafts particularly attractive in the reconstruction of bony defects in young patients. Previous reports have noted early success with this technique [1,11,21,37]; however, few reports have examined survival and complications associated with reconstruction in the pediatric and adolescent patient population, including the requirements for late limb lengthening and donor site morbidity [31]. The purpose of this study was to examine the outcomes using this technique for lower extremity limb salvage surgery in the pediatric and adolescent patient populations with a focus on long-term limb function and growth.…”

Free vascularised fibular grafts in orthopaedics

“…The biggest downside to using FVFGs in this context is their smaller cross-sectional diameter, particularly when reconstructing the femur, tibia and humerus; hence, there are usually delays in patient weightbearing. Graft hypertrophy takes time, which may be unacceptable in sarcoma patients who may have a shorter life expectancy, and it is sometimes necessary to use a doublebarrel transplant or a combined FVFG and allograft in these cases [40,41].…”