Cheng-hua Tang
RECONSTRUCTION OF THE BONES AND JOINTS OF THE UPPER EXTREMITY BY VASCULARIZED Downloaded by: National University of Singapore. Copyrighted material.
FREE FIBULAR GRAFT: REPORT OF 46 CASES ABSTRACT The vascularized free fibular graft was applied in reconstructing bone and joint structures of the upper extremity in 46 cases between August, 1977 and December, 1989. Among these, 30 were grafts of the fibular shaft and 16 were grafts of the fibular head. There were 19 bony defects after trauma or osteomyelitis, 18 bony or articular defects after resection of tumors, five congenital deformities or defects, and four replacements for fibrous dysplasia. The longest grafted fibula was 22 cm and the shortest, 5 cm. Thirty-one cases were followed for more than two years, and these were evaluated for functional ability in daily living, roentgenologic appearance, and " m Tc scan during follow-up. The results revealed quite sufficient functional restoration, solid bone healing, and adequate blood supply, in most cases. The vascularized free fibular head graft appears to be an ideal procedure for the reconstruction of defects of the lower end of the radius or the upper humerus, including the humeral head. The stability of the reconstructed wrist or shoulder joint was maintained by suturing the lateral collateral ligament, the palmar collateral ligament around the wrist, or by passing the long head of the biceps brachii through the grafted fibula at the shoulder. Methods for fixation of the fibular shaft to the recipient bone and the selection of vessels for anastomoses, both in the graft and at the recipient site, are discussed. The importance of postoperative functional exercise is emphasized.
The introduction of the vascularized free fibular graft offered an excellent method for the treatment of long-segment bone defect.1 Subsequently, in the late 1970s, the vascularized fibular-head graft was used to reconstruct the articular structures of the upper extremities. 23 These new therapeutic procedures made it possible to carry out more satisfactory reconstructions with better functional recovery. Therefore, these procedures have been utilized by increasingly more clinicians, to the benefit of increasingly larger numbers of patients. We have used vascularized fibular-shaft or fibular-head grafts in reconstructing bone and joint structures in the upper extremities in 46 cases during
the past 12 years. This paper is a summary report of our experiences.
MATERIALS AND METHODS
~
Between August, 1977 and December, 1989, vascularized free fibular transplantations have been used in 46 patients for reconstructive procedures. Among these, 30 were grafts of the fibular shaft, and 16 were grafts of the fibular head. Patient ages ranged from 3 to 52 years, with an average of 25 years. There were 12 traumatic or post-osteomyelitic bony defects; seven
Department of Orthopedics, Shanghai Sixth People's Hospital, Shanghai Reprint requests-. Dr. Tang, Orthopedic Dept., Zhabei Central Hospital, 619 New China Rd., Zhabei, Shanghai, PRC (until December, 1992) Accepted for publication February 25, 1992 Copyright © 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
285
traumatic bone non-unions; 14 bony defects after giant cell tumor resection; five congenital deformities; four bony defects after resection of fibrous dysplasia; and one case each of resection of paracortical osteosarcoma, bone cyst, chordoblastoma, and multiple exostosis. A combination of high and low epidural anesthesia was usually administered, although low epidural anesthesia plus brachial plexus block or general anesthesia may also be used. Two teams of surgeons operated simultaneously. One team harvested the fibula, while another team prepared the recipient site in the upper limb. With the patient in a prone position, the fibula was harvested through a lateral approach. A 5-to-10 mm sleeve of muscle was routinely preserved whenever the fibular shaft or head was taken. The vascular pedicle was not sectioned until the recipient site was ready. After resection of the tumor, necrotic tissue, or excision of sclerotic bone ends, the longest bony defect measured 21 cm and the shortest, 4.5 cm. The longest fibular graft was 22 cm, while the shortest was 5 cm, with an average of 13.1 cm. Types of bone fixation and vascular anastomoses are shown in Tables 1 and 2. One fibular artery and one fibular vein were anastomosed with the recipient vessels, except in two cases in which two veins of the grafted fibula were respectively anastomosed with a superficial vein and a deep
Table 1. Graft Fixation Methods with Recipient Bone Number of Cases Type of Fixation
Proximal End
Distal End
15
17
10
8
7
7
1
3
4
4
Insertion of the fibula to the intramedullary cavity, screw fixation Step-cut osteotomy in both graft and recipient, screw fixation Insertion of fibula into bone ends, screw fixation Insertion of deformed recipient bone into medullary cavity of fibula Fixation with K-wire
Table 2.
vein of the upper extremity. End-to-side anastomosis was utilized only in anastomosing the donor vessels with the brachial arteries and veins, while end-to-end anastomosis was done in all other cases. The anastomoses were done with interrupted sutures of 9-0 nylon monofilament under the operating microscope. Time necessary for harvesting the fibular graft was 30minto 1.5 hr (average: 55 min); total operating time was 10 hr at the longest and 2.5 hr at the shortest, with an average of 5.5 hr. The operated limb was immobilized in a long arm cast for at least 3 months postoperatively. Union of the grafted fibula with the recipient bone was determined regularly by roentgenographic and clinical evaluation. Joint motion or exercise were started as soon as external fixation was released, while weight bearing was not permitted until solid bone union was confirmed by x-ray and the graft began hypertrophy.
CASE REPORTS CASE 1. This patient was a female, 30-year-old clerk. She had a history of a fall 10 years previously, after which pain and limited motion of the left shoulder occurred. Roentgenography revealed a giant-cell tumor of the upper end of the left humerus and pathologic fracture. Excision of the lesion followed by bone grafting, were done at that time. Follow-up revealed recurrence of the tumor two years ago (Fig. 1). The tumor was observed to extend for a length of 6 cm along the longitudinal axis of the humerus, and a 13-cm segment of upper humerus was therefore resected during the operation. The vascularized fibular head with its shaft, measuring 16 cm in length, was harvested from the contralateral leg, and transplanted to the defect in the upper humerus. The distal end was inserted into the medullary cavity of the humerus. After appropriate length and good approximation of the fibular head and glenoid were confirmed, the graft was fixed to the recipient bone with two screws. The tendon of the long head of the biceps was transected 2 cm proximal to the musculotendinous junction, and
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Artery
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Donor
Recipient
Fibular a.
Deep brachial a. Radial a. Ulnar a. Brachial a. Anterior circumflex humeral a. Posterior circumflex humeral a.
Cases 10
Donor
Recipient
Cases
Fibular v.
Cephalic v. Brachial v. Anterior circumflex humeral v. Anterior cubital v. v. of dorsal wrist Radial v. Deep brachial v. Basilic v. Posterior circumflex humeral v.
18 6 4 4 3 3
2 1 1
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Figure 1. Case 1. Recurrence of giant cell tumor in left humeral head with pathological fracture.
Figure 2. Case 1. The grafted fibula was in a good position, and solid bony union of the graft with the recipient bone was observed on x-ray five months after operation.
the proximal cut end was passed obliquely through the grafted fibular head. The proximal biceps tendon was then sutured at the distal end, using Bunnell's crisscross sutures. The peroneal artery and vein were anastomosed to the brachial artery and vein, respectively, by end-to-side anastomosis. Postoperative x-ray film showed the grafted fibula in a good position, with solid union of the fibula to the humerus five months after surgery (Fig. 2). Follow-up two years later revealed that the reconstructed shoulder joint had restored function to 60 degrees of abduction, 45 degrees of adduction, 80 degrees of flexion, and 30 degrees of extension. A weight of 5 kg could be carried on the left side. CASE 2. This patient was a 24-year-old male farmer. He was born with a deformed, shortened, and pseudarthritic right arm. X-ray showed the humerus to be slender, curved, and defective in its central segment. The right elbow joint was structurally deformed, and the right ulna constricted and thin (Fig. 3). The patient was admitted with a diagnosis of congenital malformation of the right humerus. The bone ends in the central portion of the deformed humerus were remolded during the operation, and a bony defect of about 9 cm in length remained. The defect was filled by a homolateral fibular-shaft graft measuring 12.5 cm in length. The ends of the graft
Figure 3. Case 2. Congenital deformity and pseudoarthritis of the right humerus.
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were inserted 1.5 cm into the intramedullary cavity of the grafted fibular shaft, with the proximal junction stabilized by one screw (Fig. 4). The peroneal artery and vein were anastomosed to the deep brachial artery and vein, respectively. The operated limb was immobilized postoperatively by a long arm cast for three months.
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Follow-up six months later showed that the results were satisfactory. The patient could lead a normal life and take part in farm labor without notable discomfort. CASE 3. This patient was a 38-year-old male barber. He complained of swelling and pain of the left wrist for four months, and was admitted because x-ray revealed a giant-cell tumor at the distal end of the radius (Fig. 5). Angiography was carried out to demonstrate the vasculature in the wrist and hand before operation. The tumor was found during surgery to extend longitudinally for 3.5 cm, and it protruded into the surrounding soft tissue. It was resected, together with an 8-cm segment of the lower end of the radius. A 10cm segment of vascularized right fibular head with its shaft was taken and transplanted to the defect of the distal radius. The ends of the donor and recipient bones were trimmed in a step-like shape, opposed to each other, and fixed with two screws. The fibular artery and vein were anastomosed with the radial artery and its venae comitantes, respectively. The soft tissue around the fibular head was sutured to the palmar and dorsal ligaments, the radial collateral ligament, and the articular capsule of the wrist joint. X-rays taken after cast removal showed good bone healing (Fig. 6). Nearly normal function of the wrist was restored and the patient returned to his original work as a barber eight months after surgery (Figs. 7, 8).
i RESULTS Figure 4. Case 2. The deformed segment of humerus was resected and replaced by a graft of vascularized fibular shaft.
288
Thirty-one patients have been regularly followed for more than two years. The longest follow-up period was 12 years. Evaluative items of follow-up included
Figure 5. Case 3. Giant cell tumor at the distal end of the radius.
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in the reconstructed parts; fair—able to meet the needs of daily life partially but having significant inconvenience at times; poor—unable to carry on daily life, or with significant shortening of the limb, or pain or discomfort at the operative sites. Roentgenologic evaluations were-, excellent—single operation, well healed within half a year, 99mTC s c a n showed good circulation of the bone; good—single operation, well healed within one year; fair—single operation, healed after more than one year, or bone healing after repeated operations; poor—failure of healing after repeated operations. All cases showed good circulation by 99mTC s c a n one year after surgery. Results of the follow-up are shown in Tables 3 and 4.
CASE SELECTION AND OPERATIVE INDICATIONS.
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DISCUSSION Au-
togenous vascularized fibula transplantation offers a satisfactory method for the reconstruction of shoulder and wrist joints, or for segmental defect of the bone shaft in the upper extremity. There is no danger of foreign-body synthetic-graft reaction, or loosening of graft fixation, as may often happen in bone allograft or Figure 6. Case 3. X-ray showed obvious bony callus 45 formed around the junction of the fibula and the radius after prosthesis implantation. For traumatic defects of cast removal. less than 6 cm, many surgeons use a vascularized iliac bone graft, while we prefer a vascularized fibular graft, because the fibula is relatively easy to harvest, tubular (1) patients' adaptability to daily life and professional in structure, and tends to hypertrophy to a size similar work; (2) condition of the bones as shown by x-ray; and to the shaft of the recipient bone in the upper limb. (3) results of 99mTC scanning. Criteria for evaluation Vascularized fibular grafts were used in our Deincluded (1) functional assessment, i.e., life and work partment following resection of benign tumors or tumors adaptability, rated as: excellent—able to satisfactorily of low- or medium-grade malignancy, such as paracorcarry on daily life and to work or study normally; tical osteosarcoma, chondroblastoma, and giant-cell good—able to carry on daily life, with no discomfort tumor with malignant change. These tumors were usu-
Figure7. Case3.Dorsiflexionof the reconstructed wrist.
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Figure 8. Case 3. Palmar flexion of the reconstructed wrist.
ally excised up to 7 cm beyond the tumor margin, along with their surrounding soft tissue, if invaded. After marrow examination taken at the cut end proves to be negative for tumor cells, the vascularized fibular graft is then harvested to fill the defect. Reconstruction of bony defects after resection of high-malignancy bone tumors has been reported recently;7 however, we have not attempted it in the upper extremity as yet. MAINTENANCE OF STABILITY OF RECONSTRUCTED JOINTS.
When the fibular head is transplanted to replace a resected head of humerus, the reconstructed shoulder joint is often unstable, because of the small size of the fibular head and its lack of broad articular surface. In order to stabilize the grafted head, the long tendon of the biceps brachii was cut at the level of the surgical neck of the humerus, before resecting the humeral head. The distal and proximal cut ends were then dissected free from the surrounding tissue and from the humeral head, respectively. An oblique hole was drilled through the fibular head from its inner surface downward and lateral at an angle of 30 to 45 degrees.
Table 3. Functional Recovery Excellent Number of cases Percentage (%)
Table 4.
13 41.9
290
11 35.5
Fair 5 16.1
Poor 2 6.5
Total 31 100
Roentgenologic Evaluation Excellent
Number of cases Percentage (%)
Good
22 71.0
Good 8 25.8
Poor
Total
1
0
31
3.2
0
100
Fair
The proximal end of the cut t e n d o n was then led through the hole from inside outward, and sutured with the distal cut end. With this procedure, the fibular head can be effectively kept close to the glenoid cavity of the scapula (Fig. 9). Normally, the dorsal border of the distal end of the radius extends lower than the palmar border, causing a palmar tilt at an angle of 10 to 15 degrees. The styloid process is lower than the medial border of the distal end of the radius by 1.0 to 1.2 cm, forming a radial inclination of the articular surface of 20 to 25 degrees. To meet the anatomic requirements, it is more appropriate to use a contralateral fibula as donor. The tip of the fibular head should b e placed lower than the styloid process of the ulna. About 0.5 to 1.0 cm of the biceps femoris tendon at its insertion and the joint capsule of the tibiofibular joint were preserved when the head was taken, and later sutured t o the radial collateral ligament of the wrist and the palmar and dorsal joint capsuleof the wrist (Fig. 10). Such ligamentous or capsular reconstructions may prevent joint dislocation and enhance the stability of the reconstructed joint. Some authors fix the fibula with transarticular fixation by Kirschner wires; however, we did not use this kind of fixation, since it may injure the articular surfaces of the graft and the carpal bones. SELECTION OF METHODS FOR BONE FIXATION.
In
cases of recipient bone of similar diameter t o the donor, step-cut osteotomies are m a d e in each b o n e and the donor is fixed t o the recipient with one or two screws. This technique is frequently used in joining fibula to ulna or radius. If the diameter of o n e end of the grafted fibula is similar t o that of the recipient bone while the other is much smaller, the latter end can be inserted into the recipient bone, and the ends of similar size may b e fixed in the same way as described above. This technique is often used in the repair of
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CHOICE OF BLOOD VESSELS FOR ANASTOMOSIS.
Figure 10. Ligamentous reconstruction of the wrist joint during surgery.
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Figure 9. Maintenance of stability of the reconstructed shoulder and fixation of the grafted fibula.
defects in the mid-upper segment of the ulna, midlower segment of the radius, and upper or lower segments of the humerus. When both ends of the fibular graft are of much smaller diameter than the recipient bone, the smaller ends are both inserted into the medullary cavity of the larger recipient bone and fixed with screws, a technique often used in grafting fibula to reconstruct defects of the humerus. In cases of bone shaft defects reconstructed by fibular graft, it is necessary only to approximate the ends and to fix each juncture with one screw. When the fibular head is used to replace the distal end of the radius or the head of the humerus, it is advisable to place two screws at the ladder-step juncture, to reduce shearing stress. These two screws should be placed at an angular distance of about 30 degrees, to prevent longitudinal splitting of the bone. In our experience, there was little interference with blood circulation after these modes of fixation, and healing was solid and dependable. Not a single case in this series showed evidence of refracture or loosening of the graft during follow-up. We do not usually accomplish fixation by applying Kirschner wires that pass through the medullary cavity of the fibula, for fear of compromising the intramedullary circulation. Unexpectedly, in four cases of congenital anomalies of the radius in children, where we were compelled to use Kirschner wires for fixation, the results were rather satisfactory. Further research is needed to clarify whether this can be done in adults. Tay-
lor used the anterior tibial artery and veins as the vascular pedicle for the grafted fibula head.8 Mizumoto used the lateral inferior genicular artery (LIGA) and its veins for anastomosis. 910 We found during the operation, that the use of the peroneal artery and veins was sufficient for blood supply to the tip of the fibular head, confirmed by obvious bleeding from the tip before cutting the pedicle. The peroneal artery and vein alone were used in all cases in our series for fibular-head transplantation. Recipient vessel selection was made after accomplishing bone fixation. In the forearm, the radial or ulnar vessels were usually selected; however, there is more flexibility in choosing the artery and vein for anastomosis in the upper arm. Selection of recipient vessels was decided according to the position and direction of the donor vascular pedicle, as seen after fibular fixation. At the upper humeral level, the anterior and posterior circumflex humeral arteries may also be used. The brachial and deep brachial arteries can be used as recipient vessels along their whole length. Since the superficial veins are usually wider and easier to dissect, they were usually preferentially chosen for anastomosing with the peroneal vein. One vein was sufficient for venous return in most cases; however, another deep vein was needed to anastomose with the peroneal vein, if the venous drainage through only one vein proved to be insufficient.
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REFERENCES
resection and free vascularized iliac bone graft. Clin Orthop 202:232, 1986 Usui M, Ishii S, Yamamura M, et al.: Microsurgical reconstructive surgery following wide resection of bone and soft tissue sarcomas in the extremities. J Reconstr Microsurg 2:77, 1986 Taylor GI, Wilson KR, Rees MD, et al: The anterior tibial vessels and their role in epiphyseal and diaphyseal transfer of the fibula: Experimental study and clinical applications. Br I Plast Surg 41:451, 1988 Mizumoto S: Free vascularized fibula head transplantation after resection of giant cell tumor in the distal radius: Report of two cases. ] [apn Soc Surg Hand 5:694, 1988 10. Mizumoto S: Vascular anatomy of the proximal fibula: An anatomical study for vascularized fibula head graft. J Japn Soc Surg Hand 5:690, 1988
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Taylor GI, Miller GD, Ham FJ: The free vascularized bone graft: A clinical extension of microvascular techniques. Plast Reconstr Surg 55:533, 1975 Pho RWH: Free vascularized fibular transplantation for replacement of lower radius. I Bone Joint Surg 61B:362, 1979 Weiland AJ, Kleinert HE, Kutz JE, Daniel RK: Free vascularized bone grafts in surgery of the upper extremity. I Hand Surg 4: 129, 1979 Campanacci M: Resection of the distal end of the radius. Ital Orthop Traumatol 5:145, 1977 Murray JA, Schlafly B: Giant-cell tumors in the distal end of the radius. I Bone Joint Surg 68A-.687, 1986 Leung PC, Chan KT: Giant-cell tumor of the radius treated by
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RECONSTRUCTION OF THE BONES AND JOINTS OF THE UPPER EXTREMITY BY VASCULARIZED Downloaded by: National University of Singapore. Copyrighted material.
FREE FIBULAR GRAFT: REPORT OF 46 CASES ABSTRACT The vascularized free fibular graft was applied in reconstructing bone and joint structures of the upper extremity in 46 cases between August, 1977 and December, 1989. Among these, 30 were grafts of the fibular shaft and 16 were grafts of the fibular head. There were 19 bony defects after trauma or osteomyelitis, 18 bony or articular defects after resection of tumors, five congenital deformities or defects, and four replacements for fibrous dysplasia. The longest grafted fibula was 22 cm and the shortest, 5 cm. Thirty-one cases were followed for more than two years, and these were evaluated for functional ability in daily living, roentgenologic appearance, and " m Tc scan during follow-up. The results revealed quite sufficient functional restoration, solid bone healing, and adequate blood supply, in most cases. The vascularized free fibular head graft appears to be an ideal procedure for the reconstruction of defects of the lower end of the radius or the upper humerus, including the humeral head. The stability of the reconstructed wrist or shoulder joint was maintained by suturing the lateral collateral ligament, the palmar collateral ligament around the wrist, or by passing the long head of the biceps brachii through the grafted fibula at the shoulder. Methods for fixation of the fibular shaft to the recipient bone and the selection of vessels for anastomoses, both in the graft and at the recipient site, are discussed. The importance of postoperative functional exercise is emphasized.
The introduction of the vascularized free fibular graft offered an excellent method for the treatment of long-segment bone defect.1 Subsequently, in the late 1970s, the vascularized fibular-head graft was used to reconstruct the articular structures of the upper extremities. 23 These new therapeutic procedures made it possible to carry out more satisfactory reconstructions with better functional recovery. Therefore, these procedures have been utilized by increasingly more clinicians, to the benefit of increasingly larger numbers of patients. We have used vascularized fibular-shaft or fibular-head grafts in reconstructing bone and joint structures in the upper extremities in 46 cases during
the past 12 years. This paper is a summary report of our experiences.
MATERIALS AND METHODS
~
Between August, 1977 and December, 1989, vascularized free fibular transplantations have been used in 46 patients for reconstructive procedures. Among these, 30 were grafts of the fibular shaft, and 16 were grafts of the fibular head. Patient ages ranged from 3 to 52 years, with an average of 25 years. There were 12 traumatic or post-osteomyelitic bony defects; seven
Department of Orthopedics, Shanghai Sixth People's Hospital, Shanghai Reprint requests-. Dr. Tang, Orthopedic Dept., Zhabei Central Hospital, 619 New China Rd., Zhabei, Shanghai, PRC (until December, 1992) Accepted for publication February 25, 1992 Copyright © 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
285
traumatic bone non-unions; 14 bony defects after giant cell tumor resection; five congenital deformities; four bony defects after resection of fibrous dysplasia; and one case each of resection of paracortical osteosarcoma, bone cyst, chordoblastoma, and multiple exostosis. A combination of high and low epidural anesthesia was usually administered, although low epidural anesthesia plus brachial plexus block or general anesthesia may also be used. Two teams of surgeons operated simultaneously. One team harvested the fibula, while another team prepared the recipient site in the upper limb. With the patient in a prone position, the fibula was harvested through a lateral approach. A 5-to-10 mm sleeve of muscle was routinely preserved whenever the fibular shaft or head was taken. The vascular pedicle was not sectioned until the recipient site was ready. After resection of the tumor, necrotic tissue, or excision of sclerotic bone ends, the longest bony defect measured 21 cm and the shortest, 4.5 cm. The longest fibular graft was 22 cm, while the shortest was 5 cm, with an average of 13.1 cm. Types of bone fixation and vascular anastomoses are shown in Tables 1 and 2. One fibular artery and one fibular vein were anastomosed with the recipient vessels, except in two cases in which two veins of the grafted fibula were respectively anastomosed with a superficial vein and a deep
Table 1. Graft Fixation Methods with Recipient Bone Number of Cases Type of Fixation
Proximal End
Distal End
15
17
10
8
7
7
1
3
4
4
Insertion of the fibula to the intramedullary cavity, screw fixation Step-cut osteotomy in both graft and recipient, screw fixation Insertion of fibula into bone ends, screw fixation Insertion of deformed recipient bone into medullary cavity of fibula Fixation with K-wire
Table 2.
vein of the upper extremity. End-to-side anastomosis was utilized only in anastomosing the donor vessels with the brachial arteries and veins, while end-to-end anastomosis was done in all other cases. The anastomoses were done with interrupted sutures of 9-0 nylon monofilament under the operating microscope. Time necessary for harvesting the fibular graft was 30minto 1.5 hr (average: 55 min); total operating time was 10 hr at the longest and 2.5 hr at the shortest, with an average of 5.5 hr. The operated limb was immobilized in a long arm cast for at least 3 months postoperatively. Union of the grafted fibula with the recipient bone was determined regularly by roentgenographic and clinical evaluation. Joint motion or exercise were started as soon as external fixation was released, while weight bearing was not permitted until solid bone union was confirmed by x-ray and the graft began hypertrophy.
CASE REPORTS CASE 1. This patient was a female, 30-year-old clerk. She had a history of a fall 10 years previously, after which pain and limited motion of the left shoulder occurred. Roentgenography revealed a giant-cell tumor of the upper end of the left humerus and pathologic fracture. Excision of the lesion followed by bone grafting, were done at that time. Follow-up revealed recurrence of the tumor two years ago (Fig. 1). The tumor was observed to extend for a length of 6 cm along the longitudinal axis of the humerus, and a 13-cm segment of upper humerus was therefore resected during the operation. The vascularized fibular head with its shaft, measuring 16 cm in length, was harvested from the contralateral leg, and transplanted to the defect in the upper humerus. The distal end was inserted into the medullary cavity of the humerus. After appropriate length and good approximation of the fibular head and glenoid were confirmed, the graft was fixed to the recipient bone with two screws. The tendon of the long head of the biceps was transected 2 cm proximal to the musculotendinous junction, and
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Artery
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Donor
Recipient
Fibular a.
Deep brachial a. Radial a. Ulnar a. Brachial a. Anterior circumflex humeral a. Posterior circumflex humeral a.
Cases 10
Donor
Recipient
Cases
Fibular v.
Cephalic v. Brachial v. Anterior circumflex humeral v. Anterior cubital v. v. of dorsal wrist Radial v. Deep brachial v. Basilic v. Posterior circumflex humeral v.
18 6 4 4 3 3
2 1 1
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Figure 1. Case 1. Recurrence of giant cell tumor in left humeral head with pathological fracture.
Figure 2. Case 1. The grafted fibula was in a good position, and solid bony union of the graft with the recipient bone was observed on x-ray five months after operation.
the proximal cut end was passed obliquely through the grafted fibular head. The proximal biceps tendon was then sutured at the distal end, using Bunnell's crisscross sutures. The peroneal artery and vein were anastomosed to the brachial artery and vein, respectively, by end-to-side anastomosis. Postoperative x-ray film showed the grafted fibula in a good position, with solid union of the fibula to the humerus five months after surgery (Fig. 2). Follow-up two years later revealed that the reconstructed shoulder joint had restored function to 60 degrees of abduction, 45 degrees of adduction, 80 degrees of flexion, and 30 degrees of extension. A weight of 5 kg could be carried on the left side. CASE 2. This patient was a 24-year-old male farmer. He was born with a deformed, shortened, and pseudarthritic right arm. X-ray showed the humerus to be slender, curved, and defective in its central segment. The right elbow joint was structurally deformed, and the right ulna constricted and thin (Fig. 3). The patient was admitted with a diagnosis of congenital malformation of the right humerus. The bone ends in the central portion of the deformed humerus were remolded during the operation, and a bony defect of about 9 cm in length remained. The defect was filled by a homolateral fibular-shaft graft measuring 12.5 cm in length. The ends of the graft
Figure 3. Case 2. Congenital deformity and pseudoarthritis of the right humerus.
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were inserted 1.5 cm into the intramedullary cavity of the grafted fibular shaft, with the proximal junction stabilized by one screw (Fig. 4). The peroneal artery and vein were anastomosed to the deep brachial artery and vein, respectively. The operated limb was immobilized postoperatively by a long arm cast for three months.
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Follow-up six months later showed that the results were satisfactory. The patient could lead a normal life and take part in farm labor without notable discomfort. CASE 3. This patient was a 38-year-old male barber. He complained of swelling and pain of the left wrist for four months, and was admitted because x-ray revealed a giant-cell tumor at the distal end of the radius (Fig. 5). Angiography was carried out to demonstrate the vasculature in the wrist and hand before operation. The tumor was found during surgery to extend longitudinally for 3.5 cm, and it protruded into the surrounding soft tissue. It was resected, together with an 8-cm segment of the lower end of the radius. A 10cm segment of vascularized right fibular head with its shaft was taken and transplanted to the defect of the distal radius. The ends of the donor and recipient bones were trimmed in a step-like shape, opposed to each other, and fixed with two screws. The fibular artery and vein were anastomosed with the radial artery and its venae comitantes, respectively. The soft tissue around the fibular head was sutured to the palmar and dorsal ligaments, the radial collateral ligament, and the articular capsule of the wrist joint. X-rays taken after cast removal showed good bone healing (Fig. 6). Nearly normal function of the wrist was restored and the patient returned to his original work as a barber eight months after surgery (Figs. 7, 8).
i RESULTS Figure 4. Case 2. The deformed segment of humerus was resected and replaced by a graft of vascularized fibular shaft.
288
Thirty-one patients have been regularly followed for more than two years. The longest follow-up period was 12 years. Evaluative items of follow-up included
Figure 5. Case 3. Giant cell tumor at the distal end of the radius.
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in the reconstructed parts; fair—able to meet the needs of daily life partially but having significant inconvenience at times; poor—unable to carry on daily life, or with significant shortening of the limb, or pain or discomfort at the operative sites. Roentgenologic evaluations were-, excellent—single operation, well healed within half a year, 99mTC s c a n showed good circulation of the bone; good—single operation, well healed within one year; fair—single operation, healed after more than one year, or bone healing after repeated operations; poor—failure of healing after repeated operations. All cases showed good circulation by 99mTC s c a n one year after surgery. Results of the follow-up are shown in Tables 3 and 4.
CASE SELECTION AND OPERATIVE INDICATIONS.
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DISCUSSION Au-
togenous vascularized fibula transplantation offers a satisfactory method for the reconstruction of shoulder and wrist joints, or for segmental defect of the bone shaft in the upper extremity. There is no danger of foreign-body synthetic-graft reaction, or loosening of graft fixation, as may often happen in bone allograft or Figure 6. Case 3. X-ray showed obvious bony callus 45 formed around the junction of the fibula and the radius after prosthesis implantation. For traumatic defects of cast removal. less than 6 cm, many surgeons use a vascularized iliac bone graft, while we prefer a vascularized fibular graft, because the fibula is relatively easy to harvest, tubular (1) patients' adaptability to daily life and professional in structure, and tends to hypertrophy to a size similar work; (2) condition of the bones as shown by x-ray; and to the shaft of the recipient bone in the upper limb. (3) results of 99mTC scanning. Criteria for evaluation Vascularized fibular grafts were used in our Deincluded (1) functional assessment, i.e., life and work partment following resection of benign tumors or tumors adaptability, rated as: excellent—able to satisfactorily of low- or medium-grade malignancy, such as paracorcarry on daily life and to work or study normally; tical osteosarcoma, chondroblastoma, and giant-cell good—able to carry on daily life, with no discomfort tumor with malignant change. These tumors were usu-
Figure7. Case3.Dorsiflexionof the reconstructed wrist.
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Figure 8. Case 3. Palmar flexion of the reconstructed wrist.
ally excised up to 7 cm beyond the tumor margin, along with their surrounding soft tissue, if invaded. After marrow examination taken at the cut end proves to be negative for tumor cells, the vascularized fibular graft is then harvested to fill the defect. Reconstruction of bony defects after resection of high-malignancy bone tumors has been reported recently;7 however, we have not attempted it in the upper extremity as yet. MAINTENANCE OF STABILITY OF RECONSTRUCTED JOINTS.
When the fibular head is transplanted to replace a resected head of humerus, the reconstructed shoulder joint is often unstable, because of the small size of the fibular head and its lack of broad articular surface. In order to stabilize the grafted head, the long tendon of the biceps brachii was cut at the level of the surgical neck of the humerus, before resecting the humeral head. The distal and proximal cut ends were then dissected free from the surrounding tissue and from the humeral head, respectively. An oblique hole was drilled through the fibular head from its inner surface downward and lateral at an angle of 30 to 45 degrees.
Table 3. Functional Recovery Excellent Number of cases Percentage (%)
Table 4.
13 41.9
290
11 35.5
Fair 5 16.1
Poor 2 6.5
Total 31 100
Roentgenologic Evaluation Excellent
Number of cases Percentage (%)
Good
22 71.0
Good 8 25.8
Poor
Total
1
0
31
3.2
0
100
Fair
The proximal end of the cut t e n d o n was then led through the hole from inside outward, and sutured with the distal cut end. With this procedure, the fibular head can be effectively kept close to the glenoid cavity of the scapula (Fig. 9). Normally, the dorsal border of the distal end of the radius extends lower than the palmar border, causing a palmar tilt at an angle of 10 to 15 degrees. The styloid process is lower than the medial border of the distal end of the radius by 1.0 to 1.2 cm, forming a radial inclination of the articular surface of 20 to 25 degrees. To meet the anatomic requirements, it is more appropriate to use a contralateral fibula as donor. The tip of the fibular head should b e placed lower than the styloid process of the ulna. About 0.5 to 1.0 cm of the biceps femoris tendon at its insertion and the joint capsule of the tibiofibular joint were preserved when the head was taken, and later sutured t o the radial collateral ligament of the wrist and the palmar and dorsal joint capsuleof the wrist (Fig. 10). Such ligamentous or capsular reconstructions may prevent joint dislocation and enhance the stability of the reconstructed joint. Some authors fix the fibula with transarticular fixation by Kirschner wires; however, we did not use this kind of fixation, since it may injure the articular surfaces of the graft and the carpal bones. SELECTION OF METHODS FOR BONE FIXATION.
In
cases of recipient bone of similar diameter t o the donor, step-cut osteotomies are m a d e in each b o n e and the donor is fixed t o the recipient with one or two screws. This technique is frequently used in joining fibula to ulna or radius. If the diameter of o n e end of the grafted fibula is similar t o that of the recipient bone while the other is much smaller, the latter end can be inserted into the recipient bone, and the ends of similar size may b e fixed in the same way as described above. This technique is often used in the repair of
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FREE FIBULAR GRAFT/TANG
CHOICE OF BLOOD VESSELS FOR ANASTOMOSIS.
Figure 10. Ligamentous reconstruction of the wrist joint during surgery.
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Figure 9. Maintenance of stability of the reconstructed shoulder and fixation of the grafted fibula.
defects in the mid-upper segment of the ulna, midlower segment of the radius, and upper or lower segments of the humerus. When both ends of the fibular graft are of much smaller diameter than the recipient bone, the smaller ends are both inserted into the medullary cavity of the larger recipient bone and fixed with screws, a technique often used in grafting fibula to reconstruct defects of the humerus. In cases of bone shaft defects reconstructed by fibular graft, it is necessary only to approximate the ends and to fix each juncture with one screw. When the fibular head is used to replace the distal end of the radius or the head of the humerus, it is advisable to place two screws at the ladder-step juncture, to reduce shearing stress. These two screws should be placed at an angular distance of about 30 degrees, to prevent longitudinal splitting of the bone. In our experience, there was little interference with blood circulation after these modes of fixation, and healing was solid and dependable. Not a single case in this series showed evidence of refracture or loosening of the graft during follow-up. We do not usually accomplish fixation by applying Kirschner wires that pass through the medullary cavity of the fibula, for fear of compromising the intramedullary circulation. Unexpectedly, in four cases of congenital anomalies of the radius in children, where we were compelled to use Kirschner wires for fixation, the results were rather satisfactory. Further research is needed to clarify whether this can be done in adults. Tay-
lor used the anterior tibial artery and veins as the vascular pedicle for the grafted fibula head.8 Mizumoto used the lateral inferior genicular artery (LIGA) and its veins for anastomosis. 910 We found during the operation, that the use of the peroneal artery and veins was sufficient for blood supply to the tip of the fibular head, confirmed by obvious bleeding from the tip before cutting the pedicle. The peroneal artery and vein alone were used in all cases in our series for fibular-head transplantation. Recipient vessel selection was made after accomplishing bone fixation. In the forearm, the radial or ulnar vessels were usually selected; however, there is more flexibility in choosing the artery and vein for anastomosis in the upper arm. Selection of recipient vessels was decided according to the position and direction of the donor vascular pedicle, as seen after fibular fixation. At the upper humeral level, the anterior and posterior circumflex humeral arteries may also be used. The brachial and deep brachial arteries can be used as recipient vessels along their whole length. Since the superficial veins are usually wider and easier to dissect, they were usually preferentially chosen for anastomosing with the peroneal vein. One vein was sufficient for venous return in most cases; however, another deep vein was needed to anastomose with the peroneal vein, if the venous drainage through only one vein proved to be insufficient.
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REFERENCES
resection and free vascularized iliac bone graft. Clin Orthop 202:232, 1986 Usui M, Ishii S, Yamamura M, et al.: Microsurgical reconstructive surgery following wide resection of bone and soft tissue sarcomas in the extremities. J Reconstr Microsurg 2:77, 1986 Taylor GI, Wilson KR, Rees MD, et al: The anterior tibial vessels and their role in epiphyseal and diaphyseal transfer of the fibula: Experimental study and clinical applications. Br I Plast Surg 41:451, 1988 Mizumoto S: Free vascularized fibula head transplantation after resection of giant cell tumor in the distal radius: Report of two cases. ] [apn Soc Surg Hand 5:694, 1988 10. Mizumoto S: Vascular anatomy of the proximal fibula: An anatomical study for vascularized fibula head graft. J Japn Soc Surg Hand 5:690, 1988
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Taylor GI, Miller GD, Ham FJ: The free vascularized bone graft: A clinical extension of microvascular techniques. Plast Reconstr Surg 55:533, 1975 Pho RWH: Free vascularized fibular transplantation for replacement of lower radius. I Bone Joint Surg 61B:362, 1979 Weiland AJ, Kleinert HE, Kutz JE, Daniel RK: Free vascularized bone grafts in surgery of the upper extremity. I Hand Surg 4: 129, 1979 Campanacci M: Resection of the distal end of the radius. Ital Orthop Traumatol 5:145, 1977 Murray JA, Schlafly B: Giant-cell tumors in the distal end of the radius. I Bone Joint Surg 68A-.687, 1986 Leung PC, Chan KT: Giant-cell tumor of the radius treated by
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