Free Vascularized Fibular Grafting For Malignant Bone and Soft Tissue Tumor: Ragiological, Clinical and Functional Outcome Kaya M, Wada T, Nagoya S, Sasaki M, Matsumura T and Yamashita T Dept. of Orthop. Surg. Sapporo Medical University CTOS 14 th Annual Meeting, November 15, 2008 London, UK

Reconstructive options after bone and soft tissue tumor removal Tumor Megaprosthesis Treated Bone pasteurized autologous bone liquid nitrogen treated bone extracorponeal irradiated bone Allograft Vascularized Fibula Distractive osteogenesis

Reconstructive options after bone and soft tissue tumor removal Tumor Megaprosthesis Treated Bone pasteurized autologous bone liquid nitrogen treated bone extracorponeal irradiated bone Allograft Vascularized Fibula Distractive osteogenesis

Purpose To analyze the clinical results of free vascularized fibula graft (FVFG) reconstruction after the removal of malignant bone and soft tissue tumor.

Knee Arthrodesis

Indications Malignant bone tumor of distal femur and proximal tibia Possible to preserve of popleteal vessels and nerves

Distal FemurProximal Tibia Reconstruction Methods

12 patients who were followed more than 5 years were enrolled. Follow up periodsAve. 95 months Histology OS11 Pts. MFH1

Clinical Results Limb sparing83.3 ％ （ 10/12 Pts. ） skip metastasis 1 Pt Infection1 Union 83.3 ％（ 10/12 Pts. ） Time to the Union 6 Mo.

Complications Stress fracture 7 Pts. Peroneal nerve palsy5 Delayed-union2

PainFunctionEmotionalExternal WalkingGait Total acceptancesupportability MSTS functional score ( mean, %)

Sling procedure

Malawar’s Indications IA VB

J Bone Joint Surg Br, 1999 Reconstruction Methods

9 patients were reconstructed with this methods Follow up periodsAve. 95 months Histology OS11 Pts. CS3 MFH1

CaseAge HistologyUnionFUResults （ M ） 1.43CS+90CDF 2.20OS +30DOD 3.10 OS +91 CDF 4.17 OS +191CDF 5.30 OS +196 CDF 6.34MFH+164 CDF 7.14OS+150 CDF 8.47CS +32CDF 9.20CS +12 CDF Clinical Results

Complications # of case Additional Treatment 5 NoneFibula Head 5 None Absorption Fracture 1 ORIF+bone graftFracture 1 ORIF+bone graft Delayed Union 1Bone graftDelayed Union 1Bone graft Infection1 DebridementInfection1 Debridement

painfunctionemotionhandmanual lift positiondexiterityability MSTS Functional Score (mean, %)

Hip Arthrodesis

I II III Enneking & Dunham Indications Malignant bone tumor arised in pelvic bone Possible to preserve of femoral vessels and sciatic nerve

6 patients were reconstructed with this methods Follow up periodsAve. 7.1 yrs. (0.7-12) Histology CS3 pts. OS2 pleomorphic adenoma pleomorphic adenoma 1

Reconstruction Methods Type II 1 Type II+III 3 Type I+II+III 2

Clinical Results # Histology Relapse GraftFU(Y) Metastasis Results 1OS ＋ N/A 0.7 lung DOD 2CS - union 12- CDF 3 CS - union 12- CDF 4 CS - union 11- CDF 5 Adeno - non-union 3.5- CDF 6 OS - union 3.5lung,spineDOD

Clinical Results # Histology Relapse GraftFU(Y) Metastasis Results 1OS ＋ N/A 0.7 lung DOD 2CS - union 12- CDF 3 CS - union 12- CDF 4 CS - union 11- CDF 5 Adeno - non-union 3.5- CDF 6 OS - union 3.5lung,spineDOD

Complications # of caseadditional treatment Infection2 debridementInfection2 debridement fracture 1 ORIFfracture 1 ORIF Delayed union 2bone graftDelayed union 2bone graft Wound trouble1 debridementWound trouble1 debridement Non union2 ORIF+bone graftNon union2 ORIF+bone graft

MSTS functional evaluation CasePainFunctionEmotionalExternal WalkingGait Total acceptancesupportability 1N/AN/AN/AN/.AN/AN/A N/A N/AN/AN/AN/.AN/AN/A N/A

MSTS functional evaluation CasePainFunctionEmotionalExternal WalkingGait Total acceptancesupportability 1N/AN/AN/AN/.AN/AN/A N/A N/AN/AN/AN/.AN/AN/A N/A

Free Vascularized Fibula Graft Advantage Biological reconstruction Durability Disadvatage Complicated methods High risk of complication

Knee Athrodesis Long durability Excellent pain relief and support Poor in emotional acceptance and gait ability Social acceptance?? Golden standard = Tumor Megaprosthesis

Proximal humerus reconstruction Tumor Megaprosthesis Clavicula Pro Humero Reconstruction Sling Procedure

Proximal humerus reconstruction Tumor Megaprosthesis Clavicula Pro Humero Reconstruction Sling Procedure Biological spacer Even in case with glenoid resection Maximize the elbow and hand function by reconstructing the mobile shoulder

Hip Arthrodesis Low grade tumor ; good indication for this procedure High grade tumor; its use cannot be recommended Good durability and function Severe functional loss in case with non union or infection

Summary We evaluated the clinical results of FVFG reconstruction We evaluated advantage and disadvantage of this method Careful patients selection and accurate surgical technique determine the clinical results

Thank you for your attention.