Vascularised fibula. Rodolfo Capanna

8/6/2019 Vascularised fibula. Rodolfo Capanna

1/138

Vascularised fibula

Rodolfo Capanna M.D.

PDF created with pdfFactory Pro trial version www.pdffactory.com
http://www.pdffactory.com/http://www.pdffactory.com/


2/138

206 VASCULARIZED BONE GRAFTS

AGE 2 - 65 (average 24)

ONCOLOGY: 148 (71%)

TRAUMATOLOGY: 58 (29%)

SITE: humerus 38

radius 10

ulna 7

metacarpal 1

femur 57

tibia 82

mandibolar 8

calcaneum 3

3838

77

8282

5757 11

33

1010

88

BONE LOSS: 6-23 Cm.



3/138

DONOR SITES

Fibula: 196

Iliac crest: 7

Metatarsal: 1

M.F. joint : 1



4/138

Male, 29 y

Osteoblastoma



5/138


6/138

Follow-up

6 years



7/138PDF created with pdfFactory Pro trial version www.pdffactory.com


8/138

Our experience with vascularized iliac crest graft

after calcanectomy for calcaneus tumors

3 cases (1999, 2001, 2005)

Age at surgery 18 - 29

Diagnosis:

No surgical complications

Free weight-bearing at 6 months Follow-up: average 60.3 months (20 89)

ISOLS/MSTS score: average 80% (53,3 93,3)

B. F. HistiocytomaOsteoblastoma

Giant Cell Tumor

2 total - 1 subtotal calcanectomy



9/138



10/138



11/138



12/138



13/138



14/138



15/138


16/138



17/138



18/138

FIBULA

Taylor G. I. The free vascularized bone graft: a clinical extension of

microsurgical technique

Plast Recon Surg 1975



19/138

V. FIBULA ALONE Good matching of diaphyseal diameter for upper limb

Sufficient mechanical resistance

Adequate length for intercalary defects

INDICATIONS



20/138


21/138

FIBULA + ALLOGRAFT

Biologic potential of V.F. + allograft mechanical resistance

Very stable assembling for segments under weight bearing Fusion between two components at medium term

INDICATIONS



22/138

AllograftVascularised fibula

Inadequate SizeLiving Tissue

HypertrophyFracturesBone Repair and Hypertrophy

Appropriate SizeMechanical Strenght

Creeping SubstitutionFracturesBone Resorption

Combination V.F. + Allograft



23/138

march 1988

The history

Jenni .. 11 yrs..

osteosarcoma of the

meta-diaphyseal tibia



24/138


25/138



26/138



27/138



28/138



29/138



30/138



31/138

1 m 2 y 5 y



32/138

1 m

2 yr

5 yr



33/138

november 1988

The history

Sara 8 yrsEwing sarcoma of the

meta-diaphyseal tibia



34/138



35/138

3 m 2 y



36/138



37/138

1993

The technique


I i h l i


38/138

Intra-epiphyseal resection



39/138

I i h l i


40/138

Intra-epiphyseal resection



41/138



42/138



43/138



44/138

I t i h l ti


45/138

Intraepiphyseal resection

11 y11 y1 y1 y



46/138


47/138

3 m 7 y



48/138


COMPLICATIONS


49/138

COMPLICATIONS

Valgus deformity

of the ankle: 3 (2.6%)

Flexor tendons

retraction: 6 (5.2%)

Extensor tendons

retraction: 1 (0.8%)

DONOR SITE

Vascularized fibular diaphysis


V l d f it 2 6%


50/138

Valgus deformity 2.6%

Distal 6 cm. should

be preserved

T.F. synostosis is not able

to prevent valgus def.(Kanaya 2002)

Due to: - Proximal migration of the fibula

- Valgus ankle instability

- Inhibition of the growth of the

lateral part of tibial epiphysis

*


Fl t d t ti 5 2%


51/138

Flexor tendons retraction 5.2%

Early complication (2-3 m.)

Treatment: lengthening of

involved tendons

Due to: - Adhesion of F.H.L. to the musclesof posterior compartment

- Ischemic retraction of F.H.L.


DIAPHYSIS

COMPLICATIONS


52/138

Fracture: 20 (17,5%) Non Union: 12 (10,5%)

Infection: 5 (4,3%)

Soft T. necrosis: 4 (3,5%)

Microvascular failure: 4 (3,5%)

Peroneal nerve palsy: 1 (0,8%)

DIAPHYSISCOMPLICATIONS

RECIPIENT SITE

Vascularized fibular diaphysis


Fractures Lower Extremity 1


53/138


VFG Alone

29 CASES : 9 FRACTURES (31%)all healed conservatively

2 m2 m 1 y1 y 2 y2 y 4 y4 y 10 y10 y




54/138

y

VFG + Massive Allograft

61 CASES: 6 FRACTURES (9.8 %)4 healed conservatively2 surgery


Biologic properties of vascularized bone allow an early


55/138

healing of fracture when a stable osteosynthesis is present

3 m.


FRACTURES


56/138

FRACTURES

20/114 17,5 %

20 healed 100 % 3 secondary procedures 15 %

Overall

fracture rate17,5%

Upper limb

29%

Lower limb

17%

VF alone

31 %

VF + allograft

9.8 %


COMPLICATIONS RECIPIENT SITE


57/138

NON UNION: 12 (10,5%)

All healed after secondary procedures

COMPLICATIONS RECIPIENT SITE


COMPLICATIONS DIAPHYSIS


58/138

COMPLICATIONS

Soft tissue necrosis: 4 (3,5%)

DIAPHYSIS




59/138

COMPLICATIONS


DIAPHYSIS

3 amputations

1 Ilizarov



60/138


61/138



62/138



63/138



64/138

COMPLICATIONS


3 amputations

1 Ilizarov



65/138

BLOOD SUPPLY


66/138

Taylor:

A.T.A. is able to supply the

epiphysis by an epiphyseal

branch and the proximal 2/3 of

the diaphysis by means of tiny

musculoperiosteal branches



67/138


68/138


69/138


Reconstruction of the radius


70/138

Osteosynthesis: platesOsteosynthesis: plates

Anastomosis: R.A./A.I.A.Anastomosis: R.A./A.I.A.

Ligaments reconstructionLigaments reconstruction



71/138

Results: radius


72/138

Female Osteosarcoma

8 yrs. at surgery

7 yrs. F.U.

1 yr

4 yrs

TOTAL GROWTH: 5.2 cm

GROWTH RATE: 0.75 cm/yr


FUNCTIONAL OUTCOME


73/138


Reconstruction of the humerus


74/138

Reconstruction of the humerus

Osteosynthesis: platesOsteosynthesis: plates

Anastomosis: D.B.A./B.A.Anastomosis: D.B.A./B.A.

Ligaments reconstructionLigaments reconstruction


Results: humerus


75/138

3 yrs.

Male

5 yrs at surgery

3 yrs F.U.

Total growth: 3.2cm.

Growth rate: 1.06

cm/y



76/138

COMPLICATIONS


77/138

Temporary palsy peroneal n. : (56%)

Permanent deficit E.H.L., E.D.C : (8%)

Permanent deficit T.A.: (4%)

Ankle instability : (4%) Knee instability : 0

Premature closure of the G.P.: (20%)

Fractures : (20%)

Subacromial displacement : (16%)

Non union : 0

Infection : 0

DONOR

SITE

RECIPIENT

SITE

VF with growth plate


Premature closure of growth plate 20%


78/138

Postop

F.U. 8 y.

2 cases supplied by peroneal A. 3 cases with damage to rec. branch A.T.A.


Fracture 20%


79/138

Torsion stress Break point: proximal

screw

Excessive stiffness of

implant


S l ti

Fracture 5


80/138

Solution:

Elastic implant Reconstruction plates

Long plates, few screws

Locking Compression Plate


Subacromial displacement 16%


81/138


EVOLUTION OF

VASCULARIZED BONE GRAFTS


82/138


Fusion

Hypertrophy

Remodelling


FUSION


83/138

Vascularized bone preserves more than double

vital osteocytes than a non vascularized bone

Arata, J Recon Micro 1994

Vascularized bone preserves endostal and periosteal

vascularization favouring fusion by a mechanism similar

to common fracture healing

Zdeblick T.A. Clin Orthop 1988


FUSION


84/138

IntraopIntraop.. 3 m3 m 8 m8 m 12 m12 m



85/138

FUSION


86/138

1 m. 5 m.


FUSION


87/138



88/138


89/138

FUSION


90/138

3 m. 12 m.

Vascularized fibula and its periosteum promotes allograftfusion even in case of insufficient contact

(osteotomy gap > 2mm)

18 m.

Fibula

Allograft

Femur


Vascularized Fibula

Fractures


91/138

20/114 (17,5 %)

20 fusion (100 %)

3 surgical revision (15 %)

Firenze

114 cases

Kasashima

62 cases

Arai

60 cases

Lee

46 cases

El Gammal

25 cases

Fracture Tot 17,5 % 24 % 22% 39 % 12 %

Upper limb 29 % 14% 11 % / /

Lower limb 17 % 40 % 24.5 % 39 % 12 %

The introduction of combined technique (allograft+ V.F.)

markedly decreased the incidence of fractures in weight bearing segments


EVOLUTION OF



92/138


Fusion

Hypertrophy

Remodelling


Hypertrophy


93/138


HYPERTROPHY


94/138

6 m 5 aa



95/138


96/138



97/138


In a long bone hypertrophy

occurs expecially at cortical level


98/138

Osteogenic action

of vascularized periosteum

Biologic response to theincreasing mechanical stress

Hypertrophy up to reach

the host diameter,

but never overcoming itPDF created with pdfFactory Pro trial version www.pdffactory.com

HYPERTROPHY


99/138

1 m1 a 4 a


HYPERTROPHY


100/138


Stress fractures are relatively common and

proportional to weight bearing


101/138

2 m2 m 1 y1 y 2 y2 y 4 y4 y 10 y10 y

Their healing with hypertrophyc callus contributes

to accelerate the hypertrophy processPDF created with pdfFactory Pro trial version www.pdffactory.com

Combination V.F. + Allograft


102/138


Progressive fibular hypertrophy

favours a gradual integration between two components

3 y 7 y


103/138

3 y. 7 y



104/138


Open allograft, unstable osteosynthesis

Postop. 3 y. . 8 y.

1


105/138

Early fusion with host bone Progressive allograft resorption

Fibular hypertrophy and allograft internal repair

Postop. 6 y.



106/138

Early fusion with host bone Progressive allograft resorption

Fibular hypertrophy and allograft internal repair

Postop. 6 y.


Open allograft , stable osteosynthesis2


107/138

No allograft resorption Slow fibular hypertrophy and fusion with allograft

Postop. 2 y.



108/138

No allograft resorption Slow fibular hypertrophy and fusion with allograft

2 y. 5 y.


EVOLUTION OF

VASCULARIZED GRAFTS


109/138

Fusion

Hypertrophy

Remodelling


Morphologic remodelling potential

is very high in pediatric age


110/138



111/138

2 m. 4 m. 12 m.



112/138



113/138


114/138

9 years old


115/138

4 m4 yrs

Osteosarcoma

Resection: 7 cm.

F.U. 4 years

TOTAL GROWTH : 3.3 cm.AVERAGE GROWTH : 0.82 cm/yr



116/138

Proportional growth

of neoradius with omolateral ulna


117/138

7 y. 3 y. 5 y.



118/138


119/138

Eterotopic fibula Ortotopic fibula


R G : 4 years oldR G : 4 years old


120/138

R.G.: 4 years oldR.G.: 4 years old

Ewing SarcomaEwing Sarcoma

proximal femurproximal femur

IntraIntra--articular resectionarticular resection

Reconstructive objectives

Articular function recovery

Growth potential recovery


R G : 4 years oldR G : 4 years old


121/138

R.G.: 4 years oldR.G.: 4 years old

Ewing SarcomaEwing Sarcoma

proximal femurproximal femur

IntraIntra--articular resectionarticular resection

Reconstructive objectives

Articular function recovery

Growth potential recovery



122/138

1. Allograft epiphysis resection

2. A groove is created on theallograft

3. Fibular osteotomy

4. Concentric assembling

5. Step-cut osteotomy

6. Stable osteosynthesis

7. Circumflex vessels anastomosis



123/138










124/138









Fast healing Allograft V.F. integration

Longitudinal growth

Epiphyseal remodelling


125/138



126/138



127/138

Postop.2 m.

8 m.

18 m.

4 Yrs.Postop.


POSSIBLE FUTURE

PROSPECTIVES


128/138

Stem cells

Periostium


VASCULARIZED FIBULA +TIBIAL PERIOSTEUM

Male 22 years

Femoral open fracture with 18 cm bone loss


129/138

Comminuted open fracture of omolateral tibia and fibula

Reconstruction with controlateral V.F. + tibial periosteum + chronOS + stem cells



Male 22 years



130/138

Comminuted open fracture of omolateral tibia and fibula Reconstruction with controlateral V.F. + tibial periosteum + chronOS + stem cells

Tibia

Perone

M. Interossea



Male 22 years



131/138




Male 22 years



132/138




Male 22 years


C i d f f l l ibi d fib l


133/138




134/138


Male 22 years


C i t d f t f l t l tibi d fib l


135/138




Male 22 years


Commin ted open fract re of omolateral tibia and fib la


136/138




Male 22 years


Comminuted open fracture of omolateral tibia and fibula


137/138


F.U. 7 m



138/138

Vascularised fibula. Rodolfo Capanna

Documents

Transcript of Vascularised fibula. Rodolfo Capanna