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This digital library houses the book on Oncology and Orthopedic Oncosurgery.

It includes academic lectures, presentations from national and international congresses, published papers, case discussions, performed surgical procedures, and proprietary techniques developed.

The digital format was chosen because the web allows the inclusion of texts with numerous visual resources, such as images and videos, which would not be possible in a printed book.

The content is intended for students, healthcare professionals, and the general public interested in the field.

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Author drpprb@gmail.com Categories Techniques 0 comment

Chondrosarcoma of the Pelvis – Total internal pelvectomy

Chondrosarcoma of the Pelvis – Total internal pelvectomy. Female patient, 19 years old, complaining of discomfort and increased volume of the left pelvis. Clinically, there was mild pain upon palpation of the iliac wing, with a palpable, hard, adherent tumor. Responded to on December 18, 2002, with the following imaging exams: 11/13/1983 12/18/2002.

Chondrosarcoma of the Pelvis – Management – ​​Total internal pelvectomy technique

Figura 1: Radiografia de 18/12/2002, bacia frente, com lesão condensante acometendo o ilíaco esquerdo
Figure 1: Radiograph of 12/18/2002, front pelvis, with condensing lesion affecting the left iliac
Figura 2: Radiografia da bacia in let, evidenciando inúmeros focos de calcificação.
Figure 2: Radiograph of the basin in let, showing numerous foci of calcification.
Figura 3: Radiografia em alar, grande tumor extracortical, intra e extrapélvico.
Figure 3: Alar radiograph, large extracortical, intra and extrapelvic tumor.
Figura 4: Radiografia da bacia em obturatriz, tumor obliterando o forame.
Figure 4: X-ray of the pelvis in obturatrix, tumor obliterating the foramen.
Figura 5: Radiografia do tórax, de 18/12/2002, sem alterações.
Figure 5: Chest X-ray, dated 12/18/2002, no changes.
Figura 6: Cintilografia óssea, fase tardia, frente, com hipercaptação no ilíaco direito.
Figure 6: Bone scintigraphy, late phase, front, with high uptake in the right iliac.
Figura 7: Cintilografia óssea, fase tardia, posterior, com hipercaptação no ilíaco direito.
Figure 7: Bone scintigraphy, late, posterior phase, with high uptake in the right iliac.
Figura 8: Cintilografia localizada da bacia, detalhando o comprometimento do ilíaco direito.
Figure 8: Localized pelvis scintigraphy, detailing the involvement of the right iliac.
Figura 9: RM axial, com baixo sinal em T1, com grande tumor extracortical, comprometendo a tábua interna e a tábua externa do ilíaco direito.
Figure 9: Axial MRI, with low signal on T1, with a large extracortical tumor, affecting the internal and external tables of the right iliac.
Figura 10: RM coronal, com baixo sinal em T1, com grande tumor extracortical, comprometendo as tábuas internas e externa do ilíaco direito.
Figure 10: Coronal MRI, with low signal on T1, with a large extracortical tumor, affecting the internal and external tables of the right iliac.
Figura 11: RM axial alto sinal em T2, com grande tumor extracortical, comprometendo a tábua interna e a tábua externa do ilíaco direito.
Figure 11: Axial high-signal T2 MRI, with a large extracortical tumor, affecting the internal and external tables of the right iliac.
Figura 12: RM coronal, com alto sinal em T2, com grande tumor extracortical, comprometendo a tábua interna e a tábua externa do ilíaco direito.
Figure 12: Coronal MRI, with high signal on T2, with a large extracortical tumor, affecting the internal and external tables of the right iliac.
Figura 13: RM axial T1 spir, com supressão de gordura, evidenciando reação periosteal em espículas e focos de calcificação.
Figure 13: Axial T1 spir MRI, with fat suppression, showing periosteal reaction in spicules and foci of calcification.
Figura 14: RM axial T1, com saturação de gordura e contraste, evidenciando espessa área de captação (alto sinal) devido à capa de cartilagem neoplásica maligna, ao redor da lesão (com baixo sinal).
Figure 14: Axial T1 MRI, with fat saturation and contrast, showing a thick uptake area (high signal) due to the layer of malignant neoplastic cartilage around the lesion (low signal).
Figura 15: Outro corte de axial T1, com saturação de gordura e contraste, evidenciando espessa área de captação (alto sinal) devido à capa de cartilagem neoplásica maligna, ao redor da lesão (com baixo sinal).
Figure 15: Another T1 axial section, with fat saturation and contrast, showing a thick uptake area (high signal) due to the layer of malignant neoplastic cartilage around the lesion (low signal).
Figura 16: RM coronal T1, com saturação de gordura e contraste, evidenciando espessa área de captação (alto sinal) devido à capa de cartilagem neoplásica maligna, ao redor da lesão (com baixo sinal).
Figure 16: Coronal T1 MRI, with fat saturation and contrast, showing a thick uptake area (high signal) due to the layer of malignant neoplastic cartilage around the lesion (low signal).
Figura 17: Tomografia axial, densidade para osso, grande tumor acometendo o ilíaco esquerdo.
Figure 17: Axial tomography, bone density, large tumor affecting the left iliac bone.
Figura 18: Tomografia axial, densidade para tecidos moles, grande tumor acometendo o ilíaco esquerdo.
Figure 18: Axial tomography, soft tissue density, large tumor affecting the left iliac.
Figura 19: Tomografia coronal, densidade para osso, com grande tumor acometendo o ilíaco esquerdo.
Figure 19: Coronal tomography, bone density, with a large tumor affecting the left iliac bone.
Figura 20: Tomografia coronal, densidade para tecidos moles, com grande tumor acometendo o ilíaco esquerdo.
Figure 20: Coronal tomography, soft tissue density, with a large tumor affecting the left iliac bone.
Figura 21: Paciente em decúbito lateral direito, demarcação do retalho de pele que será ressecado em bloco, juntamente com o tumor. A seta aponta a biópsia realizada em outro serviço por cirurgião geral, em sentido perpendicular à incisão cirúrgica, complicando a abordagem.
Figure 21: Patient in right lateral decubitus, demarcation of the skin flap that will be resected en bloc, together with the tumor. The arrow points to the biopsy performed in another service by a general surgeon, in a perpendicular direction to the surgical incision, complicating the approach.
Figura 22: Incisão ampla para permitir uma ressecção com margem de segurança, para garantir a cura deste condrossarcoma, já que a cirurgia é o único recurso para o tratamento desta lesão. Observe o grande retalho de pele que precisa ser removido, devido à incisão errônea da biópsia.
Figure 22: Wide incision to allow a resection with a safety margin, to guarantee the cure of this chondrosarcoma, as surgery is the only resource for treating this lesion. Note the large flap of skin that needs to be removed due to the erroneous biopsy incision.
Figura 23: Dissecção com cuidadosa hemostasia, seccionando e amarrando os segmentos musculares seccionados.
Figure 23: Dissection with careful hemostasis, sectioning and tying the sectioned muscle segments.
Figura 24: Isolamento do nervo femoral.
Figure 24: Isolation of the femoral nerve.
Figura 25: Dissecção dos vasos ilíacos.
Figure 25: Dissection of the iliac vessels.
Figura 26: Exposição da veia ilíaca interna para ligadura.
Figure 26: Exposure of the internal iliac vein for ligation.
Figura 27: Ligadura da veia ilíaca interna.
Figure 27: Ligation of the internal iliac vein.
Figura 28: Ligadura da artéria ilíaca interna.
Figure 28: Ligation of the internal iliac artery.
Figura 29: Dissecção da região sacro ilíaca e preparação para osteotomia.
Figure 29: Dissection of the sacroiliac region and preparation for osteotomy.
Figura 30: Dissecção do tendão do músculo psoas, separando-o do músculo ilíaco, que será removido junto com a peça cirúrgica, como margem de segurança oncológica.
Figure 30: Dissection of the psoas muscle tendon, separating it from the iliac muscle, which will be removed along with the surgical piece, as an oncological safety margin.
Figura 31: Ressecção em bloco da hemipelve esquerda e revisão da hemostasia.
Figure 31: En bloc resection of the left hemipelvis and review of hemostasis.
Figura 32: Aspecto da reconstrução, com o retalho de pele para o fechamento da ferida operatória.
Figure 32: Aspect of the reconstruction, with the skin flap to close the surgical wound.
Figura 33: Aspecto da peça cirúrgica, ressecada em bloco, juntamente com a pele, o trajeto da biópsia e tecidos moles sadios ao redor, como margem.
Figure 33: Appearance of the surgical specimen, resected en bloc, together with the skin, the biopsy path and surrounding healthy soft tissues, as a margin.
Figura 34: Visão do anel obturatório e do segmento da sínfise púbica do lado esquerdo, superiormente.
Figure 34: View of the obturator ring and the pubic symphysis segment on the left side, superiorly.
Figura 35: Visão da face ventral da hemipelve ressecada, juntamente com o colo femoral e o complexo capsulo-ligamentar do quadril, evidenciando o grande volume tumoral.
Figure 35: View of the ventral surface of the resected hemipelvis, together with the femoral neck and the capsulo-ligamentous complex of the hip, showing the large tumor volume.
Figura 36: Radiografia do pós-operatório imediato, após a ressecção completa da hemipelve esquerda, juntamente com o colo femoral e o complexo capsulo-ligamentar da articulação do quadril esquerdo.
Figure 36: Radiograph of the immediate postoperative period, after complete resection of the left hemipelvis, together with the femoral neck and the capsulo-ligamentous complex of the left hip joint.
Figura 37: Radiografia da peça cirúrgica, mostrando o tumor extracortical, acometendo a tábua interna e a tábua externa do ilíaco esquerdo.
Figure 37: Radiograph of the surgical specimen, showing the extracortical tumor, affecting the internal table and the external table of the left iliac bone.
Figura 38: Radiografia da peça cirurgica, mostrando o acetábulo e a cabeça femoral ressecada em bloco.
Figure 38: Radiograph of the surgical specimen, showing the acetabulum and femoral head resected en bloc.
Figura 39: Radiografia da peça cirúrgica, em alar.
Figure 39: Radiograph of the surgical specimen, in alar.
Figura 40: Aspecto da peça cirurgia com tecidos moles macroscopicamente sadios, envolvendo o tumor.
Figure 40: Aspect of the surgical specimen with macroscopically healthy soft tissues surrounding the tumor.
Figura 41: Corte da peça cirúrgica mostrando a lesão circundada por tecido sadio.
Figure 41: Section of the surgical specimen showing the lesion surrounded by healthy tissue.
Figura 42: Avaliação da peça cirúrgica pelo departamento de Patologia.
Figure 42: Assessment of the surgical specimen by the Pathology department.
Figura 43: Vários cortes para o estuda das margens.
Figure 43: Various cuts to study the margins.
Figura 44: Em maior aumento, detalhando o aspecto macroscópico deste condrossarcoma.
Figure 44: In higher magnification, detailing the macroscopic appearance of this chondrosarcoma.
Figura 45: Os vários cortes permitem avaliar melhor a peça de ressecção.
Figure 45: The various cuts allow a better evaluation of the resection piece.
Figura 46: Corte evidenciando o revestimento pela pele e tecido celular subcutâneo, o tumor e a cabeça femoral ressecada.
Figure 46: Section showing the covering of the skin and subcutaneous cellular tissue, the tumor and the resected femoral head.
Figura 47: Paciente com 20 anos de idade, pós-operatório de um ano. Carga total com auxílio de muletas.
Figure 47: 20-year-old patient, one year postoperative. Full load with the aid of crutches.
Figura 48: Pós -operatório de um ano, carga total nos MMII, com flexão dos joelhos, visão de frente.
Figure 48: One year post-surgery, full load on the lower limbs, with knee flexion, frontal view.
Figura 49: Pós-operatório de um ano, carga total nos MMII, com flexão dos joelhos, visão de perfil esquerdo.
Figure 49: One year postoperatively, full load on the lower limbs, with knee flexion, left profile view.
Figura 50: Pós-operatório de um ano, carga total nos MMII, com flexão dos joelhos, visão de perfil direito, boa função.
Figure 50: One year post-surgery, full load on the lower limbs, with knee flexion, right profile view, good function.
Figura 51: Pós-operatório de um ano e seis meses, carga total nos MMII, ortostática, visão de frente.
Figure 51: One year and six months postoperative, full load on the lower limbs, standing, frontal view.
Figura 52: Pós-operatório de um ano e seis meses, carga total nos MMII, ortostática, visão posterior. Observem o encurtamento do lado esquerdo, pela ascensão do fêmur.
Figure 52: One year and six months postoperative, full load on the lower limbs, standing, posterior view. Note the shortening on the left side, due to the rise of the femur.
Figura 53: Pós-operatório de um ano e seis meses, carga total nos MMII, ortostática, visão de perfil.
Figure 53: One year and six months postoperative, full load on the lower limbs, standing, profile view.
Figura 54: Pós-operatório de um ano e seis meses, carga total nos MMII, ortostática, visão lateral.
Figure 54: One year and six months postoperative, full load on the lower limbs, standing, lateral view.
Figura 55: Após um ano e seis meses, carga total com flexão dos MMII.
Figure 55: After one year and six months, full load with lower limb flexion.
Figura 56: Carga total monopodal sobre o membro operado!!! Boa recuperação funcional.
Figure 56: Total single-leg load on the operated limb!!! Good functional recovery.
Figura 57: Radiografia do pós-operatório de um ano e seis meses. O membro inferior esquerdo parece flutuar, mas na realidade existe uma fibrose cicatricial que apoia o membro e impede maior ascensão.
Figure 57: One year and six months postoperative radiograph. The left lower limb appears to float, but in reality there is a scarring fibrosis that supports the limb and prevents further ascension.
Figura 58: RM coronal T1, após dois anos da cirurgia, sem sinais de recidiva.
Figure 58: Coronal T1 MRI, two years after surgery, with no signs of recurrence.
Figura 59: RM axial T1, após dois anos da cirurgia, sem sinais de recidiva.
Figure 59: Axial T1 MRI, two years after surgery, with no signs of recurrence.
Figura 60: RM coronal T2 Stir, após dois anos da cirurgia, sem sinais de recidiva.
Figure 60: Coronal T2 Stir MRI, two years after surgery, with no signs of recurrence.
Figura 61: RM axial T2 Stir, após dois anos da cirurgia, bom aspecto local.
Figure 61: Axial T2 Stir MRI, two years after surgery, good local appearance.
Figura 62: RM coronal T2, após dois anos da cirurgia.
Figure 62: Coronal T2 MRI, two years after surgery.
Figura 63: RM sagital T1 Spir, com contraste, após dois anos da cirurgia.
Figure 63: Sagittal T1 Spir MRI, with contrast, two years after surgery.
Figura 64: RM axial T1 Spir, com contraste, após dois anos da cirurgia.
Figure 64: Axial T1 Spir MRI, with contrast, two years after surgery.
Figura 65: RM coronal T1 Spir, com contraste, após dois anos da cirurgia, bom aspecto, sem recidiva.
Figure 65: Coronal T1 Spir MRI, with contrast, two years after surgery, good appearance, without recurrence.
Figura 66: RM coronal T1 Spir, com contraste, após dois anos da cirurgia.
Figure 66: Coronal T1 Spir MRI, with contrast, two years after surgery.
Figura 67: Tomografia do tórax normal, após três anos da cirurgia.
Figure 67: Normal chest tomography, three years after surgery.
Figura 68: RM do tórax normal, após três anos da cirurgia.
Figure 68: MRI of the normal chest, three years after surgery.
Figura 69: Pós-operatório de três anos, carga total nos MMII, ortostática, visão posterior.
Figure 69: Three years post-surgery, full load on the lower limbs, standing, posterior view.
Figura 70: Pós-operatório de três anos, visão em perfil. Observem o encurtamento do lado esquerdo, pela ascensão do fêmur.
Figure 70: Three years post-operative, profile view. Note the shortening on the left side, due to the rise of the femur.
Figura 71: Pós-operatório de três anos. O encurtamento do lado esquerdo, é facilmente compensado por um salto tipo Anabela.
Figure 71: Three-year postoperative period. The shortening on the left side is easily compensated by an Anabela-type heel.
Figura 72: Pós-operatório de três anos, visão de perfil. O encurtamento é compensado pelo salto tipo Anabela.
Figure 72: Three years post-operative, profile view. The shortening is compensated by the Anabela heel.
Figura 73: Quadris e joelhos em flexão, com carga total, sem auxílio de muletas, com compensação no calçado.
Figure 73: Hips and knees in flexion, with full load, without the aid of crutches, with compensation in the shoes.
Figura 74: Carga total, monopodal, sobre o membro operado, no pós-operatório de três anos.
Figure 74: Total single-leg load on the operated limb, three years postoperatively.
Figura 75: Aspecto clínico da paciente após quatro anos da cirurgia, 07/02/2006.
Figure 75: Clinical appearance of the patient four years after surgery, 02/07/2006.
Figura 76: Após quatro anos da cirurgia, compensação com calçado.
Figure 76: Four years after surgery, compensation with shoes.
Figura 77: Após 12 anos e três meses da cirurgia, Bom aspecto clínico, discrepância de MMII inalterada.
Figure 77: 12 years and three months after surgery, good clinical appearance, unchanged lower limb discrepancy.
Figura 78: Carga total monopodal, sem auxílio, apoiando no membro operado, após 12 anos e três meses da cirurgia.
Figure 78: Single-leg total load, without assistance, supporting the operated limb, 12 years and three months after surgery.
Figura 79: Flexão dos MMII com carga, muito boa função, Pelvectomia sem reconstrução.
Figure 79: Lower limb flexion with load, very good function, Pelvectomy without reconstruction.
Figura 80: Em 12/05/2015, após 12 anos e três meses da cirurgia. Aspecto estável da discrepância. Muito bom resultado cosmético e funcional.
Figure 80: On 05/12/2015, 12 years and three months after surgery. Stable aspect of the discrepancy. Very good cosmetic and functional result.
The patient happily displays her life without significant limitations. Shows complete overcoming of the functional deficit, carrying out activities of daily living with ease, figures 81 to 90.
Figura 81: Piquenique com amigos.
Figure 81: Picnic with friends.
Figura 82: Curtindo a Cachoeira.
Figure 82: Enjoying the Waterfall.
Figura 83: Namoro feliz.
Figure 83: Happy dating.
Figura 84: Jogando boliche!!!
Figure 84: Playing bowling!!!
Figura 85: Exibindo feliz a gravidez.
Figure 85: Happily displaying the pregnancy.
Figura 86: Batizando a filha.
Figure 86: Baptizing the daughter.
Figura 87: Passeio no parque.
Figure 87: Walk in the park.
Figura 88: Família completa. De volta à cachoeira.
Figure 88: Complete family. Back to the waterfall.
Figura 89: Opa!!! Torcendo na copa de 2014!
Figure 89: Oops!!! Supporting the 2014 World Cup!
Figura 90: Curtindo o campo.
Figure 90: Enjoying the countryside.
Figura 91: Radiografias da bacia, mostrando a pelvectomia interna à esquerda, em 12/05/2015.
Figure 91: X-rays of the pelvis, showing the internal pelvectomy on the left, on 05/12/2015.
Figura 92: Pós-operatório de 12 anos e três meses de pelvectomia à esquerda. Aspecto da adaptação do MIE.
Figure 92: Postoperative period 12 years and three months after left pelvectomy. Aspect of MIE adaptation.
Figura 93: Escanometria mostrando o encurtamento do MIE de 5,08 cm, em 12/05/2015.
Figure 93: Scanometry showing the shortening of the MIE of 5.08 cm, on 05/12/2015.
Figura 94: Radiografia da bacia evidenciando a ascensão proximal do MIE, apoiado em tecido fibroso cicatricial.
Figure 94: X-ray of the pelvis showing the proximal rise of the MIE, supported by fibrous scar tissue.
Figura 95: Radiografia com carga, em 12/05/2015.
Figure 95: X-ray with load, on 05/12/2015.
Figura 96: Radiografia da bacia em Lowenstein, em 16/06/2015.
Figure 96: Radiograph of the basin in Lowenstein, on 06/16/2015.
Figura 97: Laudo das radiografias de 12/05/2015.
Figure 97: X-ray report from 05/12/2015.
Figura 98: RM do tórax normal, em 16/06/2015.
Figure 98: Normal chest MRI, on 06/16/2015.
Figura 99: RM do tórax, sem alteração, 16/06/2015.
Figure 99: MRI of the chest, no changes, 06/16/2015.
Figura 100: RM da pelve evidenciando a acomodação do MIE, em 16/06/2015.
Figure 100: MRI of the pelvis showing accommodation of the MIE, on 06/16/2015.
Figura 101: RM da pelve, coronal com saturação de gordura, com as alterações adaptativas do MIE, em 16/06/2015.
Figure 101: MRI of the pelvis, coronal with fat saturation, with adaptive MIE changes, on 06/16/2015.
Figura 102: RM da pelve, em 16/06/2015.
Figure 102: MRI of the pelvis, on 06/16/2015.
Figura 103: RM da pelve, em 16/06/2015.
Figure 103: MRI of the pelvis, on 06/16/2015.
Figura 104: Laudo da RM da pelve, de 16/06/2015, parte a.
Figure 104: Pelvis MRI report, dated 06/16/2015, part a.
Figura 105: Laudo da RM da pelve, em 16/06/2015, parte b.
Figure 105: Pelvis MRI report, on 06/16/2015, part b.

Video 1 : Gait with full support on the operated limb, single-leg load with good balance, good flexion function of the hips and knees with load. Excellent functional result for a total internal hemipelvectomy, without reconstruction, 12 years and three months after surgery.

Author: Prof. Dr. Pedro Péricles Ribeiro Baptista

 Orthopedic Oncosurgery at the Dr. Arnaldo Vieira de Carvalho Cancer Institute

Office :  Rua General Jardim, 846 – Cj 41 – Cep: 01223-010 Higienópolis São Paulo – SP

Phone: +55 11 3231-4638  Cell:+55  11 99863-5577   Email:  drpprb@gmail.com

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Author drpprb@gmail.com Categories Techniques 0 comment

Auto Transplantation of the Distal Fibula Growth Plate

Auto Transplantation of the Distal Fibula Growth Plate. Patient in December 1996, eight years old, with osteosarcoma of the distal meta-epiphyseal region of the tibia, treated with neo-adjuvant chemotherapy (Figures 1 to 4).

Autotransplantation of the distal fibula growth plate. Osteosarcoma of the distal region of the tibia. Tibialization of the distal fibula with preservation of the epiphyseal plate.

Figura1: Radiografia frente do tornozelo direito, com lesão meta-epifisaria da tíbia, com limites imprecisos e triângulo de Codmann.
Figure 1: Radiograph of the front of the right ankle, with a meta-epiphyseal lesion of the tibia, with imprecise limits and Codmann's triangle.
Figura 2: Radiografia perfil do tornozelo direito, com osteossarcoma da região distal da tíbia.
Figure 2: Profile x-ray of the right ankle, with osteosarcoma of the distal region of the tibia.
Figura 3: Radiografia frente de osteossarcoma do tornozelo direito, em quimioterapia neo-adjuvante.
Figure 3: Frontal radiograph of osteosarcoma of the right ankle, undergoing neo-adjuvant chemotherapy.
Figura 4: Radiografia em perfil de osteossarcoma do tornozelo, em quimioterapia.pré-operatória.
Figure 4: Lateral radiograph of osteosarcoma of the ankle, undergoing preoperative chemotherapy.
The tomography shows a tumor close to the growth plate, requiring its resection, as an oncological margin (figure 5). How to reconstruct this segment in a seven-year-old child and avoid lower limb discrepancy? Our proposal was to resect the distal 1/3 of the tibia and reconstruct it with the fibula on the same side, transferring the fibula to replace the tibial defect. In this transfer, we would take the vascularized fibula, with the physeal plate, arthrodesing its epiphysis with the talus and nailing the proximal 1/3 of the fibula in the proximal segment of the tibia. We perform x-rays, arteriography and planning for execution (figures 6.7 and 8).
Figura 5: Tomografia do tornozelo mostrando lesão produtora de osso na metáfise da tíbia que ultrapassa a placa fisária e compromete a epífise
Figure 5: Tomography of the ankle showing a bone-producing lesion in the tibial metaphysis that goes beyond the physeal plate and compromises the epiphysis
Figura 6: Escanograma da tibia, para planejamento cirúrgico.
Figure 6: Scanogram of the tibia, for surgical planning.
Figura 7: Angiografia da região distal da tibia, para estudo da vascularização, visando o planejamento cirúrgico.
Figure 7: Angiography of the distal region of the tibia, to study the vascularization, aiming at surgical planning.
Figura 8: Planejamento cirurgico: Ressecção do 1/3 distal da tíbia, tibialização dos 2/3 distais da fíbula com a epífise e a placa de crescimento, abertura de janela na tibia para encaixe do terço médio e preservação da integridade da artéria nutrícia da fíbula.
Figure 8: Surgical planning: Resection of the distal 1/3 of the tibia, tibialization of the distal 2/3 of the fibula with the epiphysis and growth plate, opening of a window in the tibia to fit the middle third and preservation of the integrity of the nutrient artery of the fibula.
Planning this procedure must include the creation of an orthosis that will serve to immobilize the operated limb. We make a raw foot plaster that will serve as a mold for modeling the orthosis, made of polypropylene (figure 9).
Figura 9: Órtese de polipropileno, confeccionada no pré-operatório, sob molde de gesso, que será utilizada após a cirurgia, para a proteção da reconstrução e início da marcha.
Figure 9: Polypropylene orthosis, made pre-operatively, under a plaster mold, which will be used after surgery, to protect the reconstruction and start of walking.
The tumor resection surgery, encompassing the entire distal third of the tibia, and the reconstruction of this segment with autotransplantation of the growth cartilage from the fibula to the tibia are detailed in figures 10 to 20.
Figura 10: Incisão antero-medial do tornozelo e 1/3 distal da tíbia, com preservação dos vasos safenos, e ressecção do tumor.
Figure 10: Anteromedial incision of the ankle and distal 1/3 of the tibia, with preservation of the saphenous vessels, and resection of the tumor.
Figura 11: Tumor ressecado, exposição do tálus e da região distal da fíbula para transposição.
Figure 11: Resected tumor, exposure of the talus and the distal region of the fibula for transposition.
Figura 12: Retirada da cartilagem epifisária da fíbula, seta amarela, com preservação da placa de crescimento da fíbula, seta azul, detalhe do maléolo tibial, seta vermelha.
Figure 12: Removal of the fibula epiphyseal cartilage, yellow arrow, with preservation of the fibula growth plate, blue arrow, detail of the tibial malleolus, red arrow.
Figura 13: Realização de uma cavidade no tálus para colocação da epífise fibular visando obter a artrodese fíbulotalar.
Figure 13: Creating a cavity in the talus to place the fibular epiphysis in order to obtain fibulotalar arthrodesis.
Figura 14: Colocação da epífise fibular na cavidade do tálus, seta amarela e posicionamento proximal da diáfise fibular no 1/3 proximal da tíbia, seta azul.
Figure 14: Placement of the fibular epiphysis in the talus cavity, yellow arrow and proximal positioning of the fibular shaft in the proximal 1/3 of the tibia, blue arrow.
Figura 15: Canaleta aberta lateralmente na tíbia (seta amarela) para permitir o encavilhamento proximal da fíbula (seta azul), sem lesar a artéria nutrícia, mantendo os 2/3 distais da fíbula como um autotransplante vascularizado.
Figure 15: Channel open laterally in the tibia (yellow arrow) to allow proximal nailing of the fibula (blue arrow), without damaging the nutrient artery, maintaining the distal 2/3 of the fibula as a vascularized autotransplant.
Figura 16: Passagem de fio de Kirschner (seta amarela) pelo calcâneo-tálus-epífise fibular-placa de crescimento-diáfise da fíbula-tíbia proximal, estabilizando a reconstrução com uma síntese mínima, geralmente suficiente e de baixa morbidade para as crianças. A seta azul evidencia a placa de crescimento da fíbula, que substituirá a da tíbia.
Figure 16: Passage of a Kirschner wire (yellow arrow) through the calcaneus-talus-fibular epiphysis-growth plate-diaphysis of the fibula-proximal tibia, stabilizing the reconstruction with a minimal synthesis, generally sufficient and with low morbidity for children. The blue arrow highlights the growth plate of the fibula, which will replace that of the tibia.
Figura 17: Peça ressecada, a seta amarela destaca a sindesmose tíbio-fibular.
Figure 17: Resected piece, the yellow arrow highlights the tibiofibular syndesmosis.
Figura 18: Corte da peça ressecada. A seta azul destaca a reação periosteal e a seta amarela salienta a proximidade do tumor à placa de crescimento.
Figure 18: Section of the dried piece. The blue arrow highlights the periosteal reaction and the yellow arrow highlights the proximity of the tumor to the growth plate.
Figura 19: Região meta-epifisária ampliada.
Figure 19: Enlarged meta-epiphyseal region.
Figura 20: Detalhe da proximidade da placa de crescimento como tumor.
Figure 20: Detail of the proximity of the growth plate to the tumor.
Radiographic documentation and monitoring of the patient’s rehabilitation after reconstruction are illustrated in figures 21 to 46.
Figura 21: Radiografia frente do autotransplante da fíbula vascularizada, transferindo a cartilagem de crescimento para substituir a que foi ressecada da tíbia.
Figure 21: X-ray of the autotransplantation of the vascularized fibula, transferring the growth cartilage to replace that which was resected from the tibia.
Figura 22: Radiografia perfil da reconstrução com a fíbula vascularizada, fixada com fio intramedular.
Figure 22: Profile radiograph of the reconstruction with the vascularized fibula, fixed with intramedullary wire.
Figura 23: Aspecto clínico após seis meses.
Figure 23: Clinical appearance after six months.
Figura 24: Paciente com carga parcial, após seis meses da reconstrução, em quimioterapia adjuvante.
Figure 24: Patient with partial load, six months after reconstruction, undergoing adjuvant chemotherapy.
Figura 25: Pós-operatório de onze meses, alinhamento dos MMII, carga com apoio.
Figure 25: Eleven months post-operative, lower limb alignment, weight bearing with support.
Figura 26: Carga com apoio, após onze meses.
Figure 26: Load with support, after eleven months.
Figura 27: Alinhamento do membro operado, perfil, carga com apoio após onze meses.
Figure 27: Alignment of the operated limb, profile, load with support after eleven months.
Figura 28: Flexão com carga total após um ano da cirurgia.
Figure 28: Flexion with full load one year after surgery.
Figura 29: Alinhamento e função após um ano da cirurgia.
Figure 29: Alignment and function one year after surgery.
Figura 30: Carga total monopodal após um ano da cirurgia, paciente já fora de quimioterapia.
Figure 30: Total single-leg weightlifting one year after surgery, patient no longer undergoing chemotherapy.
Figura 31: Cintilografia óssea, fase tardia, mostrando captação no 1/3 distal da perna, confirmando a presença de vascularização da fíbula transplantada.
Figure 31: Bone scintigraphy, late phase, showing uptake in the distal 1/3 of the leg, confirming the presence of vascularization of the transplanted fibula.
Figura 32: Cintilografia óssea da perna destacando a captação da fíbula e a ossificação do trajeto da transferência proximal, promovendo uma fusão proximal.
Figure 32: Bone scintigraphy of the leg highlighting capture of the fibula and ossification of the proximal transfer path, promoting proximal fusion.
Figura 33: Radiografia frente, após três meses da reconstrução.
Figure 33: Front X-ray, three months after reconstruction.
Figura 34: Radiografia perfil, após três meses da reconstrução.
Figure 34: Profile x-ray, three months after reconstruction.
Figura 35: Paciente após um ano e seis meses, fora de quimioterapia, bom alinhamento.
Figure 35: Patient after one year and six months, out of chemotherapy, good alignment.
Figura 36: Carga total, monopodal, após um ano e seis meses.
Figure 36: Full load, single leg, after one year and six months.
Figura 37: Radiografia frente, em 1998.
Figure 37: Front X-ray, in 1998.
Figura 38: Radiografia perfil, em 1998.
Figure 38: Profile x-ray, in 1998.
Figura 39: Radiografia frente, após um ano da cirurgia. Fíbula integrada e já tibializada com significativo espessamento cortical.
Figure 39: Front X-ray, one year after surgery. Fibula integrated and already tibialized with significant cortical thickening.
Figura 40: Radiografia perfil, após um ano da cirurgia. Fíbula já tibializada
Figure 40: Profile x-ray, one year after surgery. Fibula already tibialized
Figura 41: Paciente após um ano e sete meses da reconstrução. Bom alinhamento dos MMII.
Figure 41: Patient one year and seven months after reconstruction. Good alignment of the lower limbs.
Figura 42: Carga total, monopodal, após um ano e sete meses da cirurgia.
Figure 42: Full load, single leg, one year and seven months after surgery.
Figura 43: Flexão com carga total, após um ano e sete meses.
Figure 43: Flexion with full load, after one year and seven months.
Figura 44: Radiografia após um ano e sete meses, fíbula tibializada e fise viável, solução biológica que permite a equalização dos membros com o crescimento.
Figure 44: Radiograph after one year and seven months, tibialized fibula and viable physis, biological solution that allows limbs to equalize with growth.
Figura 45: Pós-operatório da reconstrução evidenciando a placa de crescimento da fíbula, transferida para substituir a da tíbia, que foi ressecada.
Figure 45: Post-operative reconstruction showing the fibula growth plate, transferred to replace the tibia, which was resected.
Figura 46: Radiografias ilustrando a evolução do autotransplante de cartilagem de crescimento, desde o pós-operatório precoce até após dois anos e um mês da reconstrução.
Figure 46: Radiographs illustrating the evolution of growth cartilage autotransplantation, from the early postoperative period to two years and one month after reconstruction.
This technique of autotransplantation of the fibula, with its growth plate, to replace the distal segment of the tibia, in young children, is an excellent alternative for autologous biological reconstruction that preserves the growth of the limb, avoiding discrepancies. It was published in the Brazilian Journal of Orthopedics and Traumatology in November 1998, vol. 33 – number 11.

Author: Prof. Dr. Pedro Péricles Ribeiro Baptista

 Orthopedic Oncosurgery at the Dr. Arnaldo Vieira de Carvalho Cancer Institute

Office :  Rua General Jardim, 846 – Cj 41 – Cep: 01223-010 Higienópolis São Paulo – SP

Phone: +55 11 3231-4638  Cell:+55  11 99863-5577   Email:  drpprb@gmail.com

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Author drpprb@gmail.com Categories Techniques 0 comment

Autologous bone graft – Obtaining techniques

Autologous bone graft is used in various situations in orthopedics, traumatology and mainly in reconstructions of orthopedic oncological surgeries.
In bone defects, it is certainly what promotes the best and fastest bone consolidation, has the best integration and fastest remodeling.
Secondly, we can resort to homologous bone graft, bone from a tissue bank, obtained from a cadaver, which has the disadvantage of antigenicity, has a higher rate of infection, takes longer to incorporate and structural fragility can occur in the integration process. Lastly, we can mention artificial freeze-dried products, which aim to be osteoinductive.
Our objective is to publicize the technique we use to obtain the greatest amount of bone graft with the lowest morbidity.
We believe that, whenever it is possible to use the autologous graft, we will be providing the alternative that allows the best result.
When we need a small amount of graft, we don’t question its indication too much. As an example, in the case of the need to resect the proximal 3/4 of the radius, due to a tumor lesion, which we intend to resolve by performing a distal radio-ulnar “synostosis”, figures 1 to 4.

Autologous bone graft – Obtaining techniques

Figura 1: Radiografias do antebraço com lesão nos 2/3 proximais do rádio devido à sarcoma de Ewing, pré quimioterapia acima, e pós quimio pré operatória abaixo.
Figure 1: Radiographs of the forearm with damage to the proximal 2/3 of the radius due to Ewing's sarcoma, pre-chemotherapy above, and post-preoperative chemotherapy below.
Figura 2: Intraoperatório, ressecção de 3/4 do segmento proximal do rádio. A seta amarela assinala a interposição de enxerto ósseo autólogo.
Figure 2: Intraoperatively, resection of 3/4 of the proximal segment of the radius. The yellow arrow indicates the interposition of an autologous bone graft.
When we need Reconstruction with opening of the distal radio-ulnar syndesmosis, interposition of an autologous bone graft and fixation with two fragmentary Inter screws, figure 2. Three years after performing the distal radio-ulnar synostosis, we can verify the consolidation, the total integration of the graft and observe that the radius and ulna phases continue with symmetrical growth, with good function, figures 3 and 4.
Figura 3: Radiografia após três anos da sinostose radio ulnar distal. Consolidação e total integração do enxerto. As fases do rádio e da ulna continuam com crescimento simétrico.
Figure 3: Radiograph after three years of distal radio-ulnar synostosis. Consolidation and total integration of the graft. The radius and ulna phases continue with symmetrical growth.
Figura 4: Paciente após a cirurgia, boa flexão dorsal, boa flexão volar e, após anos, observamos uma boa função do punho no paciente já adulto.
Figure 4: Patient after surgery, good dorsal flexion, good volar flexion and, after years, we observed good wrist function in the adult patient.

Há três décadas atuamos no Instituto do Câncer Dr. Arnaldo Vieira de Carvalho, o primeiro Hospital do Câncer do Brasil, completando 95 anos neste ano de 2016, figura 5 e 6.

Figura 5: Instituto do Câncer Dr Arnaldo Vieira de Carvalho, o primeiro Hospital do Câncer do Brasil, fundado em 1921
Figure 5: Dr Arnaldo Vieira de Carvalho Cancer Institute, the first Cancer Hospital in Brazil, founded in 1921
Figura 6: Radiografia da pelve evidenciando área mais escura na asa do ilíaco, correspondente à baixa densidade óssea. Pelve com trans iluminação mostrando que naquela área central as tábuas interna e externa se fundem. Nesta zona NÃO há enxerto.
Figure 6: X-ray of the pelvis showing a darker area on the iliac wing, corresponding to low bone density. Pelvis with trans lighting showing that in that central area the inner and outer boards merge. There is NO graft in this area.
The need to obtain grafts in quantity, to make major biological reconstructions viable, made us improve the surgical technique to obtain autologous grafts with less morbidity and in significantly greater quantities. Is it possible to obtain an autologous bone graft to fill a large bone defect, of just one internal plate of the iliac, like the one in figure 7? Let’s demonstrate that yes, it is possible, figure 8.
Figura 7: É possível obter enxerto ósseo autólogo para preencher toda esta falha óssea, de apenas uma tábua interna do ilíaco?
Figure 7: Is it possible to obtain an autologous bone graft to fill this entire bone gap, from just one internal table of the iliac bone?
Figura 8: Radiografia de reconstrução com enxerto autólogo obtido de uma única tábua do osso ilíaco. Flexão com carga total após oito meses.
Figure 8: Radiograph of reconstruction with autologous graft obtained from a single table of the iliac bone. Flexion with full load after eight months.
Video 1: We can obtain as much autologous graft from the iliac bone as the abundant water in this stream. – Algonquin Park Ontario Canada.
The graft obtained must be applied in the reconstruction in order to avoid the formation of pseudoarthrosis lines, which will be explained later. The key points and technique for obtaining a good graft from the iliac bone are described in figures The incision must be superficial, only in the skin and subcutaneous tissue, so as not to damage the lateral femoral cutaneous sensory nerve. Before proceeding with the dissection, we carefully cauterized the subcutaneous vessels with electrocautery. figures 9 and 10.
Figura 9: Ampla incisão superficial, apenas na pele e tecido subcutâneo, para não lesar o nervo sensitivo fêmur cutâneo lateral, para obtenção de enxerto ósseo.
Figure 9: Wide superficial incision, only in the skin and subcutaneous tissue, so as not to damage the lateral femoral cutaneous sensory nerve, to obtain a bone graft.
Figura 10: Hemostasia com cuidadosa cauterização dos vasos do subcutâneo.
Figure 10: Hemostasis with careful cauterization of the subcutaneous vessels.
Figura 11: Realiza-se o descolamento do sub-cutâneo lateral e medialmente, nova hemostasia e com o bistuti elétrico desinserimos os músculos oblíquo do abdomem e ilíaco.
Figure 11: The lateral and medial subcutaneous tissue is detached, new hemostasis is achieved and the abdominal oblique and iliac muscles are removed using an electric scalpel.
Figura 12: Esta desinserção inicia-se anteriormente por sobre a crista ilíaca e vai desviando para lateral póstero-inferiormente à crista.
Figure 12: This disinsertion begins anteriorly above the iliac crest and deviates laterally postero-inferior to the crest.
Figura 13: Desinserimos o músculo ilíaco da espinha ilíaca antero superior e rebatemos cuidadosamente o nervo sensitivo fêmoro cutâneo lateral da coxa.
Figure 13: We detach the iliacus muscle from the anterior superior iliac spine and carefully retract the lateral femorocutaneous sensory nerve of the thigh.
Figura 14: Com uma gase "ruginamos" o perimísio do músculo ilíaco, separando-o da tábua interna.
Figure 14: Using gas, we "roar" the perimysium of the iliac muscle, separating it from the internal table.
At this stage, with the detachment of the thin periosteum, there are a large number of nutrient vessels that begin to flow blood. These must be obliterated with bone tissue hemostatic, aiming to buffer them. We need to notice that there is a small area of ​​the iliac bone where the external and internal plates are very close, almost fused. In this small “island” there is no graft (marked by the yellow arrow), figure 15. After this adequate hemostasis, we place the tip of a compress in the greater sciatic notch and leave it over the sacroiliac, to dam the blood and the graft . We begin with an osteotome to remove the upper cortex of the iliac crest. We must begin graft removal with controlled hemostasis, figure 16.
Figura 15: Hemostasia da tábua interna. Calibrosa artéria nutrícia, que é obliterada com cera para osso, seta vermelha. A seta amarela assinala a região clara, onde a tábua interna e a externa se fundem. NÃO HÁ ENXERTO AÍ!
Figure 15: Hemostasis of the inner table. Large nutrient artery, which is obliterated with bone wax, red arrow. The yellow arrow marks the light region, where the inner and outer boards merge. THERE IS NO GRAFTING THERE!
Figura 16: Retirada da cortical superior da crista ilíaca, com osteótomo. Boa hemostasia, sangramento controlado.
Figure 16: Removal of the upper cortex of the iliac crest, with an osteotome. Good hemostasis, controlled bleeding.
With curved and sharp osteotomes, modeled on the anatomy of the region, we remove the inner cortex in the thinnest layer possible. Exposure of the spongy tissue allows blood to drain. This blood should not be aspirated, it should be allowed to collect at the bottom, forming a clot. This collected blood has potent toti cells. It will be collected with a compress and placed in a vat where we will store the obtained graft, nourishing and preserving it, figures 17 to 19.
Figura 17: Retirada da cortical interna em camada a mais fina possível. Coágulo ao fundo proveniente do sangue que escorre ao retirar-se a cortical. NÃO deve ser aspirado.
Figure 17: Removal of the inner cortex in the thinnest possible layer. Clot at the bottom originating from the blood that drains when the cortex is removed. It should NOT be vacuumed.
Figura 18: Esquema ilustrativo da retirada da cortical da tábua interna do ilíaco. Vamos retirando a cortical que não está coberta pelo coágulo coletado no fundo.
Figure 18: Illustrative diagram of the removal of the cortex from the internal table of the iliac. We are removing the cortex that is not covered by the clot collected at the bottom.
Figura 19: Esquema ilustrando a cortical interna retirada, contornando a área sem enxerto, para não perfurar o osso ilíaco.
Figure 19: Scheme illustrating the internal cortex removed, bypassing the area without a graft, so as not to perforate the iliac bone.

After removing the entire inner cortex, we store the graft in a vat, soaked by the collected clot, thus preserving the totipotent cells, which will also be placed in the bone defect. Next, with a sharp chisel and WITHOUT using a hammer, we proceed with the removal of the spongy iliac bone, figures 20 to 23.

Figura 20: Tábua interna do ilíaco com todo o osso esponjoso exposto, após a retirada da cortical interna.
Figure 20: Internal plate of the iliac bone with all the cancellous bone exposed, after removal of the internal cortex.
Figura 21: Devemos retirar o enxerto esponjoso "RASPANDO" o osso com formão afiado, com ligeiros movimentos de pressão e rotação. Não se deve bater com martelo.
Figure 21: We must remove the cancellous graft by "SCRAPPING" the bone with a sharp chisel, with slight pressure and rotation movements. Do not hit with a hammer.
Figura 22: Osso esponjoso sendo recolhido com pinça. Não se aspira o sangue, coleta-se o coágulo com compressa, à medida que houver necessidade de visualizar a profundidade, para coletar mais enxerto.
Figure 22: Cancellous bone being collected with forceps. The blood is not aspirated, the clot is collected with a compress, as there is a need to visualize the depth, to collect more graft.
Figura 23: Após o emprego de formões afiados, completamos a raspagem com curetas.
Figure 23: After using sharp chisels, we completed the scraping with curettes.
With this care in collecting the graft, without the use of a hammer, by “scraping” the internal table, already decorticated, we do not drill the bone and maintain the iliac anatomy as much as possible, figure 24. The graft obtained is placed in a vat together with the collected blood, preserving the nutrition of the totipotent cells by imbibition, figure 25. This graft must be fixed, mixing the cortical bone material obtained with the spongy part, to be placed in the bone gap, figure 26. In the gaps segments, we must obtain splinters and intertwine them, making a tie, as a bricklayer lays bricks when building a wall, avoiding the formation of traces of pseudarthrosis, figure 27.
Figura 24: Enxerto retirado, sem lesar a "ilha" formada pela tábua interna e externa intactas, seta amarela. Setas brancas: 1- crista ilíaca, 2- teto acetabular e 3- coluna posterior, de onde foi retirado enxerto.
Figure 24: Graft removed, without damaging the "island" formed by the intact inner and outer plank, yellow arrow. White arrows: 1- iliac crest, 2- acetabular roof and 3- posterior column, from where the graft was removed.
Figura 25: Enxerto autólogo, retirado de uma tábua anterior interna do ilíaco.
Figure 25: Autologous graft, taken from an internal anterior table of the iliac.
Figura 26: O enxerto autólogo é dimensionado e mesclado, o osso esponjoso com o osso cortical obtido, para a reconstrução de 18 cm de falha óssea.
Figure 26: The autologous graft is sized and merged, the cancellous bone with the obtained cortical bone, for the reconstruction of 18 cm of bone defect.
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Figura 27: Nas reconstruções segmentares, o enxerto deve ser colocado entrelaçado, para evitar linhas de possível pseudoartrose.
Figure 27: In segmental reconstructions, the graft must be placed interlaced, to avoid lines of possible pseudarthrosis.
Note in figures 28 and 29, x-ray and photo of the iliac bone, the evidence of the absence of a graft in the area indicated by the yellow arrows. On the radiograph, the rarefaction area and the transparency of this region are highlighted by transillumination.
Figura28: Anatomia do ilíaco, radiografia: A seta assinala a área sem enxerto.
Figure 28: Iliacus anatomy, x-ray: The arrow marks the area without a graft.
Figura 29: Osso ilíaco por trans iluminação, podemos constatar a ausência de enxerto nesta "ilha", apontada pela seta amarela.
Figure 29: Iliac bone by trans illumination, we can see the absence of graft in this "island", indicated by the yellow arrow.
When the patient needs to be positioned in the prone position, as in spinal surgeries, we can obtain an autologous graft more easily, exposing the iliac bone. In this approach, the best incision is horizontal, at the level of the posterior superior iliac spine. This incision is more cosmetic and can be easily hidden by a bikini, in addition to facilitating both the exposure of the iliac crest and the posterior column, figures 30 and 31.
Figura 30: Incisão horizontal, na altura da espinha póstero-superior, para exposição da tábua externa e retirada de enxerto do ilíaco posterior.
Figure 30: Horizontal incision, at the level of the posterosuperior spine, to expose the external table and remove the posterior iliac graft.
Figura 31: Assepsia e antissepsia para incisão horizontal, na altura da espinha póstero-superior, para exposição da tábua externa e retirada de enxerto do ilíaco posterior.
Figure 31: Asepsis and antisepsis for horizontal incision, at the level of the posterosuperior spine, to expose the external table and remove the posterior iliac graft.
We incise the skin and subcutaneous cellular tissue, perform careful hemostasis and remove the perimysium of the gluteus maximus muscle. We place Hohmann retractors supported on the iliac crest and reflect the subcutaneous tissue superiorly, Figure 32. The same detachment is performed distally and we support a Bennet retractor on the greater sciatic notch and remove the external cortex, Figure 33.
Figura 32: Rebatimento da pele e subcutâneo com afastadores de Hohmann, apoiados na crista ilíaca, superiormente. Exposição do músculo glúteo máximo.
Figure 32: Reflection of the skin and subcutaneous tissue with Hohmann retractors, supported on the iliac crest, superiorly. Exposure of the gluteus maximus muscle.
Figura 33: Cortical externa retirada e exposição para retirada do enxerto esponjoso. Seta amarela destacando a "ilha", que deve ser preservada. Seta azul assinala o afastador de Bennet, apoiado na incisura isquiática maior.
Figure 33: External cortex removed and exposed for removal of the cancellous graft. Yellow arrow highlighting the "island", which must be preserved. Blue arrow marks Bennet's retractor, supported on the greater sciatic notch.
We scrape the spongy bone with sharp chisels and remove the graft from the sacroiliac region, crest and posterior column. We perform hemostasis of the nutrient vessels with bone wax, figure 34. The graft obtained is chopped into thin sticks, to facilitate reabsorption and reintegration, figure 35.
Figura 34: Osso esponjoso já retirado, raspando com formões afiados. Hemostasia dos vasos nutrícios com cera para osso.
Figure 34: Spongy bone already removed, scraping with sharp chisels. Hemostasis of nutrient vessels with bone wax.
Figura 35: Enxerto ósseo picado em forma de finos palitos.
Figure 35: Bone graft chopped into thin sticks.

It is important to remember the concept of repairing bone defects with bone grafts: IN A BIOLOGICAL RECONSTRUCTION, EVERY BONE GRAFT  PLACED TO FILL CAVITIES OR SEGMENTAL FAULTS GOES THROUGH A  REABORTION PHASE  TO  BE LATER REINTEGRATED , REPAIRING THE BONE LOSS. The graft must be intertwined and go beyond the level of the osteotomy, avoiding pseudarthrosis, as exemplified by this case of chondrosarcoma in figures 36 to 38, blue arrows.

Figura 36: Enxerto ósseo picado e entrelaçado em paliçada, preenchendo a falha óssea segmentar.
Figure 36: Bone graft chopped and intertwined in a palisade, filling the segmental bone gap.
Figura 37: Radiografia, frente, reconstrução com enxerto ósseo autólogo e osteossíntese com placa especial.
Figure 37: Radiograph, front, reconstruction with autologous bone graft and osteosynthesis with a special plate.
Figura 38: Radiografia, perfil, reconstrução com enxerto ósseo autólogo e osteossíntese com placa especial.
Figure 38: Radiograph, profile, reconstruction with autologous bone graft and osteosynthesis with a special plate.
Below, we present an example of cavity reconstruction, in the case of a giant cell tumor, treated with intra-lesional curettage, adjuvant electrothermia, crimping with a dental ball and filling with an autologous bone graft, taken from the internal table of an iliac bone. Full integration of the graft and excellent function of the operated knee, figures 39 to 49.
Figura 39: Radiografia do joelho, frente, com grande lesão de rarefação óssea, comprometendo toda a região epífise metafisária do fêmur direito.
Figure 39: X-ray of the knee, front, with a large bone rarefaction lesion, affecting the entire metaphyseal epiphyseal region of the right femur.
Figura 40: Radiografia do joelho, perfil, grande lesão epífise metafisária do fêmur direito, com erosão da cortical anterior.
Figure 40: X-ray of the knee, profile, large metaphyseal epiphyseal lesion of the right femur, with erosion of the anterior cortex.
Figura 41: RM do joelho, grande lesão de rarefação óssea, comprometendo toda a região epífise metafisária do fêmur direito.
Figure 41: MRI of the knee, large bone rarefaction lesion, affecting the entire metaphyseal epiphyseal region of the right femur.
Figura 42: Incisão medial e ressecção do trajeto da biópsia.
Figure 42: Medial incision and resection of the biopsy path.
Figura 43: Retirada da cortical medial e abertura de ampla janela para curetagem intralesional. A cortical rebatida e campos suturados protegem o leito operatório.
Figure 43: Removal of the medial cortex and opening of a wide window for intralesional curettage. The reflected cortex and sutured fields protect the operating bed.
Figura 44: Adjuvância com eletrotermia.
Figure 44: Electrothermal adjuvant.
Figura 45: Preenchimento da cavidade com enxerto ósseo autólogo compactado e colocação de pedaço de osso córtico esponjoso para ocluir a "janela".
Figure 45: Filling the cavity with compacted autologous bone graft and placing a piece of cancellous cortical bone to occlude the "window".
Figura 46: Radiografia do joelho operado, frente, com enxerto totalmente integrado. Restauração integral da anatomia.
Figure 46: Radiograph of the operated knee, front, with fully integrated graft. Full restoration of anatomy.
Figura 47: Paciente no pós-operatório, membro alinhado, carga total.
Figure 47: Post-operative patient, limb aligned, full load.
Figura 48: Flexão de 145 graus do joelho operado.
Figure 48: 145 degree flexion of the operated knee.
Figura 49: Bom alinhamento com carga total no joelho operado.
Figure 49: Good alignment with full load on the operated knee.
The iliac bone is also a rich source of structural graft, with better quality in terms of integration than the fibula. Obtaining this type of graft deforms the anatomical contour of the pelvis, as there is a need to remove the iliac crest together with the internal and external cortex, forming a triangular block, as exemplified by the cases of simple bone cyst, shown in figures 50 to 60.
Figura 50: Cisto ósseo simples do fêmur, com fratura.
Figure 50: Simple bone cyst of the femur, with fracture.
Figura 51: Tomografia de fratura em cisto ósseo simples. A cortical do segmento proximal aparece afundada dentro da falha óssea na epífise.
Figure 51: Tomography of fracture in simple bone cyst. The cortex of the proximal segment appears sunken within the bone defect in the epiphysis.
Figura 52: Aspecto intraoperatório após a curetagem da lesão na diáfise, metáfise e epífise femoral. Segmento de enxerto estrutural retirado da crista ilíaca e reconstrução com placa angulada. A lâmina da placa é apoiada pelo enxerto, que mantem a distância entre a epífise e o segmento proximal.
Figure 52: Intraoperative appearance after curettage of the lesion in the femoral diaphysis, metaphysis and epiphysis. Structural graft segment removed from the iliac crest and reconstruction with an angled plate. The plate blade is supported by the graft, which maintains the distance between the epiphysis and the proximal segment.
Figura 53: Placa fixada, enxerto estrutural da crista ilíaca apoiando a lâmina e enxerto impactado preenchendo o restante da cavidade.
Figure 53: Plate fixed, structural graft from the iliac crest supporting the blade and impacted graft filling the rest of the cavity.
Figura 54: Radiografia de reconstrução de cisto ósseo com fratura. Observa-se o contorno do enxerto estruturado sendo integrado e a consolidação do enxerto fragmentado impactado.
Figure 54: Radiograph of bone cyst reconstruction with fracture. The contour of the structured graft being integrated and the consolidation of the impacted fragmented graft are observed.
Figura 55: Radiografia de reconstrução de cisto ósseo com fratura, bom alinhamento. Consolidação do enxerto fragmentado impactado.
Figure 55: Radiograph of bone cyst reconstruction with fracture, good alignment. Consolidation of the impacted fragmented graft.
Video 2: Aesthetic and functional aspect. Good reconstruction, anatomical, and good flexion function with full load.
Another example of the use of a structural graft can be seen in this case of reconstruction of the first metatarsal, due to injury caused by a giant cell tumor, figures 57 to 60.
Figura 57: Tumor de células gigantes do primeiro metatarsiano; radiografia com a lesão lítica; incisão e exposição do tumor e peça resseca.
Figure 57: Giant cell tumor of the first metatarsal; radiography with the lytic lesion; incision and exposure of the tumor and resection of the piece.
Figura 58: Reconstrução do primeiro metatarseano com enxerto ósseo autólogo estruturado, obtido da crista ilíaca.
Figure 58: Reconstruction of the first metatarsal with structured autologous bone graft, obtained from the iliac crest.
Figura 59: Radiografia da reconstrução; aspecto clínico pós operatório.
Figure 59: X-ray of the reconstruction; post-operative clinical appearance.
Figura 60: Aspecto estético e funcional da reconstrução.
Figure 60: Aesthetic and functional aspect of the reconstruction.
Figura 61: Sarcoma de Ewing do úmero, quimioterapia, cirurgia de ressecção e reconstrução biológica autóloga com fíbula e enxerto estrutural de crista ilíaca.
Figure 61: Ewing sarcoma of the humerus, chemotherapy, resection surgery and autologous biological reconstruction with fibula and iliac crest structural graft.
Figura 62: Paciente em pós-operatório de dois meses, ainda em quimioterapia e após 24 anos, grávida.
Figure 62: Patient two months post-operatively, still undergoing chemotherapy and after 24 years, pregnant.
Video 3: Good aesthetics and function, 22 years after surgery.

This case can be seen in full by accessing the link: http://bit.ly/sarcoma-de-Ewing

The fibula can also be used vascularized in reconstructions, including with the growth plate to replace the one that will be resected due to the tumor. It is a fibula autotransplantation with the physeal plate, performing osteosynthesis with the extensible internal fixation device, figures 63 and 64.

Figura 63: Sarcoma de Ewing do úmero, Quimioterapia + ressecção do tumor. Planejamento da reconstrução com dispositivo de fixação interna extensível.
Figure 63: Ewing sarcoma of the humerus, Chemotherapy + tumor resection. Reconstruction planning with an extensible internal fixation device.
Figura 64: Reconstrução com autotransplante de placa de crescimento da fíbula, com microcirurgia. Radiografia da osteossíntese com o dispositivo extensível.
Figure 64: Reconstruction with autotransplantation of the fibula growth plate, with microsurgery. Radiography of osteosynthesis with the extendable device.

In the reconstruction of small segments, such as in reconstruction of the radius, due to trauma or tumors, we can use the free fibula with good results, figures 65 and 66.

This case can be seen in full by accessing the link: http://bit.ly/tgc_radio

Figura 65: Tumor de células gigantes do rádio. Ressecção da lesão.
Figure 65: Giant cell tumor of the radius. Resection of the lesion.
Figura 66: Peça ressecada. Obtenção de enxerto autólogo de fíbula. Reconstrução do punho.
Figure 66: Dried piece. Obtaining an autologous fibula graft. Wrist reconstruction.
Still undergoing reconstructions of the pelvis, figure 67
Figura 67: Reconstrução da pelve com enxerto autólogo de fíbula em Sarcoma de Ewing.
Figure 67: Reconstruction of the pelvis with autologous fibula graft in Ewing Sarcoma.
Figura 68: Reconstrução de fratura do colo femoral com enxerto autólogo estrutural de crista ilíaca.
Figure 68: Reconstruction of femoral neck fracture with autologous structural iliac crest graft.
Another source of graft is the femoral or tibial condyles, figures 69 and 70.
Figura 69: Artrodese do joelho, com emprego de enxerto ósseo autólogo estrutural do côndilo femoral.
Figure 69: Arthrodesis of the knee, using an autologous structural bone graft from the femoral condyle.
Figura 70: Artrodese do joelho com enxerto do planalto tibial e patela.
Figure 70: Knee arthrodesis with tibial plateau and patella graft.

Author: Prof. Dr. Pedro Péricles Ribeiro Baptista

 Orthopedic Oncosurgery at the Dr. Arnaldo Vieira de Carvalho Cancer Institute

Office :  Rua General Jardim, 846 – Cj 41 – Cep: 01223-010 Higienópolis São Paulo – SP

Phone: +55 11 3231-4638  Cell:+55  11 99863-5577   Email:  drpprb@gmail.com

Proximal tibial reconstruction with auto transplantation
Author drpprb@gmail.com Categories Academic Articles 0 comment

Proximal tibial reconstruction with auto transplantation

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Proximal tibial reconstruction with auto transplantation of the fibular growth plate: two case reports, describing the surgical technique

Introduction

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.

Case description

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.

Conclusions

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.

Background

In the skeletally immature population, the proximal tibia hosts a growth plate that accounts for nearly 30 % of the final limb length in adulthood (Digby 1916). This is the second most frequent location of primary bone tumors, with the first being the distal femur (Mercuri et al. 1991). Tumors that develop in the proximal tibia before skeletal maturity can affect the growth plate and lead to discrepancies in the final length of the lower limbs (Fig. 1).

Figure 1: a Radiography of the tibia showing a proximal metaphyseal bone tumor. b MRI image showing no compromise of the proximal epiphysis by the tumor. c Resected specimen
Figure 1: a Radiography of the tibia showing a proximal metaphyseal bone tumor. b MRI image showing no compromise of the proximal epiphysis by the tumor. c Resected specimen

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.

Surgical technique

With the patient on supine position, a single incision is used. Starting above the proximal tibiofibular joint, the incision bends to the anterior tibial crest and down along it, bending again medially a few inches below the previously planned fibular osteotomy (Fig. 2a). The anterior tibialis muscle is exposed. Its perimysium is opened and the muscle is retracted laterally, leaving the inner layer of the perimysium attached to the tibial periosteum, in order to preserve the wide margin of tumor resection (Fig. 2b). The neck of the fibula is identified and the common peroneal nerve is dissected. The proximal tibiofibular joint is addressed and the joint capsule, along with the anterior and posterior ligaments, popliteal ligament, fibular collateral ligament and the femoral biceps tendon are released from the fibular head (Fig. 2c).

Figure 2: a Single incision, b opening of the perimysium and lateralization of the anterior tibial muscle, c dissection of the proximal part of the fibula and d dissection of tibial epiphysis
Figure 2: a Single incision, b opening of the perimysium and lateralization of the anterior tibial muscle, c dissection of the proximal part of the fibula and d dissection of tibial epiphysis

The proximal epiphysis of the tibia and the anterior tuberosity are isolated from the metaphyseal region (Fig. 2d). A Kirschner wire is inserted horizontally trough the epiphysis where the proximal fixation of the plate will take place. The position of the plate is checked in this moment (Fig. 3a). The tumoral bone segment to be resected is measured, and oncologic margins are added. The distal osteotomy of the tibia at the diaphyseal region is performed. The posterior muscles attached to this portion of the bone are detached proximally, leaving the epiphyseal region that will be separated from the tumor by transepiphyseal osteotomy, and preserving as much of the epiphyseal bone and articular cartilage as possible. The tumor is now completely dissected and removed (Fig. 3b, c).

Figure 3: a Introduction of a wire-guide in the epiphysis and checking the position for the plate. b Separation of the tibial epiphysis from the tumor by transepiphyseal osteotomy and c tumor resected
Figure 3: a Introduction of a wire-guide in the epiphysis and checking the position for the plate. b Separation of the tibial epiphysis from the tumor by transepiphyseal osteotomy and c tumor resected

The bone gap is replaced by the ipsilateral fibula, which at this moment is isolated from the tibiofibular joint and the lateral collateral ligament. Two cm of periosteum is removed from the fibular shaft where the distal osteotomy will take place (Fig. 4a). After osteotomy, this segment of the fibular bone without its periosteum will be inserted in the bone marrow of the tibial shaft (Fig. 4b). The proximal segment of the fibula is medially transferred to the center of the remaining tibial epiphysis, along with all its muscles and nurturing arteries. The cartilage of the proximal epiphysis of the fibula is gently removed, so it can allow bone consolidation between the remaining proximal tibial epiphysis and the transposed fibula (Additional file 1: Video 5). The fibular collateral ligament is reinserted to the lateral periosteum of the tibia (Fig. 4c).

Figure 4: a Small periosteal removal from the fibula, b nailing the fibula in the medullary canal of the tibia, c repositioning of the fibula under the center of the tibial plateau and reinsertion of the lateral ligament and d proximal and distal osteosynthesis with screws
Figure 4: a Small periosteal removal from the fibula, b nailing the fibula in the medullary canal of the tibia, c repositioning of the fibula under the center of the tibial plateau and reinsertion of the lateral ligament and d proximal and distal osteosynthesis with screws

The osteosynthesis with screws is performed and a Baptista’s extendable internal fixation device, previously tailored for each case (Baptista and Yonamine 2001), is placed on the medial side of the leg (Fig. 4d). This device, made in Brazil by IMPOL, consists of two plates connected by a trapezoidal shaped rail interlocking that allows longitudinal sliding between them, but creates stability in all other directions (Additional file 2: Video 1) (Fig. 5a1, b1). The proximal plate has a platform to support the remaining portion of the tibial plateau and screw holes for attachment to the epiphysis (Fig. 5a2). The distal plate is low profile, to facilitate its coverage by the skin of the medial leg, and has holes for the screws in the tibial diaphysis (Fig. 5b2). The channels on each plate fit each other, stabilizing the junction while allowing slippage (Fig. 5ab). This device allows lengthening according to the fíbula longitudinal growth. It also provide axial compression when weight bearing starts.

Figure 5: a1 proximal plate, front view, b1 distal plate, front view, a2 proximal plate, side view, b2 distal plate, side view and ab fitting of the two plates, mounting the device
Figure 5: a1 proximal plate, front view, b1 distal plate, front view, a2 proximal plate, side view, b2 distal plate, side view and ab fitting of the two plates, mounting the device

The harvested fibula is interposed between the tibial epiphysis and the distal portion of the tibia. The surrounding soft tissues are reattached. After checking for vascular patency of the lateral side of the fibula, a closed vacuum wound drain is placed and the soft tissues are anatomically approximated. The limb is immobilized with an orthesis until osseous union of the proximal and distal junctions and hipertrophy of the fibula are radiographically confirmed (Additional file 3: Video 2) (Fig. 6), which usually occurs from 3 to 8 months postoperatively (Additional file 4: Video 3). Full weight bearing is authorized according to radiography consolidation and fibular hypertrophy (Additional file 5: Video 4).

Figure 6: a Surgical wound and b custom made orthesis
Figure 6: a Surgical wound and b custom made orthesis

Case presentation

Case 1

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.

In this case, we did not use fix angle screws in the proximal plate, which resulted in valgus deviation that was clinically observed and radiographically evidenced by tilting of the screws (Fig. 7a–c). The patient underwent the first scanometry of the lower limbs one year after surgery, when 0.75 cm fibular growth was observed and reorientation of the screws was done (Fig. 7b–e). Spontaneous correction of the angular deviation was clinically observed and flattening of the screws was radiographically documented, confirming the fibular longitudinal growth and the sliding of the device. The second scanometry, held 26 months postoperatively, demonstrated 1.2 cm growth of the transposed fibula (Fig. 7f). The patient is now a 26 year old man who has been followed up for 14 years without recurrences. He has equalized, satisfactory functioning lower limbs (Additional file 6: Video 6) (Fig. 8).

Figure 7: a Preoperative magnetic resonance, b 4 months postoperative radiograph showing the slope of the tibial epiphysis screws, c patient at 4 months after surgery with valgus knee deviation, d patient at 1 year and 2 months after surgery, with fixed valgus deformity and e 1 year and 2 months postoperative radiograph showing fibula hypertrophy, screws tilt correction and growth of 0.75 cm and f radiography postoperative 2 years and 2 months with growth of 1.2 cm
Figure 7: a Preoperative magnetic resonance, b 4 months postoperative radiograph showing the slope of the tibial epiphysis screws, c patient at 4 months after surgery with valgus knee deviation, d patient at 1 year and 2 months after surgery, with fixed valgus deformity and e 1 year and 2 months postoperative radiograph showing fibula hypertrophy, screws tilt correction and growth of 0.75 cm and f radiography postoperative 2 years and 2 months with growth of 1.2 cm
Figure 8: a patient 3 years and 7 months postoperatively, at full load, b 3 years, 7 months, bending under load and good function of the knee, and c radiograph 3 years, 7 months, fibula hypertrophied, already fully tibializated
Figure 8: a patient 3 years and 7 months postoperatively, at full load, b 3 years, 7 months, bending under load and good function of the knee, and c radiograph 3 years, 7 months, fibula hypertrophied, already fully tibializated

Case 2

A 31 months old male patient presenting with Ewing’s sarcoma of the proximal right tibia underwent tumor resection with preservation of the proximal tibial epiphysis. The proximal fibula and its physis were medially transferred to the center of the tibial epiphysis, maintaining its blood supply. The osteosynthesis was performed using an extendable internal fixation device. In this case, the proximal plate was improved by creating a support to the remaining tibial plateau, aiming to improve stability and prevent angular deviations (Fig. 9b). Slots were made at every 3 mm of the distal plate to help observation of sliding between the plates, which would evidence fibular growth. After surgery, the limb was kept in an orthesis.

Figure 9: a The proximal-plate with a horizontal support, for proximal tibia epiphisial support, b immediate postoperative radiograph, c 3 months postoperative radiograph, showing the distal tibio-fibular consolidation and d 6 months postoperative radiograph, showing hypertrophy the fibula
Figure 9: a The proximal-plate with a horizontal support, for proximal tibia epiphisial support, b immediate postoperative radiograph, c 3 months postoperative radiograph, showing the distal tibio-fibular consolidation and d 6 months postoperative radiograph, showing hypertrophy the fibula

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.

Discussion

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.

Conclusions

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.

Autor : Prof. Dr. Pedro Péricles Ribeiro Baptista

 Oncocirurgia Ortopédica do Instituto do Câncer Dr. Arnaldo Vieira de Carvalho

Consultório: Rua General Jardim, 846 – Cj 41  –  Cep: 01223-010   Higienópolis  São Paulo – S.P.

Fone:+55 11 3231-4638  Cel:+55 11 99863-5577  Email: drpprb@gmail.com

A370afda41a7ae62dcb8d1b721b92bed 3
Author drpprb@gmail.com Categories Chapters 0 comment

Bone Aneurysmal Cyst

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Aneurysmal Bone Cyst

Aneurysmal bone cyst (AOC) belongs to the group of pseudotumor bone lesions. This group of diseases produces bone changes that mimic tumor lesions, from the point of view of radiographic imaging.

Aneurysmal Bone Cyst

The injuries that are part of this group are:

simple bone cyst.

aneurysmal bone cyst.

juxtacortical bone cyst (intraosseous ganglion).

metaphyseal fibrous defect (non-ossifying fibroma).

eosinophilic granuloma.

fibrous dysplasia (osteofibrodysplasia).

myositis ossificans.

brown tumor of hyperparathyroidism.

intraosseous epidermoid cyst.

giant cell reparative granuloma.

The aneurysmal bone cyst, also called multilocular hematic cyst, is a lesion of insufflative bone rarefaction filled with serosanguineous fluid, interspersed with spaces varying in size and separated by septa of connective tissue containing trabeculae of bone or osteoid tissue and ostoclastic giant cells (fig 1 ).

Figura 1 - C.O.A. múltiplos septos de tecido conjuntivo
Figure 1 - COA multiple connective tissue septa

The origin and etiology of this process are still unknown, despite having been described by Jaffe and Lichtenstein since 1942. Cytogenetic studies suggest that there is a correlation between this lesion and chromosome 17 translocation phenomena.

The presence of osteoclast-type giant cells suggests that a process of localized bone reabsorption occurred, accompanied by accumulation of blood and septated either by connective tissue or by osteoid tissue with bone trabeculae.

These blood-filled cavities do not have blood supply that can be demonstrated by arteriography or intracystic contrast infusion and consequently do not have a pulsatile character. These pockets are not empty therefore they are not cysts nor do they represent any form of aneurysm. The term “aneurysmal bone cyst” is not appropriate for this condition.

It is therefore a benign lesion and according to Enneking it can be classified as active or aggressive benign. The presence of areas of fibrosis and reparative ossification is related to cyst regression or the result of a previous fracture (fig 2).

Figura 2 - Rm. axial T1. cisto ósseo aneurismático da tíbia.
Figure 2 - Rm. axial T1. aneurysmal bone cyst of the tibia.

The stores occur in varying numbers and sizes, clumping together and causing erosion of the bone trabeculae, which expand and inflate the cortex. Histologically, blood gaps are observed separated from each other by connective septa and osteoclastic cells, without atypia.

However, this “phenomenon” of an aneurysmal bone cyst may appear alongside other tumor lesions such as osteoblastoma  ,  chondroblastoma  ,   chondromyxoid fibroma,  giant  cell tumor, teleangiectatic  osteosarcoma,   fibrous  dysplasia  and brown  tumor of hyperparathyroidism , in addition to metastatic lesions secondary to  thyroid  or  kidney neoplasia . These tumors with their characteristic histology may present isolated areas of the classic aneurysmal bone cyst. Therefore, small biopsy fragments can make accurate diagnosis difficult (fig 3).

Figura 3: Tumor de células gigantes do fêmur, com área de cisto ósseo aneurismatico. A escolha do local de biópsia deve permitir a obtenção de amostra representativa da heterogeneidade da lesão. A) COA ; B) TGC
Figure 3: Giant cell tumor of the femur, with an area of ​​aneurysmal bone cyst. The choice of the biopsy site should allow obtaining a representative sample of the heterogeneity of the lesion. A) COA; B) TGC

The choice of the biopsy site must allow obtaining a representative sample of the heterogeneity of the lesion:  A) COA  ;  B) TGC

Figura 4: Ressonância magnética, corte sagital, de tumor de células gigantes do fêmur, com área de cisto ósseo aneurismatico. Observa-se que a lesão apresenta áreas de conteúdo líquido (a-COA) e áreas sólidas (b-TGC).
Figure 4: Magnetic resonance imaging, sagittal section, of a giant cell tumor of the femur, with an area of ​​aneurysmal bone cyst. It is observed that the lesion has areas of liquid content (a-COA) and solid areas (b-TGC).
Figura 5: Corte axial de ressonância magnética de tumor de células gigantes do fêmur, com área de cisto ósseo aneurismatico. Idem: conteúdo líquido (a-COA) e áreas sólidas (b-TGC).
Figure 5: Axial MRI section of a giant cell tumor of the femur, with an area of ​​aneurysmal bone cyst. Idem: liquid content (a-COA) and solid areas (b-TGC).

It is observed that the lesion has areas of liquid content ( a-COA ) and solid areas ( b-TGC ).

The anamnesis and images of the lesion must be carefully analyzed, the biopsy site must be chosen that allows a sample to be taken from the different areas that appear heterogeneous on MRI, to allow for an accurate diagnosis.

The classic aneurysmal bone cyst has a homogeneous appearance, while the aforementioned tumor lesions, when accompanied by areas of aneurysmal bone cyst, necessarily become heterogeneous.

It is more frequent in the first three decades of life, with its peak incidence between 5 and 20 years of age, with a slight predominance in females.

The patient generally presents with mild pain at the site of the injury and when the affected bone is superficial, inflammatory signs such as increased volume and heat can be observed. Generally, the patient correlates the onset of symptoms with some trauma.

In evolution there may be a slow, progressive or rapidly expansive increase. It affects any bone, most frequently the lower limbs (tibia and femur representing 35% of cases) and vertebrae, including the sacrum and in the pelvis mainly the iliopubic branch. They can mimic joint symptoms when located in the epiphysis. Compromise in the spine can cause compressive neurological symptoms, although in most cases it affects the posterior structures.

GOALS

At the end of reading this chapter, the reader will be able to:

  • know the group of pseudo-tumor lesions;
  • characterize the typical aneurysmal bone cyst;
  • determine the imaging tests necessary to clarify the injury;
  • make the differential diagnosis;
  • choose the best treatment for each situation.

CONCEPTUAL SCHEME: COA

Figura 6: No estadiamento ósseo realizado com a cintilografia encontramos lesão única com captação discreta na periferia da lesão.
Figure 6: In the bone staging performed with scintigraphy, we found a single lesion with discrete uptake on the periphery of the lesion.
Figura 7: A tomografia revela área radiolucente; erosão óssea; afilamento da cortical e insuflação. sem focos de calcificação.
Figure 7: Tomography reveals a radiolucent area; bone erosion; cortical thinning and inflation. no foci of calcification.
Figura 8: COA da tíbia com insuflação da cortical.
Figure 8: AOC of the tibia with cortical inflation.
Figura 9: Aspecto homogênio com erosão da cortical.
Figure 9: Homogeneous appearance with cortical erosion.

In the bone staging performed with scintigraphy, we found a single lesion with discrete uptake on the periphery of the lesion.

Radiographically, it appears as a radiolucent insufflation lesion, preferably in the metaphyseal region of long bones (it can also occur in the epiphysis and diaphysis), with the presence of septa scattered throughout its content, with a “bullous” (or honeycomb) appearance, with thinning and expansion of the cortex, eccentric in 50% of cases or central location. They can also occur centrally in the cortical bone and in less than 8% of cases on the surface.

The radiographic appearance, however, is homogeneous. As the lesion progresses, a Codman’s triangle may form, giving a false impression of soft tissue invasion, which does not occur because the lesion always has a surface of connective tissue that circumscribes it (pseudo-capsule that delimits the area of injury to the compromised bone and adjacent tissues).  

Magnetic resonance imaging, by performing cuts in different planes, often shows the presence of liquid levels, highlighting the numerous pockets separated by the connective septa. The diagnosis of an aneurysmal bone cyst on biopsy is accepted with greater ease when the MRI analysis of the entire lesion does not reveal any heterogeneous aspect. The presence of a heterogeneous structure on magnetic resonance imaging, in which the solid area presents contrast impregnation, implies the need to obtain a sample from this area for diagnosis, as this must be a case of association of an aneurysmal bone cyst with one of the aforementioned lesions.

Figura 10: Aspecto bolhoso, com septos conjuntivos
Figure 10: Bullous appearance, with connective septa
Figura 11: Níveis líquidos.
Figure 11: Liquid levels.
Figura 12: Curetagem intralesional, bolsas com conteúdo sanguíneo.
Figure 12: Intralesional curettage, pockets with blood content.
The treatment of choice has been marginal resection or intralesional curettage, followed by filling the cavity with an autologous or homologous graft, when necessary. The cavity can also be filled with methylmethacrylate, although our preference is to use an autologous graft when possible, as it is a benign lesion. Some authors associate intralesional adjuvant treatment with the application of phenol, electrothermia or cryotherapy. In classic aneurysmal bone cysts, I do not see the point of this therapy, which, however, should be applied when the surgeon finds a “suspicious” area that was not detected on imaging. If the aforementioned benign tumors are involved, which may be accompanied by areas of aneurysmal bone cyst, local adjuvant therapy will be beneficial.
Figura 13: Cavidade após curetagem ampla.
Figure 13: Cavity after wide curettage.
Figura 14: Aspecto macroscópico do material obtido da cavidade.
Figure 14: Macroscopic appearance of the material obtained from the cavity.
Figura 15: Preenchimento da cavidade com enxerto ósseo.
Figure 15: Filling the cavity with bone graft.

Some bone segments such as the ends of the fibula, clavicle, rib, distal third of the ulna, proximal radius, etc. can be resected, without the need for reconstruction.

In other situations, we may need segmental reconstructions with free or even vascularized bone grafts or joint reconstructions with prostheses in advanced cases with major joint involvement. In the spine, after resection of the lesion, arthrodesis may be necessary to avoid instability.

Radiotherapy should be avoided due to the risk of malignancy, however it is reserved for the evolutionary control of lesions that are difficult to access, such as the cervical spine, for example, or other situations in which surgical reintervention is not recommended.

Embolization as an isolated therapy is controversial. However, it can be used preoperatively to minimize bleeding during surgery. This practice is most often used in cases of difficult access, although its effectiveness is not always achieved. Infiltration with calcitonin has been reported with satisfactory results in isolated cases.

Recurrence may occur, as the phenomenon that caused the cyst is unknown and we cannot guarantee that surgery repaired it. The recurrence rate can reach thirty percent of cases.

Questions:

1- The aneurysmal bone cyst:

a- it is a tumoral lesion

b- it is a metastatic lesion

c- occurs alone or accompanies other bone injuries

d- it is a pseudo-aneurysm

 

2- Differential diagnoses of COA include:

a- Chondrosarcoma

b- TGC

c- Ewing sarcoma

d- cortical fibrous defect

 

3- According to Enneking’s classification, the COA is:

a- active benign lesion

b- latent benign lesion

c- low-grade malignant lesion

d- high-grade malignant lesion

 

4- In relation to the COA, it is correct to state:

a- occurs more frequently in elderly patients

b- presents osteoclast-type giant cells

c- should preferably be treated with wide resection

d- presents foci of calcification

 

5- The radiographic appearance of the COA is:

a- condensing bone lesion

b- heterogeneous bone lesion

c- homogeneous bone rarefaction lesion

d- bone lesion without precise limits.

 

6- The preferential treatment of the COA is:

a- intralesional curettage

b- segmental resection

c- segmental resection + endoprosthesis

d- Arthrodesis

 

7- The tumor lesions that most frequently present areas of aneurysmal bone cyst are:

a- tgc; chondrosarcoma; osteosarcoma and Ewing’s sarcoma 

b- fibrous defect; tgc; adamantinoma and chordoma

c- osteoblastoma; chondroblastoma; chondromyxoid fibroma and tgc;  

d- osteosarcoma; chondroblastoma; eosinophilic granuloma and lipoma

 

Bibliography

 

  1. ALEOTTI, A.; CERVELLATTI, AA;BOVOLENTA, MR;ZAGOS,S. Et al Birbeck granules: contribution to the understanding of intracytoplasmic evolution. L.Submicrosc. Cytol. Pathol.,30(2):295, 1998.
  2. AVANZI, O.; JOILDA. FG;SALOMÃO, JC;PROSPERO, JD Aneurysmal bone cyst in the spine. Rev. Brás. Ortop., 31:103,1996
  3. AVANZI, O.; JOILDA. FG;PROSPERO, JD;CARVALHO PIN TO, W. Benign tumors and pseudotumor lesions in the vertebral hill. Rev. Brás. Ortop.,31:131,1996.
  4. BIESECKER, JL;HUVOS,AG.;MIKÉ. V. Aneurysm cap cysts.A clinicopathologic study of 66 cases, Cancer, 26:615,1970
  5. BURACZEWSKI, J.;M Pathogenesis of aneurysmal cap cyst. Relationship between the aneurysmal cap cyst and fibrous dysplasia of cap. Cancer, 28:116,1971.
  6. CDM Fletcher…[et al] . Classification of tumor. Pathology and genetics of tumors of sun tissue and bone. World Health Organization
  7. DABSKA, M,;BURACZEWSKI, J.- Aneurysmal cap cyst. Pathology, clinical course and radiological appearance. Cancer . 23:371,1969.
  8. DAHLIN, DC,;IVINS, JC- Benignin chondroblastoma of cap. A clinicopathology and electron microscopy study. Cancer .29:760,1972.
  9. DAILEY, R.; GILLILAUD, C.;McCOY, GB Orbital aneurysmal cap cyst in a patient with renal carcinoma. Am.J. Ophthalm., 117:643, 1944.
  10. DORFMAN ,HD;CZERBIAK,B.Bone tumors. St. Louis,CVMosby Co.,1997. P855.
  11. DORFMAN ,HD; STEINER, GC;JAFFE, HL Vascular tumors of thr cap. Hum. Pathol.,2:349, 1971.
  12. JAFFE, HL;LICHTENSTEIN, L. Aneurysmal cap cyst :observation on fifty cases. J.Bone Join Surg.,39 A:873, 1957.
  13. JAFFE, HL;LICHTENSTEIN, L .Benign chondroblastoma of cap. A reinterpretation of the so called calcifying or chondronaous giant cell tumor. Am J. .,18:969, 1942.
  14. JAFFE, H. L. Aneurysmal cyst.Bull cap. Hosp. J.Dis.,11:3,1950.
  15. LICHTENSTEIN, L Aneurysmal cap cyst. A pathological entity commonly mistaken for giant cell tumor and occasionally for hemangioma sarcoma. Cancer, 3:279,1954.
  16. MARTINEZ, V.;SISSONS.HA Aneurysmal cap cyst.A review of 123 cases including primary lesions and those secondary to other cap pathology. Cancer,61:2291, 1988.
  17. PROSPERO, JD;RIBEIRO BAPTISTA, PP;de Lima Jr., H. Bone diseases with multinucleated giant cells. Differential diagnosis. Rev. Brás. Ortop.,34:214,1999.
  18. RIUTTER,DJ,;VAN RUSSEL, THG;VANder VELDE, EA Aneuryamal cap cyst. A clinicopathological study of 105 cases. Cancer. 39:2231,1977.
  19. SCHAJOWICZ, F. Giant cell tumors aneurysmal cap cyst of the spine. J.Bone Joint Surg.,47B:699, 1965.

Authors of the case

Author: Prof. Dr. Pedro Péricles Ribeiro Baptista

 Orthopedic Oncosurgery at the Dr. Arnaldo Vieira de Carvalho Cancer Institute

Office :  Rua General Jardim, 846 – Cj 41 – Cep: 01223-010 Higienópolis São Paulo – SP

Phone: +55 11 3231-4638  Cell:+55  11 99863-5577   Email:  drpprb@gmail.com

Endoprótese em Revisões de Artroplastias
Author drpprb@gmail.com Categories Lectures 0 comment

Endoprosthesis in Arthroplasty Revisions

Endoprótese em Revisões de Artroplastias

Check out the video of the lecture

Endoprosthesis in Arthroplasty Revisions

Summary

The use of unconventional endoprostheses in orthopedic oncosurgery has emerged as an alternative in cases of complications and failures in arthroplasties, offering an approach that deserves special attention. The publication of our lecture, held at the Advanced Hip Surgery Course in November 2022 at Hospital Sírio Libanês in São Paulo/SP, representing the Dr. Arnaldo Vieira de Carvalho Cancer Institute, the first cancer hospital in Brazil, aims to disseminate this distinctive technique as a solution for complex cases of revision in failed arthroplasties.

In the United States, hundreds of thousands of hip arthroplasties are performed annually, with revisions accounting for about 20% of them. A significant portion of the expenses underscores the importance of effective solutions for these cases.

The Paprovisky classification, used by hip surgeons to catalog femoral defects and provide guidance for treatment, mentions the use of endoprostheses as a last resort. The dogma instilled in surgeons to “always preserve bone stock” has resulted in numerous revision surgeries, representing a high social cost and creating significant hardships for patients.

We analyze two cases of hip prostheses that have been revised multiple times to illustrate the complexity of these situations and the need to keep an open mind to innovative approaches.

It is essential to recognize that arthroplasty revisions pose unique challenges, requiring detailed surgical planning, knowledge of described materials and surgical techniques, as well as a deep understanding of our patient’s clinical conditions and expectations.

The alternative use of unconventional endoprostheses and “en bloc resection” of the affected problematic segment should be considered, allowing us to offer all alternatives and opt for the one with the least morbidity and the highest probability of rapid functional recovery for the elderly patient.

As we progress in medical practice, it is essential to continue exploring and refining these techniques to provide the best possible care for our patients.

Artrodese do doelho com Solução Protética ou Biológica
Author drpprb@gmail.com Categories Surgeries 0 comment

Knee Arthrodesis

Artrodese do doelho com Solução Protética ou Biológica

Knee Arthrodesis with Prosthetic or Biological Solution

In some cases of bone tumors and severe trauma, failure of prostheses or osteosynthesis can represent a significant challenge. It is in this scenario that knee arthrodesis emerges as a viable alternative. This technique can be performed in several ways, one of which is with a diaphyseal-type prosthesis or through a biological solution using autologous graft and osteosynthesis.

For example, when we are faced with the failure of an infected primary prosthesis or in situations of aggressive bone tumors or trauma, arthrodesis can become an alternative to amputation.

Let us consider this case of recurrent chondrosarcoma, after two unsuccessful surgical attempts, in which the need for a wide resection is present, and reconstruction with arthrodesis may be the only alternative to avoid amputation. In these cases, arthrodesis using a diaphyseal prosthesis may offer the chance of preserving this limb.

Success requires careful resection, with the removal of compromised tissues, preserving the popliteal vessels and nerves in the region. Then, reconstruction is carried out with a modular prosthesis of the diaphyseal type, in this case it was specially molded, with the manufacture of a polyethylene segment, aiming to give a more aesthetic shape to the “neo knee” region, minimizing the defect left by the extensive resection of the segment affected by the tumor and meeting the objective of ensuring a wide resection, with safe oncological margins.

In this other example of a giant cell tumor, which destroyed the entire tibial plateau and the proximal 1/3 of the tibia, the approach may be biological. In this patient, we used autologous bone from the site itself, in the case of the femoral condyles, to fill the bone gap left by the resection of the neoplasm.

It is important to highlight that the technique requires precision and care, both in resection and reconstruction. The plate used for fixing must be positioned to ensure adequate alignment and avoid unwanted rotations. The integration of arthrodesis with the biological autograft is essential for the success of the procedure.

In cases of severe trauma, with extensive bone destruction due to high-energy trauma, arthrodesis may be the only viable option to restore limb stability and avoid amputation. These cases, which we are showing, were presented at the International Knee Trauma Congress, in Ribeirão Preto – SP, showing our experience with these two arthrodesis techniques, using diaphyseal prostheses or osteosynthesis with biological reconstruction. For more information about these techniques and appreciation of other similar clinical cases, visit the website  www.oncocirurgia.com.br ,

 By sharing knowledge and experience, we will be able to advance developments in the treatment of complex orthopedic conditions.

Check out the video of the surgery below.

Tumor Ósseo Primitivo: Sarcoma de Ewing
Author drpprb@gmail.com Categories Surgeries 0 comment

Ewing’s sarcoma Transposition of the radius to the ulna

Tumor Ósseo Primitivo: Sarcoma de Ewing

Ewing's sarcoma
Transposition of the radius to the ulna

Ewing’s sarcoma. In 2007, we performed a surgical procedure to treat a primitive bone tumor, diagnosed as Ewing Sarcoma . This form of tumor is known for its aggressiveness and treatment challenges. The surgical intervention involved resection of the ulna, a bone in the forearm, which was affected by the injury.

Before surgery, tests such as bone scintigraphy and resonance were performed to stage the extent of the tumor. The results indicated a single injury to the right ulna. We opted for a surgical approach after the neoadjuvant chemotherapy phase.

The surgery began with meticulous preparation of the patient and the delimitation of the biopsy path to guide the resection, with an oncological margin. The iliac bone was prepared to obtain an autologous graft segment, necessary for wrist reconstruction, after removal of the compromised ulna segment. We use the term cautery (electric scalpel) to dissect tissues with better hemostasis and precision, minimizing damage to surrounding tissues and obtaining a better oncological margin.

After circumferential delimitation of the tumor, we performed resection of the compromised ulna, followed by preparation for the reconstruction by placing the head of the radius, the other bone of the forearm, in the groove between the humeral condyles, suitable to function with flexion-extension, in this new forearm with a single bone. The iliac bone graft segment was then used to promote distal radio-ulnar synostosis, that is, the fusion of the radius and ulna bones, stabilizing the new wrist.

During surgery, suture techniques were used to fix the head of the radius to the tendon of the triceps brachii muscle, to ensure the stability of the new elbow, providing satisfactory flexion-extension. Screw and pin were used to ensure adequate fixation of the distal radio-ulnar synostosis.

After completion of the surgery, an x-ray was performed to evaluate the outcome of the procedure. The tumor was completely resected, and bone reconstruction was successful. The patient was advised on postoperative care, including physical therapy to promote functional recovery of the affected limb.

The surgery was an important milestone in the patient’s journey against Ewing’s sarcoma, representing a significant step in the treatment of this complex disease and providing good function of the operated limb.

Through a multidisciplinary approach and appropriate technology, we are able to fulfill our commitment to providing the best possible care to patients facing such complex and difficult health challenges.

Prof. Dr. Pedro Péricles Ribeiro Baptista     drpprb@gmail.com   +55 11 99863-5577

Check out the video of the surgery below.

842ca578342915ccb8ae069595ba7233 3
Author drpprb@gmail.com Categories Academic Articles 0 comment

Technical Aspects of Laparoscopic

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Technical Aspects of Laparoscopic . Situs inversus is a rare anomaly characterized by transposition of organs to the opposite side of the body. We report a 16-
year-old woman with known situs inversus totalis and gallstone disease who underwent a successful laparoscopic
cholecystectomy. Diagnostic and technical challenges of the operation are discussed.

Technical Aspects of Laparoscopic Cholecystectomy in a Patient with Situs Inversus Totalis – Case Report

INTRODUCTION

Situs inversus is a autosomal recessive morphogenetic abnormality, characterized by the transposition of the abdominal viscera to the opposite side.1 This inversion of the topography can occur in the abdominal cavity and the chest or, more rarely, in one of the two. Its incidence is estimated at 1:5,000 to 1:20,000 live births.2 The clinical diagnosis of gallstones in these patients is more difficult because the clinical presentation is confusing, especially because of the pain localized to the left hypochondrium. There is no evidence showing a higher incidence of gallstones in people with situs inversus than in those with the orthotopic topography of the abdominal viscera.2 Several studies have shown that laparoscopic cholecystectomy is safe in these patients, however, due to the rarity of this condition, there is no standardization of procedure’s technique.1-5 Our objective is to present the case of a women with situs inversus and cholelithiasis who underwent laparoscopic cholecystectomy and discuss the technique used.

Figure 1 – Dressings corresponding to the trocar positions. A) Right Pararectus (10mm); B) Umbilicus (10mm); C) Left Pararectus (5mm); D) Epigastric (5mm)
Figure 1 – Dressings corresponding to the trocar positions. A) Right Pararectus (10mm); B) Umbilicus (10mm); C) Left Pararectus (5mm); D) Epigastric (5mm)
Figure 2 – Videolaparoscopic view of the mirrored anatomy of the abdominal organs.
Figure 2 – Videolaparoscopic view of the mirrored anatomy of the abdominal organs.
through trocar placed adjacent to the xiphoid process while the Assistant surgeon on the right of the patient maneuvers the camera. Cholangiography was
Figure 3 - Intra-operative Cholangiography.
Figure 3 - Intra-operative Cholangiography.
CASE REPORT

The patient was an overweight (BMI = 26.9) 16 year old adolescent female with an established diagnosis of situs inversus totalis, who presented with a four month history of biliary colic, that localized to the left hypochondrium. Chest radiograph, electrocardiogram, and ultrasound revealed dextrocardia, sinus rhythm and situs inversus totalis with the presence of multiple gallstones with an average diameter of 6 mm. The laparoscopic cholecystectomy was performed with the patient in the semi-lithotomy position with the surgeon between patient’s legs. The trocars were positioned as shown in Figure 1. After the optic was introduced, the mirrored anatomy of the abdominal organs was noted (Figure 2). The surgeon maneuvers his instruments through the pararectus trocars and performs the dissection of the infundibulum with the right-hand forceps while both the Assistant surgeon on the right and the Assistant surgeon on the left of the patient pull the bottom of the gall bladder postero-superiorly performed intraoperatively (Figure 3) to identify anatomical variations of the biliary tree; none was noted. After 90 minutes of surgery the gallbladder was removed through the umbilicus. The patient was discharged the next day.
 
DISCUSSION
In 1600, Fabricius described the transposition of the abdominal organs in a man.5 The first report of a laparoscopic cholecystectomy in a patient with situs inversus was published in 1991.5 Although it is a condition in which there is an alteration of the anatomy, there is no predisposition to gallbladder disease. The technical challenge performing a laparoscopic cholecystectomy in a patient with inversion of the abdominal organs – when confronted with the mirror image – consists in adapting the position of the surgeon, the Assistants, and the trocars for the dissection of the gallbladder hilum and the exposure of the gallbladder. Most reports in the literature describe the mirrored arrangement of both the trocars and the surgical team1,3,5 corresponding to the inversion of the abdominal organs. This positioning, which at first seems more logical, accentuate the cognitive bias and hampers the dissection of the Calot’s triangle. The surgeon is not accustomed to seeing the falciform ligament crossing superiorly and to the left across the video screen. There is constant crossing of the instruments as the base of gallbladder is brought forward, a frequent need for dissection with the left hand,4 and even placement of an extra trocar. 2 In this context it was suggested that laparoscopic cholecystectomy would be more easily performed by a left-handed surgeon.4  When operating between the legs of the patient, the adaption to the inversion of the position of the intracavitary organs seems faster. The surgeon performed the dissection of the gallbladder hilum with his right hand in the region anterior and posterior to Cabot’s triangle (Figure 4) and there were no crossing of the instruments. The camera and the forceps adjacent to the xiphoid were handled by both the first and second Assistant surgeons as needed during the surgeon’s dissection. The placement of clips and the sectioning of the cystic duct were performed with the surgeon’s left hand, while the catheter for cholangiography was inserted with the right hand. If a 10mm trocar is placed in the left flank, the surgeon 
Figure 4 - View of Calot’s Triangle
Figure 4 - View of Calot’s Triangle
could clip and section the structures exclusively with the right hand. We conclude that laparoscopic cholecystectomy in patients with situs inversus totalis has advantages when performed by the technique described above, since it avoids crossing of the instruments and permits the dissection with the right hand, facilitating the adaptation to the cognitive bias associated with the inversion of the abdominal organs
 

Autor : Prof. Dr. Pedro Péricles Ribeiro Baptista

 Oncocirurgia Ortopédica do Instituto do Câncer Dr. Arnaldo Vieira de Carvalho

Consultório: Rua General Jardim, 846 – Cj 41  –  Cep: 01223-010   Higienópolis  São Paulo – S.P.

Fone:+55 11 3231-4638  Cel:+55 11 99863-5577  Email: drpprb@gmail.com

57f63d38fd5439114eaceb6b8fce4d27 3
Author drpprb@gmail.com Categories Academic Articles 0 comment

Use of extensible internal device in the femur of young dogs

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Use of extensible internal device in the femur of young dogs. 1,2Departments of Veterinary Surgery and Anesthesiology, and 5Animal Reproduction and Radiology, School of Veterinary Medicine and Animal Science, São Paulo State University (UNESP), Botucatu Campus, São Paulo, Brazil 3,4Department of Orthopedics and Traumatology, Santa Casa Medical School, São Paulo, Brazil 6Department of Basic Sciences, School of Animal Science, Pirassununga Campus, São Paulo University (USP), São Paulo, Brazil

L. T. Justolin1, S. C. Rahal2, P. P. R. Baptista3, E. S. Yoname4, M. J. Mamprim5, J. C. C. Balieiro6

Use of extensible internal device in the femur of young dogs

Summary

An extensible internal device (EID) was developed to preserve growth plate during the treatment of fracture complications or segmental bone loss from tumour resection in children. Since this type of extensible, transphyseal, internal fixation device has only been used in a few paediatric cases; the aim of this study was to evaluate an in vivo canine study, a surgical application of this device, and its interference with longitudinal growth of the non-fractured distal femur. Ten clinically healthy two- to three-month-old poodles weighing 1.5–2.3 kg were used. Following a medial approach to the right distal femur, one extremity of the EID, similar to a T-plate, was fixed in the femoral condyle with two cortical screws placed below the growth plate. The other extremity, consisting of an adaptable brim with two screw holes and a plate guide, was fixed in the third distal of the femoral diaphysis with two cortical screws. The EID was removed 180 days after application. All of the dogs demonstrated full weight-bearing after surgery. The values of thigh and stifle circumferences, and stifle joint motion range did not show any difference between operated and control hindlimbs. The plate slid in the device according to longitudinal bone growth, in all but one dog. In this dog, a 10.5% shortening of the femoral shaft was observed due to a lack of EID sliding. The other dogs had the same longitudinal lengths in both femurs. The EID permits longitudinal bone growth without blocking the distal femur

Autor : Prof. Dr. Pedro Péricles Ribeiro Baptista

 Oncocirurgia Ortopédica do Instituto do Câncer Dr. Arnaldo Vieira de Carvalho

Consultório: Rua General Jardim, 846 – Cj 41  –  Cep: 01223-010   Higienópolis  São Paulo – S.P.

Fone:+55 11 3231-4638  Cel:+55 11 99863-5577  Email: drpprb@gmail.com

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