Tibialization of the distal fibula

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Tibialization of the distal fibula. The authors describe the treatment of a nine-year-old child with osteosarcoma of the distal third of the right tibia, treated with neo-adjuvant chemotherapy and subsequently undergoing resection of the affected bone segment.

Tibialization of the distal fibula with preservation of the epiphyseal plate

Reconstruction was performed by arthrodesing the ipsilateral distal fibular epiphysis with the talus, preserving the fibular epiphyseal plate. Preliminary postoperative evaluation using axial slice scintigraphy demonstrated signs of capture of the fibula throughout the transposed extension and at the level of the projection of the distal fibular growth plate. It is not yet possible to distinguish the hypercapture of the physeal plate from the reparative process of arthrodesis at the level of the talus. Radiographic controls from September/98, nine months after surgery, show complete integration of the transposed fibula, both proximally and distally. Thickening of the fibula is already evident and the fibular growth plate can be easily distinguished.

INTRODUCTION: Osteosarcoma of the tibia in a child

Osteosarcoma is the most common primary malignant bone tumor between the first and second decades of life(21). It generally affects the metaphyses of long bones, with the most common locations being the distal third of the femur and the proximal third of the tibia. Location in the distal third of the tibia represents approximately 3% of cases.

With the evolution of chemotherapy treatment, there was new encouragement in the approach to this condition, as it provided an increase in the average survival rate(2,7,19,21,22). This fact led to better improvements in the surgical techniques used until then. Malignant neoplasms previously treated with radical surgery, currently, when they respond favorably to neo-adjuvant chemotherapy, are approached with the aim of preserving the involved limb, with or without a biological solution(1,2,4,8,13,14,22). This concept has expanded, raising the expectations of the surgeon who seeks to combine the preservation of the affected body segment with the maintenance of maximum function(4,8,13).

CASE REPORT

Female child, nine years and three months old, with a history of direct trauma to the right ankle two months ago, evolving with pain and local edema. She sought medical treatment and was diagnosed with a contusion. Plaster immobilization was performed for six days. Fifteen days later, she noticed an increase in volume in her ankle, which was painful and hardened, and sought our service. The radiograph revealed a radiolucent lesion, centrally located, in the distal third of the tibia, with imprecise radiographic limits and a thin laminar periosteal reaction (fig. 1). Bone scintigraphy showed intense uptake only at the site and nuclear magnetic resonance (fig. 2) showed intense involvement of the meta-epiphyseal region, with evident involvement of the tibial epiphyseal plate. Laboratory tests demonstrated changes in bone metabolism, with very high alkaline phosphatase and serum calcium. We performed a needle biopsy, and the diagnosis of chondroblastic osteosarcoma was confirmed. Neo-adjuvant chemotherapy treatment began, with three cycles of chemotherapy. As part of the pre-operative surgical planning, we performed arteriography (fig. 3) to visualize the emergence of the nutrient artery of the fibula, a time that we considered important to identify the safe site for the osteotomy and its transposition. A polyethylene cruropodal orthosis was made prior to surgery, aiming for adequate immobilization, providing better support for the limb in the postoperative period (fig. 4). After neo-adjuvant chemotherapy, she underwent surgical treatment.

DESCRIPTION OF OPERATIVE TECHNIQUE

The surgery is performed with a medial convex arcuate incision starting at the level of the head of the fibula, passing through the anterior surface of the leg, up to the end of the lateral malleolus. The lesion is resected with a macroscopic oncological margin in the soft tissues and a 3.0 cm bone margin (fig. 5). After resection of the tumor, using the interosseous membrane as a guide, we approached the site of the osteotomy of the proximal fibula, above the emergence of the nutrient artery, confirmed by a previous arteriographic study (fig. 6). In this case, as the resection of the tibial segment was smaller, we opened a slit on the lateral surface of the proximal segment of the tibia, approximately 3.5 cm long and wide enough to enable its interlocking, with minimal deperiostization. from the proximal end of the transposed segment, and without harming the nutrition provided by the nutrient artery. Next, we remove the cartilage from the fibular epiphysis and carve a hole in the dome (fig. 7) of the talus, allowing this distal fibular epiphysis to fit. We continued with the careful passage of a 2.5mm diameter wire through the medullary canal of the fibula, crossing the physeal plate. This thread continues through the epiphysis and is passed through the talus and calcaneus until it appears on the skin (fig. 8).

We proceeded with nailing the proximal end of the fibula segment into the bed prepared on the tibia. The steel wire is then passed in a retrograde direction, through the medullary canal of the tibia, to the metaphyseal region (fig. 9). The tibial malleolus was arthrodesed to the talus and fixed with a 1.5 mm diameter wire, passing through the talus and crossing the epiphyseal segment that was embedded in it. The stabilization of the proximal fragment was complemented by placing a bone pin between the fibula and the tibia, within the tibial medullary canal, in order to prevent the fibula from migrating proximally, as there is a discrepancy in diameter between the ends of the fragments. This pin was obtained from the tibia itself, during the preparation of the bed for the placement of the fibular segment (fig. 10).

In the immediate postoperative period, the limb was kept in immobilization with the previously made cruropodal device. Six weeks after surgery, we performed bone scintigraphy with axial sections, confirming good vascularization of the graft (fig. 11). In the metaphyseal region of the transplanted fibula, the increase in hyperuptake may be due to the vascularization of the physeal plate itself and also to the reparative process at the site of the talofibular arthrodesis. Radiographic controls from September/98, nine months after surgery, show complete integration of the transposed fibula, both proximally and distally. The thickening of the fibula is already evident and its growth plate can be easily distinguished (fig. 12).

DISCUSSION

Advances in polychemotherapy in the treatment of osteosarcoma have brought new perspectives regarding the prognosis and approach of affected patients. Controlling the disease through chemotherapy made it possible to preserve limbs, allowing new possibilities and the most varied solutions to be proposed(4,8,13). One of the solutions was the replacement of the affected segment with non-conventional internal prostheses. However, in young children, there are basically two major problems: patients continue to grow and prostheses become insufficient, making amputation necessary in some cases, often years after the start of treatment(5 .6); Furthermore, prostheses suffer excessive wear and young patients have to undergo early revisions. Prosthetics in children have very limited indications(6). With the considerable increase in survival, it became necessary for the orthopedic surgeon to look for long-lasting limb-saving surgical solutions. The use of a homologous graft to fill the bone gap is an option. However, in addition to the greater difficulty in integrating the graft, the greater number of complications, even exceeding those of endoprostheses, it also requires a bone bank, which is not always possible in our reality(6). The use of autologous grafts is sometimes limited when there is a need to replace large resections. Vascularized bone grafting has been used more frequently and presents good results. When replacing segments of the tibia, the option has been to use the ipsilateral or contralateral vascularized fibula, and several techniques have been proposed(3,5,9-12,15-18,23-25). Some of these techniques are performed in two operative stages, which increases morbidity. Microsurgical techniques are also used, but they require a specialized team, with prolonged surgical time. The technique presented here is quick, easy to perform, performed in a single surgical procedure and does not require a microsurgical technique. In an attempt to preserve the length of the limb, we transposed a segment of the fibula with the distal physis, hoping that it will remain active. We cannot yet say, due to the short follow-up period, that preservation of the physis in the fibular transposition technique will lead to bone growth, nor how this growth will occur.

PRELIMINARY CONCLUSIONS

The biological solution in the treatment of osteosarcoma is an increasingly common reality in our country and should always be considered. We believe that the presence of bone hyperuptake at the level of the projection of the physeal plate of the distal fibula in bone mapping exams may be evidence that it is viable, although it is impossible to distinguish how much of this process is due to bone reaction at the level of fixation of the epiphysis of the fibula in the body of the talus. Considering the short follow-up period and the fact that this is a single case, it is not possible to definitively evaluate the treatment method used. What we can say with satisfaction, at the moment, is that the radiographic controls from September/98, nine months after surgery, show complete integration of the transposed fibula, both proximally and distally. Thickening of the fibula is already evident and the fibular growth plate can be easily distinguished. We believe that growth will occur and we hope that there will be adaptation of this physeal plate, so that it grows with the speed of the tibia, as we know that the speed of growth is also influenced by the location in which it is located.

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