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Imaging of Vascularized Fibula Autograft Placed Inside a Massive Allograft in Reconstruction of Lower Limb Bone Tumors

¹ Dipartimento di Oncologia Muscolo-Scheletrica, Istituto Ortopedico Rizzoli, Via Pupilli 1, Bologna 40136, Italy.
² Present address: Institut Gustave Roussy, Rue Camille Desmoulins, Villejuif 94800, France.
³ Centro Traumatologico Ortopedico, Via Largo Palagi 1, Firenze 50139, Italy.

View larger version (78K): [in a new window]   Fig. 1A. —9-year-old girl with osteosarcoma of proximal tibia. Dotted line on radiographs corresponds to level of CT scans. Preoperative anteroposterior radiograph shows metaphyseal ossified tumor.

View larger version (83K): [in a new window]   Fig. 1B. —9-year-old girl with osteosarcoma of proximal tibia. Dotted line on radiographs corresponds to level of CT scans. Preoperative coronal T1-weighted MR image (TR/TE, 500/20) shows tumor close to epiphyseal plate, but no abnormal signal is shown in epiphysis.

View larger version (74K): [in a new window]   Fig. 1C. —9-year-old girl with osteosarcoma of proximal tibia. Dotted line on radiographs corresponds to level of CT scans. Radiograph of resected segment shows resection level through epiphysis (arrow).

View larger version (54K): [in a new window]   Fig. 1F. —9-year-old girl with osteosarcoma of proximal tibia. Dotted line on radiographs corresponds to level of CT scans. Anteroposterior radiograph at 2 years of patient who had been walking without any support for a few months shows fibula fusiform hypertrophy and previously unnoticed stress fracture (arrow).

View larger version (82K): [in a new window]   Fig. 2A. —10-year-old boy with intercalary reconstruction of proximal tibia because of osteosarcoma. Dotted line on radiographs corresponds to level of axial CT scans. Anteroposterior radiograph at 1 year shows patient wearing partial weight-bearing brace. Undisplaced fracture (arrows) of both grafts appeared with minimal pain and swelling.

View larger version (74K): [in a new window]   Fig. 2B. —10-year-old boy with intercalary reconstruction of proximal tibia because of osteosarcoma. Dotted line on radiographs corresponds to level of axial CT scans. Anteroposterior radiograph obtained 1 month after A. After treatment in long leg cast, intense callus formation in fibula fracture (solid arrow) is seen, although fracture lines on allograft (dotted arrow) with resorption of allograft margins (arrowhead) are more evident.

View larger version (121K): [in a new window]   Fig. 3D. —14-year-old boy with intercalary reconstruction of proximal tibia for fibrosarcoma. Dotted line on radiographs corresponds to level of CT images. CT scan at 4 years (obtained 3 years after C) shows fracture (arrow) of allograft, although small ossifications (arrowhead) are seen on allograft surface. Inner portion of this implant did not change before and after complete weight bearing. After fracture, no rapid hypertrophy of fibula occurred. All these were considered signs of failure of transplanted fibula vascularity.

View larger version (109K): [in a new window]   Fig. 2F. —10-year-old boy with intercalary reconstruction of proximal tibia because of osteosarcoma. Dotted line on radiographs corresponds to level of axial CT scans. CT scan at 2 years (obtained 9 months after fracture) shows intense hypertrophy of fibula. Fibula fracture callus (arrow) penetrates fractured allograft.

View larger version (100K): [in a new window]   Fig. 2G. —10-year-old boy with intercalary reconstruction of proximal tibia because of osteosarcoma. Dotted line on radiographs corresponds to level of axial CT scans. CT scan at 3 years shows further increase of fibula diameter with entrapment of residual allograft (arrowhead) by hypertrophic callus (arrow).

View larger version (106K): [in a new window]   Fig. 2H. —10-year-old boy with intercalary reconstruction of proximal tibia because of osteosarcoma. Dotted line on radiographs corresponds to level of axial CT scans. CT scan at 5 years shows remodeling of both grafts concomitant to spongiosis of newly formed bone (arrow and arrowhead). In this implant, weight rapidly shifted to fibula after allograft fracture and resorption. Fibula fracture callus penetrated allograft fragments, inducing intense remodeling of allogenic bone.

View larger version (78K): [in a new window]   Fig. 4A. —12-year-old boy with intercalary reconstruction of proximal tibia because of osteosarcoma. Dotted line on radiographs corresponds to level of CT images. Postoperative anteroposterior radiograph shows fibula autograft (solid arrow) and massive allograft (dotted arrow).

View larger version (80K): [in a new window]   Fig. 4B. —12-year-old boy with intercalary reconstruction of proximal tibia because of osteosarcoma. Dotted line on radiographs corresponds to level of CT images. Anteroposterior radiograph at 1 year shows patient wearing partial weight-bearing brace. Decrease in cortex density of fibula and complete fusion of osteotomies (arrows) are evident.

View larger version (75K): [in a new window]   Fig. 4C. —12-year-old boy with intercalary reconstruction of proximal tibia because of osteosarcoma. Dotted line on radiographs corresponds to level of CT images. Anteroposterior radiograph at 3 years in patient who had been walking for 18 months with no support shows further remodeling of implant. Transverse fusion of transplanted fibula to allograft is noted.

View larger version (77K): [in a new window]   Fig. 4D. —12-year-old boy with intercalary reconstruction of proximal tibia because of osteosarcoma. Dotted line on radiographs corresponds to level of CT images. Anteroposterior radiograph at 6 years shows displaced fracture (arrow) (healed in cast) of distal portion of implant.

View larger version (117K): [in a new window]   Fig. 4E. —12-year-old boy with intercalary reconstruction of proximal tibia because of osteosarcoma. CT scan at 3 months shows fibula autograft (solid arrow) and massive allograft (dotted arrows).

View larger version (131K): [in a new window]   Fig. 4F. —12-year-old boy with intercalary reconstruction of proximal tibia because of osteosarcoma. CT scan at 1 year shows fibula diameter is increased, but not its cortical thickness; faint line of density on endosteal surface of allograft (arrow) starts to be visible.

View larger version (115K): [in a new window]   Fig. 4G. —12-year-old boy with intercalary reconstruction of proximal tibia because of osteosarcoma. CT scan at 3 years shows dense line on most of endosteal surface of allograft (arrow). Medial transverse fusion is shown between spongiotic fibula cortex and endosteal allogenic bone (arrowhead).

View larger version (121K): [in a new window]   Fig. 4H. —12-year-old boy with intercalary reconstruction of proximal tibia because of osteosarcoma. CT scan at 6 years shows allograft is denser on all its surface. Fibula cortex is increased in both thickness and density. Medial fusion is complete. In this implant weight remained mainly on allograft.

View larger version (50K): [in a new window]   Fig. 1D. —9-year-old girl with osteosarcoma of proximal tibia. Dotted line on radiographs corresponds to level of CT scans. Postoperative anteroposterior radiograph shows fibula autograft (solid arrow) and massive allograft (dotted arrow).

View larger version (53K): [in a new window]   Fig. 1E. —9-year-old girl with osteosarcoma of proximal tibia. Dotted line on radiographs corresponds to level of CT scans. Anteroposterior radiograph at 1 year shows patient wearing partial weight-bearing brace. Fibula cortex is thin and porotic. Arrows indicate osteotomy sites.

View larger version (59K): [in a new window]   Fig. 1G. —9-year-old girl with osteosarcoma of proximal tibia. Dotted line on radiographs corresponds to level of CT scans. Anteroposterior radiograph at 4 years; patient had returned to sports activities at school. Bowing of fibula (arrow) is due to its growth, although tibia has lost its proximal growth plate.

View larger version (122K): [in a new window]   Fig. 1H. —9-year-old girl with osteosarcoma of proximal tibia. Postoperative CT scan at 2 months shows fibula inserted in allograft. Solid arrow indicates fibula autograft; dotted arrow indicates massive allograft.

View larger version (124K): [in a new window]   Fig. 1I. —9-year-old girl with osteosarcoma of proximal tibia. CT scan at 2 years shows intense hypertrophy of fibula. Its cortex increased in both thickness and density (arrow). Fracture lines (arrowhead) in allograft are noticed.

View larger version (132K): [in a new window]   Fig. 1J. —9-year-old girl with osteosarcoma of proximal tibia. CT scan at 4 years shows further hypertrophy of fibula diameter creating osseous bridge (arrows) between thickened cortex of fibula and endosteal surface of allograft. In this implant, weight was first on allograft but shifted to fibula after allograft fracture.

View larger version (79K): [in a new window]   Fig. 2C. —10-year-old boy with intercalary reconstruction of proximal tibia because of osteosarcoma. Dotted line on radiographs corresponds to level of axial CT scans. Anteroposterior radiograph obtained 3 months after B when patient had returned to protected walking in partial weight-bearing brace. Whole fibula graft hypertrophied with remodeling of fracture callus. Fracture line of allograft (arrow) is still evident with further resorption of fracture margins (arrowhead).

View larger version (83K): [in a new window]   Fig. 2D. —10-year-old boy with intercalary reconstruction of proximal tibia because of osteosarcoma. Dotted line on radiographs corresponds to level of axial CT scans. Anteroposterior radiograph at 5 years, when patient had been walking without any support for 3 years, shows striking hypertrophy of fibula autograft brought to fusion to residual allograft (arrows).

View larger version (117K): [in a new window]   Fig. 2E. —10-year-old boy with intercalary reconstruction of proximal tibia because of osteosarcoma. Dotted line on radiographs corresponds to level of axial CT scans. CT scan at 1 year shows fibula autograft (solid arrow) and massive allograft (dotted arrow).

View larger version (71K): [in a new window]   Fig. 3A. —14-year-old boy with intercalary reconstruction of proximal tibia for fibrosarcoma. Dotted line on radiographs corresponds to level of CT images. Postoperative anteroposterior radiograph shows fibula autograft (solid arrow) and massive allograft (dotted arrow).

View larger version (64K): [in a new window]   Fig. 3B. —14-year-old boy with intercalary reconstruction of proximal tibia for fibrosarcoma. Dotted line on radiographs corresponds to level of CT images. Anteroposterior radiograph obtained at 4 years in patient who had been walking without any support for 2 years shows no changes in density or thickness of fibula cortex (solid arrow). Undisplaced fracture is evident on medial cortex of allograft (dotted arrow). Remodeling of proximal osteotomy progressed from epiphyseal plate for almost 2 cm into combined graft (arrowheads).

View larger version (130K): [in a new window]   Fig. 3C. —14-year-old boy with intercalary reconstruction of proximal tibia for fibrosarcoma. Dotted line on radiographs corresponds to level of CT images. CT scan at 1 year shows fibula inserted in allograft. Solid arrow indicates fibula autograft; dotted arrow indicates massive allograft.

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