The technique of pedicled vascularized fibular graft for lateral tibial condyle reconstruction after en bloc resection of aggressive giant cell tumours was described by SP Chow et al. Early follow-up of two patients was presented in 1986. We present the 25 years follow-up of one patient with a literature review of alternative present day treatment options. The patient maintained community ambulant status despite developing late stage osteoarthritis. Although this procedure is performed rarely, it remains an alternative to the more sophisticated treatment options making it a useful method in centres with limited facilities and expertise. © 2011 The Author(s).published_or_final_versio

Ahmed, SK

Chow, SP

Fung, BKK

Ip, WY

Strategies in Trauma and Limb Reconstruction

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Title Lateral tibial condyle reconstruction by pedicled vascularizedfibular head graft: Long-term resultAuthor(s) Ahmed, SK; Fung, BKK; Ip, WY; Chow, SPCitation Strategies In Trauma And Limb Reconstruction, 2011, v. 6 n. 3, p.163-166Issued Date 2011URL http://hdl.handle.net/10722/142427Rights Creative Commons: Attribution 3.0 Hong Kong LicenseCASE REPORTLateral tibial condyle reconstruction by pedicled vascularizedfibular head graft: long-term resultSyed Kamran Ahmed • Boris Kwok Keung Fung •Wing Yuk Ip • Shew Ping ChowReceived: 19 March 2009 / Accepted: 2 May 2011 / Published online: 17 May 2011 The Author(s) 2011. This article is published with open access at Springerlink.comAbstract The technique of pedicled vascularized fibulargraft for lateral tibial condyle reconstruction after en blocresection of aggressive giant cell tumours was described bySP Chow et al. Early follow-up of two patients was pre-sented in 1986. We present the 25 years follow-up of onepatient with a literature review of alternative present daytreatment options. The patient maintained communityambulant status despite developing late stage osteoarthritis.Although this procedure is performed rarely, it remains analternative to the more sophisticated treatment optionsmaking it a useful method in centres with limited facilitiesand expertise.Keywords Lateral tibial condyle reconstruction Pedicled vascularized fibular graft Aggressive giant cell tumoursBackgroundEn bloc resection of aggressive giant cell tumours ofbone has been shown to produce better local control ofdisease [1]. Numerous options are available for defectreconstruction, each with a different set of complicationswhich remains a matter of concern.The senior author developed a technique of pedicledvascularized fibular graft using fibular head as a replace-ment of the lateral tibial defect after en bloc resection of agiant cell tumour in 1982. Early follow-up of two cases waspublished in 1986 [2]. The long-term problems especiallytumour recurrence and disabling knee arthritis remained amatter of concern.Although the literature has supported the use of pedicledfibula for tibial defect reconstruction in the years to follow,no further reports of lateral tibial condyle reconstructionwith the vascularized pedicled fibular head graft have beencited so far.We present a 25 years follow-up of one such case and aliterature review of current alternative treatment optionsavailable.Details of surgical procedureApplied anatomyThe blood supply of the upper fibula is derived fromnutrient vessels entering the shaft at the junction of theupper and middle third and by periosteal vessels. Duringmobilization, there should be minimal dissection to pre-serve the periosteal blood supply. The articular surface ofthe proximal fibula faces medially and forms the proximaltibiofibular joint. As seen in an AP view, it slopes at anangle of 30 to the horizontal plane. As seen on the lateralview, there is also a 10 downward and posterior slope ofthe lateral tibial condyle, whereas the head of the fibula hasan anterior slope of 20. The fibula lies posterior to thecentral weight bearing portion of the lateral tibial condyleS. K. Ahmed (&)  B. K. K. Fung  W. Y. Ip  S. P. ChowDivision of Hand and Foot Surgery, Department of Orthopaedicsand Traumatology, Queen Mary Hospital, University of HongKong, 102, Pok Fu Lam Road, Pokfulam, Hong Konge-mail: drkamran72@yahoo.comB. K. K. Funge-mail: bkkfung@hku.hkW. Y. Ipe-mail: wyip@hkusua.hku.hkS. P. Chowe-mail: spchow@hku.hk123Strat Traum Limb Recon (2011) 6:163–166DOI 10.1007/s11751-011-0108-1(Fig. 1a). In order to conform to the surfaces of the femoralcondyle in full extension, the whole graft needs to beshifted anteriorly and fixed with the fibular head directedposteriorly and laterally (Fig. 1b). The medial displace-ment of the graft ensures lateral stability by tightening thelateral collateral ligament and the biceps femoris tendon(Fig. 1c).Surgical technique (Fig. 1a–c)A longitudinal curvilinear incision is used for anterolateralapproach. The common peroneal nerve is identified andsaved. The fibula is sectioned slightly lower than the levelof resected tibial condyle. The upper portion of the fibula ismoved medially with its blood supply intact, preserving theattachments of joint capsule, lateral collateral ligament andbiceps femoris tendon. The fibular graft is then jammedinto tibia and the fixation supplemented by a screw. Theplace between the graft and the remaining bone is packedwith cancellous graft from the iliac crest. The wound isclosed over suction drains. The average operating time is2 h.Rehabilitation guidelinesA long leg cast is applied for 6 weeks, followed by hingedknee brace until clinical and radiographic evidence of bonyunion is seen, usually at 3 months.Case reportA 22-year-old female presented with a history of left kneepain and swelling of 10 month duration. On examination,there was mild swelling in the region of the lateral tibialcondyle. The range of knee motion was from 0 to 120.Plain radiographs revealed an eccentric, expansile andradiolucent lesion in the lateral tibial plateau reaching up tothe joint line consistent with a giant cell tumour (Fig. 2a).A tomogram was performed which revealed a possiblecortical breach along the joint line (Fig. 2b). An en blocresection was performed, confirming the preoperativediagnosis, and reconstruction was performed as described.Full weight-bearing ambulation was started at 15 weeks(Fig. 2c). The patient maintained a good joint space at5 years from surgery, and she was able to swim, playbadminton and tennis without any discomfort (Fig. 2d).She maintained 0–90 of knee motion and had a mildresidual lateral laxity at 45 of knee flexion (Fig. 2e).Clinical follow-up at 25 years showed tri-compartmen-tal osteoarthritis (Fig. 3a). She had a 10 fixed flexioncontracture, with a range of knee motion from 10 to 70.The tibia developed 08 of varus at the knee (Fig. 3b).At 5 years, the Knee Society Score (KSS) was 83 andKnee Society Functional Assessment (KSFA) Score was90. The 25 years follow-up KSS is 75, and the KSFA scoreis 70.There has been no tumour recurrence. Occasional use oforal pain medications and activity modification wasrequired. The patient had developed a stiff knee gait withtime, but was satisfied with the final result of the procedure.DiscussionThe use of fibular head autograft for joint surfacereplacement of the lateral tibial plateau was suggested byJackson in 1972. A recent cadaver study has shown that thesurface area of the fibular head is 3.12 cm2 whereas that ofthe central weight-bearing portion of the lateral tibial pla-teau is 3.64 cm2. The authors have objectively documentedgood results in five patients with severely comminutedlateral tibial condyle fractures treated with a fibular headautograft [3].The same concept was adapted by Chow et al. for thereconstruction of the tibial condyle after en bloc resectionof giant cell tumours, with preservation of the blood supplyas a pedicled vascularized graft in 1982. A vascularizedgraft does not undergo resorption and creeping substitution.Fig. 1 Applied anatomy. a Thenormal anatomy andrelationship of the proximaltibia and fibula. b The AP andlateral diagrammatic views afterthe fibula transfer. c Surgicaltechnique diagram164 Strat Traum Limb Recon (2011) 6:163–166123Fig. 2 Early result. a Preoperative X-ray showing aggressive giantcell tumour of the lateral tibial condyle. b AP tomogram showing theextent of lesion and possible joint penetration. c Early healing at12 weeks, patient still in brace. d X rays at 5 years showing wellpreserved joint surfaces despite early arthritic change. e Early clinicalphotograph at 2 yearsFig. 3 Twenty-five years result. a X-rays showing tri-compartmental osteoarthritis of the knee joint. b Clinical photographs at 25 yearsStrat Traum Limb Recon (2011) 6:163–166 165123It rather progresses to rapid fusion and adapts to physio-logical load.It is encouraging to have no tumour recurrence at25 years follow-up. The gradual degeneration in the kneejoint in our patient was anticipated initially, due tomeniscus damage and joint laxity. Despite this fact, thepatient remained fully active in full time employment at25 years.The present day trend in patients undergoing en blocresection for aggressive giant cell tumours is the use ofhemicondylar and total condylar osteoarticular allograftsand allograft prosthetic composites [4]. Although encour-aging results have been reported, appropriate size matchingof the allograft, technically demanding reconstruction ofthe ligaments, tendons and capsule and above all the risk oftissue-transmitted diseases remains a concern. The reported5 years survival and good results in major series are 73%.The articular cartilage deterioration is evident in as manyas one third patients by 5 years [4].Another well cited option is the reconstruction withvascularized patella [5]. The procedure has shown to delaythe need for a future reconstructive procedure for approx-imately two decades. Apart from the development ofosteoarthritis, the reported complication rates are high witha 50% re-operation rate [5]. Patellectomy has been shownto induce long-term disability due to thirty percent decreasein quadriceps strength.The use of iliac crest graft as described by Lee HG in1957 is an inferior option as it replaces joint surface withbone instead of cartilage.Finally, the most popular method of intralesional exci-sion, which is controversial for the treatment of aggressivegiant cell tumours, is most suited for contained lesions [1].However, with careful patient selection, it still remains theprocedure of choice for most of the giant cell tumoursaround the knee.We would like to stress the need of careful preoperativeassessment of tumour spread by MRI and further byintraoperative frozen sections if doubt exists about theaggressiveness of the lesion.The tissue banks and their regulations are still new tomost of the developing nations.Our experience shows that the pedicled vascularizedfibular head transfer is a very promising option for selectedyoung patients, especially in centres without the sophisti-cated facilities or expertise. It avoids the use of allograft,prosthesis and disabling knee arthrodesis in young patients,as well as providing sufficient bone stock for futurereconstructive options.Acknowledgments Written consent for publication of long follow-upphotographs was obtained from the patient.Conflict of interest The authors declare no conflict of interest.Open Access This article is distributed under the terms of theCreative Commons Attribution License which permits any use, dis-tribution and reproduction in any medium, provided the originalauthor(s) and source are credited.References1. Faisham WI, Zulmi W, Halim AS, Biswal BM, Mutum SS, EzaneAM (2006) Aggressive giant cell tumour of bone. Singap Med J47(8):683–6972. Chow SP, Chan KC, Tang SC, Billet DM (1986) Reconstruction ofthe lateral tibial condyle by a pedicled vascularized fibular graftafter en bloc resection of giant cell tumour. Int Orthop10(4):239–2433. Russell TA, Kumar A, Davidson RL, Klinar DF, Kuester DJ(1996) Fibular head autograft. A salvage technique for severelycomminuted lateral fractures of the tibial plateau: report of fivecases. Am J Orthop 25(11):766–7714. Dion N, Sim FH (2002) The use of allografts in musculoskeletaloncology. Instr Course Lect 51:499–5065. Tomeno B, Anract P, Thomine JM, Alexandre G, d’Aubigne´ RM(1997) Long term results of condylar reconstruction using patellaas vascularized graft. Rev Chir Orthop Reparatrice Appar Mot83(8):752–755166 Strat Traum Limb Recon (2011) 6:163–166123

Lateral tibial condyle reconstruction by pedicled vascularized fibular head graft: Long-term result

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Lateral tibial condyle reconstruction by pedicled vascularized fibular head graft: Long-term result

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