1462 Sarcoma of the Distal Fibula; Presentation of an Anatomical Reconstruction and Literature Review

Introduction Musculoskeletal tumours affecting the lower limb, and the distal fibula in particular, are rare. Substantial variation exists in both reconstructive techniques employed in their management and reported results; a consequence of their low incidence and the specific challenges presented by the location. Advances in imaging and neo-adjuvant chemotherapy have sparked a paradigm shift in the management of these cases. Where amputation was once the mainstay, limb salvage surgery is now a viable option and multiple techniques exist, but outcomes are poorly studied. Method We performed a literature review and report a three-patient case series. All three patients underwent our novel reconstruction technique, utilising a vascularised ipsilateral fibula graft. Results 102 patient cases of distal fibula resection were identified. 57 of these patients had malignant disease. Evidence that limb salvage surgery produces good functional outcomes for sarcoma patients is limited; 25% of patients with malignant disease were reported as having poor outcomes or disease progression. All three patients undergoing our novel reconstructive technique have had good functional and oncological outcomes. Conclusions This is the largest literature review of patients undergoing distal fibula resection. Reconstruction is complex and no single solution exists. We present the use of a vascular proximal ipsilateral fibula graft, which to the best of our knowledge, has not been previously reported. The reconstructive method we present appears to be a durable technique offering an excellent functional outcome and is an appealing alternative to arthrodesis or amputation in appropriate patients.

Ossification of Non-vascularized Free-Fibula Graft for Mandibular Reconstruction after Resection of Ameloblastoma: Review of Literature and Presentation of 2 cases

Introduction: Ameloblastoma is a benign neoplasm of odontogenic epithelial origin occurring more commonly in the mandibular posterior region and rarely in the maxilla. About 50-60% of ameloblastomas occur in the mandibular ramus area, while only 10% is seen in mandibular anterior region. Ameloblastomas are slow growing, locally invasive, rarely malignant tumours affecting the jaw. Mostly commonly seen in the 4th-6th decade of life affecting males more commonly than females. The resection of the mandibular segment without adequate reconstruction leads to functional as well as esthetic loss. Case Report: Here we describe two case reports of ameloblastoma with segmental resection and reconstruction using fibula graft. Discussion & Review of Literature: Avascular fibula graft with its high bone density, ease of access to harvest, and tendency to show less resorption helps to achieve satisfactory esthetic contour and function in reconstruction of segmental defects of mandible Conclusion: This article describes two case reports of ameloblastoma with segmental resection and reconstruction using fibula graft along with review of literature.

The choice of methods for fixing bone fragments in autoplasty of long tubular bone defects

The aim of the study was to analyze the effect of different methods of fixing bone fragments after transplantation of the fibula into a large defect of long tubular bones on the results of treatment. The study included 10 patients (group 1) with major tibia defects in whom the method of postoperative fixation of the segment of the operated limb allowed to give an early mechanical load on the graft itself and 10 patients (group 2) where the impact of mechanical load on the graft was excluded due to its transplantation into the hummers defect (6 cases) or minimized when replacing the tibia defect (4 cases). The degree of graft hypertrophy, the rate of its fusion with the recipient bed, and the number of postoperative complications under different conditions of mechanical stimulation of the fibula graft were studied. The rate of fusion of the graft with the recipient bed in both groups of patients was the same, but the incidence of complete stress fractures of the fibula graft in the second group was three times higher than in the first and was 30%, against the background of a slight degree of graft hypertrophy (from 19% to 45%). The use of the Ilizarov device for fixing fragments of the post-resection bone bed and graft in a stable and dynamic mode allows to give an early postoperative load on the lower limb, stimulates the rate of graft hypertrophy and reduces the likelihood of developing complete stress fractures.

Mandibulektomi segmental dengan rekonstruksi cangkok tulang fibula non-vaskularisasi pada pasien ameloblastoma tipe folikulerSegmental mandibulectomy with non-vascularised fibular bone graft reconstruction in follicular ameloblastoma patient

Pendahuluan: Ameloblastoma adalah tumor invasif lokal dengan insidensi kekambuhan yang tinggi jika tidak dieksisi sepenuhnya. Mandibulektomi segmental sebagai pilihan tatalaksana yang dapat menyebabkan deformitas dan asimetri pada wajah, serta masalah pengunyahan. Pemulihan defek setelah reseksi mandibula menimbulkan masalah yang cukup berat. Tujuan laporan kasus ini untuk melaporkan hasil rekontruksi menggunakan cangkok tulang non-vaskularisasi mandibulektomi segmental pada pasien dengan ameloblastoma mandibula. Laporan kasus: Pria berusia 33 tahun datang ke Poliklinik Rawat Jalan Bagian Bedah Mulut dan Maksilofasial RS Persahabatan dengan keluhan utama pembengkakan mandibula yang perlahan bertambah dan tidak nyeri sejak enam tahun lalu. Pemeriksaan ekstra oral tampak asimetri wajah, bukaan mulut tidak ada limitasi, tidak teraba pembesaran kelenjar getah bening regio leher. Pemeriksaan intraoral didapatkan adanya benjolan regio mandibula kiri dengan batas tegas, konsistensi padat, permukaan tampak trauma oklusi gigi antagonis, immobile, dan terdapat nyeri tekan. Gambaran radiologis menunjukan lesi radiolusen multilokuler menyerupai honeycomb pada corpus mandibula kiri meluas ke regio ramus mandibula kiri. Pemeriksaan biopsi menunjukkan hasil ameloblastoma tipe folikuler pada mandibula kiri dan dilakukan mandibulektomi segmental dengan rekonstruksi cangkok tulang fibula non-vaskularisasi. Sembilan bulan setelah operasi, cangkok tulang non-vaskularisasi tidak menunjukkan komplikasi intraoral dengan bekas luka submandibular ekstraoral baik. Simpulan: Cangkok tulang fibula non-vaskular dapat dipertimbangkan sebagai salah satu pilihan untuk rekonstruksi setelah mandibulektomi segmental pada pasien ameloblastoma.Kata kunci: Mandibulektomi segmental, cangkok fibula non-vaskularisasi, ameloblastoma folikuler. ABSTRACTIntroduction: Ameloblastoma is a locally invasive tumour with a high incidence of recurrence if not completely excised. Segmental mandibulectomy as a treatment option that can cause facial deformities and asymmetry and mastication problem. Recovery of the defect after mandibular resection presents a severe problem. This case report was aimed to report the results of reconstruction using a segmental non-vascularised mandibulectomy bone graft in a patient with mandibular ameloblastoma. Case report: A 33-year-old male came to the Outpatient Polyclinic of the Oral and Maxillofacial Surgery Division of Persahabatan General Hospital with the chief complaint of mandibular inflammation, which was slowly increasing yet painless since six years prior. Extraoral examination showed facial asymmetry, no limitation in mouth opening, no palpable enlargement of lymph nodes in the neck region. Intraoral examination revealed a lump in the left mandibular region with firm borders, solid consistency. The surface appears to be traumatic occlusion of the antagonist tooth, immobile, and tenderness was found. Radiological features showed a multilocular, honeycomb-like radiolucent lesion on the left mandibular body extending into the left mandibular ramus region. A biopsy showed follicular ameloblastoma in the left mandible, and a segmental mandibulectomy was performed with non-vascular fibular bone graft reconstruction. Nine months after surgery, non-vascular bone grafts showed no intraoral complications with either extraoral submandibular scar. Conclusion: Non-vascular fibular bone graft can be considered an option for reconstruction after segmental mandibulectomy in ameloblastoma patients. Keywords: Segmental mandibulectomy, non-vascularised fibula graft, follicular ameloblastoma.

Devitalized Autograft Associated with the Vascularized Fibula Graft: Irradiation versus Freezing Methods

Background Among the alternatives for the management of malignant bone tumors is the “devitalized autograft associated with vascularized fibula graft.” The devitalization process is achieved by pasteurization, irradiation, or freezing. The combination of these grafts has been broadly researched for more than 25 years. However, there is no research currently published comparing the various methods or their respective outcomes. Methods A retrospective study was compiled of 26 devitalized autografts associated with vascularized fibula performed to limb salvage of malignant bone tumors. They were divided into two groups according to the devitalization method: either freezing (12 procedures) or irradiation (14 procedures). Clinical, radiographic, and scintigraphic results were assessed at least 24 months after surgery. Results The union rates reached 83.3% in the freezing group and 92.8% in the irradiated group but did not express different outcomes. Scintigraphic viability was observed in all the grafts that achieved radiographic union (Mann–Whitney U-test: p = 0.005). Three patients had nonunion, with only one having no viability in the scintigraphy (Mann–Whitney U-test: p = 0.001). There was no malignant recurrence in the autograft, only in surrounding soft tissues. Local recurrence was statistically higher in larger tumors (Mann–Whitney U-test: p = 0.025). Conclusion Both groups presented similar union rates and are considered safe to devitalize bone graft despite different outcomes observed. The survivor rates observed could be limited by the existence of the techniques.