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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.

Biological Bone Reconstruction part III

Biological Bone Reconstructions part III

Figure 1: Osteofibrodysplasia is an aggressive lesion that slowly and progressively erodes the tibia and spreads both proximally and distally, deforming and destroying the bone. Its treatment requires oncological removal of the affected segment, a procedure that should be carried out as early as possible to contain the progression of the lesion and preserve the function of the limb.
Figure 2: For the resection and reconstruction of this segment, a broad approach is needed that allows both surgery with an adequate margin and biological reconstruction by means of tibialization of the fibula, performed through the interosseous membrane. This objective technique makes it possible to completely remove the biopsy path, soft tissue, periosteum and the affected segment, ensuring osteotomies well away from the tumor. It also provides a healthy muscle bed for transposition of the fibula, which can be carried out efficiently through the anatomical septum represented by the interosseous membrane.
Figure 3: After dissecting the proximal and distal ends of the fibula, we are ready to fit both the distal and proximal segments inside the medullary canal of the tibia. This allows us to obtain a reconstruction with living bone, which is essential for reconstructing this segment of the tibia. The two ends have already been fitted, with the tibialis anterior muscle covering the translated fibula, ensuring stability and integration into the new bone bed.
Figure 4: Immediate post-operative X-ray of this tibialization through the interosseous membrane, showing proximal and distal consolidation. The patient is wearing the protective orthosis, specifically modeled for his case, and starting partial loading, which encourages progressive strengthening of the fibula.

Video 1: We put a rubber sole on the orthosis to improve support during gait training, providing greater comfort and stability for the patient.

Figure 5: Notice how that narrow fibula, transferred by the interosseous membrane, gradually transforms into a new, thick tibia. This adaptation provides the patient with a functional recovery through a biological, autologous and definitive solution.
Figure 6: A one-year-old child with an antecurvatum deformity of the tibia and an ulcer on the heel. The cause? Impressively, the compression of a short plaster splint! This inadequate approach sought to contain a diaphyseal deformity by immobilizing only the ankle - a misguided conduct and without any indication in the treatment of this aggressive lesion, which is osteofibrodysplasia
Figure 7: Such conduct is inexplicable! A patient with osteofibrodysplasia showing diaphyseal deformity and being subjected to inadequate immobilization with a short splint.
Figure 8: I explained the necessary treatment to the parents. However, they traveled abroad to consult other professionals in the field and only returned after two years, accepting our approach. On this occasion, the child was already 3 years old and had a significant increase in the lesion, with worsening deformity, making it necessary to remove around half of the tibial diaphysis
Figure 9: In the scanogram, we marked the planning of the tibial and fibular osteotomies for resection of the lesion and reconstruction with the fibula. We used the MRI to measure the distance between the joint interlines and the proximal and distal osteotomies of the tibial segment to be removed. We found that, distally, the fibula had a very narrow medullary canal, making it impossible to pass an intramedullary wire to stabilize the assembly
Figure 10: For this surgery, we also made a polypropylene orthosis, covered in E.V.A., to be used in the post-operative period. We performed an access starting laterally at the head of the fibula, descending anteriorly and distally to the ankle interline and then diverting to the side, which facilitated fibular exposure
Figure 11: Tibialization through the interosseous membrane with a thin Kirschner wire. First, we identified the knee joint to measure and mark the level of the proximal osteotomy. We then repeated the procedure for the distal marking, taking the ankle joint as a reference.
Figure 12: We protect the posterior region and perform the proximal osteotomy. We then repeated the procedure for the distal osteotomy, ensuring precision in the surgical approach.
Figure 12: We resected the affected segment and exposed the fibula proximally and distally. Next, we identified the interosseous membrane and sectioned the fibula, proceeding with its initial wedging in the proximal region. After this fixation, we performed the distal fibular osteotomy, completing the process with the final splinting, accompanied by slight flexion and traction to optimize positioning.
Figure 13: As the fibula was too thin to support a screw and its medullary canal too narrow for an intramedullary wire to pass through, we opted to stabilize the reconstruction with a homologous tibial ruler. This ruler was fixed as a support plate to ensure stability during manipulation with dressings, as well as providing protection within the orthosis.
Figure 14: Once the surgery was completed, we observed a good appearance in the immediate post-operative period. The radiograph shows the reconstruction performed, accompanied by the resected piece. In addition, we analyzed the section and histology of the osteofibrodysplasia lesion, allowing a detailed assessment of the approach and the results obtained.
Figure 15: One week after the surgery, we visited the child at home, where we observed a good progression in the recovery process.
Figure 16: Control radiograph taken six weeks after reconstruction, showing a good clinical appearance of the surgical wound.
Figure 17: Children recover quickly and efficiently

Video 2: At just six weeks old, he can already walk with the help of his parents.

Video 3: The following week, in the seventh week, she was able to walk on her own, showing good mobility.

Figure 18: After four months, we observed good integration of the graft and an excellent clinical appearance.

Video 4: Walking freely, with slight claudication, now starting to walk without the orthosis.

Figure 19: At the seventh month after surgery, total bone integration can already be seen.

Video 5: We can see the child happy, playing and walking very well, showing good balance and ease.

Figure 20: Child one year and one month post-operatively, showing good integration of the graft and thickening of the transplanted fibula. He is walking well, with no signs of lameness, showing excellent progress.

Video 6: With perfect balance and great poise, still making a charm of walking on tiptoe.

Figure 21: Tibialization of the diaphysis of the fibula using this technique is quick and easy to perform. Its indication is not restricted to the treatment of tumor lesions, but can also be used in large bone defects caused by orthopedic trauma. Children show an accelerated recovery and prompt integration of this autologous, vascularized graft. It is a definitive solution whose effectiveness can be assessed 10 years after surgery.

Case Author

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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