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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 Reconstructions part II

Reconstruções Ósseas Biológicas parte II

Biological Bone Reconstructions part II

Figure 1: Ewing's sarcoma of the left pelvis. After preoperative chemotherapy, it was necessary to resect the entire segment of the compromised iliac wing. We planned to remove the compromised segment of the iliac, performing a supra-acetabular osteotomy and another at the level of the sacrum.
Figure 2: We removed the tumor and reconstructed the pelvis with two segments of autologous fibula autograft, providing support from the acetabular roof to the sacrum. This reconstruction allowed the posterior column to be restored, re-establishing the continuity of the pelvis.

Video 1: Walking well at the moment, with the aid of a walker, showing good mobility and partial support for the operated limb.

Figure 3: Patient 4 months after the operation -@ undergoing post-operative chemotherapy
Figure 4: In 2011, 1 year and 8 months after surgery, the patient was cured. He made an excellent functional recovery, with full monopodal loading on the operated limb, as well as good flexion, also with full loading

Video 2: Walking without the aid of a walker, still with slight lameness.

Figure 5: In 2022, 12 and a half years after surgery, the patient is cured, an adult and attending college.

Video 3: Walking well, with little lameness and good muscle strength in the operated limb.

Figure 6: Let's describe how we first created the extendable internal fixation device in 1999. We needed to solve the case of a 9-year-old child with Ewing's sarcoma, who had a good response to chemotherapy and required the resection of 20 cm of the femoral shaft. How to reconstruct? It was during the surgery on this case of Ewing's sarcoma that we developed the extendable internal fixation device. It was subsequently adapted to suit each patient and lesions in different locations.
Figure 7: We planned to remove this patient's affected segment medially, as this approach facilitates vascular anastomosis. In this biological reconstruction, we used a vascularized autologous fibula. We placed two pins in the distal femoral epiphysis to guide the insertion path of the lamina plate and resected the tumor, ensuring a good oncological margin.
Figure 8: After inserting the lamina plate, we jammed the vascularized autologous fibula graft into the distal epiphysis and the medullary canal of the diaphysis proximally. We then fixed the stem with screws, stabilizing the reconstruction and facilitating vascular anastomosis.
Figure 9: In the third month, we can already see consolidation in the proximal and distal foci. In the fifth month, we see the progression of this integration and, eight months after surgery, we see bone remodeling. However, there is an impasse: the lamina plate, fixed to the femoral epiphysis and attached by screws to the diaphysis, prevents the femur from growing, as the growth physis has been blocked.
Figure 10: To release this blockage, streamlining the system and maintaining stability while the fibula gained enough thickness to support the load, we initially designed two molded plates. When superimposed, these plates form a device with holes for screw fixation, as shown in the diagram, as well as a channel to stabilize the osteosynthesis. At the same time, this design allows the stem to slide, following the growth provided by the distal epiphyseal plate throughout the child's puberty. This dynamic can be seen in the frontal video and in the video of the device in profile
Figure 11: To place the device, we made an approach to the proximal segment of the stem, exposing the screws previously positioned from medial to lateral. We removed these screws and interposed the lamina between the femoral shaft and the plate stem. We then superimposed the plate segment, modeled as a channel, over the plate stem and adjusted the holes for fixation. Osteosynthesis was completed by placing the screws in an anterior-to-posterior direction, ensuring stability in the varus, valgus, antecurvatum and retrocurvatum rotational planes. In addition, this configuration allowed the stem to slide, following the growth of the femur provided by the distal epiphyseal plate.
Figura 12
Figure 13: The fastening system is streamlined. We can see the appearance of the first and second holes from the old screw placement. The vascularized fibula reshapes itself, begins to thicken and the apex of the stem disappears. Clinically, we can see an overgrowth, probably due to the greater local vascularization caused by the two surgical interventions on this limb.
Figure 14: In this X-ray, we can see the shadow of the displacement of the rod, highlighted by the red circle and the outline. In the other highlighted image, we can see the first and second holes, and now the third hole in the rod is starting to appear, showing the displacement of the plate. The patient is now fully loaded and clinically has equalized lower limb length.
Figure 15: This scan, taken earlier, showed the left femur at 31 centimeters and the operated side at 33 centimeters, documenting a momentary overgrowth of 2 cm.

Video 4: This video illustrates how extensible internal fixation devices slip. The resolution of this case has allowed this technique to be extrapolated to other reconstructions in growing children, making it possible to order custom-made devices adapted to each case.

Figure 16: In 2001, we published this technique in the Revista Brasileira de Ortopedia, promoting the use of the dynamic fixation method, indicated for growing children.
Figure 17: Osteosarcoma in the proximal metaphysis of the right tibia in an 11-year-old patient. It can be seen that the proximal physis of the tibia is located at the same level as the apex of the fibula, while the growth cartilage of the fibula is located more inferiorly. The resection required in this case involves a proximal trans-epiphyseal osteotomy and another in the proximal third of the tibial diaphysis. It is worth remembering that the patellar ligament inserts into the tuberosity of the proximal epiphysis of the tibia.
Figure 18: The first step is to design the plate mold for the desired osteosynthesis on a heat-shrinkable material and send it to the industry for the manufacture of the plate and the appropriate device for each case. In this case of the tibia, the planning involves resection of the affected segment by a trans-epiphyseal proximal osteotomy, preserving the patellar ligament inserted into it. The pre-modeled plate for this case was curvilinear, and the device had a triangular shape for better adaptation to the crest of the tibial diaphysis. The front radiograph shows the tumor, and the diagram illustrates the osteotomy planes, highlighting the placement of the plate on the medial surface of the tibia, where it was modeled. We can see that all the implant material comes pre-modeled to ensure better adaptation and facilitate reconstruction.
Figure 19: Before surgery, a plaster cast is made and split to create a polypropylene crural-podal splint. This immobilizer helps with the period needed for osseointegration and thickening of the autograft. The biopsy was carried out on the lateral aspect. To resect this path and protect the osteosynthesis cover, we made a wide suprapatellar curvilinear incision, which descended longitudinally to the distal third of the leg and curved distally and medially. This provides a good flap for exposure and posterior coverage. The surgery began with a dissection around the patellar tendon, followed by opening the perimysium of the tibialis anterior muscle. Finally, we fixed the plate with screws positioned proximally and distally.
Figure 20: In the patient, now undergoing post-operative chemotherapy, we can see a slight valgus of the operated knee. The X-ray shows the inclination of the screws, which were not locked, allowing an angular deviation. However, after about a year and four months, this slight deformity was corrected, as can be seen in the photograph with monopodal loading. The X-ray also shows the horizontalization of the tibial epiphysis, realigning the operated limb. This correction occurred due to the growth of the epiphyseal plate of the transplanted fibula, which, over time, pushed the tibial epiphysis upwards. This gradual growth process resulted in a 0.75 cm increase in the length of the tibia.
Figure 21: Patient off chemotherapy, cured and working as a cattle drover in Minas Gerais at the time, with excellent function of the operated limb.

Vídeo 5

Figure 22: Here, as an adult, the patient is fully loaded in symmetrical flexion. The X-ray shows complete integration of the fibula, now tibialized, with a significant increase in thickness

Video 6: Patient shows good function and balance, demonstrating excellent recovery and adaptation.

Figure 23: We also published this case in the Revista Brasileira de Ortopedia in July 2001. After that, we participated as co-supervisors in a master's thesis at the Botucatu School, in the state of São Paulo, where we carried out several operations on dogs, making devices adapted for them. This study confirmed the stability of the osteosynthesis and the dynamization provided by the device. This thesis was published in 2008 in an international veterinary journal. Later, in 2016, we published the progress of this work in Springer Plus, also an international journal.

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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