TOTAL REMOVAL AND VASCULARIZED FIBULAR BONE FRAGMENT PLASTICS FOR THE RIGHT CLAVICLE IN A GIANT CELL TUMOR

TOTAL REMOVAL AND VASCULARIZED FIBULAR BONE FRAGMENT PLASTICS FOR THE RIGHT CLAVICLE IN A GIANT CELL TUMOR

Minasov B.Sh., Valeev M.M., Biktasheva E.M., Yakupov R.R.,
Nikitin V.V., Mavlyutov T.R.
Bashkir State Medical University, Ufa, Russia

Giant cell tumor (GCT) of a bone is one of the most common bone tissue tumors considered by many authors as potentially malignant growth. GCT is identified enough frequently. Its percentage is about 8.6 % among all bone tumors and 15.8 % among malignant bone tumors. Metadiaphysis of the long bones take the leading place according to lesioned regions.
Among the segments of the extremities, GCT is the most common for the knee joint region. It is seldom identified in flat bones and very rare in facial skeleton [1-7].
Hip joint replacement with use of the modern technique for bone defect replacement after removal of tumor nidus improved the outcomes of the surgical treatment in patients with GCT [8-13]. The problem is the cases of total lesion of a bone [14-17].
The objective of the study – to demonstrate the clinical result of total removal and free fibular graft on the microvascular anastomoses of the clavicle affected by giant-cell tumor.
The study was approved by the ethical committee of Bashkir State Medical University. The patient gave the written consent for publishing the results of the study.
 The patient L., age of 22, addressed to the traumatology and orthopedics clinic of Bashkir State Medical University. He has some complaints concerning moderate pain, presence of a tumor-like formation in the region of the right clavicle. The examination was conducted: X-ray, computer tomography of the right clavicle. The destructive changes in the right clavicle were found (Fig. 1). A scintigram showed the high accumulation of a pharmacological agent in the region of the right clavicle.

Figure 1. The photoradiography and CT images before the surgery: a) the photoradiography image; b) the CT image

figure 1a        figure1b


Trepanobiopsy for the lesioned clavicle was performed. The histological preparation showed the uniform regions of quietly homogenous hypercellular tissue with relatively smooth distribution of multinucleated giant cells.
On November 16, 2011 the surgery was conducted with regionary analgesia and the semilunar layer-by-layer incision in the region of the right clavicle. The revision showed that the clavicle was affected by the tumor completely. The clavicle was totally resected (Fig. 2).

The figure 2. The surgery stages: a) planning the surgical incision; b) the stage of separation of the right clavicle affected by the giant cell tumor

figure 2a   figure 2b   figure 2c 

The decision was made to replace the removed clavicle with a vascularized fragment of the left fibular bone. Under regionary analgesia a wavy incision along the external surface of the left leg was made. The fibular bone was separated with layer by layer technique on the border between the upper and the middle one-third of the leg. A fragment of the bone (17 cm) was resected. The distal separation included the fibular vascular bundle, a perfused bone fragment of the fibular bone (Fig. 3).

Figure 3. The surgery stages: a) planning the surgery incision in the donor region; b) separation of the bone autograft; c) closure of the donor wound

figure 3a   figure 3b   figure 3c 

The bone flap on the vascular pedicle was transferred to the region of the right clavicle. The subclavicular artery and vein were separated for application of microvascular anastomosis. The vein of the autograft was connected to the subclavicular vein by the end to end type with use of the suture 8/0 with the atraumatic needle. The longitudinal arteriotomy of the subclavicular vein was performed. The arterial anastomosis was applied by the end to side type with use of the suture 8/0 with the atraumatic needle for the subclavicular artery and the autograft artery. Perfusion was initiated. External osteosynthesis of the graft, the acromial process of the scapula and the sternum was performed with use of the hook-shaped plate (Fig. 4).

Figure 4. The surgery stages: a) the bone autograft is placed to the recipient region; b) separation of the subclavian artery and vein for application of microsurgical anastomosis; c) fixation of the autograft, the acromion and the sternum; d) wound closure in the recipient region

figure 4a   figure 4b   figure 4c   figure 4d 

The patient received the full course of the rehabilitation. The examination 5 years after the surgery did not show any recurrent tumor. The function of the right upper extremity was within the full range (Fig. 5).

Figure 5. The long term result 5 years after the surgery

figure 5a    figure 5b   figure 5c   figure 5d

CONCLUSION

Total resection of the clavicle and its replacement with a vascularized bone autograft are the single radical options for complete destruction of the clavicle by tumor. A fragment of the fibular bone presents the “ideal” plastic material.

Information about financial provision and conflict of interests
The study was conducted without sponsorship.
The authors declare the absence of clear and potential conflicts of interests regarding the publication of the article.

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