Reconstruction of Bone Defects After Malignant Tumor Resection

Limb Lengthening Academic Case Presentation

Austin T. Fragomen, MD
Austin T. Fragomen, MD

Associate Attending of Orthopaedic Surgery, Hospital for Special Surgery
Fellowship Director, Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery
Director, Limb Lengthening Clinic, Hospital for Special Surgery
Associate Professor of Clinical Orthopaedic Surgery, Weill Cornell Medical College


Reconstruction of bone defects after malignant tumor resection if often accomplished with fibular allograft. Fracture and nonunion are known complication of this technique. The following case will illustrate a method for treating a failed structural allograft utilizing autologous bone graft and external fixation.  This is an alternative to salvage with a free vascularized fibular autograft.

Brief Clinical History:

This is a 30 year old female who had resection of an osteosarcoma of the distal tibia as an adolescent. The defect was reconstructed with a fibular allograft which fractured and was augmented with bone graft and internal fixation. She presented with a long standing deformity of the lower leg and a nonunion of the tibia.

Preoperative Clinical Photos:

  • Figure 1 and 2:  Front and back photos of the lower extremities show a deformity with varus, procurvatum, and shortening.
  • Figure 3 and 4: AP and Lateral radiographs show a nonunion of the distal tibia with loosening of the hardware. 
  • Figure 5: This 51” standing x-ray shows 3cm of tibial shortening.

Preoperative Problem List

  • 1. Nonunion tibia and fractured fibular allograft with deformity
  • 2. Retained hardware
  • 3. Tibial shortening of 3cm

Treatment Strategy

The strategy was for a staged approach to limb salvage. The first stage was a reconstruction of the nonunion with acute deformity correction, preservation of the allograft as a structural device, removal of the internal fixation, bone grafting with autologous iliac crest bone graft, and fixation with a circular frame that provided constant compression. The second stage was extension of the external fixator to the proximal tibia and osteoplasty of the tibia and fibula for limb length equalization. 

Basic Principles

Distraction osteogenesis requires adequate blood flow to the site of the osteotomy to ensure adequate regenerate bone formation. The proximal tibia provides an ideal environment for distraction to progress successfully. The distal tibia, in this patient, has been through multiple surgeries and the tibia is in a state of nonunion. These factors make attempting to distract through the same nonunion repair unlikely to heal. In other words an osteotomy through the nonunion with gradual correction and lengthening would likely lead to a persistent nonunion. Therefore, proximal tibia osteotomy is preferred to ensure success.

Images During Treatment:

  • Figues 6-8: The previous incisions were used, the nonunion was mobilized and reduced, and autograft was laid throughout the nonunion area. 
  • Figure 9: The nonunion was compressed and alignment controlled with the circular frame.
  • Figure 10: The patient was returned to the OR for staged proximal tibial osteotomy. 
  • Figure 11: The full, stacked external fixator is seen with equal leg lengths and no deformity. 

Technical Pearls:

In order to obtain small morsels of iliac crest bone graft the acetabular reamer was used on the outer table of the iliac crest. The crest was reamed down to the inner table. The reamings were collected and additional cancellous graft was harvested with curettes. 

With correction of the varus-procurvatum deformity and debridement of poorly vascularized bone at the nonunion site the extensor tendons became lax and a functional drop foot ensued. Later lengthening of the tibia re-tensioned these tendons and led to a full functional recovery.

Outcome clinical photos and radiographs:

  • Figure 12-14: Final radiographs show full healing of nonunion and osteotomy sites and restoration of alignment.

Avoiding and Managing Problems

Infection of the retained fibular allograft through a pin site infection was a concern unique to this case. To prevent deep infection the pins and wires were placed outside of the graft zone, and the patient was kept on oral antibiotics the duration of the reconstruction. 

When the patient developed dorsiflexor tendon laxity the foot was protected with a neutral foot splint to prevent equinus contracture. Daily ankle and knee exercises helped ensure free joint motion during the lengthening. 

Rh-BMP (Recombinant human bone morphogenic protein) was avoided due to the history of local bone cancer for fear of recurrence. 

References and Suggested Reading

1. McCoy TH, Kim HJ, Cross MB, Fragomen AT, Healey JH, Athanasian EA, Rozbruch SR.  Bone tumor reconstruction with the Ilizaorv method.  J Surg Oncol.  2013 Mar;107(4):343-52

2. Westrich GH, Geller DS, O’Malley MJ, Deland JT, Helfet DL. Anterior iliac crest bone harvesting using the corticocancellous reamer system. J Orthop Trauma. 2001 Sept;15(7):500-6

3. Bae DS, Waters PM, Gebhardt MC. Results of free vascularized fibula grafting for allograft nonunion after limb salvage for malignant bone tumors.  J Pediatr Orthop. 2006  Nov;26(6):809-14


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