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Seu et al. Femoral head reconstruction in pediatric patient

Native femoral head

Cadaveric allograft shell
Harvested fibula

Desc. br.
Lateral femoral
circumflex artery

Peroneal artery

Native femur

Figure 3: Schematic depicting final inset. Note intussusception of Figure 4: X-ray at 9 months postoperation indicating bony
the distal portion of the fibula autograft into the femoral diaphysis integration

measures should be taken in pediatric patients to due to their osteogenic capacity and resistance to
preserve growth potential, as well as restoration of a infection, chemotherapy, and radiotherapy [5,19,20] .
durable, functional joint that mimics native form. However, a fibular autograft alone would not provide
the structural integrity needed to reconstruct the
Reports of using the Capanna technique in pediatric proximal femur and stabilize the hip joint [21] . The
patients are limited [12] , however the decision to utilize vascularized fibula within an allograft shell capitalizes
this technique was pursued because it offered the on the immediate tensile strength of the allograft
patient the best prospective outcome in preservation with the advantage of a biological autograft that can
of growth potential and durable joint function. The use remodel and revascularize with the patient [8,11,15] . The
of the decellularized cadaveric allograft in particular patient’s postoperative radiographs demonstrated
was opted because of its increased strength when bone healing and alignment and are likely to achieve
compared to the fibula autograft alone [13] . Because complete union in the future.
the defect was extensive and required a long vascular
pedicle, a larger portion of the autologous fibula than The key to the success for this patient’s reconstruction
previously described by Capanna et al. was needed. was the participation and cooperation of a multi-
[11]
The peroneal vessels provided the pedicle length disciplinary team in preoperative planning and
necessary for anastomosis to the descending branch throughout the surgery itself. Perspectives and
of the lateral femoral circumflex vessels. The epiphysis techniques specific to orthopedic oncology, such as
of the fibula was utilized to give the patient the best the design and inset of the final construct, as well as
chance at continued growth, as previously described plastic and reconstructive surgery, including knowledge
in similar procedures [14] . Because the peroneal artery of lower extremity vasculature and technical skill in
is subject to atherosclerosis in adults, the anterior tibial microsurgical anastomoses, were critical to providing
artery is most often used as the vascular pedicle [15,16] . the patient with the most appropriate treatment plan.
However, in children, atherosclerosis has typically Patients requiring complex skeletal reconstruction
not yet developed; thus, the peroneal artery is a good would benefit from seeking treatment at tertiary care
option in cases where increased pedicle length is centers where they have access to specialized surgical
needed. teams that can ensure that the patient is receiving
personalized care.
This patient underwent neoadjuvant chemotherapy,
which has been shown to be effective in shrinking The major contraindication for this technique is the
tumor size and allowing a closer margin than inherently variant nature of vascular anatomy in the
would be considered safe in a tumor without this leg. Even in remarkably similar cases, surgeons
treatment [17,18] . It is known that vascularized fibular should proceed with caution prior to surgery, making
autografts are a preferred reconstruction material sure to utilize preoperative angiography in determining

212 Plastic and Aesthetic Research ¦ Volume 4 ¦ November 30, 2017