SURGEONS PERFORM A FIRST FOR HUMERAL RECONSTRUCTION WITH INFECTION

Macquarie University Hospital’s multidisciplinary team approach to surgery has enabled surgeons to provide a unique live bone harvest for a difficult shoulder reconstruction case.

In 2017, Karen Jones injured her shoulder where she was hit by the hammer from a Hammer Throw event in an athletics carnival. She had a complicated comminuted fracture of her upper humerus that required surgery with internal fixation. Unfortunately, this fracture did not heal and ultimately developed an infection.

Three months later, the shoulder deteriorated and she was referred to Macquarie University Hospital, where she saw Associate Professor Des Bokor, Orthopaedic surgeon, and Professor Anand Deva, Plastic and Reconstructive surgeon.

Both surgeons joined Macquarie University Hospital ten years ago when it first opened its doors, and have championed the Hospital’s unique approach to innovative surgery, advanced technology and inter-disciplinary collaboration in an effort to bring patients novel procedures and excellent care.

“This was a difficult and complex case, needing a non-standard procedure,” said Professor Deva. “The patient had a number of conditions including systemic leukocytosis, poor circulation, relative osteoporosis, poor bone structure and decreased blood supply.

“To start with an infected unhealed fracture, one is already behind the eight-ball. So we had to address the infection in addition to performing a long-lasting humeral reconstruction.

“We knew a traditional bone graft wouldn’t work to treat the infection, so we had to look at an innovative solution. We planned a free vascularised fibular graft, with a good blood supply that could fight the infection.”

Vascularised bone flaps with blood supply have been used to treat failed union since the late 1990s but mainly in the lower limb. The application to the humerus has only been used on a few previous occasions worldwide.

The surgeons performed the procedure in two stages. During stage one, Professor Bokor removed the old rod from the humerus, and cleared the bone in preparation for the new graft.

During stage two, Professor Deva dissected the bone from the leg with a live blood supply, fashioning it to slot into the existing shoulder. He also performed the highly delicate microsurgery to connect the blood supply.

“We utilised high-resolution scans of the area to guide us in fashioning the bone flap,” explained Professor Deva. “Additionally, the use of a trapdoor of bone to secure the flap under the joint was a strategy that was worked out on the table and allowed much more stable fixation

“Vascularised fibular grafts allow for rapid inflow of good blood supply and help the body resolve any underlying infections, also augmenting the potential of bone healing by bringing living cells into the fracture environment.”

In terms of recovery, days three to five are critical for vascular complications, monitored by way of skin colour. Today, Karen has a healed fracture with no signs of underlying infection.

“This was an outstanding outcome for a difficult case,” said Professor Bokor.

“It’s the multidisciplinary teams that can form at Macquarie University Hospital and enable the unique combining of surgical skills from different disciplines that allow doctors to plan innovative surgery.

“This gives patients advanced solutions for challenging health problems. Often, it provides them with a solution simply not available elsewhere.”