We have certainly learned a lot since we started looking into limb salvage surgery for Esme. More than we really wanted to know. We contacted and consulted with surgeons from Gainesville, FL, Boston, MA, Salt Lake City, UT, Atlanta, GA, New York City, NY, Philadelphia, PA, Houston, TX, and Washington, DC. There were several options discussed, and each option had 2 things in common: first, most of her left humerus must be removed, and second, it must be rebuilt. Of the options we were given, the following three were mentioned the most:

Option 1 uses a metal implant.

Option 2 uses an allograft (donor bone).

Option 3 uses an allograft and vascularized fibular graft.

Each procedure has its own advantages and disadvantages. After many hours of research and many phone calls, emails, and discussions, we have decided to go with option 3. The surgeon we are using is Dr. Mark Scarborough with the University of Florida Orthopaedics and Sports Medicine Institute. Dr. Scarborough comes highly recommended by other surgeons and by a family in Atlanta whose daughter had a successful rotationplasty performed by Dr. Scarborough.

Vascularized Fibula

Without getting into the fine details, basically the limb salvage surgery involves removing the cancerous portion of the humerus plus a safe margin. The main goal of limb salvage of the upper extremity is keeping good function to the hand and the elbow. Most of Esme’s left fibula will be removed, leaving enough bone at the ankle to retain proper function. The section of fibula will be implanted with allograft bone and grafted to the remaining portion of her distal humerus.

There were several reasons we chose this option. One reason is growth. With options 1 and 2, there is no possibility of growth. There are expandable metal implants, but after reading about some of the complications we decided against this option (and yes, we realize there are complications to every procedure and no guarantees). And with option 2, the allograft bone is essentially dead bone and will not grow, and can weaken over time and is easily fractured. With option 3, there is the possibility that the fibula will continue to grow, both in length and girth. Since the fibula is Esme’s own bone, it should graft with her remaining section of humerus with fewer issues.

Another reason we chose option 3 is functionality. When the allograft bone is used, the connective tissue is still attached to the bone. The surgeon is able to reconnect the remaining muscles in the shoulder so Esme will still have some shoulder function. She will probably never be able to raise her left arm over her head, but raising her arm to 90 degrees should be possible.

We feel relief that we finally have a definite plan, but we also dread the fact that Esme has to go through all of this. More details as surgery approaches.

While seeing Dr. Scarborough we had a repeat X-ray of Esme’s arm. In the image below, you can see her film from December on the left that clearly shows the osteosarcoma. The image on the right is from Dr. Scarborough’s office. As you may recall from a previous post, Esme’s latest MRI indicated a pathologic fracture which is noted in the image on the right.