What is the procedure for osteochondroma of the left humerus using tumor excision via anterolateral approach and fibula bone grafting?

Surgical Procedure for Osteochondroma of Left Humerus: Tumor Excision with Anterolateral Approach and Fibula Bone Grafting

The surgical management of osteochondroma of the left humerus requires wide excision with negative surgical margins through an anterolateral approach, followed by fibula bone grafting to restore structural integrity and function of the affected limb. 1

Preoperative Planning

• Complete imaging workup:

  • Plain radiographs: To assess cortical and medullary continuity with parent bone
  • MRI: To define tumor extent and relationship to neurovascular structures
  • CT scan: To evaluate cortical destruction and plan resection margins
  • Chest imaging: To rule out pulmonary metastases 1

• Laboratory studies:

  • Complete blood count
  • Basic metabolic panel
  • Coagulation profile

• Anesthesia planning:

  • General anesthesia with endotracheal intubation
  • Positioning: Supine or lateral decubitus position with arm abducted

Surgical Technique: Step-by-Step Procedure

1. Patient Positioning and Preparation

• Position patient supine or in lateral decubitus position
• Prep and drape the left upper extremity from shoulder to fingertips
• Prep and drape the ipsilateral leg for fibula harvest
• Apply tourniquet to upper arm (if feasible based on tumor location)

2. Anterolateral Approach to Humerus

• Make a longitudinal incision along the anterolateral aspect of the arm
• Identify and protect the radial nerve as it courses through the spiral groove
• Develop the interval between the brachialis and brachioradialis muscles
• Retract the deltoid and pectoralis major proximally 1, 2

3. Tumor Exposure and Excision

• Carefully expose the osteochondroma while preserving surrounding healthy tissues
• Identify the base/stalk of the osteochondroma
• Perform wide excision with negative surgical margins (at least 1-2 cm beyond visible tumor)
• Remove the cartilaginous cap completely along with the underlying bony stalk
• Send specimen for histopathological examination 1

4. Fibula Graft Harvesting

• Make a lateral incision over the middle third of the fibula
• Identify and protect the common peroneal nerve
• Expose the fibula subperiosteally
• Preserve at least 6-8 cm of the distal fibula to maintain ankle stability
• Harvest appropriate length of fibula (typically 2-3 cm longer than the defect)
• Close the donor site in layers with a drain 3

5. Bone Grafting and Fixation

• Prepare the recipient site by freshening the bone edges
• Shape the fibula graft to fit the defect
• Position the fibula graft to restore humeral alignment and rotation
• Secure the graft with appropriate internal fixation:
  • Plate and screws for metaphyseal defects
  • Intramedullary fixation for diaphyseal defects 1, 3
• Consider supplemental cancellous bone grafting around the junction sites

6. Wound Closure

• Irrigate the wound thoroughly
• Place a surgical drain
• Close the deep fascia, subcutaneous tissue, and skin in layers
• Apply sterile dressing and splint the arm in functional position

Postoperative Care

• Immobilize the arm for 2-3 weeks in a posterior splint or arm sling
• Begin passive range of motion exercises after initial healing (2-3 weeks)
• Progress to active range of motion at 4-6 weeks
• Follow-up imaging at 6 weeks, 3 months, 6 months, and then annually 1
• Physical therapy to regain strength and function

Potential Complications and Management

• Neurovascular injury: Careful identification and protection of neurovascular structures during surgery
• Infection: Prophylactic antibiotics and meticulous surgical technique
• Nonunion: Consider revision surgery with additional bone grafting and fixation
• Recurrence (2-6% with adequate margins): Regular follow-up with imaging 1
• Donor site morbidity: Ankle instability, claw toe deformity, peroneal nerve injury 3
• Malignant transformation (approximately 1% of solitary osteochondromas): Wide surgical excision if detected 1

Expected Outcomes

• Excellent functional outcomes with low recurrence rates when performed with adequate surgical margins
• Return to full activities typically within 3-6 months
• Long-term durability of reconstruction with fibula grafting
• Median MSTS score of 30/30, ASES score of 98.3, and Constant score of 93.5% can be expected with vascularized fibula grafting 3

The surgical approach described provides the optimal balance between complete tumor removal and preservation of limb function, which directly impacts the patient's quality of life and reduces the risk of recurrence or malignant transformation.