What is the procedure for osteochondroma of the left humerus using tumor excision through an anterior approach and fibula bone grafting?

Surgical Procedure for Osteochondroma of Left Humerus: Tumor Excision via Anterior Approach with Fibula Bone Grafting

The surgical excision of osteochondroma of the left humerus with fibula bone grafting is the optimal treatment approach to prevent local recurrence and restore structural integrity of the bone.

Preoperative Planning

• Complete imaging workup including:

  • Plain radiographs (AP and lateral views)
  • MRI to assess extent of lesion and relationship to neurovascular structures
  • CT scan to evaluate cortical involvement and for surgical planning

• Laboratory studies:

  • Complete blood count
  • Basic metabolic panel
  • Coagulation profile

Surgical Procedure Step-by-Step

1. Patient Positioning and Anesthesia

• General anesthesia with endotracheal intubation
• Patient positioned supine with the affected arm extended on an arm board
• Sterile preparation and draping of the left upper extremity and ipsilateral leg (for fibula harvest)

2. Anterior Approach to the Humerus

• Make a longitudinal incision along the anterior aspect of the arm, centered over the tumor location
• Develop the interval between the biceps and brachialis muscles
• Identify and protect the musculocutaneous nerve and brachial vessels
• Retract the biceps muscle laterally and the brachialis muscle medially

3. Tumor Exposure and Excision

• Identify the osteochondroma and surrounding normal tissue
• Carefully dissect around the tumor, preserving a cuff of normal tissue 1
• For low-grade peripheral osteochondromas, aim to completely remove the tumor with a covering of normal tissue 1
• Use an oscillating saw to remove the tumor at its base from the humerus
• Ensure complete excision of the cartilaginous cap, which is essential to prevent recurrence 1
• Send the specimen for histopathological examination
• Debride the surgical site with a high-speed burr to remove any residual tumor cells

4. Fibula Bone Graft Harvesting

• Make a lateral incision over the middle third of the fibula
• Identify and protect the common peroneal nerve and superficial peroneal nerve
• Expose the fibula subperiosteally
• Measure the required graft length based on the humeral defect
• Harvest the appropriate length of fibula (typically 6-8 cm), preserving at least 6 cm of distal fibula to maintain ankle stability
• Close the donor site in layers after achieving hemostasis

5. Bone Grafting and Fixation

• Shape the fibular graft to fit the defect in the humerus
• Place the graft into the defect
• Secure the graft with appropriate fixation (plates and screws or K-wires) if necessary
• Confirm proper placement with intraoperative fluoroscopy

6. Wound Closure

• Irrigate the surgical site thoroughly
• Achieve meticulous hemostasis
• Close the wound in layers:
  • Deep fascia with absorbable sutures
  • Subcutaneous tissue with absorbable sutures
  • Skin with non-absorbable sutures or staples
• Apply sterile dressing and arm sling

Postoperative Care

• Pain management with appropriate analgesics
• Prophylactic antibiotics for 24 hours
• Limb elevation to reduce swelling
• Early passive range of motion exercises starting 1-2 weeks postoperatively
• Progressive rehabilitation protocol:
  • Weeks 1-2: Passive range of motion
  • Weeks 3-6: Active-assisted range of motion
  • Weeks 6-12: Strengthening exercises
  • After 12 weeks: Return to full activities as tolerated

Potential Complications and Management

• Neurovascular injury: Careful dissection and protection of neurovascular structures during surgery is essential 2
• Incomplete excision: Ensure complete removal of the cartilaginous cap to prevent recurrence 1
• Recurrence: Occurs in approximately 6% of cases; requires close follow-up 2
• Donor site morbidity: Peroneal nerve injury (most common complication), compartment syndrome, fibula fracture 3
• Infection: Prophylactic antibiotics and meticulous surgical technique

Follow-up Protocol

• Wound check at 2 weeks with suture removal
• Clinical and radiographic evaluation at 6 weeks, 3 months, 6 months, and then annually
• Monitor for local recurrence and restoration of function
• Follow-up should continue for at least 2 years to detect any recurrence 1

Special Considerations

• For tumors located posterolaterally, a more complete excision (92%) can be achieved compared to posteromedial lesions (68%) 2
• If the tumor is large or in close proximity to neurovascular structures, consider computer-assisted navigation for precise excision
• In cases of multiple osteochondromas, counsel patients about the risk of developing secondary chondrosarcomas 1

This surgical approach provides optimal exposure for tumor excision while minimizing the risk of neurovascular injury and ensuring complete removal of the osteochondroma to prevent recurrence.