What is the step-by-step procedure for tumor excision and fibula graft in a patient with multiple myeloma affecting the left arm?

Surgical Procedure for Multiple Myeloma Left Arm Tumor Excision with Fibula Graft

The surgical management of multiple myeloma affecting the left arm with tumor excision and fibula graft reconstruction is recommended for patients with localized disease causing bone destruction that threatens limb function or structural integrity. 1

Preoperative Assessment and Planning

• Multiple myeloma is a primary malignancy of the bone marrow affecting the entire skeletal system, making diffuse lytic lesions in the appendicular skeleton 1
• Comprehensive imaging is essential before surgery:
  • Full skeletal survey with plain radiographs 1
  • MRI and/or CT scan to determine the extent of bone involvement 1
  • PET/CT scan to assess active disease and detect any extramedullary involvement 1
• Laboratory evaluation should include:
  • Complete blood count with differential 1
  • Serum chemistry including calcium, creatinine, LDH, and beta2-microglobulin 1
  • Serum and urine protein electrophoresis with immunofixation 1
  • Serum free light chain assay 1

Surgical Procedure

Step 1: Patient Positioning and Preparation

• Position the patient supine with the affected left arm extended on an arm board 1
• Prepare and drape both the left arm (surgical site) and the right leg (donor site for fibula graft) 2
• Administer appropriate prophylactic antibiotics 1

Step 2: Tumor Exposure and Resection

• Make a longitudinal incision over the affected area of the left arm, considering the location of neurovascular structures 1
• Carefully dissect through subcutaneous tissues and identify major neurovascular structures 1
• Isolate and protect the neurovascular bundles 1
• Perform en bloc excision of the tumor with appropriate surgical margins 1
  • For multiple myeloma, intralesional curettage with fixation or en bloc excision may be considered depending on the extent of disease 1

Step 3: Fibula Graft Harvest

• Make a lateral incision over the middle third of the right leg 2
• Identify and protect the common peroneal nerve 2
• Dissect and expose the fibula, preserving at least 6-8 cm of both proximal and distal fibula to maintain knee and ankle stability 2
• Identify and preserve the peroneal vessels that will supply the vascularized fibula graft 2
• Harvest the appropriate length of fibula with its vascular pedicle 2

Step 4: Preparation of Recipient Site

• Prepare the ends of the remaining bone in the left arm to receive the fibula graft 1
• Ensure clean, viable bone ends with good blood supply 1

Step 5: Fibula Graft Placement and Fixation

• Transfer the vascularized fibula graft to the defect in the left arm 2
• Perform microvascular anastomosis of the peroneal vessels to suitable recipient vessels in the arm 2
• Secure the fibula graft to the host bone using appropriate fixation methods:
  • Options include plate fixation, intramedullary nailing, or a combination of techniques 1
  • Consider cement augmentation during fixation for additional stability 1

Step 6: Wound Closure

• Place surgical drains as needed 2
• Close the wound in layers with appropriate sutures 2
• Apply sterile dressing and splint or cast as appropriate 2

Postoperative Management

• Thromboprophylaxis should be administered according to American Society of Clinical Oncology (ASCO) guidelines 1
• Bisphosphonate therapy should be considered to prevent further bone disease 1
• Regular follow-up with imaging to assess bone union and graft incorporation 2
• Rehabilitation protocol to maintain range of motion and strength 2

Special Considerations

• Bone union with vascularized fibula grafts typically occurs within 10 months 2
• Functional outcomes are generally better for upper extremity reconstructions compared to lower extremity 2
• Potential complications include fracture after bone union, infection, and disease recurrence 2
• Continued systemic therapy for multiple myeloma is essential after surgical intervention 1

Prognosis and Outcomes

• Vascularized fibular grafts have shown substantial bone union rates in tumor reconstruction cases 2
• Multiple myeloma patients require ongoing monitoring for disease progression 1
• Regular surveillance with laboratory tests and imaging is necessary to detect recurrence or progression 1