A case of replacement of the upper end of the humerus by a fibular graft reviewed after twenty-nine years.

In recent years, after resection of the ends of long bones, increasing use has been made of acrylic resins and stainless steel for replacement, to the exclusion of the bone-grafting procedures described by earlier workers. Rovsing (1910), after resecting the proximal two-thirds of the humerus for round-cell sarcoma in a man aged twenty-six, used a graft of the proximal end of the fibula to replace the defect. Two months after operation the patient was said to have free passive movements and to be able to feed himself. Alb#{233}e (1915) advocated the use of tibia or fibula to replace the proximal end of the humerus or femur removed for benign new growths, and supported this by describing Murphy’s case of a girl aged ten with osteitis fibrosa cystica of the upper two-thirds of the humerus. The whole of this area was resected and replaced by a transplant from the tibia! crest, placed within the periosteal tube of the humerus. Almost complete regeneration ofthe humerus had occurred within eight months after operation. Morison (1914) used a fibular graft to replace the upper two-thirds of the shaft of the humerus, excised for chondrosarcoma. In this case the head of the humerus was retained, but failed to unite to the proximal end of the graft. In spite of this the patient was able to abduct the arm 90 degrees three years after the operation. Skillern (1920) described the case of a girl of seventeen in whom he had excised the upper two-thirds of the humerus for osteogenic sarcoma and replaced it by fibula. but there was no follow up. A further case was reported by Behrend ( 1930) in a woman of fifty with chronic diffuse osteomyelitis involving the upper two-thirds of the humerus: a year after operation she had a good range of movement. The longest follow-up recorded was that of Schauffler ( 1926) who reported the case of a girl of fifteen who was treated by fibular transplantation for bone loss from septic arthritis of the shoulder. Five years later she was married and able to care for her house and children. German workers performed much pioneer work on joint transplantation and arthroplasty using both autografts and homografts during the early part of this century. Borelius (1914) performed the operation for giant-cell tumour in a man aged twenty-five who had a good range ofmovement four and a halfmonths later, though the deltoid was atrophic. Lexer (1925) undertook fibular replacement ofth#{235} upper humerus on four occasions with excellent functional results. He illustrated this by a radiograph showing a soundly united fibular graft, three months after operation, but he did not report the follow-up of his cases in detail. Fibular grafts have been used frequently in recent years for the replacement of radial and tibia! defects (Hey Groves 1917, Eikenbary 1928, Miller and Phalen 1947), but there are few reports of their use in the replacement of the humerus.