Dr. James C. Wittig, one of the world’s top orthopedic oncologists, led a team of residents and innovators in 2024 to successfully implement a surgical solution for an exceedingly rare orthopedic oncology patient.

“My team and I combined a custom-designed prosthesis with a free vascularized fibula transplant to save this young patient’s arm,” Wittig said. At the time, he was Chairman of Orthopedic Surgery at Morristown Medical Center and Medical Director of Orthopedic Oncology and Sarcoma Surgery at Atlantic Health System in New Jersey.

Today, he is the founder and CEO of Mandala Medical Group, which is developing a range of social impact-based organizations, including a new non-profit, Pediatric Cancer Foundation New Jersey, which will launch in September 2025.

“My surgical team and I were blessed to perform a one-of-a-kind limb-sparing surgery on a very special young patient who presented to us with a diaphyseal osteosarcoma, a rare type of bone cancer that accounts for only 10% of osteosarcomas.”

Typically, patients develop diaphyseal osteosarcomas between 12 and 20 years of age, most commonly in their femur or tibia. This patient was just six years of age with cancer in their humerus—an exceedingly rare case.

“The younger the patient, the bigger the challenges,” said Wittig, who has performed thousands of limb-saving and life-saving surgeries, with a special emphasis on treating children. “We confronted special challenges because of our patient’s age.”

“In patients older than 10 or 12 years, the tumor can be resected, and the growth plates preserved above and below. The resulting defect can be replaced in a way that permits bone to grow longitudinally as the patient matures,” the doctor explained. “But, in patients around 12 years of age and younger, arm growth may end up exceptionally short and compromise physical appearance.”

Our challenge, in this case, was to create a reliable reconstruction that allows for restoration of the bone and preserves the potential for full future use of the arm. Ideally, the reconstruction will last the rest of the patient’s life.

“The approach I chose was a free vascularized fibula transplant combined with the creation of a special, 3D-printed custom prosthesis,” Wittig said. “Transplanting the fibula was our best option for restoring the resected humeral segment, facilitating healing, and achieving full or close-to-full limb function in the future.”

The surgical plan included resecting the cancerous portion of the humerus, harvesting a section of the fibula with its blood vessels as a graft (called a free vascularized fibula), and creating a biological bridge that would restore the bony architecture between the remaining proximal and distal shafts of the humerus.

Wittig worked in collaboration with a long-term surgical partner, Eric Chang, MD, Plastic & Reconstructive Surgeon. Dr. Chang connected the blood vessels in the harvested fibula with those in the humerus, thereby restoring blood supply and allowing the fibula to gradually grow and hypertrophy into a bone that looks and functions like a normal humerus.

“But, we faced a significant challenge, Wittig explained. “The transplanted fibula would be thin with an indeterminate and potentially lengthy healing time. It was imperative to stabilize the bone for however long it would take the fibula to heal.”

One way to achieve this is with a human donor bone. However, due to the high risk of infection, that option was ruled out.

Another option would be to place the child in a full upper-body cast for six months to a year.

“In an active six-year-old, a full body cast is simply not plausible,” Wittig said. “It would also interfere with post-operative chemotherapy. We had to get creative.”

Their innovative solution was to design a 3D-printed, custom-made, metal implant cylinder that came in two pieces, like a clamshell. The implant connects to the remaining proximal and distal segments of the humerus following resection. The harvested fibula sits in the center of the implant.

This custom-made prosthetic implant stabilizes the bone and absorbs all forces until the fibula fully heals. Once that happens, the fibula takes over and functions as a normal, healthy humerus.

“The implant no longer serves a purpose but can remain in the patient indefinitely. It is much less likely to ever fail once the fibula heals, he said.”

To achieve all this, he had to make high-precision cuts. He utilized special 3-D printed cutting guides created by the company that was making the prosthesis. The humoral tumor was approximately 15 centimeters in length and terminated a couple of centimeters from the patient’s growth plates above and the olecranon fossa below.

Prior to resecting the tumorous segment, Dr. Chang and the team performed a meticulous dissection and separation of all the neurovascular structures in the area to preserve the extremity.

“Preoperative chemotherapy effectively killed the tumor, enabling me to cut within just 5mm of the tumor using custom cutting guides on the prosthesis that fit the bone in three dimensions,” Wittig said. “This is much closer than the 2cm margin we typically achieve. We were only able to save about 1.5 centimeters of the proximal and distal shafts, above and below the growth plates. But, it was enough to allow us to recess a harvested section of the patient’s fibula in these areas.”

For more information on this successful and industry-changing approach, contact Mandala Medical Group.

Originally published on HealthTechZone.