Making Bones As Good As New

By Claudia Wallis

The last thing Robert Labollita remembers about the night of May 17, 1983, is driving from a restaurant toward his home in Dumont, N.J. The next morning Labollita found himself in a hospital in nearby Englewood. He had fallen asleep at the wheel, flipped his car and, in the resulting crash, knocked out a 4-in. segment of his upper arm bone, the humerus. The lower part of his arm dangled precariously from torn muscle and tendons. Labollita, now 27, recalls, "When I came to, they had already performed emergency surgery to remove the remaining pieces of bone." There was no hope of mending the shattered segment.

Suzanne Sommers of Clinton, N.J., was diapering her eight-month-old daughter Allison in 1977 when she heard a distinct pop in the child's leg. Ordinarily an infant's bones are so pliable that considerable force is required to break them, but in Allison's case, the tibia, the major bone of the lower leg, had snapped like a pretzel. When doctors examined the child, they found that she was suffering from a rare congenital defect known as pseudarthrosis (false joint) of the tibia. In the one out of 140,000 children who is born with this condition, a leg bone may be so weak and unstable that it gives way almost as easily as a knee joint. Fully 50% of these children ultimately lose the affected limb.

Both Labollita and Allison Sommers were candidates for amputation. But today Labollita is lifting 50-lb. dumbbells with his recovered arm, and Allison, now 8, is running and jumping on two healthy legs. The treatment that made their recoveries possible is a delicate, experimental form of surgery called the free vascularized fibular graft. This procedure uses segments of the fibula, the secondary bone in the lower leg, to replace large sections of bone elsewhere in the body that are missing or damaged as a result of accidents or such diseases as osteomyelitis. It also opens up the possibility of saving the limbs of some of the 1,900 Americans who are afflicted each year with bone cancer, the disease that cost young Ted Kennedy Jr. his right leg in 1973.

There is nothing new about using the fibula as a spare part. Important to four-legged animals, the bone is not essential to man, though the lower 30% helps to anchor the anklebone. As a result, surgeons have long used pieces of the fibula to patch damaged bones. "It is the outstanding transplant bone," says Dr. Harold Dick, chief of orthopedic surgery at New York City's Columbia- Presbyterian Medical Center. But traditionally, a simple bone graft taken from the fibula or from any of several bones in cadavers can be used to repair only a small area. In cases like Labollita's, where the gap was more than 3 in. long, ordinary bone grafts fail for lack of an adequate blood supply to nourish them. Amputation may then become necessary.

With the new technique, first reported by Australian Surgeon Ian Taylor in 1975, much larger grafts are possible. The procedure permits nourishing blood vessels to be transplanted along with the needed fibula section. The operation depends on painstaking microsurgical techniques developed in the 1960s that allow teams of surgeons, operating under a microscope, to reconnect the fragile transplanted vessels. Supplied with blood, the grafted bone will adjust to its new location and eventually become almost indistinguishable from the host bone.

At present, only four surgical teams are using vascular fibular grafts: one in Paris, another in Shanghai, Dick's group in New York City and a fourth team headed by Dr. Andrew Weiland at Johns Hopkins in Baltimore. Weiland insists that "this is very preliminary work," but results on more than 200 patients have been outstanding. Both American teams claim a nearly perfect record in treating victims of pseudarthrosis, a condition, says Dick, that "has classically been the enigma of orthopedic surgery."

Because the new treatment is still on trial, it has been used only as a last resort for children who could not be helped by ordinary bone grafting or attempts to stimulate electrically the healing of bones. In Allison's case, although doctors had recommended amputation, her parents decided to take a chance on the method. Allison's recovery is especially remarkable because she fell and broke her new bone one year after the surgery. Says Dick: "We thought we were really in the soup." The transplant, however, healed like a normal bone.

Practitioners of the new technique say the grafts can replace virtually any long bone in the body. The method has already been used to construct an entire lower arm bone (radius) for a child born without one. More common applications are replacement of bones lost or damaged as a result of accidents, infection or cancer. In 1976 Timothy Jones, then ten years old, faced complete amputation of his leg as a result of a malignant tumor found just below his hip socket. Weiland's brand-new operation, recalls Jones, now a college student, "was the only other opportunity we had." Today Jones has nothing more than a slight limp as a reminder of the experience: "I feel no pain, I run, I play sports-football--I can do practically anything."

As with any bone surgery, the vascularized graft poses the possibility of infection, and since the operation is more time-consuming than a simple bone graft (5 1/2 to eight hours instead of three to four), the risks are greater. "The longer time you have the wound open," says Dick, "the more the chances of contamination." For patients with pseud- arthrosis, the true test of the efficacy of the technique will not come until the affected children reach skeletal maturity, in their mid- to late teens. Explains Weiland: "Orthopedists by nature are very cautious." As far as the patients and their families are concerned, however, the verdict is already in. Says Sommers, watching her daughter frolic on her slightly uneven legs: "If we had elected to amputate, how would we have felt? This was the answer to our prayers."

With reporting by Barry Kalb/New York