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 Harzem Özger · Franklin H. Sim
Ajay Puri · Levent Eralp
Editors

Orthopedic Surgical
Oncology For Bone
Tumors
A Case Study Atlas
Orthopedic Surgical Oncology For Bone Tumors
Harzem Özger • Franklin H. Sim
Ajay Puri • Levent Eralp
Editors

Orthopedic Surgical
Oncology For Bone Tumors
A Case Study Atlas
Editors
Harzem Özger Franklin H. Sim
Professor Emeritus Department of Orthopaedic Surgery
Department of Orthopaedics and Traumatology Mayo Clinic
Istanbul University, Istanbul Faculty of Medicine Rochester, MN
Istanbul, Turkey USA

Ajay Puri Levent Eralp

Department of Surgical Oncology Professor Emeritus
Tata Memorial Hospital, HBNI Department of Orthopaedics and Traumatology
Mumbai, Maharashtra Istanbul University, Istanbul Faculty of Medicine
India Istanbul, Turkey

ISBN 978-3-030-73326-1    ISBN 978-3-030-73327-8 (eBook)

https://doi.org/10.1007/978-3-030-73327-8

© Springer Nature Switzerland AG 2022

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction
on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation,
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Foreword

This case study atlas represents the development of tumor surgery in sarcomas over the last
40 years. It illustrates techniques ranging from life-saving amputations to rotationplasty, from
resection–reimplantation to tumor prosthesis, allografts and autograft reconstruction with free
flaps and distraction techniques to growing prosthesis. As surgical techniques evolved, so did
imaging techniques, contributing to the success of the surgeon. While multimodality treatment
facilitated life-saving success before the development of limb-saving techniques, the chapters
in this atlas demonstrate the evolution of surgical techniques, including procedures for the
treatment of difficult “gray zone” individual cases, especially in centers experienced in the
management of bone tumors.

Department of Orthopaedics Rainer Kotz

Medical University of Vienna
Vienna, Austria

v
Preface

Knowledge and application of the right tenets and philosophy is the cornerstone of correct
diagnosis and treatment in bone and soft tissue tumors. While resection with safe margins can
determine the fate of the patient, a durable reconstruction determines function and impacts on
the quality of life. Medicine is both a science and an art. We, orthopedic oncologists, are
merely artists, who utilize our science and philosophy to perform our craft. Distinguished
global experts in bone and soft tissue tumors have collaborated to compile this surgical atlas.
These luminaries present either classical surgical methods or their signature operation tech-
niques in a standardized format and language in an attempt to share their knowledge, experi-
ence, and craft—in other words, “their art”—so as to help the readers decide on the best
possible method to treat these complex and challenging cases in their own unique sociocultural
milieu.
We, the editors, are profoundly grateful to our authors for their outstanding work and dedi-
cated efforts undertaken during the tragic and chaotic times of COVID-19 pandemic. The edi-
tors would like to thank Springer for believing in our surgical atlas project and enabling the
publication of this atlas and express our heartfelt gratitude to the dedicated Springer team—
Aruna Sharma, who skillfully orchestrated the busy to-and-fro email traffic, and Barbara
Pittaluga, who meticulously oversaw and supported the project right from its initiation to
conclusion.
An atlas like this would not have been possible was it not for the large number of patients
who entrusted their lives and limbs to us, unfailingly trusting in us and believing that we would
all do our best to try and help them overcome the unique challenges and struggles that they
were facing. We salute all of them for their exemplary courage and fortitude in the face of life-
threatening crises.

Istanbul, Turkey Harzem Ozger

Rochester, MN, USA  Franklin H. Sim
Mumbai, Maharashtra, India  Ajay Puri
Istanbul, Turkey  Levent Eralp

vii
Contents

Part I Philosophy of Limb Salvage Surgery

1 When and Why Biological/Implant Reconstruction? ���������������������������������������������   3

Harzem Özger and Bugra Alpan

Part II Mobile Spine

2 Biological Reconstruction Using Frozen Autograft

in Total En Bloc Spondylectomy for Spinal Tumors����������������������������������������������� 29
Satoru Demura, Satoshi Kato, and Hiroyuki Tsuchiya
3 Implant Reconstruction of the Mobile Spine����������������������������������������������������������� 37
Syed Mohammed Karim, Matthew T. Houdek, Michael J. Yaszemski,
and Peter S. Rose

Part III Sacrum

4 Biological Sacral Reconstruction������������������������������������������������������������������������������� 47

Matthew T. Houdek, Franklin H. Sim, Michael J. Yaszemski,
and Peter S. Rose
5 Total Sacrectomy Without Spinopelvic Reconstruction ����������������������������������������� 53
Piya Kiatisevi, Bhasanan Sukanthanak, Pongsiri Piakong,
and Chaiwat Piyaskulkeaw
6 Implant Reconstruction of the Sacrum: Modular Sacrum Prosthesis������������������� 61
Wei Guo

Part IV Pelvis

7 Biological Reconstruction of the Pelvis: I:

Liquid-Nitrogen Treated Autograft and Onlaid Free Vascular Fibula ����������������� 71
Harzem Özger, Bugra Alpan, and Mehmet Veli Karaaltın
8 Biological Reconstruction of the Pelvis: II:
Femoral Head Plus Total Hip Replacement������������������������������������������������������������� 85
Xiaohui Niu and Hairong Xu
9 Implant Reconstruction of the Pelvis: I: Modular Hemipelvic Prosthesis ����������� 95
Wei Guo
10 Implant Reconstruction of the Pelvis: II: Modular Pedestal Cup Prosthesis������� 105
M. P. A. Bus and M. A. J. van de Sande

ix
x Contents

11 Implant Reconstruction of the Pelvis: III High Acetabular Placement

and Prosthetic Femoral Extension����������������������������������������������������������������������������� 111
Harzem Özger and Bugra Alpan
12 Implant Reconstruction of the Pelvis: IV: 3D-Printed
Custom-Made Prosthesis������������������������������������������������������������������������������������������� 121
Davide Maria Donati and Tommaso Frisoni

Part V Proximal Femur

13 Biological Reconstruction of the Proximal Femur

with Extracorporeally Irradiated Autograft������������������������������������������������������������ 135
Dündar Sabah
14 Implant Reconstruction of the Proximal Femur: Modular Prosthesis ����������������� 143
Apichat Asavamongkolkul
15 Prosthetic Reconstruction for Soft Tissue Sarcomas
with Bone Involvement����������������������������������������������������������������������������������������������� 153
Philip D. Rowell, Jennifer L. Nevin, Rosti Novak, Kim M. Tsoi,
Peter C. Ferguson, and Jay S. Wunder

Part VI Femoral Diaphysis

16 Biological Reconstruction of the Femoral Diaphysis:

Van Nes Rotationplasty ��������������������������������������������������������������������������������������������� 167
Ajay Puri
17 Implant Reconstruction of the Femoral Diaphysis: I:
Intercalary Femur Prosthesis������������������������������������������������������������������������������������� 177
Joseph Benevenia, Zachary Cavanaugh, Joseph Ippolito, Jennifer Thomson,
and Luis Guinand
18 Implant Reconstruction of the Femoral Diaphysis:
II—Short-Segment Dynamic Compression Stem���������������������������������������������������� 181
Lee Jae Morse, Andrew S. Fang, and James O. Johnston

Part VII Distal Femur

19 Biological Reconstruction of the Distal Femur—I:

Massive Allograft and Inlaid Free Vascular Fibula������������������������������������������������� 191
Antonio D’Arienzo, Simone Colangeli, Lorenzo Andreani,
Olimpia Mani, and Rodolfo Capanna
20 Biological Reconstruction of the Distal Femur: II:
Resurfacing Allograft-­Prosthesis Composite����������������������������������������������������������� 203
Domenico Andrea Campanacci, Roberto Scanferla, and Francesco Muratori
21 Biological Reconstruction of the Distal Femur:
III Liquid Nitrogen Treated Autograft and
Inlaid Free Vascular Fibula (the “Frozen Hotdog”) ����������������������������������������������� 211
Harzem Özger, Bugra Alpan, and Şükrü Yazar
22 Implant Reconstruction of the Distal Femur: I—Modular Prosthesis ����������������� 225
Giulia Trovarelli, Jim Georgoulis, Elisa Pala, Andreas F. Mavrogenis,
and Pietro Ruggieri
Contents xi

23 Implant Reconstruction of the Distal Femur: II—Joint-­Preserving Resection

and Reconstruction with ­Image-­Guided Computer Navigation����������������������������� 235
Kwok Chuen Wong and Shekhar Madhukar Kumta
24 Implant Reconstruction of the Distal Femur: III—Expandable Prosthesis��������� 247
Gerhard M. Hobusch, Martina Schinhan, and Reinhard Windhager
25 Implant Reconstruction of the Distal Femur—IV: Prosthesis Revision ��������������� 253
Jendrik Hardes, Arne Streitbürger, Markus Nottrott, Lars Erik Podleska,
and Wiebke K. Guder
26 Percutaneous Osseointegration Prosthesis��������������������������������������������������������������� 265
Taylor J. Reif, Austin T. Fragomen, and S. Robert Rozbruch

Part VIII Proximal Tibia

27 Biological Reconstruction of the Proximal Shaft of Tibia—I:

Pedicle Frozen Autograft ������������������������������������������������������������������������������������������� 275
Norio Yamamoto and Hiroyuki Tsuchiya
28 Biological Reconstruction of the Proximal Tibia—II:
Distraction-­Epiphysiolysis Before Resectioning of the Tumor������������������������������� 291
Blanca Vázquez-García and Mikel San-Julián
29 Implant Reconstruction of the Proximal Tibia:
Modular Prosthesis and Rotational Gastrocnemius Flap��������������������������������������� 299
Philipp T. Funovics

Part IX Tibial Diaphysis and Ankle

30 Biological Reconstruction of the Tibial Diaphysis and Ankle—I:

Ilizarov Technique������������������������������������������������������������������������������������������������������� 313
Hidenori Matsubara and Hiroyuki Tsuchiya
31 Biological Reconstruction of the Tibial Diaphysis and Ankle—II:
Fibular Centralization Technique����������������������������������������������������������������������������� 325
Ajay Puri
32 Biological Reconstruction of the Tibial Diaphysis and Ankle—III:
Arthrodesis with Massive Allograft��������������������������������������������������������������������������� 333
Simone Colangeli, Lorenzo Andreani, Antonio D’Arienzo, Olimpia Mani,
Giuseppe Restuccia, and Rodolfo Capanna
33 Implant Reconstruction of the Tibial Diaphysis and Ankle:
3D-Printed Custom-Made Prosthesis����������������������������������������������������������������������� 345
Panayiotis J. Papagelopoulos and Olga Savvidou

Part X Foot

34 Biological Reconstruction of the Foot: Free Vascular Iliac Flap����������������������������� 357

Harzem Özger, Bugra Alpan, and Murat Topalan
35 Implant Reconstruction of the Foot 3D-Printed Custom-­Made Prosthesis����������� 367
Panayiotis J. Papagelopoulos and Olga Savvidou
xii Contents

Part XI Shoulder Girdle

36 Biological Reconstruction of the Shoulder Girdle:

Scapular Massive Allograft ��������������������������������������������������������������������������������������� 381
Olimpia Mani, Lorenzo Andreani, Giovanni Beltrami, Francesca Totti,
and Rodolfo Capanna
37 Implant Reconstruction of the Shoulder Girdle: Scapular Prosthesis������������������ 391
Joseph Benevenia, Zachary Cavanaugh, Joseph Ippolito,
Jennifer Thomson, and Luis Guinand

Part XII Proximal Humerus

38 Proximal Humerus, Biological Reconstruction ������������������������������������������������������� 399

Bulent Erol
39 Claviculo-Pro-Humero Reconstruction Following
Proximal Humeral Resection������������������������������������������������������������������������������������� 405
Peter F. M. Choong and Emma L. P. Choong
40 Biological Reconstruction of the Proximal Humerus—III:
Massive Allograft and Inlaid Free Vascular Fibula Epiphyseal Transfer������������� 417
Matthew T. Houdek, Elizabeth P. Wellings, and Steven L. Moran
41 Implant Reconstruction of the Proximal Humerus������������������������������������������������� 425
L. van der Heijden and M. A. J. van de Sande
42 Implant Reconstruction of the Proximal Humerus—II:
Reverse Prosthesis������������������������������������������������������������������������������������������������������� 441
Giulia Trovarelli, Alessandro Cappellari, Andrea Angelini,
and Pietro Ruggieri

Part XIII Humeral Diaphysis

43 Biological Reconstruction of the Humeral Diaphysis:

Irradiated Autograft��������������������������������������������������������������������������������������������������� 453
Kuan-Lin Chen, Chao-Ming Chen, Po-Kuei Wu, and Wei-Ming Chen
44 Implant Reconstruction of the Humeral Diaphysis:
Total Humerus Prosthesis������������������������������������������������������������������������������������������ 465
Lee M. Jeys, Guy V. Morris, and Vineet Kurisunkal

Part XIV Distal Humerus and Elbow

45 Implant Reconstruction of the Distal Humerus and Elbow:

Modular Prosthesis����������������������������������������������������������������������������������������������������� 481
Philipp T. Funovics

Part XV Forearm, Wrist and Hand

46 Biological Reconstruction of the Forearm, Wrist,

and Hand—I: Free Vascular Fibula��������������������������������������������������������������������������� 493
Harzem Özger, Bugra Alpan, and Cihangir Tetik
47 Biological Reconstruction of the Forearm, Wrist,
and Hand—II: Transposition of the Distal Ulna����������������������������������������������������� 503
Ajay Puri
Contents xiii

48 Implant Reconstruction of the Forearm, Wrist and Hand:

Distal Radius Endoprosthesis ����������������������������������������������������������������������������������� 513
Lee M. Jeys, Rachel Mahoney, and Vineet Kurisunkal

Part XVI Complications of Orthopedic Oncologic Reconstructions

49 Complications of Orthopedic Oncologic Reconstructions

Using Biological Reconstruction������������������������������������������������������������������������������� 521
Levent Eralp, Ahmet Salduz, and Emre Ozmen
50 Complications of Orthopedic Oncologic Reconstructions
Using Implants ����������������������������������������������������������������������������������������������������������� 545
Levent Eralp, Ahmet Salduz, and Emre Ozmen
 Part I
Philosophy of Limb Salvage Surgery
 When and Why Biological/Implant
Reconstruction?
Harzem Özger and Bugra Alpan
1.1 Principles of Limb Salvage Surgery
The main principle of treatment for bone and soft tissue
tumors is to remove the tumor in its entirety. There are two
main methods for achieving this goal [1–3]:
1. Amputation
2. Limb Salvage Surgery (LSS)
Amputation, which is a form of ablative treatment,
removes the tumor-afflicted extremity at a safe level. When
compared to LSS, it can be performed in a much shorter
duration, is a relatively easier procedure, and can facilitate
faster recovery. Nevertheless, it is a radical procedure and
a valuable part of the body is lost forever. For all illnesses,
especially for cancer, motivation is an important part of the
patient’s treatment process. This motivation is tremen-
dously affected with the loss of a limb that comes with
amputation. This, by itself, justifies the endeavor to sal-
vage the limb.
Limb salvage surgery is the resection of the tumor with
safe margins by including a cuff of healthy tissue while pre-
serving the limb. The absolute requirement for attempting
LSS is the probability of removing the tumor as safely as
with an amputation. In addition to osseous or osteoarticular
losses, resection may also involve sacrification of critical
structures such as muscles, ligaments, skin, nerves, vessels,
and/or neighboring organs. In a broad sense, the aim of sub-
sequent reconstruction is to ensure integrity, viability, soft
H. Özger (*)
Department of Orthopaedics and Traumatology,
Istanbul University, Istanbul Faculty of Medicine,
Istanbul, Turkey
B. Alpan
Department of Orthopaedics and Traumatology, Acibadem
Mehmet Ali Aydinlar University, School of Medicine,
Istanbul, Turkey
e-mail: bugra.alpan@acibadem.edu.tr
© Springer Nature Switzerland AG 2022
H. Özger et al. (eds.), Orthopedic Surgical Oncology For Bone Tumors, https://doi.org/10.1007/978-3-030-73327-8_1
1
tissue coverage, and function of the limb. Despite the fact
that reconstructive procedures are often the more intriguing
and emphasized parts in LSS, reconstruction can never be
considered apart from the resection. While an impressive and
sophisticated reconstruction is likely to fail due to local
recurrence in the setting of an inadequate resection, the
patient’s survival is also at stake with compromised margins.
On the other hand, a carefully planned and skillfully exe-
cuted resection in a well-selected patient will sometimes
mandate a certain type of reconstruction or give more than
one reconstructive option to the surgeon. Nevertheless, the
resection is dependent on tumor-related (specific pathology,
location, size) and patient-related (demographics) or
treatment-­related (previous invasive diagnostic/inappropri-
ate procedures, response to neoadjuvant treatment) factors.
Therefore, LSS is a total concept including all things done
(or not done) starting from the time of presentation to the
completion of reconstructive efforts and even the completion
of adjuvant treatment. LSS is the mainstay of treatment today
for most musculoskeletal malignancies and the treatment
protocols have been standardized for common pathologies
like osteosarcoma and Ewing’s sarcoma in much of the
developed world or the developing countries.
Van Nes rotationplasty is a very valuable intermediate
surgical treatment method between amputation and LSS [2,
3]. When compared to amputation, it preserves significant
function, avoids phantom limb pain, and results in less limb
length discrepancy. However, cultural expectations, peculiar
cosmesis, need for knowledge and experience of specific sur-
gical technique, and the need for access to a skilled prosthe-
tist limit its use.
In the light of this general perspective on amputation and
LSS, the goals of treatment in musculoskeletal malignancies
can be summarized and prioritized as:
1. saving the patient’s life,
2. saving the limb,
3. preserving function of the limb,
3
4 H. Özger and B. Alpan

4. achieving good cosmesis of the limb, 1.2 When and Why Biological
5. compatibility of the treatment method with psycho-socio-­ Reconstruction?
cultural status of the patient.
The main advantage of biological reconstruction is that when
The treating team must adhere to these priorities and the healing process is complete, the reconstruction material
carefully assess issues such as the required knowledge, becomes totally incorporated into the patient’s body [5–11].
skill, experience, technical resources, and presence of a The biologically reconstructed segment, which either main-
specialist team for each case. Respecting these criteria in tains its vitality and thus unites with the recipient site or
the appropriate order and informing the patient and/or the regains its vitality by creeping substitution after uniting with
family explicitly about the objectives that can be achieved, the recipient site, eventually becomes the patient’s own. The
it is almost always possible to avoid an ablative surgery living nature of the healed segment gives it responsive capa-
today. The local control rate is shown to be similar for bility so that it can remodel, heal if it is fractured or hypertro-
amputation and LSS in the era of advanced imaging and phy under weight-bearing conditions (Fig. 1.1). Therefore,
multimodal adjuvant treatment. The decision to perform a biological reconstruction offers a potentially life-long limb
limb-sparing surgery or what kind of reconstruction to salvage solution, which even facilitates safe participation in
undertake in extreme cases, however, is a very individual- recreational activities in survivors of musculoskeletal
ized process, which should take into account the total malignancies.
impact of the planned procedure on the patient and the Biological reconstruction reduces soft tissue problems
medical team in terms of health-related quality of life, eco- through three different mechanisms. Biological materials
nomical burden, psychosocial effects, allocation of medi- occupy less space (Fig. 1.2), allows adherence of soft tissues
cal resources, and oncological risks [2–4]. onto their surfaces, and also may bring their own soft tissue
Reconstruction in limb salvage surgery can be performed cover as in an osteo-myofasciocutaneous flap. Hence, wound
in two ways: problems and secondary deep infections are less commonly
encountered. Furthermore, early postoperative complica-
1. Biological reconstruction tions such as infected hematoma can be effectively treated. If
• Biological methods utilize materials, which are either the healing of biological reconstruction fails partially, as
living or have the capacity to revitalize and are would be the case in the setting of mechanical insufficiency
obtained from either the patient (autograft) or from while the graft’s vitality is preserved, complications like
another person (allograft), to reconstruct the post-­ graft fracture or nonunion might occur and yet can be treated
resection defect [5–11]. by revision of osteosynthesis as in a normal fracture
• Distraction osteogenesis is also a very important, (Fig. 1.3). Limb length discrepancy can be managed in the
albeit less commonly used biological method in ortho- same way as in a non-oncological setting (Fig. 1.4). If, how-
pedic oncology [12]. ever, biological potential has been lost or cannot be regained
• The definition of biological reconstruction may be in a reasonable time, the reconstructed segment might end up
extended to include hybrid methods (e.g., allograft/ as dead bone and fail totally due to deep infection and/or
recycled autograft and prosthesis composites) and bio- resorption. Biological reconstruction has the advantage of
logical aspects of non-biological methods (e.g., bone possible conversion to implant reconstruction even in this
lengthening in the setting of tumor prosthesis or bioex- worst-case scenario (Fig. 1.5).
pandable prostheses) [5, 13]. While biological methods yield durable reconstructions
2. Implant (non-biological) reconstruction with relatively less morbid and biologically manageable
• Tumor prostheses or megaprostheses are the main complications, the major disadvantage is the substantially
instruments of non-biological defect reconstruction long healing time, which particularly causes problem regard-
[14, 15]. ing lower extremity reconstructions due to prolonged period
• Bone cement is also a very versatile non-biological of restricted weight-bearing (Fig. 1.6). These limb salvage
material, which can be used with tumor pros- considerations are most compatible with a patient who has a
theses or osteosynthesis implants for defect high likelihood of survival and thus can afford to wait for the
reconstruction. lengthy healing period. This, in turn, depends on the pres-
• Non-biological methods may harbor biological com- ence of good prognostic factors such as being non-metastatic
ponents (e.g., graft/prosthesis composites or bioex- at presentation, showing a good neoadjuvant treatment
pandable parts) as also mentioned for biological response, not having a large tumor and not having sustained
methods [5, 13]. a pathological fracture.
1 When and Why Biological/Implant Reconstruction?
Fig. 1.1 Early postoperative radiograph demonstrates intercalary
biological reconstruction following resection of proximal humerus
chondrosarcoma in a 35-year-old-male patient (a). The patient pre-
sented with fracture of the vascular fibula graft at postoperative
3 months (b). The fracture was conservatively managed following
On the other hand, certain disadvantages associated with
implant reconstruction, such as loss of joint surfaces, loss of
physeal plates on both sides of the joint, and loss of bone
stock, which could actually be spared, make biological
reconstruction with intercalary resection the treatment of
choice for some cases or a necessity in others. The feasibility
of a safe intercalary resection is closely related with
radiological findings. An interim radiological evaluation
may be reasonable in cases, for which biological
reconstruction is planned. For example, a magnetic
resonance imaging (MRI) examination performed after the
second cycle of a “3-cycle neoadjuvant chemotherapy” may
demonstrate whether if radiological response is good and
therefore intercalary resection is safe or if there is tumor
progression and an endoprosthetic reconstruction will be
safer. Thus, the reconstruction strategy may be worked out
before final preoperative MRI. Which MRI parameters
should be used to determine surgical margins are open to
debate. While the safest margins can be accepted as those
determined according to pre-­ chemotherapy short tau
inversion recovery (STIR) or turbo inversion recovery
magnitude (TIRM) sequences on MRI, the margins most
encouraging for intercalary resection, are those determined
according to post-chemotherapy contrast-­ enhanced
5
closed reduction (c). Follow-up radiograph at postoperative 7 years
shows excellent remodeling after fracture healing (d). The case is an
excellent example of how biological reconstruction allows simple
and effective management of limb salvage complications
sequences in a good-responder. As a general rule, the surgi-
cal margins are determined according to radiology at pre-
sentation for osteosarcoma and according to follow-up
imaging after neoadjuvant treatment for Ewing’s sarcoma
since chemosensitivity and radiosensitivity are thought to
play a bigger role in local tumor control in the latter
pathology.
Although more rarely performed, biological reconstruc-
tion may also play an important role after intraarticular
resection in small children (Fig. 1.7) and particularly in the
upper extremity. Long-term complications of implant recon-
struction, such as periprosthetic infection, inevitable need for
revision, and continuing loss of bone stock, also bring forth
biological reconstruction as the method of choice, in younger
patients, particularly in the skeletally immature.
Biological reconstruction might be considered economi-
cally advantageous when compared to implant reconstruction
in general. While this advantage may vary according to spe-
cific method of biological reconstruction used, harvesting a
non-vascular structural bone graft has virtually no cost and
recycling techniques, such as liquid-nitrogen cryotreatment,
autoclaving, and pasteurization, also have minimal economic
impact and demand minimal resource and equipment. While
microsurgical reconstruction with a vascular bone flap is a
6 H. Özger and B. Alpan

Fig. 1.2 The MRI section, the radiograph, and the clinical photo dem-
onstrate an exulcerated telangiectatic osteosarcoma of the proximal
humerus in a 12-year-old non-metastatic male patient (a–c). MRI
shows extensive tumor necrosis following neoadjuvant chemotherapy
(a). Wide intraarticular resection was performed including the exulcer-
ated part (d). Free vascular fibular graft with proximal epiphysis was
used for biological reconstruction of the humerus (e). Despite signifi-
cant skin and subcutaneous tissue sacrification, the relatively small vol-
ume occupied by the fibula graft, in comparison to tumor prosthesis,
facilitated excellent primary soft tissue coverage (f–h)
1 When and Why Biological/Implant Reconstruction?
Fig. 1.3 Early postoperative radiograph demonstrates “frozen hotdog”
(liquid nitrogen recycled autograft shell & inlaid vascular fibula combi-
nation) reconstruction in a 14-year-old-male patient with distal femur
osteosarcoma (a). Delayed union of the shell resulted in graft fracture
and implant failure in the proximal osteotomy site at postoperative
9 months (b) and in the distal osteotomy site at postoperative 24 months
(d). Image taken from standing AP orthoroentgenogram at 4 years
time, resource, and effort demanding procedure, it can still be
considered as a relatively low-cost treatment if utilized in a
specialized center setting where the procedure is being per-
formed routinely by a dedicated microsurgery team. The
availability of a national bone bank might also favor massive
allograft use as a more economical option compared to
implant reconstruction. Finally, the long-term solution pro-
vided by biological reconstruction also eliminates the costs of
future implant revisions.
In the light of these treatment concerns, biological recon-
struction may be best indicated in a younger patient with good
prognostic factors and a tumor suitable for safe intercalary
resection (Figs. 1.8 and 1.9). Wound problems are better
prevented or managed with biological reconstruction. While
economic factors should not be cited as a criterion for
determining the best treatment strategy, they often emerge as a
reality of medical procedures and biological methods offer
serious advantages to implant reconstruction.
7
shows that full consolidation of the hotdog segment was finally achieved
after two revision surgeries (c, e). The final radiological outcome con-
firms that biological activity was preserved, most probably due to inlaid
vascular fibula. Mechanical failures of biological reconstruction can be
treated in similar fashion to normal fracture complications as long as
there is “sufficient” biological potential
1.3  hen and Why Implant (Non-­
W
biological) Reconstruction?
Advanced design features of modern-day implants facili-
tate near-normal biomechanics especially around the knee
joint, which frequently undergoes non-biological recon-
struction in the oncological setting [14, 15]. Furthermore,
the modularity of most megaprosthetic systems used today
allows the surgeon to precisely adjust the extremity length
and rotation and to modify the reconstruction plan intraop-
eratively [14, 15]. These aspects provide great comfort for
both the patient and the surgeon. Taking into account the
good function and the relative ease of application, implant
reconstruction should be considered as the treatment of
choice when the joint surface cannot be salvaged due to
tumor invasion or proximity and an intraarticular (or
extraarticular) resection is warranted. While epiphyseal
tumor involvement in MRI is not an absolute indication for
8 H. Özger and B. Alpan
Fig. 1.4 Anteroposterior standing orthoroentgenogram of a 20-year-­
old-male patient shows leg length discrepancy of 8 cm in the left lower
extremity 9 years after “frozen hotdog” (liquid nitrogen recycled auto-
graft shell & inlaid vascular fibula combination) reconstruction of the
intraarticular resection, plain infiltration of the joint carti-
lage, extension into the joint space or extension over the
ligaments, and joint capsule mandate an intraarticular (or
extraarticular) resection (Figs. 1.10, 1.11, 1.12 and 1.13).
Implant reconstruction offers the main advantage of
almost immediate or at least faster recovery of functions
depending on anchorage properties, such as the use of
cemented or cement-less stems, and any associated soft tis-
sue reconstruction. Similarly, early weight-bearing can often
be allowed in the lower extremity in stark contrast to biologi-
cal reconstruction. Therefore, the healing time is substan-
tially shorter for implant reconstruction than that of biological
reconstruction. Patients with bad prognostic factors such as
being metastatic at presentation, showing a bad neoadjuvant
treatment response, having a large tumor, and having sus-
tained a pathological fracture should be very carefully
assessed for biological reconstruction and must strongly be
considered for implant reconstruction since the prognosis is
often incompatible with the prolonged healing expected in
biological methods (Fig. 1.14). Although pediatric patients
tolerate and function very well with implant reconstruction
especially around the knee, biological reconstruction is
left femur due to osteosarcoma (a, b). Following plate removal, length-
ening of 4 cm was performed with an intramedullary motorized mag-
netic nail (c–f). The procedure was performed in a very similar fashion
to lengthening in a non-oncological setting
reserved as the primary option for them due to above-­
mentioned reasons. Nevertheless, implant reconstruction
should be favored particularly in adults with lower extremity
tumors due to their relatively diminished bone healing capac-
ity, increased body weight, and time constraints related to
going back to work and other daily activities. Consequently,
an adult patient with bad prognostic factors and a lower
extremity tumor where the joint is non-salvageable is the
ideal candidate for implant reconstruction.
An important yet debatable indication for implant
reconstruction might be not having the surgical skill, expe-
rience, infrastructure, and organization to perform a bio-
logical reconstruction where an intercalary resection might
be considered. The orthopedic oncologist might not be
familiar with the biological method(s); a microsurgeon
and/or necessary operation room setting for microsurgery,
equipment, and facilities required for bone recycling or
bone bank for allograft use might not be available.
Furthermore, tumor destruction may render the bone use-
less as a recycled autograft, the patient might not accept
any donor-site morbidity ruling out any graft/flap harvest,
and the patient may not allow the use of cadaveric bone
1 When and Why Biological/Implant Reconstruction?
Fig. 1.5 Post-chemotherapy MRI shows good radiological response in
an 11-year-old non-metastatic male patient with distal femur osteosar-
coma extending into the epiphysis at presentation (a). Intercalary
(intraepiphyseal) resection and biological reconstruction with “frozen
hotdog” (liquid nitrogen recycled autograft shell & inlaid vascular fib-
ula combination) technique was performed (b, c). Despite full consoli-
grafts due to sociocultural and/or religious reasons.
Patients might also reject biological reconstruction due to
concerns about oncological safety of bone recycling meth-
ods or viral disease transmission risk associated with fresh
frozen massive allografts. In such cases, the most biologi-
cal approach for an implant reconstruction must be sought.
If, for example, intercalary resection can be performed, the
joint might be salvaged and an intercalary diaphyseal
endoprosthesis might be implanted.
1.4 The Gray Zone
Some cases of musculoskeletal tumors fall into a gray zone
with regard to whether a limb salvage surgery can be per-
formed or not, before any discussion of whether biological
or implant reconstruction is better indicated. A huge exul-
9
dation of the hotdog segment, local recurrence was detected in the
epiphysis of the medial condyle at postoperative 38 months (d, e).
Despite local recurrence, a second attempt at limb salvage was success-
ful with resection of the biologically reconstructed segment following
preoperative radiotherapy and implant reconstruction of the distal
femur (f, g)
cerated tumor or one with imminent skin breakdown, neu-
rovascular involvement, and anticipation of significant soft
tissue defect are common features. These cases, especially
if they are skeletally immature, might actually be good can-
didates for Van Nes rotationplasty. However, psycho-socio-
cultural incompatibility may exclude rotationplasty in
some cases.
Yet for other cases in the gray zone, the indication for
limb salvage surgery might be a definite one but the deci-
sion to perform a biological or implant reconstruction is
difficult with regard to oncological safety and possible
critical gains with the biological method. In certain cases,
neither method is clearly the better choice. In those cases,
the patient’s and the treating team’s preferences are deci-
sive. In rarer cases, when a significant advantage or dra-
matic difference in treatment outcome is anticipated,
riskier and unconventional solutions might be sought
10 H. Özger and B. Alpan

a b instead of conventionally accepted methods. There are

certain prerequisites, however, to implement such uncon-
ventional methods. Any intended reconstructive gain must
not breach the principles of safe resection and compro-
mise local control under any circumstance. Tailoring the
chemotherapeutic regimen according to interim clinical
and radiological evaluations, preoperative use of radio-
therapy or concomitant chemoradiotherapy (even in not
very sensitive tumors like osteosarcoma) (Figs. 1.15 and
1.16), special resection techniques (Figs. 1.17, 1.18, and
1.19), advanced neurovascular reconstruction, and exten-
sive use of both local and free flaps (Fig. 1.20) can all be
used to “safely modify” the surgical margins rather than
violating them [16–21]. For these reasons, such uncon-
ventional procedures should only be undertaken by a
competent and experienced multi-disciplinary team in a
specialized orthopedic oncology center, which can pro-
vide the necessary technical resources, after an extensive
discussion with the patient regarding all options, risks,
and possible complications.
Provided that all aspects of limb salvage surgery are under
Fig. 1.6 Anteroposterior femur radiographs at early postoperative control, such “innovative” and “extraordinary” procedures
period (a) and at 4 years (b) demonstrate the moderate amount of offer prospective benefits in terms of function, complica-
hypertrophy in a single barrel vascular fibula graft, which was utilized
tions, and oncological outcome. Even if the long-term out-
for intercalary reconstruction of the proximal femur in a 15-year-old-­
female patient with Ewing’s sarcoma. Despite good oncological and come is not excellent for a specific limb salvage procedure,
functional outcome, the patient had to wait for a prolonged period of preserved joint or bone stock might pave the way for conver-
time for full weight-bearing due to risk of graft fracture

a b c d e

Fig. 1.7 Early postoperative femur radiograph (a) demonstrates intraar-
ticular biological reconstruction of the proximal femur using free vascular
fibular graft with the proximal epiphysis in a 4.5-year-old non-­metastatic
male patient with osteosarcoma. Consecutive radiographs at postoperative
2, 6 and 12 years (b–d) demonstrate healing and hypertrophy of the fibula
despite several graft fractures and osteosynthesis revisions over the years.
The fibular head has strikingly remodeled as the new femoral head (e).
While there is a leg length discrepancy of approximately 10 cm, which
needs to be addressed, the hip function is excellent given the non-anatom-
ical characteristic of the reconstruction method (f, g)
1 When and Why Biological/Implant Reconstruction?
a b
Fig. 1.8 Coronal MRI section demonstrates a distal femur osteosar-
coma involving the metaphysodiaphyseal region in a 9-year-old non-­
metastatic male patient at presentation (a). Note that the tumoral
involvement is sharply limited by the physeal plate with regard to both
the bone and the soft tissues (white solid arrow). MRI following neoad-
juvant chemotherapy shows good radiological response with regression
of the soft tissue component, regression of bone marrow edema, and
demarcation of the osseous lesion (b). The anatomical features, the
treatment response, and the patient’s age indicate an ideal candidate for
intercalary biological reconstruction. An intercalary resection with safe
margins is possible with careful and skillful execution. White dashed
lines show the planned proximal (diaphyseal) and distal (juxtaphyseal
11
c d
through the epiphysis) osteotomy sites. On the contrary, an intraarticu-
lar resection with distal femur endoprosthetic reconstruction will result
in loss of patient’s own knee joint, loss of bone stock in the proximal
femur due to stem insertion, loss of proximal tibial physis, and will
cause significant limb length discrepancy unless a growing prosthesis,
which in turn has its own potential complications, is implanted.
Anteroposterior femur radiograph (c) and still images taken from a
running video of the patient at postoperative 24 months (d, e) show
excellent radiological and functional outcome after “frozen hotdog”
(liquid nitrogen recycled autograft shell & inlaid vascular fibula
combination) reconstruction
12
a b
Fig. 1.9 The coronal MRI section and the plain radiograph show the
tumoral involvement in the proximal tibial diaphysis of a 14-year-old
non-metastatic female patient with Ewing’s sarcoma (a, b). White
dashed lines represent the planned osteotomy sites for intercalary resec-
tion. The tumor volume is relatively small and the lesion is relatively far
from the joint, making an intercalary resection safe and feasible. Early
H. Özger and B. Alpan
c d
postoperative radiograph shows biological reconstruction with “frozen
hotdog” (liquid nitrogen recycled autograft shell & inlaid vascular fib-
ula combination) technique (c). The surgical staples indicate a skin-­
grafted area over medial gastrocnemius flap. Radiograph at postoperative
8 years shows fully consolidated hotdog segment (d)
1 When and Why Biological/Implant Reconstruction?
a b c d
Fig. 1.10 Coronal MRI at presentation demonstrates a distal femur
osteosarcoma involving the metaphysodiaphyseal region in a 14-year-­
old-male patient (a). Note that there is suspicious tumoral extension
distally into the epiphysis of the medial femoral condyle reaching the
subchondral bone (white chevrons) and also over the soft the tissues
beyond the perichondrium (white solid arrows). Although suspicious
osseous and soft tissue involvement of the medial part of the epiphysis
has regressed in the MRI following neoadjuvant chemotherapy, the soft
tissue component on the metaphysodiaphyseal region (white arrows)
has responded only moderately (b). Classic knowledge for surgical
margins in osteosarcoma dictates that the resection must be planned
13
according to MRI findings at presentation and therefore an intercalary
resection is neither safe nor feasible in this case. Furthermore, a less
pronounced limb length discrepancy (LLD) might be anticipated with
the loss of physes around the knee due to the patient’s age. Postoperative
radiograph shows reconstruction with distal femur replacement pros-
thesis (c). Acute lengthening of 2 cm was performed during implant
reconstruction in this patient to minimize expected LLD. Clinical pho-
tos at postoperative 4 years show good active knee range of motion (d,
e), while still images taken from a walking video show completely nor-
mal ambulation (f)
14
a c e f
d
Fig. 1.11 The coronal MRI and the AP radiograph demonstrate
tumoral involvement of the proximal tibial metaphysis and epiphysis,
extending across the joint cartilage, joint capsule, and ligaments into
the knee joint in a 21-year-old non-metastatic male patient with osteo-
sarcoma (a, b). Salvage of the joint was not possible. Furthermore, the
patient, who operated heavy machinery, expressed his desire to return to
work as soon as possible. A modified extraarticular proximal tibia
H. Özger and B. Alpan
g
resection (including all intraarticular and periarticular soft tissues of the
knee joint) was performed following neoadjuvant chemotherapy (c, d).
While the standing anteroposterior orthoroentgenogram shows implant
reconstruction of the proximal tibia (e), clinical images at postoperative
5 years (f–h) demonstrate excellent function of the patient, who
returned to work right after the adjuvant chemotherapy was over
1 When and Why Biological/Implant Reconstruction? 15

a c

Fig. 1.12 Coronal and axial MRIs demonstrate Grade II chondrosar- ticular resection (c) followed by implant reconstruction of the proximal
coma of the proximal femur in a 48-year-old-male patient (a, b). The femur (d) was performed for oncological safety and to allow immediate
tumor location and the patient’s age rule out any attempt to salvage the ambulation with full weight-bearing
femoral head with the intent of biological reconstruction. Wide intraar-
16
a b
c d
Fig. 1.13 Post-chemotherapy coronal and axial MRIs demonstrate
proximal humerus osteosarcoma with poor response and extensive
intramedullary involvement in a 27-year-old-male patient (a, b). The
extent of tumoral involvement in the humeral head ruled out any joint
salvage attempt (a–c). Thorax CT scan also revealed a nodule, which
was consistent with pulmonary metastasis (d). Wide intraarticular
resection and reconstruction with cement-less tumor prosthesis was
planned. White dashed lines in a and b represent the proposed site of
distal osteotomy. However, the remaining bone segment in the distal
H. Özger and B. Alpan
e f
humerus was too short to accommodate the prosthesis stem. This prob-
lem was overcome by using the liquid-nitrogen recycled distal diaphy-
seal segment (white arrows) to augment primary stability of the stem
and to increase bone–prosthesis interface for osseointegration (e).
Radiographs at postoperative 15 months show stable glenohumeral
joint (f) and excellent stem stability with complete fusion of the recy-
cled segment despite some resorption (g). The patient was lost due to
pulmonary metastases at 2 years postoperatively without any incident
in his salvaged limb
1 When and Why Biological/Implant Reconstruction?
a b
d e
Fig. 1.14 Coronal whole-body MRI section demonstrates a pathologi-
cal femur fracture in a 58-year-old-female patient with known history
of endometrium carcinoma (a). Whole-body MRI also revealed multi-
ple bone metastases in the pelvis and spine (b–d). Treatment objectives
were determined as pain management and to facilitate immediate mobi-
lization to allow continuation of other oncological treatments. Non-­
biological reconstruction with tumor prosthesis was planned. Remaining
distal healthy bone stock was measured to entertain the possibility of
17
f
g
joint salvage with intercalary tumor prosthesis (e). However, intraar-
ticular resection with distal femoral replacement was deemed more reli-
able in terms of anchorage Intraoperative image shows the resected
segment involving the distal femur articular surface (f). Postoperative
radiographs show the distal femoral endoprosthetic reconstruction,
which allowed immediate ambulation of the patient (g). She was lost
due to widespread carcinoma mestastases at 9 months postoperatively
without any incident in her salvaged limb
18
a b
e f
Fig. 1.15 Anteroposterior femur radiograph and coronal MRI section
show pathological fracture and epiphyseal invasion in a 5-year-old non-­
metastatic female patient with distal femur osteosarcoma (a, b). The
patient fell into a “gray-zone” category since she was not the ideal
candidate for either intercalary biological reconstruction or tumor
prosthesis reconstruction. While her interim radiological response to
neoadjuvant chemotherapy was moderate, the pathological fracture and
the epiphyseal involvement made a joint salvage procedure questionable
in terms of oncological safety. Tumor prosthesis, on the other hand, would
predispose such a small child to all possible manageable and/or non-
manageable future complications of implant reconstruction regardless of
whether a growing prosthesis was used. The options of amputation or Van
Nes rotationplasty were discussed with the family; however, the family
rejected both treatment options. Eventually, intercalary (intraepiphyseal)
H. Özger and B. Alpan
c d
g h I
resection and biological reconstruction were performed following
preoperative radiotherapy, which is unconventional for osteosarcoma as
well as in a small child. The resection yielded a shelled-out distal femur
articular segment composed of articular and epiphyseal cartilage with very
little bone stock, which resembled an orange-peel and hence the procedure
was coined as “orange-peel resection” (c, d). The radiograph in (e) shows
the resected specimen, while the intraoperative image in (f) demonstrates
the extreme nature of the reconstruction since the fixation of the distal
fragment had to be augmented by sutures. Early postoperative radiograph
(g) shows the “frozen hotdog” (liquid nitrogen recycled autograft shell &
inlaid vascular fibula combination) reconstruction. Postoperative
radiograph at 5 years (h) shows excellent healing of the hotdog segment,
while the patient has good knee function and ambulation despite limb
length discrepancy (i, j)
1 When and Why Biological/Implant Reconstruction?
a b
e f
i j
Fig. 1.16 Clinical image shows rapidly growing distal femur osteosar-
coma causing a massive swelling and varicose veins around the knee of
a 5-year-old-female patient at presentation (a). Plain radiograph shows
pathological fracture of the distal femur (b), while axial CT images
demonstrate that the distal femur epiphysis is engulfed by the tumoral
mass (c, d). The patient had received two cycles of neoadjuvant chemo-
therapy with a two-drug regimen, under which the tumor had pro-
gressed, in another institution. The patient fell into a “gray-zone”
category since she was not the ideal candidate for either intercalary
biological reconstruction or tumor prosthesis reconstruction, similar to
the case in Fig. 1.15. The options of amputation or Van Nes rotationplasty
were discussed with the family; however, the family rejected both
treatment options. A conventional osteosarcoma treatment approach did
not seem compatible with safe limb salvage at this point. Therefore, a
tailored multidisciplinary approach was required. After obtaining
informed consent from the family regarding the risks of limb salvage
surgery, both in terms of local and systemic tumor control, urgent
concomitant chemoradiotherapy (ifosfamide and etoposide,
19
c
g
k l
10 × 300 cGy) followed by one cycle of methotrexate was administered.
Remarkable shrinkage of the tumor even with clinical examination
3 weeks after starting chemoradiotherapy was found to be encouraging
for limb salvage (e). While MRIs at 4 weeks of oncological treatment
showed decrease in tumor size with heterogeneous areas of tumor
necrosis, extensive epiphyseal involvement eliminated any possibility
of joint salvage and intercalary biological reconstruction (f–h). Planning
of tumor prosthesis reconstruction posed yet another challenge. Even if
the remaining proximal femoral segment could accommodate the
femoral stem, there would be no bone stock left for future revisions or
any lengthening procedure. Eventually limb salvage was performed
with wide intraarticular resection and reconstruction with distal femur
tumor prosthesis (i, j). A 4-cm-long custom-made pentagonal stem was
used to spare proximal femur bone stock (k, l). Clinical image at
postoperative 6 months shows successful limb salvage in this patient,
who was still under oncological treatment without any evidence of
disease at the time this work was being prepared for publication (m)
20
a c
Fig. 1.17 Post-chemotherapy coronal MRI shows epiphyseal invasion
in a 15-year-old non-metastatic male patient with proximal tibia osteosar-
coma (a). The tumor did not have a significant soft tissue component or
intramedullary extension. There was no sign of pathological fracture.
While the epiphyseal involvement made an intercalary resection risky, all
other prognostic factors favored a biological reconstruction. Following a
discussion with the patient and the patient’s family regarding the risks
and benefits of a joint-preserving resection and obtaining informed con-
Fig. 1.18 The plain radiograph (a) and the MRI (b) demonstrate par-
osteal osteosarcoma of the proximal femur in a 12-year-old-female
patient. While the MRI gives the impression that only the medial cortex
of the femoral neck and the lesser trochanteric region is involved, it
must be remembered that parosteal osteosarcoma is neither chemo- nor
radio-sensitive and therefore surgical treatment with wide resection is
the absolute rule. Taking into consideration the young age of the patient
and the potential detrimental effects of proximal femur tumor prosthe-
sis on especially the acetabulum, an intercalary biological reconstruc-
tion was intended. The risks and benefits of such a reconstruction were
discussed with the family. One of the two main challenges regarding an
intercalary resection in this setting was preserving the blood supply and
thus avoiding avascular necrosis of the femoral head. The other chal-
lenge was to avoid compromising the surgical margins. The planned
proximal osteotomy sites in the subcapital region and at the trochanteric
apophysis are marked with red dashed lines (b). First intraoperative
image (c) shows the femoral head following intercalary resection (c).
H. Özger and B. Alpan
d
sent, limb salvage was performed with biological reconstruction. An
intraepiphyseal osteotomy was performed as planned in the coronal MRI
section (green dashed line in a). Since the thickness of the remaining
proximal tibia articular segment resembled a biscuit, the resection was
coined as the “biscuit procedure” (b). Radiograph at postoperative
15 years shows excellent hypertrophy of the double-barrel vascular fibula
reconstruction in the metaphyseal region with no degenerative changes in
the knee joint (c). The patient has completely normal knee function (d, e)
The articular cartilage and the bleeding cut surface of the femoral head
can be clearly seen. The second intraoperative image (d) shows the free
vascular fibula and the liquid-nitrogen recycled autograft before they
were combined into a frozen hotdog graft. Early postoperative radio-
graph demonstrates biological reconstruction of the proximal femur
with the “frozen hotdog” technique (e). A local recurrence developed in
the inferior aspect of the femoral neck 4 years after the index operation
and soon after the patient was allowed to bear full weight without assis-
tive devices for the first time since the operation (f). Despite this dis-
couraging complication, the locally recurring mass was resected by
preserving the original reconstruction (g). The CT images obtained
9 years after the index operation and 5 years after the resection of local
recurrence demonstrate full consolidation of the hotdog segment, with
a completely preserved hip joint and no evidence of disease (h, i). She
has good range-of-motion in her hip and is ambulatory without any pain
or limp (j–l)
1 When and Why Biological/Implant Reconstruction? 21

a b c

e f h i

k l
g
22
a b d e
i k m o
l n
j
Fig. 1.19 The plain radiograph shows a lytic lesion in the proximal
tibial diaphysis and a sclerotic lesion in the distal fibular diaphysis in a
46-year-old-female patient (a). Coronal and transverse MRI sections
show the intramedullary tibial lesion with cortical thinning and imminent
pathological fracture (b, c). An open biopsy (both for tibia and for fibula)
and frozen pathological examination were performed to rule out any
malignancy. The frozen exam yielded fibrous dysplasia in the tibia and
non-specific non-malignant findings in the fibula. A prophylactic intra-
medullary (IM) nail fixation was performed in the same session (d). The
definitive pathological examination of the whole biopsy specimen, how-
ever, yielded osteofibrous dysplasia (OFD) like adamantinoma, which
required wide resection of all contaminated volume, with amputation
rather than limb salvage emerging as a reasonable treatment option. From
this point on, the patient fell into a “gray-zone” category both in terms of
feasibility of a safe resection and difficulty of reconstruction. The chal-
lenging situation was explained to the patient, who opted for a limb sal-
vage procedure, understanding the oncological risks associated with limb
salvage regardless of reconstruction method. Following removal of the
IM nail, tibial diaphyseal segment harboring the lytic lesion was resected
as shown by the radiograph of the specimen (e). Previously biopsied dis-
tal fibular segment was also removed. Subsequently, a frozen hotdog
H. Özger and B. Alpan
g h
p q
r t
reconstruction was performed using the liquid-nitrogen recycled tibial
segment with transposition of the remaining ipsilateral fibula (f–h).
Despite excellent healing of the biological reconstruction, local recur-
rence was observed in the proximal tibia as shown by coronal and trans-
verse MRI sections at 20 months postoperatively (i, j). Once again, the
patient was offered amputation as a potential treatment option. Conversion
from biological to implant reconstruction was also proposed to the patient
as a “gray-zone” indication in terms of both oncological outcome and
possible anchorage problems. The mutual decision was to continue with
limb salvage. Intraarticular wide resection of the proximal tibia was
performed together with the locking plate (k). Significant length of distal
tibial diaphysis, which had been previously reconstructed with frozen
hotdog technique, could be spared for prosthesis stem insertion (l).
Pentagonal stem was inserted into the distal tibia with excellent primary
stability and the bone–prosthesis interface was augmented with a chunk
of cancellous autograft obtained from preparation of the femoral side (m,
n). The standing AP orthoroentgenogram shows the proximal tibia
prosthesis in the early postoperative period (o). Radiographs (p, q) and
clinical pictures (r–t) at 24 months postoperatively following implant
reconstruction show excellent radiological and functional outcome.
Furthermore, the patient remained tumor-free at the last follow-up visit
1 When and Why Biological/Implant Reconstruction? 23

a b c e

f i j

Fig. 1.20 A 16-year-old-female osteosarcoma patient presented with
local recurrence in the anterior aspect of her knee, in the setting of a
total femur prosthesis, which was implanted in another institution (a–
d). The case was considered to fall into the “gray-zone” category in
terms of decision-making and execution of treatment plan. Amputation
was a valid treatment option from the oncological perspective. However,
an amputative surgery would necessitate hip disarticulation, which
would be devastating from the psychological perspective of the patient.
The possibility of limb salvage, which could achieve wide margins
comparable to that of an amputation, was sought. Classic tumor prin-
ciples dictated the removal of all tissue volume contaminated by the
previous procedure. An extreme musculoskeletal defect with extreme
reconstructive challenges could be anticipated in such a resection. The
mutual decision of the surgeon and the patient’s family was to perform
limb salvage, with the informed consent that limb salvage did not guar-
antee any systemic tumor control. The locally recurring tumor was
widely resected, including the whole implant and the proximal half of
the tibia (e). The massive osseo-articular defect was reconstructed with
a total femur plus proximal tibia replacement prosthesis (f). The mas-
sive soft tissue defect, on the other hand, required advanced microsurgi-
cal reconstruction involving the transfer of a free chimeric serratus
anterior—latissimus dorsi myocutaneous flap as well as extensive split-
thickness skin grafting (g, h). Standing AP orthoroentgenogram at
6 months postoperatively shows stable implant with good alignment
and negligible limb length discrepancy (i), while the clinical image at
the same time demonstrates excellent wound healing (j)
24
Fig. 1.21 Coronal section from post-neoadjuvant preoperative
contrast-­enhanced MRI shows osteosarcoma of the proximal tibia in a
9-year-old non-metastatic male patient (a). At presentation, the patient
had a pathological fracture accompanied by significant soft tissue com-
ponent and epiphyseal tumor extension. Despite the difficulty of achiev-
ing a safe intercalary resection in such a setting, biological reconstruction
with joint salvage was aimed after discussing the risks and benefits of
the treatment options with the family. To facilitate resectability of the
tumor with safer margins, concomitant chemoradiotherapy (cisplatin,
10 × 300 cGy) was administered preoperatively in addition to the stan-
dard neoadjuvant chemotherapy regimen. Persistent epiphyseal involve-
ment (white arrows) and areas of tumor necrosis (encircled by white
dashed lines) can be observed (a). An intraepiphyseal osteotomy was
planned just below the joint surface (red dashed line) in a similar fash-
ion to the biscuit procedure described in Fig. 1.17 (b). The first intraop-
erative image shows the proximal tibia articular segment with only the
cartilage remaining on the medial aspect after the resection (c). The
second intraoperative image shows the resected segment from the supe-
rior aspect with macroscopically intact margins (d). The radiograph of
H. Özger and B. Alpan
the resected segment demonstrates successful execution of the planned
osteotomy (e). Early postoperative radiograph shows “frozen hotdog”
(liquid nitrogen recycled autograft shell & inlaid vascular fibula combi-
nation) reconstruction of the proximal tibia (f). The patient underwent
augmentation of the medial tibial plateau with structural iliac autograft
and medial proximal locking plate 16 months after the index procedure.
At 5 years postoperatively, the patient has a limb length discrepancy of
65 mm (g). Follow-up radiograph at 5 years shows that the diaphyseal
part has fully consolidated while there is some resorption in the metaph-
yseal part of the recycled bone and the medial tibial plateau is still
defective, causing the proximal edge of the medial plate to articulate
with the medial femoral condyle (h). The patient is allowed to bear
weight as tolerated with a pair of crutches (i) and the knee range-of-­
motion is good (j, k). Although the radiological and functional out-
comes are not excellent, oncological objectives have been achieved so
far. The ipsilateral distal femoral epiphysis has been spared and the
knee function has been remarkably preserved. The reconstruction can
be revised using another biological tool such as massive allograft or
could be converted to tumor prosthesis if everything else fails
1 When and Why Biological/Implant Reconstruction?
sion to another limb salvage method (Fig. 1.21) or to a more
functional amputation at a later age, for example, for a skel-
etally immature child.
1.5 Conclusion
Both biological and non-biological methods have their own
advantages and disadvantages. At the same time, each
method has its unique indications as well as overlapping
ones. While the choice of treatment is clear-cut for some
cases, the indications might fall into a “gray zone” category
in others where multiple parameters must be considered
simultaneously in the light of surgeon’s and/or institution’s
capabilities and experience. To conclude which reconstruc-
tion should be preferred when and why, one must first remind
the unchanging limb salvage philosophy with the following
analogy:
Tumor resection with safe margins denotes "1"; each achieved
limb salvage goal puts a "0" beside "1", adding value to the treat-
ment. Thus, preserving the limb yields "10", a functional limb
"100", good cosmetic appearance "1000" and so on. If the mar-
gins are compromised, however, the surgeon and the patient are
left with a "0" to begin with and all reconstruction efforts
whether biological or implant are cancelled out.
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Techn Orthop. 2018;33(3):183–90. https://doi.org/10.1097/
BTO.0000000000000313.
3. Morris CD, Wustrack RL, Levin AS. Limb-salvage options in grow-
ing children with malignant bone tumors of the lower extremity. JBJS
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4. Futani H. Long-term follow-up after limb salvage in skeletally
immature children with a primary malignant tumor of the distal
end of the femur. J Bone Joint Surg. 2006;88:595–603. https://doi.
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5. San-Julian M, Vazquez-Garcia B. Biological reconstruction in bone
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jos.2019.01.015.
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The combined use of recycled bone and vascularised fibula in
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 Part II
Mobile Spine
 Biological Reconstruction Using Frozen
Autograft in Total En Bloc 2
Spondylectomy for Spinal Tumors

Satoru Demura, Satoshi Kato, and Hiroyuki Tsuchiya

2.1 Introduction
Total en bloc spondylectomy (TES) is one of the surgical
procedures which was recognized and accepted as a treat-
ment for spinal tumors after its development in 1989 [1, 2].
The procedure enables en bloc excision of the diseased ver-
tebrae to achieve local control [3]. However, TES is techni-
cally demanding operations; it requires adequate knowledge
and consideration of surgical anatomy, physiology, and bio-
mechanics around the spine. Currently, we modified TES
procedure using frozen autograft, expecting the recycle of
resected bone and additional cryoimmunological effect [4,
5]. We describe the surgical procedure, tips, pitfalls, and
solutions through the representative case (Fig. 2.1).
2.2 Brief Clinical History
A 48-year-old male, who showed low back pain, was diag-
nosed with metastasis from renal cell carcinoma at L2.
Previously, he had undergone left nephrectomy for pri-
mary renal cell carcinoma followed by sunitinib malate. He
was referred to our hospital and scheduled for excisional
surgery.

Fig. 2.1 Schematic representation of total en bloc spondylectomy (TES) using frozen autografts

S. Demura (*) · S. Kato · H. Tsuchiya

Department of Orthopaedic Surgery, Graduate School of Medical
Sciences, Kanazawa University, Kanazawa, Japan
e-mail: seikei@med.kanazawa-u.ac.jp; skato323@gmail.com;
tsuchi@med.kanazawa-u.ac.jp

© Springer Nature Switzerland AG 2022 29

H. Özger et al. (eds.), Orthopedic Surgical Oncology For Bone Tumors, https://doi.org/10.1007/978-3-030-73327-8_2
30 S. Demura et al.

2.3  reoperative Clinical Photos

P
and Radiographs

See Figs. 2.2, 2.3.

a b c

Fig. 2.2 The plain radiographs showed osteolytic legion at L2. Positron emission tomography-computed tomography (PET-CT) showed a hyper-
activity to the vertebral body. (a) Frontal radiograph. (b) Lateral radiograph. (c) Reconstructed sagittal image of PET-CT

a b c

Fig. 2.3 Preoperative MRI. (a) Sagittal T1-weighted image. (b) Sagittal T2-weighted image. (c) Contrast-enhanced T1-weighted image
2 Biological Reconstruction Using Frozen Autograft in Total En Bloc Spondylectomy for Spinal Tumors
2.4 Preoperative Problem List
(a) Need to preserve neurovascular structures around the
spine for en bloc tumor resection
(b) Need to prevent excessive bleeding during the surgery
(c) Need to restore spinal column stability after large bone
defect
2.5 Treatment Strategy
(a) Oncologically adequate excision of the spine tumor
(b) Recycling of resected bone for large bone defect with fro-
zen autografts adequately processed by liquid nitrogen
(c) Spinal column reconstruction to obtain sufficient spinal
stability
2.6 Basic Principles
(a) We prefer TES by a single posterior approach above L1.
Anterior–posterior combined approach would be rec-
ommended below L2 to avoid injury to major vessels. In
case of TES below L3, en bloc corpectomy by anterior
approach is performed to preserve lumbosacral plexus
nerves.
(b) An anterolateral retroperitoneal approach was per-
formed in this representative case. The psoas muscles
were retracted, then crus of bilateral diaphragm was cut
off in case of en bloc corpectomy at L2. The bilateral
segmental vessels of the corresponding level were
ligated and cut off.
(c) A posterior midline incision was made and was extended
two vertebrae above and below the involved segments.
The spinous and the inferior articular processes of the
neighboring vertebra were removed to expose the supe-
rior articular process of the resected vertebra.
(d) A curved T-saw guide was then introduced through the
inter-vertebral foramen in a cephalocaudal direction.
T-saw [6] (flexible multi-filament threadwire saw) was
31
passed through the hole in the wire guide. With a
­reciprocating motion of the T-saw, the bilateral pedicles
were cut.
(e) En bloc laminectomy (including spinous process, artic-
ular processes, transverse process, and pedicle) was
performed.
(f) For dissection of the posterior part of the tumor verte-
bral body, transection of the bilateral L2 nerve roots was
performed, then dissection between the dura mater and
posterior longitudinal ligament or the capsule of the epi-
dural tumor was made. Hoffmann ligament and the lat-
eral root ligament were cut off carefully not to violate
the tumor capsule and dura mater.
(g) The psoas muscle was dissected ventrally from the lat-
eral wall of the vertebral body. The major vessels are
carefully retracted from the anterior aspect of the verte-
bral body with the surgeon’s fingers and spatula.
(h) To maintain stability, a temporary posterior instrumen-
tation is set. The proximal and distal cutting of the disc
was made using an L-shaped osteotome or T-saw.
(i) The vertebral body is mobilized like a clockwise rota-
tion around the dura and removed carefully to avoid
injury to the spinal cord.
(j) From the resected vertebrae, the tumor and soft tissue
(ligament, disc, and cartilage) were curetted away. The
resected vertebra was then placed into liquid nitrogen
(−196°) for 20 min. The frozen vertebra was crushed,
and packed into a titanium cage. If the uncontaminated
healthy bone is available such as a rib or iliac bone in
the same approach, combination of the autograft, and/or
frozen allograft would accelerate bone union. In addi-
tion, bone grafting around the titanium cage is good
option.
(k) A titanium cage is inserted properly for anterior recon-
struction and the posterior instrumentation is adjusted
to compress the cage slightly. Transverse connector
increases the stability in axial rotation.
(l) The wound is closed over a negative suction drain.
(m) The hard type brace is applied from 3 to 6 months until
spinal reconstruction is stable condition.
32 S. Demura et al.

2.7 Intraoperative

See Fig. 2.4.

b c

Fig. 2.4 (a) Posterior image after resection of tumor vertebra. (b) Specimen of en bloc lamina. (c) Specimen of en bloc vertebral body
2 Biological Reconstruction Using Frozen Autograft in Total En Bloc Spondylectomy for Spinal Tumors 33

2.8 Technical Pearls complete dissection by the surgeon’s fingers anterior to the
vertebral body, the smallest size of spatulas is inserted and
The tip of the T-saw guide for en bloc laminectomy should sequentially extended. Enough size of spatulas is able to
be introduced along the medial cortex of the pedicle so that prevent the surrounding tissues and organs from iatrogenic
the spinal cord and the nerve root are not injured. When injury.
the T-saw guide is passed, the T-saw can be found beneath
the inferior border of the pars interarticularis. In the proce-
dure of en bloc corpectomy, the spinal branch of the seg- 2.9  utcome Clinical Photos
O
mental artery which runs along the nerve roots is identified and Radiographs
and divided. It helps to detach the segmental artery that
appears just lateral to the cut edge of the pedicle. After See Figs. 2.5, 2.6

a b

Fig. 2.5 Follow-up radiograph at 3 years. (a) Frontal radiograph. (b) Lateral radiograph
34
a b
Fig. 2.6 Reconstructed CT image showed sufficient bony fusion. (a) Reconstructed coronal image. (b) Reconstructed sagittal image
2.10 Avoiding and Managing Problems
(a) Intraoperative bleeding; excessive bleeding with hyper-
vascular spinal tumors sometimes occurs. For that rea-
son, we recommend to embolize not only a feeding artery
but also segmental arteries above and below at three lev-
els preoperatively. During the surgery, it would be better
to manage relatively hypotensive anesthesia. Tranexamic
acid also helps to reduce the total blood loss.
(b) Damage to major vessel and segmental vessels; blunt
dissection of the anterior part of the vertebral body is
risky maneuver in TES. In the upper thoracic spine from
T1 to T4, dissection is less likely to damage the thoracic
aorta or azygos vein. But care should be taken because
variation in the intercostal artery originating from the
neighboring intercostal artery exists [7]. The segmental
artery must be carefully detached anteriorly below T5
before manipulation of the affected vertebra. At L1 and
S. Demura et al.
L2 levels, the crus of diaphragm exists and should be
dissected from the vertebral body because the segmental
arteries run between the diaphragm insertion and verte-
bral body. After dissection, the segmental vessels of the
corresponding level were ligated and cut off.
(c) Damage to spinal cord; spinal cord monitoring is neces-
sary for circumferential spinal cord decompression.
Slight spinal cord shortening is acceptable, on the other
hands, stretching the spinal cord causes irreversible
mechanical damage. Interruption of bilateral segmental
arteries more than four consecutive levels (ligation of
nerve roots) has a risk of producing ischemic spinal cord
dysfunction [8].
(d) Spinal column reconstruction; biological bony fusion is
mandatory for long-term spinal column stability. Spinal
shortening increases the biomechanical spinal stability
of the anterior and posterior spinal column. Shortening
from 5 to 10 mm leads to increased spinal cord blood
flow experimentally [9].
2 Biological Reconstruction Using Frozen Autograft in Total En Bloc Spondylectomy for Spinal Tumors 35

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340–9.
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Sci. 2001;6(5):424–9.
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Y. Total en bloc spondylectomy: a new surgical technique for pri-
K, Tanaka S. Cadaveric vascular anatomy for total en bloc spon-
mary malignant vertebral tumors. Spine. 1997;22:324–33.
dylectomy in malignant vertebral tumors. Spine (Phila Pa 1976).
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1996;21(12):1401–7.
spondylectomy for spinal tumors: improvement of the technique
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and its associated basic background. J Orthop Sci. 2006;11:3–12.
Y. Effects on spinal cord blood flow and neurologic function sec-
4. Murakami H, Demura S, Kato S, Yoshioka K, Hayashi H,
ondary to interruption of bilateral segmental arteries which sup-
Inoue K, Ota T, Shinmura K, Yokogawa N, Fang X, Tsuchiya
ply the artery of Adamkiewicz: an experimental study using a dog
H. Systemic antitumor immune response following reconstruction
model. Spine (Phila Pa 1976). 2008;33(14):1533–41.
using frozen autografts for total en bloc spondylectomy. Spine J.
9. Kawahara N, Tomita K, Kobayashi T, Abdel-Wanis ME, Murakami
2014;14(8):1567–71.
H, Akamaru T. Influence of acute shortening on the spinal cord: an
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experimental study. Spine (Phila Pa 1976). 2005;30(6):613–20.
A, Yamamoto N, Tomita K. Pedicle frozen autograft recon-
 Implant Reconstruction of the Mobile
Spine 3
Syed Mohammed Karim, Matthew T. Houdek,
Michael J. Yaszemski, and Peter S. Rose

3.1 Brief Clinical History 3.2  reoperative Clinical Photos

P
and Imaging
A 45-year-old right-hand dominant female with body mass
index (BMI) 46 kg/m2 had approximately 2 years of atrau- See Figs. 3.1, 3.2, 3.3, 3.4, 3.5.
matic neck pain with intermittent altered sensation and
motor function in the right upper extremity that became
progressively worse over the 12 months prior to referral to
our clinic. Advanced imaging studies demonstrated a tumor
involving the right side of the cervical spine with biopsy
results consistent with synovial sarcoma. Systemic stag-
ing studies demonstrated no evidence of metastatic disease.
Neoadjuvant chemotherapy and radiotherapy were admin-
istered with repeat staging studies again demonstrating no
metastatic disease.

Fig. 3.1 Anteroposterior (AP) radiograph of the cervical spine demon-

strates a lytic lesion of the right C7 lateral mass (arrow)

S. M. Karim · M. T. Houdek · M. J. Yaszemski · P. S. Rose (*)

Department of Orthopedic Surgery, Mayo Clinic,
Rochester, MN, USA
e-mail: Karim.SyedMohammed@mayo.edu;
Houdek.Matthew@mayo.edu; Yaszemski.Michael@mayo.edu;
Rose.Peter@mayo.edu

© Springer Nature Switzerland AG 2022 37

H. Özger et al. (eds.), Orthopedic Surgical Oncology For Bone Tumors, https://doi.org/10.1007/978-3-030-73327-8_3
38 S. M. Karim et al.

Fig. 3.2 Fluorodeoxyglucose (FDG)-positron emission tomography (PET)/CT further characterizes the lytic lesion in the right C7 lateral mass
and demonstrates its extra osseous extension and FDG avidity

Fig. 3.3 Magnetic resonance image (MRI) in the coronal plane dem- Fig. 3.5 CT angiogram demonstrates the relationship of the tumor
onstrates the anatomic extent of the tumor (shaded green) with the cervical vasculature

3.3 Preoperative Problem List

(a) Wide local excision of tumor with negative margins in a

region with numerous critical neurovascular and visceral
structures
(b) Difficulty with access to the anterior aspect of the cervi-
cothoracic junction, particularly in a patient with BMI
46 kg/m2
(c) Reconstruction of resulting bony defect to restore spinal
stability after resection
(d) Consequences of preoperative radiotherapy (wound
healing, altered surgical planes, esophagitis, decreased
local biologic capacity for bony fusion) and chemother-
apy (immunosuppression, decreased cell counts, nausea/
Fig. 3.4 Post gadolinium MRI in the axial plane demonstrates encase-
ment of the right vertebral artery (arrow) in tumor
vomiting/poor nutritional status)
Another random document with
no related content on Scribd:
 But here General Concha interceded by exclaiming: “Stop,
Manolito, stop the firing! For God’s sake remember we are in Her
Majesty’s palace!”
So the firing was stopped, and the little girls, alarmed at the
noise, fell into each other’s arms, and cried with fright, whilst the
Countess of Mina strove to still their fears. The noise of firing was
heard down the corridors and the staircases known by the names of
those of the Lions and the Ladies. General Dulce was not content
with quelling the invasion of the palace by firing down the chief
staircase to prevent the ascent of any interloper, but, leaving
Barrientos in command of half the Guard at that spot, he went with
the other half into the Salon of the Ambassadors, and there fired on
the insurgents from the windows, until the whole Plaza de la Armeria
was swept free from any more possible invaders of the royal abode.
In the meanwhile Boria, Don Diego Leon, and others, were
caught in the Campo del Moro, the gardens of the palace. No mercy
was shown to the would-be perpetrators of such a deed as the
kidnapping of the royal children, and Diego de Leon, who had been
covered with laurels for his brilliant services in the civil war, was shot
with his accomplices without demur.
In the meanwhile General Espartero, in his Palace of la Buena
Vista, was ignorant of the tragic scenes enacted at the palace until
they were over. Brought thither by the sound of firearms, he arrived
just as the insurrectionary force had been driven from the palace,
and hastening up the staircase stained with blood, he found the royal
children in their room weeping bitterly and much terrified, albeit at
the time of the alarming scene they had shown more courage than
could have been expected at such an early age. The Regent led the
little girls to a window of the palace to still the fears of the people,
who had hastened from all quarters at the noise of the firing, and the
halberdiers who had defended their young Queen and her sister so
bravely were all publicly applauded, promoted, and subsequently
given the Cross of San Fernando. The fact of gunshot penetrating
the royal apartment was unprecedented in history, and although the
halberdiers pressed into the room to protect the royal children, they
abstained from firing there on the invaders without, for fear of hurting
those in their charge. When the Cortes opened, Espartero escorted
the Princesses to the ceremony, and they were received with
enthusiastic demonstrations of loyalty.
A short time afterwards Argüelles had to insist on the Order of the
Palace, by which the French Ambassador was not allowed entry to
the palace without official permission from the Regent.
When the Infante Don Francisco and Luisa Carlota decided to go
to Spain to see what personal influence could do in obtaining power
over their nieces, the King of France did all he could to prevent the
fulfilment of the plan. Difficulties were put in the way of the illustrious
travellers having horses for the journey, but Luisa Carlota exclaimed:
“This new obstacle will not stop us, as, if we can’t get horses, we will
go on foot.”
The exiled Queen-mother did all she could to influence her
children against their aunt, and she placed within the leaves of a
book of fashions, which she sent them from Paris, a paper which ran
thus: “Do not trust that woman! She causes nothing but disgrace and
ruin. Her words are all lies; her protestations of friendship are
deceptions; her presence is a peril. Beware, my child. Your aunt
wants to get rule over your mind and your heart to deceive you, and
to claim an affection of which she is unworthy.”
It was in 1842 that, eluding the vigilance of the Countess of Mina,
the lady-in-chief of the royal children, Luisa Carlota managed to see
a good deal of her young niece Isabel. The Infanta constantly joined
the young Queen in her walks, and, not content with talking to the
young girl about her cousin Don Francisco, so as to make her think
of him as an eligible parti, she one day gave her niece a portrait of
her son in his uniform as Captain of the Hussars. This portrait
Isabella was seen to show to her little sister, and so annoyed was
the Marchioness of Belgida, the chief Lady-in-Waiting, at what she
considered the breach of confidence on the part of the Infanta, that
she resigned her post. Argüelles had striven to warn Luisa Carlota
against the imprudence of her course, for the question of the young
Queen’s marriage was one in which the dignity of the Government,
the honour of the Queen, and the good name of the Regent, had all
to be considered. Therefore any attempt to compromise the Queen
by forcing any opinion from her which could not be based on
experience was detrimental to all concerned. In the Cortes he said: “I
do not believe in absolute isolation for a young Queen, but I think
she ought to be surrounded by those who will give her a good
example of prudence and self-reflection.” On the day that the
Marchioness of Belgida’s resignation was accepted the widowed
Countess of Mina was raised to be a grandee of Spain of the first
order, and she was appointed to the post vacated by the Countess.
Then, in pursuance of the opinion of the Ministers, Espartero had the
Princesses taken to Zaragossa so as to prevent further intrigues
about the Queen’s marriage.
In the “Estafeta del Palacio Real,” Antonio Bermejo compares
Olozaga with Argüelles. “He was,” he says, “austere like Argüelles,
who might be a little brusque, but never had a word or a single
phrase left the lips of this old man which could sully the purity of a
Princess. Moreover, the new guardian of the Queen was so dense
that he let a book be circulated in the royal apartment, called
‘Theresa, the Philosopher,’ which was said to be at the root of much
of the light behaviour of our girls. Who allowed this book in the
palace? Whence came this vile work, calculated to pollute the throne
of San Ferdinand? Narvaez and Gonzalez Brabo saw the book lying
on a chimney-piece in the palace, and they indignantly cast it into the
fire. It was thus that people sought to shake the foundation of the
throne; it was thus that the seed of corruption was sown which
resulted in so much weakness and failure!”
 CHAPTER VIII
MINISTERIAL DIFFICULTIES IN THE PALACE

1843

There is doubtless truth in the opinion that the wish of the

Government for the majority of the Queen to be declared at the age
of thirteen instead of fourteen proceeded from the desire of self-
interested personages to rid the country of the Regent, and hasten
the time when the power would be fully in the hands of the young
Sovereign, when it could be turned to the designs of the Moderates.
This project soon took form by the Ministry presenting a petition
to Isabella, saying:
“The nation wishes and desires to be governed by Your Majesty
yourself. Your Majesty will have heard the result of the vote taken in
the Cortes which is about to assemble, and there the oath required
by the Constitution from a constitutional monarch will be received by
the same Cortes.”
So on November 8, 1843, the proposal was carried by a majority
of 157 over 16, and Queen Isabel was endowed with full power as
Queen of the realm—a Queen of only thirteen years of age, whose
education had been grossly neglected, and who was inclined to
follow the dictates of an undisciplined sensual nature.
 R E C E P T I O N O F I S A B E L L A I I . AT T H E E S C O R I A L

From a Painting by R. Benjumea

Don Salustiano de Olozaga was then appointed President of the

Ministry which had supported the deed, whilst Francisco Serrano,
who was subsequently to play such an important part in the history
of Spain, remained Minister of War, and Frias Minister of the Marine.
But on November 29 the nation was astounded by the publication
in the Gazette of the decree for the dissolution of the Government
which had put the full power in the young Queen’s hand.
The reason for this course was not far to seek. Olozaga was not
only anxious to free himself from a Parliament with a majority of
Moderates (Tories), but he wished to be freed from the influence of
Narvaez, who represented the influence of the Queen-mother in the
palace. It was the fact of this influence which had decided both
Cortina and Madoz to refuse office.
 The fact of the Provisional Government having appointed
Olozaga guardian of the young Queen showed that he was known to
have great influence over her, and whilst holding that appointment he
had been flattered by the grant of the decoration of the Golden
Fleece. This distinction was declared by some to have been the
outcome of his own astuteness, and it certainly made him unpopular.
The decree for the dissolution of the Parliament was promptly
followed by incriminating whispers against the President of the
Council.
Mysterious allusions were made to Olozaga having been so
wanting in respect to his Queen that he insisted with undue force on
the dissolution of the Parliament, and when she objected and wished
to quit the apartment, he locked the door, and forcibly drew her back
to the table, where he made her sign the document.
“There are,” says Don Juan Rico y Amat, “those who say that this
report was got up by the Moderates on the exaggerated story of the
young Queen, as they wished to get him out of power; but this theory
is opposed by the difficulty of believing that a story which tended to
lessen the dignity of the Crown could have arisen only through
Isabella herself, and those acquainted with the Minister knew the
story was in accordance with his imperious, impetuous nature, well
known in the palace. It had, moreover, often been noticed that the
Prime Minister had entered the royal apartments with a freedom
unbefitting the respect due to royalty.”
Olozaga wrote to General Serrano, saying that the fact of the
Queen sending him a letter saying she would be glad to have the
decree, granted at the instance of Olozaga, returned to her, for the
rectification of the first lines, saying, “For grave reason of my own I
have just dissolved,” etc., showed the absurdity of the invention that
it had been obtained from her by force. “But if anybody,” continued
Olozaga, “still insists on such an idea, I will have the honour of
suggesting a means whereby the truth will be declared in my
presence.”
None of the Moderates surrounding the Queen had the courage
to seize the reins of government at this time of confusion, and
Narvaez himself, whose power in the palace was well known, and
whose position as Captain-General of Madrid would have assured
him of a large number of followers, hesitated to take the rudder of
the deserted ship.
Whilst all was hesitation in the audience chamber, a young man
suddenly made his appearance, and passed with fearless step and
bold bearing through the assembly of timorous people, right up to
within two steps to the throne in the Salon of Ambassadors, and
there assumed the leadership which was shunned by those who
could have claimed it, by exclaiming in a loud, commanding tone:
“The Queen before all! A revolution or I....” And thus by this splendid
coup the premiership was taken by Gonzalez Brabo, a man almost
unknown in Madrid, except for his talent as a journalist.
His paper, El Guirigay, had been prohibited for its gross attacks
on the Queen-mother, and his Liberal ideas were well known. The
splendid coolness and courage with which this young man thus
contravened the storm of revolution in the very palace itself was
calculated to arouse the hatred of the populace, who had looked to a
revolution as a reform in all the conditions which make life
burdensome.
Thus three days later, when Gonzalez Brabo crossed the Plaza
de Oriente for his audience with the Queen at the palace, his coach
was stopped by a mob, and the threatening attitude of the people
would have checked anyone less cool and determined in his course.
The day of the reopening of the Congress after its suspension for
the formation of the new Cabinet was a very anxious one, for it was
clearly seen that the Queen had either been treated with flagrant
disrespect or her report of the Minister’s conduct had been untrue.
The mace-bearers, with their plumed hats and their breasts
bearing the embroidered arms of the city, were standing in
statuesque immobility on their elevated places directly under the
canopy at the head of the chamber. Every seat was filled; the boxes
had their full complement of ladies, and outsiders and
representatives of the press crowded the gangways. The President
of the Congress sat at the official table, flanked by his officials, and
all was expectation when the slight, dapper figure of Brabo, dressed
in black and bearing the scarlet portfolio of office under his arm,
walked with determined step to the seat of honour on the black[15]
bench of the Ministers, and from thence returned the astonished
glances of the deputies with a scornful smile and a contemptuous
look. After waiting for the storm of dissentient remarks to subside,
the Minister rose to his feet, and in clear, concise tones declared that
he had been summoned by the Queen to the palace at 11.30 on
November 3, and, being admitted to the royal presence, he found
that the audience included all the staff of the gentiles hombres,
including General Domingo Dulce, who had distinguished himself so
bravely on the night of the attempted kidnapping of the little
Princesses; Don Maurice Carlos de Onis, President of the Senate;
the Duke of Rivas; the Count of Ezpeleta; the Marquis of
Peñaflorida, and the Marquis of San Felices, Secretary of the
Senate, with Don Pedro José Pidal, President of the Congress of
Deputies, the President of the Academy of Languages, etc. The
gathering also included the Patriarch of the Indias and the Notary of
the King. And it was in the presence of this august assembly that Her
Majesty had made the following declaration: “On the evening of the
28th of last month, Olozaga proposed my signing a decree for the
dissolution of the Cortes, and I replied that I did not wish to sign it,
having, among other reasons, the fact that this Cortes had declared
me to be of age. Olozaga insisted; I again objected, rising from my
seat and proceeding to the door at the left-hand side of the table.
Olozaga intercepted my passage and locked the door. Upon this I
turned to the other door, but he then stepped to that one, which he
also locked. Then, catching me by the dress, he made me sit down,
and seized me by the hand and forced me to sign the document.
Before leaving me he told me to say nothing of the occurrence to
anybody, but this I declined to promise.”
[15] The Ministerial seats are now upholstered in blue.

“Then,” continued Brabo, “at Her Majesty’s request, we all signed

the royal declaration, for its transmittance to the archives.”
It was with great dignity and cleverness that Olozaga followed the
statement of Brabo by refuting the points, holding his own as to his
innocence, and yet not incriminating the Queen of untruth. When the
unfortunate man had entered the Cortes with his brothers, cries of
“Death to him!” came from a box filled with officers of the regiment of
San Fernando, whilst shouts of “Viva!” came from other directions.
“Happen what may,” said Olozaga, “I deserve the confidence of
the Queen, which I won as a Minister;” and it was in a voice
trembling with emotion that he continued: “The life I have led justifies
me—the person of my heart, my daughter, my friends. My
colleagues have all found me always an upright man, incapable of
failing in my duties, and this opinion I cannot sacrifice to the Queen,
nor to God, nor to the Universe. Being a man of integrity, I must
show myself as such before the world, even if it were on the steps of
the scaffold itself.”
It is difficult to get an impartial opinion upon this episode, so
fraught with importance and so conclusive of the short-sighted policy
of putting the kingdom into the hands of a young girl of thirteen, who
was utterly inexperienced in the art of government, as the Regent
had lived away from the palace, and fate had sundered her from
mother, aunts, uncles, and relatives, who, in any other station of life,
might have aided her with their counsels. In the excitement of the
moment the Minister had doubtless treated the Queen as he would
his own daughter, and, keenly anxious to gain the decree which
would empower him to rid himself of the majority of Moderates in the
House, Olozaga had not stopped to consider how an exaggerated
report might colour his action to the tone of that of a man guilty of
gross lèse-majesté. The Queen was but a child in his eyes, and
when she demurred at the seeming cruelty and ingratitude of
dissolving a Cabinet which had been so favourable to the
anticipation of her majority, it is probably true that the Minister patted
her familiarly on the wrist, and said, with a smile of satisfaction and
superiority: “I will accustom My Lady to such cruelties!”
The return of the Queen-mother was now solemnly demanded by
a deputation of grandees, senators, and deputies. The necessity of
the young Queen having a person of experience at her side was
eloquently set forth; and those who were envious of the power of
Gonzalez Brabo eagerly advised a course which would curtail his
influence and lead to the supremacy of the Moderates. So Maria
Cristina returned to Spain on February 28, 1844, arriving at
Barcelona on March 4, and at Madrid on March 21.
However, Gonzalez Brabo managed to retain power under the
new state of affairs, albeit at the price of being termed a traitor by his
own party.
In spite of being accused of acting as a panderer to the
Moderates, Olozaga’s advice to the Queen to legalize the marriage
of her mother with Don Fernando Muñoz was a step of good policy.
The ceremony in the chapel of the royal palace was celebrated by
the Patriarch of the Indias.
 The husband was endowed with the decorations and dignities of
his position, and the Queen published the following decree:

“With due regard to the weighty reasons set forth by my august

mother, Doña Maria Cristina de Bourbon, I have authorized her, after
listening to the counsel of my Ministry, to contract a marriage with
Don Fernando Muñoz, Duke of Rianzares, and I declare that the fact
of her contracting this marriage of conscience, albeit with a person of
unequal rank, in no way lessens my favour and love; and she is to
retain all the honours and prerogatives and distinctions due to her as
Queen-mother. But her husband is only to enjoy the honours,
prerogatives, and distinctions, due to his class and title; and the
children of this marriage are to remain subject to Article 12, of Law 9,
Title 11, Book 10, of the Novisima Recopilacion, being able to inherit
the free property of their parents according to the laws.
“Signed by the Royal Hand
and the Minister of Grace and Justice,
“Luis Mayans.
“Given in the Palace,
“October 11, 1844.”

Wherever the young Queen appeared with her sister in the

country, their simple, unsophisticated ways filled the people with love
and admiration. One day, being only accompanied by two Ladies-in-
Waiting, they went to a village fête not very far from San Sebastian.
“Do you come from San Sebastian?” asked the peasants, with
the freedom characteristic of the country-folk in Spain.
“Yes, we do,” replied the Queen.
“And do you belong to the military?”
 “No,” said the Queen, repressing a smile, “we are not military
people.”
“But at least you are Castilians?”
“Yes,” returned the Queen promptly; “we are girls from Madrid.”
“And do you like this part?” queried the interlocutor.
“Very much,” replied the Queen. “It is very cheerful.”
“Well,” continued the peasant, with frank familiarity, “sit down a bit
and see the lads dance.”
“Thank you very much,” replied the Queen, “but we must be
going.”
“You will have noticed,” rejoined the peasant, “that the roads are
very bad, and you will get very tired. These mountains are only fit for
strong feet, and not little delicate ones like yours.”
“Never mind,” returned Isabel; “we like to accustom ourselves to
everything. You don’t know, then, who we are?”
“It is not easy to guess,” was the answer; “but you are certainly
daughters of people of position and money.”
Then Isabel said: “I am the Queen.”
“The Queen! the Queen!” cried the people with delight; and cider,
fruits, and cakes, were pressed upon the royal party.
The Queen and her sister received constant signs of affection in
the neighbourhood of Guipuzcoa. They went to Pampeluna to
receive the Duke and Duchess of Nemours and the Duke of Aumale,
the arrival of the distinguished French guests was celebrated in the
city by a magnificent banquet and bull-fight, and the distinguished
Frenchmen stayed with the Count of Ezpeleta.
The fall of Miraflores, the able Prime Minister, was heralded by
the evident desire of both the Queens for a change of Ministry, and
those who wished to compass the fall of the Prime Minister were
listened to by the royal ladies.
Miraflores found Queen Isabella alone one day in the palace, and
Her Majesty said to the Minister:
“I have heard that the scandal this afternoon in the Congress has
been so great that the President of the Congress put on his hat in his
want of consideration for the Court.”
Miraflores explained that this act proceeded from no want of
respect for the Cortes.
“Nevertheless it must be dissolved to-morrow,” was the reply.
Narvaez became Minister of War as well as President of the
Congress. The part played at the palace in the change of Ministries
is seen in the scene between Pacheco and the Queen-mother.
Maria Cristina remarked to the Minister that the Government
would not last long. Upon this Pacheco placed two ounces of gold
upon the mantelpiece, saying:
“I bet you that money that the Cabinet will not fall to-morrow as
you say.”
Whereupon the Queen took another two ounces from her purse,
and placing them beside those of the diplomat, she said:
“The bet is made: if the Ministry does not fall to-morrow, the
money is yours; if it does, it is mine.” And the Ministry did fall.
This insidious influence of the camarilla was daily becoming more
dangerous. Presumptuous and illegal, it held its sway over all that
was prudent and constitutional, and thus the intrigues of the palace
came between the Cortes and the throne, and the country and the
Queen, exercising power to the detriment of the national
representation, the throne, the nation, and the Sovereign. “The royal
palace,” says Don Antonio Bermejo, “was a gilded cage where men
were slaves to envy and idleness.”
 CHAPTER IX
ROYAL MATRIMONIAL SCHEMES—HOW ISABELLA’S SISTER FLED FROM
PARIS IN 1848

1843–1848

Isabella’s marriage was now a burning subject of discussion and

intrigue. The objection offered to her marriage with one of the sons
of the Infanta Luisa Carlota was the hatred reigning between the
mother of the proposed bridegroom and Queen Maria Cristina.
Louis Philippe of France had also his own designs in these
marriage prospects, and would fain have united the Dauphin to the
young Queen. But, as we know, England put her veto upon this
alliance, as it would have upset the balance of European power; so
the French King had to be contented with the marriage of his
younger son, the Duke of Montpensier, with Isabel’s sister Luisa
Fernanda.
There was a strong party in favour of the Queen’s marriage with
the Count of Montemolin, son of Don Carlos, as this union would
have put an end to the rivalry reigning between these two branches
of the Royal Family.
But finally attention was turned to the sons of Don Francisco de
Paula as the most suitable candidates for the hand of the Queen.
Miraflores explains that it was natural for the Duke of Cadiz, the
eldest son of the Infante, to be preferred by the existing Cabinet in
Spain and the Queen-mother, as he was a quiet, judicious Prince,
who had accepted and fulfilled with honour the post of Colonel of a
cavalry regiment; whilst Don Henry was of a turbulent disposition,
whose conduct left much to be desired at the Court of the Queen-
mother, to whom he had written from Bayonne very disrespectfully,
and in Brussels he had distinguished himself by publishing ideas
which bordered on being revolutionary.

I S A B E L L A I I ., Q U E E N O F S PA I N

After a Painting by De Madrazo

Whilst the royal party was at Pampeluna a mysterious document

in French fell into the hands of the Minister of Foreign Affairs, signed
“Legitimista.” The document ran thus:

“To the Minister of Foreign Affairs.

“Before the Duc de Nemours and the Duc d’Aumale left Paris as
the emissaries of His Majesty the great ‘Père de famille,’ French
legitimists knew that the meeting at Pampeluna was merely a matter
of form. The Duc d’Aumale cannot be the husband of Doña Isabel;
his father knows it; M. Guizot and M. Bresson know it; and the
Queen, wife of the Citizen-King, knows it, and she is the most
strongly opposed to the union.
“The Duc de Montpensier will be the husband of the Infanta; this
is what is arranged, and what will take place. The Citizen Louis has
made a plan by which he thinks that in time Montpensier will occupy
the throne of Spain by the side of the immediate heiress, Luisa
Fernanda, because experienced doctors in medicine have declared
to Bresson that the Queen is very ill with an hereditary disease which
will take her to the grave. Why has not the Princess got it? That is a
mystery which time will reveal. Who will give his hand in marriage to
Queen Isabel? We hear that the candidature of Prince Henry is in
favour. But this illustrious youth cannot be the husband of the
Queen, neither can his brother, Don Francisco de Asis.
“The Minister whom I have the honour of addressing is ignorant
of the reason, and I can give it to him.
“The Minister must know that when Princess Luisa Carlota was
on her death-bed she did not, even in this sad moment, forget the
troubles of her sister; and impelled by conscientious scruples, she
sent for her illustrious sons, and, taking them each by the right hand,
she said these solemn words to them, in a sad tone and with a
tenderness which was truly Christian: ‘My sons, I wish to reach
heaven, I wish to quit you and the world without remorse, and
therefore I declare I repent having contributed through imprudent
affection to thwarting the legitimate succession of the Crown of
Spain, and this I swear on my salvation. So I command you as a
mother, as a Princess, and as a repentant sinner, to swear that
neither of you will aspire to the hand of Isabella.’”

Narvaez showed that this document was a fraud, as, at the death
of the Infanta, Don Henry was at some distance from Madrid, and
Francisco was at Pampeluna.
Isabella’s own feelings about her marriage were hardly taken into
consideration at all. As a matter of fact, she had been more inclined
to Prince Henry, the younger son of Doña Luisa Carlota, than to
Francisco, and it will be remembered that even as a child she had
admired the portrait of the Prince, which had been secretly sent by
the mother to the young Queen; but inclination had no part in the
negotiations, which were regulated entirely by self-interest and
policy, so the tide of influence was soon seen to be in favour of the
eldest son of Prince Francisco de Paula.
Don Henry was furious when he found he was left out in the cold
in the negotiation for the marriages of Isabella and her sister.
In a letter to Bulwer Lytton he writes:

“The old man at the Tuileries is very delighted and pleased. He

has written three letters full of hypocritical words, telling the great
Mama that she has drawn the first prize, and that she is very
fortunate to be marrying her daughters to Paquito (Francisco) and
Montpensier. A French fellow has arrived at the palace. You will
recollect that I told you before last night that, judging from the
appearance of things, you and I were going to have our noses put
out of joint.
 “Istarez is very pleased. Cristina is delighted, and from what I
hear the weddings will take place very soon. When I see you I will
give you more particulars, which I cannot trust to the pen.”

The Queen-mother had been inclined to the idea of the Count of

Trapani, her brother, who had been educated in a Jesuit college at
Naples, as her son-in-law; but, as this idea had not been welcome to
the Government, attention had again been turned to one of the sons
of the Infante Don Francisco de Paula. Don Francisco, Duke of
Cadiz, the eldest, was favoured by France, whilst England gave
preference to Don Henry, Duke of Seville. As Miraflores says, it was
natural for the Queen-mother to prefer the eldest son of Don
Francisco, as he was a quiet Prince and one who had fulfilled his
duties with credit as Colonel of a cavalry regiment; whilst Don Henry
was of a more turbulent nature, and his antagonistic conduct to the
Queen-mother had excited some disturbance in the palace. In the
letters he sent from Brussels to Madrid he had manifested a
revolutionary spirit, which filled the Moderates with alarm. However,
poor Isabel preferred this hot-headed Prince to his more peaceful-
minded brother, and long were the arguments the young Queen held
with her mother against the project of her union with the elder
brother. Fortunately, however, the young Queen seemed somewhat
pleased with the appearance of Don Francisco, and at the fêtes
given in honour of the engagement she seemed very cheerful.
In an interview with Queen Maria Cristina, Bulwer Lytton said: “I
can understand your joy as a mother at seeing your eldest daughter
destined for a Prince who will make for the happiness of the royal
domestic hearth; but as to the marriage of the Infanta——”
Here Cristina interrupted him, saying: “It is decided that her union
with Montpensier will take place on the same day as that of the
Queen.”
 The Duke of Rianzares had evidently favoured the alliance of the
Princess Luisa Fernanda with the Duke of Montpensier, for when the
matter was fully arranged Louis Philippe wrote to Queen Maria
Cristina:
“Please give my kind regards to the Duke of Rianzares, and
thank him for the part he has taken in the matter I have so much at
heart.”
So France and her supporters in Spain gained the day, and the
double wedding of the young sisters was fixed for October 10, 1846.
It was with all the magnificent state for which the Court of Spain is
famed that the reception by Isabel and Fernanda took place at the
palace (for the publication of the marriage contracts) in the Salon of
the Ambassadors. Alexandre Dumas was among the distinguished
Frenchmen accompanying the bridegroom of the Infanta Fernanda,
and the great author attended a bull-fight with the noblemen as
toreadors, and the fêtes all the week were of surpassing splendour.
The religious ceremony itself was held in the Church of Atocha
with all imaginable pomp and splendour. The Patriarch of the Indias
received the brides at the door of the church, and noticeable among
the French guests was Alexandre Dumas, author of “The Three
Musketeers.” All the Diplomatic Corps were there with the exception
of the English.
In the ceremony the Patriarch placed upon the open palms of the
Queen’s bridegroom the thirteen pieces of money pledged as his
dowry, which was then passed by the bridegroom to the hands of his
bride, saying, “This ring and this money I give you as a sign of
marriage,” and the Queen replied, “I accept them.”
The same ceremony was used with the Infanta and her
bridegroom, and then the prelate, with his mitre and crook, escorted
the royal couples to the altar, and there read the Mass. During the
Epistle the Patriarch presented the candles, veils, and conjugal yoke,
and at the conclusion of the Gospel the Patriarch turned to the
Queen and her bridegroom, and said to the latter: “I give Your
Majesty a companion, and not a servant; Your Majesty must love her
as Christ loves His Church.” And then the same words were said to
the other couple. The periodical which published this account of the
wedding remarked that the Queen and her husband looked smiling
and pleased, but the Infanta looked sad.
The attempt on the life of the Queen soon after her marriage
caused great excitement, and the trial of Angel de la Riva, a native of
Santiago, in Galicia, and editor of a paper called El Clamor Publico,
who was caught just after firing the shot, was followed with the
deepest interest.
The testimony of Don Manuel Matheu, officer of the Royal Guard
of Halberdiers, a man of thirty-five years of age, gives some idea of
the etiquette of the time.
He declared that on May 4, 1847, he was on duty, so when the
Queen returned from her drive he went as usual to receive her at the
foot of the staircase with his little company of six halberdiers, and a
Captain with a lamp, and two other attendants with their axes. On
descending from the carriage, Her Majesty said to him: “Do you
know that on passing through the Calle de Alcalá two shots were
fired at me.”
The officer returned: “Two shots at Your Majesty?”
“Yes,” was the reply; “you cannot doubt it; I saw them get down
from a carriage or cab.”
The Colonel was not aware if Her Majesty said an open carriage
or a shut one.
“I felt something,” she added, “pass over my forehead which hurt
me.”
 “And as this was evident,” continued the officer, “I could but give
credit to Her Majesty’s words. Moreover, Her Highness the Infanta
Doña Maria Josefa added: ‘There is no doubt of the fact, for I myself
saw the men.’”
Then Her Majesty told the witness he was to inform the Ministers
of what had happened. This he did, leaving a message at the door of
the Secretary of State, and sending a halberdier to inform the
Minister of War.
It is not necessary to give further particulars of the long trial of the
accused. He was, as we know, first condemned to be beaten to
death, and being saved from this dreadful fate by the able defence of
Perez Hernandez, he was in November, 1847, condemned to twenty
years’ imprisonment. But on July 23, 1849, the Queen showed her
generous spirit by commuting the sentence to four years’ exile from
Madrid and all the royal resorts, as Her Majesty nobly gave full
benefit to the representation of the murderous lawyer’s madness, or
the influence exercised by others.
In the rapid and unexpected flight of the French Royal Family
from the Palace of the Tuileries, Princess Clementina, wife of the
Duke of Saxony, and the Duchess of Montpensier, were separated
from the King and Queen. When the Duke of Montpensier
accompanied his father to the carriages waiting for them in the Place
de la Concorde, he thought he would have no difficulty in returning to
fetch his wife, who had been confined for some days in her
apartments on account of her interesting condition of health. But the
crowds which had collected meanwhile in the gardens made it
impossible for the Prince to return to the palace. He had fortunately
left the Princess in the care of some of his suite and Monsieur Julio
de Lasteyrie, who was distinguished for his loyalty and popularity. So
the Duke mounted his horse and followed his father.
 Directly Monsieur Lasteyrie saw that the palace was invaded, he
gave his arm to the Duchess of Montpensier, and in the confusion of
the moment they passed unnoticed from the gates and mingled with
the crowd. Monsieur de Lasteyrie hoped to arrive in time to put the
Princesses into the royal carriages, which, however, started off at a
gallop just as they arrived within sight of them.
So Lasteyrie escorted the royal ladies to the house of his mother.
In a few minutes Princess Clementina left the timely refuge, and
continued her way to the Trianon, where she met her father; whilst
the Duchess of Montpensier remained for the night under the
protection of Madame de Lasteyrie.
There she heard from her husband at Dreux that she was to join
him at the Castle of Eu, whither the King was going.
But the monarch found it impossible to get to this haven, so when
the young Princess arrived there the following day she found the
place deserted. Hearing an alarming rumour that a party of workmen
were coming to pillage the Palace of Eu, as they had ransacked the
one at Neuilly, the Duchess quietly left the place, and repaired to the
house of Monsieur Estancelin, a diplomat of the Bavarian Embassy.
Under the escort of this gentleman and that of General Thierry she
started off for Brussels. On passing through Abbeville, the sight of
the carriage attracted attention, and the people cried: “There are
royal fugitives in that coach!” Monsieur Estancelin put his head out of
the window, and, as his name was known in the district, he declared
that the lady was his wife, and he was going abroad with her. To put
the people off the scent, he then gave orders to the postilion to drive
to the house of a friend of his, well known for his republican opinions.
Arrived at the house, Estancelin whispered in the ear of his friend the
name and rank of the lady under his escort.
But the man, in fear of the consequences of the discovery of the
secret, declined to give his aid in the matter, in spite of all arguments
of both gentlemen in charge of the Princess, setting forth the
dreadful consequences of her being frightened or subjected to
imprisonment in her delicate condition.
It was all in vain; the republican declined to receive the Princess,
and they had to turn away from the door in despair, for several
people had gathered in front of the house, curious to see who could
be seeking shelter at such a late hour.
So Monsieur Estancelin bade General Thierry conduct the lady
out of the town by a particular gate leading to the bank of the river,
whilst he went in search of other friends, who might aid him to get
fresh horses and a carriage with which he would meet them.
So the poor Princess started forth with her military ally.
Unfortunately, the gate of the town led through a narrow exit only
meant for pedestrians. So they wandered along in the cold rain,
picking their way over the stones and rubbish of this out-of-the-way
road. The General, alarmed at the drenched condition of the
Princess and her evident exhaustion and fatigue, decided that he
had better let her sit on a stone to rest, whilst he went in search of a
guide or a refuge.
The officer hastened along the road, fearing to call the attention
of the enemy to the lady in his care, and yet anxious to get a guide to
the rendezvous appointed by Estancelin. Finally, to his delight, he
was accosted by a friend of Estancelin, who had sent him in search
of the couple, and, quickly returning to the Princess, they escorted
her to the carriage which was waiting on the highroad to Brussels.
“What dreadful adventures this awful night!” exclaimed General
Thierry, as the Duchess of Montpensier sought to recover one of her
shoes which had slipped off her weary wet feet in the mud.
“Never mind,” returned the brave Princess; “I prefer these
adventures to the monotony of the round table of work in the
sumptuous salons of the Tuileries.”
The relief with which the letter announcing the safety of her sister
was received by Queen Isabella can well be imagined, as in those
days the limited communication by telegraph was stopped on
account of the fog.
The fall of Louis Philippe relieved England of the fear of the upset
of the balance of European power from the astuteness with which he
had arranged the marriages of the Spanish Queen and her sister.
There was no doubt of the intentions which had led to the Duke
of Montpensier being the brother-in-law of the Queen, and the
unsuspicious girl was a prey to the reports which were spread by the
ambitious Orleanists.
 CHAPTER X
A ROYAL QUARREL AND THE RECONCILIATION

It was soon seen that General Serrano’s influence with the Queen
surpassed the ordinary grade, and the Moderates were alarmed.
There were two parties in the royal palace—one on the side of
the Queen, and the other on that of the King; and the leaders of
these parties fostered the difference between the royal couple.
Francisco Pacheco, the King’s partisan, declared that a President
of the Congress was wanted who would give more independence to
the Crown, and who would receive the counsels of an intelligent
husband of the Sovereign; for the King-Consort should not be in a
position so secondary to that of the illustrious mother-in-law that she
can boast of having more power than he has.
When Isabella saw that Queen Maria Cristina’s influence in the
State was much resented by the Ministers, she advised her to go on
a visit to her daughter, the Duchess of Montpensier, and this counsel
was followed.
However, the want of union between the King and Queen was
soon evident to the world, and when it was announced that Isabella
was going to spend the rest of the summer at Aranjuez alone, whilst
the King remained in Madrid, it was seen that the Serrano influence
had become serious enough to cause a separation between the
royal couple. Isabella’s naturally good heart seemed softened when
she was leaving the palace, and it was evidently remorse which
prompted her to look anxiously back from the carriage, in search of a
glimpse of the husband at one of the windows of the royal pile. But
the coach rattled on, and the Queen’s search was in vain; whilst her
sad face, with its traces of tears, showed that things might have
been better had not the differences of the royal couple been
fostered, for their own ends, by intriguers of the camarilla.
Forsaken by his wife, Francisco followed the advice of his friends,
to enjoy himself in his own way; so he repaired to the Palace of the
Pardo, where banquets, hunting-parties, and other festivities
deadened his sense of injury at his wife’s conduct.
Those interested in the welfare of the land were disappointed
when the birthday of the Queen was celebrated by her holding a
reception alone at Aranjuez, whilst the King had a hunting expedition
at the Pardo. The Ministers came to the reception at Aranjuez, and
then promptly returned to the capital, leaving the Queen with her
trinity of Bulwer, Serrano, and Salamanca. General Salamanca was
at last sent by the King to Aranjuez to advise Isabella to return, but
she would not accept the condition of a change in the Serrano
position.
This refusal made the King decline to assist at the reception of
the Pope’s Nuncio at Aranjuez, and he was forbidden to return to the
royal Palace of Madrid.
Benavides, a courtier, anxious to heal this unhappy division in the
Royal Family, came to Francisco, and said:[16]
“This separation cannot go on; it is not good for the Queen or for
Your Majesty.”
[16] “Estafeta del Palacio Real,” Bermejo, vol. ii.

“That I can understand,” returned the King; “but she has chosen
to outrage my dignity as husband, and this when my demands are
not exaggerated. I know that Isabelita does not love me, and I
excuse her, because I know that our union was only for State
reasons, and not from inclination; and I am the more tolerant as I,
too, was unable to give her any affection myself. I have not objected
to the course of dissimulation, and I have always shown myself
willing to keep up appearances to avoid this disgraceful break; but
Isabelita, either from being more ingenuous or more vehement than I
am, could not fulfil this hypocritical duty—this sacrifice for the good
of the nation. I married because I had to marry, because the position
of King is flattering. I took the part, with its advantages. I have no
right to throw away the good fortune which I gained from the
arrangement. So I made up my mind to be tolerant, if they were
equally so with me, and I was never upset at the presence of a
favourite.”
Here the King was interrupted by Benavides saying:
“Allow me, Sire, to observe one thing. That which you now say
with regard to tolerance of a favourite is not in accordance with your
present line of conduct, for do you not demand the withdrawal of
General Serrano before agreeing to the reconciliation we are
asking?”
Then, with a singular calmness, the King returned:
“I do not deny that this Serrano is the main drawback to an
agreement with Isabelita, for the dismissal of the favourite would be
immediately followed by the reconciliation desired by my wife; but I
would have tolerated him, I would have exacted nothing, if he had
not hurt me personally by insulting me with unworthy names, failing
in respect to me, and not giving me proper consideration—and
therefore I hate him. He is a little Godoy, who has not known how to
behave; for he at least got over Charles IV. before rising to the
favour of my grandmother.”
 The Minister of the Government listened with astonishment to the
King’s words. Don Francisco saw it, and continued:
“The welfare of fifteen million people demands this and other
sacrifices. I was not born for Isabelita, nor Isabelita for me, but the
country must think the contrary. I will be tolerant, but the influence of
Serrano must cease, or I will not make it up.”
Benavides replied that the Ministry deplored this unhappy
“influence,” which was getting burdensome to the Queen herself; but
Serrano had such a fatal ascendancy everywhere, and had won over
to his side the opposing elements, that any sudden step to put an
end to the evil would result in deplorable consequences for the
nation. “However, the Ministry has decided to get rid of this
pernicious influence,” continued Benavides. “It is seeking a way to
do so without a collision and its consequences; and one of the things
which would help to this course of the Cabinet would be the
immediate reconciliation of Your Majesties, as the preliminary to the
other steps which will lead to Serrano’s overthrow.”
The King refused. He said that his dignity demanded the
withdrawal of the “influence.” Fresh evident proofs had been given
that this hateful man was the cause of the Queen’s separation from
him, and therefore he was not inclined to go back from his word
about him.
So Pacheco and all the other Ministers, excepting Salamanca,
determined to resign if Serrano did not retire from the Court.
Benavides and Pacheco were among the deputation who
petitioned the favourite to agree to this step, but it was in vain. The
Ministers went backwards and forwards to La Granja without gaining
their purpose. Finally, in pursuance of the Pope’s advice, the Queen
decided to return to Madrid; and Salamanca, as Prime Minister, went
to the Escorial to report the fact to Bulwer.