Free Vascularized Fibular Graft Research Articles

Vascular bundle transplantation combined with porous bone substituted scaffold for the treatment of early-stage avascular necrosis of femoral head

Various reasons leading to disruption of blood supply will result in avascular femoral head necrosis. Decompression of lesion area, structural support to subchondral bone, and rebuilding of blood supply system are the keys for a successful hip preserve surgery. Reconstruction of local vascular network is always a huge challenge in clinical. Based on tantalum rod implantation and free vascularized fibular grafting, we propose the combined application of vascular bundle transplantation and porous bone substitute scaffold implantation as a potential novel treatment method. It may simultaneously achieve decompression, support and blood supply reconstruction. The hypothesis provides some new ideals and possibilities for solving this clinical problem of femoral head necrosis.

Vascularized Fibular Grafting in Treatment of Femoral Neck Nonunion: A Prognostic Study Based on Long-Term Outcomes.

The purpose of this study was to evaluate the long-term efficacy and prognostic factors predicting success of revision surgery with free vascularized fibular grafting (FVFG) for treatment of femoral neck nonunion. We prospectively enrolled patients who underwent revision surgery with FVFG between January 2001 and January 2013 in a tertiary hospital in China. A total of 98 patients with a minimum 5-year follow-up were included for analysis. The criteria for FVFG failure were conversion to hip arthroplasty, recommendation for a hip arthroplasty, or a Harris hip score of <80 points. Demographic information, the preoperative neck shortening ratio (NSR), the fixation method, and postoperative radiographic parameters including the postoperative NSR and neck-shaft angle (NSA) were recorded for prognostic analysis. At an average of 9.8 ± 3.5 years (range, 3 to 17 years) postoperatively, the overall success rate of this surgical procedure was 77% (75 of 98). The success and failure groups had no significant differences in age, fixation method, interval between initial fixation and revision surgery, or postoperative NSA. The success group had a significantly higher NSR than the failure group both preoperatively (77.8% versus 62.4%, p < 0.001) and postoperatively (87.6% versus 78.4%, p = 0.001). The receiver operating characteristic (ROC) curve analysis revealed an optimal cutoff for preoperative NSR of 60% to predict the outcome. Patients with a preoperative NSR of >60% had a success rate of 91% (68 of 75). Revision surgery with FVFG and internal fixation is an effective and important option for treating nonunion of the femoral neck in young patients without severe preoperative shortening and neck resorption (preoperative NSR of >60%). Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Effectiveness of free vascularized fibular graft for bone defect after resection of lower limb malignant tumor

To analyze the effectiveness of free vascularized fibula grafts (FVFG) for extensive bone defects after resection of lower limb malignant bone tumors. Between November 2015 and July 2018, 15 cases of lower limb malignant bone tumors were treated. There were 12 males and 3 females with an average age of 12.3 years (range, 9-21 years). There were 11 cases of osteosarcoma and 4 cases of Ewing's sarcoma. The tumor located at middle femur in 8 cases, lower femur in 4 cases, and middle tibia in 3 cases. The disease duration was 2-6 months (mean, 3.2 months). The tumor was completely removed, and the length of the bone defect was 8-23 cm (mean, 17.7 cm). The bone defect was repaired by FVFG, and combined inactivated tumor bone was used in 8 cases of femoral bone defect. The average operation time was 280 minutes (range, 180-390 minutes). The average blood loss was 310 mL (range, 200-480 mL). All incisions healed by first intention. All patients were followed up 2-24 months with an average of 14.5 months. Bone healing achieved in all patients at 9-18 months (mean, 12.3 months) after operation except 1 patient which was followed up only 2 months. The fibula grafts had active metabolism and the average bone metabolism score was 184 (range, 111-257) in effected side and 193 (range, 127-259) in contralateral side. There was no difference between bilateral sides. The average Enneking score was 24.6 (range, 20-30) at last follow-up. No ankle instability or paralysis of common peroneal nerve occurred. FVFG appeared very efficient in repair of extensive bone defect after resection of lower limb malignant bone tumor.

Metal trabecular bone reconstruction system better improves clinical efficacy and biomechanical repair of osteonecrosis of the femoral head than free vascularized fibular graft: A case-control study.

In this study, we aim to compare and analyze the biomechanical repair and clinical efficacy of osteonecrosis of the femoral head (ONFH) with the use of metal trabecular bone reconstruction system and free vascularized fibular graft. The study enrolled 66 adult patients from medical records of nontraumatic ARCO 2A-3B stage ONFH. A simple ONFH model without surgical treatment was established in 13 cases, 29 cases were treated with metal trabecular bone reconstruction system, and 24 cases were treated with free vascularized fibular graft. Computer-recognized and extracted femur outlines were imported, and three-dimensional reconstructions were performed. The stress concentration and stress peak value were analyzed, and the Harris score, visual analog scale pain score, and operation status of the above patients were compared. Finally, quality of life assessment was performed using SF-36 scale. Metal trabecular bone reconstruction system provided less operation time, blood loss, and the total length of postoperative hospital stay than free vascularized fibular graft. Metal trabecular bone reconstruction system promoted bone reconstruction, increased bone mineral density and Harris score. The total clinical effective rate of young patients (20-40 years) was higher than that of older patients (41-60 years). Metal trabecular bone reconstruction system provided higher physical component summary, mental component summary, and role/social component summary than free vascularized fibular graft. This study demonstrates that both metal trabecular bone reconstruction system and free vascularized fibular graft can prevent or delay the progression of ONFH, while metal trabecular bone reconstruction system is a better choice because of better short-term clinical efficacy.

Treatment of Large Bone Defect of Long Bones: Comparison of Free Vascularized Fibular Graft with Compression-Distraction Technique

We treated 18 patients with congenital pseudarthrosis of tibia and 27 patients with acquired bone loss. Out of 18 cases of congenital pseudarthrosis of tibia the free vascularized fibular grafts (FVFGs) were performed in 16 cases and compression-distraction techniques in 2 cases. In patients with angular deformities and shortenings in the lower leg soft tissue distraction and correction were conducted. The mean soft tissue distraction period was 78.4 days, the length of bone defect 10.7 cm, the mean operative time 3.2 hours, and primary bone healing achieved in 12 cases. The mean union period was 7.3 months and the mean period of full weight bearing was 10.8 months. In 4 cases pseudarthroses and deformities developed and healed secondarily, and the treatment period ranged from 16 months to 26 months. The mean length of bone defects was 9.7 cm and the mean period of full weight bearing 14 months. The mean length of bone defects in the group of Ilizarov technique was 6.6 cm, the mean period of distraction 82 days and the mean period of full weight bearing 12.2 months. The complications include pseudarthrosis, refracture, angular deformity, equinovarus and temporary peroneal nerve palsy in the FVFG group and in the group of compression-distraction technique, refracture, equinovarus and temporary peroneal nerve palsy. The FVFG is suitable for the treatment of pseudarthrosis in young patients and the compression-distraction technique is effective option for the treatment of bone defects of patients with infection and deformity.

Congenital Forearm Pseudarthrosis, a Systematic Review for a Treatment Algorithm on a Rare Condition.

A congenital forearm pseudarthrosis is a rare condition and is strongly associated with neurofibromatosis type 1. Several surgical techniques are described in the literature, but the most optimal treatment strategy remains unclear. This systematic review aims to develop a treatment algorithm that may aid in clinical decision making. The PROSPERO registration number for this study was CRD42018099602 and adheres to the PRISMA guidelines for systematic reviews. Embase, MEDLINE, Cochrane Central, Web of Science, and Google Scholar databases were searched for published studies reporting on congenital forearm pseudarthrosis not related to other underlying pathologies like bacterial infection or fibrous dysplasia. Results were not restricted by date or study type, only English literature was allowed. Studies were assessed for quality using the critical appraisal checklist for case reports from the Joanna Briggs Institute. Patient characteristics, underlying disease, type of surgery, union rate, and functional outcome were extracted from included studies. Of 829 studies identified, 47 were included in this review (17 case series and 30 case reports, a total of 84 cases). A one-bone forearm procedure showed highest union rates (92%), however, it results in loss of forearm rotation. Free vascularized fibula grafting showed high union rates (87%) and was related to good functional outcome of elbow flexion and forearm rotations. Other procedures showed disappointing outcomes. Congenital forearm pseudarthrosis is best treated with a free vascularized fibula grafting, a one-bone forearm procedure should be used as a salvage procedure. Evidence extracted from the case reports was sufficient to generate a treatment algorithm to be used in clinical pediatric practice. Level IV-therapeutic.

Regenerative techniques in the management of post-traumatic segmental bone defects at a level one trauma center

Introduction: Segmental loss of bone after traumatic injury can be managed with primary amputation or attempted limb salvage with bony regeneration. We aimed to describe our experience of treating traumatic bone loss at a tertiary level one trauma center and propose an approach to help in the treatment of these patients. Methods: Ten patients were identified via a search of the hospital's medical records covering a 5-year period. Each patient was then retrospectively reviewed with injury factors, treatment options, and final outcomes. Each patient was treated based on an anatomic approach developed by the unit to manage segmental bone loss. Results: Of the patients who underwent bony regeneration, we had four distal tibial fractures: three in the upper limb and one distal femoral fracture. Both primary amputation patients had tibial fractures. The mean bone loss was 88.5 mm. We employed bone transport in four cases, Masquelet in two, a free vascularized fibular graft and soft-tissue flap in one instance, and a combination of free vascularized fibula graft and Masquelet in another case. All patients achieved union, although the mean time to union in smokers was 1403 days, compared to 499 days in nonsmokers. Complications included three returns to theater for bone grafting and three recurrent soft-tissue infections. Post regeneration, the patients had a mean Short Form-36 score of 54.2, and most of the patients were “very satisfied” with the outcome of their surgeries. Conclusion: The regeneration of bone after traumatic loss is onerous on patients, is demanding for clinicians, and requires significant health resources. It should only be considered with appropriate patient buy-in and in the absence of contraindications.

Comparison of Pediatric Intercalary Allograft Reconstructions with and without a Free Vascularized Fibula.

Lower extremity intercalary allograft reconstruction has traditionally been used to facilitate limb salvage. Combining the allograft with a free vascularized fibula graft has been described; however, there is a paucity of data comparing the outcome of these reconstructions. Twenty-nine pediatric patients (15 boys and 14 girls) underwent lower extremity limb salvage with the use of intercalary cadaveric allograft at a mean age of 12 years. The most common diagnosis was osteosarcoma (n = 18). Patients underwent reconstruction with an allograft alone (n = 11) or supplemented with a free vascularized fibula graft (n = 18). The mean time to union of the allograft was 11 months, with 10 patients requiring additional bone grafting. There was no difference in the need for an additional bone graft (OR, 0.87; p = 1.0) between patients with a free vascularized fibula graft and those without. The allograft was revised in three patients because of fracture (n = 2) and fracture and infection (n = 1). In all of these patients, the allograft was not supplemented with a free vascularized fibula graft (p < 0.001). Five patients underwent an amputation, most commonly for disease recurrence. At last follow-up, the mean Mankin and Musculoskeletal Tumor Society rating was 90 percent, with 19 patients (66 percent) who achieved a "good" or "excellent" outcome according to the Mankin score. Use of an intercalary allograft to reconstruct a lower extremity provides a durable means of reconstruction; however, supplementation with a free vascularized fibula graft reduces the risk of allograft revision. Therapeutic, III.

Long-term follow-up of fibular graft for the reconstruction of bone defects.

The use of fibular graft for the reconstruction of bone defects has been demonstrated to be a reliable method. The aim of this study was to assess the clinical outcome of graft union, functional outcome (hypertrophy of the graft bones) and complications of both non-vascularized and vascularized grafts.From 1981 to 2015, 10 patients were treated using non-vascularized fibular graft or free vascularized fibular graft. The outcomes were bony union time, graft hypertrophy and complications based on radiograph and functional outcomes according to the Musculoskeletal Tumor Society (MSTS) score. Mobility of the ankle at the donor site was evaluated using the Kofoed ankle score system.This study included 10 patients with an average follow-up of 6.8 years. The union rate for all patients was 100%. The mean union time was 21.3 weeks for vascularized fibular grafts and 30.5 weeks for non-vascularized fibular grafts (P = .310). There was a significant difference between the upper limbs and the lower limbs regarding hypertrophy of the grafts in 5 patients (P = .003). The mean MSTS score in 10 patients was 84% (range 53%–97%). Stress fracture of the graft occurred in 1 patient. Donor site complications, including valgus deformity and length discrepancy, between 2 legs occurred in 2 patients who were under 18 years of age at the time of operation (P = .114). The mean Kofoed score was 96.8 (range 88–100).A greater increase in hypertrophy of grafts was observed with reconstruction in the lower limbs. There was no difference in MSTS score between these 2 types of grafts. Children were more likely to experience the valgus deformity at the donor site after harvesting the fibula. Keeping at least the distal 1/4 of the fibula intact during the surgery is a valid means of ensuring ankle stability at the donor site, and children should be considered for prophylactic distal tibiofibular synostosis creation to prevent the valgus deformity of the ankle at the donor site.

Outcomes of Conversion Total Hip Arthroplasty From Free Vascularized Fibular Grafting

BackgroundConversion total hip arthroplasties (THAs) from prior free vascularized fibular grafting (FVFG) are infrequently reported in the literature. We characterized the perioperative outcomes of patients undergoing conversion THA and compared them with those of a matched cohort of patients undergoing primary THA for osteonecrosis of the femoral head and neck (ONFHN). MethodsThe institutional database was queried for patients with FVFG requiring conversion to THA. This cohort was then matched 1:1 for age, gender, and American Society of Anesthesiologists (ASA) score for patients with ONFHN undergoing primary THA. Medical records were reviewed for intraoperative and postoperative complications, which were then compared between conversion and primary THA patient cohorts. ResultsTwo hundred eighty-eight THA patients were included for analysis (144 patients with FVFG matched to 144 patients with ONFHN and no prior FVFG). Patients with prior FVFG who underwent THA had significantly greater operative time and blood loss (P < .001). Although not significant, there were more intraoperative fractures in the FVFG cohort (P = .053). Postoperatively, patients with FVFG had significantly greater blood transfusions (P < .001) and hematoma formation (P = .004) than the matched cohort. There was no difference in length of stay, discharge disposition, or venous thromboembolism; however, patients who underwent conversion THA showed increased deep infection (P = .044) and rate of return to the operating room (P = .010). ConclusionAlthough there are numerous treatment strategies for patients with ONFHN, many patients will ultimately require THA. Patients undergoing conversion after FVFG are more likely to have complications including increased blood loss, hematoma formation, and intraoperative fractures. Consequently, surgeons should concentrate on preoperative optimization and prepare for specific technical challenges.

Abstract: Free Vascularized Fibula Grafting in the Operative Treatment of Malignant Bone Tumors of the Upper Extremity: A Systematic Review of Outcomes and Complications

BACKGROUND AND OBJECTIVES: Vascularized bone grafting after tumor resection can be an important component in the treatment of bony neoplasms of the upper extremity. The radiographic, clinical, and patient-centered outcomes following VBG of the upper extremity have been reported in several studies; however, no large-scale analysis of outcomes has been performed and no standardization of reporting exists. The purpose of this study was to determine the outcomes of free vascularized fibula grafting (FVFG) in the treatment of upper extremity sarcomas and analyze the reporting of specific clinical and patient-centered parameters during follow-up. METHODS: A systematic review of the literature of FVFG used in the treatment of upper extremity sarcomas was performed. We excluded case reports and studies in which data was aggregated from multiple different procedures for various diagnoses. The outcomes assessed were patient demographics, classification and location of the tumor, the use of preoperative and/or postoperative radiation and/or chemotherapy, bony union, and patient-centered outcomes. RESULTS: A total of 56 studies were included in final analysis. The most common diagnosis was osteosarcoma (35.1%) and the most common recipient site was the humerus (57.3%) followed by the radius (36.2%) and ulna (5.8%). FVFG had a median union rate of 93.3%, with the median time to union being 5.0 months. The most common complications were fracture (11.7%), nerve injury (7.5%), infection (5.7%), and hammer toe deformity (3.3%). The reoperation rate was 34.5%. The most commonly reported standardized assessment of clinical outcomes following treatment was the Musculoskeletal Tumor Society Score, which had a mean of 79% and a median of 80% postoperatively. CONCLUSION: FVFG in the treatment of malignant bony neoplasms of the upper extremity has a high rate of union and good overall outcomes; however, postoperative complication rates are high. A greater degree of standardization is needed in the reporting of patient-centered outcomes. Reporting outcomes of individual patients or stratifying data based on diagnosis, graft site, and age would facilitate future comparative studies.

Onlay vascularized fibular grafting as a salvage procedure for the management of nonunion after reconstruction of the femur following tumor resection.

The femur is prone to nonunion after biologic reconstruction following tumor resection, due to high bending forces. Nonunion at the host-graft junction is difficult to treat since the graft is in an avascular state. We aimed to investigate the clinical and radiographic results of an onlay free vascularized fibular grafting (VFG) as a salvage procedure for nonunion management after biologic reconstruction of the femur following bone tumor resection. We retrospectively reviewed 10 patients (8 men and 2 women, median age: 15.5 years, range: 10-47) who underwent an onlay VFG for nonunion after intercalary reconstruction of the femur using an allograft ( n = 7) or pasteurized autograft ( n = 3), following tumor resection. The median follow-up period after VFG was 85.7 (24.6-163.5) months. The median time to union between the host bone and the VFG osteotomy sites was 3.5 (2.8-4.5) months. The median time to union at the host-graft junctions was 10.6 (6.6-12.7) months. Two postoperative complications requiring revision surgery occurred in two patients: one graft fracture and one deep infection with synchronous graft fracture. Internal fixation was required in the patient with graft fracture. The patient with the infection and synchronous graft fracture was treated using debridement, antibiotics, and an external fixator. The median Musculoskeletal Tumor Society functional score was 88% (60-97%) at the final follow-up. Onlay VFG as a salvage procedure for nonunion of a biologic intercalary reconstruction of the femur after tumor resection is a useful treatment option.

Free chimeric vascularized fibular graft and sural flap for reconstruction of composite extremity defects

Objective To report clinical application of free chimeric vascularized fibular graft combined with sural flap for reconstruction of composite extremity defects after open fracture. Methods From June 2010 to July 2014, free chimeric vascularized fibular grafts and sural flaps were used to treat 4 patients with composite extremity defects at Department of Orthopaedics, The Sixth People’s Hospital. They were 3 men and one woman, aged from 39 to 61 years(average, 48.5 years). There were 2 cases of soft tissue defects on the forearm complicated with radial defect, one case of soft tissue defects on the forearm complicated with ulnar shaft defect, and one case of soft tissue defects on the leg complicated with tibial defect. The length of bone defect ranged from 8 cm to 18 cm (average, 13.0 cm); the size of soft tissue defects ranged from 22 cm × 6 cm to 23 cm × 15 cm (average, 22.3 cm × 9.7 cm). Results The area of flap ranged from 25 cm × 9 cm to 26 cm × 18 cm (average, 25 cm × 13 cm); the length of fibular graft ranged from 8 cm to 18 cm (average, 13 cm). The 4 patients were followed up for 8 to 42 months (average, 20.5 months). All the chimeric flaps survived. All the fractures united after an average of 8.5 months. The last follow-ups revealed no refracture. All the patients were satisfied with the outcomes. Conclusion Free chimeric vascularized fibular graft combined with sural flap is a reliable choice for reconstruction of composite extremity defects after open fracture. Key words: Sural nerve; Surgical flaps; Soft tissue injury

Bayesian Network Meta-Analysis of the Effectiveness of Various Interventions for Nontraumatic Osteonecrosis of the Femoral Head.

Objective To assess the effectiveness of various therapeutic hip preservation strategies on patients with nontraumatic osteonecrosis of the femoral head (ONFH). Design This is a systematic review of previous literature and in-depth Bayesian network meta-analysis of randomized controlled trials (RCTs) to compare the clinical effect of various operation methods and one physical intervention (extracorporeal shockwave). Data Sources Electronic literature, for studies published up to December 2017, was collected from PubMed, Medline, and the Cochrane Library. Study Selection We selected RCTs on patients with ONFH. Treatment methods included extracorporeal shockwave (ESW), core decompression (CD), multiple drilling decompression (DD), vascularized fibular grafting (VFG), free-vascularized fibular grafting (FVFG), inverted femoral head grafting (IFHG), vascular iliac pedicle bone grafting (VIPBG), osteotomy, and tantalum implantation (TI). Outcome The primary outcome was Harris score; the secondary outcome was Harris hip score (HHS), including total hip arthroplasty requirement (THA) and progression to collapse. Results A total of 14 randomized controlled trials were investigated. ESW had the highest improvement on Harris score (probability best 52%), followed by VFG (probability was 38%). In the meanwhile, VFG also proved to be superior in reducing the failure rates of treatment (probability lowest 59%), followed by ESW (probability lowest 24%). In femoral necrosis stage-II, VFG achieved the highest probability in preventing treatment failures (52%) and showed better performance in reducing treatment failure rates than CD. Conclusion ESW therapy (ESWT) is the most effective intervention to improve HHS, and VFG shows superior effect on reducing treatment failure rates.

One-Barrel Microsurgical Fibula Flap for Reconstruction of Large Defects of the Femur.

Various methods for reconstructing large femur bone defects after tumor resection have been introduced. In this study, we reviewed the clinical outcomes of using a 1-barrel free vascularized fibular graft (FVFG) protected by a lateral locking plate for large femoral defects not involving the knee joint.Between August 2007 and August 2013, we treated 7 patients with large femoral bone defects after tumor resection. The mean age of the patients was 19 years (range, 12-36 years), and 3 were women. All defects were free of infection before the procedure. Femoral bone defects were reconstructed using a 1-barrel FVFG protected by a lateral locking plate. The mean bone defect size was 10.5 cm (range, 6-16 cm). We reviewed clinical outcomes at the last follow-up.All patients survived beyond the last follow-up; the mean follow-up period was 54 months (range, 26-100 months). Two patients sustained stress fractures of the FVFG, but the lateral locking plate protected the fractured graft until in situ bone healing obtained. Mean time to bone union of both host-graft junctions was 24 months (range, 18-31 months). The mean Musculoskeletal Tumor Society score (%) was 85.8% (range, 80-95%).A 1-barrel FVFG protected by a lateral locking plate maintained a stable graft-host bone construct, successfully leading to bone healing, even in cases of stress fractures of the graft, and appears to be a good option for large femur bone defects.

Early MRI Detection and Closed Bone Graft Epiphysiodesis May Alter the Course of Avascular Necrosis Following Unstable Slipped Capital Femoral Epiphysis.

Unstable slipped capital femoral epiphysis (SCFE) has an increased incidence of avascular necrosis (AVN). Early identification and surgical intervention for AVN may help preserve the femoral head. We retrospectively reviewed 48 patients (50 hips) with unstable SCFE managed between 2000 and 2014. AVN was diagnosed based on 2 different postoperative protocols. Seventeen patients (17 hips) had a scheduled magnetic resonance imaging (MRI) between 1 and 6 months from initial surgery, and the remaining 31 patients (33 hips) were evaluated by plain radiographs alone. If AVN was diagnosed, we offered core decompression and closed bone graft epiphysiodesis (CBGE) to mitigate its affects. At final follow-up, we assessed progression of AVN using the Steinberg classification. Overall 13 hips (26%) with unstable SCFEs developed AVN. MRI revealed AVN in 7 of 17 hips (41%) at a mean of 2.5 months postoperatively (range, 1.0 to 5.2 mo). Six hips diagnosed by MRI received surgical intervention (4 CBGE, 1 free vascularized fibula graft, and 1 repinning due to screw cutout) at a mean of 4.1 months (range, 1.3 to 7.2 mo) postoperatively. None of the 4 patients treated with CBGE within 2 months postoperatively progressed to stage IVC AVN. The 2 patients treated after 4 months postoperatively both progressed to stage VC AVN.Plain radiographs demonstrated AVN in 6 of 33 hips (18%) at a mean of 6.8 months postoperatively (range, 2.1 to 21.1 mo). One patient diagnosed with stage IVB AVN at 2.4 months had screw cutout and received CBGE at 2.5 months from initial pinning. The remaining 5 were not offered surgical intervention. Five of the 6 radiographically diagnosed AVN, including the 1 treated with CBGE, progressed to stage IVC AVN or greater. Although all patients with positive MRI scans developed radiographic AVN, none of the 4 patients treated with CBGE within 2 months after pinning developed grade IVC or greater AVN. Early MRI detection and CBGE may mitigate the effects of AVN after SCFE. Level III-retrospective comparative study.

Free vascularized fibula grafting in the operative treatment of malignant bone tumors of the upper extremity: A systematic review of outcomes and complications.

Vascularized bone grafting after tumor resection can be an important component in the treatment of bony neoplasms of the upper extremity. The purpose of this study was to determine the outcomes of free vascularized fibula grafting (FVFG) in the treatment of upper extremity sarcomas. A systematic review of the literature of FVFG used in the treatment of upper extremity sarcomas was performed. A total of 56 studies were included in final analysis. The most common diagnosis was osteosarcoma (35.1%) and the most common recipient site was the humerus (57.3%). FVFG had a median union rate of 93.3%, with the median time to union being 5.0 months. The most common complications were fracture (11.7%), nerve injury (7.5%), infection (5.7%), and hammer toe deformity (3.3%). The reoperation rate was 34.5%. The most commonly reported standardized assessment of clinical outcomes following treatment was the Musculoskeletal Tumor Society Score, which had a median of 80% postoperatively. FVFG in the treatment of malignant bony neoplasms of the upper extremity has a high rate of union and good overall outcomes; however, postoperative complication rates are high. A greater degree of standardization is needed in the reporting of patient-centered outcomes to facilitate future comparative studies.

Mandibular Reconstruction with Free Vascularized Fibular Graft.

An iliac block graft is the most commonly used biomaterial for reconstruction following resection of the mandible. Its use has some disadvantages, however, including limitations on the amount of bone that may be harvested, and the subsequent increase in burden on the iliac bone. Therefore, recently, free vascularized fibular grafts have been used as an alternative in some cases. Here, we report the advantages of, and issues related to reconstruction using free vascularized fibular grafts observed at Tokyo Dental College Chiba Hospital. Eight patients undergoing mandibular reconstruction using free vascularized fibular grafts between January 2003 and January 2017 were investigated. Of these, 6 were men, and 2 were women. Age ranged from 38 to 74 years (average, 54 years). Primary diseases comprised malignant tumor in 3 patients, benign tumor in 3, and radiation osteomyelitis of the mandible in 2. The defects were classified as follows according to the CAT system (Condylar Head, Mandibular Angle, Mental Tubercle): 3 cases of Body, 2 of AT, and 1 case each of TT, ATTA, and CATT. The resection range of the mandible was 5-16 cm (average, 10 cm). The single barrel technique was used in 7 cases, and the double barrel technique in 1. In terms of the flap survival ratio, complete engraftment was achieved in 6 out of the 8 cases. Two cases of radiation osteomyelitis of the mandible, with necrosis caused by vascular breakdown after wound infection, were observed, however. While the advantages of mandibular reconstruction by this method include comparatively safe conditions and functional recovery, there were also some problems. It was inappropriate for cases of radiation osteomyelitis of the mandible; those where anti-inflammatory therapy was ineffective; and those where greater resection of the soft tissue was required. Further study is needed to clarify the criteria for selecting this procedure.

EFFICACY OF TWO DIFFERENT RECONSTRUCTION MODALITIES AFTER SURGICAL RESECTION OF MANDIBULAR FIBROUS DYSPLASIA (A CLINICAL STUDY)

Objective: To evaluate efficacy of Nonvascularized bone graft ( NVBG) with bone marrow aspirate concentrate (BMAC) compared with free vascularized fibula graft in reconstruction of mandible after surgical treatment of monostatic mandibular fibrous Dysplasia. Patients and methods: The present study was carried out of three years on 14 patients (8 males & 6 female) ranging from 9- 18 years who had monostatic fibrous dysplasia and need segmental resection and immediate reconstruction. The patients were divided randomly into two equal groups; group I patients grafted with free vascularized fibula graft after segmental resection and group II patients grafted with iliac crest or rib bone graft and injected with BMAC at surgical site after radical excision of lesion. They were selected from those attending the out patient clinic at Faculty of Dental Medicine, Al Azhar University, Assuit branch and the Faculty of Dentistry, in coordination with Plastic Surgery at Suez Canal University Hospital over a period of 4 years (July 2013 –July 2017). Postoperative clinical, radiographic evaluation were performed at 6 month and 12 month till two years after that to assess recurrence of lesion and bone graft density.Results: Both groups was clinically uneventful except two cases in group I and one case in group II .All patients had adequate facial contour, proper facial symmetry and good take post operatively. Radiographic evaluation showed at six month, there was a highly statistically significant difference between two groups. This means that, newly formed bone of group I was significantly denser than group II. At 12 months, the mean of the group I was more than the mean of group II . These showed a difference between means of two groups but this difference was not a statistically significant . Conclusion: Conventional grafting techniques with NVBGs improved by BMAC injection with satisfactory outcomes . Thereby it can be used as alternative modality for free vascularized bone graft in mandibular reconstruction in cases with massive monostatic fibrous dysplasia depend on the size of the lesion

Outcomes and Complications of Reconstruction with Use of Free Vascularized Fibular Graft for Spinal and Pelvic Defects Following Resection of a Malignant Tumor.

Following resection of malignant tumors of the spine and pelvis, reconstructive surgeons often face large structural defects. Unlike reconstruction in the extremities, wherein a free vascularized fibular graft (FVFG) is a highly utilized option for segmental osseous reconstruction, there are limited data on the use of an FVFG in the spine and pelvis. The aim of this study was to review our institution's experience with reconstruction with use of an FVFG following oncological resection in the spine and pelvis. We reviewed 24 cases involving the use of an FVFG in reconstruction of segmental osseous defects of the spine and pelvis following oncological resection from 2000 to 2015. The cohort consisted of 12 male and 12 female patients with a mean age of 37 years and a mean follow-up of 5 years. Fifty-four percent of the reconstructions were spinopelvic or sacropelvic. The overall 2, 5, and 10-year rate of survival was 76%, 55%, and 37%, respectively. With regard to disease-free survival, the overall 2, 5, and 10-year rate was 81%, 72%, and 48%. The overall rate of union was 86%, with a mean time to union of 7 months. Complications were common, with 83% of the patients sustaining at least 1 postoperative complication. Following the procedure, the mean Musculoskeletal Tumor Society rating was 53%. An FVFG provides a durable means of reconstruction of osseous defects in the spine and pelvis. Although patient function was acceptable following these large reconstructions, the rate of postoperative complications was high. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.