Free Vascularized Fibular Research Articles

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.

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.

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.

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.

CORR Insights®: Free Vascularized Fibular Grafting Improves Vascularity Compared With Core Decompression in Femoral Head Osteonecrosis: A Randomized Clinical Trial.

CORR Insights®: Free Vascularized Fibular Grafting Improves Vascularity Compared With Core Decompression in Femoral Head Osteonecrosis: A Randomized Clinical Trial.

Mandibular Reconstruction Using the Free Vascularized Fibula Graft: An Overview of Different Modifications.

The reconstruction of the mandible is a complex procedure because various cosmetic as well as functional challenges must be addressed, including mastication and oral competence. Many surgical techniques have been described to address these challenges, including non-vascularized bone grafts, vascularized bone grafts, and approaches related to tissue engineering. This review summarizes different modifications of the free vascularized fibula graft, which, since its introduction by Hidalgo in 1989, has become the first option for mandibular reconstruction. The fibula free flap can undergo various modifications according to the individual requirements of a particular reconstruction. Osteocutaneous flaps can be harvested for reconstruction of composite defects. 'Double-barreling' of the fibula can, for instance, enable enhanced aesthetic and functional results, as well as immediate one-stage osseointegrated dental implantation. Recently described preoperative virtual surgery planning to facilitate neomandible remodeling could guarantee good results. To conclude, the free fibula bone graft can currently be regarded as the "gold standard" for mandibular reconstruction in case of composite (inside and outside) oral cavity defects as well as a way of enabling the performance of one-stage dental implantation.

Updated Surgical Techniques and Expanded Indications of Free Vascularized Fibular Graft

Updated Surgical Techniques and Expanded Indications of Free Vascularized Fibular Graft

Reconstruction of Large Femur and Tibia Defect with Free Vascularized Fibula Graft and Locking Plate

Reconstruction of Large Femur and Tibia Defect with Free Vascularized Fibula Graft and Locking Plate

Sauvé-Kapandji法に加え橈骨頭切除術を施行後に生じたradioulnar impingementに対し遊離血管柄付き腓骨を用いて遠位橈尺関節再建術を施行した1例

Sauvé-Kapandji法に加え橈骨頭切除術を施行後に生じたradioulnar impingementに対し遊離血管柄付き腓骨を用いて遠位橈尺関節再建術を施行した1例

Free Vascularized Fibular Strut Autografts to the Lumbar Spine in Complex Revision Surgery: A Report of Two Cases.

This case report presents two patients who underwent fibular strut grafting for complex revisions of previous lumbar spine arthrodeses. A case review of the Electronic Medical Record at the index institution was performed to evaluate the timeline of events of the two patients who underwent fibular strut grafting for complex revisions of previous lumbar spine arthrodesis, including imaging studies, progress notes, and laboratory results. One patient had developed chronic L3 vertebral body osteomyelitis from a prior fibular allograft and instrumentation placed for a traumatic burst fracture. The second patient had a severe scoliosis recalcitrant to prior arthrodeses in the context of Marfan syndrome and a persistent L4-5 pseudarthrosis. Both patients underwent free vascularized fibular autograft revision arthrodeses. At most recent long-term follow-up, both patients had improved clinically and neither had required further revision. The use of free vascularized fibular grafting is an excellent option for a variety of spinal indications, and these two reports indicate that the technology may have an indication for use after multiple failed surgeries for osteomyelitis or correction of a multi-level large spinal deformity secondary to Marfan syndrome.

Spinal Reconstruction with Free Vascularized Fibular Grafts

Spinal Reconstruction with Free Vascularized Fibular Grafts

Reconstruction of Proximal Humeral Defects with Shoulder Arthrodesis Using Free Vascularized Fibular Graft: Surgical Technique.

We describe upper-extremity reconstruction after proximal humeral bone loss by means of glenohumeral arthrodesis using a vascularized fibular graft and double plate fixation. Use preoperative imaging to estimate the length of the humeral defect, the absence or presence of a glenoid defect, and the available length of fibular graft. Place the patient in the beach-chair position, securing him/her with side supports. The approach is a typical anterior approach to the shoulder following an anterolateral approach to the humeral shaft. Harvest the full length of the fibula, after leaving 6 cm proximally and distally for ankle and knee stability. Ream the humeral medullary canal by hand to avoid fracture and prepare the profunda brachii or brachial artery as recipient vessels. Insert the bare osseous fibula into the humeral canal, pass the graft pedicle through the loose tunnel, and anastomose the vessels. It is very important to bend the lateral plate to match the contour of the osseous surfaces. Immobilize the shoulder until union is achieved and then start scapula-thoracic exercises. We recently reported on a retrospective series of nine shoulder arthrodeses performed with use of a free vascularized fibular graft. IndicationsContraindicationsPitfalls & Challenges.

One-and-a-Half-Barrel Vascularized Free Fibular Flap for the Reconstruction of Segmental Mandibular Defect

We designed one-and-a-half-barrel vascularized free fibular flap which is a further modification of the double-barrel technique, and we tried to overcome the discrepancy between mandible and fibula flap. We used this flap in case of a segmental mandibular defect that occurred as a result of a giant cell reparative granuloma excision. This new modification eliminated volume insufficiency of the classical technique and volume excess of the double-barrel technique.A segmental mandibular defect that occurred as a result of giant cell reparative granuloma excision was reconstructed using one-and-a-half-barrel vascularized free fibular flap. The size discrepancy between mandible and free fibula flap is a well-known problem, and this new modification of free fibular flap eliminated volume insufficiency or excess problems of the other techniques.

Several Considerations in Free Vascularized Fibular Head Grafting for Giant Cell Tumor of Distal Radius

Several Considerations in Free Vascularized Fibular Head Grafting for Giant Cell Tumor of Distal Radius

The Effect of Postoperative Corticosteroid Administration on Free Vascularized Fibular Grafting for Treating Osteonecrosis of the Femoral Head

Free vascularized fibular grafting (FVFG) has been reported to be an effective method of treating osteonecrosis of the femoral head (ONFH). This study evaluated whether postoperative maintenance doses of corticosteroids had an adverse effect on FVFG outcomes in patients with corticosteroid-induced ONFH. We retrospectively reviewed the records of 39 patients (67 hips) who had received maintenance doses of corticosteroids following FVFG. This group was matched to a group of patients who had not received corticosteroids treatment after operation. The mean follow-up duration was 5.4 years for the postoperative corticosteroid administration group (PCA group) and 5.0 years for the control group. At the latest follow-up, the average increase in Harris hip score was 11.1 ± 8.7 points for all hips in the PCA group and 12.6 ± 7.4 points for all hips in the control group (P > 0.05). In the PCA group, through radiographic evaluation, 49 hips were improved, 10 hips appeared unchanged, and 8 hips appeared worse. In the control group, 47 hips were improved, 13 hips appeared unchanged, and 7 hips appeared worse. The results suggested that postoperative maintenance doses of corticosteroids do not have an adverse effect on FVFG outcomes in patients with corticosteroid-induced ONFH.

Application of the “All-on-Four” Concept and Guided Surgery in a Mandible Treated With a Free Vascularized Fibula Flap

In this article, we describe the first case in the literature in which 3D computer-assisted treatment planning and guided surgery enabled a patient affected by extreme paraphysiologic mandibular bone atrophy to be treated with a free vascularized fibula flap and, after a period of healing, the flapless installation of 4 immediately loaded dental implants. The computer-fabricated surgical guide allowed placement of the implants according to the "All-on-Four" concept in a proper spatial preplanned position and by tilting 1 implant, avoiding an area of bone discontinuity. Additionally, this technique allowed the production of a prefabricated temporary prosthesis, delivered after implant insertion, which could be immediately loaded. The use of a fibula flap makes it possible to create greater bone thickness while computer-assisted treatment planning and guided surgery provide several advantages over the traditional technique.

Reconstruction of Proximal Humeral Defects with Shoulder Arthrodesis Using Free Vascularized Fibular Graft

Treatment of proximal humeral bone loss resulting from tumor resection or from infection following shoulder arthroplasty represents a reconstructive challenge. Shoulder arthrodesis is an appropriate salvage procedure but is associated with a high rate of complications. The purpose of this report is to describe the surgical technique and report the functional outcomes in a series of patients treated with shoulder arthrodesis using free vascularized fibular graft. Nine patients were included in this study. Two-stage reconstruction was performed in three patients with a methicillin-resistant Staphylococcus aureus infection following primary shoulder hemiarthroplasty. The remaining six patients had an aggressive or malignant tumor of the proximal aspect of the humerus, and tumor resection included the rotator cuff in all of these patients and the axillary nerve in three. All nine patients underwent shoulder arthrodesis using free vascularized fibular graft; eight patients had fixation with two plate-screw constructs, and one patient had fixation with only one plate and screws. Clinical and radiographic evaluation of all patients was performed at a mean of sixty months postoperatively. The Musculoskeletal Tumor Society (MSTS) function score and the Toronto Extremity Salvage Score (TESS) were used to assess overall function of the upper limb. Mean active shoulder abduction and flexion were both 80° (range, 60° to 100°). All but one patient could bring the hand to the mouth. The mean MSTS function and TESS values were twenty-four of thirty and 82%, respectively, representing a good functional outcome. Two of nine patients had a major complication. Union and fibular hypertrophy were achieved in seven of the nine patients. Shoulder arthrodesis using free vascularized fibular graft with double plate fixation is a reliable salvage procedure in patients with major proximal humeral bone loss.

One and a Half Barrel Vascularized Free Fibular Flap for the Reconstruction of Segmental Mandibular Defect

Ulkur, Ersin MD; Karagoz, Huseyin MD; Kocyigit, Ismail D. DDS, PhD; Oksuz, Sinan MD; Acikel, Cengiz MD; Urhan, Muammer MD

Use of Vascularized Free Fibular Head Grafts for Upper Limb Oncologic Reconstruction

Transfer of a vascularized fibular graft is the method of first choice for reconstruction of defects of long bones. In particular, the vascularized fibula head graft is preferred for patients with bone defects of the upper limb involving the distal radius or the proximal humerus. The aim of the present study was to analyze the operative results, complications, and postoperative function after vascularized fibula head graft transfer and the indications for this procedure. From 1998 through 2008, vascularized fibula head graft transfer was performed in eight patients to reconstruct bone defects following resection of tumors of the upper limb. The primary site of the tumor was the proximal humerus in four patients and the distal radius in four patients. The postoperative course of the transferred bone was examined, and functional results were evaluated. All vascularized fibula head grafts were transferred successfully. During the follow-up period, absorption of the transferred fibula head was not observed. The mean overall functional rating of the reconstructed shoulder joint was 70 percent. The range of motion of the reconstructed wrist joint showed no specific patterns, and instability of the wrist joint was observed in only one case. The authors believe that the vascularized fibula head graft transfer is a safe and reliable method for reconstructing the upper limb, especially for patients with a defect of the distal radius or the proximal humerus. This procedure is also useful for pediatric patients, in whom bone growth is expected after transplantation, and for salvage procedures after reconstructive materials of an artificial joint have failed.

Modified Free Vascularized Fibular Grafting for the Treatment of Femoral Neck Nonunion

To evaluate a modified free vascularized fibular grafting procedure with an anterior approach to the hip as a treatment for femoral neck nonunions. Retrospective radiographic and clinical review. Level I trauma center. Twenty-six femoral neck nonunions treated between November 2000 and December 2005. Harris Hip scoring system and radiographic standard evaluation for bone union. The average follow-up period was 29.3 months (range, 12-63 months). The average duration of the surgery was 2.5 hours (range, 2-4 hours). Average blood loss was 300 mL (range, 200-400 mL). The neck-shaft angle was improved by 2.3 degrees on average. Twenty-four of 26 femoral neck nonunions healed without any severe complications. Average union time was 5.3 months (range, 3-9 months). Twenty-four patients had well-functioning hips with an average Harris hip score of 87.9 as compared with the average preoperative Harris hip score of 57.8. One case developed osteonecrosis of the femoral head requiring total hip arthroplasty 2 years after the index procedure. One case developed an immediate postoperative infection. The clinical result indicates that the anterior approach modification of free vascularized fibular grafting is a valuable procedure in the treatment of femoral neck nonunions.