Vascularized Fibular Graft Research Articles

Free vascularized fibula grafts for salvage of failed oncologic long bone reconstruction and pathologic fractures

Vascularized bone grafts, particularly the free fibula transfer, have incited revolutionary changes in the field of skeletal reconstruction. In no place has this been more evident than in oncologic reconstruction. The free vascularized fibula graft has been used to good effect for primary long-bone reconstruction, long-bone allograft complication salvage, and pathologic fracture salvage of the long bones. Although many of these procedures often entail significant complications, limb salvage has been made possible in a majority of patients using transfers of free vascularized fibula grafts. The purpose of this review is to critically evaluate the technique of onlay free vascularized fibula grafts for salvage of allograft complications and pathologic fractures of the long bones. This will be accomplished by reviewing the problem of allograft complications and pathologic fractures, the current treatment modalities available, the outcomes of these treatments, and future directions of treatment for this particular problem.

Long-term Follow-up Results of the Free Vascularized Fibular Graft in Congenital Pseudarthrosis of the Tibia

Purpose: To report the long-term follow-up results of a free vascularized fibular graft (FVFG) for the treatment of patients with congenital pseudarthrosis of the tibia (CPT). Materials and Methods: Fourteen patients with CPT, who underwent FVFG and were followed-up for more than 4 years, were enrolled in this study. The average age at FVFG was 4.5 years (range, 1~10.6 years) with an average follow-up of 11.6 years (range, 4~26.6 years). In 11 cases, 24 additional procedures were performed due to the secondary problems, such as delayed union, nonunion, leg length discrepancy, and deformity of the tibia. The clinical and radiological data were reviewed to evaluate the outcomes of the FVFG. Results: Bone union and hypertrophy of the fibular graft was observed in all cases. The average time of union in 7 cases, in whom bone union was achieved without the aid of any supplementary procedures, was 6.7 months (range, 3.5~11 months). At the last follow-up, the mean limb length discrepancy was 2.5 cm (range, 0~8 cm), and the average anterior apex and valgus angulation of the tibial shaft were 18.4 o (range, 0~85 o ) and 9.9 o (range, −5~34 o ), respectively. The mean ankle alignment was valgus 7.2 o

Biological reconstruction after resection of bone tumors of the proximal tibia using allograft shell and intramedullary free vascularized fibular graft: Long‐term results

Reconstruction after excision of bone tumor of the proximal tibia is a challenging issue for the reconstructive surgeon. The combined use of a free fibular flap and allograft can provide a reliable reconstructive option in this location. This article describes the authors' long-term follow-up using this technique. Twenty-seven patients that had resection of proximal tibia bone tumors underwent reconstruction using this technique. Only 21 patients that had primary reconstruction were included in this study. All patients had their surgeries performed at least 24 months before the end of the study. The average age at time of operation was 18.1 years. The average follow-up time was 139.3 months. Limb salvage was 82.7%. The average length of the resected tibial segment was 15.3 cm and that of the residual proximal tibia remaining after resection was 2.7 cm. The average time of union of fibula was 5.4 months and for union of allograft was 19.1 months. Primary union of the allograft was achieved in 90.5% of cases. Full weight-bearing was achieved at an average of 21.6 months. Ten patients (47.6%) had 14 local complications. The (MTSRS) average score at final follow-up was 27.3. Local recurrences occurred in two patients (9.5%). Distant metastasis to the lung occurred in three patients (14.3%). One patient died of disease. This technique provides good long-term results in reconstruction of proximal tibia. The viability of the fibula is a cornerstone in both success of reconstruction as well as successful management of complications.

Reconstruction of large limb bone defects with a double-barrel free vascularized fibular graft

The use of a free, vascularized fibular graft is an important technique for the reconstruction of large defects in long bones. The technique has many advantages in strong, tubular bones; a more reliable vascular anatomy with a large vascular diameter and long pedicle is used, minimizing donor-site morbidity. Due to limitations in both fibular anatomy and mechanics, they cannot effectively be used to treat large limb bone defects due to their volume and strength. From 1990 to 2001, 16 clinical cases of large bone defects were treated using vascularized double-barrel fibular grafts. Patients were evaluated for an average of 10 months after surgery. All the patients achieved bony union; the average bone union took 10 months post surgery, and no stress fractures occurred. Compared with single fibular grafts, the vascularized double-barrel fibular grafts greatly facilitate bony union and are associated with fewer complications, suggesting that the vascularized double-barrel fibular graft is a valuable procedure for the correction of large bone defects in large, long bones in addition to enhancing bone intensity. The vascularized double-barrel fibular graft is superior to the single fibular graft in stimulating osteogenous activity and biological mechanics for the correction of very large bone defects in large, long bones. Free vascularized folded double-barrel fibular grafts can not only fill up large bone defects, but also improve the intensity margin. Therefore, this study also widens its application and enlarges the treatment targets. However, in the case of bone deformability, special attention should be paid to bone fixation and protection of donor and recipient sites.

Pseudarthrose congénitale de l’avant-bras. À propos de deux cas et revue de la littérature

Congenital pseudarthrosis of the forearm represents a rare entity which is often associated with neurofibromatosis type I. Isolated pseudarthrosis of the ulna is the most frequent deformity, followed by pseudarthrosis of the radius and both forearm bones. The treatment of these deformities remains difficult: conventional bone grafts rarely lead to complete fusion. The reconstruction by a vascularized fibular graft represents the treatment of choice if the radial head is not dislocated. This procedure allows restoration of a balance between radius and ulna during growth. The presence of a vascularized graft enhances the potential for bony fusion in a fibrous environment. In cases of isolated ulna pseudarthrosis, a luxation of the proximal radial epiphysis may occur when the ulnar deformity increases with time. The single-bone forearm represents a salvage procedure that creates a stable upper limb with a satisfactory wrist and elbow function. The two clinical cases of a pseudarthrosis of both forearm bones and of an ulna pseudarthrosis are presented.

Free vascularized fibular graft for treatment of pathological femoral neck fracture and osteonecrosis of the femoral head: A case report with a long‐term follow‐up

We present a case of a 34-year-old white female patient who, 13 years ago, sustained a pathological intracapsular femoral neck fracture on a pre-existing aneurysmal bone cyst. Three months later radiographic and magnetic resonance imaging evaluation revealed both femoral neck fracture and stage IV osteonecrosis of the femoral head according to Steinberg classification system. Management was accomplished with combined free vascularized fibular grafting and internal osteosynthesis with a 130 degrees blade plate. Union was achieved in 7 months. Progression of osteonecrosis was arrested. Hip salvage and a satisfactory subjective and clinical outcome were achieved. At the last follow-up, 13 years postoperatively, the patient had satisfactory functional outcome.

Hip Resurfacing After Failed Free Vascularized Fibular Graft

Metal-on-metal resurfacing of the hip is a bone sparing arthroplasty that may be an option when a head-sparing nonarthroplasty option fails. We present the first published report of 5 cases of failed free vascularized fibular graft treated with modern hip resurfacing arthroplasty. This selected group of patients had avascular necrosis with less than 20% head involvement and cysts less than 1 cm in diameter. Follow-up ranging from 2 to 5 years (mean, 38 months) showed improvement in hip function without evidence of prosthesis loosening. There were no femoral neck fractures or revisions. A vascularized fibular bone graft does not prevent good early results with hip resurfacing but may add technical complexity owing to its position within the femoral head and neck.

Analysis of modified free vascularized fibular grafting for the treatment in patients with avascular necrosis of femoral head (AVNFH)

Objective To evaluate the clinical efficacy and its complications in patients with avaseular necrosis of femoral head (AVNFH) by modified free vascularized fibular grafting. Methods 50 patients(75 hips) with AVNFH ，the disease was caused by trauma in 20 cases(30 hips)，use of steroids in 15cases (23 hips)，consumption of alcohol in 11 cases (16 hips) and especially condition in 4eases (6 hips).Of 75 hips，27 were classified as stage Ⅱ;38 as stageⅢ，10 as stageⅣaccording to Steinberg system; the Harris hip scores were 78.5，65.4 and 57.4 before treatment respectively. Results The duration of the fibular osteotomy was 10 to 35 min( 18 min on average).The duration of the total operation was 80 to 130 min(95 min on average).After operation，Harris hip scores in most cases were improved. According to postoperative X-ray，60 hips ( 80.0% ) were improved to different extents and 13 hips ( 17.3% ) had no significant changes. Deterioration occurred in 2 hips(2.7% ).Conclusion The modified free vascularized fibular grafting is an effective methods for the treatment in patients with avascular necrosis of femoral head Key words: Femoral head; Bene transplantation

An Intramedullary Free Vascularized Fibular Graft Combined with Pasteurized Autologous Bone Graft in Leg Reconstruction for Patients with Osteosarcoma

The use of pasteurized autologous bone graft has been an innovation in limb-salvage surgery; however, its principal disadvantage is fracture, infection, pseudoarthrosis, and bone resorption. We present two cases in which an intramedullary free vascularized fibular graft combined with pasteurized autologous bone graft was performed for immediate femur or tibia reconstruction following osteosarcoma resection. The rationale of this method is to combine the mechanical strength of a pasteurized bone with the biological activity of a vascularized bone. The pasteurized bone graft provides bone stock and early stability and the addition of the vascularized bone graft substantially facilitates host-pasteurized bone union. This combination procedure may be a recommended option for reconstruction of the lower leg, preserving knee joint function for patients with osteosarcoma.

Management of Radiation-associated Fractures

High-dose radiation is injurious to bone and is a known risk factor for the development of late fracture. Management of radiation-induced fractures is generally thought to be difficult, with prolonged healing times and a high nonunion rate. There is a relative paucity of literature to guide treatment. Fractures of the long bones typically should be managed with intramedullary nailing. A low threshold should exist for supplemental bone grafting, and a vascularized fibula graft should be considered for persistent nonunion. To prevent refracture, fixation should be left in situ indefinitely. Resection of the fracture site and reconstruction with an oncologic endoprosthesis is an effective salvage procedure. Periarticular fractures should be treated with joint arthroplasty, which allows early mobilization and avoids prolonged healing times. Fractures of expendable bones, primarily the clavicle, typically should be managed with débridement or resection.

Vascularized Fibula Graft for Humeral Reconstruction

Vascularized Fibula Graft for Humeral Reconstruction

Vascularised fibula graft inlaid in a massive bone allograft: Considerations on the bio-mechanical behaviour of the combined graft in segmental bone reconstructions after sarcoma resection

Vascularised fibula transfer (VFT) is a trustworthy procedure in the reconstruction of skeletal defects secondary to several pathological conditions. Over the last 20 years, progress in diagnosis in skeletal oncology and in adjuvant therapy has increased the possibility of applying limb-saving procedures in the treatment of bone sarcoma. In this context, VFT appeared to be a valuable reconstructive tool following the wide segmental resection of the long bones of the limbs. The vascularized fibula allows for fast bone fusion. It also demonstrates a tendency of progressive hypertrophy and, in those instances in which it is associated with an avascular massive bone allograft (MBA), it induces a process of osteo-integration which enhances the biomechanical properties of a combined graft. In order to assess the progression of the morphologic and structural changes of combined bone grafts we reviewed a group of 31 bone sarcoma patients who had had tibia reconstruction with a VFT inlaid in a massive allograft. Patients had been operated on between 1994 and 2006. Ages ranged from 4 to 31 years (mean 14 years). Thirty patients had received neo-adjuvant chemotherapy. Morphological variations were investigated by means of serial X-ray and CT scan examinations. All patients were regularly reviewed over an average time of 75 months (range 14-154 months). Computer assisted analysis was repeated at every control and performed at the same levels within the reconstruction, so that subsequent CT exams could be compared. We measured the sagittal and transverse diameters, total and medullary area, cortical thickness and cortical density of the VFT. Cortical thickness and cortical density of the massive bone allograft were measured as well. Two different remodelling patterns of the combined graft could be noted over time, that depended on the load trend on the vascularised fibula and that varied according to the persisting integrity of the allograft shell.

Osteomyelitis - Rekonstruktion von großen Knochendefekten bei Kindern

Reconstruction of Large Skeletal Defects Due to Osteomyelitis with the Vascularized Fibular Graft in Children. J Bone Joint Surg Am. 2007;89:2233-2240

Rigid bridging of massive femur defect using double vascularized fibula graft with hydroxyapatite

The presence of large and massive segmental defects of the diaphyseal bone following tumor resection is a significant problem for orthopedic surgeons. Double or folded free vascularized fibula graft (FVFG) is used in massive femur defects and is considered to be a reliable reconstructive procedure. However, folded or double fibula grafts cannot prevent stress fractures. Here, a novel surgical procedure for bridging of massive femur defects using double FVFG and hydroxyapatite with autogenous bone grafts to prevent stress fractures is reported.

Surgical and Molecular Advances in Osteonecrosis: Editorial Comment

Surgical and Molecular Advances in Osteonecrosis: Editorial Comment

Long-term Followup of Vascularized Fibular Grafting for Femoral Head Necrosis

Vascularized fibular grafting has been used for treatment of osteonecrosis of the femoral head and although some reports demonstrate successful short- to mid-term outcomes, long-term results are still unknown. We retrospectively reviewed 135 patients (151 hips) who underwent vascularized fibular grafting for osteonecrosis of the femoral head. One-hundred and ten patients (124 hips) were followed for a minimum 10 years (mean, 13.9 years; range, 10-23.7 years). The mean Harris hip score improved from 72 to 88. At the latest followup, we found improved or unchanged radiographs in 37 of 59 hips initially Stage II hips and 39 of 65 Stage III hips. Thirteen hips (13 patients) (10.5%) failed treatment and underwent total hip arthroplasty. The location and size of the necrotic lesion and the patient's age influenced long-term survival of the graft. Postoperative complications included clawing of the big toe in 17 patients, partial peroneal nerve palsy in two, and superficial infection in two. Subtrochanteric fracture occurred in two hips. The data suggest free vascularized fibular grafting was successful in maintaining joint function and delaying the need for joint replacement procedure. Graft survival was associated with the patient's age and size and location of the lesion but not etiology and stages of the disease.

Long-term follow-up on the use of vascularized fibular graft for the treatment of congenital pseudarthrosis of the tibia

BackgroundCongenital pseudoarthrosis of the tibia (CPT) is one of the most difficult conditions to treat.MethodsFive girls and 3 boys with CPT were treated by vascularized fibular grafting (VFG). The average age at VFG was 7.0 years (range: 1.9–11.5 years) with an average follow-up term of 11.7 years (range: 4.9–19.6 years). Five of the children had undergone multiple operations before VFG, while the other 3 had no such history.ResultsBone consolidation was obtained in all cases after an average term of 6.6 months (range: 4–10 months); this was with the first VFG in 7 cases but with the second VFG in 1 case. Complication of stress fracture and ankle pain occurred in 1 and 3 cases, respectively, only in cases undergoing multiple operations. Leg-length discrepancy was more prominent in the patients with multiple previous operations (mean: 7.5 cm), than in the cases with no prior surgery (mean: 0.7 cm).ConclusionThe long-term results of VFG for CPT were excellent, especially in the cases, with no prior surgery. VFG should be considered as a primary treatment option for CPT.

Non-Vascularised Fibular Grafting After Resection of Distal Femoral Tumours: An Initial Observation.

Background: Vascularized fibular grafting, allografting, megaprosthesis and allograft-prosthesis composite are suitable limb salvage techniques after resection of the whole of distal femur but are not easily available in underdeveloped countries. This difficulty prompted the use of non-vascularized fibular grafting in bridging wide distal femoral defects that have resulted from excision of tumours. Objective: To study the incorporation of long non- vascularized fibular autografts in arthrodesis of the knee as a limb salvage technique in a developing country. Method: Non-vascularized fibular grafts were used in spanning wide bone defects that had resulted from excision of distal femoral tumours in two patients. One of the defects was 10cm and the other was 15cm. long. A customized external fixator was used for initial immobilization of the limbs after surgery. Later the limbs were immobilized with re-enforced plaster-of-Paris cast. Result: The grafts showed a peculiar mode of avascular necrosis. In one patient 2cm and in the other patient 3cm of one of the ends of graft was not incorporated. Conclusion: Although the two patients were lost to follow-up, the initial observation showed such a wide non-vascularized fibular grafting for arthrodesis of the knee after resection of the distal femoral tumours is a feasible limb salvage technique in resource poor countries. Keywords: limb salvage; non-vascularized fibular graftNigerian Journal of Orthopaedics and Trauma Vol. 6 (2) 2007: pp. 83-85

Reconstructive Arthrodesis using a Non-living Fibular Graft with an Attached Periosteal Sleeve for Osteosarcoma of the Distal Tibia - A Case Report -

According to previous reports, ankle arthrodesis is regarded as the best reconstructive procedure after limb salvage surgery for osteosarcoma of the distal tibia. Of the many arthrodesis options, vascularized fibular graft (VFG) is widely accepted as the most successful method. However, reconstruction using VFG is not always possible, because VFG is a complicated surgical procedure and is associated with high rates of morbidity at donor sites. The authors devised a novel reconstructive surgical procedure that exploits the osteogenic potential of the periosteum. A 10-year-old female patient with osteosarcoma of the distal tibia underwent limb salvage surgery and the ipsilateral distal fibula and periosteal sleeve were transported to the defect for ankle arthrodesis. The transported fibula and periosteal new bone formation acted as a dual strut bone graft providing better stronger stability than fibula alone transfer. The authors believe the proposed procedure is an easier alternative to the surgically demanding VFG method.

Free fibula flap for humerus segmental reconstruction: report on 13 cases

In the period between 1994 and 2004, 13 patients (10 male, 3 female) presenting with post-traumatic defects to the humerus were treated with vascularised fibula graft. Age ranged from 21 to 62 (mean 37) years. Length of the bony defect ranged from 6 to 16 cm. Graft fixation was performed with plates in 12 cases, and in one case only screws were used. All patients were clinically reviewed between 120 days and 14 months after surgery. In one patient the flap was lost and a second free fibula flap was performed to achieve the reconstructive goal. Mean time for segmental bony union was 6 months (range from 3 to 13 months). Vascularised fibula graft allows for a successful humerus reconstruction when traditional techniques provide unsatisfactory results.