Vascularized Fibular Graft Research Articles

Reconstruction of post-traumatic long bone defect with vascularised free fibula: A series of 28 cases

Introduction:The severe long bone defects usually follow high-energy trauma and are often associated with a significant soft-tissue injury. The goal of management of these open long bone defects is to provide stable fixation with maintenance of limb length and soft-tissue coverage. The purpose of this article is to present the clinic-radiological outcome, complications and treatment of post-traumatic long bone defect with vascularised fibula transfer.Materials and Methods:Retrospective records of 28 patients were analysed who presented with post-traumatic long bone defects and in whom reconstruction with vascularised free fibula was done. Demographic data were recorded and clinical and radiological assessment was done.Results:Out of 28 patients in whom vascularised free fibula transfer was carried out three flaps were lost while non-union occur in three patients. Three patients developed a stress fracture of transferred free fibula in the post-operative period. Few of the patients experienced some problems in the donor leg; however, all of them improved in subsequent follow-up.Discussion:It is clearly evident from this study that timing of surgery plays an important role in the micro-vascular reconstruction in trauma cases. All the complication like flap loss, non-union or delayed union occur in patients in whom reconstruction was delayed.Conclusion:The free vascularised fibula graft is a viable method for the reconstruction of skeletal defects of more than 6 cm, especially in cases of scarred and avascular recipient sites or in patients with combined bone and soft-tissue defects. Results are best when the reconstruction is done within 1 week of trauma.

OP031: Double barrel vascularized fibula graft in mandibular reconstruction: A 10-year experience with an algorithm

This retrospective study aims to report an algorithm to assist surgeons in selecting different modes of the double barrel vascularized fibula graft for mandibular reconstruction. Forty-five patients who underwent reconstruction of mandibular defects with different modes of the double barrel vascularized fibula graft were reviewed. Our algorithm for deciding on any one of the different modes for different mandibular defects is influenced by the factors including history of radiotherapy, the length of mandibular body defect, and the need to preserve the inferior mandibular border. Postoperative functional outcomes included diet type and speech, and aesthetic results gained at post-operative 2 years. Patients with implant-borne prosthetic teeth underwent assessment of their masticatory function. There were four modes of mandibular reconstruction according to our algorithm, which included double barrel vascularized fibula graft ( n = 21), partial double barrel fibula graft ( n = 11), condylar prosthesis in combination with partial/double barrel fibula graft ( n = 11), and double barrel fibula onlay graft ( n = 2). Flap survival in all patients was 97.78%. Good occlusion, bony unions and wound closures were observed in 44 patients. Eleven patients received dental implantation in the transplanted fibula at post-operative 9–18th months. One patient wore removal partial dentures. For 11 patients with implant-borne prosthetic teeth, the average postoperative ipsilateral occlusal force was 41.5 ± 17.7% of the contralateral force. Good functional and aesthetic results were achieved in 38 patients with more than 2 years follow-up, including regular diet, normal speech and excellent or good appearance, especially for patients with dental rehabilitation. Good aesthetic and functional results can be achieved after dental rehabilitation by following our algorithm when choosing the different modes of double barrel vascularized fibula graft for mandibular reconstruction.

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.

Pedicled vascularized fibular graft with Ilizarov external fixator for reconstructing a large bone defect of the tibia after tumor resection

BackgroundLarge bony defects in the middle or distal third of the tibia resulting from surgical resection of malignant bone tumors present a difficult reconstructive challenge. Various methods of reconstruction are available, such as allografts, vascularized fibular graft (either free or pedicled), or endoprothesis replacement for distal defects.Materials and methodsTwelve patients—eight males and four females with mean age of 18 years at operation (range 14–25 years)—with malignant bone tumors of the tibial shaft were selected as candidates for wide resection of the tumor and reconstruction of the bony defect by ipsilateral vascularized fibular graft based on the peroneal vessels. Preoperative staging studies, including plain radiography, local MRI, isotopic bone scan, and chest CT, were done for every patient before biopsy. Ilizarov external fixation was then applied in all cases. The average length of the bony gap bridged was 14.5 cm (13–16.5 cm) and the mean length of the harvested graft was 16.3 cm (15–18 cm). The average operation time was 7.5 h (5.5–9.5 h).ResultsThe mean follow-up period was 38 months (range 32–52 months). Bony union at the proximal and distal ends of the fibula occurred in nine patients (75 %) and at a mean time of 5.5 months (range 4.5–8 months). Graft hypertrophy occurred in all patients. The mean percentage of hypertrophy was 95 % (range 80–160 %). The mean MSTS functional score was 84 % (range 80–92 %). A leg length discrepancy of 2 cm was reported in two patients and was managed using a shoe lift.ConclusionReconstruction of bony defects of the middle or distal tibia after bone tumor resection using pedicled vascularized fibula is a useful limb salvage procedure. The procedure can be performed relatively quickly and inexpensively and has a low rate of late complications. It leads to a good outcome regarding the union, hypertrophy, and function.

Below-Knee Amputation with a Vascularized Fibular Graft and Headless Compression Screw

Distal tibiofibular bridging (Ertl modification) in a below-knee amputation can provide an improved transmission of torque from the distal femur to the prosthesis. Without this bridge, the distal tibia and fibula are left freely rotating and translating in the soft-tissue envelope. The distal fibular segment creates a bone bridge that allows for increased distal weight bearing and more versatile prosthetic design. The purpose of this article is to describe the authors' technique for performing the Ertl modification to the below-knee amputation using a segment of vascularized fibula and a headless compression screw.

Two‐staged hindfoot reconstruction with vascularized fibula graft for calcaneal osteomyelitis caused by methicillin‐resistant Staphylococcus aureus: A case report

Hindfoot reconstruction after calcaneal osteomyelitis is a challenging procedure designed to restore the weight bearing function of the heel and to allow a functional reconstruction of the Achilles tendon. Some patients require subtalar arthrodesis after primary calcaneal osteosyntesis or hindfoot reconstruction due to the considerable pain associated with weight-bearing caused by the irregular surface of the subtalar joint. To date, no reports have shown a case of hindfoot reconstruction with subtalar arthrodesis using a pedicled vascularized fibula graft. We report a case of a 24-year-old woman who presented with calcaneal methicillin-resistant Staphylococcus aureus osteomyelitis after open comminuted fracture due to a fall. Radical debridement of bone and soft tissue was repeated six times in combination with negative pressure wound therapy, followed by hindfoot reconstruction with pedicled vascularized fibula and subtalar arthrodesis. Good functional restoration had been achieved by the final follow-up 18 months after surgery.

The reconstruction of large bone defects in the upper limb

Large bone defects in the upper limb pose many challenges in reconstructive surgery. Conventional and innovative methods have been described, employing the use of microsurgical and non-microsurgical techniques to overcome both bony and soft tissue defects. This article reviews the success and pitfalls of different techniques of reconstruction of large bone defects in the upper limb, including microsurgical transfer of the free vascularised fibula graft as a diaphyseal bone replacement and as a hemivascularised joint transplant, and non-microsurgical options using conventional bone grafting, the induced membrane technique and the role of callotatic distraction-lengthening procedures.

Management of postinfection defects in long bones with a vascularized fibular bone graft

Background Management of chronic osteomyelitis is a difficult task, complicated by problems including combined bone and soft-tissue loss, bacterial colonization, fibrotic local tissue, and local factors detrimental to wound healing. Vascularized bone grafts, by definition, are placed with their vascularity intact and are thus immediately viable. Objective The aim of this study was to review the clinical and radiographic results of a vascularized fibular graft (VFG) in the management of defects in upper and lower limbs with chronic osteomyelitis. Patients and methods Six patients with chronic osteomyelitis (two tibiae, two ulnae, one femur, and one radius) underwent radical debridement, followed by reconstruction using a VFG, and were evaluated for radiographic and clinical success using standard anteroposterior and lateral radiographs. Four men and two women were included and their average age at surgery was 38.8 years (range 30-50 years). Union, solid hypertrophy, range of motion, grip strength, failure of anastomosis, and recurrence of infection were evaluated at the final follow-up. Results Radiological assessment indicated union in all cases after an average period of 10.6 weeks in upper limb cases and 18 weeks in lower limb cases. Solid hypertrophy and weight bearing were allowed for lower limb cases after an average period of 12 months. No failure of the graft or recurrence of infection was encountered in this study. Conclusion VFG for the reconstruction of long bone defects following radical debridement in cases of chronic osteomyelitis effectively achieves union and eradicates infection.

The Vascularized Fibular Graft in the Pediatric Upper Extremity: A Durable, Biological Solution to Large Oncologic Defects

Skeletal reconstruction after large tumor resection is challenging. The free vascularized fibular graft (FVFG) offers the potential for rapid autograft incorporation as well as growing physeal transfer in pediatric patients. We retrospectively reviewed eleven pediatric patients treated with FVFG reconstructions of the upper extremity after tumor resection. Eight male and three female patients were identified, including four who underwent epiphyseal transfer. All eleven patients retained a functional salvaged limb. Nonunion and graft fracture were the most common complications relating to graft site (27%). Peroneal nerve palsy occurred in 4/11 patients, all of whom received epiphyseal transfer. Patients receiving epiphyseal transplant had a mean annual growth of 1.7 cm/year. Mean graft hypertrophy index increased by more than 10% in all cases. Although a high complication rate may be anticipated, the free vascularized fibula may be used to reconstruct large skeletal defects in the pediatric upper extremity after oncologic resection. Transferring the vascularized physis is a viable option when longitudinal growth is desired.

Bilateral Fibular Graft: Biological Reconstruction after Resection of Primary Malignant Bone Tumors of the Lower Limb

This paper deals with bilateral vascularized fibular grafts (BVFG) as a method for reconstruction of metadiaphyseal defects of the femur and tibia in young patients suffering from malignant bone tumors of the lower limb. This reconstructional technique was used in 11 patients undergoing metadiaphyseal resection of lower limb malignant bone tumors. All patients with Ewing's sarcoma and osteosarcoma had multimodal treatment according to the EURO-E.W.I.N.G 99 or COSS-96 protocol. Median FU was 63 months. None of the patients experienced local recurrence during FU. 2 patients died due to distant disease during FU. Full weight- bearing was permitted after a mean of 8 months. The median MSTS score was 87%. Complications occurred in five patients. None of the complications led to failure of the biological reconstruction or to amputation. Biological reconstruction of osseous defects is always desirable when possible and aims at a permanent solution. Good functional and durable results can be obtained by using BVFG for the reconstruction of metadiaphyseal defects of the femur and tibia. Radiotherapy in the multimodal setting increases the risk for graft or fixation failure.

Biological Reconstruction for Sarcoma

Particularly in children and young adults, bone allografts and autografts seem to be a perfect and long-lasting alternative to the use of prostheses after bone resection due to bone or soft tissue sarcomas. However, several topics like osteoarticular massive allografts are still discussed controversially. Might allograft-prosthetic composites reconstructions serve as stable and durable alternatives? Questions like this as well as the long-term results have not been answered sufficiently yet. In a review, L. A. Holzer and A. Leithner focus on the historical highlights, the present role, and possible future options for biological extremity reconstruction. While hand transplantation is already an option, above-elbow transplantation or limb regeneration might become a topic in the future. K. Rabitsch et al. report their experience with intercalary reconstructions of the lower limb using a vascularized fibula and an allograft in 12 patients. Although the event-free survival was only 51% at a two-year follow-up full weight bearing was achieved in all cases with all autografts still in place. The authors conclude that this method is a stable and durable reconstruction technique. M. Niethard et al. illustrate their technique using bilateral vascularized fibular grafts for reconstruction of metadiaphyseal defects of the femur and tibia in 11 patients. Despite a similar complication rate as reported by K. Rabitsch et al., all of the complications were manageable without the loss of the biological reconstruction. The authors also report on the increased risk of fixation failure after radiotherapy. L. E. Ritacco et al. describe the workflow for structural allograft selection of their renowned three-dimensional virtual bone bank system. Preoperative planning includes a 3D CT-derived bone model to define the exact size and shape in comparison to the planned resection. F. Traub et al. provide a retrospective analysis of their experience in biological reconstruction following the resection of pelvic tumors. Twenty-seven patients were evaluated for oncological as well as clinical and functional outcome. Hip transposition was used in 16 patients, and autologous nonvascularized fibular grafts were used in five patients. Despite the difficult situation after pelvic resection, MSTS score (mean 16.5) was good or excellent in most of the patients. The second paper by K. Rabitsch et al. reports on the technique of distal radius osteoarticular allografts, which were used in five patients. With all allografts still in place at a mean follow-up of 32 months the functional results were good or excellent (DASH 8, Mayo wrist 84). L. A. Aponte-Tinao et al. describe their high level of experience in biological upper extremity reconstruction in 70 patients, including 38 osteoarticular allografts, 24 allograft-prosthetic composites, and eight intercalary allografts. After a mean follow-up of 5 years the authors conclude that intercalary humeral allografts had the best outcome, while the other techniques led to articular deterioration, fracture, and allograft resorption with the need for revision surgeries in 16 patients. G. L. Farfalli et al. compare 50 nonconstrained knee allograft-prosthetic composites with 36 matched constrained ones. In both groups the authors observed more allograft fractures when the prosthetic stem did not bypass the host-donor osteotomy. However, both groups had good or excellent MSTS functional scores. These papers represent an exciting and insightful snapshot of the current techniques of biological reconstruction after sarcoma resection. Some sophisticated methods, existing challenges, and possible future topics are highlighted in this special issue, which may inspire the reader and provide a stimulus for the present discussion on limb salvage techniques.

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.

Congenital pseudarthrosis of the tibia: Management and complications

Congenital pseudarthrosis of the tibia (CPT) is a rare pathology, which is usually associated with neurofibromatosis type I. The natural history of the disease is extremely unfavorable and once a fracture occurs, there is a little or no tendency for the lesion to heal spontaneously. It is challenging to treat effectively this difficult condition and its possible complications. Treatment is mainly surgical and it aims to obtain a long term bone union, to prevent limb length discrepancies, to avoid mechanical axis deviation, soft tissue lesions, nearby joint stiffness, and pathological fracture. The key to get primary union is to excise hamartomatous tissue and pathological periosteum. Age at surgery, status of fibula, associated shortening, and deformities of leg and ankle play significant role in primary union and residual challenges after primary healing. Unfortunately, none of invasive and noninvasive methods have proven their superiority. Surgical options such as intramedullary nailing, vascularized fibula graft, and external fixator, have shown equivocal success rate in achieving primary union although they are often associated with acceptable results. Amputation must be reserved for failed reconstruction, severe limb length discrepancy and gross deformities of leg and ankle. Distinct advantages, complications, and limitation of each primary treatment as well as strategies to deal with potential complications have been described. Each child with CPT must be followed up till skeletal maturity to identify and rectify residual problems after primary healing.

Double-barrel vascularised fibula graft in mandibular reconstruction: A 10-year experience with an algorithm

This retrospective study aims to report an algorithm to assist surgeons in selecting different modes of the double-barrel vascularised fibula graft for mandibular reconstruction. A total of 45 patients who underwent reconstruction of mandibular defects with different modes of the double-barrel vascularised fibula graft were reviewed. Our algorithm for deciding on any one of the different modes for different mandibular defects is influenced by factors including history of radiotherapy, the length of mandibular body defect and the need to preserve the inferior mandibular border. Post-operative functional outcomes included diet type and speech, and aesthetic results gained at post-operative 2 years. Patients with implant-borne prosthetic teeth underwent assessment of their masticatory function. There were four modes of mandibular reconstruction according to our algorithm, which included double-barrel vascularised fibula graft (n=21), partial double-barrel fibula graft (n=11), condylar prosthesis in combination with partial/double-barrel fibula graft (n=11), and double-barrel fibula onlay graft (n=2). Flap survival in all patients was 97.78%. Good occlusion, bony unions and wound closures were observed in 44 patients. Eleven patients received dental implantation in the transplanted fibula at post-operative 9-18th months. One patient wore removal partial dentures. For 11 patients with implant-borne prosthetic teeth, the average post-operative ipsilateral occlusal force was 41.5±17.7% of the contralateral force. Good functional and aesthetic results were achieved in 38 patients with more than 2 years of follow-up, including regular diet, normal speech and excellent or good appearance, especially for patients with dental rehabilitation. Good aesthetic and functional results can be achieved after dental rehabilitation by following our algorithm when choosing the different modes of double-barrel vascularised fibula graft for mandibular reconstruction.

Vascularized fibular grafts in patients with avascular necrosis of femoral head: a systematic review and meta-analysis

Vascularized fibular grafting (VFG) has been initiated to treat avascular necrosis of the femoral head (ANFH) since the late 1970s. There are a number of review articles updating the use of VFG to treat the ANFH. None of them applied statistical analysis for combining results from different studies to obtain a quantitative estimate of the overall effect and potential harm of VFG in comparison to other treatment. Several electronic databases were searched to find studies using VFG to treat ANFH. The outcomes sought included Harris Score, failure rate (conversion to total hip arthroplasty (THA) and/or femoral head collapse), and complications rate. Included studies were assessed for methodological bias and estimates of effect were calculated. Potential reasons for heterogeneity were explored. The clinical results of 69.0 % of VFG-treated patients and 25.0 % of non-VFG-treated patients were good to excellent (OR 0.13; p < 0.01). The conversion rate to THA of VFG-treated and that of other methods treated hips was 16.5 % and 42.6 % (OR 0.19; p < 0.001). Collapse rate of VFG-treated and that of non-VFG-treated hips was 16.7 % and 63.6 % (OR 0.09; p < 0.05). The complication rate of VFG-treated and that of other methods treated patients was 23.8 % and 8.9 % (OR 3.44; p = 0.09). For Steinberg stage I, II ANFH, failure rate of VFG-treated and that of non-VFG-treated hips was 9.8 % and 40.2 % (OR 0.17; p < 0.001). For Steinberg stage II, III ANFH, failure rate of VFG-treated and that of non-VFG-treated hips was 16.5 % and 42.8 %, respectively (OR 0.17; p < 0.001). VFG is a justified method that can prevent the ANFH from progressing to collapse, and that can retard or avoid hip replacement, especially in the hips of Steinberg stage I, II, and III.

Postoperative Alopecia in Children After Orthopaedic Surgery

To report the cases of postoperative alopecia encountered after orthopaedic surgery at a single-level I trauma pediatric hospital. We report on 3 children who developed postoperative alopecia after an orthopaedic surgery. The chart review included demographics and independent variables including age, ethnicity, weight, sex, presence of coexisting medical conditions, type and duration of surgery performed, examination findings at presentation and diagnosis of alopecia, and outcomes were recorded. Inpatient and outpatient clinic notes, operative reports, and recorded vital signs were also reviewed. Three children (2 female, 1 male) were noted to develop postoperative alopecia. The average age at surgery was 13.7 years (range, 12 to 16). There was no significant past medical history, and 2 of 3 patients had obesity as a comorbidity. The type of surgery included: 2 proximal femoral osteotomies with proximal femoral osteoplasties and 1 wide resection of a congenital tibia pseudarthrosis with contralateral vascularized fibular grafting and internal fixation. Mean surgical duration was 5.9 hours (range, 4.4 to 7.1), and no intraoperative episodes of hypotension (<50 mm Hg) or hypothermia (T<35.9°C) occurred. The patients presented 2 to 3 weeks after surgery with hair loss localized over the posterior portion of the head. All patients were noted to have hair regrowth within 8 to 12 weeks, with 1 patient fully recovered and 2 patients continuing hair regrowth at most recent follow-up. Postoperative alopecia is an uncommon but usually self-limited complication that can occur in children undergoing orthopaedic surgery. Although rare, the treating physician should be aware of its occurrence and course, and appropriate padding of the head during surgery is advised. Level IV--retrospective case series.

Ilizarov Distraction and Vascularized Fibular Osteocutaneous Graft for Postosteomyelitis Skeletal Deformity of the Forearm

The reconstruction of large skeletal defects secondary to osteomyelitis is a challenging problem. This paper reports on the treatment of bone defects caused by osteomyelitis of the radius using an Ilizarov distraction technique and a vascularized fibular graft. A 25-year-old man first presented with a right radial defect caused by osteomyelitis when he was 3 years old. His right forearm was shortened and angulated with a dislocation of the distal radio-ulnar joint. The defect in the radial shaft was noted on a radiograph. The reconstruction of his radial bone defect was performed in three separate operations. A two-stage Ilizarov application was performed. Ten months after this operation, the radial bone defect was reconstructed with a vascularized fibular osteocutaneous graft. The right radius was shortened by 10 mm due to the angulation in the distal fixation of the graft 14 years after surgery. Although limited motions of the right thumb extension and wrist supination were noted, other hand functions were adequately restored. The Ilizarov technique is an effective method for correcting distal radio-ulnar joint dislocations and shortened, angulated ulnar bones. The specific features of the vascularized fibular graft make it suitable for the bone reconstruction of large defects in the radius.

Evaluation of long-term outcomes of pasteurized autografts in limb salvage surgeries for bone and soft tissue sarcomas

Pasteurized autografts used in limb salvage operations for malignant musculoskeletal tumors have several advantages, including reduced disease transmission, economic efficiency, accessibility, and anatomical conformation. However, their use has been associated with bone absorption, fracture, and pseudarthrosis. Few studies exist which have assessed the long-term outcomes of pasteurized autografts. The purpose of this study was to investigate the clinical outcomes of patients treated with pasteurized autografts and to compare these outcomes across various graft types. A retrospective analysis of 46 patients treated with pasteurized autografts between 1992 and 2010 was conducted. The analysis included 22 intercalary bone grafts, 17 inlay grafts, 4 composite grafts, and 3 osteochondral grafts, with the mean follow-up period of 8.7years (2-17years). The 10-year survival rate of the 46 pasteurized autograft cases analyzed was 93.5%, and the average bone union time between host and pasteurized autogenous bone was 9.5months. Infections were identified in 6 (13%) patients, fractures in 7 (15%) patients, non-union in 8 (17%) patients, and bone absorption in 6 (13%) patients. Inlay grafts were completely incorporated with the host bone at the follow-up period. Combination with a vascularized fibular graft significantly reduced the risk of non-union and bone absorption (p<0.05 and p<0.01, respectively), with an average functional score of 23.1/30 (83.8%). Our findings show that pasteurized bone grafts in combination with vascularized fibular grafts have improved outcomes and potential clinical indications.

Value of a skin island flap as a postoperative predictor of vascularized fibula graft viability in extensive diaphyseal bone defect reconstruction

To evaluate the feasibility and reliability of free vascularized fibular graft with skin island flap for reconstruction of large diaphyseal bone defect. The clinical results of vascularized fibular graft and experiences related to the importance and reliability of a monitoring island flap for the reconstruction of various long-bone defects were reviewed in 87 patients. Bony reconstruction was achieved in 82 of the 87 patients. Arterial thrombosis of anastomosed vessel in two patients and venous congestion of monitoring flap in nine patients occurred in the early postoperative periods. All of them were managed by immediate thrombectomy and reanastomosis, alternatively the thrombotic veins were replaced by new veins to anastomose with the superficial veins in five patients. Partial flap necrosis was noted in six patients, but additional surgical intervention was not required. The vascularized fibula survived and bony fusion was achieved in all patients. Postoperative stress fractures of the fibula graft occurred in 19 (21.8%) patients (once in seven patients, twice in five patients, three or more times in seven) as the mechanical stress to the graft increased. Included fracture on the tibia in 12 patients, humerus in one and femur in six. Treatments included casting in 11 patients, percutaneous pinning in one case, and adjustment of external fixator in seven patients. Bony union was finally achieved an average of 9.6 months after fracture. Correct alignment between the recipient bone and the external fixator is a prerequisite to preventing graft fracture. Vascularized fibula transfer is a valuable procedure for long-bone defects, and a skin island-monitoring flap is a simple, extremely useful, and reliable method for assessing the vascular status of vascularized fibula. Level IV. Retrospective study.

Handgelenksarthrodese mit gefäßgestieltem Fibulasegment bei handgelenksnahen Unterarmtumoren

Total tumor resection and defect resconstruction by vascularized fibula graft and total wrist fusion. Primary extended bone tumors of the distal radius. Tumor infiltration of the whole carpus or of the neurovascular structures. En bloc resection of the tumor including the biopsy scar. Raising of a microvascular fibula graft including the peroneal vessels. Defect reconstruction using the fibula and stabilization of the total wrist fusion with a locking compression plate (LCP). Functional therapy of the fingers is possible, below elbow cast for 6 weeks. Weight bearing after 12 weeks according to bone healing. The operation technique described for preservation of the extremity in primary extended bone tumors of the distal radius was performed in our clinic in 2patients since 2009. Tumor-free and pain-free hand function was found at the 2.5-year follow-up examinations. The patients had free range of motion of the fingers and preserved sensorimotor function. The MSTS (Musculoskeletal Tumour Society) scores by Enneking were 80% and 70%.