Vascularized Fibular Graft Research Articles

Treatments of avascular osteonecrosis of the hip: Current treatments

Conservative treatments for aseptic osteonecrosis of the femoral head have their ancestor in the core decompression of the femoral neck, recommended by Ficat. Due to inconsistent results, this treatment has been optimized by either vascularized fibular grafting, or by injecting autologous stem cells into the necrotic zone. The French promoters have published long-term results, showing efficacy in the early stages of the disease, where the femoral head has not yet lost its sphericity. Over the last 10years, comparative studies, sometimes randomized, opposing them to simple core decompression, have been published by non-promoters, confirming the possibility of stabilization or even regression of necrosis area. But these techniques are not easy to implement. Cell therapy requires treatment of marrow samples by centrifugation to obtain a pellet with a high concentration of haematopoietic cells. The now proven long-term efficacy as well as the safety of this technique make it the method of choice for treating young patients detected at the sub-radiological stage by MRI. Unfortunately, many are seen late with detached cephalic cartilage or collapsed femoral head and have no other option than total hip arthroplasty. This technique is very reliable. With alumina ceramics, results of more than 20years show the absence of wear and osteolysis, although other complications such as instability or periprosthetic fractures may occur in these young and active patients.

有茎血管柄付き腓骨移植により再建した外傷後脛骨偽関節の 1 例

有茎血管柄付き腓骨移植により再建した外傷後脛骨偽関節の 1 例

Intercalary bone graft of the tibia: case series and review of the literature.

We report a series of patients treated with intercalary bone graft (IBG) of the tibia diaphysis (TD) after resection of primary bone tumors. The purpose of this study was to evaluate the mid- and long-term survival of TD IBG reconstruction in children and adults, characterizing patterns of success and failure. A total of 35 patients were included in this retrospective study. Median age was 22years (range, 8-57). This series included 19 patients (54.3%) treated with homologous bone graft alone and 16 patients (45.7%) treated combining intercalary allograft with fibular autograft. Complications were recorded according to Henderson classification. Median follow-up was 36months (range, 1-165). Local recurrence occurred in 2 patients (5.7%) after 12 and 60months, respectively. Major complications included graft fracture (9 cases), non-union (5 cases) and infection (4 cases). Other complications were axial deformity (2 cases), superficial infection (2 cases), compartmental syndrome (1 case). Intercalary bone grafts of TD have been recommended as a reliable solution with long-term success rates and good functional outcome in more than 80% of patients. However, approximately half of the patients may require further surgeries to treat major complications (deep infection, delayed or non-union and graft fracture). Additional vascularized fibula graft may ameliorate final result.

One bone forearm with vascularized fibular graft. Clinical experience and literature review

One-Bone-Forearm (OBF) is a procedure in which the proximal stump of the ulna is fixed to the distal stump of the radius. Historically, the indications for OBF have been represented by forearm instability due to trauma, infection, tumor resection, and congenital deformities with severe radius and ulna bone loss. When major bone loss prevents direct fixation between ulna and radius a Vascularized Fibular Bone Graft (VFBG) may allow forearm bone reconstruction and fixation. In this study we report our clinical experience in 4 cases of OBF with VFBG performed in 3 patients. Compared to standard OBF technique with direct osteodesis, OBF with VFBG showed similar clinical results and high rate of healing even in case of bone infection. Moreover, composite osteocutaneous VFBG might concurrently allow to treat local soft tissue defects.

Histopathological Findings of Failed Free Vascularized Fibular Grafting for Osteonecrosis of the Femoral Head after Long-Term Follow-Up.

Purpose The aim of this study was to report the histopathology of failed free vascularized fibular grafting (FVFG) for osteonecrosis of the femoral head (ONFH) after a mean follow-up of 11.5 years (ranged from 10.6 to 14.2 years). Methods Six hips of 5 patients with a history of steroid use, aged 34–67 years, were in stage II of ONFH as classified by the Ficat and Arlet classification at the time of FVFG treatment. Grafting failure led to osteoarthritis of the hip joint during a mean of 11.5 years of follow-up. Femoral head specimens were first evaluated macroscopically. Bone specimens were sectioned into long strips, divided into necrotic, transitional, and healthy zones, and then prepared for nondecalcified and decalcified histopathological examination using hematoxylin and eosin (HE) staining, Goldner's trichrome staining, and immunofluorescence (IF) staining. Results Femoral head articular cartilage surfaces appeared thin, opaque, and partially cartilaginous missing, with gradual collapse detected in weight-bearing areas. The interface with the fibular graft showed well union, with no obvious gaps between graft and host bone, as observed macroscopically. The necrotic area was filled with fibular graft, cancellous bone, and cartilaginous or soft tissue invasion. Histopathology results revealed well integration between fibular graft and host bone, with thickened trabecular bone. Gaps occurred in transitional and healthy zones. In the necrotic zone, cartilaginous or soft tissue invasion occurred, while thin or missing articular cartilage exposed subchondral bone to hip joint surfaces. By IF counterstaining with CD-31 and α-SMA, blood vessel transplanted during fibular grafting could be clearly observed along the graft from healthy to necrotic zones. In the necrotic zone, blood vessels presented obviously and spread into the surrounding area of the graft tip. Conclusion After FVFG procedure with a mean follow-up of 11.5 years, fibular grafts retained their integrity as viable, vascularized, cortical bone that fused well with host bone and formed thickened trabecular bone surrounding the surface of the graft. However, the revascularization of FVFG's blood vessels spreading from the tip of the fibular graft into subchondral area of necrotic lesion did not improve significantly in these failure cases. The local necrotic lesion failed to be repaired as healthy trabecular bone to buttress articular surface and was occupied by soft tissues.

Combined massive allograft and intramedullary vascularized fibula transfer: the Capanna technique for treatment of congenital pseudarthrosis of the tibia

Background and purpose — Congenital pseudarthrosis of the tibia (CPT) is caused by local periosteal disease that can lead to bowing, fracturing, and pseudarthrosis. Current most successful treatment methods are segmental bone transport and vascularized and non-vascularized bone grafting. These methods are commonly hampered by discomfort, reoperations, and long-term complications. We report a combination of a vascularized fibula graft and large bone segment allograft, to improve patient comfort with similar outcomes.Patients and methods — 7 limbs that were operated on in 6 patients between November 2007 and July 2018 with resection of the CPT and reconstruction with a vascularized fibula graft in combination with a bone allograft were retrospectively studied. The mean follow-up time was 5.4 years (0.9–9.6). Postoperative endpoints: time to discharge, time to unrestricted weight bearing, complications within 30 days, consolidation, number of fractures, and secondary deformities.Results — The average time to unrestricted weight bearing with removable orthosis was 3.5 months (1.2–7.8). All proximal anastomoses consolidated within 10 months (2–10). 4 of the 7 grafts fractured at the distal anastomosis between 6 and 14 months postoperatively. After reoperation, consolidation of the distal anastomosis was seen after 2.8 months (2–4). 1 patient required a below-knee amputation.Interpretation — This case series showed favorable results of the treatment of CPT through a combination of a vascularized fibula graft and large bone segment allograft, avoiding the higher reintervention rate and discomfort with ring frame bone transport, and the prolonged non-weight bearing with vascularized fibula transfer without reinforcement with a massive large bone segment allograft.

Quantitative Characterization of Bone Viability of Femoral Head and Subchondral Bone by Using Single Photon Emission Computerized Tomography/Computerized Tomography (SPECT/CT).

BackgroundVascularized fibular grafting (VFG) has been successfully employed for treating avascular necrosis of the femoral head (ANFH). In this study, we aimed to evaluate the bone viability of the femoral head and subchondral bone following VFG by using single photon emission computerized tomography and computerized tomography (SPECT/CT).Material/MethodsBetween March 2011 and June 2014, 14 ANFH patients (17 hips) treated with VFG at Zhongshan Hospital, Fudan University, were prospectively enrolled. The patients included 9 males and 5 females with an average age of 26.6 years (range, 18–34 years). According to the ARCO (Association Research Circulation Osseous) stage criteria, 3 hips corresponded to stage IIA, 4 hips to stage IIB, 2 hips to stage IIC, 5 hips to stage IIIA, and 3 hips to stage IIIB. A novel method based on SPECT/CT was developed to quantitative characterized the bone viability of femoral head and subchondral bone prior to surgery and at 3 months after VFG. All patients were followed for an average duration of 3.8 years (ranging 2.6–5.5 years).ResultsThe bone viability of the femoral head (Vfh) and subchondral bone (Vsb) of patients’ hips at ARCO stage III was 58.9±7.6 and 48.9±6.1, respectively, which were significantly lower than the preoperative Vfh (78.1±5.2) and Vsb (69.8±4.3) of hips at stage II (P<0.05). The Vfh of hips at stage II improved to 104.0±9.7 at 3 months post-intervention, and there was no significant difference compared with the Vfh (97.3±7.4) of hips at stage III (P=0.15). The Vsb of hips at stage III improved to 80.4±7.3 at 3 months after VFG; however, this value was significantly lower than that of hips at stage II (92.7±5.5) (P<0.05).ConclusionsThe Vfh and Vsb of our patients were associated with their ARCO stages, and could be improved after vascularized fibular grafting procedure as measured by SPECT/CT.

Clinical Outcome of Free Vascularized Fibula Graft in the Surgical Treatment of Extremity Osteosarcoma.

ObjectiveTo determine the clinical outcome and complications associated with use of free vascularized fibular graft (FVFG) in the resection and reconstruction of extremity osteosarcoma (OS).MethodsThis is a retrospective study recruiting a consecutive series of 18 patients who had undergone resection of extremity OS between May 2009 and June 2017 in our clinic center. Reconstruction of the bone defect with FVFG was performed for each patient. Surgery‐related complications and time of bone union were recorded at the follow‐up visit. The functional outcome of the reconstructed limb was assessed with the musculoskeletal tumor society (MSTS) scoring system. Patients were further classified into low extremity group and upper extremity group according to the tumor location. The Student t‐test was used to compare the surgical outcome between the two subgroups.ResultsThere were 11 males and seven females with an average age of 25.9 ± 14.2 years. The mean length of the bone resection was 11.9 ± 4.1 cm. The mean follow‐up duration was 3.1 ± 1.2 years. As for tumor location, six cases were located in the femur, five in the tibia, four in the humerus, two in the ulna, and one in the radius. All the patients had successful graft healing at an average of 4.9 months after surgery. At the 2‐year follow‐up, an excellent functional outcome was observed in 88.9% of the patients (n = 16). The mean score of MSTS was 27.0 ± 4.6. Screw loosening and autograft fracture were observed in one patient with femur tumor, who had a low MSTS score of 11. Besides, there were three cases with delayed incision healing. Patients with lower extremity OS were found to have significantly longer duration of hospital stay and more blood loss than those with upper extremity OS. The incidence of postoperative complication was higher in the lower extremity group but with marginal significance (0% vs 36.3%, P = 0.1). There was no significant difference regarding time to bone union and the functional outcome as indicated by MSTS score.ConclusionsFVFG technique can be effectively applied to the reconstruction of bone defects after OS resection with satisfactory functional outcome and low incidence of complications.

A cross sectional study of outcomes of muscle pedicle grafting in neck of femur fractures and avascular necrosis of femoral head

Avascular necrosis (AVN) of the femoral head is a progressive disease that generally affects patients in the second through fifth decades of life; if left untreated, it leads to complete deterioration of the hip joint. Treatments range from simple decompression of the femoral head, to muscle pedicle bone grafting of the involved area, or by using a vascularized fibular graft with varying degree of success. If the disease have progresses further causing secondary arthritis, Total Hip Arthroplasty may be necessary.We present a study of management of 60 young patients aged less than 50 years having either early stage AVN (stage I and II A/B of Ficat & Arlet classification) or Neck of the femur fractures, treated with quadratus femoris muscle pedicle bone grafting & cancellous screws. With aim To evaluate the results of the above modality in the management of AVN of the hip & neck femur fractures and to study the radiological & functional outcome of the procedure in young patients.

Is frozen tumour-bearing autograft with concurrent vascularized fibula an alternative to the Capanna technique for the intercalary reconstruction after resection of osteosarcoma in the lower limb?

The use of frozen tumour-bearing autograft combined with a vascularized fibular graft (VFG) represents a new technique for biological reconstruction of massive bone defect. We have compared the clinical outcomes between this technique and Capanna reconstruction. From June 2011 to January 2016 a retrospective study was carried out of patients with primary osteosarcoma of lower limbs who underwent combined biological intercalary reconstruction. Patients were categorized into two groups based on the reconstructive technique: frozen tumour-bearing autograft combined with concurrent VFG (Group 1) and the Capanna method (Group 2). Demographics, operating procedures, oncological outcomes, graft union, limb function, and postoperative complications were compared. A total of 23 patients were identified for analysis: eight in Group 1 and 15 in Group 2. There was no difference in the demographics (age, sex, and affected site) and operating procedures (resection length, duration of surgery, and blood loss) between the two groups. No significant difference was found in local recurrence in Group 1 versus Group 2 (p = 0.585). Mean union time for the frozen autograft-host junction was 8.4 months (7.0 to 11.0), significantly earlier than for the allograft-host junction in Group 2 (mean 14.1 months (10.0 to 28.0); p < 0.001). Mean Musculoskeletal Tumor Society scores in groups 1 and 2 were 90.3% (SD 7.4%) and 88.0% (SD 9.0%), respectively, with no significant statistical difference (p = 0.535). In terms of complications, infection (n = 1, 6.7%) and delayed union (n = 2, 13.3%) occurred in Group 2, but no such complications were observed in Group 1. Frozen tumour-bearing autograft in combination with VFG can be used as an alternative to the Capanna reconstruction in properly selected patients with osteosarcoma. Cite this article: Bone Joint J 2020;102-B(5):646-652.

Mid- to long-term results of modified non-vascularized allogeneic fibula grafting combined with core decompression and bone grafting for early femoral head necrosis

PurposeThe aim of this study was to determine mid-and-long term follow-up results of patients with early femoral head osteonecrosis who were treated by modified free vascularized fibular grafting combined with core decompression and bone grafting.MethodsForty-four patients at early ONFH were included in this study. Visual analog scale (VAS) pain scores, range of hip motion (ROM), and Harris hip score (HHS) were recorded to assess the clinical outcome; Western Ontario McMaster Osteoarthritis index (WOMAC) scores and Short Form 36 health survey (SF-36) were conducted to measure the living quality; X-ray film or magnetic resonance imaging (MRI) was used to evaluate radiographic progression; survivorship was defined as patients did not undergo the total hip arthroplasty (THA) or fusion at the last follow-up. Median follow-up was 7.4 years (6–8.2 years).ResultsThe mean VAS score, ROM, and HHS were significantly improved at the final follow-up compared with preoperative values (p < 0.001). Health assessment including WOMAC scores and SF-36 were also better than those preoperatively (p < 0.001). Seven patients progressed to Ficat III and the four patients progressed to Ficat IV with osteoarthritis. Eight patients who cannot tolerate the pain and had poor living quality underwent THA.ConclusionModified non-vascularized allogeneic fibula Grafting combined with core decompression and bone grafting could improve the clinical outcomes and enhance the quality of life for patients with early ONFH.

Surgical Outcomes, Complications, and Long-Term Functionality for Free Vascularized Fibula Grafts in the Pediatric Population: A 17-Year Experience and Systematic Review of the Literature.

In the pediatric population, bony defects of the extremities pose a significant challenge for which free vascularized fibular grafts (FVFGs) represent a valuable reconstructive option. The purpose of this study was to explore surgical outcomes, complications, and long-term functionality of FVFG for this patient group. Using MEDLINE and PubMed databases, studies were identified of pediatric extremity reconstruction using FVFG which reported functional outcomes and/or complications. The operative logs at a tertiary pediatric center were then reviewed for cases of FVFG between January 2000 and 2017. Demographic characteristics, surgical indications, operative details, graft survival, bony union, complications, and functionality of the reconstruction were recorded. A total of 366 studies were identified with 23 ultimately meeting inclusion criteria in the systematic review. In the institutional series, 29 patients were included with mean age of 9.7 years (1-17 years). Indications for reconstruction included malignant bone tumor (n = 11), osteomyelitis (n = 9), congenital pseudoarthrosis (n = 6), and osteofibrous dysplasia (n = 3). Major postoperative complications included graft nonunion (24.1%), fracture (17.2%), and hardware failure (17.2%). Thirteen patients (44.8%) experienced delayed complications, while two (6.8%) experienced an immediate complication. Complications occurred in the donor site in 2 cases and the recipient site in all 13 cases. Long-term graft survival was achieved in 27 patients (93.1%), and 23 (79.3%) had full functional recovery, with an average Musculoskeletal Tumor Society score of 90% (60-100%). Mean follow-up was 5.17 years (2-12 years). This review and institutional series demonstrate the versatility of FVFG to facilitate limb reconstruction in large defects or serve as a salvage option in complex cases. While immediate and donor-site complications are uncommon, delayed recipient-site complications are frequent, and patients and families should be counseled regarding this expectation. Though technically challenging, excellent long-term graft viability and functional recovery can be achieved in the large majority of patients.

Bony Hypertrophy in Vascularized Fibular Grafts.

Background: Vascularized fibula graft (VFG) transfer is an established method of repairing large skeletal defects resulting from trauma, tumor resection, or infection. It obviates the process of creeping substitution that conventional bone grafts undergo and therefore exhibits better healing and improved strength. The aim of this study is to evaluate hypertrophy in VFG. Methods: We retrospectively reviewed patients undergoing VFG and studied immediate and late postoperative radiographs. Orthogonal views were measured for width of graft cortex and intramedullary canal, as well as adjacent recipient bone. Changes were measured for total cross sectional area, cortical area, intramedullary area, and graft width. Results: Thirty patients were included in the analysis, with recipient sites including 3 forearm, 4 humerus, 12 tibia, and 11 femur. Mean follow-up was 7.6 years (0.5-24.9 years). Patients' mean age was 31 (16-59 years). Average hypertrophy was 254% in early postoperative period and 340% in the late postoperative period. There was rapid graft hypertrophy in early postoperative period that plateaued with time. The width of the graft increased over time but didn't exceed the width of the adjacent recipient bone. In the later postoperative period, the size of graft intramedullary canal increased. Upper and lower extremity grafts showed similar hypertrophy. Conclusions: Using VFG to treat large skeletal defects is an attractive option in part due to the graft's ability to hypertrophy. We describe an early period of periosteal hypertrophy, followed by endosteal hypertrophy. These processes have relevance to function, mechanical strength, and surgical decision-making.

大腿骨開放骨折後の骨欠損に対してMasquelet法と血管柄付き腓骨移植を併用した 1 例

大腿骨開放骨折後の骨欠損に対してMasquelet法と血管柄付き腓骨移植を併用した 1 例

A Case Report of a Free Vascularized Fibular Graft for Hand Reconstruction: Defect at the Metacarpal Region

A Case Report of a Free Vascularized Fibular Graft for Hand Reconstruction: Defect at the Metacarpal Region

Osseointegration of Dental Implants Placed in Free Fibula Graft

Objective: The aim of this article is to review survival/success rate of dental implants inserted invascularized free fibula grafts. Background: Placement of dental implants following mandibular reconstruction during ablative surgery using vascularized free fibula grafts has proved to be a successful technique to achieve good mastication and complete dental rehabilitation. Insertionof implantsinto the new mandible provides a better access to the bone, interdental relationships are easier to assess, and oral rehabilitation can be acquired in a short span of time. Result: Study design, treatment methods, follow-ups, defect location, and morphology varied among studies. A definite conclusion could not be reached. Future studies with long-term follow-ups are required. Conclusion: Osseointegration of dental implants is a relatively safe technique with minimal complications. Patient selection plays a vital role, dental implants may be placed primarily, thus reducing the time to oral rehabilitation. Vascularized fibula grafts are a suitable method of mandibular reconstruction and are amenable to be successful in both primary and secondary endosseous implantation.

Joint-preservation surgery for pediatric osteosarcoma of the knee joint.

The multi-disciplinary approach involving imaging, multi-agent chemotherapy, meticulous surgical procedures, and careful postoperative care has facilitated an increase in the use of limb-sparing surgery for pediatric osteosarcoma. Osteosarcoma usually occurs around the metaphysis of the distal femur or proximal tibia and needs wide excision with the adjacent joint and replacement by a megaprosthesis. The recent advancement in imaging modalities and surgical techniques supports joint-preservation surgery (JPS), involving the preservation of the adjacent epiphysis, for select patients following careful assessment of the tumor margins and precise tumor excision. An advantage of this surgery is that it maintains the adjacent joint and preserves the growth of the residual epiphysis, which provides excellent limb function. Various reconstruction options are available, including allograft, tumor-devitalized autograft, vascularized fibula graft, distraction osteogenesis, and custom-made implants. However, several complications are inevitable with these options, such as loosening, non-union at the host-graft junction, infection, fracture, implant loosening, breakage, deformity, limb-length discrepancy related to the reconstruction methods, or patient growth in pediatric osteosarcoma. Surgeons should fully understand the advantages and disadvantages of this procedure. In this review, we discuss the concept of JPS, types of reconstruction methods, and current treatment outcomes. It is our opinion that the further analysis by multi-institutional setting is necessary to clarify long-term outcomes and establish global guidelines on the indications and surgical procedure for JPS.

Bone Defect Management with Vascularized Fibular Grafts in the Treatment of Grade III-IV Osteomyelitis.

This study is a retrospective analysis of our experience in microsurgical bone transfers for complex limb reconstructions. The aim of this study is to evaluate reliability of the vascularized fibula technique: infection recurrence, hypertrophy, time to bone union, complications, and time to healing in severe osteomyelitis (Cierny-Mader III and IV) cases over a 38 to 93 month follow-up. From March 2010 until December 2015, 18 patients' limbs (6 females and 1 2 males; mean age 48.7 years) were reconstructed with 10 free fibula flaps, 5 pedicled fibula flaps, 3 peroneus brevis osteomuscular flaps. We reconstructed 2 radiuses, 2 ulnae, 4 femurs, 4 tibiae, 1 acetabulum and 3 fibular malleoli. We considered as successful results all cases where patients had successful functional bone reconstruction with no recurrence of infection during the follow up (mean time 63.6 months). We obtained 14 complete functional reconstructions, 2 limb salvages with impaired function, and 2 failures which underwent major amputations. In only one case there was an infection recurrence. The bone defect reconstruction with vascularized fibula grafts in severe bone infections is an effective option, but requires a well trained multidisciplinary team to manage the high rate of complications. Complications, in our series, were demonstrated to be significantly associated to patients defined as B-hosts according to Cierny-Mader's classification (P < 0.05), and caliber discrepancy between fibula and reconstructed bones such as Tibia and Femur (P < 0.005). Furthermore, stress fractures in the grafted fibulae were prognostic indicators for overall treatment failure (P < 0.05).

Analysis of vascularized fibula graft integration to the extracorporeal irradiated bone after replantation: 2-year follow-up

Background: Major bone segmental defects in oncologic patients continue as a therapeutic challenge to orthopedic surgeons. The few alternatives for its management and the relationship between functional outcome and surgical complications remain among the main restrictions for the indication of different techniques. One of these alternatives is the vascularized fibular graft in association with the creation of a bone channel made from resection of the tumor bone segment after being submitted to the extracorporeal irradiation technique. There is little subject information about long-term follow-up either prospective than retrospective studies. Aim of the study: Retrospective evaluation of vascularized fibular graft union capacity from diaphysis and metaphysis and its integration to the irradiated bone after transplantation. Methods: Eleven patients submitted to extracorporeal irradiation technique and replantation with vascularized fibular graft had their radiographic images on 6, 12 and 24 months of postoperative period evaluated. Results: We observed 45,4% in diaphysis integration in the first year and 72,7% in the second year of follow-up, progressive in the diaphysis focus, and maintenance of the metaphysis focus (33,3%). Conclusion: The fibula has a good capacity for bone integration, showing less influence on the union of the metaphysis portion.Descriptors: Bone Transplantation; Osteosarcoma; Microsurgery; Surgical Oncology.ReferencesMyers GJ, Abudu AT, Carter SR, Tillman RM, Grimer RJ. The long-term results of endoprosthetic replacement of the proximal tibia for bone tumours. J Bone Joint Surg Br. 2007;89(12):1632-37.Muscolo DL, Ayerza MA, Aponte-Tinao L, Farfalli G. Allograft reconstruction after sarcoma resection in children younger than 10 years old. Clin Orthop Relat Res. 2008;466(8):1856-62.Puri A, Gulia A, Jambhekar N, Laskar S. The outcome of the treatment of diaphyseal primary bone sarcoma by resection, irradiation and re-implantation of the host bone: extracorporeal irradiation as an option for reconstruction in diaphyseal bone sarcomas. J Bone Joint Surg Br. 2012;94(7):982-88.Hong AM, Millington S, Ahern V, McCowage G, Boyle R, Tatersall M et al. Limb preservation surgery with extracorporeal irradiation in the management of malignant bone tumor: the oncological outcomes of 101 patients. Ann Oncol. 2013;24(10):2676-80.Manfrini M, Vanel D, De Paolis M, Malaguti C, Innocenti M, Ceruso M et al. Imaging of vascularized fibula autograft placed inside a massive allograft in reconstruction of lower limb bone tumors. AJR Am J Roentgenol. 2004;182(4):963-70.Spira E, Lubin E. Extracorporeal irradiation of bone tumor. A preliminary report. Isr J Med Sci. 1968;4(5):1015-19.Krieg AH, Davidson, AW, Stalley PD. Intercalary femoral reconstruction with extracorporeal irradiated autogenous bone graft in limb-salvage surgery. J Bone Joint Surg Br. 2007;89(3):366-71.Ceruso M, Falcone C, Innocenti M, Delcroix L, Capanna R, Manfrini M. Skeletal reconstruction with a free vascularized fibula graft associated to bone allograft after resection of malignant bone tumor of limbs. Handchir Mikrochir Plast Chir. 2001;33(4):277-82.Ortiz-Cruz E, Gebhardt MC, Jennings LC, Springfield DS, Mankin HJ. The results of transplantation of intercalary allografts after resection of tumors. A long-term follow-up study. J Bone Joint Surg Am. 1997;79(1):97-106.Farfalli GL, Aponte-Tinao L, Lopez-Millán L, Averza MA, Muscolo DL. Clinical and functional outcomes of tibial intercalary allografts after tumor resection. Orthopedics. 2012;35(3):e391-96.Aponte-Tinao L, Farfalli GL, Ritacco LE, Averza MA, Muscolo DL. Intercalary femur allografts are an acceptable alternative after tumor resection. Cln Orthop Relat Res. 2012;470(3):728-34.

Evaluation of the Efficacy of Pasteurized Autograft and Intramedullary Vascularized Fibular Transfer for Osteosarcoma of the Femoral Diaphysis.

ObjectiveTo assess the treatment of osteosarcomas of the femoral diaphysis through wide en bloc excision and reconstruction of the defect by pasteurized autograft combined with vascularized fibular transfer.MethodsA single‐center, retrospective study was performed of 15 selected patients (six females, nine males) whose lesion in the middle diaphysis of the femur were treated by en bloc excision and reconstruction of the bone defect with recycled pasteurized autograft combined with vascularized fibular graft between January 2000 and December 2011. The primary diagnoses of the patients were osteosarcoma (15 patients), and one of these patients had a pathological fracture. The mean patient age at the time of surgery was 22.3 years (range, 10–40 years). All these cases of bone tumors were staged according to Ennekingʼs criteria with three stage IIA cases, and 12 stage IIB cases. The patients were examined clinically and radiologically every month during the first 6 months after surgery to exclude the evidence of infection and local recurrence, then at 3‐monthly intervals for 2 years and then at 6‐monthly intervals for life. Function was assessed using the Musculoskeletal Tumor Society Scoring system (MSTS).ResultsAt a mean follow‐up of 65.1 months (range, 31–131 months), all the patients had achieved bony union at the final follow‐up. The mean time to bone union of the proximal junctions of vascularized fibula was 8.7 months (range, 6.0–13.0 months) and that of the distal junctions was 9.2 months (range, 6.0–12.0 months). Mean union time of the proximal junctions of the pasteurized autogenous bone was 14.3 months (range, 10.0–25.0 months) and that of the distal junctions was 15.6 months (range, 10.0–27.0 months). There were two fractures of the pasteurized bone during the operation. One patient, in whom the plate had been removed after union at 3 years postoperatively, sustained a fracture in a fall. This was treated with external fixation and united uneventfully. One patient, in whom two of the proximal screws had been broken, developed coxa vara. There was no infection. There were three pulmonary metastases and no local recurrence. The mean function score was 81.8%. Five patients died of their underlying disease, and the disease‐specific survival of patients was 69.1%.ConclusionsPasteurized autogenous bone graft combined with a vascularized fibula graft is a useful reconstruction method for large bone defects after resection of osteosarcoma in the femur.