A vascularized fibula model to study vascularized canine bone grafts

We have refined the experimental canine vascularized fibula model in 26 dog experiments. Our results have demonstrated that both periosteal and endosteal blood flow are retained following end-to-end anastomosis of the bone graft pedicle artery and vein. The success of this model depends on detailed knowledge of the surgical anatomy and upon meticulous microvascular surgical technique.     

Prevention of ankle valgus after vascularized fibular grafts in children

Ankle valgus after the use of vascularized fibular grafts is a specific complication of the donor site ankle in the growing child. Incidence of this deformity and prevention strategy are documented poorly. The goal of the current study was to evaluate the rate of such deformities and to analyze efficiency of two prevention methods. Charts of 20 children surgically treated for sarcomas of long bones with a mean followup of 4.1 years were studied retrospectively. Ankle valgus was considered if the tibiotalar angle on radiographs with the patient standing was 5 degrees or greater in valgus than that of the opposite ankle, and deformity was considered severe if it required surgical treatment. Prevention was done in some patients with a tibiofibular syndesmotic screw or with reconstruction of the fibula using a tibial autograft. Valgus occurred in nine patients (45%) and was severe in five (25%). Valgus prevention with a syndesmotic screw was efficient and lacking in complications, whereas patients with fibula reconstruction had a high incidence of deformity and relevant complications. The authors recommend using a tibiofibular screw in all patients whose growth plates are open in the lower limbs at the time of surgery.     

Free vascularized fibula grafts in limb-salvage surgery

The authors review the outcome of a consecutive series of 24 free vascularized fibular grafts performed as part of a limb-salvage procedure following tumor excision. There were 15 women and nine men with a mean age of 26 years (range: 6 to 52 years). The minimum follow-up was 12 months. The mean length of the graft was 13.1 cm. (range: 4.5 to 25 cm). Fifteen grafts were used in the upper limb, eight in the lower limb, and one in the pelvis. Bony union was achieved in 21/24 patients at a mean of 9.3 months. Complications occurred in 13/24 patients of whom 11 required a second operation. Four patients died of metastatic disease. The mean Musculoskeletal Tumor Society (MSTS) functional score in the remaining 20 was 84.5 percent, with 16 patients having a good or excellent outcome. Free vascularized fibula grafts offer a reliable method of reconstruction after excision of bone tumors. Although the incidence of complications appears high, they are relatively easy to correct, bony union is achieved in the majority, and functional outcome is good.     

Free vascularized fibula grafts in surgery of the upper limb

Twenty patients with intractable diseases in the upper extremity were treated using free vascularized fibula grafts. There were 13 men and seven women. Three patients had traumatic bone defects, five had post-traumatic nonunions, two had congenital pseudoarthroses, seven had defects after tumor resection, and three had other lesions. The reconstructed sites were the humerus in two patients, the radius and/or ulna in 17, and the metacarpal and phalangeal bones in one. The length of the bone defect ranged from 3 to 18 cm (mean: 8.4 cm). Follow-up periods ranged from 6 to 204 months. No patient required additional bone grafts. The mean period required to obtain radiographic bone union was 4.4 months. There were no cases with fractures of the grafted bone, but malunion occurred in four cases. The vascularized fibula graft is indicated in patients with large bone defects or intractable nonunions in the humerus, radius, and/or ulna.     

Mandibular reconstruction in children using the vascularized fibula

In this study, the authors review their experience with vascularized fibula transfers for mandibular reconstruction in children. They outline the indications for such reconstruction, their method of contouring the fibula to accurately resemble the resected mandible, reconstruction of the temporomandibular joint, and the use of vascularized muscle for the management of associated soft-tissue deficiencies. Ten consecutive patients, 5 to 17 years of age and undergoing this procedure, were assessed from a medical, dental, radiographic, and photographic standpoint. The fibulae were elevated via a lateral approach, osteotomized, as required, and fixation was achieved with titanium miniplates and screws. All transfers survived, with viability confirmed by early postoperative bone scanning. Five patients had temporomandibular joint reconstruction, and five patients required simultaneous reconstruction of soft-tissue defects with associated vascularized muscle. The postoperative follow-up ranged from 3 to 30 months The occlusion of the remaining dentition, mandibular symmetry and projection, adequacy of lining and skin cover, and maximal mouth opening were reassessed. Occlusion was class 1 in all patients, and free-flap stability and function were in the normal range. However, soft-tissue contour was a problem. All wounds healed primarily without donor-site complications and with minimal recipient-site complications.     

Ipsilateral pedicle vascularized fibula grafts for reconstruction of tibial defects and non-unions

Between October 1983 and August 1998, 31 patients with non-union or bone defect of the tibia have undergone 32 vascularized fibula transfers to reconstruct lower legs. Of these 32 vascularized fibula transfers, there were 19 pedicle transfers from the ipsilateral leg. There were 17 males and two females. The average patient age was 53 (21 to 84) years old. All patients achieved good bone reconstruction. All patients are currently able to walk without a brace, except for one. As to major complications, three of these 19 had delayed union, with only one postoperative fracture. In the cases with delayed union or fractured grafted fibulas, the periods to walking without a brace were longer than in the cases without such major complications. From the results, the ipsilateral pedicle vascularized fibula graft appears to be a useful option for reconstruction of tibial defects.     

A quantitative analysis of donor site morbidity after vascularized fibula transfer

Eleven patients with free vascularized fibula graft transplants to the upper extremity were studied for donor-side morbidity effects. Based on their surgical follow-up times, the patients were divided into either group 1 (5 +/- 2 months) or group 2 (21 +/- 8 months) to examine the effects of surgical trauma more closely. Gait evaluation was performed using two walkways containing different ground conditions. Knee and ankle-foot motion was measured using a three-dimensional electrogoniometer. Basic temporodistance factors and ground reactions were obtained from foot switches, instrumented floor mats, and a force plate. A modified Cybex II isokinetic dynamometer was used to quantitate ankle-foot strengths. Moderate knee and ankle-foot motion changes were seen while walking on the level, sideslope, and ramp in patients evaluated less than 10 months after their surgical procedure. Minimal joint motion effects were discovered in patients with follow-up times longer than 10 months. Muscle strengths were significantly impaired in both groups, especially foot inversion and eversion. An inverse relationship existed between the length of resected fibula and ankle evertor muscle strength. Donor side morbidity does not appear to be caused by surgical soft-tissue trauma exclusively. These patients need to be studied for several more years to determine the long-term functional effects of free vascularized fibular graft transfer.     

Functional development of the donor leg after vascularized fibula graft in childhood

PURPOSE: To evaluate the effect of free vascularized fibula grafts on developing donor leg function, the authors reviewed their experience of procedures performed in children. METHODS: Over a 10-year period, 30 children (average age 7.2 years, without gender concern) underwent fibula harvest via an anterolateral approach. Graft length averaged 6.0 cm. Follow-up averaged 8 years. RESULTS: No vascular injury or shank dysplasia ensued. Neural injury occurred in 8 patients: to the profound peroneal nerve in 1 and to the superficial peroneal nerve in 7. Symptoms resolved spontaneously at 3 to 5 months in 6, but persisted in 2 patients in the latter group at 8 years' follow-up. Of 24 children who underwent rapid walking (200 m) followed by immediate stair climbing (50 steps), 2 (whose grafts were longer than average) had slight and 1 had obvious ankle pain. However, muscle strength and range of motion in the donor ankle were no different from values in the recipient leg in the 24 cases. X-ray findings showed that, with growth, the remaining 2 fibular segments in the donor leg became longer, but the length of the gap between did not change. Thus, the gap left by harvest became relatively shorter long after operation, benefiting the stability of the ankle joint in adulthood. CONCLUSION: Unlike free vascularized fibula grafts performed in adulthood, from which serious complications to the donor leg have been reported, the procedure performed in childhood appears not to have an adverse effect on functional development.     

Postoperative results of vascularized double fibula grafts for femoral pseudoarthrosis with large bony defect

In open femoral bone fractures osteomyelitis may develop as a complication. Many difficulties are experienced in the treatment of those fractures because an extended bone defect may be formed after repeated operations, and then amputation of the femoral bone becomes necessary. Since 1981 the present authors have performed the vascularized double fibula grafts in the treatment of 18 patients with successful results. With this grafting method, both vascularized double fibula grafts are collected at the same time, one as an intramedullary graft and the other as an onlay graft. The most important point in carrying out grafting by this method is to prepare the recipient bone bed adequately. In many cases, it is necessary to carry out the primary operation to curette the focus, and resect necrotic tissues and sequestrated bone before the vascularized double fibula grafts, and then grafting is performed as a second operation after infection has been controlled following the initial operation. Although differences in time required for recovery cannot be eliminated completely, it becomes possible for 16 out of 18 patients to walk without the use of a brace and crutches within 13 months on average. © 1994 Wiley-Liss, Inc.     

A comparative experimental study of vascularized and nonvascularized nerve grafts

In order to compare vascularized and nonvascularized nerve grafts in a normal bed, 96 median nerve grafts were performed in rabbits. The median nerves were grafted in situ bilaterally, whether vascularized or nonvascularized. The length of the grafts was 2 cm, 4 cm, or 6 cm. A morphometric study was performed eight weeks and 24 weeks after the operation. No significant differences were found between vascularized and nonvascularized grafts at the same levels of nerve grafts. However, significant differences between vascularized and nonvascularized grafts were found for 4-cm and 6-cm grafts at eight weeks, and for 6-cm grafts at 24 weeks postoperatively, comparing the proximal normal nerve segments with the nerve segments distal to the nerve grafts.     

An anatomic study of vascularized fibular grafts

Objective： To study the applied anatomy of the vascular and muscular innervations related to vascularized fibular grafts. Methods： Thirty-four cadaveric lower extremities were dissected for this study. The observations included fibular length, fibular nutrient artery, arcuate arteries, and innervation of fibular muscles. The fibulas were averagely divided into four segments and the locations of relevant vessels and nerves were ascertained. Results： All specimens had 1 fibular nutrient artery and 4-9 arcuate arteries except 1 specimen which had only 1 arcuate artery. The fibular nutrient artery and the first threearcuate arteries were constantly located between the distal half of the 1/4 segment and 2/4 segment of the fibula. The muscular branch of the superficial peroneal nerve passed through the surface of the periosteum in the 2/4 segment of the fibula.
Conclusions： The most proximal osteotomy point locates at the midpoint of the 1/4 segment by which it ensure the maximal potential for preserving the nutrient vessels. The muscular branch of the superficial peroneal nerve is fragile to injury at the 2/4 segment of the fibula.     

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. © 2009 Wiley‐Liss, Inc. Microsurgery, 2009.     

Congenital pseudarthrosis of the fibula and valgus deformity of the ankle in young children

Treatment of cases of congenital pseudarthrosis of the fibula presenting with severe or progressive valgus deformity in early childhood is challenging. The purpose of the study presented was to analyse the deforming mechanisms to get therapeutic recommendations for this condition. A 2.5-year-old child was treated by resection of pseudarthrosis and distal tibiofibular fusion (Langenskiold operation) with autogenous bone grafting, associated with subtalar arthroereisis: progressive correction of the deformity was achieved. A 21-month-old child was treated with resection of pseudarthrosis, homologous bone grafting and fibular osteosynthesis: after failure, Langenskiold operation with autogenous bone grafting was performed and stabilization of the deformity was achieved. In young children with congenital pseudarthrosis of the fibula and valgus deformity, early surgical treatment is advisable: fibular ostheosynthesis has limited indications; distal tibiofibular fusion remains the treatment of choice, providing correction that may exceed the simple stabilization of deformity expected. Radiographic findings lead the authors to suggest that part of the effectiveness of the procedure is due to abnormal growth patterns.     

吻合血管的游离腓骨移植修复桡骨远端骨缺损重建腕关节8例报告

目的 :评价吻合血管的游离腓骨移植重建骨巨细胞瘤切除后桡骨远端的可行性和疗效。方法 :将带血管的腓骨近端用 2或 3枚螺钉固定于大块切除瘤体后的桡骨远端 ,腓动脉两端与切断的桡动脉远近两端吻合 ,腓静脉与皮静脉吻合。膝关节外侧副韧带和股二头肌腱固定于胫骨的适当位置。结果 :平均骨愈合时间 3 .5个月。 5例术后 1周桡动脉造影 ,证实吻合的腓动脉血流通畅。末发现患侧前臂有残留性疼痛及腕关节不稳。腕关节外形基本正常 ,主动运动良好 ,患侧手的握力均比较满意。结论 :本方法是目前治疗桡骨远端骨缺损、重建腕关节较理想的方法     

Free vascularized nerve grafts: an experimental study in the rabbit

An experimental animal model of a vascularized graft is presented as an alternative to recover faster function. The technique is described and the model compared to a conventional graft in the sciatic nerve of a rabbit. Results are evaluated with histological studies and quantified using a computer to measure the thickness of the myelin sheath as a correspondence factor of regeneration. Results showed a more favorable regeneration when a vascularized graft was used.     

The role of vascularized fibula in skeletal reconstruction

Since March 1988, 144 oncologic bone resections have been surgically treated with vascularized fibula (VF). In 30 patients VF was used after the failure of previous reconstructions, while in 114 cases (79%) VF immediately followed tumor resection. In 14 cases VF was pedicled on its vessel and used to reconstruct the ipsilateral tibia. In 17 young children, the proximal fibula was used to reconstruct with a potential growth the proximal humerus, the distal radius or the proximal femur. In 103 cases VF was combined with bone allografts. In 70 of these the fibula was inserted inside the massive allograft as a viable rod. There were 7 mechanical failures, 9 deep infections, and 10 local recurrences. According to functional evaluation, 69 patients (48%) presented with excellent functional results, 39 patients (27%) had good results while fair of poor results were recorded in 36 cases (25%).     

A biomechanical analysis of donor-site ankle instability following free fibular graft harvest

BACKGROUND: Recent studies concerning the free fibular graft have focused on the high prevalence of donor-site morbidity. The prevalence of ankle pain has been reported to range from 10% to 40%, but its etiology is unclear. The literature is vague with regard to the amount of distal fibular bone that is needed to maintain ankle stability. The aim of the present study was to determine the percentage of the fibula that can be removed while still preserving ankle stability. METHODS: Eleven fresh, paired cadaveric legs were tested. One leg from each pair was tested with the foot mounted in three positions (neutral, 15 degrees of inversion, and 15 degrees of eversion) while an external and internal rotational torque and axial load were imposed. Each specimen was also mounted in a Telos apparatus, and a varus load was applied across the ankle. Each specimen was tested first with an intact fibula to establish baseline stability and then underwent sequential fibular resections, from proximal to distal, until ankle instability was encountered. The contralateral specimen from each pair was then used to evaluate repetitive loading of a stable distal fibular segment over 2000 cycles. RESULTS: Only 10% of the fibula was needed distally to maintain ankle stability. Once the residual fibular length was <10% of the total fibular length, a significant change in motion was seen in the ankle joint (p < 0.05). On visual inspection, a residual fibular length of 10% represented a fibular osteotomy just proximal to the syndesmotic ligaments. The greatest motion occurred with the ankle inverted and in external rotation. No significant change in ankle stability occurred during cyclic testing when the residual fibular length was 10% of the total fibular length. CONCLUSIONS: While previous reports in the literature have suggested that 6 to 8 cm of residual distal fibular length is needed to maintain ankle stability, our data support the possibility that ankle stability can be maintained with even less residual fibular length.     

吻合血管复合腓骨穿支皮瓣的应用解剖及临床应用

目的 报道吻合血管的复合腓骨穿支皮瓣的应用解剖及修复复合组织缺损的临床效果.方法 24侧下肢标本采用有色乳胶从腘动脉灌注,解剖观测腓动脉及其穿支血管的分布、蒂长、管径等.临床设计切取小腿外侧区的腓动脉穿支皮瓣与游离腓骨形成复合腓骨穿支皮瓣移植修复肢体复合组织缺损共16例,皮瓣面积为6 cm×4cm～16cm×8 cm,骨缺损长度6～16 cm,移植腓骨长度8～20 cm.结果 腓动脉沿途平均发出5.3支穿支,其中40.6%为肌皮穿支、59.4%为隔皮穿支,分布在腓骨后缘3.1 cm范围内.平均直径1.1 mm,穿支间距4～8 cm,外踝后上方15～25 cm、4～7 cm范围内均可发现穿支血管.移植的16例复合腓骨穿支皮瓣全部成活,随访10～36个月,平均22.3个月,移植的腓骨在术后3～5个月愈合,随时间延长及患者负重移植骨逐渐增粗.受区外形与肢体功能恢复满意.结论 腓动脉穿支数目及位置相对恒定,根据腓动脉皮穿支的发出位置,可设计复合腓骨穿支皮瓣,临床应用证明是修复肢体长段骨缺损合并皮肤软组织缺损的良好选择.