Free vascularized fibular grafts

Postoperative results in 21 patients with bone defects that had been treated with a free vascularized fibular graft (FVFG) were evaluated. Pathogeneses in 21 patients were bone defect or pseudarthrosis after trauma in eight, massive bone defect after resection of bone and soft tissue tumor in six, congenital pseudarthrosis of the tibia in six, and congenital arteriovenous fistula in the forearm in one patient. The follow-up ranged from 15 months to 12 years, with an average of four years and six months. At final review, 12 patients went on to primary bony union, and six additional patients obtained union following an additional conventional bone graft. Three FVFGs resulted in a non-vascularized fibular graft. However, two patients obtained union with additional bone graft. Only one patient failed to obtain bony union and eventually required an above-knee amputation. Bony union rates in congenital pseudarthrosis of the tibia treated with the FVFG were lower than those in other diseases. Variables related to the surgical procedures and other factors affecting results and complications were also evaluated.     

Free vascularized fibular grafts for reconstruction of skeletal defects

Nourished by the peroneal vessels, the versatile free vascularized fibular graft can be transferred to reconstruct skeletal defects of the extremities. It may be combined with skin, fascia, muscle, and growth-plate tissue to address the needs of the recipient site. It may be cut transversely and folded to reconstruct the length and width of tibial or femoral defects. The main indications for this graft are defects larger than 5 to 6 cm or with poor vascularity of the surrounding soft tissues. Detailed preoperative planning, experience in microvascular techniques, and careful postoperative follow-up are necessary to minimize complications and improve outcome. The free vascularized fibular graft has been successfully applied as a reconstruction option in patients with traumatic or septic skeletal defect, after tumor resection, and has shown promise in patients with congenital pseudarthrosis.     

Free vascularized fibular graft

A case of severe bone and soft-tissue injury of the anterior side of the lower leg is presented. Extent of loss of the tibia was 20 cm. Loss of tibia was covered with free vascularized fibular graft extended to 26 cm, which appears to be the longest ever reported. Repair was successful.     

Late fracture of vascularized fibular grafts

Subsequent fractures following the bone union were analyzed in 62 cases of vascularized fibular graft reconstruction. Fifteen cases (24%) of fractures, including four cases of two fractures, were observed. All fractures but one occurred within a year after obtaining bone union. Eighteen fractures occurred in the lower extremity. In the patients with tibial reconstructions, a significantly higher incidence of fractures was demonstrated in cases where there was a large bone defect and an inaccurate alignment of the graft. Proper graft alignment is an important factor in preventing stress fractures. Vascularized fibular grafts should be protected against excessive mechanical stresses during the first year following bony graft union. © 1998 Wiley-Liss, Inc. MICROSURGERY 18:337–343, 1998     

Free vascularized fibular grafts in the treatment of congenital pseudarthrosis of the tibia

Five patients with congenital pseudarthrosis of the tibia treated by a free vascularized fibular graft are described. Follow-up evaluation ranged from 15 to 81 months, with a mean of 40 months. Bony union was attained in three of five cases as determined roentgenographically. The remaining two cases failed to attain bony union. All cases except one, who was treated with a below-knee amputation, subsequently attained bony union. However, four cases had five fractures after bony union. We discussed unsolved problems regarding the free vascularized fibular graft and fracture after bony union.     

Free vascularized nail grafts

A considerable amount of literature has been written on microneurovascular surgery for the reconstruction of partial defects in fingers, but little has been published on reconstruction to replace lost fingernails. We report on two clinical cases in which a free vascularized nail graft and a “double onychocutaneous flap” were used successfully. We suggest that the free vascularized nail graft is a superiormethod in reconstruction to treat fingernail loss or deformity.     

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.     

Medial femoral condyle vascularized bone grafts for scaphoid nonunions

Free vascularized bone grafts from the medial femoral condyle provide both structural support and blood supply to promote union in the difficult subset of scaphoid nonunions complicated by humpback deformity and proximal pole avascular necrosis. These nonunions have not consistently achieved union when treated with grafts which fail to restore scaphoid geometry or vascularity. The rationale, indications, contraindications, technique and results of bone grafting scaphoid nonunions with grafts harvested from the medial femoral condyle are presented.     

Free vascularized bone transplants in problematic nonunions of fractures

Three cases with nonunion of long bones and problems of bone loss or infection, when conventional bone graft would probably not have been successful, were treated successfully by free vascularized bone transplant to provide a vascular bed in the nonunion site and internal splint, the donor bone being the composite rib graft based on posterior intercostal vessels and proximal fibula based on its peroneal vascular pedicle. The operative technique was divided into five stages, and each stage posed different problems at the donor and recipient areas and vessel anastomoses. Despite these disadvantages, all three cases proceeded to solid bony union in less than 4 months after surgery. Thus the patients were able to be rehabilitated early to retain satisfactory limb function within a relatively short period of time.     

Free vascularised fibular grafts in orthopaedics

Bony defects caused by trauma, tumors, infection or congenital anomalies can present a significant surgical challenge. Free vascularised fibular bone grafts (FVFGs) have proven to be extremely effective in managing larger defects (longer than 6 cm) where other conventional grafts have failed. FVFGs also have a role in the treatment of avascular necrosis (AVN) of the femoral head, failed spinal fusions and complex arthrodeses. Due to the fact that they have their own blood supply, FVFGs are effective even in cases where there is poor vascularity at the recipient site, such as in infection and following radiotherapy. This article discusses the versatility of the FVFG and its successful application to a variety of different pathologies. It also covers the applied anatomy, indications, operative techniques, complications and donor-site morbidity. Though technically challenging and demanding, the FVFG is an extremely useful salvage option and can facilitate limb reconstruction in the most complex of cases.     

Ankle and pantalar arthrodeses using vascularized fibular grafts

From 1989 to 1998 ankle and pantalar arthrodeses using vascularized fibular grafts were performed for seven patients. The indications for surgery were chronic nonunion following fracture of the distal tibia in four patients, rheumatoid arthritis in two, and talus necrosis in one. The ankle joint was fused in the two patients with a pilon fracture, and in the other five patients, both the ankle and subtalar joints were fused. In one patient, additional bone grafting was required for delayed union. In the other six patients, the mean period required to obtain radiographic bone union was 6 months (range, 4-9 months). The time until the patients could walk without braces ranged from 6 to 20 months (mean, 12.3 months). Local infection was not encountered in any patients. This procedure represents a viable option for patients in whom a standard, less complicated arthrodesis cannot be performed.     

Free vascularized fibular flap in distal radius reconstruction

Free vascularized bone transfers are indicated to reconstruct large bone loss, either after traumatism or bone tumor resection. Free vascularized fibular transplant is particularly well designed for reconstruction of large defect of the distal radius. Anatomy is constant and harvesting is versatile and reliable. It may be used as bony transplant alone, osteocutaneous or osteocutaneomuscular. The length of the fibula harvested can be up to 25 cm. In children bone reconstruction, the proximal physis of the fibula can be transferred to allow secondary bone growth but there is a need for double anastomosis of the anteriotibial and the fibular bundles. Donor site sequelae are minimal.     

Free vascularized fibular bone flap in the rat

Free vascularized fibula bone flap has been widely used in reconstruction of the mandible, long segment defect, congenital pseudarthroses, and osteomyelitis. Such applications stirred an interest in basic studies of bone biology, bone healing process, and incorporation of recipient bone defect. An experimental free vascularized fibula rat model is presented here for such investigations. We performed 16 angiograms and anatomic dissections in eight rats for collecting data on fibular length, blood supply, and the caliber of significant vessels. The fibula was harvested with part of the flexor hallucis longus muscle with an average length of 28 mm. The pedicle can be taken in continuity with the popliteal vessels (average diameter of 0.8 mm and 0.9 mm of artery and vein, respectively, with an average pedicle length of 14 mm). This vascularized fibula bone was harvested and transferred to the groin area of the same rat and anastomosed to the saphenous vessels. Twelve transplantations were performed, with a 7-day flap survival rate of 100%. The free fibula vascularized bone flap in the rat is a reliable model for further investigations.     

Dorsal distal radius vascularized pedicled bone grafts for scaphoid nonunions

Fractures of the scaphoid, particularly its proximal pole, are at risk of progressing to nonunion because of the tenuous, retrograde blood supply. The overall incidence of scaphoid fractures developing nonunion ranges from 10% to 15%, whereas proximal pole fractures of the scaphoid can have up to a 30% incidence of nonunion. Avascular necrosis of these proximal pole fractures can occur in 14% to 39% of cases. Dorsal distal radius vascularized pedicled bone grafting is an alternative to conventional measures for the treatment of displaced proximal pole fractures, established nonunions, and avascular necrosis of the proximal fragment. This graft is based on the 1,2-intercompartmental supraretinacular artery, which has reliable anatomy and predictable course between the first and second extensor compartments. The graft can be harvested and inset into the prepared fracture site using a single-incision approach. The indications, contraindications, technique, and results of treatment are reviewed and detailed.     

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 osteocutaneous fibular graft to the tibia

We reviewed the clinical results of reconstruction performed for extensive tibial bone and soft tissue defect with a free vascularized osteocutaneous fibular graft in 46 patients (43 male and 3 female). The mean duration of follow-up was 30 months (range 13-76 months). The mean age at the time of reconstruction was 41 years (range 15-66 years). In the 46 consecutive procedures of free vascularized osteocutaneous fibular grafts, bony union was achieved in 43 grafted fibulae at an average of 3.75 months after operation. There were two delayed unions and one non-union. Forty-four cutaneous flaps survived, and two cutaneous flaps failed due to deep infection and venous insufficiency. One necrotized cutaneous flap was replaced with a latissimus dorsi free flap and the other with a soleus muscle rotational flap without replacing the grafted fibulae; unions were obtained without significance complications. All grafted fibulae hypertrophied during the follow-up periods. The most common complication was fracture of the grafted fibulae in 15 patients, and it occurred at an average of 9.7 months after the reconstruction. The fractured fibulae were treated with long leg above-the-knee cast immobilization or internal fixation with conventional cancellous bone graft. Free vascularized osteocutaneous fibular graft is a good treatment modality for the reconstruction of extensive bone and soft tissue defect in the leg. Fracture of the grafted fibula, one of the most common complications after this operation, can easily be treated with cast immobilization or internal fixation with conventional cancellous bone graft.     

Free vascularized fibular graft for tibial pseudarthrosis in neurofibromatosis

Four patients with neurofibromatosis and a dysplastic type of congenital pseudarthrosis of the tibia were treated by resection of the lesion and reconstruction of the extremity with a free vascularized fibular graft. Solid union of the graft was achieved within 3 months in 3 children. However, valgus malalignment of the tibia progressed in all 3. One child was treated with resection of a lateral fibrotic band and another with distal tibial epiphysial distraction and realignment. In the fourth patient, who was skeletally mature, a nonunion developed proximally.     

Free vascularized fibular graft for tibial pseudarthrosis in neurofibromatosis

Four patients with neurofibromatosis and a dysplastic type of congenital pseudarthrosis of the tibia were treated by resection of the lesion and reconstruction of the extremity with a free vascularized fibular graft. Solid union of the graft was achieved within 3 months in 3 children. However, valgus malalignment of the tibia progressed in all 3. One child was treated with resection of a lateral fibrotic band and another with distal tibial epiphysial distraction and realignment. In the fourth patient, who was skeletally mature, a nonunion developed proximally.     

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.