Does the Addition of a Vascularized Fibula Improve the Results of a Massive Bone Allograft Alone for Intercalary Femur Reconstruction of Malignant Bone Tumors in Children?

BackgroundMassive bone allograft with or without a vascularized fibula is a potentially useful approach for femoral intercalary reconstruction after resection of bone sarcomas in children. However, inadequate data exist regarding whether it is preferable to use a massive bone allograft alone or a massive bone allograft combined with a vascularized free fibula for intercalary reconstructions of the femur after intercalary femur resections in children. Because the addition of a vascularized fibula adds to the time and complexity of the procedure, understanding more about whether it reduces complications and improves the function of patients who undergo these resections and reconstructions would be valuable for patients and treating physicians.Questions/purposesIn an analysis of children with bone sarcomas of the femur who underwent an intercalary resection and reconstruction with massive bone allograft with or without a vascularized free fibula, we asked: (1) What was the difference in the surgical time of these two different surgical techniques? (2) What are the complications and number of reoperations associated with each procedure? (3) What were the Musculoskeletal Tumor Society scores after these reconstructions? (4) What was the survival rate of these two different reconstructions?MethodsBetween 1994 and 2016, we treated 285 patients younger than 16 years with a diagnosis of osteosarcoma or Ewing sarcoma of the femur. In all, 179 underwent resection and reconstruction of the distal femur and 36 patients underwent resection and reconstruction of the proximal femur. Additionally, in 70 patients with diaphyseal tumors, we performed total femur reconstruction in four patients, amputation in five, and a rotationplasty in one. The remaining 60 patients with diaphyseal tumors underwent intercalary resection and reconstruction with massive bone allograft with or without vascularized free fibula. The decision to use a massive bone allograft with or without a vascularized free fibula was probably influenced by tumor size, with the indication to use the vascularized free fibula in longer reconstructions. Twenty-seven patients underwent a femur reconstruction with massive bone allograft and vascularized free fibula, and 33 patients received massive bone allograft alone. In the group with massive bone allograft and vascularized fibula, two patients were excluded because they did not have the minimum data for the analysis. In the group with massive bone allograft alone, 12 patients were excluded: one patient was lost to follow-up before 2 years, five patients died before 2 years of follow-up, and six patients did not have the minimum data for the analysis. We analyzed the remaining 46 children with sarcoma of the femur treated with intercalary resection and biological reconstruction. Twenty-five patients underwent femur reconstruction with a massive bone allograft and vascularized free fibula, and 21 patients had reconstruction with a massive bone allograft alone. In the group of children treated with massive bone allograft and vascularized free fibula, there were 17 boys and eight girls, with a mean ± SD age of 11 ± 3 years. The diagnosis was osteosarcoma in 14 patients and Ewing sarcoma in 11. The mean length of resection was 18 ± 5 cm. The mean follow-up was 117 ± 61 months. In the group of children treated with massive bone allograft alone, there were 13 boys and eight girls, with a mean ± SD age of 12 ± 2 years. The diagnosis was osteosarcoma in 17 patients and Ewing sarcoma in four. The mean length of resection was 15 ± 4 cm. The mean follow-up was 130 ± 56 months. Some patients finished clinical and radiological checks as the follow-up exceeded 10 years. In the group with massive bone allograft and vascularized free fibula, four patients had a follow-up of 10, 12, 13, and 18 years, respectively, while in the group with massive bone allograft alone, five patients had a follow-up of 10 years, one patient had a follow-up of 11 years, and another had 13 years of follow-up. In general, there were no important differences between the groups in terms of age (mean difference 0.88 [95% CI -0.6 to 2.3]; p = 0.26), gender (p = 0.66), diagnosis (p = 0.11), and follow up (mean difference 12.9 [95% CI-22.7 to 48.62]; p = 0.46). There was a difference between groups regarding the length of the resection, which was greater in patients treated with a massive bone allograft and vascularized free fibula (18 ± 5 cm) than in those treated with a massive bone allograft alone (15 ± 4 cm) (mean difference -3.09 [95% CI -5.7 to -0.4]; p = 0.02). Complications related to the procedure like infection, neurovascular compromise, and graft-related complication, such as fracture and nonunion of massive bone allograft or vascularized free fibula and implant breakage, were analyzed by chart review of these patients by an orthopaedic surgeon with experience in musculoskeletal oncology. Survival of the reconstructions that had no graft or implant replacement was the endpoint. The Kaplan-Meier test was performed for a survival analysis of the reconstruction. A p value less than 0.05 was considered significant.ResultsThe surgery was longer in patients treated with a massive bone allograft and vascularized free fibula than in patients treated with a massive bone allograft alone (10 ± 0.09 and 4 ± 0.77 hours, respectively; mean difference -6.8 [95% CI -7.1 to -6.4]; p = 0.001). Twelve of 25 patients treated with massive bone allograft and vascularized free fibula had one or more complication: allograft fracture (seven), nonunion (four), and infection (four). Twelve of 21 patients treated with massive bone allograft alone had the following complications: allograft fracture (five), nonunion (six), and infection (one). The mean functional results were 26 ± 4 in patients with a massive bone allograft and vascularized free fibula and 27 ± 2 in patients with a massive bone allograft alone (mean difference 0.75 [95% CI -10.6 to 2.57]; p = 0.39). With the numbers we had, we could not detect a difference in survival of the reconstruction between patients with a massive bone allograft and free vascularized fibula and those with a massive bone allograft alone (84% [95% CI 75% to 93%] and 87% [95% CI 80% to 94%], respectively; p = 0.89).ConclusionWe found no difference in the survival of reconstructions between patients treated with a massive bone allograft and vascularized free fibula and patients who underwent reconstruction with a massive bone allograft alone. Based on this experience, our belief is that we should reconstruct these femoral intercalary defects with an allograft alone and use a vascularized fibula to salvage the allograft only if a fracture or nonunion occurs. This approach would have resulted in about half of the patients we treated not undergoing the more invasive, difficult, and risky vascularized procedure.Level of Evidence Level III, therapeutic study.     

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.     

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.     

腓骨移植治疗肢体侵袭性骨肿瘤和恶性骨肿瘤

目的：比较游离腓骨或吻合血管腓骨移植治疗切除四肢侵袭性骨肿瘤或恶性骨肿瘤后引起的长段骨缺损的临床疗效。方法：对１８例吻合血管移植及４例游离腓骨移植术的病例术后，采用ＥＣＴ、彩色多普勒血管超声检查、Ｘ线照片检查及随访，时间为术后２～１２年，移植骨最长达２６ｃｍ。结果：侵袭性骨肿瘤和恶性骨肿瘤１８例，肿瘤切除后用吻合血管腓骨移植重建缺损，１５例桡骨远端骨巨细胞瘤患者作游离腓骨移植重建缺损，结果前者愈合良好，移植骨片与受骨接合牢固，游离腓骨移植则愈合较差。结论：吻合血管腓骨移植可一期重建因骨肿瘤或骨恶性肿瘤广泛切除后造成的６ｃｍ以上的骨缺损，其优越性远远超过游离腓骨移植。     

Ischemic optic neuropathy and implications for plastic surgeons: report of a new case and review of the literature

The healing process of structural pasteurized autogenous bone graft has not been studied in detail. The purpose of this investigation was to assess the reparative process of pasteurized bone graft histologically, and clarify the factors influencing the outcome. From among 51 cases using pasteurized autogenous bone graft since 1992, 10 specimens were retrieved after lower extremity reconstruction of tibia or femur with or without simultaneous fibula flap, and subjected to the analysis. Regeneration of the grafted bone was assessed as the ratio of the number of viable cells to that of whole cells. Pasteurized bone combined with a vascularized fibula showed markedly better repair. Long duration from implantation to retrieval was associated with a better reparative process with vascularized fibula (P = 0.03), whereas other factors had no significant impact. This study demonstrated that pasteurized autogenous bone graft remained structurally stable for many years, although facilitators such as the combined use of a vascularized fibula are required to promote regeneration of the graft.     

带血管腓骨复合异体骨修复长骨肿瘤切除后骨缺损

目的 探讨带血管腓骨复合异体骨重建长骨恶性肿瘤切除后骨缺损的临床结果.方法 2006年4月至2009年10月对19例四肢长骨恶性骨肿瘤患者行保肢手术,男11例,女8例;年龄11～37岁,平均(18.5±7.6)岁.肱骨5例、股骨7例、胫骨7例.肿瘤切除后骨缺损长度(13.2±4.3)cm,采用带血管自体腓骨复合大段异体...     

Asynchronous osteoradionecrosis of the mandible treated with sequential fibula osteoseptocutaneous flaps: a report of two cases

Osteroradionecrosis of the mandible is one of the most serious complications of radiotherapy in head and neck cancer. Once osteoradionecrosis of the mandible has been established, conservative therapy is often useless. Two cases of asynchronous bilateral osteoradionecrosis of the mandible are presented. In both cases, successful reconstruction was performed with 2 free fibula osteoseptocutaneous flap transfers from both legs. We believe that adequate debridement, with removal of dead or hypovascular bone and surrounding soft tissue, followed by vascularized composite bone grafts, is the key for a successful outcome. In our cases, the oral function after 2 reconstructive surgeries with the fibula osteoseptocutaneous flap was acceptable. Furthermore, the patient could walk without difficulty.     

游离皮瓣在组合移植中的应用

目的 探讨游离皮瓣在组合移植中的应用及其临床效果。方法1991年1月～2003年12月，行皮瓣或肌皮瓣的组合移植手术56例，其中男37例，女19例。年龄5～41岁，平均27．6岁。分别修复肢体特大面积软组织缺损、大面积皮肤和节段性长管状骨复合缺损，实现合并皮肤缺损的拇指缺失的一期修复和再造。移植的组织包括背阔肌肌皮瓣、肩胛皮瓣、股外侧皮瓣、拇趾皮肤趾甲瓣以及腓骨。移植组织的共同血管蒂与受区血管直接吻合建立血液循环者35例，以桥式交叉方式与健侧肢体选定的血管吻合建立临时血液供应者21例。结果所有患者获随访10～128个月，平均28个月，除2例背阔肌肌皮瓣与游离腓骨组合移植失败外，余均成活。涉及骨缺损修复成功的32例，移植的腓骨平均术后14．5周与宿主骨连接。术后修复和重建的肢体均恢复负重和活动功能；其中1例小腿皮肤与骨骼复合缺损成功修复3年后，因足趾压迫性溃疡而要求截肢。结论游离皮瓣在组合移植中的应用能有效实现肢体复杂组织缺损的修复和复杂缺失的再造。     

Osteocutaneous free transfer of vascularized fibula in cervico-thoracic spinal reconstruction with filling of an esophageal fistula: A case report

The case under review is a 60-year-old patient with a vertebral plasmocytoma treated by cervico-thoracic fusion 2 years previously. He presented a thoracic spinal septic non-union complicated by esophagospinal fistula. We performed vascularized fibula transplant with cutaneous pad to fill the esophageal fistula. Control CT at day 5 confirmed vascular anastomosis permeability and bone transplant position. Osseointegration was achieved at 18 months postoperatively. The patient was alive 3 years after the last procedure (5 years after tumorectomy). A systematic review of the literature on spinal reconstruction by vascularized fibula transplant showed the diversity of surgical techniques available. In view of the multiplicity of possible organ and soft tissue defects involving the spine, reminders are provided of the different approaches and recipient vessels in this type of reconstruction depending on location.     

Microsurgical reconstructive surgery following wide resection of bone and soft tissue sarcomas in the upper extremities

A preliminary report is presented of six cases of microsurgical tissue transfer following wide tumor resection, utilizing free vascularized fibula graft (five cases) and free vascularized muscle graft (one case). In five cases, the grafted tissue survived completely, and the attempted functional reconstruction was successful. Although the follow-up period has been relatively short, there has been no local recurrence or distant metastasis in any of the cases.     

Combined osteocutaneous microvascular flap procedure for extensive bone and soft tissue defects in the tibia

Recent experience with bone healing seems to advocate vascularized bone grafts in cases of large bone gaps or significant scarring, following irradiation, in the presence of low-grade infection, and in congenital pseudarthrosis of the tibia. When extensive bone and skin replacement are needed, the microvascular procedures currently available may not meet specific reconstructive requirements. To augment the advantages of the vascularized fibular graft for tibial substitution (strength, straightness, length, and predictability of vascular supply) with the benefits of free skin, muscle, or musculocutaneous flaps, separate on-demand harvesting of these tissue units and their microvascular combination can be useful in selected cases. In a study of 4 patients, the vascularized fibula was combined with a free latissimus dorsi flap. The procedure was facilitated and shortened by connecting the peroneal vessels to branches of the thoracodorsal or to the scapular circumflex artery and vein outside the operative field. The main supporting vessels of the combined composite tissue block were then anastomosed only to one pair of vessels in the leg.     

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.     

Intercalary reconstructions after bone tumor resections: a review of treatments

An intercalary reconstruction is defined as replacement of the diaphyseal portion of a long bone after segmental skeletal resection (diaphysectomy). Intercalary reconstructions typically result in superior function compared to other limb-sparing procedures as the patient’s native joints above and below the reconstruction are left undisturbed. The most popular reconstructive options after segmental resection of a bone sarcoma include allografts, vascularized fibula graft, combined allograft and vascularized fibula, segmental endoprostheses, extracorporeal devitalized autograft, and segmental transport using the principles of distraction osteogenesis. This article aims to review the indications, techniques, limitations, pros and cons, and complications of the aforementioned methods of intercalary bone tumor resections and reconstructions in the context of the ever-growing, brave new field of limb-salvage surgery.     

Free vascularized osteocutaneous fibular graft to the tibia in 51 consecutive cases

The authors reviewed retrospectively the clinical results of 51 consecutive cases of vascularized osteocutaneous fibular graft to the tibia for the reconstruction of extensive tibial bone and soft-tissue defects. The mean duration of follow-up was 31 months (range: 13 to 76 months). In the 51 procedures of free vascularized osteocutaneous fibula graft from the contralateral side, bony union was achieved in 48 cases at an average of 3.74 months after the operation, except for two cases of non-union and two cases of delayed union. Forty-eight cutaneous flaps survived, and three cutaneous flaps failed due to deep infection and venous thrombosis. All united fibulae hypertrophied during the follow-up periods. Stress fracture of the grafted fibula was the most common complication (16 cases), and it was treated with above-the-knee cast immobilization or internal fixation with a conventional cancellous bone graft. The free vascularized osteocutaneous fibular graft is recommended as a useful treatment modality for the reconstruction of extensive tibial defects combined with soft tissue injury.     

Simultaneous vascularized bony reconstruction of the maxilla and mandible using a single fibula: A case report

Simultaneous maxillary and mandibular reconstruction is exceedingly rare. These are complicated cases, requiring consideration of multiple variables: defect components, donor site morbidity, recipient vessels, and so forth. We describe a unique case of secondary maxillary/mandibular reconstruction in a 59‐year‐old male. The original defect was created after removal of a buccal squamous cell carcinoma, involving the external cheek skin, buccal mucosa, right mandibular body, and right inferior maxilla; a free vertical rectus abdominis musculocutaneous flap was used for the initial reconstruction. At the time of presentation to our clinic, the patient was tube‐feed‐dependent, unable to speak, and distressed regarding his appearance. We revised his reconstruction, rebuilding his maxilla and hemimandible using two free fibula flaps from a single fibula. The fibulae were vascularized via vein grafts and an ALT flap was used for external cheek resurfacing. All flaps survived and there were no complications at seven months since his surgery (when this report was written). The patient had intelligible speech and maintained adequate nutrition with a soft diet. Simultaneous vascularized bony reconstruction of the maxilla and mandible using a single fibula flap may be performed safely and with good outcomes.     

Bilaterales Fibulainterponat

Bilateral vascularized fibula graft (BVFG) is actually not a satisfying method for the replacement of metadiaphyseal defects of the femur and tibia in young patients suffering from malignant bone tumors. This reconstruction was used in five patients (two female, three male, average age 15.2 years, femur n=3, tibia n=2) undergoing metadiaphyseal resection of malignant bone tumors between November 2000 and August 2003. The median length of the defect to be bridged was 16.4 cm (range 11.5-23). In the two cases of tibia reconstruction, the ipsilateral fibula was transposed into the osseous defect (fibula pro tibia). The vessels of the contralateral fibula graft were microscopically anastomosed end-to-side upon the a. and v. tibialis anterior. For the reconstruction of femoral defects, two free fibula grafts were used. All patients had multimodal treatment according to the EURO-E.W.I.N.G 99 or COSS-96 protocol. Median follow-up was at 34 months. In all cases, R0 status was achieved. None of the patients experienced local recurrence during follow-up. Radiographic signs of osseous remodeling were detected the earliest after 2 months. Full weight-bearing on the affected leg was permitted after 8-18 months. Complications occurred in four patients (bleeding 1, infection and pseudarthrosis 1, fracture 1, plate fracture 1). None of the complications led to failure of the reconstruction or to amputation. The MSTS scores was very good in two patients, good in two, and intermediate in one. Biological reconstruction of osseous defects is always desirable when possible. Good functional and durable results can be obtained using BVFG for the reconstruction of metadiaphyseal defects of the femur and tibia.     

Freier Fibulatransfer

Since its introduction by Taylor in 1975, microvascular free fibula transfer has become the gold standard in osseous reconstructions requiring vascularized bone transfer. Various modifications of the free fibula have been described in the literature. We reviewed a series of 76 free vascularized fibula transfers during a 7-year period. Data was retrospectively analyzed with respect to type of procedure and outcome, general surgical complications, and flap-related (specific) complications. Of all 76 free fibula flaps, 47 cases healed uneventfully (62%). Interestingly, 53% of all extremity reconstruction cases had at least one of the above complications, whereas in maxillofacial cases the complication rate was only 25%. Complete osseous consolidation at the time of evaluation was confirmed in 58 patients (76%). Complete flap failure occurred in four patients (5%). The complication rates reflect the complexity of the procedures and appear strongly related to the underlying disease and predisposing medical risk factors. Time will tell if advances, e.g., in the field of tissue engineering, will eventually replace autologous vascularized bone transfer.     

Use of a vascularized fibula for spinal reconstruction in neurofibromatosis

We report a case of reconstruction of a dysplasic thoracic spine with vascularized fibula in Recklinghausen's disease. We present the case of a thirteen-year-old lady with neurofibromatosis type 1 who developed a dystrophic thoracic kyphoscoliosis. A T9 compression due to a severe scaloping of the thoracic spine caused an important deformation and a medullar compression (with dorsal pain, right sciatica and a pyramidal syndrome). The surgery consisted in medullar liberation by a T9-T10 corporectomy and an osteosynthesis with arthrodesis T3-L3. A free vascularized fibula bone graft, with an end-to-end anastomosis on a thoracic pedicle, was realized to fill the T8-T11 spinal defect. All the symptoms decreased after surgery and the patient could walk normally few months later. At one-year follow-up the radiographs showed a stable montage and a solid bony fusion. Analysing the literature, vascularized bone graft can be recommended to fill the bony spinal defect due to surgery in cases of tumor, infection, trauma or severe scoliosis. Compared to non-vascularized grafts, which are exposed to resorption, fatigue fracture and then instability, the vascularized fibula grafts provide a rapid fusion, a biomechanically stable and long-standing support with low risks of infection.     

小腿外侧复合组织瓣移植修复口腔颌面肿瘤切除后的缺损

目的评价小腿外侧复合组织瓣移植修复口腔颌面肿瘤切除后缺损的临床应用价值. 方法 1999年11月～2002年12月,对28例口腔颌面部肿瘤患者术后应用小腿外侧复合组织瓣游离移植,修复骨及软组织缺损.手术采用血管吻合、单叶皮瓣和坚固内固定等恢复口腔颌面缺损器官的形态及完整性.其中21例为带腓骨的腓骨皮瓣移植,7例为携带肌肉的腓骨肌皮瓣移植.采用游离小腿外侧皮瓣,大小3.0 cm×5.5 cm～8.0 cm×12.0 cm,腓骨长度5.5～16.0 cm.有3例同期植入种植体共5枚. 结果术后24例成功,3例部分皮瓣坏死,1例肌皮瓣坏死.3例同期植入的5枚种植体均达到良好的骨整合效果,并已行上部义齿修复.26例获随访1～36个月,平均18.5个月,23例患者面部外形恢复、张闭口及语音功能达到满意或较满意. 结论小腿外侧复合组织瓣有充足的可供取用的组织量,尤其是对同时伴有大量骨缺损患者.且具备血管蒂长、管径粗、易于吻合,以及供区隐蔽等优点,是修复重建口腔颌面部软硬组织缺损可选择的方法之一.