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 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.     

Vascularised fibular graft for congenital pseudarthrosis of the tibia. Long-term results

Five children with congenital pseudarthrosis of the tibia treated by free vascularised fibular grafts were followed up until skeletal maturity. The ipsilateral fibula was used in four cases, the contralateral fibula in one. All our cases achieved bone union, but leg length discrepancy, atrophy of the foot and ankle stiffness were frequent complications, due perhaps to the many previous operations. Vascularised fibular grafting might achieve better results if it were done as the primary procedure.     

Management of post-traumatic bone defects of the tibia using vascularised fibular graft combined with Ilizarov external fixator

IntroductionPost-traumatic bone defects of the tibia present a difficult reconstructive challenge. Various methods of reconstruction are available, such as allografts, vascularised fibular graft (either free or pedicled) and bone transport technique.Patients and methodsFourteen patients with an average age of 34.1 years at operation (range, 12–65) with post-traumatic bony defects of the tibia were selected for reconstruction with vascularised fibular graft combined with Ilizarov external fixation. There were 12 male and two female. The size of the bony gap was 10.4 cm (range, 7–13) and the average length of the fibula used was 16.4 cm (range, 14–21).ResultsThe mean follow up period was 20.4 months (range, 10–37). All patients had bony union at both proximal and distal ends of the fibula primarily except one patient that required secondary iliac bone graft at the distal end of the fibula to obtain union. The average time for bone healing was 3.9 months (range, 3–9). The average time spent in Ilizarov frame was 5.9 months (range, 5–11). Unprotected full weight-bearing was achieved within an average of 7.3 months (range, 6–12).ConclusionVascularised fibular bone graft combined with an Ilizarov frame is a successful approach to safely and effectively reconstruct bone defects of the tibia. It has the advantages of vascularised fibular bone grafts together with the biomechanical advantages of Ilizarov frame that allows weight bearing to start almost immediately after surgery. This leads to a good outcome regarding the union and function.     

Residual nonunion following vascularised fibular graft treatment for congenital pseudarthrosis of the tibia: a report of two cases

Resection and reconstruction using a vascularised fibular graft is a viable alternative treatment for congenital pseudarthrosis of the tibia, although distal junctional nonunion and residual deformity are known complications that are difficult to treat. We illustrate 2 cases in which bony union was achieved following a technique using fibular grafting and intramedullary nailing, without additional bone grafting. This technique was feasible because of hypertrophy of the fibular graft.     

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.     

Reverse-flow vascularized fibular graft: a new method

The reverse-flow island flap is a relatively recent concept. We have applied this concept to the vascularized bone graft. We report a new method of the reverse-flow vascularized fibular graft for two patients with a pseudarthrosis and massive bone defect of the tibia. The peroneal artery and venae comitantes were severed proximally and elevated with the fibula while maintaining distal vascular continuity. The reverse-flow vascularized fibula was grafted to the posterior aspect of the bone defect of the tibia. Bony union was obtained in both cases. The reverse-flow vascularized fibular graft has many advantages compared with free vascularized fibular graft.     

先天性胫骨假关节的手术治疗

目的探讨先天性胫骨假关节的手术方式及疗效。方法对自1994年1月-2008年1月收治的先天性胫骨假关节7例。彻底切除假关节部位异常骨组织和增生的纤维结缔组织,钻通骨髓腔．创建新鲜的骨折断端。植骨方法分别为带血管蒂的腓骨移植或自体髂骨移植。固定方法采用髓内钉或Ilizarov外固定架固定,结合石膏及支具外固定。结果随访2-11年,5例骨折最终愈合,此5例中一次手术骨愈合3例,再骨折2例3次。失败2例,其中l例报告植骨Ilizamv外固定失败后,拒绝再治疗。另1例双侧胫腓假关节患儿,随访11年,共行5次髓内针内固定,3次Ilizarov外固定,均失败,患儿已14岁,轮椅生活,拒绝截肢。结论目前先天性胫骨假关节的治疗效果仍是不够理想．彻底切除病变组织带血管蒂的腓骨移植结合Ilizarov外固定或可提高治愈率。     

Vascularised bone grafts in the treatment of long bone defects

Reconstruction of large bony defects of long bones was performed using vascularised fibular grafts in four patients at the Department of Orthopaedic Surgery of the University of Ioannina Medical School. Indications for grafting procedures in this small series had been the loss of bone due to the extensive resection of avascular and necrotic bone from septic pseudoarthrosis in three patients and congenital pseudarthrosis secondary to neurofibromatosis in a child. Primary skeletal union with graft hypertrophy occurred in three of the patients. The fourth patient had an asymptomatic nonunion at the proximal end of the graft. The result in each patient was the presence of a well-aligned limb that had normal or nearly normal motion and acceptable length. © 1994 Wiley-Liss, Inc.     

Free vascularised fibular graft for reconstruction of defects of the lower limb after resection of tumour

We describe a retrospective review of 38 cases of reconstruction following resection of the metaphysiodiaphysis of the lower limb for malignant bone tumours using free vascularised fibular grafts. The mean follow-up was for 7.6 years (0.4 to 18.4). The mean Musculoskeletal Tumor Society score was 27.2 (20 to 30). The score was significantly higher when the graft was carried out in a one-stage procedure after resection of the tumour rather than in two stages. Bony union was achieved in 89% of the cases. The overall mean time to union was 1.7 years (0.2 to 10.3). Free vascularised fibular transfer is a major operation with frequent, but preventable, complications which allows salvage of the limb with satisfactory functional results.     

Vascularised bone transfer for defects and pseudarthroses of forearm bones.

During a five-year period, 15 patients with defects or pseudarthroses of the forearm bones were operated on. All had previously undergone one to six conventional operations. A vascularised fibular graft was used in ten cases, a radial graft in three cases and a humeral graft in two cases. Bone graft viability and healing were assessed clinically and patients have been observed for seven months to five years. 14 patients have finished treatment: 13 were cured and only two repeat osteosyntheses were required. In one case there was resorption of the central part of the fibular graft. Primary bony union was achieved in three to six months. Care must be taken in precise pre-operative assessment of the state of the forearm arteries. We advocate wider usage of vascularised radial and humeral grafts.     

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     

桡骨远端瘤段切除后单纯自体腓骨移植与吻合血管腓骨移植重建桡腕关节疗效比较

目的分析单纯自体腓骨移植与吻合血管腓骨移植在桡骨远端瘤段切除后修复桡骨远端缺损和重建桡腕关节远期效果.方法 1979年1月～2002年9月对15例桡骨远端肿瘤患者行瘤段切除后,6例行单纯自体腓骨移植,9例行吻合血管腓骨移植重建桡腕关节.随访1年,参照Enneking系统及国际肢体修复讨论会所制定的同种/带血管蒂骨移植的影像学评价方法,进行肢体功能、影像学及供区的功能评价.结果 8例吻合血管腓骨移植恢复肢体功能的80%,6个月内完成骨愈合;6例单纯自体腓骨移植恢复肢体功能的67%,其中4例移植骨在5 cm以内术后6个月骨愈合可,2例骨移植超过12 cm者愈合延迟,分别为13个月和16个月;1例术后2个月行肘下截肢术.结论应用腓骨头替代桡骨远端重建腕关节是合适的;吻合血管腓骨移植重建桡腕关节不受骨缺损长度影响,且植骨愈合率高、时间短,无骨吸收.可作为桡骨远端肿瘤手术治疗的一种有效手段.     

Vascularised fibular graft for the treatment of congenital pseudarthrosis of the tibia: long-term complications in the donor leg

Treatment of congenital pseudarthrosis of the tibia is still controversial, and vascularised fibula graft is a reliable method for consolidation, although complications can occur in the donor leg after fibula grafting. This study evaluates 16 patients with congenital pseudarthrosis of the tibia (CPT) treated with contralateral fibular graft, with regard to complications in the donor leg, and assesses the influence of distal tibiofibular joint arthrodesis in these complications. All patients with CPT were consecutively submitted to surgical treatment with contralateral fibular graft. The mean follow-up was 94 months, varying from 44 to 162 months. The long-term effects in the donor leg were determined, and 12 cases with distal tibiofibular arthrodesis (group 1) were compared with a group without arthrodesis (group 2). Half of the patients had proximal migration of the lateral malleolus. Eight patients had ankle valgus. Group 1 had an average valgus tilt angle of 5.8°, while group 2 had an average angle of 1.5°. There was no significant difference between the patients with or without distal tibiofibular joint arthrodesis. The patients with a distal fibula remnant smaller than 5 cm had greater valgus tilt angle measurements. Distal tibiofibular arthrodesis was not effective in preventing all the complications in the donor leg; however, it can lessen the severity of the complications. Our results show that a distal fibular remnant greater than 5 cm should be retained to prevent ankle valgus.     

Free vascularised fibular graft in the treatment of congenital pseudarthrosis of the tibia

Five cases of congenital pseudarthrosis of the tibia successfully treated by a free vascularised fibular graft are described. Follow-up ranged from 5 to 34 months with a mean of 17.5 months. The technique, which includes radical excision of abnormal bone and soft tissue around the pseudarthrosis, also permits primary bone lengthening, and correction of deformity. The early results indicate that satisfactory bony union is achieved in a relatively short period of time.     

Free vascularised fibular grafting in the treatment of large skeletal defects due to osteomyelitis

Treatment of skeletal defects secondary to osteomyelitis is a challenging problem. The purpose of this study was to present our experience of the use of free vascularised fibular grafts to treat such defects. Ten patients with a mean age of 31 years (range 16–50 years) and a skeletal defect with a mean length of 9.5 cm (range 6–17 cm) were managed with a protocol which included radical debridement of the lesion and a vascularised fibular graft. The mean follow-up time was 26 months. Union of the graft occurred in all patients, at a mean of 4.5 months. No recurrence of osteomyelitis was observed. The mean time to full weight bearing was ten months, and all patients were pain-free and able to walk without supportive devices. A free vascularised fibular graft is a viable option for the management of large skeletal defects resulting from osteomyelitis.     

Reconstruction of distal radius by fibula following excision of grade III giant cell tumour: Follow-up of 18 cases

The purpose of this study was to evaluate the long-term results of vascularised fibular graft for reconstruction of the wrist after excision of grade III giant cell tumour in the distal radius. From January 1998 to September 2003, 18 patients with wrist defects due to distal radius grade III giant cell tumour resection were treated with vascularised fibular graft and were followed-up. The limb function was restored to an average 80% of normal function and bone union was achieved within six months in 18 patients with vascularised fibular graft. MSTS score averaged 25.6 and ranged between 21 and 29; Mayo wrist score averaged 56 with a range from 40 to 65. It is appropriate to use the head of the fibula as a substitute for the distal radius. The healing of vascularised fibular graft is very quick and without bone resorption. Thus, in the procedure for reconstruction and limb salvage after bone tumour resection of distal radius, the free vascularised fibular graft with fibular head is an ideal substitute.     

Free vascularised fibular grafts for congenital pseudarthrosis of the tibia

We describe 11 patients with congenital pseudarthrosis of the tibia treated by a free vascularised fibular graft (FVFG) and followed up from 10 to 64 months (mean 38). Bony union was achieved in nine of the 11 cases: two failures required amputation. The mean time for union in the successful cases was five months. Nine of the 11 patients had had an average of four surgical procedures before the FVFG, so the graft was a salvage procedure for which the only alternative was amputation. FVFG is recommended as a primary procedure for the treatment of congenital pseudarthrosis of the tibia if there is a large tibial defect (over 3 cm) or shortening of more than 5 cm. The primary use of this operation is not advised for cases in which standard orthopaedic procedures are expected to succeed. For a small defect with a favourable prognosis (Boyd and Sage 1958), we recommend conventional bone grafting, intramedullary nailing and electrical stimulation.     

Reconstruction with non-vascularised fibular grafts after resection of bone tumours

We evaluated 31 patients who were treated with a non-vascularised fibular graft after resection of primary musculoskeletal tumours, with a median follow-up of 5.6 years (3 to 26.7 years). Primary union was achieved in 89% (41 of 46) of the grafts in a median period of 24 weeks. All 25 grafts in 18 patients without additional chemotherapy and/or radiotherapy achieved primary union, compared with 16 of the 21 grafts (76%; 13 patients) with additional therapy (p=0.017). Radiographs showed an increase in diameter in 70% (59) of the grafts. There were seven fatigue fractures in six patients, but only two needed treatment. Non-vascularised fibular transfer is a simpler, less expensive and a shorter procedure than the use of vascularised grafts and allows remodelling of the fibula at the donor site. It is a biological reconstruction with good long-term results, and a relatively low donor site complication rate of 16%.     

Vascularized free fibular bone graft in the management of congenital tibial pseudarthrosis

Congenital pseudarthrosis of the tibia (CPT) remains one of the most challenging problems confronting the orthopaedic surgeon. The operative results are frequently less than successful; many cases require several surgical procedures, and a significant number of them ending in amputation. The purpose of this study was to access the surgical results, complications, secondary procedures, and long‐term results of free vascularized fibular graft (FVFG) in the treatment of congenital pseudarthrosis of the tibia. Between 1992 and 2007, nine patients with CPT were treated consecutively at our clinic with free fibula transfer. There were six females and three males. The mean age at the time of operation was 6.5 years (range, 1–12 years). Stability, after reconstruction with FVFG, was maintained with internal fixation in five patients, unilateral frame external fixation in three patients, and intramedullary pin in one patient. Average postoperative follow‐up time was 9 years (range, 2–15 years). In seven patients, both ends of the graft healed primarily within 3.7 months (range, 1.5–6 months). In one patient, the distal end of the graft did not unit. This patient required three subsequent operations to achieve union. Stress fracture occurred in the middle of the grafted fibula in one patient, who underwent four additional operations before union, was achieved. Despite the relatively high‐complication rate, FVFG remains a valid method for the treatment of CPT. However, even achieving union of pseudarthrosis is not enough for the resolution of the disease. This is only half of the problem; the other half is to maintain union. Long‐term follow‐up beyond skeletal maturity, if possible, is necessary to evaluate surgical results. © 2009 Wiley‐Liss, Inc. Microsurgery, 2009.