VASCULARIZED FIBULAR TRANSFER FOR LIMB RECONSTRUCTION AFTER BONE RESECTION FOR MALIGNANT TUMORS IN CHILDREN: 30 CASES

Abstract

Purpose of the study: Assessment of limb reconstruction results using vascularized fibular grafts after bony resection for malignant tumors in children.

Material and methods: Thirty children (9 girls and 21 boys)underwent surgery between 1993 and 2000. Mean age was 11 years. Tumor localizations were: femur (n=17), tibia (n=6), humerus (n=5), radius (n=1) and distal ulna (n=1). Mean length of bone resection was 16 cm (range 10–26 cm). For 22 children, the adjacent epiphysis was preserved. For the eight others, fusion was also performed. Two surgical teams operated sequentially: the first team performed the tumor resection and the second (an orthopedist for the osteosynthesis and a plastician for the vascularized fibular transfer) the limb reconstruction. Radiographic and clinical assessment was completed with bone scintigraphy. The index of graft hypertrophy was determined with the De Boer and Wood method. Functional outcome was assessed with Enneking criteria.

Results: Mean follow-up was 51 months (range 2 – 9 years). Early amputation was necessary for two children due to local oncological complications. One patient died of pulmonary metastasis eight months after limb reconstruction. Among the 27 other patients, primary healing was achieved in 22. In the five with primary nonunion, bone scintigraphy showed objective signs of a lack of blood supply to the graft. Secondary union was achieved with a complementary autologous bone graft in four cases. All cases of stress fracture healed with orthopedic treatment. For the 22 patients with primary union, the graft hypetrophy was 22–190% (mean 61%). For the five patients without bone vascularization on the scintigraphy, the fibular graft failed to hypertrophy. Functional outcome was satisfactory. The modified Enneking score (30 point scale) was 26 (range 19–30 points).

Discussion: Limb reconstruction results are directly related to good patency of vascular anastomoses. Postoperative bone scintigraphy is useful to determine blood supply to the graft and to establish the final prognosis. In the case of vascular failure, an autologous bone graft can be proposed early to enable union. Close collaboration between the plastic surgery and the orthopedic team is the key to successful limb reconstruction with a vascularized fibular graft.