Various kinds of bone have been used as a donor for vascularised bone grafts (VGF) to the upper extremities; among them the fibula has been widely used because of its structural characteristics and low donor site morbidity. Vascularised fibular graft is indicated in patients with large bone defects, bone tumour resection, established or infected non-union, congenital pseudarthrosis, avascular necrosis or bone defects surrounded by scarred, infected and poorly vascularised soft tissue or failure of conventional techniques. Between 1994 and 2003 nine patients were treated with vascularised fibular graft (VFG) and five for reconstruction of upper extremities defects, following trauma of the forearm with failure of conventional treatments. Four were male and one were female; the mean age was 32 years; the reconstructed sites were four radius and one ulna. The mean lengths of the bone defect was 9 cm. All patients were evaluated pre-operatively with angiography and/or magnetic resonance imaging. Two patients had a concomitant arthrodesis of the wrist. The bone graft was stabilised with plates (AO/LCP), screws, K-wires and the forearm was immobilised in plaster or with external fixation for several months. Cancellous iliac bone graft was packed about the proximal and distal junctions. In two recent cases autologous platelet gel was added at the sites of fixation. Bone healing was assessed clinically by the absence of pain and mobility on stress, and radiologically. Patients’ satisfaction and function results were assessed by the DASH questionnaire. After an average duration of follow-up of 48 months (from December 1996 to December 2003), all but one of the patients had radiographic evidence of osseous union of both bone junctions. All wounds healed primarily and no patient had problems related to the donor leg. Three patients had returned to their pre-injury occupation. Vascularised fibula transfer is a valuable technique for the reconstruction of extensive long-bone defects in the upper extremities. The fibula allows a transfer of a bone that is structurally similar to the radius and is of sufficient length for the reconstruction of most skeletal defects in the forearm. In these serious forearm injuries, rapidity of fracture healing is not the primary issue, but rather control of infection and bone stability. The only disadvantage of VFG is that it is more costly; because more technical expertise is required for the microvascular work and the operating time is extended. The reliability and the value of vascularised fibula transfer will increase, with further experience, careful patient selection and appropriate pre and post-operative technical details

Vascularised soft tissue transfer may be helpful in the salvage of severe sepsis involving avascular tissues hosting joint replacements or other metal work. Transferred tissue covers the exposed implants and delivers intravenous antibiotics. Twenty-one cases for the knee, elbow and shoulder are presented. Gastrocnemius flaps were used for seven knee replacements and 10 knee fractures. Antegrade radial artery flaps were used for two elbow replacements. Pectoralis major or minor flaps were used for two shoulder replacements. All procedures were performed by an orthopaedic surgeon with supplementary plastics training. Synchronous bony surgery included revision arthroplasty in seven cases, conversion to fusion in one case and preservation of existing hardware in the remainder. Sepsis was eliminated in the longterm in 9 of 10 knee fracture fixation cases, 5 out of 7 knee replacements and both elbow replacements. Both shoulder replacements remained septic despite multiple repeat procedures. Complications included necrosis of two gastrocnemius flaps, one from pre-existing partial compartment syndrome and one when combined with fusion of the knee. One other knee replacement developed further sepsis three years post procedure. No limb required amputation. These procedures are well within the remit of orthopaedic surgeons, the non reliance on plastics surgeons allowed prompt treatment combined with bony procedures. Results were good for the knee and elbow but disappointing for the shoulder—this, probably related to the natural mobility of the joint

Purpose: Therapeutic options for shaft reconstruction are allografts, shaft prosthesis, and autografts, which may be vascularised or not. The purpose of this work was to assess mid-term results and complications after upper limb reconstructions using a vascularised fibula in children and adolescents undergoing surgery for tumour resection. Material and methods: A vascularised fibular graft was used for reconstruction in ten patients who underwent surgery for resection of upper limb tumours between 1994 and 2000. The patients were seven boys and three girls, aged seven to seventeen years. the vascularised fibula was used for reconstruction after tumour resection in the same operation for eight patients and to salvage a proximal humeral prosthesis in two patients. The eight single-procedure reconstructions concerned four resections of the humeral shaft and four resections of the radius. Tumour histology was: classical osteosarcoma (n=7), low-grade osteosarcoma (n=1), Ewing tumour (n= 1) and aggressive enchondroma (n=1). Six patients were on chemotherapy at the time of the fibular transfer. Graft lengths varied from nine to 21 cm (mean 14 cm). Plate fixation was used in most cases. All patients wore a cast for six to twelve weeks after surgery. Results: Results were analysed retrospectively after 3.9 years follow-up (range 1 – 7 years). Mean time to bone healing was three months (range 1.5 – 5 months). Five of the six humeral shaft reconstructions fractured due to trauma, requiring revision surgery in four cases. All patients who were reoperated achieved bone healing rapidly. One radius had to be revised to add supplementary bone. The mean functional score (MSTS) was 25.5/30 (range 21 – 30). One patient died from lung metastasis and the others exhibited complete tumour remission. Discussion: Vascularised fibula reconstruction of the upper limb provides good radiological results, particularly for the radius. For the humerus, the results are better for younger children because the bone can grow in thickness. Certain mechanical complications may occur if normal sports activities are resumed too early. Functional outcome after these shaft reconstructions is nearly normal

Vascularised bone grafts have been most commonly applied in reconstructions of the lower extremities. However, the indications for vascularised bone grafts in the upper extremities have now been expanded, as this technique is becoming more widely appreciated. Between 1993 and 2000, 12 patients who had segmental bone defects following trauma of the forearm received vascularised fibular grafts, among them six men and six women. The average age was 39 years (range 16–65 years). The reconstructed sites were the radius in eight patients and the ulna in four. The length of the bone defect ranged from 6 to 13 cm. In four cases the fibular graft was raised as a vascular osteoseptocutaneous fibular graft. For fixation of the grafted fibula, plates were used in ten cases, screws and Kirschner wires in two. In these two cases an external skeletal fixator was used for immobilisation of the extremity. The follow-up period ranged from 93 to 10 months. In 11 patients grafting was successful. There were no instances of fractures of the grafted bone; however, non-union occurred at the proximal site in one case and only one patient required an additional bone graft. No patient showed evidence of resorption of the graft or symptoms related to the donor leg. No recurrence of local infection was encountered in the patients with previous osteomyelitis. The mean period to obtain radiographic bone union was 4.8 months (range 2.5–8 months). With the use of fibular grafts a segment of diaphyseal bone can be transferred that is structurally similar to the radius and ulna and that is of sufficient length for the reconstruction of most skeletal defects in the forearm. A vascularised fibular graft is indicated in patients with intractable non-unions, where conventional bone grafting has failed or for large bone defects (in excess of 6 cm) in the radius or ulna

Purpose: To describe our experience with vascularised fibulas used in sarcoma limb salvage surgery using standardized patient outcome measures. Methods: All vascularised fibulas and osteochondral allografts performed in the Capital District Health authority were assessed. A complete chart review and current functional assessment of the patients using the Toronto Extremity Salvage score (TESS) and the Musculosketal Tumour Society (MSTS) score were performed. Results: Nineteen patients with 19 tumors were recorded. The tumors range from 11 osteosarcomas, 4 Ewing’s sarcoma, 3 Malignant Fibrous Histiocytoma’s and 1 Chondrosarcoma. Average age was 23. The patient demographics are 75% male, 42% smokers, 86% femoral lesions and 13 % presented with pathological fracture. There were 9 hip fusions, 3 knee fusions, 6 intercalary grafts and one osteochondral graft. There was 21 % mortality with 21% lung mets, 20% local recurrence, 15.7% rates of amputation or infection or and non union. Allograft fracture rates of 10% were noted. Two patients underwent numerous operations (18) due to non-compliance. Rate of surgical failures defined as patients requiring re-operation after 2 years is 21%. Of 19 patients 10 are working, 4 are unable and 4 are deceased and 1 lost to follow up. Average follow up is 9.8 years (range of 4–18). Our functional results include TESS averaging 57.5 with a range of 30–105 and MSTS scores of average of 16.8 with a range of 3–28 and a percent score average of 55.8. The average score on the subjective assessment question was 4 equaling a response of accept it and would do it again. The Halifax outcome and functional data corresponds well with that in the literature. Conclusions: The biological repair of a combination of large Allografts with Vascularised Fibula’s is an excellent long term solution for construct survival with unrestricted patient activity

Purpose: Reconstruction using a revascularised fibula has advantages in terms of remodelling the transplant to the stress forces and of better resistance against infections. Osteosynthesis offers mechanical advantages (stabilisaton facilitating primary and stress fracture healing) but with the risk of preventing hypertrophy of the fibula which is not exposed to the stress forces. Material and methods: Our series of 25 vascularised fibular transfers (maximum follow-up 15 years) concerned post-trauma tissue loss (11 cases) and tumour resections (14 cases). For this study of remodelling, we retained only oncological reconstructions because in the event of trauma sequelae, many factors can interfer (infection, preservation of the homolateral fibula with tibial tissue loss). None of the patients were lost to follow-up and remodelling was assessed at two years or more. Results: There was one failure requiring leg amputation (infected nonunion of the distal tibia on a radiated osteo-sarcoma). All the other fibulae healed. Three metaphyseal resections of the distal femur were assembled with a lateral plate using the fibula as a medial strut under compression. This type of assembly favours remodelling and excellent results were obtained in three cases. Five arthrodeses of the knee were performed using a fibula with a femorotibial nail. Healing was slow and the fibula thickened little, particularly when it was simply apposed on the tutor (three cases) rather than encased under compression (two cases). For five proximal humeri, use of a thin plate in three cases (forearm plate) was sufficient to allow healing without inhibiting remodelling. Discussion: For the lower limb, good remodelling is obtained with an assembly allowing compression of the fibula placed medially to the shaft alignment. For metaphyseal loss, we advise a lateral plate with a fibular strut medially. For arthrodesis, a nail is probably more prudent. The position of the lateral tutor decreases the stress on the fibula and is recommended less than the medial strut position. For the humerus, synthesis is required but may be minimal to allow optimal remodelling. Conclusion: Vascularised fibula transfer is a reliable technique which can be recommended for major resections (mean 160 mm) in active subjects. Axial compression forces applied to the graft and use of light osteosynthesis appear to favour healing and remodelling

Fibula autograft reconstruction, both vascularised (v) and non-vascularised (nv), has been established as a standard method in limb salvage surgery of bone and soft tissue tumours of the extremities. This study retrospectively analyses the results of fibula autograft procedures in general and in relation to vascular reconstruction or simple bone grafting. Since the implementation of the Vienna Tumour Registry in 1969, 26 vascularised and 27 non-vascularised fibula transfers have been performed at our institution in 53 patients, 26 males and 27 females with an average age of 21 years (range 4 to 62 years). Indications included osteosarcoma in 18, Ewing’s Sarcoma in 15, adamantinoma in 5, leiomyosarcoma in 3 and others in 12. Thirty patients were operated for reconstruction of the tibia (8v/22 nv), 7 for the femur (6v/1nv), 7 for defects of the forearm (4v/3nv), 5 for metarsal defects (all v), 3 for the humerus (1v/2nv) and one patient was treated for a pelvic defect (nv). Average follow-up was 63 months (range 2 to 259 months). 43 patients showed successful primary bony union of the autograft. In 12 cases pseudarthrosis indicated further surgical revision, 9 of these patients were primarily reconstructed by use of a nv autograft. 4 patients, 2 with v and 2 with nv reconstruction, suffered a fracture of the transplant and were operated for secondary osteosynthesis. 10 patients with v bone graft developed wound healing disturbances which led to surgery, 2 patients with nv grafts suffered such complications. In 2 patients recurrent infection of a nv and a v fibula transfer led to the implantation of a modular tumour prostheses or amputation, retrospectively. Function of all patients with primary bone healing was rated satisfactory. The use of fibula autograft in limb-salvage surgery under oncological conditions allows biological reconstruction with good functional outcome, especially when primary bone healing is achieved. Vascularised bone grafting seems to have a better outcome in terms of primary bone healing than simple fibula bone grafting, and thus represents a feasible choice in the reconstruction of bone defects from tumour resection

To determine union rate in complicated nonunions of the scaphoid treated with a vascularised bone graft. Vascularised bone grafting for scaphoid nonunions (1–2 ICSRA, Zaidemberg technique) has shown initial enthusiasm. Its usefulness has been challenged in cases where the proximal pole of the scaphoid is avascular. Complicated nonunions where the proximal pole is highly likely to be avascular occur in revision surgery and proximal pole nonunions. Fourteen patients were retrospectively followed up. Eight had nonunion following previous scaphoid surgery (two previous ORIF, two previous nonvascular grafting, and four with two previous surgeries). Six patients had no previous surgery for a proximal pole nonunion of 12.5 months’ duration. All patients were male with an average age of twenty-four. Delay from fracture to vascularised bone grafting was twenty months. Graft harvesting was done according to the Zaidemberg technique by two orthopaedic surgeons. CT-scan was used to confirm union in all patients except two who were lost of the follow-up. Twelve patients were followed up by an independent surgeon at a postoperative minimal period of four months. Functional status was assessed with the DASH questionnaire and follow x-rays were performed to determine the presence of degenerative changes. Union was confirmed by CT-scan in eleven of twelve followed patients (92%) at an average time of six months following vascularised graft. Radio-scaphoid osteoarthritis was seen in the one patient that didn’t achieve union. This series suggests that the Zaidemberg graft is useful and may be proposed in situations of revision surgery and proximal pole non-unions. We achieved a high union rate in these complicated nonunions even though there was high likelihood that the proximal pole was avascular. This study stresses the importance of protective immobilization until documented union by CT-scan in this difficult subset of patients

Autografts produced by recycling of tumor-bearing bone have been used for bridging intercalary bone defects but they are known to act as massive allografts after recycling procedures due to devitalisation. Recycled bone is superior to massive allografts since it allows anatomical reconstruction. Vascularised fibular grafts are inserted into recycled bone segments to provide biological support and to promote healing. Twelve patients with a mean age of 13.3 years (6–31), who had undergone curative resection of malignant bone tumor followed by biological reconstruction comprised of recycled bone combined with vascularised fibula, were followed up for a mean period of 16.8 (6–46). The tumor was located in distal femur in 7 patients, proximal femur in 2, proximal tibia in 2 and mid-diaphyseal tibia in 1. Cryopreservation with liquid nitrogen was employed for all patients. Contralateral single strut vascularised fibular grafts were used in all except one patient for whom bilateral fibula grafts were harvested to span a longer defect. Plates were used for fixation in 11 patients, and intramedullary nailing in one case. Mean length of bony defect was 16.1 cm (9.0–25.0). Mean fibular graft length was 17.5 cm (10.0–23.0 cm). Complete union and full weight bearing was achieved in 6 patients, and mean time to detect the commencement of union was 6 months (4–8). Incomplete union was detected in 4 patients and no union in 2. Five patients were complicated by implant failure, 1 with deep infection and 1 with drop foot. In order to fill large defects after resection of bone tumors, recyled bone combined with vascularised fibular graft is an effective reconstructive tool. Union rate of this technique is quite satisfactory with good functional results

Aim

Segmental bone defects following osteomyelitis in pediatric age group may require specifically designed surgical options. Clinical and radiographic elements dictate the option. Different elements play a role on the surgeon's choice. Among them, the size of the defect, the size and the quality of the bone stock available, the status of the skin envelope, the involvement of the adjacent joint. When conditions occur, vascularized fibula flap may represent a solution in managing defects of the long bones even during the early years of life.

Infected non-union after severe open fracture or unsuitable fracture operation is frequently associated with bone defect and its treatment has been controversial. We have used microsurgical vascularised composite graft for these problematic cases. Fifty one patients aged 17∼70 year old (43.6 years old in average), including 41 men and 10 women. Follow-up has been more than 6 months. The vascularised composite graft included a free fibular osteocutaneous flap in 41 cases, a vascular pedicled fibular osteocutaneous flap in 2 cases, a free iliac osteocutaneous flap in 5 cases, a vascularised cutaneous flap in 2 cases and other in one case. All infected non-unions were united without trouble and co-existing infection was successfully eradicated. This method also enables the patients rapid bone union and subsequent early functional recovery. This success was attributed to greater transport of oxygen and good antibiotic perfusion in presence of good blood supply. We conclude that microsurgical vascularised composite graft for infected non-union is an extremely useful method with early bone union and subsidence of infection.

Introduction and Objectives: Muscular neurotisation is one of the reconstructive techniques used in peripheral nerve surgery. A funded study was designed to evaluate function and maturation of the motor endplate in reconstructions done using free and vascularized nerve grafts.

Materials and Methods: An experiment was designed with 3 groups of female Wistar rats: a control group which underwent heterotopic neurotization of the superior gastrocnemius through the peroneal nerve. Group A consisted of 25 animals (free nerve graft, FNG) which underwent neurotisation of the gastrocnemius using an autologous EPS nerve graft. Group B consisted of 25 animals (vascularised nerve grafts, VNG) which underwent neurotisation of the gastrocnemius using vascularized peroneal nerve grafts. Animals were sacrificed and studied in groups of 5 individuals at 4, 8, 12, 16, and 20 weeks. Results were obtained using electromyographic and nervous conduction studies measuring graft conduction latency, motor action potential, and wave duration. Statistical analysis was done using Student’s t-test, Wilcoxon, Kruskal–Wallis, and Mann-Whitney U tests.

Results: Latency: There was no difference in latency between VNG and FNG groups except during the first and last month, although latencies tended to shorten and approach normal values. There was no difference in the control group. Amplitude: The FNG group never showed a normal amplitude, while the VNG group did only in the fifth month. No difference was noted between the control and VNG group in the first month. Potential duration: This parameter normalised in the VNG group in the fifth month but never normalised in the FNG group. In fact, during the fifth month there was no difference between the VNG and control groups, and by the second month, it was different from the FNG group.

Discussion and Conclusions: 1) There was no significant difference between FNG and VNG neurotisation in conduction latency as measured by nerve fiber conduction speed or motor unit excitement. 2) There was no significant difference in conduction amplitude between FNG and VNG as measured by the number of excited motor units. 3) There was a statistically significant difference in motor action potential duration between the FNG and VNG groups, with a shorter duration in the VNG group as measured by synchrony and maturation of motor unit conduction.

Purpose

Scaphoid non-unions can result in debilitating wrist problems. This study compared treatment of scaphoid non-unions using either a non vascularised (NVBG) or a vascularised bone graft (VBG).

Aims: Osteomyelitis after open injuries or internal fixation of forearm fractures is uncommon. Established chronic infections do not respond fully to antibiotic suppression or limited debridement. We describe a two-stage treatment of segmental chronic osteomyelitis where wide excision of the affected area was followed by spanning external fixation and supplementary local and systemic antibiotic delivery. The bony defect was subsequently filled by vascularised fibula transfer, held by internal or external fixation.

Methods: Eleven male patients (mean age 41 years) with post-traumatic segmental chronic osteomyelitis were reviewed. There were 6 radii and 5 ulnas; the mean post-debridement defect was 7.7cm (range 5–11cm). The first stage involved wide excision and metalwork removal, followed by application of a spanning external fixator to restore distal radio-ulnar congruency. Gradual distraction was needed in some cases with long standing subluxation. ‘Dead-space’ management used gentamicin beads or gentamicin-loaded calcium sulphate, supplemented with systemic antibiotics according to tissue culture results.

A second stage reconstruction was performed after 4–6 weeks, using a free vascularised fibular graft, fixed using internal and/or external fixation.

Results: The mean follow-up period was 42.4 months. There was no recurrence of infection and union occurred at both graft-host junctions in all patients. The mean period to radiographic bone union was 4.4 months (range 4–6 months).

Patients gained an average of 46° forearm rotation (range 0–105°) with wrist or elbow motion significantly improved in 3 patients. At last review, all patients had a pain-free stable forearm with unhindered hand functions of grasp, hook and pinch. SF-36 assessment showed varied results, although mean values for the physical components of the survey were lower than general population values, while mental/emotional scores were as good.

Conclusions: Staged reconstruction, as described, is a suitable treatment strategy for this challenging problem and produces a good functional outcome.

Free, vascularised fibular grafting is well described in limb salvage surgery. The mechanical properties of the fibula make it ideal for replacement of bony defects after tumour resection and it can be sacrificed with minimal morbidity. We review the outcome of a consecutive series of 24 patients.

Between 1993 and 2002 we performed free vascularised fibular grafts in 24 patients as part of a limb salvage procedure following tumour excision. Pre-operatively patients were staged using the Musculoskeletal Tumour Society (MSTS) system. Post-operatively patients were followed up with radiographs and clinical examination. From the radiographs graft hypertrophy and time to bony union was documented. Functional outcome was assessed using the MSTS scoring system. Complications were recorded.

There were 15 women and 9 men with a mean age of 26 years (6–52). Mean follow up was 51 months (12–106). There were 19 malignant tumours, all stage 2b, and 5 giant cell tumours. The mean length of graft was 12.5 cm. (4.5–25). 16 grafts were used in the upper limb and 8 in the lower limb. Arthrodesis was performed in 8 cases and intercalary reconstruction in 16 cases. Fixation of grafts was achieved with a plate and screws in 21, a blade plate in 2 and an IM nail in 1. In 6 cases the resected tumour bone was reinserted as autograft after extracorporeal irradiation. In all but one patient the tumour margins were clear. Primary bony union was achieved in 22 patients (92%) at a mean of 35 weeks (12–78). Graft hypertrophy was seen in 7/29 cases (24%). Complications included 2 wound breakdowns, 3 stress fractures, 1 muscle contracture, 1 malunion and 1 painful plate. Overall 8 patients (33%) required second operation. 2 patients died of recurrent disease and one has metastases. The mean MSTS functional score was 87% (80–93).

Free vascularised fibula grafts offer a reliable method of reconstruction after excision of bone tumours. The complication rate appears high and some patients require a revision procedure. However, the problems are relatively easy to correct, bony union is achieved in the majority and functional outcome is good.

Introduction Free, vascularised fibular grafting is well described in limb salvage surgery. The mechanical properties of the fibula make it ideal for replacement of bony defects after tumour resection and it can be sacrificed with minimal morbidity. We review the outcome of a consecutive series of 24 patients.

Methods Between 1993 and 2002 we performed free vascularised fibular grafts in 24 patients as part of a limb salvage procedure following tumour excision. Pre-operatively patients were staged using the Musculoskeletal Tumour Society (MSTS) system. Post-operatively patients were followed-up with radiographs and clinical examination. From the radiographs graft hypertrophy and time to bony union was documented. Functional outcome was assessed using the MSTS scoring system. Complications were recorded. There were 15 women and nine men with a mean age of 26 years (6 to 52). Mean follow-up was 51 months (12 to 106). There were 19 malignant tumours, all stage 2b, and five giant cell tumours. The mean length of graft was 12.5 cm (4.5 to25). Sixteen grafts were used in the upper limb and eight in the lower limb. Arthrodesis was performed in eight cases and intercalary reconstruction in 16 cases. Fixation of grafts was achieved with a plate and screws in 21, a blade plate in two and an IM nail in one. In six cases the resected tumour bone was reinserted as autograft after extracorporeal irradiation.

Results In all but one patient the tumour margins were clear. Primary bony union was achieved in 22 patients (92%) at a mean of 35 weeks (12 to 78). Graft hypertrophy was seen in 7/29 cases (24%). Complications included two wound breakdowns, three stress fractures, one muscle contracture, one malunion and one painful plate. Overall eight patients (33%) required second operation. Two patients died of recurrent disease and one has metastases. The mean MSTS functional score was 87% (80 to 93).

Conclusions Free vascularised fibula grafts offer a reliable method of reconstruction after excision of bone tumours. The complication rate appears high and some patients require a revision procedure. However, the problems are relatively easy to correct, bony union is achieved in the majority and functional outcome is good.

We assessed the usefulness of vascularized bone transfer for treatment of aggressive musculoskeletal tumours. Classification by reconstruction method with vascularized bone transfer of our 33 patients was made into five types: 1) intercalary type in 6 cases, 2) arthrodesis type in 5 cases, 3) arthroplasty type using fibular head in 8 cases, 4) hybrid type with recycling autograft as heat treated bone or irradiated bone in 4 cases, and 5) inlay type after curettage of benign tumour chiefly for femoral head and/or neck in 10 cases.

From October 1975 to December 1999, 33 patients composed of 18 males and 15 females with age ranging from 9 to 69 years (average of 30 years) received vascularized bone transfer. There were 28 cases of bone tumour and 5 cases of soft tissue tumour. In 31 cases we grafted the fibula of 8 to 20 cm in size and in 2 cases the ileum of 8 cm in size. Postoperative follow-up period ranged from 10 months to 15 years with average of 65 months.

Primary union was achieved in 31 cases postoperatively between 1.5 month and 4 months with average of 3 months. As complication, we observed fracture of the graft in 4 cases and local recurrence in 3 cases. Postoperative functional evaluation ranged from 33.3% to 96.7% with average of 76.7%. As for oncological therapeutic results, continuous disease free cases accounted for 27, case of no evidence of disease for 1, case alive with disease for 1, and cases of death of disease for 4.

Intercalary transfer of vascularized bone is best indicated for defect of long bone. Arthrodesis was performed in only one knee joint where reconstruction with prosthesis is usually indicated. In arthroplasty type, remodeling of fibular head was observed. In hybrid type, rapid bone union and low complication rate can be expected when compared to recycling autograft alone. In inlay type, femoral head necrosis even after wide curettage can be prevented.

Purpose: We report the long-term outcome after treatment of scaphoid nonunion using a graft harvested on the anterior aspect of the radius and vascularised with the anterior carpus artery.

Material and methods: We treated 72 patients, 11 women and 61 men. Mean age was 31.4 years (15–61) and mean delay from initial fracture of the scaphiod to treatment of nonunion was 22 months (4–120 months). Twenty-seven patients had had prior tratments (11 Mati-Russe, 16 screw fixations). Alnot classification was 40 grade 2A, 28 grade 2B and 4 grade 3A. the patients were generally treated as out-patients under locoregional anaesthesia. A single approach was needed. After reduction and fixation of the scaphoid, the graft was harvested from the anterior aspect of the radius and inserted in the bone gap, usually fixed with a temporary pin. A palmar brace was maintained until bone healing.

Results: Bone healing was achieved in 66 patients (91.6%). Mean delay to healing was 9.8 weeks (6–24). Pain relief was achieved in all patients; 59 were completely pain free. Mean flexion improved from 45° to 56° and mean extension from 54° to 65°. Muscle force improved from 50% to 90% of the healthy side. There were three cases of reflex dystrophy, two cases of styloid radial osteoarthritis and three cases of postoperative stiffness requiring secondary arthrolysis. Functional outcome was excellent in 46 patients, good in 13, fair in 9 and poor in 4.

Discussion: The vascularised graft advocated by Judet as early as 1964 has proven its efficacy for repeated nonunions of the scaphoid. In our series, there was a direct correlation between the grade of the nonunion and the final outcome, the best results being obtain for grade 2A.

Conclusion: Use of a bone graft vascularised with the anterior carpus artery only requires on approach, and provides a high rate of bone healing. We recommend this method for first line treatment of nonunion of the scaphoid.

Purpose: Transfer of the vascularised fibula causes an imbalance in the lower limb due to the small calibre of the bone compared with the recipient bone (femur, tibia). “Femorisation” or “tibialisation” is slow, requiring prolonged protection with an orthesis. The doubled fibula or “shotgun” technique which maintains fibular periosteal vascularisation may overcome this inconvenience.

Material and methods: We report a series of eight free vascular shotgun fibular transfers at a mean four years follow-up (1–11). The recipient site was the lower limb in all patients who had undergone multiple operations, seven for chronic osteitis and one for chondrosarcome (five femoral supracondylar grafts, one knee arthrodesis, two metaphyseal tibial grafts). A cortico-cancellous autologous graft was associated during the same operation for six patients; Osteo-synthesis was achieved in seven cases with an external fixator and in one case with locked centromedullary nailing.

Results: The bone scintigraphy obtained in all cases at the third postoperative day showed intense uptake in the graft in six cases. We had seven cases of osteitis with no case of recurrent sepsis. Mean delay to bone healing assessed radiographically was 5.2 months. Hypertrophy of the fibula was noted at last follow-up in four cases. The external fixator was removed on the average at 6.8 months (5–9). Weight bearing was allowed in all cases with an adjustable protective orthesis. There was one fracture of the graft in a patient with a knee arthordesis which was treated with a corticocancellous autologous bone graft.

Conclusion: This series demonstrates the interest of doubling the free fibular transplant compared with other bone transfers to the lower limbs, improving the balance of the bone calibre and resistance. For patients with loss of supracondylar femoral bone, we describe a widened posterior access allowing the preparation of the recipient site with a single installation for the graft harvesting and fibular transfer.

We did a retrospective comparative analysis of twenty five patients treated with Ilizarov bone transport [IBT] and twenty one patients treated with vascularised fibular graft [VFG] from 1994 to 2003 in one institution, for post traumatic tibial bone defects of more than six centimetres.

The aim of the study was to find out if there were any differences in achieving radiological end points, bone and functional score and return to work (final outcome), hospital stay and operating time (logistic factors) and complication rates. The mean defect size in the IBT group was 11.9 centimetres and in the VFG group 14.6 centimetres.

Twenty one and sixteen patients in the IBT and VFG group respectively achieved the radiological end point that is union of the defect and graft hypertrophy [p 0.5]. Nineteen patients in the IBT group and fifteen in the VFG group returned to productive work [p 0.72]. Bone and functional results were analyzed by Paley's evaluation system and there were no significant differences in the two groups of patients [bone result p 0.97 and functional result p 0.1]. The logistic factors were significantly less of IBT group [p < 0.05]. Two patients in the IBT group and one patient in the VFG group had amputation and one patient in VFG group died. Three cases in the VFG group had flap loss. Stress fracture of the graft occurred in eight patients in the VFG group [p 0.0007].

The final outcome was same in both groups. Hospital stay, operating time and refractures were significantly less in IBT group.