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.

This is a prospective study assessing the results of patients receiving large fragment allograft and a vascularised fibular graft following primary malignant tumour resections around the hip and the knee.

18 patients underwent tumor resection followed by reconstruction with large fragment allograft and vascularised fibular graft. Eight patients underwent resection arthrodesis of the hip, four underwent resection arthrodesis of the knee and six underwent intercalary resections. Following tumour resection with adequate margins, an appropriate sized allograft fragment was internally fixed with either a plate or an intramedullary nail. A vascularised fibular graft was used to span the gap between the remaining host bones. Osteosarcoma was the commonest diagnosis. The patients were clinically assessed by MSTS functional scoring system and radiologically assessed at regular intervals.

The mean age was 26 years (range12–70) and majority of the patients was men. 11 patients received preoperative chemotherapy. Mean follow-up was 85 months (range 8–153). Six patients have died of metastatic disease at a mean of 33 months. Complications included local recurrence in two, deep infection in one and stress fracture of the fibula in two cases. One patient with local recurrence and the other with deep infection underwent an amputation. Majority of the patients had good or excellent MSTS scores at final follow-up and 75% of the patients are engaged in physically active occupations. Graft hypertrophy was evident in majority of the patients.

Our experience clearly indicates that reconstruction with large fragment allograft and vascularised fibular graft is a useful limb salvage procedure with the fibula hypertrophying slowly with time. The eventual fracture of the allograft or failure of the allograft-plate composite is to be expected but is not deleterious due to the physiological response of the vascularised fibula to the weight bearing stresses over time. We feel that this biological solution is likely to demonstrate superior long-term results compared to a prosthetic reconstruction.