Segmental excision of long-bone sarcomas can require complex reconstruction, often resulting in the use of prosthetic replacements at a young age. The use of vascularised free fibula grafting (VFFG) is well established as a reconstruction modality in sarcoma surgery. Aims. To analyse the experience of two European sarcoma centres and their use of vascularised free fibula grafting as a primary and revision procedure in limb salvage for diaphyseal long-bone defects in sarcoma surgery. Methods. A retrospective analysis was carried out of 70 consecutive patients undergoing VFFG between 1996 and 2009 under the Oxford Sarcoma Service (Nuffield Orthopaedic Centre) and the Dutch Orthopaedic Tumour Society (Leiden University Hospital). Clinical and radiological assessments were made and functional outcome scores collected. Results. 70 patients, 42 male, with a mean age of 20 years (3–61) received a VFFG (a primary procedure in 76%) and underwent mean follow up of 82 months (11–181). 83% of grafts were located in the lower extremity with 71% resulting from reconstruction of malignant tumours. VFFGs with a mean length of 17.4 cm (6–25) were used to reconstruct defects with a mean length of 13.5 cm (8–21). 92% of VFFGs achieved union at mean of 59 weeks (16–250). Predictors for non-union included defects greater than 12cm, malignant disease processes and an immature skeleton. 65% of patients had at least one complication with 51% requiring at least one revision procedure, although only 3 required removal of the graft (2 endoprosthetic replacements and 1 amputation). Mean MSTS score at final follow-up was 26.7 (20–30). Conclusion. The vascularised free fibula graft has been proven to provide a stable reconstruction of bony defects after tumor resection and results in a functional extremity, however it is accompanied by a high risk of complications and revision surgery

Following resection of primary malignant bone tumours of the humerus, limb salvage can be performed by vascularized fibula graft for reconstruction of large segmental defects. In 12 patients with malignant bone tumour of the proximal humerus, tumour was resected and the bone defect reconstructed by vascularized fibula graft. Median age of the patients was 23 years. Median follow up was 114 months. In 10 patients humeral head had to be resected and was replaced by fibular transplant including head and shaft of the ipsilateral fibula. Humeral head could be left in place in 2 patients. Median length of transplant was 17.2 cm. Radiographic union could be seen after 8 months in median. In 7 patients partial necrosis of the fibular head occurred, in 4 patients fracture of the transplant happened following trauma. In these 4 cases revision surgery was required. Partial necrosis of the head of fibula had no significant influence on shoulder function. One patient died of disease, the others are disease free. Enneking Index was 61% in median at time of last follow up. At donor side 3 cases of transient peroneal palsy could be seen. We conclude that vascularized fibula graft is a successful surgical procedure for upper limb salvage especially for preservation of joint function also in long term follow up

Purpose. Analyze the results of reconstruction of post osteomyelitic bone defect using non-vascularised fibula graft in children and correlation of results with magnitude of defect. Methods. 11 boys and 15 girls (mean age 6.8±2.33 years) were prospectively enrolled in the study. All had primary acute hematogeneous osteomyelitis with diaphyseal sequestration and active discharging sinuses. 7 femur, 12 tibia, 3 humerus, 3 radius and 1 ulna were the bone involved. As first step a radical debridement and sequestrectomy was performed. Second step was considered after a ‘dry’ period judged clinically and by normalized CRP. A subperiosteal resection of fibula was done and used as graft to fill in the diaphyseal defect. Graft was stabilized using intramedullary ‘K’ wires and supported by post-operative casts. Weight-bearing was started on radiological evidence of union. Results. mean follow up was 3.02±0.74 years with mean union time of 38.76±12.02 weeks. Delayed union (n=4) was seen at sites with large discrepancy between diameter of native bone and graft (like proximal tibial metaphysis). These cases united with plate fixation and bone grafting. There was weak positive correlation between union time and preoperative bone defect (+0.699). Subgroup analysis showed that there no significant difference between union times of patients with defect <4cms (mean of 31.7±11.5 weeks) and defect >4<6cms (mean 36.6±9 weeks), however the union time of patients with defect >6cms was significantly more (51±6.7 weeks). Conclusion. Non-vascularised fibula graft gives predictable results in children with post-osteomyelitic bone defects. Delayed unions are expected if the size of bone defect is >6cms or there is large discrepancy between the diameters of native and grafted bone

Objective and Purpose: Pilon fractures are complex fractures of the tibial articular surface usually associated with high energy trauma and major soft tissue injury. We investigated the effectiveness of Ilizarov external fixator in such cases. At our hospital, we obtain excellent results performing reconstruction using vascularised fibular grafts for the infectious non-union.

Methods and Materials: We examined 21 cases treated with the Ilizarov apparatus for the fresh pilon fracture from 1999. There were 13 males and 8 females, with an average of 44 years. The AO classification was A2 type in 2 cases, B1 in 4, C1 in 3, C2 in 3, and C3 in 9, with open fractures of Gustilo type?Uor ?Va in 7 cases. 11 cases were treated by the Ilizarov technique only. 10 cases were treated by the additional limited open reduction with screw, K-wire and fibular plating. The average time between injury and surgery was 4 days. We examined 6 cases treated with the vascularised fibular graft for the infectious non-union cases after internal fixation. Age at the surgery was from 19 to 70 (mean 46).

Results: All fractures were united and removed at an average of 10 weeks (range 8–12 weeks). Complications included 5 cases of superficial pin tract infections. There is no deep infections and no pseudarthrosies.

Conclusion: The use of Ilizarov fixator is a safer method of treatment of pilon fractures, especially for the severe soft tissue injury and we don ft delay surgery for soft tissue considerations.

Large benign lytic lesions of the proximal femur present a significant risk of pathological fractures. We report our experience of treating 9 consecutive patients with such defects treated with curettage and fibula strut grafting without supplementary osteosynthesis to evaluate the outcome of this type of reconstruction. The mean age at the time of diagnosis was 13 years (8–21). Follow up ranged from 2 to 215 months (median 15). Histological diagnosis was fibrous dysplasia in 10 patients and unicameral cyst in 2. All the patients were at risk of pathological fracture. None of the patients developed pathological fracture after surgery and the lesions consolidated fully within one year. Local recurrence occurred in one patient (8%). Minor donor site complications occurred four patients. All the patients were able to fully weight usually within 3 months of surgery. At the time of review all but one patient were completely asymptomatic and fully weight bearing. The only symptomatic patient was the patient with local recurrence which has recently been treated. We conclude that fibula strut graft is a good method of reconstruction of cystic defects in the proximal femut. It prevents pathological fracture, allows mechanical reinforcement of the lesion and delivers biological tissue allowing early consolidation of the defect

The purpose of this study was to assess the outcome of 15 patients (mean age 13.6 years (7 to 25)) with a primary sarcoma of the tibial diaphysis who had undergone excision of the affected segment that was then irradiated (90 Gy) and reimplanted with an ipsilateral vascularised fibular graft within it.

The mean follow-up was 57 months (22 to 99). The mean time to full weight-bearing was 23 weeks (9 to 57) and to complete radiological union 42.1 weeks (33 to 55). Of the 15 patients, seven required a further operation, four to obtain skin cover. The mean Musculoskeletal Society Tumor Society functional score at final follow-up was 27 out of 30 once union was complete. The functional results were comparable with those of allograft reconstruction and had a similar rate of complication.

We believe this to be a satisfactory method of biological reconstruction of the tibial diaphysis in selected patients.

Introduction. The use of vascularised fibula grafts is an accepted method for reconstructing the distal femur following resection of malignant childhood tumours. Limitations relate to the mismatch of the cross-sectional area of the transplanted fibula graft and thel ocal bone, instability of the construct and union difficulties. We present midterm results of a unique staged technique—an immediate defect reconstruction using a double-barrel vascularised fibula graft set in in A-frame configuration and a subsequent intramedullary femoral lengthening. Materials & Methods. We retrospectively included 10 patients (mean age 10 y)with an osteosarcoma of the distal femur, who were treated ac-cording to the above-mentioned surgical technique. All patients were evaluated with regards to consolidation of the transplanted grafts, hypertrophy at the graft-host junctions, leg length discrepancies, lengthening indices, complications as well as functional outcome. Results. The mean defect size after tumour resection was 14.5 cm, the mean length of the harvested fibula graft 22 cm, resulting in a mean (acute) shortening of 4.7 cm (in 8 patients). Consolidation was achieved in all cases, 4 patients required supplementary bone grafting. Hypertrophy at the graft-host junctions was observed in78% of the evaluable junctions. In total 11 intramedullary lengthening procedures in 9 patients had been performed at the last follow up. The mean Muskuloskeletal Society Rating Scale(MSTS) score of the evaluable 9 patients was 85% (57% to 100%)with good or excellent results in 7 patients. Conclusions. A-frame vascularised fibula reconstructions showed encouraging results with respect to defect reconstruction, length as well as function and should therefore be considered a valuable option for reconstruction of the distal femur after osteosarcoma resection. The surgical implementation is demanding though, which is emphasized by the considerable high number of com-plications requiring surgical intervention, even though most were not serious

Introduction. The purpose of this study is to evaluate the radiological and clinical outcomes in Northern Ireland of free vascularised fibular bone grafting for the treatment of humeral bone loss secondary to osteomyelitis. Upper limb skeletal bone loss due to osteomyelitis is a devastating and challenging complication to manage for both surgeon and patient. Patients can be left with life altering disability and functional impairment. This limb threatening complication raises the question of salvage versus amputation and the associated risk and benefits of each. Free vascularised fibula grafting is a recognised treatment option for large skeletal defects in long bones but is not without significant risk. The benefit of vascularised over non-vascularised fibula grafts include preservation of blood supply lending itself to improved remodeling and osteointegration. Materials & Methods. Sixteen patients in Northern Ireland had free vascularised fibula grafting. Inclusion criteria included grafting to humeral defects secondary to osteomyelitis. Six patients were included in this study. Patients were contacted to complete DASH (Disabilities of the Arm, Shoulder and Hand) questionnaires as our primary outcome measure. Secondary outcome measures included radiological evaluation of osteointegration and associated operative complications. Complications were assessed via review of Electronic Care Record outpatient and in-patient documents

Introduction. Vascularized fibular grafting following tumor resection is an essential treatment option in limb salvage surgery. This study aimed to assess the surgical and oncological outcomes of patients treated in Denmark between 2010 and 2022. Method. We present a retrospective review of a national cohort comprising 27 patients. The indications were 13 cases of Ewing sarcoma, 12 cases of osteosarcoma, and 2 cases of giant cell tumor. The median age at surgery was 16 years (range: 2-39), and the median follow-up was 82 months (range: 12-138). Patients were analyzed overall and stratified into upper and lower extremity groups based on tumor location. Result. The primary rate of graft union was 63%, and after secondary procedures, the overall rate of graft union was 67%, with a median time to union of 13 months (range: 7-29). The reoperation rate was 74%, while the rate of limb salvage was 93%, with two patients undergoing amputation during follow-up. The 5-year overall survival rate was 81% (95% CI: 61-92). Patients with upper extremity tumors were more likely to attain graft union (92% vs. 47%, p=0.02) and less likely to undergo multiple reoperations (17% vs 60%, p=0.047) compared to patients with lower extremity tumors. Conclusion. Vascularized fibula grafting remains a valuable option in limb salvage surgery with acceptable long-term outcomes. However, especially in lower extremity cases, a low rate of graft union and multiple reoperations are to be expected

Introduction. The presence of pluripotent mesenchymal cells in the periosteum along with the growth factors produced or released following injury provides this tissue with an important role in bone healing. Utilising this property, vascularised periosteal flaps may increase the union rates in recalcitrant atrophic long bone non-union. The novel chimeric fibula-periosteal flap utilises the periosteum raised on an independent periosteal vessel, thus allowing the periosteum to be inset freely around the osteotomy site, improving bone biology. Materials & Methods. Ten patients, with established non-union, underwent fibula-periosteal chimeric flaps (2016–2022) at the Canniesburn Plastic Surgery Unit, UK. Preoperative CT angiography was performed to identify the periosteal branches. A case-control approach was used. Patients acted as their own controls, which obviated patient specific risks for non-union. One osteotomy site was covered by the chimeric periosteal flap and one without. In two patients both the osteotomies were covered using a long periosteal flap. Results. Union rate of 100% (11/11) was noted with periosteal flap osteotomies, versus those without flaps at 28.6% (2/7) (p = 0.0025). Time to union was also reduced in the periosteal flaps at 8.5 months versus 16.75 months in the control group (p = 0.023). Survival curves with a hazard ratio of 4.1, equating to a 4 times higher chance of union with periosteal flaps (log-rank p = 0.0016) was observed. Conclusions. The chimeric fibula-periosteal flap provides an option for atrophic recalcitrant non-unions where use of vascularised fibula graft alone may not provide an adequate biological environment for consolidation

Introduction. A significant burden of disease exists with respect to critical sized bone defects; outcomes are unpredictable and often poor. There is no absolute agreement on what constitutes a “critically-sized” bone defect however it is widely considered as one that would not heal spontaneously despite surgical stabilisation, thus requiring re-operation. The aetiology of such defects is varied. High-energy trauma with soft tissue loss and periosteal stripping, bone infection and tumour resection all require extensive debridement and the critical-sized defects generated require careful consideration and strategic management. Current management practice of these defects lacks consensus. Existing literature tells us that tibial defects 25mm or great have a poor natural history; however, there is no universally agreed management strategy and there remains a significant evidence gap. Drawing its origins from musculoskeletal oncology, the Capanna technique describes a hybrid mode of reconstruction. Mass allograft is combined with a vascularised fibula autograft, allowing the patient to benefit from the favourable characteristics of two popular reconstruction techniques. Allograft confers initial mechanical stability with autograft contributing osteogenic, inductive and conductive capacity to encourage union. Secondarily its inherent vascularity affords the construct the ability to withstand deleterious effects of stressors such as infection that may threaten union. The strengths of this hybrid construct we believe can be used within the context of critical-sized bone defects within tibial trauma to the same success as seen within tumour reconstruction. Methodology. Utilising the Capanna technique in trauma requires modification to the original procedure. In tumour surgery pre-operative cross-sectional imaging is a pre-requisite. This allows surgeons to assess margins, plan resections and order allograft to match the defect. In trauma this is not possible. We therefore propose a two-stage approach to address critical-sized tibial defects in open fractures. After initial debridement, external fixation and soft tissue management via a combined orthoplastics approach, CT imaging is performed to assess the defect geometry, with a polymethylmethacrylate (PMMA) spacer placed at index procedure to maintain soft tissue tension, alignment and deliver local antibiotics. Once comfortable that no further debridement is required and the risk of infection is appropriate then 3D printing technology can be used to mill custom jigs. Appropriate tibial allograft is ordered based on CT measurements. A pedicled fibula graft is raised through a lateral approach. The peroneal vessels are mobilised to the tibioperoneal trunk and passed medially into the bone void. The cadaveric bone is prepared using the custom jig on the back table and posterolateral troughs made to allow insertion of the fibula, permitting some hypertrophic expansion. A separate medial incision allows attachment of the custom jig to host tibia allowing for reciprocal cuts to match the allograft. The fibula is implanted into the allograft, ensuring nil tension on the pedicle and, after docking the graft, the hybrid construct is secured with multi-planar locking plates to provide rotational stability. The medial window allows plate placement safely away from the vascular pedicle. Results. We present a 50-year-old healthy male with a Gustilo & Anderson 3B proximal tibial fracture, open posteromedially with associated shear fragment, treated using the Capanna technique. Presenting following a fall climbing additional injuries included a closed ipsilateral calcaneal and medial malleolar fracture, both treated operatively. Our patient underwent reconstruction of his tibia with the above staged technique. Two debridements were carried out due to a 48-hour delay in presentation due to remote geographical location of recovery. Debridements were carried out in accordance with BOAST guidelines; a spanning knee external fixator applied and a small area of skin loss on the proximal medial calf reconstructed with a split thickness skin graft. A revision cement spacer was inserted into the metaphyseal defect measuring 84mm. At definitive surgery the external fixator was removed and graft fixation was extended to include the intra-articular fragments. No intra-operative complications were encountered during surgeries. The patient returned to theatre on day 13 with a medial sided haematoma. 20ml of haemoserous fluid was evacuated, a DAIR procedure performed and antibiotic-loaded bioceramics applied locally. Samples grew Staphylococcus aureus and antibiotic treatment was rationalised to Co-Trimoxazole 960mg BD and Rifampicin 450mg BD. The patient has completed a six-week course of Rifampicin and continues on suppressive Co-Trimoxazole monotherapy until planned metalwork removal. There is no evidence of ongoing active infection and radiological evidence of early union. The patient is independently walking four miles to the gym daily and we believe, thus far, despite accepted complications, we have demonstrated a relative early success. Conclusions. A variety of techniques exist for the management of critical-sized bone defects within the tibia. All of these come with a variety of drawbacks and limitations. Whilst acceptance of a limb length discrepancy is one option, intercalary defects of greater than 5 to 7cm typically require reconstruction. In patients in whom fine wire fixators and distraction osteogenesis are deemed inappropriate, or are unwilling to tolerate the frequent re-operations and potential donor site morbidity of the Masqualet technique, the Capanna technique offers a novel solution. Through using tibial allograft to address the size mismatch between vascularised fibula and tibia, the possible complication of fatigue fracture of an isolated fibula autograft is potentially avoidable in patients who have high functional demands. The Capanna technique has demonstrated satisfactory results within tumour reconstruction. Papers report that by combining the structural strength of allograft with the osteoconductive and osteoinductive properties of a vascularised autograft that limb salvage rates of greater than 80% and union rates of greater than 90% are achievable. If these results can indeed be replicated in the management of critical-sized bone defects in tibial trauma we potentially have a treatment strategy that can excel over the more widely practiced current techniques

Aims. The aim of the study was to investigate the controversial issue of whether the pelvic ring should be reconstructed following resection of the sarcomas of the ilium. Patients and Methods. From our database, we identified 64 patients who underwent excision of a tumour involving the ilium between 1976 and 2015. A total of 35 underwent complete resection, of whom 24 were reconstructed with a non-vascularised fibula graft, and four with extracorporeal irradiation and reimplantation. A total of 29 patients had a partial resection. The mean follow-up was 9.2 years (1.1 to 25.6). Functional outcomes were assessed using the Toronto Extremity Salvation Score (TESS) at final follow-up. In all, 32 patients (50%) had a chondrosarcoma. Results. The mean TESS for all patients was 71.6% (17% to 100%). The mean TESS for those who underwent total resection with reconstruction was 72.0% (17% to 100%) and without reconstruction it was 53.3% (20% to 90%) and for those who underwent partial resection it was 76.3% (31.3% to 100%). The rate of local recurrence was 42.2% and this was more common in those treated by partial resection (p = 0.048). The risk of local recurrence was related to the margin achieved at resection. Conclusions. Given the high rate of local recurrence following excision of a tumour from the ilium, obtaining wide surgical margins should be a priority even if this requires more aggressive surgery. In young patients, where late recurrence may occur, more radical complete resection should be considered. When total resection of the ilium is considered, reconstruction should also be considered as it confers a higher functional outcome than total resection without reconstruction. Cite this article: Bone Joint J 2017;99-B:538–43

Purpose. We retrospectively evaluated the outcome of fibula grafts in upper limb post infectious diaphyseal gap nonunions and assessed the following modifiers: age, site, vascularised/ nonvascularised, and length of the graft on time to union, graft incorporation, complication rate and reoperation rate. Methods. Thirty seven paediatric upper limb segmental defects treated over a period of 10 years were identified. Twenty two post septic defects in 21 children were treated with intramedullary fixation and vascularised/ nonvascularised fibula grafting. Union time was assessed from records and radiographs. Graft incorporation was assessed using Pixel value ratio (Hazra et al). Complications were defined as nonunion, delayed union, implant failure, refractures, graft loss and infection. Results. Twenty one children with 22 nonunions, 9 boys and 12 girls, mean age 6.5 years were followed up for a mean of 24 months. Defects (humerus-8, radius-8, ulna-6) ranged from 10 mm to 85 mm before surgery. Seven vascularised grafts(mean length = 69.9 mm) 3 in ulna and 4 in radius and 14 nonvascularised (48.8 mm) were 8 in humerus, 4 in radius, 3 in ulna. Primary union was 81% at a mean of 4.7 months. Mean pixel value for graft incorporation was 1.3 (SD = 0.2) on immediate postoperative radiograph and 1.08 (SD 0.16) at mean of 2 years. Complications included nonunion requiring surgery in 4, delayed union in 6, wire migration in 6, refractures in 4, infection reactivation in 2 with loss of graft in 1. Time to union was 5.5 (SD 2.9) months in nonvascularised and 3.1 (SD 0.6) in vascualrised group (P = 0.04). Complication rate was 1.2 and 0.2 in nonvascularised and vascularised grafts(p = 0.04). Bone, age and the graft length did not significantly affect union time, graft incorporation, complication and reoperation rate. The complication rate was significantly higher in children ≤8 year; however other outcomes were not significantly different. Conclusion. Vascularised grafts and children aged >8 year did significantly better in fibular grafting for post-septic upper limb diaphyseal nonunions

Management of symptomatic osteonecrosis of the hip includes either some type of head preservation procedure or a total hip arthroplasty (THA). In general, once there is collapse of the femoral head, femoral head preservation procedures have limited success. There are a number of different femoral head preservation procedures that are presently performed and there is no consensus regarding which one is most effective. These procedures involve a core decompression with some type of vascularised or nonvascularised grafting of the femoral head. Core decompression with bone grafting of the femoral head with stem cells harvested from the iliac crest and vascularised fibula grafts are the two most popular femoral head preservation procedures. Once the femoral head has collapsed then a THA should be performed when the patient has significant disability. In the past, total hip arthroplasty in osteonecrosis patients was not considered a highly successful procedure because it was performed in younger patients (most patients are younger than fifty years of age) and longevity was limited by wear and osteolysis. The advent of reliable cementless acetabular and femoral fixation and alternative bearing surfaces (i.e. highly crosslinked polyethylene liners) has been associated with improved outcomes and enhanced longevity. THA is considered the procedure of choice even for young patients (less than 30 years old) with collapse of the femoral head and significant pain and disability

Aims:Vascularized fibula has been widely used in limb salvage surgery to reconstruct large bone defects. Aim of this study is the analysis of the complications related both to the donor and the recipient site in a series of patients affected by bone tumors. Material and methods: In the period from 1988 to 2002, 114 patients ranging in age between 4 and 64 years underwent bone reconstruction by mean of a vascularized fibula graft. There were 64 men and 50 women and all them were affected by malignant neoplasm. The upper limb was involved in 25 cases and the lower extremity in 89 cases. The length of resection ranged between 7 and 28 cm, the follow up between 6 and 166 months. Results: Several complications have been noted either at the donor or at the recipient site. The most common complications affecting the donor leg, have been the retraction of flexor tendons (6), the valgus deformity of the ankle (3) the retraction of extensor hallucis longus (1) and a transient palsy of the peroneal nerve (1). The most frequent complications observed at the recipient site has been a fracture of the graft (15) followed by non union (12), infection (5 cases), failure of plate (5), skin necrosis (4), transient palsy of the peroneal nerve (3) and joint stiffness. Because of complications, a total failure of the procedure occurred in 4 cases. Conclusions: Although the vascularized fibula graft is the recommended procedure in dealing with challenging reconstruction of large diaphyseal defects, this option is not free of complications. However, in our experience, when conservative treatment of complications was not successful, further surgery was able to lead to recovery in the majority of cases

Purpose: Management of extensive tibial loss raises the question of indications for vascularised grafts. These techniques depend on the number of functional vascular trunks available. We developed a modified technique which allows using this type of graft without sacrificing the tibial pedicle, making it usable when only one trunk remains functional. We use the fibular arterial supply to bridge the remaining axis. The purpose of this work was to detail the modalities of this technique and provide early results. Material and method: Since 2000, we have reserved this technique for infected nonunion with loss of tibial tissue extending over 5 cm in patients who decline amputation. Four patients (four men, mean age 30 years) underwent the procedure. The initial trauma resulted from a motorcycle (n=3) or firearm (n=1) accident. The patients were referred to our unit within three months on the average. Prior treatments (cancellous graft in an open or intrafocal procedure) had failed in all patients who presented persistent infection. Antibiotics were administered until bone healing in all patients. Mean length of the gap was 10 cm (7 – 15 cm). The composite graft (skin and fibula with a vascularised fibular bundle) was raised from the contralateral limb and cross-leg anastomosed proximally and distally on the receiver anterior tibial bundle (all four cases). Results: All fractures consolidated between six and twelve months after initiating management of this technique. Bone and soft tissue losses healed without shortening. There were not repeated fractures after mean follow-up of twelve months (range eight months to two years). No complementary bone graft was necessary. Infection resolved in all patients. Discussion and conclusion: As for classical vascularised fibula grafts, this technique enables controlling bone and soft tissue problems together (composite graft). The graft is vascularised favouring antibiotic diffusion. The mechanical quality is better than with a pure cancellous graft but longer follow-up would be required to determine the rate of repeated fractures. This technique broadens indications for vascularised fibula grafts which can be used in unfavourable vascular contexts where only one or two leg trunks persist

We are presenting the outcome of a young adult with extensive epithelioid hemangioendothelioma of the femur treated with wide excision and vascularised fibular graft. An 18-year-old builder was referred with an aggressive primary bone tumor of the right femur. Initial staging showed no evidence of distant disease but tumor confined to a 26.5cm diaphyseal segment of the femoral shaft. The patient’s pre-operative Oxford knee score was 28 and the AKSS scores were 74 (observational) and 65 (functional). True cut open biopsy confirmed low grade angiosarcoma. The patient underwent a wide excision of the lesion through a lateral approach leaving a generous cuff of bone and muscle tissue around the tumor. Clear resection margins were assessed intraoperatively. Histologically, the tumor was found to be epithelioid hemangioendothelioma. The 29.5cm defect was filled with a vascularised bone graft of the ipsilateral fibula. The graft was secured with a 22-hole DCS bridging plate and screws at both ends. Intraoperative knee range of motion was from 0 to 125 degrees without recurvatum and graft movement. The patient had an unremarkable recovery. At the latest follow-up, one year after his operation, the patient had made an excellent functional recovery with non-symptomatic full weight bearing and had also returned to his work as a builder. He demonstrated a knee range of motion of 0 to 115 with a slight genu varum. The patient’s post-operative Oxford knee score was 40 and the AKSS scores were 70 (observational) and 90 (functional). Radiographs showed excellent union at the distal aspect of the graft and a healing stress fracture of the fibula graft at the proximal aspect. Vascularized fibular graft with plating is a safe reconstruction limb salvage option for defects of long bones after tumor resection

Aims

The ulna is an extremely rare location for primary bone tumours of the elbow in paediatrics. Although several reconstruction options are available, the optimal reconstruction method is still unknown due to the rarity of proximal ulna tumours. In this study, we report the outcomes of osteoarticular ulna allograft for the reconstruction of proximal ulna tumours.

To present the results achieved with the use of external fixation techniques in treating 52 cases of post-traumatic and post-surgical septic non-union in a low resources setting. From 2006 to 2014 52 patients were treated for post-traumatic septic non-union of the lower and upper limb bones. Clinical records and radiographs were reviewed; telephone interviews were done for patients unable to reach our institution. There were 39 males and 13 females, with an average age at the time of admission of 29 years (the youngest patient was 8 years old, the oldest 81). Tibia was involved in 43 cases (24 right side, 19 left side), femur in 9 (4 right, 5 left) and left humerus in 1. All the patients, except two, had been treated in other institutions before admission. At presentation, 19 patients had an external fixator in situ, 18 patients had infected osteosynthesis, 15 had exposed necrotic bone, with loss of soft tissues. In 20 cases hardware removal, debridement and sequestrectomy were followed by application of an external fixator. In 31 cases bone transport was done; the fixator was monolateral in 27 cases. In 1 case sequestrectomy and external fixation were followed by a vascularized fibula graft. Bifocal bone transport was utilized in one patient while the bone transport procedure was associated to limb lengthening in 10 patients. Plastic surgery was required in 13 patients. Rotational flaps, vascularized free flaps and extensive skin grafts were all used. The site of non union was cured in all the patients, in an average time of 11 months (from 4 to 32). Two patients required an amputation a few months after the end of the treatment. There was need for fixator adjustment and screws replacement in 21 patients. Non-union at the docking point was observed in 5 patients; it was septic in two of them. There was need of skin-plasty in 2 cases for skin invagination. In 3 cases an extensive skin ulcer was observed during the transport procedure. Limb length discrepancy was corrected in 10 patients. A residual limb shortening was observed in 14 patients. Ankle fusion, knee fusion, foot drop, sensory loss in the foot, reduced range of joint motion were also observed. The external fixator plays a pivotal role in the treatment of septic non unions, especially in low resources setting. The treatment is long and costly. Strict medical supervision is necessary during the entire process

We present our experience of treating 57 cases of bone defects associated with chronic osteomyelitis (COM) and an algorithm for their treatment. A retrospective analysis of our operation database revealed 377 patients treated for COM (2002–2010). 76 (20%) had bone defects, of these 57 had notes and x-rays available. The tibia was most commonly affected (63%), followed by the femur (21%). Infection control procedures included debridement, drilling and sequestrectomy. Long-term antibiotics were seldom used. Prerequisites to reconstruction surgery were; fully healed skin, absence of sequestrae on x-ray and no antibiotics for 2-months. Decision on the method of treatment of defect was made depending on; age, defect size, viability of periosteum and physes, condition of soft tissues and coexisting deformity. Initial treatment was; plaster stabilisation (15), frame stabilisation (6), free fibula structural bone grafts (9), ipsilateral vascularised fibula graft (7), non-structural cancellous bone graft (8), bone transport (8) and amputation (4). Forty three (75%) patients were successfully treated with initial strategy. Initial treatment therefore failed in 14 (25%) patients. Successful treatment subsequently used was; structural bone grafting (6), non-structural bone grafting (4), bone transport (3) and Rush Rod stabilisation (1). Little is known about osteomyelitis-induced bone defects, which cause massive morbidity in developing countries. Our novel research shows that these can be treated successfully, often by relatively simple methods. In the absence of ongoing infection, non-vascularised bone grafting techniques are often successful. Bone transport or vascularised grafting are more reliable but more complex solutions