Internal hemipelvectomy is a standard treatment for malignant tumours of the pelvis. Reconstruction using a non-vascularised fibular graft is relatively straightforward compared to other techniques. We describe the surgical and functional outcomes for a series of ten patients who underwent an internal hemipelvectomy (type I or I/IV) with reconstruction by a non-vascularised fibular graft between 1996 and 2009. A key prerequisite for this procedure was a preserved sciatic notch, confirmed pre-operatively on MRI. Graft-host union was achieved in all patients with a single fibular graft, and in the lower graft where two grafts had been used. The mean time to union was 7.3 months (3 to 12). The upper graft did not unite in four of six cases where two grafts had been used. Seven patients were eventually able to walk without a stick. The mean post-operative Musculoskeletal Tumour Society score was 75.4% (16.7 to 96.7). There were no cases of deep post-operative infection. The mean pelvic shortening was 0.9 cm (0.2 to 3.4). Recurrent tumour occurred in three cases, and death from tumour-related disease occured in one. Patients who need an internal hemipelvectomy will do well if their pelvic ring is reconstructed with a non-vascularised fibular graft. The complication rate is low, and they attain a good functional outcome

Free vascularised fibular grafting has been reported to be successful for adult patients with osteonecrosis of the femoral head (ONFH). However, its benefit in teenage patients with post-traumatic ONFH has not been determined. We evaluated the effectiveness of free vascularised fibular grafting in the treatment of this condition in children and adolescents. We retrospectively analysed 28 hips in 28 patients in whom an osteonecrotic femoral head had been treated with free vascularised fibular grafting between 2002 and 2008. Their mean age was 16.3 years (13 to 19). The stage of the disease at time of surgery, and results of treatment including pre- and post-operative Harris hip scores, were studied. We defined clinical failure as conversion to total hip replacement. All patients were followed up for a mean of four years (2 to 7). The mean Harris hip score improved from 60.4 (37 to 84) pre-operatively to 94.2 (87 to 100) at final follow-up. At the latest follow-up we found improved or unchanged radiographs in all four initially stage II hips and in 23 of 24 stage III or IV hips. Only one hip (stage V) deteriorated. No patient underwent total hip replacement. Free vascularised fibular grafting is indicated for the treatment of post-traumatic ONFH in teenage patients

The results and complications of 104 vascularised fibular grafts in 102 patients are presented. Bony union was ultimately achieved in 97 patients, with primary union in 84 (84%). The mean time to union was 15.5 weeks (8 to 40). In 13 patients, primary union was achieved at one end of the fibula and secondary union at the other end. In these patients, the mean time to union was 31.1 weeks (24 to 40). Five patients failed to achieve union, with a resultant pseudarthrosis (3 patients) or amputation (2 patients). There were various complications. Immediate thrombosis occurred in 14 cases. In two of 23 patients with osteomyelitis, infection recurred at two and six months after surgery, respectively. Both patients had active osteomyelitis less than one month before the operation. Bony infection occurred in a patient with a synovial sarcoma of the forearm one year after surgery. In 15 patients, 19 fractures of the fibular graft occurred after bony union, all except one within one year after union. In patients in whom an external fixator had been used, fracture occurred soon after its removal. Union was difficult to achieve in cases of congenital pseudarthrosis of the tibia. Appropriate alignment of the fibular graft is an important factor in preventing stress fracture. The vascularised fibula should be protected during the first year after union. Postoperative complications at the donor site included transient palsy of the superficial peroneal nerve in three patients, contracture of flexor hallucis longus in two and valgus deformity of the ankle in three. Vascularised fibular grafts are useful in the reconstruction of massive bony defects. We believe that meticulous preoperative planning, including choosing which vessels to select in the recipient and the type of fixation devices to use, and care in the introduction of the vascularised fibula, can improve the results and prevent complications

From 1979 to 1990 we treated 20 patients with large bone defects or established nonunion of the femur by vascularised fibular grafts. There were 18 men and two women with an average age at operation of 36.6 years (16 to 69). Ten patients had infected nonunion, three had post-traumatic nonunion or a bone defect without infection, four had a defect after tumour resection, and three had other lesions. The mean length of the fibular grafts was 18.1 cm. Postoperative circulatory disturbances needed revision surgery in five patients, including three with circulatory problems in the monitoring flap, but not at their anastomoses. The outcome was successful in 19 of the 20 patients with bone union at means of 6.1 months at the proximal site and 6.6 months at the distal site. Three patients had fractures of the fibular grafts but all these united in two to three months after cast immobilisation

We describe the management of nonunion combined with limb-length discrepancy following vascularised fibular grafting for the reconstruction of long-bone defects in the lower limb after resection of a tumour in skeletally immature patients. We operated on nine patients with a mean age of 13.1 years (10.5 to 14.5) who presented with a mean limb-length discrepancy of 7 cm (4 to 9) and nonunion at one end of a vascularised fibular graft, which had been performed previously, to reconstruct a bone defect after resection of an osteosarcoma. Reconstruction was carried out using a ring fixator secured with correction by half pins of any malalignment, compression of the site of nonunion and lengthening through a metaphyseal parafocal osteotomy without bone grafting. The expected limb-length discrepancy at maturity was calculated using the arithmetic method. Solid union and the intended leg length were achieved in all the patients. Excessive scarring and the distorted anatomy from previous surgery in these patients required other procedures to be performed with minimal exposures and dissection in order to avoid further compromise to the vascularity of the graft or damage to neurovascular structures. The methods which we chose were simple and effective in addressing these complex problems

We report the results of limb salvage for non-metastatic osteosarcoma of the distal tibia using resection arthrodesis, autogenous fibular graft and fixation by an Ilizarov external fixator. In six patients with primary osteosarcoma of the distal tibia who refused amputation, treatment with wide en bloc resection and tibiotalar arthrodesis was undertaken. The defect was reconstructed using non-vascularised free autogenous fibular strut graft in three patients and a vascularised pedicular fibular graft in three, all supplemented with iliac cancellous graft at the graft-host junction. An Ilizarov external fixator was used for stabilisation of the reconstruction. In five patients sound fusion occurred at a mean of 13.2 months (8 to 20) with no evidence of local recurrence or deep infection at final follow-up. The mean post-operative functional score was 70% (63% to 73%) according to the Musculoskeletal Tumour Society scoring system. All five patients showed graft hypertrophy. Union of the graft was faster in cases reconstructed by vascularised fibular grafts. One patient who had a poor response to pre-operative chemotherapy developed local tumour recurrence at one year post-operatively and required subsequent amputation

Free osteocutaneous fibular grafts, revascularised by microvascular anastomoses, have been used for one-stage reconstruction of extensive bone and skin loss in the lower leg in seven patients. The addition of an integral skin flap to a vascularised fibular graft makes reconstruction of bone defects with significant skin loss possible, and the technique for designing and raising such a flap is presented. The advantages of this transfer over other microvascular osteocutaneous flaps are the available length of straight cortical bone, the large thin skin flap, the good diameter of the vascular pedicle and the fact that dissection is carried out under a tourniquet

The management of osteonecrosis of the femoral head ranges from symptomatic therapy to total hip replacement. Conservative treatment is effective only in small, early-stage lesions. Free vascularised fibular grafting has provided more consistently successful results than any other joint-preserving method. It supports the collapsing subchondral plate by primary callus formation, reduces intra-osseous pressure, removes and replaces the necrotic segment, and adds viable cortical bone graft plus fresh cancellous graft, which has osseoinductive and osseoconductive potential. Factors predisposing to success are the aetiology, stage and size of the lesion. Furthermore, it is a hip-salvaging procedure in early pre-collapse stages, and a time-buying one when the femoral head has collapsed

This study demonstrates that harvesting a vascularized fibular graft has a significant number of minor complications. These complications do not result in significant morbidity but could be avoided by other newer methods of managing bony defects and avascular necrosis such as porous bone substitute rods. The purpose of this study was to evaluate functional outcomes of the foot and ankle following vascularized fibula graft harvest, using validated outcome measures. This study agrees with previous reports in that minor complications are commonly associated with free fibula harvest. Functional outcome scores demonstrate significant differences in pain and disability; however, the disability associated with daily activities is small. This is the first study to assess the outcomes of vascularized fibular grafts with validated outcomes measures. It is one of a few studies to assess the outcomes of vascularized fibular grafts on an otherwise normal lower extremity. Twenty-two patients were available for study, with ten attending for examination. All had undergone free fibula transfer for mandibular reconstruction. Functional outcome was assessed using MODEMS (includes SF-36) and Foot Function Index (FFI). A radiographic analysis was performed. All patients had a normal contralateral foot and ankle which was used as a control. Mean follow-up is 3.1 years. Sixty percent of patients were satisfied following surgery. Subjective complaints of weakness, instability and numbness were reported. Minor wound complications were seen in twenty-three percent of patients and clawing of the lesser toes in eighteen percent. No significant difference was seen in the SF-36 categories when compared to population norms. The FFI identified significant differences in Pain and Disability means when compared to the contralateral side. Radiographic analysis failed to demonstrate increased arthritic change or instability. Two patients had undergone further surgery for toe clawing and persistent ankle pain

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

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 chemotheraphy 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%

Introduction and Aims: The treatment of bone defects secondary to congenital pseudoarthrosis of the tibia, infections and tumors is problematic. The vascularised fibular graft has been used for many years as a way to improve blood supply and successfully achieve union. Lengthening the limb prior to grafting can improve outcomes. Method: Forty-one patients with major bone defects secondary to tumor resections, infections and congenital pseudoarthroses had reconstruction with a vascularised fibular graft. Of these, 10 patients had limb length discrepancies, which were treated by application of an external fixater for lengthening through the bone gap. Following restoration of length with an external fixater, a vascularised fibular graft was inserted to bridge the bone defect. The external fixater was not removed until union of the graft to the host bone and initial hypertrophy occurred. Results: The 10 patients (five males and five females) were aged 2.5 to 14.5 years (mean 7.6 years). The affected bones included eight tibias, one humerus and one ulna. The limb length discrepancies ranged from three to 20cm (mean 6.44cm). The duration of lengthening prior to definitive vascularised fibular graft ranged between one to 15 weeks (mean seven weeks) in nine patients. In the patient with a discrepancy of 20cm, lengthening spanned 52 weeks. At the time of the definitive vascularised fibular graft procedure, the fixater was partially disassembled to facilitate surgery and microvascular anastomosis. The frame was then reassembled and used as the fixation device to protect the graft. The fixater was removed from seven to 24 weeks (mean 16 weeks) after definitive surgery. There were no complications during the lengthening process. However, two patients experienced non-unions, which were successfully treated by autologous bone grafts. One patient had a fracture of the vascularosed fibular graft, which healed uneventfully. Conclusion: A staged approach to reconstruction of major long bone deficiencies leads to a better outcome than insertion of vascularised fibular grafts without addressing the limb length discrepancy. In this type of procedure, the patients not only bridged their bone defect, but achieved limb length equality as well

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

Vascularised fibular grafts (VFGs ) are a valuable surgical technique in limb salvage after resection of a tumour. The primary objective of this multicentre study was to assess the risk factors for failure and complications for using a VFG after resection of a tumour. . The study involved 74 consecutive patients (45 men and 29 women with mean age of 23 years (1 to 64) from four tertiary centres for orthopaedic oncology who underwent reconstruction using a VFG after resection of a tumour between 1996 and 2011. There were 52 primary and 22 secondary reconstructions. The mean follow-up was 77 months (10 to 195). . In all, 69 patients (93%) had successful limb salvage; all of these united and 65 (88%) showed hypertrophy of the graft. The mean time to union differed between those involving the upper (28 weeks; 12 to 96) and lower limbs (44 weeks; 12 to 250). Fracture occurred in 11 (15%), and nonunion in 14 (19%) patients. . In 35 patients (47%) at least one complication arose, with a greater proportion in lower limb reconstructions, non-bridging osteosynthesis, and in children. These complications resulted in revision surgery in 26 patients (35%). VFG is a successful and durable technique for reconstruction of a defect in bone after resection of a tumour, but is accompanied by a significant risk of complications, that often require revision surgery. Union was not markedly influenced by the need for chemo- or radiotherapy, but should not be expected during chemotherapy. Therefore, restricted weight-bearing within this period is advocated. Cite this article: Bone Joint J 2015;97-B:853–61

We retrospectively evaluated 18 patients with a mean age of 37.3 years (14 to 72) who had undergone pelvic reconstruction stabilised with a non-vascularised fibular graft after resection of a primary bone tumour. The mean follow-up was 10.14 years (2.4 to 15.7). The mean Musculoskeletal Tumor Society Score was 76.5% (50% to 100%). Primary union was achieved in the majority of reconstructions within a mean of 22.9 weeks (7 to 60.6). The three patients with delayed or nonunion all received additional therapy (chemotherapy/radiation) (p = 0.0162). The complication rate was comparable to that of other techniques described in the literature. Non-vascularised fibular transfer to the pelvis is a simpler, cheaper and quicker procedure than other currently described techniques. It is a biological reconstruction with good results and a relatively low donor site complication rate. However, adjuvant therapy can negatively affect the outcome of such grafts

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

Introduction: Osteochondral reconstruction following tumour resections has a high complication rate. We hypothesized that the vascularised fibular graft as a supplement to the allograft reconstruction following tumour resections would provide a biological solution. Purpose of the study: A prospective study of the results of patients receiving large fragment allografts and vascularised fibular grafts following tumour resections around the hip and the knee. Patients and methods: 18 patients underwent resection of primary malignant bone tumors followed by reconstruction with large fragment allograft and vascularised fibular graft. 8 patients underwent resection arthrodesis of the hip, six underwent resection arthrodesis of the knee and five underwent intercalary resections around the knee followed by a large fragment allograft and vascularised fibular graft reconstruction to span the gap left by resection. The patients were assessed clinically (MSTS scoring system) and radiologically at regular intervals. Results: There were 14 males and 4 females, with a mean age of 26 years (12–70). Mean follow-up was 65 months (8–144). Five patients died of metastatic disease but without local recurrence. In six of the patients with resection arthrodesis of the hip, there was evidence of fracture of the allograft but without the failure of the construct. One fibula fractured but eventually healed uneventfully. There were no cases of non-union in cases of intercalary resections. All the patients scored good or excellent in the MSTS scoring system. Discussion: Our experience clearly indicates that tumour resection followed by reconstruction with large fragment allograft and vascularised fibular graft is a useful limb salvage procedure providing a biological long-term solution with superior results when compared to prosthetic reconstruction

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

We present a case of a 19-year-old white female patient with neurofibromatosis type I who, 10 years ago, underwent free vascularized fibular grafting for isolated congenital pseudarthrosis of her left radius. An external fixator was applied for gradual distraction and correction of the deformity of the pseudarthrosic site for five weeks. Wide resection of pseudarthrosis with surrounding fibrotic and thick scar tissue and bridging of the gap with a free vascularized fibular graft followed. Four months postoperatively, union was established in both graft ends. At the last follow-up, 10 years postoperatively, the patient has excellent function with full wrist flexion-extension and forearm pronation-supination. Free vascularized fibula transfer is considered the treatment of choice for congenital radial pseudarthrosis. It allows complete excision of the pathologic tissue and covering of the gap in one operation. Due to the vascularity of the free vascularized fibular graft both sides of fibula unite easily with no additional intervention

Aims: The purpose of this study is to to assess the surgical results, complications, and long-term results of vascularized fibula in the treatment of congenital pseudarthrosis of the tibia. Methods: Seven patients who had congenital pseudarthrosis of the tibia were treated consecutively at our clinic between 1992 and 2000 with free vascularized fibular graft. There were four females and three males. The mean age at the time of operation averaged 6.5 years (range 1–12 years). Four left tibias and 3 right tibias were involved. Stability was maintained with internal fixation in four patients, external fixation in two patients and intramedullary pin in one patient. Results: The average follow-up was 2.6 years (range 6 months to 8 years). In five patients, both ends of the graft healed primarily within 2.7 months (range 1.5 to 3 months), and hypertrophy of the fibular graft occurred rapidly with a well-formed medullary canal. In one patient the distal junction did not unite and although required three subsequent operations still not healed. Stress fracture occurred in one patient underwent four additional operations before union achieved. Conclusions: Despiting the continuing problems and the relatively high complication rate, the ultimate results with free vascularized fibula transplant are generally good specially as compared with published series in whom conventional grafting techniques had failed. However, even achieving union of pseudarthrosis is not enough for the resolution of this disease and is only half of the problem; the other half is to maintaining