Purpose of the study: Transfer of a vascularised fibular is an option after tumour resection to save the limb.

Material and methods: Thirty-eight consecutive cases of malignant bone tumours located in the shaft of long bones of the lower limb were treated with a free transfer of a vascularised fibula. There were 30 femoral localisations and 8 tibial localisations, 32 first-intention transfers and six transfers after failure of an allograft. Mean age at transfer was 11.8 years (range 4.33–22.57). Adapted chemotherapy was associated. The Musculo-skeletal Tumour Society score was noted for the functional assessment. Healing was considered achieved when there was a bone bridge between the transplant and the recipient bone associated with disappearance of the osteotomy line. Outcome was expressed as mean or percentage with the 95% confidence interval. P< 0.05 was considered significant.

Results: Mean follow-up for the 38 patients was 7.56 years (range 0.37–18.4). The mean MSTS was 27.2 (range 20–30).. This mean score was significantly higher (S t = 2.11> 2.04) for vascularised fibular transfer surgery immediately after tumour resection (27.4) than after revision surgery (25.4). The healing rate was 89%. The rate of healing failure of the vascularised free transfer was significantly greater (p=0.005< 0.05) after revision (33%) than after immediate transfer (6%). The rate of good results in the Boer classification was significantly higher for tibial than femoral reconstructions (p=0.006< 0.05), for immediate surgery than revision surgery (p=0.005< 0.05), and for Ewing tumours than for osteosarcoma (p=0.0019< 0.05).

Discussion: Free transfer of a vascularised fibula is a reliable reconstruction technique for bone shaft loss of the lower limb after resection of a malignant bone tumour in children. This is a mutilating surgery with frequent complications but which can save the limb. This reconstruction surgery should be done at the same time as the resection. Healing of the vascularised fibular transplant is more difficult to achieve for femoral reconstructions than tibial reconstruction and there are more complications in the femoral localisation. Femoral reconstructions using a vascularised fibular transplant should be associated with an allograft.

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.