Background: The reconstructive surgery of the upper limb is able to avoid an amputation and a severe functional impairment. Nevertheless the therapeutic challenge is difficult because of the diversity of the injuries and the complex function of the upper limb.

Aim: The aim of this study is to assess the results of vascularised fibular bone graft in the immediate and secondary post traumatic reconstructive surgery of the upper limb.

Material and method: Between 1985 and 2006, 16 vascularised fibular bone grafts were performed for 15 post traumatic reconstructions of the upper limb. In this study there were 7 females and 8 males, with an average age of 42 years (20–79). The fibular bone grafting was performed in 9 cases in the immediate post traumatic reconstructive surgery. In 7 cases the fibular bone graft was performed after a first failed surgery, as salvage reconstructive surgery. The transfer was composed of bone and skin in 2 cases, of bone and muscle in 6 cases and of only bone in 8 cases.

Results: The percentage of bone union was 80%. Eight fibular bone graft healed spontaneously, 2 after a additional iliac crest bone grafting. The average duration of bone healing was 6,5 months, from 4 to 12 months. The functional result was good for 10 patients allowing them to go back to their initial activities.

Discussion: In severe bone and soft tissues destruction of the upper limb, a complete reconstruction in one operative session may be performed in order to reduce the time of bone healing and rehabilitation. The micro-vascularized fibular bone grafting may be an excellent therapeutic option. The other techniques as amputation or conventional bone grafting techniques are usually proposed when the vital status of the patient is not compatible with a to extended surgery.

The fibular bone grafting appeared as a very reliable technique with a small morbidity on the donor site. Malunions are frequently described in the literature. It might be partially due to the difficulty in having a stable internal fixation. It has to be as less aggressive a possible on the fibular bone graft vascularisation but has also to offer a good stability. The internal fixation used in these cases was not perfectly adapted for this bifocal fixation of the fibular bone graft on the upper limb. A better device should be developed, with an endomedullary fixation and an axial compression effect.

Conclusion: We recommend this technique in severe trauma cases of the upper limb as salvage procedure at an early stage when is compatible with the initial general status of the patient.

Purpose of the study: Assessment of limb reconstruction results using vascularized fibular grafts after bony resection for malignant tumors in children.

Material and methods: Thirty children (9 girls and 21 boys)underwent surgery between 1993 and 2000. Mean age was 11 years. Tumor localizations were: femur (n=17), tibia (n=6), humerus (n=5), radius (n=1) and distal ulna (n=1). Mean length of bone resection was 16 cm (range 10–26 cm). For 22 children, the adjacent epiphysis was preserved. For the eight others, fusion was also performed. Two surgical teams operated sequentially: the first team performed the tumor resection and the second (an orthopedist for the osteosynthesis and a plastician for the vascularized fibular transfer) the limb reconstruction. Radiographic and clinical assessment was completed with bone scintigraphy. The index of graft hypertrophy was determined with the De Boer and Wood method. Functional outcome was assessed with Enneking criteria.

Results: Mean follow-up was 51 months (range 2 – 9 years). Early amputation was necessary for two children due to local oncological complications. One patient died of pulmonary metastasis eight months after limb reconstruction. Among the 27 other patients, primary healing was achieved in 22. In the five with primary nonunion, bone scintigraphy showed objective signs of a lack of blood supply to the graft. Secondary union was achieved with a complementary autologous bone graft in four cases. All cases of stress fracture healed with orthopedic treatment. For the 22 patients with primary union, the graft hypetrophy was 22–190% (mean 61%). For the five patients without bone vascularization on the scintigraphy, the fibular graft failed to hypertrophy. Functional outcome was satisfactory. The modified Enneking score (30 point scale) was 26 (range 19–30 points).

Discussion: Limb reconstruction results are directly related to good patency of vascular anastomoses. Postoperative bone scintigraphy is useful to determine blood supply to the graft and to establish the final prognosis. In the case of vascular failure, an autologous bone graft can be proposed early to enable union. Close collaboration between the plastic surgery and the orthopedic team is the key to successful limb reconstruction with a vascularized fibular graft.

Purpose: Reconstruction after resection of malignant bone tumours remains a major challenge. Free vascularised fibular grafts may be a useful alternative in this indication.

Material: Thirty children (nine girls, twenty-one boys) were treated between 1993 and 2000. Mean age was eleven years. Tumour histology was: osteogenic osteo-sarcoma (n=20), Ewing tumour (n=5), justacortical osteosarcoma (n=3), synovialosarcoma (n=1), and chondrosarcoma (n=1). Tumours were located in the femur (n=17), the tibia (n=6), the humerus (n=5), the radius (n=1), and the distal fibular (n=1). The length of resection varied from 100 mm to 260 mm (mean 160 mm). Internal fixation was used in 27 cases and external fixation in three. The adjacent epiphysis was preserved in 22 cases and initial arthrodesis was performed in eight.

Method: Patients were followed clinically and radiographically. A bone scintigram was obtained in all patients at least once during the postoperative period. Radiological assessment was based on the hypertrophy index of the graft using the method described by DeBoer and Wood. Functional outcome was assessed using the Enneking criteria.

Results: Mean follow-up was 51 months (range 2 – 9 years). Early amputation was required in two patients due to local ocological complications. One patient died at eight months follow-up due to lung metastasis. Among the remaining 27 patients, primary bone healing was achieved in 22. The five other patients exhibited clear signs of non-vascularisation. Successful healing was achieved in four of these patients after a complementary autologous graft. All cases of stress fracture healed after simple immobilisation.

The twenty-two patients who achieved primary bone healing developed a hypertrophic graft (mean 61%, range 22 – 190%). Graft hypertrophy was not observed in the five cases requiring a secondary graft after the scintigram demonstrated lack of vascularisation. Hypertrophy of the vascularised fibular graft was more marked for lower limb reconstructions than for upper limb reconstructions..

Functional outcome was satisfactory in all cases. On the 30-point Enneking scale as modified, our patients achieved a mean 26 points (range 19 – 30).

Discussion: Outcome was directly related to patency of the vascular anastomoses. Bone scintigraphy, performed one month after reconstruction surgery, was an important element for assessing prognosis. In case of unsuccessful vascularisation, a complementary cortico-cancellous graft should be used. Early weight-bearing is advisable using adequate protective devices. Dynamic osteosynthesis systems should be helpful in improving graft hypertrophy.