After intercalary resection of a bone tumour from the femur,
reconstruction with a vascularized fibular graft (VFG) and massive
allograft is considered a reliable method of treatment. However,
little is known about the long-term outcome of this procedure. The
aims of this study were to determine whether the morbidity of this
procedure was comparable to that of other reconstructive techniques,
if it was possible to achieve a satisfactory functional result, and
whether biological reconstruction with a VFG and massive allograft
could achieve a durable, long-lasting reconstruction. A total of 23 patients with a mean age of 16 years (five to 40)
who had undergone resection of an intercalary bone tumour of the
femur and reconstruction with a VFG and allograft were reviewed
clinically and radiologically. The mean follow-up was 141 months
(24 to 313). The mean length of the fibular graft was 18 cm (12 to
29). Full weight-bearing without a brace was allowed after a mean
of 13 months (seven to 26).Aims
Patients and Methods
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:
We retrospectively reviewed 101 consecutive patients
with 114 femoral tumours treated by massive bone allograft at our
institution between 1986 and 2005. There were 49 females and 52
males with a mean age of 20 years (4 to 74). At a median follow-up
of 9.3 years (2 to 19.8), 36 reconstructions (31.5%) had failed.
The allograft itself failed in 27 reconstructions (24%). Mechanical complications such as delayed union, fracture and
failure of fixation were studied. The most adverse factor on the
outcome was the use of intramedullary nails, followed by post-operative
chemotherapy, resection length >
17 cm and age >
18 years at the
time of intervention. The simultaneous use of a vascularised fibular
graft to protect the allograft from mechanical complications improved
the outcome, but the use of intramedullary cementing was not as
successful. In order to improve the strength of the reconstruction and to
advance the biology of host–graft integration, we suggest avoiding
the use of intramedullary nails and titanium plates, but instead
using stainless steel plates, as these gave better results. The
use of a supplementary vascularised fibular graft should be strongly
considered in adult patients with resection >
17 cm and in those
who require post-operative chemotherapy.
