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Abstract Recent studies on fibular osteotomy for varus gonarthrosis and possible subsequent biomechanical changes have attracted increasing attention to the topic. Existing studies have focused mainly on proximal fibular osteotomy with short follow-up periods. The aim of this study was to investigate changes in the alignment of the coronal plane of the ankle and knee joints in patients who underwent vascularized fibula graft harvest (VFGH). The evaluation was based on functional outcomes and radiological measurements.In the comparison between the VFGH side and the contralateral side, no significant differences in the knee inclination (KI) or talar inclination (TI) angle, knee medial clear space (K-MCS) or ankle medial clear space (A-MCS) distance were noted. However, a significant difference in the hip knee (HKA) angle was observed between the operated and nonoperated sides (0.3° ± 1.8° and 1.5° ± 1.9°, respectively [p = 0.019]). Statistically significant differences in both the knee society score (KSS) and the AOFAS scores were found between the ipsilateral donor limb and the contralateral healthy limb. Although the contralateral healthy side had better clinical scores than the VFGH side, the outcomes of the VFGH side were still satisfactory or excellent.

Background: Vascularized fibula grafts (VFGs) have become one of the most preferred grafts for the reconstruction of bone defects. However, despite the many advantages over other graft options, recipient and donor site morbidities are also common. Donor site morbidity has been reported at rates ranging from 5% to 67%. The aim of this study was to present a single-center series examining the clinical, functional, and radiologic aspects of donor site morbidity following VFG harvesting. Methods: The study included 69 patients who underwent biological reconstruction with VFG for bone tumors, avascular necrosis of the femoral head, or bone defects after trauma. Patients were evaluated functionally, clinically, and radiologically for donor site morbidity. Results: Donor site morbidity was observed in 33 of 69 patients (48%). The most complications were sensation deficits around the feet and ankles (20 of 69; 29%). Knee laxity was more common in patients who underwent osteoarticular fibular resection (P =.006). Conclusion: We found VFG to be an effective method for the reconstruction of large bone defects, but associated with a relatively high rate of complications. Complications requiring surgical intervention were rare and the majority of patients did not have long-term functional limitations. Level of Evidence: Level IV, retrospective case series. [ABSTRACT FROM AUTHOR]

The vascularized fibula transfer is a well-established technique for extremity reconstruction, but operative planning and patient selection remains crucial. Although recently developed techniques for bone reconstruction, such as bone segment transfer, are becoming increasingly popular, bone defects may still require vascularized bone grafts under certain circumstances. In this study, 41 cases, 28 (68%) men and 13 (32%) women (median age: 40 years), were retrospectively analyzed. Therapy-specific data (flap vascularity [free vs. pedicled] size in cm and configuration [single- vs. double-barrel], mode of fixation [internal/external]) and potential risk factors were ascertained. Indications for reconstruction were osteomyelitis at host site (n = 23, 55%), pseudarthrosis (n = 8, 20%), congenital deformity (n = 6, 15%), traumatic defect, and giant cell tumor of the bone (n = 2, 5% each). Complete healing occurred in 34 (83%) patients after a median time of 6 months. Confounders for prolonged healing were female gender (p = 0.002), reconstruction in the lower limb (p = 0.011), smoking (p = 0.049), and the use of an external fixator (p = 0.009). Six (15%) patients required secondary limb amputation due to reconstruction failure, and one patient had persistent pseudarthrosis at last follow-up. The only risk factor for amputation assessed via logistic regression analysis was preexisting PAOD (peripheral artery occlusive disease; p = 0.008) The free fibula is a reliable tool for extremity reconstruction in various cases, but time to full osseous integration may exceed six months. Patients should be encouraged to cease smoking as it is a modifiable risk factor. [ABSTRACT FROM AUTHOR]

Elsa Daniel Alemayehu, Eskinder Kebede Department of Orthopedic Surgery and Trauma, College of Health Science, Addis Ababa University, Addis Ababa, EthiopiaCorrespondence: Elsa Daniel Alemayehu, Orthopedic Surgery and Trauma Department, Black Lion Hospital, College of Health Science, Addis Ababa University, Addis Ababa, Ethiopia, Email elladj2009@gmail.com; elsa.daniel@aau.edu.etAbstract: Giant Cell tumors (GCT) are benign tumors with aggressive characteristics and the potential to metastasize. These are seldom lethal benign bone tumors but are associated with massive local bony architecture distraction making their treatment difficult, especially if found in peri-articular locations. Several long bone giant cell tumor (GCT) cases have been reported. We report a unique treatment of distal femur GCT in a 19-year-old in a resource-limited setup whose initial presentation was following a pathologic fracture. We used a staged surgical protocol. In the first stage, distal femur resection and implantation of poly methyl methacrylate (PMMA) cement spacer for induced membrane formation was done, followed by SIGN nail and non-vascularized fibula strut graft. There was adequate healing and no recurrence was noted during the two-year follow-up.Keywords: distal femur, fracture, giant cell tumor, GCT, SIGN nail, peri-articular, polymethyl methacrylate, PMMA, vascularized fibula graft

The vascularized fibula transfer is a well-established technique for extremity reconstruction, but operative planning and patient selection remains crucial. Although recently developed techniques for bone reconstruction, such as bone segment transfer, are becoming increasingly popular, bone defects may still require vascularized bone grafts under certain circumstances. In this study, 41 cases, 28 (68%) men and 13 (32%) women (median age: 40 years), were retrospectively analyzed. Therapy-specific data (flap vascularity [free vs. pedicled] size in cm and configuration [single- vs. double-barrel], mode of fixation [internal/external]) and potential risk factors were ascertained. Indications for reconstruction were osteomyelitis at host site (n = 23, 55%), pseudarthrosis (n = 8, 20%), congenital deformity (n = 6, 15%), traumatic defect, and giant cell tumor of the bone (n = 2, 5% each). Complete healing occurred in 34 (83%) patients after a median time of 6 months. Confounders for prolonged healing were female gender (p = 0.002), reconstruction in the lower limb (p = 0.011), smoking (p = 0.049), and the use of an external fixator (p = 0.009). Six (15%) patients required secondary limb amputation due to reconstruction failure, and one patient had persistent pseudarthrosis at last follow-up. The only risk factor for amputation assessed via logistic regression analysis was preexisting PAOD (peripheral artery occlusive disease; p = 0.008) The free fibula is a reliable tool for extremity reconstruction in various cases, but time to full osseous integration may exceed six months. Patients should be encouraged to cease smoking as it is a modifiable risk factor.

The use of free vascularized fibula grafts (FVFG) in complex spinal deformity surgery intends to allow for life-long stability of the spine with good long-term clinical outcome. However, these long-term outcomes of this technique are still lacking. The objective of this study is to report the long-term postoperative outcomes and establish the long-term viability of this method for spinal reconstruction. A retrospective cohort study was conducted in all patients who underwent spinal reconstructive surgery utilizing a FVFG at a tertiary medical centre. Questionnaires taken from the participants were the Numeric Pain Rating Scale (NPRS), Oswestry Low Back Pain Disability (also known as Oswestry Disability Index (ODI)), Scoliosis Research Society 22r (SRS-22), the EQ-5D-5L and a self-assembled questionnaire regarding donor site comorbidities and patient satisfaction. Over a period of 24 years (1995–2019), we used FVFG for spinal reconstruction in 31 patients. A total of 25 patients were included in this study, 8 patients were deceased at the time of this study, and sixteen patients responded to the questionnaires. Patient satisfaction was rated 6.8 out of 10, the average SRS-22r score was 3.6, EQ-5D-5L score was 0.725, and the ODI score showed a minimal disability (0–20%) postoperatively. Overall complication-free survival was 8.9 years. Nine patients underwent a re-operation in the spinal area; five for the removal of the spinal instrumentation. Patients reported satisfied and good long-term outcomes following FVFG surgical procedure for complex spinal deformities. Therefore, considering the alternatives, this procedure provides a good long-term solution for complex spinal deformity surgery. [ABSTRACT FROM AUTHOR]

Abstract Background Morphologically, osteofibrous dysplasia-like adamantinoma is thought to be intermediate between osteofibrous dysplasia and adamantinoma. Its treatment is not well established owing to its rarity. Case presentation We report about of a 10-year-old girl with osteofibrous dysplasia-like adamantinoma initially diagnosed as osteofibrous dysplasia and treated via intercalary segmental resection with partial cortex preservation using a pedicled vascularized fibula graft for reconstruction. Bone union was observed 9 weeks after surgery. Twenty-two months after the definitive surgery, no recurrence was observed. Conclusion This case illustrates the upgrade from osteofibrous dysplasia to osteofibrous dysplasia-like adamantinoma. The surgical method may aid the treatment of osteofibrous dysplasia-like adamantinoma with incomplete cortex involvement of the tumor.

Background  Among the alternatives for the management of malignant bone tumors is the "devitalized autograft associated with vascularized fibula graft." The devitalization process is achieved by pasteurization, irradiation, or freezing. The combination of these grafts has been broadly researched for more than 25 years. However, there is no research currently published comparing the various methods or their respective outcomes. Methods  A retrospective study was compiled of 26 devitalized autografts associated with vascularized fibula performed to limb salvage of malignant bone tumors. They were divided into two groups according to the devitalization method: either freezing (12 procedures) or irradiation (14 procedures). Clinical, radiographic, and scintigraphic results were assessed at least 24 months after surgery. Results  The union rates reached 83.3% in the freezing group and 92.8% in the irradiated group but did not express different outcomes. Scintigraphic viability was observed in all the grafts that achieved radiographic union (Mann–Whitney U -test: p  = 0.005). Three patients had nonunion, with only one having no viability in the scintigraphy (Mann–Whitney U -test: p  = 0.001). There was no malignant recurrence in the autograft, only in surrounding soft tissues. Local recurrence was statistically higher in larger tumors (Mann–Whitney U -test: p  = 0.025). Conclusion  Both groups presented similar union rates and are considered safe to devitalize bone graft despite different outcomes observed. The survivor rates observed could be limited by the existence of the techniques. [ABSTRACT FROM AUTHOR]

The options for the reconstruction of diaphyseal defects following the resection of bone tumors include biological or prosthetic implants. The purpose of our study was to evaluate different types of intercalary reconstruction techniques, including massive bone allograft, extracorporeal devitalized autograft, vascularized free fibula, and modular prosthesis. We performed a systematic review of articles using the terms diaphyseal bone tumor and intercalary reconstruction. All the studies reporting the non-oncological complications such as infection, nonunion and fracture of the intercalary reconstructions were included. We excluded articles published before 2000 or did not involve humans in the study. Case reports, reviews, technique notes and opinion articles were also excluded based on the abstracts. Thirty-three articles included in this review were then studied to evaluate failure rates, complications and functional outcome of different surgical intercalary reconstruction techniques. Nonunion rates of allograft ranged 6%–43%, while aseptic loosening rates of modular prosthesis ranged 0%–33%. Nonunion rates of allograft alone and allograft with a vascularized fibula graft ranged 6%–43% and 0%–33%, respectively. Fracture rates of allograft alone and allograft with a vascularized fibula graft ranged 7%–45% and 0%–44%, respectively. Infection rates of allograft alone and allograft with a vascularized fibula graft ranged 0%–28% and 0%–17%, respectively. All of the allograft (range: 67%–92%), extracorporeal devitalized autograft including irradiation (87%), autoclaving (70%), pasteurization (88%), low-heat (90%) or freezing with liquid nitrogen (90%), and modular prosthesis (range: 77%–93%) had similar Musculoskeletal Tumor Society functional scores. Addition of a vascularized fibula graft to allograft did not affect functional outcome [allograft with a vascularized fibula graft (range: 86%–94%) vs. allograft alone (range: 67%–92%)]. Aseptic loosening rates of modular prosthesis seem to be less than nonunion rates of allograft. Adding a vascularized fibula graft to allograft seems to increase bone union rate and reduce the risk of fractures and infections, though a vascularized fibula graft needs longer surgical time and has the disadvantage of donor site morbidity. These various intercalary reconstruction techniques with or without a vascularized fibula autograft had similar functional outcome. [ABSTRACT FROM AUTHOR]

Purpose: Injuries to the long bones of the upper limb resulting in bone defects are rare but potentially devastating. Literature on the management of these injuries is limited to case reports and small case series. The aim of this study was to collate the most recent published work on the management of upper limb bone defects to assist with evidence based management when confronted with these cases. Methods: Following a preliminary search that confirmed the paucity of literature and lack of comparative trials, a scoping review using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) was conducted. A literature search of major electronic databases was conducted to identify journal articles relating to the management of upper limb long bone defects published between 2010 and 2020. Results: A total of 46 publications reporting on the management of 341 patients were reviewed. Structural autograft, bone transport, one-bone forearm and the induced membrane technique were employed in an almost equal number of cases. The implemented strategies showed similar outcomes but different indications and complication profiles were observed. Conclusion: Contemporary techniques for the management of post-traumatic upper limb bone defects all produce good results. Specific advantages, disadvantages and complications for each modality should be considered when deciding on which management strategy to employ for each specific patient, anatomical location, and defect size. [ABSTRACT FROM AUTHOR]

• The treatment of bone defect is fraught with difficulties especially in septic conditions. • Consideration of the quality of bed tissue and the size of the bone defect are condition to ensure a good result. • Illizarov fixator is an attractive technique for solving discrepancy of the upper limb. The management of large bone defect in the upper limb is fraught with difficulties and problems. It's is a long course treatment which include many components: infection, osseous loosening and shortening. We present our experience of an 12-years-old boy with septic non union of the proximal left humerus with length discrepancy of 6 cm treated with Ilizarov fixator(IL) followed by vascularized fibula graft (VFG) with a good clinical result without complications. The bone loss may be treated with allografts, bone transfer and bone substitute. Consideration of the quality of bed tissue and the size of the bone defect are condition to ensure a good result. Ilizarov fixator is an attractive and the most used technique for solving the problem of discrepancy and stabilizing in the upper limb. [ABSTRACT FROM AUTHOR]

Background: Morphologically, osteofibrous dysplasia-like adamantinoma is thought to be intermediate between osteofibrous dysplasia and adamantinoma. Its treatment is not well established owing to its rarity. Case presentation: We report about of a 10-year-old girl with osteofibrous dysplasia-like adamantinoma initially diagnosed as osteofibrous dysplasia and treated via intercalary segmental resection with partial cortex preservation using a pedicled vascularized fibula graft for reconstruction. Bone union was observed 9 weeks after surgery. Twenty-two months after the definitive surgery, no recurrence was observed. Conclusion: This case illustrates the upgrade from osteofibrous dysplasia to osteofibrous dysplasia-like adamantinoma. The surgical method may aid the treatment of osteofibrous dysplasia-like adamantinoma with incomplete cortex involvement of the tumor. [ABSTRACT FROM AUTHOR]

Abstract Background Vascularized fibula grafting is used in the treatment of large skeletal defects, recalcitrant atrophic nonunions, and infected nonunions. Few studies have examined the factors contributing to nonunion of the graft at one or both graft–recipient junctions. The purpose of this study was to determine if a correlation exists between length of the graft and primary union of the graft–recipient interface at the proximal and/or distal junction. Methods A total of 21 patients who underwent vascularized fibula grafting from 2002 to 2014 for the treatment of skeletal defects were included. Radiographs were assessed for union of the graft at the proximal and distal junctions. The rates of union at the proximal and distal junctions were determined with respect to the limb and graft. The relationship between the length of graft utilized and union was assessed. Results A total of 71.4% of patients, with an average follow-up of 30.2 months, achieved complete union at an average of 8.7 months. With respect to the limb, a union rate of 95.2% was achieved at the distal graft–recipient junction versus 71.4% at the proximal junction (p = 0.038). With respect to the graft orientation, a union rate of 90.5% was achieved at the distal graft versus 76.2% at the proximal graft (p = 0.214). The length of the graft did not have a significant correlation to the rate of union. Conclusion The length of the fibula graft does not have an association with the rate of primary union. If primary union is not achieved, likely the nonunion will have occurred at the proximal graft–recipient junction.

Introduction: In patients undergoing limb-salvage internal hemipelvectomy, pelvic ring reconstruction is mandatory to maintain the stability of the pelvis and the spinal column, which finally expected to achieve a good functional outcome. However, no optimal reconstruction method has been established. In addition, no previous reports have highlighted the long-term complications of pelvic ring reconstruction after internal hemipelvectomy. We aimed to analyze the outcome of pelvic ring reconstruction using a double-barreled free vascularized fibula graft (VFG) after internal hemipelvectomy with special reference to long-term complications. Materials and methods: We conducted a retrospective review of 9 consecutive patients (5 male, 4 female; mean age 31 years) who underwent pelvic ring reconstruction using a double-barreled free VFG after internal hemipelvectomy (P1, n = 4; P1 + 4, n = 3; P1 + 2, n = 2) at our institution between 1998 and 2013. The mean follow-up period was 55 months (range 3-131 months). Results: The mean length of the bone defect was 9 cm. The methods of fixation included a Cotrel-Dubosset rod ( n = 4), screw ( n = 3), and screw and plate ( n = 2). Bone union was achieved in 5 of 8 patients (63 %) over a 1-year follow-up. The mean period required for bone union was 5.4 months (range 3-7 months). There were 3 early postoperative complications: 2 deep infections resulting in graft removal and 1 implant failure resulting in non-union. Among 3 patients, 2 developed scoliosis within 5 years. One patient developed lumbar disc hernia as a result of scoliosis, for which surgical intervention was required. The mean Musculoskeletal Tumor Society score was 57 % at the last follow-up. Conclusions: In conclusion, this reconstruction method can achieve an early and high rate of bone union and provide good functional outcome. However, follow-up with careful attention to postoperative complications, including deep infection in the early postoperative period and spinal deformity in the long term, is necessary. [ABSTRACT FROM AUTHOR]

Introduction: Arthrodesis of the shoulder is a straightforward and established alternative to reconstruct the shoulder function after tumor resection of the proximal humerus. In most cases, some kind of intercalary bone graft is used to bridge the bony defect. However, due to low stability of a single fibula autograft and disadvantages of exogenous graft material when performing combined allo- and autograft reconstruction, efforts to develop new surgical techniques, with the intention to lower the complication rates, are ongoing. Materials and methods: We present a detailed description of the surgical technique and the outcome of three patients with osteosarcomas of the proximal humerus, which were treated with tumor resection and autologous double-barrel vascularized fibula bone graft for arthrodesis of the shoulder. The construct was stabilized using a 4.5-mm pelvic reconstruction plate positioned on the scapular spine and the lateral aspect of the humerus. Results: A wide surgical margin was achieved in all patients. Two of them could be reintegrated and are able to work with excellent shoulder function. In one patient, who developed metastasis, a deep infection under chemotherapy 16 months after index surgery complicated the postoperative course. Conclusion: The fibula's unique dual endosteal and periosteal blood supply makes it effective as a double-barrel bone graft for major long bone defects, which requires extra bone volume to prevent fractures until bone hypertrophy occurs. Additional bone and scar formation between the two struts are believed to provide a stable and long lasting construct, as seen in our patients. [ABSTRACT FROM AUTHOR]

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PURPOSE: To evaluate the distribution of biomechanical stress on the craniofacial skeleton for bilateral maxillectomy reconstruction by using the vascularized fibula graft and zygoma implants,in order to provide theoretical references for restoration of maxillary defects. METHODS: Based on digital imaging and communications in medicine (DICOM) data and the image process technology, a modularized geometrical and finite element model of the human skull was built to simulate the bilateral defect pattern of the maxilla. Biomechanical properties of the zygomatic implants and the connected implants were evaluated by using finite element analysis (FEA) method. RESULTS: The deformation tendency of the zygomatic implants was identical and the displacement of bending was not noticeable. The displacement of the zygoma fixture near the zygoma was close to zero. The neck of the zygoma fixture on the fibula bone and on the zygoma bored the largest stress, while the rest of the peri-implant bones bored a lower stress. CONCLUSIONS: Stress from occlusal forces is mainly supported by the zygomatic bone and the fibular bone. The occlusal force is effectively transmitted and the stress distribution of the peri-implant bone of such reconstruction protocol is reliable. Reconstitution of the buttresses system ensures a stable support for occlusion and stress. This is a safe and effective method to optimize bilateral maxilla rehabilitation. Supported by Combined Engineering and Medical Project of Shanghai Jiao Tong University (YG2010MS56). Dr. WU Yi-qun and YE Chen contributed equally to the study. [ABSTRACT FROM AUTHOR]

Introduction: Based on the considerable experience for management of combined bone and composite soft-tissue defects in the limbs by free vascularized fibula or osteocutaneous fibular flap grafting, the authors present the effective alternative for management of the severe comminuted tibial shaft fractures in one-stage reconstructive technique. Method: Twenty-six patients were male and 12 were female, and their mean age was 32 years (range 15-57 years). Ten tibial shaft fractures were closed and 28 were open. Based on the AO classification, there were 12 group C1 fractures and 24 group C3 fractures according to the fracture pattern and degree of comminution. Results: With the exception of eight cases that were delayed for 3-5 days for primary treatment in another hospital, 30 cases were treated on an emergency basis within an average of 12 h since the initial injury (range 6-22). Normal healing occurred in 31 fractures with a mean healing time of 21 weeks (range 18-24 weeks). Delayed union in 7 with a mean of 32 weeks (range 28-41 weeks), and there were no nonunion and infections. The vascularized fibula allows for fast bone fusion. In this context, the grafted fibula segment appeared to be a valuable reconstructive tool that offered good fracture stabilization and vascularised bone graft. Conclusion: The attached fibular flap can also provide a large piece of mobile skin to cover the soft-tissue defect in grade III open-tibial fractures. It demonstrates that this early free vascularized fibula graft is a useful and effective option for treating the severe comminuted tibial shaft fractures. [ABSTRACT FROM AUTHOR]

Summary: Reconstruction of the proximal humerus following limb-saving resection of malignant bone tumor is extremely challenging. We describe here a novel anatomical reconstruction technique in a young patient. A 6-year-old girl with Ewing sarcoma of the proximal humerus was treated by wide excision of the tumor followed by reconstruction with extracorporeally-irradiated osteoarticular autograft combined with an intramedullary inserted free vascularized fibula graft. Proper alignment of the shoulder joint was maintained with no osteoarthritic changes after 16 months. The resulting limb function was satisfactory. This biological reconstruction method was safe and without serious complication. It is indicated for the reconstruction of non-weight-bearing joints and is ideal for the proximal humerus. [ABSTRACT FROM AUTHOR]

The presence of large and massive segmental defects of the diaphyseal bone following tumor resection is a significant problem for orthopedic surgeons. Double or folded free vascularized fibula graft (FVFG) is used in massive femur defects and is considered to be a reliable reconstructive procedure. However, folded or double fibula grafts cannot prevent stress fractures. Here, a novel surgical procedure for bridging of massive femur defects using double FVFG and hydroxyapatite with autogenous bone grafts to prevent stress fractures is reported. [ABSTRACT FROM AUTHOR]

Low-grade central osteosarcoma is an unusual variant of conventional osteosarcoma. We present here two rare cases of low-grade central osteosarcoma resembling fibrous dysplasia. A 24-year-old woman diagnosed as fibrous dysplasia was treated with intra-lesional excision and curettage of the tumor but tumor recurred at 4 months after surgery. Distal femoral en-bloc resection was performed followed by arthroplasty with mega-prosthesis of the knee. A 57-year-old man diagnosed as central osteosarcoma was treated with wide excision of the tumor, followed by reconstruction with the vascularized fibula graft combined with an autogenous irradiated bone graft. Because of the difficulty in distinguishing low-grade central osteosarcoma from a benign lesion, open biopsy is needed to obtain a large tumor sample. Careful clinical and pathological evaluation is required to obtain a definite diagnosis. The treatment of low-grade central osteosarcoma is en-block resection with wide surgical margins. [ABSTRACT FROM AUTHOR]

Abstract: Authors report a case of a reconstruction of a large bone defect in the forearm with a free fibular graft occurring a good incorporation of the graft. Authors discuss the interest of fibula graft in reconstruction of large bone defect of the forearm. [Copyright &y& Elsevier]

Unlabelled: The gold standard technique for treating clavicle non-union is based on cortico-cancellous bone graft harvested from the iliac crest and fixed with a plate. In cases of large clavicular defects, this surgical procedure becomes ineffective and only reconstruction using vascularized bone grafts can be considered. Nevertheless, there are few reports in the literature dealing with this procedure and surgical technique remains unclear. We expose here a technique and results of free vascularized fibular graft for two patients with large clavicular defects., Levels of Evidence: Level IV, technical note., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)