Free vascularized fibular graft reconstruction of large skeletal defects after tumor resection

Abstract

Skeletal reconstruction of large tumor resection defects is challenging. Free vascularized fibular transfer offers the potential for rapid autograft incorporation in limbs compromised by adjuvant chemotherapy or radiation. We retrospectively reviewed 30 patients treated with free vascularized fibular graft reconstruction of large skeletal defects after tumor resections (mean defect length, 14.8 cm). The minimum followup was 2 years (mean, 4.9 years; range, 2-15 years). One patient died with liver and lung metastases at 3 years postoperatively. Loss of limb occurred in one patient. Five patients either had metastatic disease (one patient) or had metastatic disease (four patients) develop after treatment, with a mean time to metastasis of 18 months. The overall complication rate was 16 of 30 (53%), with a reoperation rate of 12 of 30 (40%). Union was attained in all 30 grafts. Primary union was attained in 23 (77%) at a mean of 6 months. Secondary union was achieved in seven (23%) after revision fixation and bone grafting; the mean subsequent time to union was 9.2 months, with an index of 1.33 additional operations per patient. Graft fracture (20%) and infection (10%) were other common complications. Despite a high complication rate, free vascularized fibular graft reconstruction offers a reliable treatment of large skeletal defects after tumor resection without increased risk of limb loss, local recurrence, or tumor metastasis.

Level of evidence: Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

Fig. 1A–B

(A) A radiograph shows an AP projection of the humerus of a patient (aged 15 years) taken 9 years after FVFG reconstruction of the proximal diaphysis after resection of an osteosarcoma. (B) A lateral view of the same humerus is shown. The fibula has hypertrophied to the approximate size of unresected portions of the distal diaphysis.

Fig. 2A–B

Five patients experienced nonunion at six different sites (one patient experienced nonunion of the proximal and distal osteosynthesis sites). These radiographs show the forearm of a 17-year-old girl who underwent resection of a giant cell tumor of the distal radius with FVFG reconstruction. (A) Nonunion of the proximal osteosynthesis site 6 months postoperatively is shown. The patient underwent bone grafting and revision internal fixation. (B) Subsequent union was achieved by 13 months postoperatively. All five patients with nonunions subsequently achieved union at a mean of 9.2 months, with an average of 1.33 additional procedures performed.

Fig. 3A–F

Fractures of the fibular graft occurred in six patients (20%). Three fractures occurred after trauma. Four of the six fractures were in patients with plate osteosynthesis of the graft. These radiographs show the arm of a 10-year-old boy who underwent FVFG reconstruction of a proximal humeral defect after resection of an osteosarcoma. (A) The incorporated graft is seen 6 months postoperatively. (B) Lateral and (C) AP views show a fracture through the grafted fibula at the most proximal screw 10 months postoperatively after a same-level fall. (D) AP and (E) lateral views show a healed fracture after 6 months of nonoperative management. (F) A radiograph shows the appearance of the humerus 3 years after the index procedure and almost 2 years after the fracture occurred.