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Background: The purpose of this study was to evaluate the long-term efficacy and prognostic factors predicting success of revision surgery with free vascularized fibular grafting (FVFG) for treatment of femoral neck nonunion., Methods: We prospectively enrolled patients who underwent revision surgery with FVFG between January 2001 and January 2013 in a tertiary hospital in China. A total of 98 patients with a minimum 5-year follow-up were included for analysis. The criteria for FVFG failure were conversion to hip arthroplasty, recommendation for a hip arthroplasty, or a Harris hip score of <80 points. Demographic information, the preoperative neck shortening ratio (NSR), the fixation method, and postoperative radiographic parameters including the postoperative NSR and neck-shaft angle (NSA) were recorded for prognostic analysis., Results: At an average of 9.8 ± 3.5 years (range, 3 to 17 years) postoperatively, the overall success rate of this surgical procedure was 77% (75 of 98). The success and failure groups had no significant differences in age, fixation method, interval between initial fixation and revision surgery, or postoperative NSA. The success group had a significantly higher NSR than the failure group both preoperatively (77.8% versus 62.4%, p < 0.001) and postoperatively (87.6% versus 78.4%, p = 0.001). The receiver operating characteristic (ROC) curve analysis revealed an optimal cutoff for preoperative NSR of 60% to predict the outcome. Patients with a preoperative NSR of >60% had a success rate of 91% (68 of 75)., Conclusions: Revision surgery with FVFG and internal fixation is an effective and important option for treating nonunion of the femoral neck in young patients without severe preoperative shortening and neck resorption (preoperative NSR of >60%)., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: Persistent infection, soft-tissue fibrosis, and damage to periosteum compound the treatment of children with a bone defect following osteomyelitis. We report on a series of twenty-six patients treated with nonvascularized fibular graft and intramedullary fixation., Methods: The series included eleven boys and fifteen girls (mean age, 6.8 years; range, three to twelve years) with gap nonunion after osteomyelitis. Initial treatment involved thorough debridement and sequestrectomy. When the infection was quiescent as indicated by inflammatory parameters, nonvascular fibular grafting with intramedullary Kirschner wire fixation (with or without additional external fixation) was performed. The time to union was noted, and a subgroup analysis was performed to correlate the size of the bone defect with the time to union., Results: The mean duration of follow-up was 3.02 ± 0.74 years (range, 1.3 to 4.2 years), and the mean time to union was 38.76 ± 12.02 weeks (range, fifteen to sixty weeks). There was a weak positive correlation between the time to union and the preoperative bone defect size (Pearson correlation coefficient, 0.699). The mean time to union was 31.7 ± 11.5 weeks for a defect of <4 cm, 36.6 ± 9 weeks for a defect of 4 to 6 cm, and 51 ± 6.7 weeks for a defect of >6 cm. Delayed union was seen at one end of the fibular graft in four (15%) of the patients and was treated with plate fixation. One patient had recurrence of infection. Limb-length discrepancy (range, 2 to 5 cm) was seen in all patients in whom the lower limb was involved and was treated with a shoe lift., Conclusions: This series illustrates the potential benefits of staged sequestrectomy and nonvascular fibular grafting for the treatment of gap nonunion following osteomyelitis in children. The procedure is simple, does not require specialized training or equipment, and has a low complication rate.

Background: Treatment of proximal humeral bone loss resulting from tumor resection or from infection following shoulder arthroplasty represents a reconstructive challenge. Shoulder arthrodesis is an appropriate salvage procedure but is associated with a high rate of complications. The purpose of this report is to describe the surgical technique and report the functional outcomes in a series of patients treated with shoulder arthrodesis using free vascularized fibular graft., Methods: Nine patients were included in this study. Two-stage reconstruction was performed in three patients with a methicillin-resistant Staphylococcus aureus infection following primary shoulder hemiarthroplasty. The remaining six patients had an aggressive or malignant tumor of the proximal aspect of the humerus, and tumor resection included the rotator cuff in all of these patients and the axillary nerve in three. All nine patients underwent shoulder arthrodesis using free vascularized fibular graft; eight patients had fixation with two plate-screw constructs, and one patient had fixation with only one plate and screws. Clinical and radiographic evaluation of all patients was performed at a mean of sixty months postoperatively. The Musculoskeletal Tumor Society (MSTS) function score and the Toronto Extremity Salvage Score (TESS) were used to assess overall function of the upper limb., Results: Mean active shoulder abduction and flexion were both 80° (range, 60° to 100°). All but one patient could bring the hand to the mouth. The mean MSTS function and TESS values were twenty-four of thirty and 82%, respectively, representing a good functional outcome. Two of nine patients had a major complication. Union and fibular hypertrophy were achieved in seven of the nine patients., Conclusions: Shoulder arthrodesis using free vascularized fibular graft with double plate fixation is a reliable salvage procedure in patients with major proximal humeral bone loss.

Background: Injuries to the tibiofibular syndesmosis commonly cause prolonged ankle pain and disability. Syndesmotic injuries are associated with slower healing rates compared with rates for other ankle ligament injuries and typically result in longer time away from sports. To our knowledge, the vascular supply to the syndesmosis and its clinical implication have not previously been studied. The purpose of this study was to describe the vascular supply to the tibiofibular syndesmosis with use of a method of chemical debridement of cadaveric specimens., Methods: Twenty-five matched pairs of adult cadaver legs, fifty legs total, were amputated below the knee. India ink, followed by Ward Blue Latex, was injected into the anterior tibial, peroneal, and posterior tibial arteries under constant manual pressure to elucidate the vascular supply of the ankle syndesmotic ligaments. Chemical debridement was performed with 6.0% sodium hypochlorite to remove soft tissue, leaving bones, ligaments, and casts of the vascular anatomy intact. The vascular supply to the syndesmosis was evaluated and recorded., Results: The anterior vascularity of the syndesmosis was clearly visualized in forty-three of fifty specimens. The peroneal artery supplied an anterior branch (the perforating branch) that perforated the interosseous membrane, an average of 3 cm proximal to the ankle joint. This branch provided the primary vascular supply to the anterior ligaments in twenty-seven specimens (63%). The anterior tibial artery provided additional contribution to the anterior ligaments in the remaining sixteen specimens (37%)., Conclusions: The location of the perforating branch of the peroneal artery places it at risk when injury to the syndesmosis extends to the interosseous membrane 3 cm proximal to the ankle joint. In the majority of specimens, injury to this vessel would result in loss of the primary blood supply to the anterior ligaments.

Background: Autogenous vascularized fibular transfer is used effectively for a variety of complex reconstructive procedures. Published series demonstrating the morbidity associated with its harvest have, understandably, been relatively small, and graft site (hip) complications have not been reported. This report describes both the donor and the graft site morbidity associated with use of vascularized fibular transfer to treat osteonecrosis of the femoral head., Methods: Between 1990 and 2006, 1270 free vascularized fibular grafts were used to treat osteonecrosis of the femoral head in 946 consecutive patients. All procedures and follow-up examinations were performed by one of two surgeons. Subjective and objective findings were recorded on standardized examination sheets at routine postoperative intervals. Data were analyzed to determine the morbidity associated with donor and graft sites., Results: There were 215 complications (a 16.9% rate) at the time of follow-up, at an average of 8.3 years, after the 1270 procedures. Of these complications, 146 (11.5%) and sixty-nine (5.4%) were referable to the donor and graft sites, respectively. A major complication requiring an additional surgical procedure or chronic pain management occurred after fifty-four (4.3%) of the 1270 procedures., Conclusions: A measurable but acceptable morbidity risk is associated with vascularized fibular transfer for the treatment of osteonecrosis of the hip. Major complications are not frequent, and many minor complications are transient and improve over time. Risks can be minimized when specific technical principles are followed.

Background: Long-bone allograft reconstruction following tumor extirpation can be complicated by problems such as nonunion at the host-allograft junction, allograft fracture, or allograft infection. Free vascularized bone grafts can be used to address these complications. The purpose of the current study was to examine retrospectively the outcomes and complications following allograft reconstruction salvage with onlay vascularized fibular grafts., Methods: A tumor registry review was conducted to identify all patients who underwent a reconstruction with a vascularized fibular graft for allograft reconstruction complications following tumor resection (host-graft nonunion, allograft fracture, or allograft nonunion) in the last nineteen years. The records of these patients were analyzed for details regarding the neoplasms and the treatment thereof, details of the free vascularized fibular graft reconstruction, time to osseous union, functional outcome, and clinical outcome., Results: Thirty-three patients satisfied the criteria for this study. The involved bones were the femur (eighteen patients), tibia (eight), and humerus (seven). Osseous union was achieved in all patients at a mean of 7.7 months. The average duration of follow-up was seventy-three months. Twenty-three patients achieved a good or excellent functional outcome. Ultimately, seven patients had a failure of the allograft reconstruction, which resulted in limb loss in five of them. Postoperative complications were relatively common in this series., Conclusions: Free vascularized fibular grafting is a useful adjunctive surgical treatment for nonunion, fracture, and infection of an intercalary allograft reconstruction in limb salvage surgery. It has, however, a high rate of associated complications often resulting in failure.

Background: Reconstruction of large skeletal defects secondary to osteomyelitis is a challenging problem. The purpose of this study was to evaluate the outcome of the use of a vascularized fibular graft to treat such defects in children., Methods: Eight patients with a mean age of seven years and a skeletal defect with a mean length of 11.8 cm (range, 6 to 17 cm) were treated with a vascularized fibular graft. A staged protocol was used for the five patients with an active infection at the time of presentation. The first procedure consisted of radical débridement, and at the second stage a free (seven patients) or pedicled (one patient) vascularized fibular graft was used. The mean follow-up time was 5.7 years., Results: Union of the graft occurred primarily in seven of the eight patients, at a mean of 3.5 months, and after iliac crest bone-grafting in the remaining patient. There was no recurrence of deep infection. Complications developed in two patients. The mean time to full weight-bearing by the seven patients with a lower-extremity reconstruction was 8.4 months, and all patients were pain-free and able to walk without supportive devices., Conclusions: A vascularized fibular graft is a viable option for the management of large skeletal defects resulting from osteomyelitis in children.

Background: Many authors have reported good results with the use of vascularized fibular grafts to treat large osteonecrotic lesions of the femoral head. To our knowledge, there have been no prospective case-controlled studies comparing the effectiveness of vascularized fibular grafting with that of nonvascularized fibular grafting for the prevention of progression and collapse of the lesion., Methods: Nineteen patients (twenty-three hips) with a large osteonecrotic lesion of the femoral head (Stage IIC in ten hips, Stage IIIC in two, and Stage IVC in eleven, according to the classification system of Steinberg et al.) underwent vascularized fibular grafting. This group was retrospectively matched according to the etiology, stage, and size of the lesion to a group of nineteen patients (twenty-three hips) who underwent nonvascularized fibular grafting during the same time period. A prospective case-controlled study of the two groups, with a mean duration of follow-up of four years, was then performed., Results: The mean Harris hip score improved for 70% of the hips treated with a vascularized graft and 35% of the hips treated with a nonvascularized graft (p < 0.05). At the time of the final follow-up, nine of the ten hips with a Stage-IIC lesion treated with a vascularized fibular graft had not collapsed whereas seven of the thirteen hips with a larger lesion (Stage IIIC or IVC) had collapsed. Three hips (13%) were converted to a total hip replacement. The mean dome depression measured 2.8 mm. In the group treated with a nonvascularized graft, five of the ten Stage-IIC hips had not collapsed and eleven of the thirteen hips with a larger lesion had collapsed. Five (22%) of the hips were converted to a total hip replacement. The mean dome depression measured 4.3 mm. The rates of radiographic progression and collapse were significantly lower and the mean dome depression was significantly less in the group treated with a vascularized fibular graft (p < 0.05)., Conclusions: Vascularized fibular grafting was associated with better clinical results and was more effective than nonvascularized fibular grafting for the prevention of collapse of the femoral head in a matched population with a Steinberg Stage-IIC or larger osteonecrotic lesion. The results of vascularized grafting were best when the procedure was used to treat precollapse lesions (Steinberg Stage IIC).

Background: The present study evaluates the minimum five-year results of vascularized fibular grafting for the treatment of osteonecrosis of the femoral head. The purposes of the present study were to review the results of fibular grafting in a large series of patients and to determine the indications for this procedure., Methods: Eighty-six patients (101 hips) were followed clinically for a minimum of five years (or until the time of death). The study group included fourteen Marcus-Enneking stage-2 hips, twenty-three stage-3 hips, and sixty-four stage-4 hips. Three patients (three hips) died from unrelated causes before the five-year evaluation, and two patients (two hips) died after the five-year evaluation. Radiographic assessment was performed with use of the Marcus-Enneking grading system, and clinical assessment was performed with use of the Harris hip-scoring system. The end point was conversion to total hip arthroplasty. Patient satisfaction was also assessed., Results: Sixty-two hips (61%) survived until the time of the five-year follow-up, and forty-two hips (42%) survived until the time of the interview (at a median of eight years postoperatively). The average Harris hip score was 58 +/- 13 at the time of presentation and 80 +/- 15 at five years. Eight (57%) of the Marcus-Enneking stage-2 hips, sixteen (70%) of the stage-3 hips, and thirty-eight (59%) of the stage-4 hips survived for at least five years. Of the eighty-one living patients (including forty-one who had a successful outcome and forty who had had a failure), forty-six patients (including twenty-one who had a successful outcome and twenty-five who had had a failure) stated that they would undergo the procedure again., Conclusions: Vascularized fibular grafting may provide a chance for normal hip function in the intermediate or long term in carefully selected patients with osteonecrosis of the femoral head.

Background: Treatment of the loss of the distal part of the radius, including the physis and epiphysis, in a skeletally immature patient requires both replacement of the osseous defect and restoration of longitudinal growth. Autologous vascularized epiphyseal transfer is the only possible procedure that can meet both requirements., Methods: Between 1993 and 2002, six patients with a mean age of 8.4 years (range, six to eleven years) who had a malignant bone tumor in the distal part of the radius underwent microsurgical reconstruction of the distal part of the radius with a vascularized proximal fibular transfer, including the physis and a variable length of the diaphysis. All of the grafts were supplied by the anterior tibial vascular network. The rate of survival and bone union of the graft, the growth rate per year, the ratio between the lengths of the ulna and the reconstructed radius, and the range of motion of the wrist were evaluated for five of the six patients who had been followed for three years or more., Results: The mean duration of follow-up of the six patients was 4.4 years (range, eight months to nine years). All six transfers survived and united with the host bone within two months postoperatively. The five patients who were followed for three years or more had consistent and predictable longitudinal growth. Serial radiographs revealed remodeling of the articular surface. The functional result was rated as excellent for all but one patient, in whom the distal part of the ulna had also been resected because of neoplastic involvement. No major complication occurred at the recipient site, whereas a peroneal nerve palsy occurred at the donor site in three patients. The palsy was transient in two patients, but it persisted in one. No instability of the knee joint was observed., Conclusions: After radical resection of the distal part of the radius because of a neoplasm in children, vascularized proximal fibular transfer, based on the anterior tibial artery, permits a one-stage skeletal and joint reconstruction, provides excellent function, and minimizes the discrepancy between the distal radial and ulnar lengths.

Background: Osteonecrosis of the femoral head, a disease primarily affecting young adults, is often associated with collapse of the articular surface and subsequent arthrosis. Free vascularized fibular grafting has been reported to be successful for patients with early stages of osteonecrosis, but little is known about its efficacy after the femoral head has collapsed., Methods: We retrospectively reviewed the results in a consecutive series of 188 patients (224 hips) who had undergone free vascularized fibular grafting, between 1989 and 1999, for the treatment of osteonecrosis of the hip that had led to collapse of the femoral head but not to arthrosis. The average duration of follow-up was 4.3 years (range, two to twelve years). We defined conversion to total hip arthroplasty as the failure end point, and we analyzed the contribution, to failure, of the size of the lesion, amount of preoperative collapse of the femoral head, etiology of the osteonecrosis, age of the patient, and bilaterality of the lesion. We used the Harris hip score to evaluate clinical status preoperatively and at the time of the most recent follow-up., Results: The overall rate of survival was 67.4% for the hips followed for a minimum of two years and 64.5% for those followed for a minimum of five years. The mean preoperative Harris hip score was 54.5 points, and it increased to 81 points for the patients in whom the surgery succeeded; 63% of the patients in that group had a good or excellent result. There was a significant relationship between the outcome of the grafting procedure and the etiology of the osteonecrosis (p = 0.017). Patients in whom the osteonecrosis was idiopathic, associated with alcohol abuse, or posttraumatic fared worse than did those with other causes, including steroid use. Survival of the joint was not significantly related to the size of the femoral head lesion, but there was an increased relative risk of conversion to total hip arthroplasty with increasing lesion size and amount of collapse. Neither patient age nor bilaterality significantly affected outcome., Conclusions: Patients with postcollapse, predegenerative osteonecrosis of the femoral head appear to benefit from free vascularized fibular grafting, with good overall survival of the joint and significant improvement in the Harris hip score. The results of this femoral head-preserving procedure in patients with postcollapse osteonecrosis are superior to those of core decompression and nonoperative treatment, as reported in the literature. Patients with larger lesions and certain diagnoses, such as idiopathic and alcohol-related osteonecrosis, have worse outcomes.

Background: We are not aware of any clinical studies in the literature comparing the results of vascularized and nonvascularized fibular grafting for the treatment of osteonecrosis of the femoral head. The purpose of this study was to compare the clinical results of free vascularized fibular grafting with those of nonvascularized fibular grafting., Methods: Two hundred patients (220 hips) with osteonecrosis of the femoral head were treated with free vascularized fibular grafting at the University of Pittsburgh Medical Center, and ninety-nine patients (123 hips) were treated with nonvascularized fibular grafting at the Kyungpook National University Hospital in Korea. From these populations, two groups of fifty hips each, followed for a minimum of three years (average, five years), were matched by the stage, size, and etiology of the lesion and by the mean preoperative Harris hip score. A retrospective case-control study of these groups was then performed to compare the postoperative Harris hip scores as well as the prevalences of radiographic progression and collapse of the femoral head following free vascularized fibular grafting with those measures following nonvascularized fibular grafting., Results: The mean Harris hip score improved for 70% of the hips treated with free vascularized fibular grafting: seventeen hips (34%) were rated excellent, fourteen (28%) were rated good, nine (18%) were rated fair, and ten (20%) were rated poor. The mean Harris hip score improved for 36% of the hips treated with nonvascularized fibular grafting: five hips (10%) were rated excellent; nine (18%), good; sixteen (32%), fair; and twenty (40%), poor. The rate of survival at seven years for the Stage-I and II hips (precollapse) was 86% after treatment with free vascularized fibular grafting compared with 30% after nonvascularized fibular grafting., Conclusions: The results of this study strongly suggest that vascularized fibular grafting is associated with better clinical and radiographic results.

One hundred and ninety-eight consecutive patients (247 vascularized fibular grafts) were studied to determine the prevalence of morbidity at the donor site after the grafts had been obtained. Objective motor weakness, subjective discomfort in the ankle and other sites in the leg, and sensory abnormalities in the lower limb (or limbs) from which the graft had been obtained were recorded. The average duration of follow-up was forty-seven months (range, twenty-four to 144 months). Kaplan-Meier analysis was used to estimate the prevalence of each finding for the entire cohort over time. Forty-seven (19.0 per cent) of the 247 lower limbs had at least one of the findings, and eighteen(24.3 percent) of the seventy-four limbs for which data were available at five years or more had findings at that time. Twenty-five (10.1 per cent) of the 247 limbs had evidence of motor weakness at three months postoperatively, although no limb had this finding subsequently. At five years or more postoperatively, the prevalence had decreased to two (2.7 per cent) of the seventy-four limbs. Twelve (4.9 per cent) of the 247 limbs had sensory deficits at three months; this increased to 11.8 per cent (95 per cent confidence interval, 7.7 to 17.7 per cent), according to the Kaplan-Meier analysis, at five years. Pain at sites other than the ankle was noted in nine (3.6 per cent) of the 247 limbs at three months and in 8.9 per cent (95 per cent confidence interval, 5.5 to 14.1 per cent), according to the Kaplan-Meier analysis, at five years. The prevalence of pain in the ankle also increased with time, from four (1.6 per cent) of the 247 limbs at three months to 11.5 per cent (95 per cent confidence interval, 7.4 to 17.6 per cent), according to the Kaplan-Meier analysis, at five years. Removal of a vascularized portion of the fibula is associated with a low prevalence of motor weakness and sensory deficits in the foot. The prevalence of pain in the ankle and lower limb increases with time, with some patients having a late onset of the symptoms. While free vascularized fibular grafts remain ideal for many applications, the morbidity must be weighed against the benefits.

We evaluated the results of reconstruction of a skeletal defect with use of a vascularized bone graft from the iliac crest or fibula in 160 patients who had been managed consecutively between 1979 and 1989. The indications for the procedure were a skeletal defect including non-union, resulting from resection of a tumor; traumatic bone loss; osteomyelitis; or a congenital anomaly. The average duration of follow-up was forty-two months (range, twelve to 112 months). For the entire series, the rate of union after the primary procedure was 61 per cent and the over-all rate at the latest follow-up examination (including the patients who had a secondary procedure) was 81 per cent. In a subgroup of seventy-six patients who had union after the primary procedure and did not have additional treatment, the average interval until union was six months and the average interval until full activity was sixteen months. The results were more favorable for the patients who had had reconstruction for resection of a tumor (of sixty-nine patients, fifty-six had union), for a congenital anomaly (of six patients, five had union), or for a non-union without infection (of twenty-five patients, twenty-three had union). The results were less satisfactory for patients who had had the reconstruction for bone loss due to osteomyelitis (of sixty patients, forty-six had union). Our data suggest that vascularized bone transfer for the reconstruction of large skeletal defects is a valuable procedure in appropriately selected patients.

The biological and biomechanical properties of normal fibulae, fibulae that had had a sham operation, and both vascularized and non-vascularized autogenous grafts were studied in dogs at three months after the operation. The study was designed to quantify and correlate changes in these properties in orthotopic, stably fixed, weight-bearing grafts and to provide a baseline for additional studies of allografts. The grafts were eight centimeters long and internally fixed. The mechanical properties of the grafts were studied by torsional testing. Metabolic turnover of the grafts was evaluated by preoperative labeling of the dogs with 3H-tetracycline for resorption of bone mineral and with 3H-proline for turnover of collagen. Cortical bone area and porosity were measured. Postoperative formation of bone was evaluated by sequential labeling with fluorochrome. The vascularized grafts resembled the fibulae that had had a sham operation and those that had not had an operation with regard to the total number of osteons and the remodeling process, as measured both morphometrically and metabolically. The vascularized grafts were stronger and stiffer than the non-vascularized grafts and were not different from the bones that had had a sham operation. In contrast, the non-vascularized grafts were smaller, weaker, less stiff, and more porotic, had fewer osteons, and demonstrated increased turnover and resorption compared with the vascularized grafts, the bones that had had a sham operation, and the bones that had not been operated on.

Free vascularized fibular bone grafts were used in nineteen children, seen consecutively, who had congenital pseudarthrosis of the tibia. The average age was 5.1 years (range, 1.4 to 11.4 years). Sixteen of the patients had been treated with electrical stimulation for at least one year, and the tibia had not united. All but four patients had had at least one previous operative procedure. At an average follow-up of 6.3 years (range, 2.0 to 11.0 years), eighteen (95 per cent) of the nineteen pseudarthroses had healed. The leg-length discrepancy averaged 1.6 centimeters (range, 0 to 4.0 centimeters), but ten tibiae had residual or progressive valgus or anteroposterior malalignment despite bracing. There was minimum morbidity at the donor site.

Four obese patients who had atrophic synovial non-union of the humeral shaft were treated with a medial approach, application of a plate anteriorly, a vascularized fibular bone graft, and cancellous grafts from the iliac crest. The average age of the patients was forty years; the average weight, 105 kilograms (232 pounds); and the average duration of the non-union, 33.5 months. Each patient had had one to five unsuccessful previous operations in an attempt to gain union. At an average follow-up of twenty-seven months, all four non-unions had healed. Three patients had regained full function of the shoulder and elbow, and the fourth patient had some limitation of motion of the shoulder due to an antecedent lesion of the rotator cuff. In one patient, a second plate had been applied because of inadequate fixation of the original plate proximally. Another patient had a superficial, partial wound slough, which healed spontaneously.

Magnetic resonance images of the leg were made preoperatively to show the vascular anatomy in twenty-nine patients (thirty-five legs) who were between the ages of fourteen and forty-one years and in whom we planned to use the fibula as a vascular graft. The fibula was harvested as a graft in thirty-two legs, and this allowed us to compare the images with the anatomical findings at operation. In these thirty-two legs, the branching pattern, the measured distance to the bifurcation of the peroneal artery, and all vascular anomalies in the area were accurately detected. No graft was taken from the other three legs. We recommend that imaging of the vascular anatomy of the leg be done before using the fibula as a vascular graft in order to detect the precise point of origin of the peroneal artery from the posterior tibial artery, to estimate the length of the vascular pedicle, and to evaluate the role of the three major vessels in supplying blood to the leg. All these aims can be accomplished with the aid of angiography, but we have found that gradient-recalled acquisition in the steady state (GRASS) magnetic-resonance imaging is more cost-effective and is associated with less morbidity. It is not adequate for older patients who have arterial stenosis or atherosclerosis or for patients who have some other underlying vascular disease. Metallic hardware may cause artefacts that obscure the vascular anatomy.

Free vascularized fibular grafts were used to treat seventeen patients who had extensive defects and pseudarthroses in long bones of the extremities. Of the seventeen, thirteen had been followed for from eighteen months to five years and could be evaluated. All thirteen grafts healed with no radiographic evidence of bone necrosis or resorption. During the immediate postoperative period, the patency of the anastomoses was monitored by observing the color of the skin of an island pedicle (so-called buoy) skin graft whose blood supply was in continuity with that of the fibular graft. Preoperative Doppler measurements were used to determine the most favorable location for the island pedicle graft. In the presence of defects of both bone and skin, the skin defect can be covered by using a large buoy flap. The largest flap used in this series measured fifteen square centimeters.

Five patients with a malignant giant-cell tumor involving the distal end of the radius were treated successfully by wide resection and reconstruction of the radius with a vascularized fibular transplant. This technique has the great advantage of early bone union at the host-graft junction and enables the patient to regain limb function early, with preservation of near-normal appearance of the limb.

Seven major reconstructions of the femoral shaft using a vascularized graft of bone from the fibula were performed at the Massachusetts General Hospital from 1981 to 1984. Three patients had a post-traumatic infected non-union; one, extensive osteomyelitis of the femoral shaft; one, a fractured allograft; one, an atrophic non-union associated with radiation therapy; and one, post-traumatic loss of a ten-centimeter segment of bone. Six of the seven patients had a skeletal femoral defect, ranging from seven to fifteen centimeters in length. The average length of fibula that was used for reconstruction was 19.6 centimeters. Primary skeletal union occurred in five of the seven patients. Two patients had healing only at the distal junction and required a conventional bone graft and supplementary internal fixation of the proximal junction. At an average length of follow-up of thirty-four months, all of the patients were able to walk. Only two patients, both of whom had an extreme limb-length discrepancy, required additional support.

Six patients with large defects in bone are described in whom we performed microvascular anastomoses of grafted fibular vessels (arteries and veins) to vessels in the recipient site. Two other patients, with massive loss of bone and skin, were treated by grafting of osteocutaneous composites also using microvascular anastomoses. All but one defect healed successfully. There is a wide potential for applications of these two techniques in the treatment of large segmental bone defects secondary to trauma or following tumor resection.