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Introduction: Weber A ankle fractures are isolated fibula fractures distal to the level of the ankle joint line. They are regarded as stable injuries that usually heal successfully without intervention. We have identified several patients that have developed symptomatic atrophic non-union of transverse Weber A fractures that are not simple avulsion fractures of the anterior talo-fibular ligament. We explored variations to the blood supply of the distal fibula as a potential cause of this rare complication. Cases: Five patients presented with ongoing ankle pain following a period of non-operative management. All shared a similar transverse atrophic non-union fracture pattern.Surgical management with open reduction and internal fixation with or without the use of bone graft achieved successful union and resolution of symptoms in all cases. Conclusions: Atrophic fracture non-unions usually result from a disruption to the blood supply at the site of injury. The arterial supply to the distal fibula consists of a complex of arterial loops which usually enable fracture healing. However, there are anatomical variations to the blood supply that potentially could account for the rare outcome of non-union of Weber A fracture patterns. Weber A fractures are generally benign ankle fractures that heal well with non-operative treatment. No alterations should be made to the management of such injuries, but patients should be counselled about the risk of a symptomatic non-union outcome.

Purpose: Severe open forearm fractures commonly involve segmental bone defects. Although several methods have been proposed to treat segmental bone defects with such fractures, research comparing the radiological and clinical outcomes of free vascularized fibular grafts (FVFG) and the Masquelet technique (MT) is rare., Methods: Data on 43 patients with open forearm fractures and segmental bone defects treated surgically in our hospital from January 2005 to January 2021 were retrospectively analyzed, and these patients were divided into an FVFG group (18 cases) and an MT group (25 cases). Clinical and radiological evaluations were performed regularly, and the minimum follow-up was 18 months., Results: All 43 patients were followed up for 18 to 190 months, with a mean of 46.93 months. The mean follow-up time was significantly longer in the FVFG group than in the MT group (p = 0.000). Bone healing time was 3-16 months, with a mean of 4.67 months. The QuickDASH score at the last follow-up was 0-38.6, with a mean of 17.71, and there was no statistically significant difference between the two groups. Operative time, hospital stay, and intraoperative bleeding for bone defect reconstruction were higher in the FVFG group compared to the MT group (p = 0.000), whereas the number of procedures was lower in the FVFG group than in the MT group (p = 0.035)., Conclusions: FVFG and the MT showed satisfactory clinical results for segmental bone defects of the forearm. Compared with FVFG, the MT exhibited a lower operative time, hospital stay, and intraoperative bleeding., Level of Evidence: Level IV. Trial registration This study was registered in the Chinese Clinical Trial Registry (registration no. ChiCTR2300067675; registered 17 January 2023), https://www.chictr.org.cn/showproj.html?proj=189458 ., (© 2024. The Author(s).)

Objective: To investigate the accuracy of positioning perforator of medial sural artery with three-dimensional ultrasound technique guided by a wide band linear matrix array volume transducer probe before operation, and the effectiveness of the flap design based on this in repairing the dorsal foot wounds., Methods: Between January 2019 and December 2022, 30 patients with skin and soft tissue defects of the dorsal foot were treated. There were 19 males and 11 females, with an average age of 43.9 years (range, 22-63 years). There were 12 cases of traffic accident injury, 15 cases of heavy crushing injury, and 3 cases of machine injury. The time from injury to hospitalization was 1-8 hours (mean, 3.5 hours). The wounds in size of 5 cm×3 cm to 17 cm×5 cm were thorough debrided and covered with vacuum sealing drainage dressing. Then the wounds were repaired with the medial sural artery perforator flaps after no obvious infection observed. To obtain the complete three-dimensional image, the number and position of the medial sural artery perforator branches and the position of the main blood vessels in the muscle were detected and recorded by wide band linear matrix array volume transducer probe before operation. Suitable perforating branches were selected to design the flap and guide the flap incision on this basis. The size of the perforating flap ranged from 6 cm×4 cm to 18 cm×6 cm. The sensitivity and positive predictive value were calculated by comparing preoperative exploration with intraoperative observation of perforating branches, so as to evaluate the positioning accuracy of three-dimensional ultrasound technique. The donor sites were sutured directly in 25 cases and repaired with free skin grafting in 5 cases., Results: The 60 perforating branches of medial sural artery were found before operation and 58 during operation in 30 patients. Among them, pre- and intra-operative perforations were consistent with 56. The sensitivity was 93.3% and positive predictive value was 96.6%. The intramuscular position and route of the main blood vessels were basically consistent with the pre- and intra-operative observation. All flaps survived and wounds healed by first intention. All incisions at the donor sites healed by first intention, and all skin grafts survived. All patients were follow up 9-24 months (mean, 14.7 months). The appearance, color, and texture of the flaps were good, and no obvious effect on wearing shoes and walking. At last follow-up, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hind score ranged from 80 to 92, with an average of 87.5. The patient satisfaction was excellent in 29 cases and good in 1 case., Conclusion: The three-dimensional ultrasound technique guided by the wide band linear matrix array volume transducer probe can accurately locate the perforating branch of the medial sural artery, and the three-dimensional imaging is more intuitive, which can be used to guide the design and incision of the medial sural artery perforator flap.

Background: The purpose of this study is to evaluate a new method involving time maximum intensity projection (t-MIP) postprocessed from dynamic computed tomographic angiography (dyn-CTA) in diagnosing peripheral arterial disease (PAD)., Methods: A population of 34 patients with known PAD was examined with a combined CTA protocol consisting of a standard CTA (s-CTA) scan of the lower extremities and a dyn-CTA scan of the calves. For each lower leg, t-MIP images consisting of the MIP 0 (sagittal MIP), MIP +θ (45° lateral MIP), and MIP -θ (- 45° lateral MIP) were automatically generated from dyn-CTA. An objective evaluation of the vascular CT attenuation of the best enhancement phase of dyn-CTA and t-MIP was measured; a subjective evaluation of vessel stenosis and occlusion was performed, assigning a score for t-MIP and s-CTA. The CT attenuation of t-MIP and dyn-CTA was compared, as were the runoff scores of t-MIP and s-CTA., Results: The CT attenuation of t-MIP CTA of three vascular segments from 68 lower extremities was higher than that of the best enhancement phase of dyn-CTA and s-CTA, with statistically significant differences at the posterior tibial artery and fibular artery (all p < 0.05). There were strong correlations (r ≥ 0.75, p < 0.05) of the runoff scores between t-MIP and s-CTA., Conclusions: There is potential clinical applicability of t-MIP in assisting with the diagnosis of lower leg vascular stenosis in dyn-CTA with reliable diagnostic accuracy and convenient immediacy.

Background: Distally based peroneal artery perforator-plus fasciocutaneous (DPAPF) flaps are widely used for reconstructing soft-tissue defects of the lower extremity. However, reports on the reconstruction of the defects over the distal forefoot using the DPAPF flaps are scarce. Herein, we describe our experience on the reconstruction of these defects using DPAPF flaps in a considerable sample size., Methods: Between February 2005 and August 2019, a total of 56 DPAPF flaps in 56 patients were used to reconstruct soft-tissue defects in the forefoot. In order to reduce the length of fascial pedicle and the total length of the DPAPF flaps, the ankles were fixed in dorsiflexion using a Kirschner wire before designing the flaps. The flaps were elevated by the anterograde-retrograde approach. Patient factors and flap factors were compared between the "survival" and "partial necrosis" groups., Results: Overall, 47 flaps had survived completely in one stage. Partial necrosis developed in nine flaps, with only one remnant defect covered using a local flap. By fixing the ankles in dorsiflexion, the length of the fascial pedicle was reduced approximately 2.35 ± 0.58 cm, the total length of the flap was simultaneously shortened by the same amount as the length of the fascial pedicle. The width of the fascia pedicle varied from 3.0 cm to 6.0 cm. The fascial pedicle width > 4 cm was found in 21 flaps. The partial necrosis rate of the DPAPF flaps with the top edge located in the 8th zone was significantly lower than that in the 9th zone (p < 0.05)., Conclusions: The DPAPF flaps can be effectively used to reconstruct the defects over the distal forefoot because of convenient harvest and reliability. By fixing the ankle in dorsiflexion with Kirschner wire and widening the fascial pedicle appropriately, the top edge and LWR of the flaps will be decreased, and thus the procedures are helpful for the flaps survival.

Background and purpose - Congenital pseudarthrosis of the tibia (CPT) is caused by local periosteal disease that can lead to bowing, fracturing, and pseudarthrosis. Current most successful treatment methods are segmental bone transport and vascularized and non-vascularized bone grafting. These methods are commonly hampered by discomfort, reoperations, and long-term complications. We report a combination of a vascularized fibula graft and large bone segment allograft, to improve patient comfort with similar outcomes.Patients and methods - 7 limbs that were operated on in 6 patients between November 2007 and July 2018 with resection of the CPT and reconstruction with a vascularized fibula graft in combination with a bone allograft were retrospectively studied. The mean follow-up time was 5.4 years (0.9-9.6). Postoperative endpoints: time to discharge, time to unrestricted weight bearing, complications within 30 days, consolidation, number of fractures, and secondary deformities.Results - The average time to unrestricted weight bearing with removable orthosis was 3.5 months (1.2-7.8). All proximal anastomoses consolidated within 10 months (2-10). 4 of the 7 grafts fractured at the distal anastomosis between 6 and 14 months postoperatively. After reoperation, consolidation of the distal anastomosis was seen after 2.8 months (2-4). 1 patient required a below-knee amputation.Interpretation - This case series showed favorable results of the treatment of CPT through a combination of a vascularized fibula graft and large bone segment allograft, avoiding the higher reintervention rate and discomfort with ring frame bone transport, and the prolonged non-weight bearing with vascularized fibula transfer without reinforcement with a massive large bone segment allograft.

Objective: The objective was to explore the relative indications of free vascularized fibular graft (FVFG) and Ilizarov bone transport (IBT) in the treatment of infected bone defects of lower extremities via comparative analysis on the clinical characteristics and efficacies., Methods: The clinical data of 66 cases with post-traumatic infected bone defects of the lower extremities who underwent FVFG (n = 23) or IBT (n = 43) from July 2014 to June 2018 were retrieved and retrospectively analyzed. Clinical characteristics, operation time, and intraoperative blood loss were statistically compared between two groups. Specifically, the clinical efficacies of two methods were statistically evaluated according to the external fixation time/index, recurrence rate of deep infection, incidence of complications, the times of reoperation, and final functional score of the affected extremities., Results: Gender, age, cause of injury, Gustilo grade of initial injury, proportion of complicated injuries in other parts of the affected extremities, and numbers of femoral/tibial defect cases did not differ significantly between treatment groups, while infection site distribution after debridement (shaft/metaphysis) differed moderately, with metaphysis infection little more frequent in the FVFG group (P = 0.068). Femoral/tibial defect length was longer in the FVFG group (9.96 ± 2.27 vs. 8.74 ± 2.52 cm, P = 0.014). More patients in the FVFG group presented with moderate or complex wounds with soft-tissue defects. FVFG treatment required a longer surgical time (6.60 ± 1.34 vs. 3.12 ± 0.99 h) and resulted in greater intraoperative blood loss (873.91 ± 183.94 vs. 386.08 ± 131.98 ml; both P < 0.05) than the IBT group, while average follow-up time, recurrence rate of postoperative osteomyelitis, degree of bony union, and final functional scores did not differ between treatment groups. However, FVFG required a shorter external fixation time (7.04 ± 1.72 vs. 13.16 ± 2.92 months), yielded a lower external fixation index (0.73 ± 0.28 vs. 1.55 ± 0.28), and resulted in a lower incidence of postoperative complications (0.87 ± 0.76 vs. 2.21±1.78, times/case, P < 0.05). The times of reoperation in the two groups did not differ (0.78 ± 0.60 vs. 0.98 ± 0.99 times/case, P = 0.615)., Conclusion: Both FVFG and IBT are effective methods for repairing and reconstructing infected bone defects of the lower extremities, with unique advantages and limitations. Generally, FVFG is recommended for patients with soft tissue defects, bone defects adjacent to joints, large bone defects (particularly monocortical defects), and those who can tolerate microsurgery.

Rationale: Currently, digital surgical techniques have been widely used in the precise treatment of mandibular resection and reconstruction with fibula flaps. Utilizing these innovative techniques in surgical planning and hardware fabrication before surgery has shown to provide great help. However, it is difficult for even experienced surgeons to place the preformed reconstruction plate in the same position as its preoperative design, causing surgical results to differ from preoperative planning. This study aims to solve these acknowledged challenges by creating newly designed equipment., Patient Concerns: Two patients suffering from long-term expansion of the mandible were admitted to our department. Case I was a 39-year-old female patient who was concerned about the disease in the middle of the mandible, Case II was a 45-year-old female patient who was concerned about the disease at the left mandibular angle and ramus region., Diagnoses: Two patients were diagnosed with the mandibular ameloblastoma based on computed tomography (CT) scan and pathological results., Interventions: Personalized 3-dimensional (3D) surgical guides were applied to 2 patients with mandibular ameloblastoma who underwent mandibular resection and reconstruction with vascularized fibula flaps using a specially optimized and designed reconstruction guide plate., Outcomes: We achieved precise mandibular repair with such a guide in full accordance with the preoperative plan and ensured the restoration of patient facial symmetry., Lessons: Optimized reconstruction guide template could accurately locate the preformed reconstruction plate. This component had the ability to ensure that the location of the actual reconstruction plates were highly consistent with preoperative designed models.

Purpose: The aim of this study was to report the histopathology of failed free vascularized fibular grafting (FVFG) for osteonecrosis of the femoral head (ONFH) after a mean follow-up of 11.5 years (ranged from 10.6 to 14.2 years)., Methods: Six hips of 5 patients with a history of steroid use, aged 34-67 years, were in stage II of ONFH as classified by the Ficat and Arlet classification at the time of FVFG treatment. Grafting failure led to osteoarthritis of the hip joint during a mean of 11.5 years of follow-up. Femoral head specimens were first evaluated macroscopically. Bone specimens were sectioned into long strips, divided into necrotic, transitional, and healthy zones, and then prepared for nondecalcified and decalcified histopathological examination using hematoxylin and eosin (HE) staining, Goldner's trichrome staining, and immunofluorescence (IF) staining., Results: Femoral head articular cartilage surfaces appeared thin, opaque, and partially cartilaginous missing, with gradual collapse detected in weight-bearing areas. The interface with the fibular graft showed well union, with no obvious gaps between graft and host bone, as observed macroscopically. The necrotic area was filled with fibular graft, cancellous bone, and cartilaginous or soft tissue invasion. Histopathology results revealed well integration between fibular graft and host bone, with thickened trabecular bone. Gaps occurred in transitional and healthy zones. In the necrotic zone, cartilaginous or soft tissue invasion occurred, while thin or missing articular cartilage exposed subchondral bone to hip joint surfaces. By IF counterstaining with CD-31 and α -SMA, blood vessel transplanted during fibular grafting could be clearly observed along the graft from healthy to necrotic zones. In the necrotic zone, blood vessels presented obviously and spread into the surrounding area of the graft tip., Conclusion: After FVFG procedure with a mean follow-up of 11.5 years, fibular grafts retained their integrity as viable, vascularized, cortical bone that fused well with host bone and formed thickened trabecular bone surrounding the surface of the graft. However, the revascularization of FVFG's blood vessels spreading from the tip of the fibular graft into subchondral area of necrotic lesion did not improve significantly in these failure cases. The local necrotic lesion failed to be repaired as healthy trabecular bone to buttress articular surface and was occupied by soft tissues., Competing Interests: The authors declare that there are no conflicts of interest., (Copyright © 2020 Thou Lim et al.)

Objective: To determine the clinical outcome and complications associated with use of free vascularized fibular graft (FVFG) in the resection and reconstruction of extremity osteosarcoma (OS)., Methods: This is a retrospective study recruiting a consecutive series of 18 patients who had undergone resection of extremity OS between May 2009 and June 2017 in our clinic center. Reconstruction of the bone defect with FVFG was performed for each patient. Surgery-related complications and time of bone union were recorded at the follow-up visit. The functional outcome of the reconstructed limb was assessed with the musculoskeletal tumor society (MSTS) scoring system. Patients were further classified into low extremity group and upper extremity group according to the tumor location. The Student t-test was used to compare the surgical outcome between the two subgroups., Results: There were 11 males and seven females with an average age of 25.9 ± 14.2 years. The mean length of the bone resection was 11.9 ± 4.1 cm. The mean follow-up duration was 3.1 ± 1.2 years. As for tumor location, six cases were located in the femur, five in the tibia, four in the humerus, two in the ulna, and one in the radius. All the patients had successful graft healing at an average of 4.9 months after surgery. At the 2-year follow-up, an excellent functional outcome was observed in 88.9% of the patients (n = 16). The mean score of MSTS was 27.0 ± 4.6. Screw loosening and autograft fracture were observed in one patient with femur tumor, who had a low MSTS score of 11. Besides, there were three cases with delayed incision healing. Patients with lower extremity OS were found to have significantly longer duration of hospital stay and more blood loss than those with upper extremity OS. The incidence of postoperative complication was higher in the lower extremity group but with marginal significance (0% vs 36.3%, P = 0.1). There was no significant difference regarding time to bone union and the functional outcome as indicated by MSTS score., Conclusions: FVFG technique can be effectively applied to the reconstruction of bone defects after OS resection with satisfactory functional outcome and low incidence of complications., (© 2020 The Authors. Orthopaedic Surgery published by Chinese Orthopaedic Association and John Wiley & Sons Australia, Ltd.)

Background/aim: Non-vascularized methods to reconstruct bone defects following tumor resection are associated with complications. As a result, the free vascularized fibular flap (FVF) has become a mainstay for reconstruction. The purpose of this study was to analyze FVF reconstruction in the upper extremity., Patients and Methods: We reviewed 28 (14 female and 14 male, mean age of 29±20 years) patients reconstructed with an FVF in the upper extremity following tumor resection. Reconstruction most commonly involved the humerus (n=17, 61%) and a malignant (n=23, 82%) tumor., Results: The limb salvage rate was 93% (n=26), with primary union occurring in 71% (n=20) of patients. Following bone grafting the overall union was 96% (n=27) at a mean 13±11 months. At most recent follow-up the mean MSTS93 rating was 82±22%., Conclusion: FVF effectively provided a functional reconstruction following tumor resection. Although, one in four patients will need additional bone grafting, the overall union rate is high., (Copyright© 2020, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Objective: To assess the treatment of osteosarcomas of the femoral diaphysis through wide en bloc excision and reconstruction of the defect by pasteurized autograft combined with vascularized fibular transfer., Methods: A single-center, retrospective study was performed of 15 selected patients (six females, nine males) whose lesion in the middle diaphysis of the femur were treated by en bloc excision and reconstruction of the bone defect with recycled pasteurized autograft combined with vascularized fibular graft between January 2000 and December 2011. The primary diagnoses of the patients were osteosarcoma (15 patients), and one of these patients had a pathological fracture. The mean patient age at the time of surgery was 22.3 years (range, 10-40 years). All these cases of bone tumors were staged according to Enneking's criteria with three stage IIA cases, and 12 stage IIB cases. The patients were examined clinically and radiologically every month during the first 6 months after surgery to exclude the evidence of infection and local recurrence, then at 3-monthly intervals for 2 years and then at 6-monthly intervals for life. Function was assessed using the Musculoskeletal Tumor Society Scoring system (MSTS)., Results: At a mean follow-up of 65.1 months (range, 31-131 months), all the patients had achieved bony union at the final follow-up. The mean time to bone union of the proximal junctions of vascularized fibula was 8.7 months (range, 6.0-13.0 months) and that of the distal junctions was 9.2 months (range, 6.0-12.0 months). Mean union time of the proximal junctions of the pasteurized autogenous bone was 14.3 months (range, 10.0-25.0 months) and that of the distal junctions was 15.6 months (range, 10.0-27.0 months). There were two fractures of the pasteurized bone during the operation. One patient, in whom the plate had been removed after union at 3 years postoperatively, sustained a fracture in a fall. This was treated with external fixation and united uneventfully. One patient, in whom two of the proximal screws had been broken, developed coxa vara. There was no infection. There were three pulmonary metastases and no local recurrence. The mean function score was 81.8%. Five patients died of their underlying disease, and the disease-specific survival of patients was 69.1%., Conclusions: Pasteurized autogenous bone graft combined with a vascularized fibula graft is a useful reconstruction method for large bone defects after resection of osteosarcoma in the femur., (© 2019 The Authors. Orthopaedic Surgery published by Chinese Orthopaedic Association and John Wiley & Sons Australia, Ltd.)

Background: Detailed knowledge of the popliteal artery division and possible anatomical variants is of paramount importance for vascular surgery., Aim: The aim of the current study was to highlight a rare unilateral case of posterior tibial artery hypoplasia., Materials and Methods: A dissection was performed at the posterior surface of the tibia in a 78-year-old Caucasian male cadaver of Greek origin., Results: The findings were consistent with unilateral posterior tibial artery hypoplasia and fibular artery enlargement. The variant fibular artery supplied the posterior surface of the distal leg and foot. Clinical implications of the fibular artery dominance are discussed., Conclusions: Rare anatomical variants of the tibial artery are of clinical significance to maximize safety and minimize intraoperative complications., (This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Vascularized bone grafting was for the first time described in the 1970s. It has become a crucial component in the reconstruction of long bone defects and non-unions in a poorly vascularised environment. Although the vascularized bone is well described for the lower extremity and mandibular reconstructions, it started to be used for the upper extremity bone defects only recently. This publication presents a case of a young man with an open fracture of both the forearm bones. The treatment of the injury has been complicated with anaerobic gas gangrene of the forearm. This resulted in a non-union, radius shortening and necrosis of both the thumb extensors and flexors muscles. Once the acute infection was managed, the patient received a two-step treatment provided jointly by orthopaedic and plastic surgeons at the University Hospital in Bratislava. At the first stage auto transplantation of the vascularized fibula into the defect of radius was performed, with radial artery and radial veins being the recipient vessels. One year later, a tendon transfer was made in order to reconstruct the extension and flexion of the thumb. Donor tendons were the following: extensor indicis proprius and flexor digitorum superficialis for ring finger. The result of the reconstruction is the full incorporation of the fibular transplant (6 months after the primary operation) and the excellent range of motion of the hand and wrist. Thanks to the tendon transfer the function of the thumb, including the opposition, was achieved two months after the secondary surgery. Key words: defect of radius, tendon transfer, anaerobic infection, gas necrosis, microsurgery.

Aim: The aim of this study was to assess outcomes of biological (nonvascularized fibula grafts and extracorporeal irradiated autologous bone grafts) methods used for reconstruction of intercalary defects after resection of femoral diaphyseal tumors., Materials and Methods: This study included 28 patients who had undergone intercalary resection in femoral diaphyseal tumors between 2011 and 2016. The mean follow-up period was 24 months (range 12-57 months)., Results: The mean union time for diaphyseo-diaphyseal union was 10.5 and 11 months in nonvascularized fibula group and extracorporeal radiotherapy (ECRT) group, respectively. The mean union time for metaphyseo-diaphyseal union was 6.5 months in both nonvascularized fibula and ECRT groups. Six patients had distant metastasis, and one patient had local recurrence. The mean Musculoskeletal Tumor Society score was 28 at the last follow-up. Two patients had surgical site infection in the nonvascularized fibula group. Implant failure was found in one patient of the ECRT group requiring revision surgery. Three patients had nonunion (two from the nonvascularized fibula group and one from the ECRT group)., Conclusion: The present study indicates that the biological reconstruction modalities provide good functional outcomes in diaphyseal tumors of femur. Nonvasularized fibula and ECRT-treated autografts reconstruction provides good results, and union timing is comparable. The outcomes of the current study are promising as compared to the results in the reviewed literature. The reconstruction method depends on the resources available at the oncological center and the conversance with the method of the treating surgeon.

Cortical bone is permeated by a system of pores, occupied by the blood supply and osteocytes. With ageing, bone mass reduction and disruption of the microstructure are associated with reduced vascular supply. Insight into the regulation of the blood supply to the bone could enhance the understanding of bone strength determinants and fracture healing. Using synchrotron radiation-based computed tomography, the distribution of vascular canals and osteocyte lacunae was assessed in murine cortical bone and the influence of age on these parameters was investigated. The tibiofibular junction from 15-week- and 10-month-old female C57BL/6J mice were imaged post-mortem. Vascular canals and three-dimensional spatial relationships between osteocyte lacunae and bone surfaces were computed for both age groups. At 15 weeks, the posterior region of the tibiofibular junction had a higher vascular canal volume density than the anterior, lateral and medial regions. Intracortical vascular networks in anterior and posterior regions were also different, with connectedness in the posterior higher than the anterior at 15 weeks. By 10 months, cortices were thinner, with cortical area fraction and vascular density reduced, but only in the posterior cortex. This provided the first evidence of age-related effects on murine bone porosity due to the location of the intracortical vasculature. Targeting the vasculature to modulate bone porosity could provide an effective way to treat degenerative bone diseases, such as osteoporosis.

Multilevel cervical reconstruction and fusion after cervical tuberculosis has always been a challenge. The current implantation materials for cervical fusion, including titanium mesh, cage, and plate are limited by its inferior biological mechanical characteristics and the properties of the metallic material. This has led to the increased risk of recurrent infection after surgery. In addition, the unique nature of tuberculosis infection results in the low rate of cervical fusion and high risk of recurrence. This case report presents 1 patient who suffered from long segmental cervical tuberculosis and had reconstruction surgery using a vascularized fibula graft. The patient had successful graft incorporation 3 months postsurgery and was followed-up for 30 months. In this review, we detail the advantages of using vascularized fibular grafts and compare it with other types of grafts., (Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: The free vascularised fibular flap (FVFF) is widely used to treat bone defects, although it must be harvested from a healthy site. The objective of this study was to assess clinical morbidity and radiological changes at the FVFF donor site in children., Hypothesis: Distal fibular stabilisation using a tibial strut decreases the prevalence of valgus ankle deformity., Material and Method: Thirty-one children managed at two centres between 1994 and 2014 were included. Mean age was 8.9 years (range, 2-14 years) and mean follow-up was 6.6 years (range, 2-21 years). Early and delayed complications were evaluated., Results: Of the 17 early complications, 82.4% resolved fully within 7 months. Valgus ankle deformity developed in 6 (19.4%) patients. Age-residual fibula index under 16 was not significantly associated with valgus ankle deformity, although the P-value was borderline (P<0.058). Residual distal fibula length did not predict valgus ankle deformity. Three techniques were used for fibular reconstruction: syndesmotic screw, tibial strut, and both. None of these techniques prevented the occurrence of valgus ankle deformity., Discussion: Clinical donor-site morbidity after FVFF harvesting, although noticeable, usually resolved promptly. Taken alone, an age-residual fibula index under 16 did not predict valgus ankle deformity. We recommend a distal tibio-fibular quadricortical syndesmotic screw or combined syndesmotic screw-tibial strut fixation to prevent valgus ankle deformity, which is common when a tibial strut is used alone., Level of Evidence: IV., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Background: Management of osteonecrosis of the femoral head remains challenging. Core decompression and free vascularized fibular grafting are commonly used surgical procedures for treatment of osteonecrosis of the femoral head. Few studies, however, have compared these two procedures in a randomized controlled study, in terms of improved vascularity of the femoral head, progression of disease, or hip scores. QUESTION/PURPOSES: (1) What is the effect of core decompression and fibular grafting on vascularity of the femoral head as measured by single-photon emission CT (SPECT)/CT? (2) Does one of these two methods lead to greater progression of Association Research Circulation Osseous (ARCO) stage as determined by serial MRI? (3) What is the relationship between the change in vascularity of the femoral head and hip function as measured by the Harris hip score (HHS) and progression to THA as an endpoint?, Methods: A randomized controlled trial was performed between June 2010 and October 2012 at Zhongshan Hospital, Fudan University. During the study period, 51 patients who presented with ARCO Stages I to IIIB bilateral osteonecrosis were potentially eligible for inclusion, and 33 patients were identified as meeting the inclusion criteria and offered enrollment and randomization. Six patients declined to participate at the time of randomization, leaving a final sample of 27 participants (54 hips). Bilateral hips of each patient were randomly assigned to surgical options: one side was treated with core decompression and the contralateral side was concurrently treated with fibular grafting. SPECT/CT examinations were performed to quantify radionuclide uptake to evaluate vascularity of the femoral head before treatment and at 6 and 36 months after surgery. With the numbers available, we found no differences between the groups regarding vascularity at baseline (64% ± 8% core decompression-treated hips versus 64% ± 7% in the fibular-grafted hips; 95% CI, -5% to 5%; p = 0.90). MR images of the hips were obtained before surgery and at 6, 12, 24, and 36 months postoperatively and staged based on the ARCO classification. All patients were assessed clinically before treatment and followed up at 6, 12, 18, 24, 30, and 36 months after treatment using the HHS. We considered a difference in the HHS of 10 as the minimal clinically important difference (MCID). Patient progression to THA was defined as the endpoint for followup. Six patients (22%) were lost to followup., Results: By SPECT/CT analysis, decompression-treated hips had lower vascularity than fibular-grafted hips at 6 months (68 % ± 6% versus 95% ± 5%; mean difference, -27%; 95% CI, -32% to -23%; p < 0.001) and 36 months (57% ± 4% versus 91% ± 3%; mean difference, -34%; 95% CI, -37% to -32%; p < 0.001). MRI analysis showed no differences between decompression-treated hips and fibular-grafted hips regarding ARCO stage at 12 months (p = 0.306) and 24 months (p = 0.06). Progression of ARCO staging was more severe in the decompression group than the fibular grafting group at 36 months (p = 0.027). The mean HHS was lower in the decompression group than in the fibular grafting group throughout the followup period, although these differences were at or below the MCID of 10 points early on. However, by 18 months, the scores favored fibular grafting (72 ± 4 versus 84 ± 4; mean difference, -13; 95% CI, -15 to -7; p < 0.001), a finding that was maintained at 24, 30, and 36 months. We found no differences between decompression-treated hips and fibular-grafted hips regarding progression to THA at 36 months (two of 21; p = 0.893)., Conclusions: Hips that underwent a vascularized fibular grafting procedure fared better than hips receiving core decompression as measured by improved vascularity and less progression of osteonecrosis as measured by ARCO staging. The mean HHS of the fibular-grafted hips was better than that of the decompression-treated hips during the entire postoperative period, but the differences were modest early on, and for the early postoperative period the differences were unlikely to have been clinically important; by 18 months after surgery, the differences probably were clinically important. The mid-term outcomes associated with vascularized fibular grafting seen in our patients are associated with improvements in femoral head vascularity and the potential for bone revitalization., Level of Evidence: Level I, therapeutic study.

Background: The objective of this study was to compare outcomes of two surgical techniques used to treat congenital pseudarthrosis of the tibia (CPT), the induced membrane technique (IM) and the transfer of the contralateral vascularised fibula (VF)., Hypothesis: The IM technique produces similar outcomes to those of VF grafting in terms of healing and function, while being simpler and having a lower complication rate., Material and Method: This retrospective multicentre study included 18 patients with a mean age of 2.8 years at surgery. Among them, 11 had neurofibromatosis type 1 (NF1). The IM technique was used in 10 patients and VF grafting in 8 patients. Mean follow-up was 9.5 years (range: 5-15 years)., Results: The two groups showed no significant differences for healing or the occurrence of complications such as limb length discrepancy and residual malalignment. Two patients required amputation, one in each group. The mean number of surgical procedures per patient was 4.7 in the IM group and 5 in the VF group., Discussion: Outcomes are similar with the two techniques. Although VF grafting theoretically involves a single stage, the mean number of surgical procedures was not lower than after the IM technique. The IM technique was associated with lower risks of complications and residual donor site abnormalities. Regardless of the reconstruction technique, the quality of the initial bone resection and internal fixation, particularly regarding alignment, is of the utmost importance., Level of Evidence: IV, comparative retrospective study., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Background: Neurofibromatosis type 1 is a hereditary disease that can lead to pseudoarthrosis of various long bones. Rarely, pseudoarthrosis affects the forearm, and to the best of our knowledge, this is the first reported case of pseudarthrosis of the distal radius treated by this unique method., Methods: We present a case of a 7-year-old male who underwent multiple operations to treat pseudoarthrosis of the distal radius., Results: After failed conservative and operative fixation augmented with autologous iliac crest bone grafting, the patient underwent a successful double-barrel vascularized free fibula graft while preserving the physis of the distal radius., Conclusion: Double-barrel vascularized free fibula bone graft can be successfully used as the definitive treatment in refractory cases of distal forearm pseudarthrosis and we believe that our technique can be applied to all cases of pseudarthrosis in other patients with a similar presentation and lesion location.

Background: Despite the growing use of medical modeling in other surgical specialties, its utilization in extremity reconstruction has remained limited., Methods: We present the application of medical modeling for ulna reconstruction using a microvascular fibula free flap., Results: Following a motor vehicle accident, the patient suffered segmental loss of the right radius and ulna with concomitant forearm soft tissue and muscle loss. Using medical modeling, imaging from the unaffected contralateral forearm and lower extremity was used to plan a reconstruction that restored the anatomic length and orientation of the ulna. Accurate ulna length was recreated from the contralateral ulna, which served as a template., Conclusions: Cutting guides for the osteotomies on both the fibula and ulna maximized surface contact at the native ulna and fibula junction to aid in osseous healing of the fibula flap, stabilized the fibula orientation on the ulna, and allowed for lag screw placement for additional fixation.

Background: Intercalary reconstruction of tibial sarcomas with vascularized fibula autografts and massive bone allografts is reliable with predictable long-term results. However, inadequate data exist comparing free and pedicled vascularized fibula autografts in combination with a massive bone allograft in patients undergoing intercalary tibia reconstructions., Questions/purposes: Among patients undergoing large-segment intercalary allografting, we sought to compare supplemental free vascularized fibular autografts with supplemental pedicled vascularized fibular autografts, in terms of (1) oncologic results, (2) complications associated with surgery, (3) Musculoskeletal Tumor Society (MSTS) scores, and (4) surgical time., Methods: Between 1994 and 2013, we treated 320 patients, younger than 40 years, with tibial sarcomas. Thirty-five patients (11%) underwent amputations. One hundred ninety-five patients (61%) were treated with intraarticular resection of the tibia, which constituted 104 tumor endoprostheses, 63 proximal tibia allograft prosthetic composites, 21 osteoarticular allografts, and seven arthrodeses with allografts. Ninety patients (28%) underwent joint-sparing intercalary reconstruction. Forty-one (13%) of these 90 patients were treated with allografts alone, two (1%) with vascularized fibula grafts, and 47 (15%) with intercalary allografts supplemented by autografts (free fibular autografts, 22 patients, 7%; pedicled fibular autografts, 25 patients, 8%). During the study period, we used free vascularized fibular autografts in association with massive bone allograft for a resection longer than 12 cm with a very small periarticular residual segment. The choice for using a pedicled fibula harvested in the ipsilateral leg initially was for patients having only diaphyseal resections and the indication was later extended to intraepiphyseal osteotomies with a small periarticular residual segment. The goals of this study are to present the long-term results in this group of patients and compare their results based on the type of vascularized fibula harvest. There were 33 male and 14 female patients with mean age of 14 ± 6 years. The median followup was 84 months (range, 7-231 months). No patients were lost to followup before 1 year. Four patients died and were not available for followup after 18 months. The mean tibia resection length was 15 ± 4 cm and mean length of the harvested vascularized fibula was 18 ± 4 cm., Results: Overall 5- and 10-year oncologic survival rates in this study were 87% ± 5% and 83% ± 6% respectively. With the numbers available, we observed no difference in survivorship free from death from disease between the study groups (85% ± 8% [95% CI, 174-232 months] of the free vascularized group versus 82% ± 8% [95% CI, 148-206 months] of the pedicled fibula graft group; p = 0.741). At last followup, 40 patients had no evidence of disease and seven had died of disease. Local recurrence was observed in two patients in the supplemental free vascularized fibula group and three patients in the supplemental pedicled vascularized fibula group, whereas metastases was observed in eight patients. With the numbers available, we observed no difference in the proportion of patients experiencing surgical complications between those treated with free vascularized fibula grafts and those treated with pedicled grafts (eight of 22 [36%] versus nine of 25 [36%] respectively; p = 0.605). With the numbers available, we observed no difference in mean MSTS scores between patients treated with free vascularized fibula grafts and those treated with pedicled grafts (24 ± 9 versus 25 ± 8; mean difference, 0.48; 95% CI, 0.54-4.6; p = 0.858). Mean surgical time was longer in the free vascularized fibula and massive bone allograft group at 9.4 ± 1.7 hours compared with that of the pedicled vascularized fibula and massive bone allograft group at 5.7 ± 1.3 hours (mean difference, 3.73 hours; 95% CI, 2.8-4.6 hours; p ≤ 0.001)., Conclusions: Intercalary reconstruction of tibia sarcomas with massive bone allografts supplemented with vascularized fibula grafts provide predictable results. Complications occur as expected in a biologic reconstruction, but are salvageable, preserving the original construct. The pedicled fibula can be an alternative to a free contralateral fibula for intraepiphyseal resections. Comparative technical ease, shorter surgical time, avoidance of additional microvascular anastomosis, and avoidance of surgery on the contralateral leg are notable advantages of pedicled vascularized fibula over free fibula grafts to supplement allografts when indicated in intercalary tibia resections., Level of Evidence: Level III, therapeutic study.

Background: Several methods have been reported for intercalary reconstruction of femoral defects. Of these, free vascularized fibula grafts (FVFG) are preferred because of their durability, bone-healing potential, and tolerance to infection. If the bone tumor invades the femoral vessels, simultaneous vascular reconstruction also becomes necessary and significant technical hurdles make limb salvage difficult., Case Presentation: We present a 10-year-old girl who underwent limb-sparing surgery for a distal femur osteosarcoma. The femoral defect was 15 cm long, and the femoral vessel defect was 10 cm long. The femur was reconstructed with bilateral FVFG, and the femoral vessels were reconstructed with saphenous vein grafts. The grafts survived without vascular compromise, and the affected limb was preserved successfully., Conclusions: Combined use of bilateral FVFG and autologous vein grafts makes limb-sparing surgery for a large osteosarcoma of the femur possible.

While the free vascularised double-barrel fibula flap has been traditionally used in the reconstruction of defects in the long bones of the lower extremities, the advantages of this type of graft can also be seen in the treatment of adjacent radial and ulnar non-unions of the forearm. The main advantage of the double-barrel fibula flap in treatment of antebrachial non-unions is that it allows for the simultaneous anatomical reconstruction of the radius and the ulna while maximising forearm functionality. In contrast to other procedures, this tailored graft also helps preserve pronation and supination of the forearm. In this article, we chronicle a case in which a microvascular osteomyocutaneous double-barrel fibula flap was used to concurrently reconstruct the radius and ulna of a patient with a severe antebrachial non-union., (2016 BMJ Publishing Group Ltd.)

Objective: To study the diaphyseal Nutrient Foramina (NF) of dry Pakistani fibulae morphometrically and topographically., Study Design: Descriptive cross-sectional study., Place and Duration of Study: Anatomy Department, Allama Iqbal Medical College, Lahore, from December 2013 to April 2014., Methodology: The materials comprised 168 dried fibulae, 80 of left side and 88 of right side. Length of bone and distance of NF from the proximal end was calculated by placing bones on osteometric board. The Foramen Index (FI) was calculated by applying the Hughes formula, dividing the distance of the foramen from the proximal end (DNF) by the total length of the bone (TL) which was multiplied by hundred FI = (DNF/TL) x 100., Results: Eighty five bones (96.6%) of right side and 79 bones (98.8%) of left side had a single nutrient foramen. Mean length of left fibula was 34.690 ±2.353 cms and of right fibula 34.905 ±2.198 cms. Mean foramen index was 47.651 ±7.601 on the left side and 50.283 ±11.478 on the right side. In the right fibulae, type-1 foramen was present in one (1.13%) bone, type-2 was present in 77 (87.5%) bones and type-3 was found in 10 (11.36%) bones. In the left fibulae, type-1 foramen was not found in any bone, type-2 in 79 bones (98.75%) and type 3 in only 1 bone (1.25%)., Conclusion: This study provides important information on the topography of nutrient foramina of fibula in Pakistani population. As microvascular bone transfer is becoming more popular, such data regarding nutrient foramina will be of importance to orthopaedic surgeons.

Using a nonvascularized fibular graft is part of the therapeutic arsenal for filling bone loss defects. It is conventionally performed by open surgery. The authors propose a minimally invasive technique for harvesting a free fibular graft. The fibula was removed subperiosteally by two or three small incisions in five patients with a mean age of nine years and nine months. The mean surgical time was 21 min and 40.5% of the length of the fibula was harvested. At the donor site, we found no removal-related complications, regeneration of the fibula was observed in 80% of cases, and the cosmetic result was considered excellent by all patients with a mean 4.3 years follow-up. This minimally invasive technique is simple and fast, with very low morbidity in our experience., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

We report on an 82-year-old man with an infected non-union of the right tibia in which the peroneal artery was the sole artery supplying the lower leg, owing to peripheral arterial disease. He underwent tibial reconstruction using the pedicled vascularised fibular graft in a flow-through manner (without ligation of either the proximal or distal ends of the peroneal artery) and achieved successful bony union.

Background: Free vascularized fibular flaps are commonly used in jaw reconstruction. CT scan images of the fibula are used in digital planning of jaw reconstruction. In order to fully describe the anatomy of the fibula, an imaging study of the fibula was undertaken. The purpose of the present study was to examine the anatomical structure of the fibula using patient CT images., Methods: The CT scan images of fibulae of 20 patients were used for the study. The results of the analysis showed that, of the widths, the anterior border of the fibula to the posterior surface was the largest dimension. The shape type analysis showed that the triangular type was most prominent near the head of the fibula, and the irregular type was most prominent towards the lateral malleolus., Results: The results of height and width related to the long axis of implant installation showed that the width of the central section was the largest. With respect to the length of available bone volume, the length near the lateral malleolus was larger than that near the head of the fibula. The results showed that there were significant differences in size between male and female fibulae., Conclusion: The present study provides a CT scan based analysis of the anatomy of the fibula. Important information for the optimal site of installation of osseointegrated implants in fibular free flap reconstructions is also provided.

Introduction: The principal nutrient artery to the femur demonstrates an increase in nitric oxide-mediated vasodilation in rats after treadmill exercise training. The present study sought to determine whether exercise training improves hindlimb bone and marrow blood flow distribution at rest and during exercise., Methods: Six 8-month old male Sprague-Dawley rats were exercise trained (ET) with treadmill walking at 15 m · min(-1) up a 15° incline for 60 min · d(-1) over a 10- to 12-wk period. Sedentary (SED) control animals were acclimated to treadmill exercise for 5 min · d(-1) during the week preceding the blood flow measurements. Blood flow to nine distinct regions of the femur, tibia, and fibula was determined at rest and during low-intensity exercise (15 m · min(-1) walking, 0° incline) using the reference sample microsphere method., Results: The results demonstrate an augmentation of exercise hyperemia above that observed in SED rats during exercise in only one region of the bone, the femoral diaphysis, of ET rats. However, whereas exercise hyperemia occurred in three of the nine hindlimb bone regions measured in SED rats, exercise hyperemia occurred in seven of nine regions in ET rats., Conclusions: These data indicate an increase in generalized hindlimb bone and marrow blood flow during physical activity after a period of exercise training. Elevations in regional bone and marrow blood flow after training may augment medullary pressure and bone interstitial fluid flow, thus benefiting bone integrity.

Bony defects caused by trauma, tumors, infection or congenital anomalies can present a significant surgical challenge. Free vascularised fibular bone grafts (FVFGs) have proven to be extremely effective in managing larger defects (longer than 6 cm) where other conventional grafts have failed. FVFGs also have a role in the treatment of avascular necrosis (AVN) of the femoral head, failed spinal fusions and complex arthrodeses. Due to the fact that they have their own blood supply, FVFGs are effective even in cases where there is poor vascularity at the recipient site, such as in infection and following radiotherapy. This article discusses the versatility of the FVFG and its successful application to a variety of different pathologies. It also covers the applied anatomy, indications, operative techniques, complications and donor-site morbidity. Though technically challenging and demanding, the FVFG is an extremely useful salvage option and can facilitate limb reconstruction in the most complex of cases.

Vascularized bone graft (VBG) is a form of vascularized bone marrow transplant in which the bone marrow is surgically grafted with its microenvironment intact. Due to the preservation of cellular viability, VBG have significant advantages over non-vascularized bone grafts. Free vascularized fibula grafts have superior material properties and tolerate infection. Bone healing can be accomplished in a shorter period, even in an irradiated bed. In addition to these properties, VBG has other biological advantages that are not always familiar to oncological surgeons. Hypertrophic change can be divided into reactive and adaptive hypertrophy. Early hypertrophy is associated with donor-derived cells, whereas later remodeling is associated with recipient-derived cells. VBG has significant advantages in enhancing neo-revascularization of necrotic bone. We reviewed VBG from a novel viewpoint that stems from our basic research., (Copyright© 2014 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.)

Background: Avascular necrosis (AVN) of the femoral head is a potential complication in patients with slipped capital femoral epiphysis (SCFE), radiographically occurring in 3-60%. This may lead to early hip fusion or hip arthroplasty. Free vascularized fibular grafting (FVFG) may provide a reasonable means to preserve the femoral head., Questions/purposes: We asked: (1) What percentage of patients with AVN after SCFE treated with FVFG underwent subsequent THA or hip fusion and what was the lifespan of the FVFG? (2) Did the graft survival rate of FVFG for AVN after SCFE coincide with historically reported rates of FVFG for idiopathic AVN? And (3) did hip function improve after FVFG?, Methods: We retrospectively reviewed 52 patients who underwent FVFG for SCFE. We calculated the longevity of the graft and factors associated with graft survival. Harris hip scores (HHS) were recorded pre- and postoperatively. Minimum followup was 1 month (median, 19 months; range, 1-136 months)., Results: Five of the 52 patients (10%) underwent conversion to THA (four) or hip fusion (one). Mean age was greater in these patients than in those not requiring further procedures: 16 versus 13 years. Median graft survival time before arthroplasty/fusion was 12 years (range, 2-16 years) while it is currently 8 years (range, 2-16 years) in patients not undergoing subsequent procedures. HHSs improved 35 points on average (38 points preoperatively to 73 points postoperatively)., Conclusions: In patients undergoing FVFG for AVN secondary to SCFE, 90% have maintained their native hips for 8 years with improved hip function, similar to other published reports of FVFG. Further followup is needed of patients currently retaining their FVFGs as to eventual conversion to THA or fusion., Level of Evidence: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Background: Osteonecrosis of the femoral head (ONFH) is a debilitating condition affecting primarily young patients. Free vascularized fibular grafting (FVFG) may provide a durable means to preserve the femoral head. When used in the precollapse stages of ONFH, this treatment may alter the course of disease., Questions/purposes: We asked: (1) In what percentage of patients does FVFG preserve the femoral head beyond 10 years? (2) When long-term preservation is not achieved, what is the duration of femoral head preservation? (3) Do demographic or etiologic factors predict FVFG survivorship? (4) What long-term improvements in function and activity can be anticipated?, Methods: We retrospectively reviewed 61 patients (65 hips) who underwent FVFG for precollapse ONFH. We calculated graft survivorship, SF-12 scores, activity levels, and Harris hip scores. Minimum followup was 10.5 years (mean, 14.4 years; range, 10.5-26 years). Results Forty-nine of 65 hips (75%) had surviving FVFG for at least 10 years. At last followup, 39 of 65 hips (60%) had surviving FVFG, with a mean graft survival time of 15 years (range, 10.5-26.1 years). Twenty-six of the 65 hips with FVFG (40%) underwent conversion to THA at a mean of 8 years postoperatively. Demographic factors, lesion size, additional procedures, and low preoperative function were not associated with changes in graft survivorship. Pain and function were similar in patients with surviving FVFG and patients who had conversion to THA. Patients with surviving FVFG were more likely to engage in impact sports or active events than were patients who had conversion to THA., Conclusions: When patients with precollapse ONFH undergo FVFG, the majority have preservation of the hip lasting for greater than 10 years with low levels of pain and reasonable function. In patients who ultimately undergo conversion surgery to THA, the mean duration of hip preservation before conversion is 8 years. We continue to use FVFG for treating patients younger than 50 years with symptomatic, precollapse ONFH., Level of Evidence: Level IV, therapeutic study. See Instructions to Authors for a complete description of levels of evidence.

A 78-year-old man had right foot ulceration. The skin perfusion pressure (SPP) at the dorsum was 12 mmHg. Angiography revealed right iliac artery occlusion and diffuse stenosis of right superficial femoral artery. After stenting of the iliac arteries, the SPP was still 23 mmHg. Hence, we also inserted stents in the right superficial femoral artery. The anterior tibial artery remained stenosed, and the posterior tibial and fibular arteries were occluded. However, as the SPP had increased to 46 mmHg the treatment was discontinued. The ulcers improved. Measurement of SPP during a procedure may be useful in determining the treatment endpoint.

The purpose of this study was to assess the outcomes of treatment of femoral head osteonecrosis using free vascularised fibular grafting in patients with Hodgkin's disease and non-Hodgkin's lymphoma. We retrospectively reviewed seven patients (14 hips) with lymphoma who underwent free vascularised fibular grafting for osteonecrosis of the femoral head, evaluating pre- and postoperative Harris hip scores, visual analog scale (VAS) pain scores, hip range of motion and radiographs. Patients were followed up for a minimum of 1.5 years (mean, 3.3 years). All these patients exhibited good recovery without severe life-threatening complications. The mean Harris hip score improved from 69 to 88, while average VAS pain score decreased from 54 to 18. At the latest follow-up, we found improvement or unchanged radiographs in all three hips with initial Steinberg stage II osteonecrosis and in nine of 11 hips with stage III or IV osteonecrosis. No hips failed treatment and underwent total hip arthroplasty. The clinical data demonstrated that free vascularised fibular grafting can slow or even halt progression of necrosis, and improve the function of the hip and quality of life in lymphoma patients.

Treatment of congenital pseudarthrosis of the tibia is still controversial, and vascularised fibula graft is a reliable method for consolidation, although complications can occur in the donor leg after fibula grafting. This study evaluates 16 patients with congenital pseudarthrosis of the tibia (CPT) treated with contralateral fibular graft, with regard to complications in the donor leg, and assesses the influence of distal tibiofibular joint arthrodesis in these complications. All patients with CPT were consecutively submitted to surgical treatment with contralateral fibular graft. The mean follow-up was 94 months, varying from 44 to 162 months. The long-term effects in the donor leg were determined, and 12 cases with distal tibiofibular arthrodesis (group 1) were compared with a group without arthrodesis (group 2). Half of the patients had proximal migration of the lateral malleolus. Eight patients had ankle valgus. Group 1 had an average valgus tilt angle of 5.8°, while group 2 had an average angle of 1.5°. There was no significant difference between the patients with or without distal tibiofibular joint arthrodesis. The patients with a distal fibula remnant smaller than 5 cm had greater valgus tilt angle measurements. Distal tibiofibular arthrodesis was not effective in preventing all the complications in the donor leg; however, it can lessen the severity of the complications. Our results show that a distal fibular remnant greater than 5 cm should be retained to prevent ankle valgus.

The purpose of this study was to evaluate the long-term results of vascularised fibular graft for reconstruction of the wrist after excision of grade III giant cell tumour in the distal radius. From January 1998 to September 2003, 18 patients with wrist defects due to distal radius grade III giant cell tumour resection were treated with vascularised fibular graft and were followed-up. The limb function was restored to an average 80% of normal function and bone union was achieved within six months in 18 patients with vascularised fibular graft. MSTS score averaged 25.6 and ranged between 21 and 29; Mayo wrist score averaged 56 with a range from 40 to 65. It is appropriate to use the head of the fibula as a substitute for the distal radius. The healing of vascularised fibular graft is very quick and without bone resorption. Thus, in the procedure for reconstruction and limb salvage after bone tumour resection of distal radius, the free vascularised fibular graft with fibular head is an ideal substitute.

The aim of this study was to compare the safety and efficacy of OsteoSet®2 DBM with autologous cancellous bone in free vascularised fibular grafting for the treatment of large osteonecrotic lesions of the femoral head. Twenty-four patients (30 hips) with large osteonecrotic lesions of the femoral head (stage IIC in six hips, stage IIIC in 14, and stage IVC in ten, according to the classification system of Steinberg et al.) underwent free vascularised fibular grafting with OsteoSet®2 DBM. This group was retrospectively matched to a group of 24 patients (30 hips) who underwent free vascularised fibular grafting with autologous cancellous bone during the same time period according to the aetiology, stage, and size of the lesion and the mean preoperative Harris hip score. A prospective case-controlled study was then performed with a mean follow-up duration of 26 months. The results show no statistically significant differences between the two groups in overall clinical outcome or the radiographic assessment. Furthermore, no adverse events related to the use of the OsteoSet®2 DBM were observed. The results demonstrate that OsteoSet®2 DBM combined with autograft bone performs equally as well as that of autologous bone alone. Therefore, OsteoSet®2 DBM can be used as a safe and effective graft extender in free vascularised fibular grafting for large osteonecrotic lesions of the femoral head.

Objective: Osteonecrosis of the femoral head, a disease primarily affecting young adults, is often associated with the collapse of the articular surface and subsequent arthrosis. Some authors have reported good results with the use of vascularized and non-vascularized fibular grafts to treat osteonecrotic lesions of the femoral head. The aim of this study was to compare the results of vascularized fibular grafting with that of non-vascularized fibular grafting in the treatment of femoral head osteonecrosis., Methods: Between January 1999 and June 2008, 11 osteonecrotic hips of 8 patients who underwent vascularized fibular grafting and 15 osteonecrotic hips of 13 patients who underwent nonvascularized fibular grafting were compared according to etiology, stage, age, sex, preoperative and postoperative first year Harris hip and VAS scores., Results: Steroid use was the most common etiologic factor, found in 26 hips of 21 patients in the entire patient population. There was no significant difference between the two groups according to their age, sex and preoperative Harris hip scores (p>0.05). According to the Ficat staging system for radiological evaluation, 4 hips were Grade 2A, 4 hips were Grade 2B, and 3 hips were Grade 3 in the vascularized group and 8 hips were Grade 2A, 3 hips Grade 2B, 3 hips Grade 3 and one hip was identified as Grade 4 in the non-vascularized group. When the Harris hip and VAS scores of both groups were evaluated, the group treated by vascularized fibular grafting had significantly higher scores than the ones treated by non-vascularized fibular grafting in the other group (p<0.05). Furthermore, when the Harris hip and VAS scores of preoperative and postoperative first year of vascularized fibular grafting patients were compared, there were significantly higher scores after the surgery., Conclusion: Although there was no significant radiological difference in the early results of both surgical techniques, the clinical results of vascularized fibular grafting treatment were significantly better than the results of non-vascularized fibular grafting treatment in the osteonecrosis of the femoral head. Vascularized fibular grafting improves the clinical status at an early period and prevents subchondral collapse.

Unlabelled: 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.

Introduction: Knee arthrodesis is one of the reconstruction options for limb preservation after malignant tumor resection. Vascularised rotatory fibular transfer allows biological and, thus,definitive reconstruction. The goal of this work was to analyse the results of knee arthrodesis with vascularised fibular graft after tumor resection and to discuss the reliability of this technique., Patients and Methods: We report a retrospective series of 13 patients with an average age of 29.6 years. The pathological diagnosis was bone sarcoma in 12 cases and synovial chondrosarcoma in one case. Resection/arthrodesis was undertaken as the primary procedure in 11 cases.In two cases, arthrodesis was indicated after failure of an endoprosthesis. Reconstruction was achieved with a vascularised fibular rotatory transfer in all cases. For stabilisation, an external fixator was utilised in eight cases, a femorotibial nail in three cases, and a plate in two cases.Mean follow-up was 6 years., Results: We encountered infection in 53% of cases, mechanical complications in 53% of cases,and nerve palsy in 23% of cases. Four patients died from metastases (only one had arthrodesis complete union). In the nine surviving patients, arthrodesis was fully united in seven cases,after an average period of 36 months. The functional score average (Enneking classification)was 20 points., Discussion: Knee arthrodesis after tumor resection is a complex technique. Septic complications and mechanical failure are frequent regardless of the technique employed. They are related to the extent of bone sacrifice but also to that of soft tissues. The use of vascularised fibula alone and stabilisation by external fixation were the main shortcomings in this series. TYPE OF STUDY RETROSPECTIVE: Level IV., (2009 Published by Elsevier Masson SAS.)

Unlabelled: Absence of the fibula after harvesting to reconstruct an upper-limb segment increases loads on the donor-side tibia and thereby provides a unique opportunity to analyze the bone adaptation process in humans. We therefore quantified densitometric and morphologic changes of the donor-side tibia in three young patients (ages 8, 13, 16 years), on the basis of computed tomography (CT) examinations of both legs (one preoperatively and two postoperatively). The range of final followup was 27-43 months. Three-dimensional models of shank bones were generated from CT data and used to measure cross-sectional area, diaphyseal cortical thickness, and cross-sectional moment of inertia. In addition, density of the newly formed bone was evaluated. The donor-side tibia showed morphologic and density adaptation with time. New bone was deposited predominantly in the interosseous space and almost replaced the bone area lost by excision of the fibula. The second moment of area grew more in the donor-side tibia than in the intact one, without fully recovering the contralateral tibia-fibula complex values, and the principal axes rotated toward the preoperative direction. Thus, while considerable adaptation had occurred by 27-43 months in these young patients, the adaptation was incomplete; the mineral density of the newly formed bone recovered normal cortical bone values only in the patient with the longest followup (43 months)., Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Wide bone resection is sometimes necessary for bone tumors, and reconstruction is a major challenge. Vascularized fibular graft is one alternative but may result in progressive limb-length discrepancy (LLD) in children with substantial growth left. Progressive distraction lengthening with an external fixator is now a standard procedure to generally correct LLD. However, lengthening of free vascularized fibular grafts for lower limb reconstruction has not been reported frequently and then only in small series or case reports. We report our experience with three patients with lengthening after tibial reconstruction with a free vascularized fibular graft and review the literature.

Objective: To study the applied anatomy of the vascular and muscular innervations related to vascularized fibular grafts., Methods: Thirty-four cadaveric lower extremities were dissected for this study. The observations included fibular length, fibular nutrient artery, arcuate arteries, and innervation of fibular muscles. The fibulas were averagely divided into four segments and the locations of relevant vessels and nerves were ascertained., Results: All specimens had 1 fibular nutrient artery and 4-9 arcuate arteries except 1 specimen which had only 1 arcuate artery. The fibular nutrient artery and the first three arcuate arteries were constantly located between the distal half of the 1/4 segment and 2/4 segment of the fibula. The muscular branch of the superficial peroneal nerve passed through the surface of the periosteum in the 2/4 segment of the fibula., Conclusions: The most proximal osteotomy point locates at the midpoint of the 1/4 segment by which it ensure the maximal potential for preserving the nutrient vessels. The muscular branch of the superficial peroneal nerve is fragile to injury at the 2/4 segment of the fibula.