Vascularized Fibula Epiphysis Transfer for Pediatric Extremity Reconstruction: A Systematic Review and Meta-analysis

Desmoplastic fibroma in a child: a 9-year follow-up case report

BACKGROUND

Desmoplastic fibroma is an extremely rare primary bone tumor. Its characteristic features include bone destruction accompanied by the formation of soft tissue masses. This condition predominantly affects individuals under the age of 30. Since its histology is similar to desmoid-type fibromatosis, an accurate diagnosis before operation is difficult. Desmoplastic fibroma is resistant to chemotherapy, and the efficacy of radiotherapy is uncertain. Surgical excision is preferred for treatment, but it entails high recurrence. Further, skeletal reconstruction post-surgery is challenging, especially in pediatric cases.

CASE PRESENTATION

Nine years ago, a 14-year-old male patient presented with a 4-year history of progressive pain in his left wrist. Initially diagnosed as fibrous dysplasia by needle biopsy, the patient underwent tumor resection followed by free vascularized fibular proximal epiphyseal transfer for wrist reconstruction. However, a histological examination confirmed a diagnosis of desmoplastic fibroma. The patient achieved bone union and experienced a recurrence in the ipsilateral ulna 5 years later, accompanied by a wrist deformity. He underwent a second tumor resection and wrist arthrodesis in a single stage. The most recent annual follow-up was in September 2023; the patient had no recurrence and was satisfied with the surgery.

CONCLUSIONS

Desmoplastic fibroma is difficult to diagnose and treat, and reconstruction surgery after tumor resection is challenging. Close follow-up by experienced surgeons may be beneficial for prognosis.

Comparing Fibula Flap Insetting Techniques for Pediatric Oncologic Extremity Reconstruction

BACKGROUND

Extremity reconstruction in skeletally immature patients presents unique challenges in terms of operative technique, bone healing, and limb function. A variety of insetting techniques have been described, with no clearly superior option. The authors hypothesized that vascularized fibula flaps placed in the intramedullary space are associated with shorter union times and better functionality compared with onlay flaps.

METHODS

In a cohort study, the authors retrospectively reviewed the medical records of all pediatric patients who underwent fibula flap extremity reconstruction at a single center from 2001 through 2018. Comorbidities, complications, and outcomes were analyzed. Complete fibula union was based on radiographic evidence of significant cortical bridging.

RESULTS

Thirty-three patients (mean age, 13.6 years; range, 2 to 18 years) underwent pedicled ( n = 7) or free ( n = 26) fibula flap reconstructions in 12 upper extremities and 21 lower extremities. Median follow-up was 69.5 months (interquartile range, 16.3 to 114.6 months). Onlay and intramedullary fibula position compared with intercalary placement (median, 13.5 and 14.6 months versus 3.4 months; P = 0.002) were associated with longer time to complete bone union. Complications including allograft fracture ( P = 0.02) and hardware removal ( P = 0.018) were also associated with longer time to complete union and eventual conversion to megaprosthesis ( P = 0.02, P = 0.038). Thirty-two patients (97%) achieved full union and a functional reconstruction.

CONCLUSIONS

Fibula flap reconstruction is safe and effective for pediatric long-bone reconstruction. Longer fibula union times were associated with onlay and intramedullary fibula placement, allograft fracture, and hardware removal.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Gait analysis: An effective tool to mechanically monitor the bone regeneration of critical-sized defects in tissue engineering applications

INTRODUCTION

Tissue engineering has emerged as an innovative approach to treat critical-size bone defects using biocompatible scaffolds, thus avoiding complex distraction surgeries or limited stock grafts. Continuous regeneration monitoring is essential in critical-size cases due to the frequent appearance of non-unions. This work evaluates the potential clinical use of gait analysis for the mechanical assessment of a tissue engineering regeneration as an alternative to the traditional and hardly conclusive manual or radiological follow-up.

MATERIALS AND METHODS

The 15-mm metatarsal fragment of eight female merino sheep was surgically replaced by a bioceramic scaffold stabilized with an external fixator. Gait tests were performed weekly by making the sheep walk on an instrumented gangway. The evolution of different kinematic and dynamic parameters was analyzed for all the animal's limbs, as well as asymmetries between limbs. Finally, potential correlation in the recovery of the gait parameters was evaluated through the linear regression models.

RESULTS

After surgery, the operated limb has an altered way of carrying body weight while walking. Its loading capacity was significantly reduced as the stance phases were shorter and less impulsive. The non-operated limbs compensated for this mobility deficit. All parameters were normalizing during the consolidation phase while the bone callus was simultaneously mineralizing. The results also showed high levels of asymmetry between the operated limb and its contralateral, which exceeded 150% when analyzing the impulse after surgery. Gait recovery significantly correlated between symmetrical limbs.

CONCLUSIONS

Gait analysis was presented as an effective, low-cost tool capable of mechanically predicting the regeneration of critical-size defects treated by tissue engineering, as comparing regeneration processes or novel scaffolds. Despite the progressive normalization as the callus mineralized, the bearing capacity reduction and the asymmetry of the operated limb were more significant than in other orthopedic alternatives.

Pediatric Microsurgery and Free-Tissue Transfer

Advancements in microsurgery, along with increased microsurgical experience in pediatric patients, have made free-tissue transfer a reliable modality for pediatric bone and soft tissue reconstruction today. Free-tissue transfer is most commonly used in children for the coverage of large or complex defects resulting from traumatic, oncologic, or congenital etiologies. While flap success and complication rates between pediatric and adult populations are similar, special considerations must be taken into account within the pediatric population. In this article, we will describe common indications, technical nuances, and clinical considerations for the management of the pediatric free-tissue transfer patient.

Vascularized Fibular Epiphyseal Transfer for Pediatric Limb Salvage: Review of Applications and Outcomes

Vascularized fibular epiphyseal transfer (VFET) offers a functional advantage in pediatric limb salvage due to the preservation of growth potential and an articular surface for remodeling. This review summarizes the available evidence on the clinical characteristics and outcomes of pediatric reconstruction applying VFET at different recipient sites and with varying techniques. VFET was used to reconstruct the proximal humerus, distal radius or ulna, proximal femur, distal fibula, calcaneus, and mandible. Although most often harvested on the anterior tibial artery, VFET has also been performed using the peroneal artery, the inferior lateral genicular artery, and a dual pedicle. Recipient site flap inset most often involved fixation with plates and/or screws as well as soft tissue reconstruction using a retained slip of biceps femoris tendon. Outcomes included limb growth, range of motion, and strength. The most common reported complications were bone flap fracture and peroneal nerve palsy. The anterior tibial artery was the most applied pedicle with reliable limb growth, but with the added risk of postoperative peroneal palsy. Bone flap fracture most often occurred at the proximal humerus and femur recipient sites. Plate fixation and the combined use of allograft had lower instances of bone flap fracture. This review highlights how the anticipated dynamic growth and remodeling this free flap offers in the long term must be weighed against its complexity and potential complications.

Vascularized Bone Graft Reconstruction for Upper Extremity Defects: A Review

Upper extremity reconstruction may pose clinical challenges for surgeons due to the often-critical, complex functional demands of the damaged and/or missing structures. The advent of vascularized bone grafts (VBGs) has aided in reconstruction of upper extremity (UE) defects due to their superior regenerative properties compared with nonvascularized bone grafts, ability to reconstruct large bony defects, and multiple donor site options. VBGs may be pedicled or free transfers and have the potential for composite tissue transfers when bone and soft tissue are needed. This article provides a comprehensive up-to-date review of VBGs, the commonly reported donor sites, and their indications for the treatment of specific UE defects.

Reconstruction of a Pediatric Lateral Femoral Condyle After Septic Necrosis with a Free Vascularized Fibular Epiphysis: A Case Report

CASE

A 5-year-old girl presented with severe valgus deformity of the right knee after septic necrosis of the lateral femoral condyle. Reconstruction was performed using the contralateral proximal fibular epiphysis on the anterior tibial vessels. Union was evident after 6 weeks, and full weight bearing was permitted after 12 weeks. Two years of follow-up showed no deformity or length discrepancy and 90° range of motion.

CONCLUSION

The pattern of 1 femoral condyle resorption due to osteomyelitis is a rare presentation. The presented method of reconstruction could be implemented as a novel technique to reconstruct the growing knee joint in such a condition.

Dual pedicle epiphyseal transfer for paediatric bony sarcoma reconstruction: Technique and review of outcomes

Skeletal reconstruction after tumour resection in paediatric patients is challenging. The resultant reconstruction needs to meet the demands of graft incorporation as well as the potential for growth. The vascularised fibular epiphyseal transfer (VFET) offers the potential for both. We retrospectively reviewed eight paediatric patients treated with VFET after bony tumour resection. All patients underwent a dual pedicle transfer with the peroneal artery for the diaphyseal blood supply and the recurrent branch of the anterior tibial artery for the physis. This is the largest series in literature for dual pedicle transfers for bony reconstruction. We present our surgical technique and outcomes in terms of functional limb salvage and growth.

Long-term Growth, Functional, and Aesthetic Outcomes after Fibula Free Flap Reconstruction for Mandibulectomy Performed in Children

Background:

The long-term outcome of mandible reconstruction when performed in children has not been well documented.

Methods:

This is a retrospective case series of patients who underwent immediate oncologic mandible reconstruction with a fibula free flap at younger than 18 years of age over a 20-year period, by a single surgeon, who had long-term follow-up.

Results:

A total of 10 patients met inclusion criteria. Patient age ranged from 3 years and 8 months to 17 years and 9 months (mean 11 years). The etiology was malignant tumors in seven patients and benign locally aggressive tumors in three patients. All fibula flaps survived. All donor sites were closed primarily. The mean follow-up duration was 10 years and 5 months (range 3–20 years). The mean patient age at follow-up was 21 years and 10 months (range 8 years and 9 months to 30 years and 9 months). All patients achieved a regular diet and normal speech. Final occlusion was normal in seven of 10 patients. The aesthetic outcome, as evaluated by clinical examination, was a symmetric mandible in eight patients (in the other two the aesthetic asymmetry and malocclusion was minor and did not require operative intervention). Dental implants were ultimately placed in three patients. Leg function was normal in eight patients. Achilles lengthening and tendon transfer was required in one patient, and one patient developed ankle pain associated with running.

Conclusion:

Mandible reconstruction in children with the fibula free flap provides excellent aesthetic and functional outcomes that are durable over time.

Free Vascularized Fibula Salvage of Failed CPH in Pediatric Sarcoma Patients

Background

Due to extended life expectancy and recent improvements in surgical techniques, limb salvage has replaced amputation as the gold standard and is now performed in 90–95% of upper extremity malignancies. However, many of these salvage procedures are associated with significant postsurgical complications. In particular, the clavicula pro humero (CPH) procedure is associated with high rates of nonunion. We present our experience with upper extremity salvage using the free vascularized fibular flap (VFF) after failure or nonunion of the original CPH procedure in the pediatric population.

Methods

Five patients under the age of 18 diagnosed with upper extremity sarcoma who underwent tumor resection with immediate CPH reconstruction complicated with nonunion, and subsequent revision with free VFF were included. Data on patient demographics, oncologic characteristics, surgical procedures, intraoperative details, postoperative complications, and time to graft union were recorded.

Results

Five patients (average age = 8.4 years; range = 5–10 years at surgery date) underwent secondary limb salvage procedure with free VFF reconstruction following failed CPH reconstruction for proximal humeral osteosarcoma (n = 4) or Ewing sarcoma (n = 1). The mean follow-up was 3.7 years. Complications occurred in five patients (100%), with three patients requiring reoperation (60%). Four patients achieved graft union (average union time = 3.7 months) and successful limb reconstruction. Four patients were alive with no local recurrence of the disease. One patient did not achieve union and was lost to follow-up.

Conclusion

Primary bone tumors in the pediatric population require wide surgical resection, and reconstruction often has high complication rates that can warrant further procedures. A free VFF is a viable option for upper extremity salvage after previously failed reconstructions because it provides vascularized tissue to a scarred tissue bed and allows for the replacement or augmentation of large bony defects.

Total hip reconstruction after sarcoma resection in children with a free vascularized fibula without osteotomy of the bone flap: Technique description and case series

BACKGROUND

Hip joint reconstruction following intra-articular resection of the femoral head in children is a highly demanding challenge. We aimed to describe the outcomes of hip reconstruction in paediatric patients with a free fibular epiphyso-diaphyseal flap based on both anterior tibial and peroneal vessels within a radius allograft.

PATIENTS AND METHODS

Four patients underwent hip reconstruction following this technique between 2013 and 2020 at La Paz University Hospital (Madrid, Spain). The postoperative follow-up period ranged between 12 months and seven years. Two of the patients were diagnosed with Ewing's sarcoma and two with osteosarcoma. The median age at the time of surgery was eight years (six to nine).

RESULTS

Three patients remained to be disease-free at the time of this study, and one died shortly after surgery, so he was excluded from the reconstruction analysis of results. No postoperative complications requiring reintervention were recorded. Imaging studies (X-ray and MRI) showed three-dimensional growth of the flap and integration of the allograft. Mean leg length discrepancy was 1.3 cm (0 to 2.3). At the last follow-up visit, all patients were able to ambulate.

CONCLUSION

For children following oncological resection of the femoral head, reconstruction with a vascularized epiphyso-diaphyseal fibula flap combined with radius allograft is a safe option. This procedure provides encouraging functional results and avoids the complications of previously published techniques or implants.

Addressing common orthopaedic calamities with microsurgical solutions

Reconstructive microsurgery has been an essential aspect of orthopaedic surgery and extremity reconstruction since the introduction of the operating microscope in the mid-20^th century. The reconstructive ladder ranges from simple healing by secondary intention to complex procedures such as free tissue transfer and vascularized composite allotransplantation. As orthopaedic surgery has evolved over the past 60 years, so too have the reconstructive microsurgical skills that are often needed to address common orthopaedic surgery problems. In this article, we will discuss a variety of complex orthopaedic surgery scenarios ranging from trauma to infection to tumor resection as well as the spectrum of microsurgical solutions that can aid in their management.

Biology and technology in the surgical treatment of malignant bone tumours in children and adolescents, with a special note on the very young

PURPOSE

The main challenge in reconstruction after malignant bone tumour resection in young children remains how and when growth-plates can be preserved and which options remain if impossible.

METHODS

We describe different strategies to assure best possible long-term function for young children undergoing resection of malignant bone tumours.

RESULTS

Different resources are available to treat children with malignant bones tumours: a) preoperative planning simulates scenarios for tumour resection and limb reconstruction, facilitating decision-making for surgical and reconstructive techniques in individual patients; b) allograft reconstruction offers bone-stock preservation for future needs. Most allografts are intact at long-term follow-up, but limb-length inequalities and corrective/revision surgery are common in young patients; c) free vascularized fibula can be used as stand-alone reconstruction, vascularized augmentation of structural allograft or devitalized autograft. Longitudinal growth and joint remodelling potential can be preserved, if transferred with vascularized proximal physis; d) epiphysiolysis before resection with continuous physeal distraction provides safe resection margins and maintains growth-plate and epiphysis; e) 3D printing may facilitate joint salvage by reconstruction with patient-specific instruments. Very short stems can be created for fixation in (epi-)metaphysis, preserving native joints; f) growing endoprosthesis can provide for remaining growth after resection of epi-metaphyseal tumours. At ten-year follow-up, limb survival was 89%, but multiple surgeries are often required; g) rotationplasty and amputation should be considered if limb salvage is impossible and/or would result in decreased function and quality of life.

CONCLUSION

Several biological and technological reconstruction options must be merged and used to yield best outcomes when treating young children with malignant bone tumours.

LEVEL OF EVIDENCE

Level V Expert opinion.

Anatomical variant of physeal blood supply to the fibula

Vascularised epiphysial fibula bone transfers in the paediatric population provides a solution to growth suppression in extremity reconstruction. We report a case of an anatomical variant to the epiphysial blood supply that has never been reported in literature. A 6-year-old girl underwent a free vascularised fibula flap for reconstruction of her right humerous following osteosarcoma resection. While identifying and dissecting the recurrent epiphysial branch, a large branch from the peroneal artery was identified which directly entered the head of the fibula. No dominant supply from the anterior tibial (AT) vessels to the head of the fibula was seen. This led to the need for a bipedicled flap with diaphyseal supply from the AT vessels and the epiphysial transfer based on the peroneal artery. The patient made an uneventful recovery from the procedure. The same technique may be used by surgeons that may encounter this unique variant in clinical practice.

Use of Vascularized Fibular Epiphyseal Transfer with Massive Bone Allograft for Proximal Humeral Reconstruction in Children with Bone Sarcoma

BACKGROUND

The vascularized fibula epiphyseal transfer provides a reconstructive option for longitudinal growth after oncologic resection of the proximal humerus in pediatric patients. However, postoperative fractures and poor shoulder function are common. The purpose of this review was to introduce a composite approach in oncologic reconstruction of the proximal humerus and assess its clinical outcomes.

METHODS

We retrospectively investigated five children (3 osteosarcoma and 2 Ewing's sarcoma) who underwent biological reconstruction with combination of vascularized fibula epiphyseal transfer and massive bone allograft after oncologic resection of the proximal humerus. The mean follow-up was 46.8 months.

RESULTS

All patients were alive at the last follow-up. There was no graft fracture, hardware failure, or infection. The mean time of osseous union was 2.9 months at fibula-humerus junction and 6.2 months at allograft-humerus junction. Hypertrophy and axial growth were evident in all, except one patient who has avascular necrosis of the fibula head. The mean hypertrophy index was 51.5%, and the mean growth was 4.4 mm per annum. The mean arm discrepancy was 4.6 cm. All reconstruction was in situ with the average abduction of 113° and forward flexion of 69°. The mean Musculoskeletal Tumor Society (MSTS) score was 85.4% at the final follow-up. All patients experienced dropped foot and resolved spontaneously.

CONCLUSIONS

The combination of vascularized fibula epiphyseal transfer with massive allograft bone provides a reliable oncologic reconstruction of proximal humerus in children. It not only offers the ability of longitudinal growth, hypertrophy, and osseous union but also diminishes reconstructive complications and improves shoulder function.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Pediatric Mandible Reconstruction: Controversies and Considerations

Mandibular reconstruction in pediatric patients has some unique considerations. The method of reconstruction has to factor in the growth potential of the neo-mandible, the native mandible, and the donor site. The condyle is considered the main growth center of the mandible. Current literature indicates that fibula, iliac crest, and scapula osseous flaps do not have the ability to grow. Costochondral grafts exhibit growth because of the costal cartilage component, although the growth is unpredictable. Preservation of the mandibular periosteum can result in spontaneous bone regeneration. Fibula bone harvest in a child mandates close follow-up till skeletal maturity, to monitor for ankle instability and valgus deformity. Dental rehabilitation maintains occlusal relationships, which promotes normal maxillary development. Elective hardware removal should be considered to facilitate future dental implant placement and possible revision procedures. After completion of growth, if occlusion or symmetry is not satisfactory, secondary procedures can be performed, including distraction osteogenesis, orthognathic-type bone sliding operations, and segmental ostectomy.

Complication of osteo reconstruction by utilizing free vascularized fibular bone graft

The success of free vascularized fibular bone graft (FVFBG) has accelerated the osteo reconstruction which results from trauma, resection of a tumor or an infectious bone segment, or correction of congenital deformity. But the complication behind should not be overlooked. The failure could necessitate a second surgery, which prolong the rehabilitation period and produce further health cost. Worst, the patients may suffer a permanent impaired ankle function, or a sustained morpho-functional loss on reconstructive area which are hard to save. To provide an overview of the complication related to reconstruction by FVFBG, a narrative review is conducted to identify the complications including their types and rates, the contributing factors, the approaches to measure and the techniques to avoid. Methodologically, by quick research on Pubmed and abstract reading of reviews, we characterize five reconstructive areas where FVFBG were most frequently applied: extremities, mandible, spine, osteonecrosis of femoral head, and penile. Following, the complications on different reconstructive areas are retrieved, studied and presented in five (or more specifically, six) separate sections. By the way, meaningful difference between FVFBG and other bone flap was presented in a few words if necessary. Donor-site morbidities were studied and summarized as a whole. In these literatures, the evidences documented on limb and mandibular reconstruction have the fullest detail, followed by the spine and lastly the penile. In conclusion, FVFBG, though a mature technique, needs further deep and comprehensive study and maybe device-based assistance to achieve better reconstructive effect and minimize donor-site damage.

Long-term results of vascularized proximal fibula epiphyseal transfer based on the anterior tibial artery in retrograde fashion

Injury of bone growth plates can result in severe disability in children. We report the long-term results of successful vascularized proximal fibula epiphyseal transfer based on the anterior tibial artery in retrograde fashion.