Vascularized proximal fibular epiphyseal transfer for distal radial reconstruction

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.

Biological Prosthesis (Hollow 3D-Printed Titanium Custom-Made Prosthesis and Bone Graft) for Humeral Reconstruction in Pediatric Oncologic Patients: Surgical Indications and Results

This study presents the mid-term outcomes of a novel "biological prosthesis" for pediatric humerus reconstruction after major bone tumor removal. This approach involves a hollow 3D-printed titanium custom-made prosthesis combined with bone grafting. The primary aim was to preserve and revitalize the unaffected autologous proximal or distal humeral stump. Between 2017 and 2021, we treated five pediatric patients (mean age 11.2 years; range 7-17) with humeral bone sarcomas. A one-stage surgical procedure involved tumor resection and implanting a hollow 3D-printed custom-made prosthesis. In two cases, we preserved the proximal humerus; in two, the distal part; and in one, both. Graft materials included homologous bone chips in three cases and free vascularized fibular grafts in two cases. All patients were clinically and radiographically assessed after a mean follow-up of 32.2 months (range of 14-68). No significant complications were observed, and no implant revisions were needed. Osseointegration was evident in all cases within eight months post-surgery; vascular support for the remaining autologous stump was demonstrated in all cases. Our hollow 3D-printed custom-made prosthesis and bone grafting offer the potential for partial or complete articular surface preservation. This approach encourages revascularization of the epiphysis, leading to satisfactory outcomes in humerus reconstruction within the pediatric population.

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.

Expanding horizons of reconstructive microsurgery in Lebanon: Reconstruction of complex traumatic wounds with anterolateral thigh perforator flaps in paediatrics patients less than 10 years of age

Paediatric complex wounds pose a challenge to the reconstructive surgeon due to the intricacy of reconstructive options required. Developments in microsurgery and microsurgical technique have brought free tissue transfer ever closer to the comfort zone of the reconstructive surgeon for reconstruction of paediatric traumatic complex wounds. We present our experience of microsurgical reconstruction in Lebanon for complex traumatic wounds in paediatric patients under the age of 10 years using the free anterolateral thigh (ALT) flap. The ALT flap has proven its value as a safe, adaptable, and aesthetically acceptable reconstructive option in paediatric complex trauma.

Vascularized fibular grafts for the treatment of long bone defects: pros and cons. A systematic review and meta-analysis

PURPOSE

To quantify union rate, complication rate, reintervention rate, as well as functional outcome after vascularized fibular bone grafts (VFGs) for the treatment of long-bone defects.

METHODS

A comprehensive search was performed in the PubMed, Web of Science, and Cochrane databases up to August 18, 2020. Randomized controlled trials, comparative studies, and case series describing the various techniques available involving VFGs for the reconstruction of segmental long-bone defects were included. A meta-analysis was performed on union results, complications, and reinterventions. Assessment of risk of bias and quality of evidence was performed with the Downs and Black's "Checklist for Measuring Quality".

RESULTS

After full-text assessment, 110 articles on 2226 patients were included. Among the retrieved studies, 4 were classified as poor, 83 as fair, and 23 as good. Overall, good functional results were documented and a union rate of 80.1% (CI 74.1-86.2%) was found, with a 39.4% (CI 34.4-44.4%) complication rate, the most common being fractures, non-unions and delayed unions, infections, and thrombosis. Donor site morbidity represented 10.7% of the total complications. A 24.6% reintervention rate was documented (CI 21.0-28.1%), and 2.8% of the patients underwent amputation.

CONCLUSIONS

This systematic review and meta-analysis documented good long-term outcomes both in the upper and lower limb. However, VFG is a complex and demanding technique; this complexity means an average high number of complications, especially fractures, non-unions, and vascular problems. Both potential and limitations of VFG should be considered when choosing the most suitable approach for the treatment of long-bone defects.

Campanacci Grade III Giant Cell Tumors of Distal End Radius Treated With Wide Excision and Reconstruction: A Retrospective Case Series

Introduction

Campanacci Grade III Giant Cell tumors of the distal radius are difficult to manage as they are associated with a high recurrence rate. Wide excision of the distal radius and reconstruction with an ipsilateral proximal fibula or ulnar translocation reduces the recurrence rate significantly and gives acceptable function to the hand and wrist.

Methods and materials

This was a retrospective study of eight patients with Campanacci grade III giant cell tumors of distal radius treated with wide excision of distal radius followed by reconstruction at our institute. Four cases were operated on with ulnar translocation and four cases were operated on with ipsilateral proximal fibula grafting after wide excision of the distal radius. Patients were studied for the Musculoskeletal Tumor Society (MSTS) score and visual analogue scale (VAS) score for pain at one year, recurrence, and complications.

Results

The mean MSTS score of the total series was 24.75 ± 1.6. The mean VAS score for the total series was 1.62 ± 0.4. Of the eight cases, two cases had a recurrence, one patient had persistent wrist paint, and two patients had wrist subluxation.

Conclusion

Wide excision of the distal radius followed by reconstruction with a proximal fibula or ulnar translocation is a good option to avoid repeated surgeries in patients with Campanacci grade III giant cell tumors of the distal radius and achieve acceptable functional results for the wrist and hand.

Vascularized Bone Grafts in Orthopaedic Surgery: A Review of Options and Indications

Vascularized bone grafts have demonstrated increased perfusion, structural integrity, and ability to achieve good outcomes in challenging clinical situations when compared with nonvascularized grafts. These grafts may be pedicled or free, and bring perfused, viable bone into areas of impaired healing. Although numerous grafts have been described, a few grafts have demonstrated particular usefulness and versatility. Pedicled grafts from the distal radius, medial femoral condyle, ribs, and fibula have improved outcomes in challenging situations without the need for microsurgery. Free grafts from the fibula and medial femoral condyle/trochlea, although they require microsurgical anastomosis, can be transferred to virtually any site in the body and have expanding indications. The capacity of these grafts to achieve favorable outcomes in difficult cases make them a powerful tool for orthopaedic surgeons to have in their armamentarium.

Lengthening and deformity correction in vascularized fibular autograft for a patient with Ewing sarcoma

We report the case of a pediatric patient with Ewing's sarcoma of the tibia treated with vascularized fibular autograft where the resulting limb deformity and leg length discrepancy (LLD) were corrected using Ilizarov external fixator. A 14-year-old girl presented to our outpatient clinic with a deformity of the right proximal and distal tibia and an 11.7 cm of LLD after tumor reconstruction surgery. Deformity correction and limb lengthening were simultaneously performed using double corticotomy on the right proximal and distal tibia. One year postoperatively, the union of the right proximal tibia had progressed, but nonunion was observed at the right distal corticotomy site. To address this, osteosynthesis with tricortical iliac bone allograft was performed after the removal of the Ilizarov external fixator. After 6 months, the union of the distal tibia was confirmed, and the varus deformity of proximal and distal tibia improved. The LLD was also decreased, but the left lower limb was still longer by 3 cm. This report shows that vascularized fibular autografts can potentially be used for the gradual correction of LLD and deformities. However, for the treatment of multiple deformities in bones previously reconstructed with vascularized fibular graft, the possibility of impaired bone forming potential of the fibular graft should be considered.

Reconstruction of traumatic tubular bone defects using vascularized fibular graft

Large segmental bone defects due to major trauma constitute a major challenge for the orthopaedic surgeon, especially when combined with poor or lost soft tissue envelope. Vascularized fibular transfer is considered as the gold standard for the reconstruction of such defects of the extremities due to its predictable vascular pedicle, long cylindrical shape, and tendency to hypertrophy, and resistance to infection. Vascularized bone grafts remain viable throughout the healing period and are capable of inducing rapid graft union without prolonged creeping substitution, osteogenesis and hypertrophy at the reconstruction site, and fight with infection. The fibular graft can be transferred solely, or as a composite flap including muscle, subcutaneous tissue, skin and even a nerve segment in order to reconstruct both bone and soft tissue components of the injury at single stage operation. Such a reconstruction can even be performed in the presence of local infection, since vascularized bone and adjacent soft tissue components enhances the blood flow at the traumatized zone, allowing for the delivery of antibiotics and immune components to the infection site. In an effort to preserve growth potential in pediatric patients; the fibular head and proximal growth plate can be included to the graft. This practice also enables to reconstruct the articular ends of various bones, including distal radius and proximal ulna. Apart from defect reconstruction, vascularized fibular grafts also proved to be a reliable in treating atrophic nonunions, reconstruction of osteomyelitic bone segments. These grafts are superior to alternative reconstructive techniques, as bone grafts with intrinsic blood supply lead to higher success rates in reconstruction and accelerate the repair process at the injury site in cases where blood supply to the injury zone is defective, poor soft tissue envelope, and local infection at the trauma zone.

Imaging following surgery for primary appendicular bone tumours

Primary bone tumours are uncommon, with sarcomas accounting for < 0.2% of all malignancies. The survival rate of primary bone sarcomas has significantly improved due to (neo)adjuvant therapy, while improved surgical techniques and development of new prostheses have shifted the surgical focus from amputation to limb preservation in the vast majority of patients. A wide variety of surgical options are available for the treatment of primary bone tumours which depend upon histological diagnosis, their appearance at the time of presentation and response to any (neo)adjuvant therapy as required. This review is intended to help radiologists familiarise themselves with the management of primary appendicular bone tumours and expected normal postoperative appearances for the various surgical techniques, and to recognise potential complications.

Vascularized fibula flap in the management of segmental bone loss following osteomyelitis in children at a Ugandan hospital

Background: Hematogenous osteomyelitis is commonly observed in the pediatric population across sub-Saharan Africa. This retrospective case series was designed to evaluate the complications and outcomes of treatment using a vascularized fibula flap (VFF) to fill segmental bone defects secondary to osteomyelitis in children in a low-resource setting in CoRSU Rehabilitation Hospital, Uganda. Methods: Clinical notes and radiographs of children with a diagnosis of osteomyelitis that subsequently underwent a VFF procedure between October 2013 and December 2017 were reviewed. All patients were clinically and radiographically evaluated in 2019. Results: Forty-four children, with an average bone defect of 10.5 cm, were included. Eighty-four percent of children had successful VFF limb reconstruction. Integration of the graft was radiologically sound in 20.8 weeks on average. The postoperative phase was uneventful in 29 % of patients. Complications were observed in the remaining patients, including flap failure (6), donor leg neurapraxia (3), cutaneous paddle necrosis (11), graft fracture (2), skin graft loss (6), fixator failure (1) and non-union (2). Functional outcomes were rated as excellent in 13 patients, good in 14, fair in 9 and poor in 8. There was no recurrence of the bone infection in any of the enrolled children. Conclusion: Despite being a complex and demanding procedure, VFF is a good option for reconstructing post-osteomyelitis bone defects, particularly when associated with loss of soft tissue envelope. Considering the more than satisfactory functional and clinical outcomes, this procedure should be kept in mind for these complex pediatric cases of bone and soft tissue loss, even in a low-resource setting.

Anatomic 3D-Printed Endoprosthetic With Multiligament Reconstruction After En Bloc Resection in Giant Cell Tumor of Distal Radius

A 34-year-old woman was diagnosed with a giant cell tumor of the right distal radius with extensive articular invasion. After en-bloc resection of 5.5 cm of the distal radius, reconstruction was done with three-dimensional printing custom-made distal radius prosthesis. In addition, a multiligament reconstruction was done to prevent postoperative radiocarpal subluxation and imitate the native distal radius. At 18 months, the range of motion was 20° dorsiflexion, 10° palmar flexion, 10° supination, and 60° pronation. Her grip strength was 60% compared with the contralateral side. No complications were seen during this 2-year follow-up. We present the combined 3-dimensional printed custom-made prosthetic with multiligament reconstruction as an innovative method without postoperative complication at 2 years.

Different reconstructive techniques for tumours of the distal tibia

AIMS

The aim of this study was to report the results of three forms of reconstruction for patients with a ditsl tibial bone tumour: an intercalary resection and reconstruction, an osteoarticular reconstruction, and arthrodesis of the ankle.

METHODS

A total of 73 patients with a median age of 19 years (interquartile range (IQR) 14 to 36) were included in this retrospective, multicentre study.

RESULTS

Reconstructions included intercalary resection in 17 patients, osteoarticular reconstruction in 11, and ankle arthrodesis in 45. The median follow-up was 77 months (IQR 35 to 130). Local recurrence occurred in eight patients after a median of 14 months (IQR 9 to 36), without a correlation with adequacy of margins or reconstructive technique. Major complications included fracture of the graft in ten patients, nonunion of the proximal osteotomy in seven, and infection in five. In the osteoarticular group, three of 11 patients developed radiological evidence of severe osteoarthritis, but only one was symptomatic and required conversion to ankle arthrodesis. Functional evaluation showed higher values of the Musculoskeletal Tumour Society (MSTS) and American Orthopaedic Foot and Ankle Society (AOFAS) scores in the intercalary group compared with the others.

CONCLUSION

Preservation of the epiphysis in patients with a distal tibial bone tumour is a safe and effective form of limb-sparing treatment. It requires rigorous preoperative planning after accurate analysis of the imaging. When joint-sparing resection is not indicated, ankle arthrodesis, either isolated tibiotalar or combined tibiotalar and subtalar arthrodesis, should be preferred over osteoarticular reconstruction. Cite this article: Bone Joint J 2020;102-B(11):1567-1573.

Clinical and radiological results of vascularized fibular epiphyseal transfer after bone tumor resection in children

INTRODUCTION

Vascularized fibular proximal epiphyseal transfer associated to a diaphyseal segment is used to treat childhood epiphyseal defect. The aim of the present study was to analyze surgical technique and long-term clinical and radiological results.

MATERIAL AND METHOD

Between 1997 and 2008, 7 patients with a mean age of 5.7 years (range, 2-8 years) were operated on for bone malignancy with vascularized fibular epiphyseal transfer: 5 Ewing sarcomas and 2 osteosarcomas, located in the proximal femur (n=3), proximal humerus (n=3) or distal radius (n=1). Mean transplant size was 13.8cm. Vascularization involved a single artery in 5 cases (3 peroneal, 2 anterior tibial) and both in 2 cases. Internal fixation used intramedullary nailing in 6 cases and screwed plate in 1. All patients underwent pre- and post-operative chemotherapy following French Pediatric Oncology Society (SFOP) protocols.

RESULTS

Mean follow-up was 11 years (range, 3 years 11 months to >17 years). All patients were alive and in tumor remission. Reconstructed joint function was satisfactory in 85% of cases. Graft thickening indicated integration in all cases. The transferred cartilage had recovered growth in 4 cases. Complications comprised postoperative infection (n =1), consolidation defects (n = 2), fractures (n = 8), malalignment requiring surgical revision (n = 1), and spontaneously resolving common peroneal nerve palsies (n = 2).

DISCUSSION

In young children, vascularized fibular epiphyseal transfer fills bone defect, reconstructs a functional joint and allows continued growth in the resected segment. Growth prostheses, in the authors' experience, always give poor results in this age-group, and fusion fails to address the growth problem. Patients should be informed about the risk of fracture, persisting over the long term.

CONCLUSION

Vascularized fibular epiphyseal transfer is a difficult technique, subject to complications, but enables reconstruction of a bone segment involving the epiphysis in young children, conserving function and growth.

LEVEL OF EVIDENCE

III, retrospective clinical study.

Osteocutaneous proximal fibular flap: an anatomical and computed tomographic angiographic study of skin and bone perforators

INTRODUCTION

Vascularized proximal fibular epiphyseal transfer is a reconstruction method for joints and growing bones. The authors investigated the vascular supply of the proximal fibula, including skin perforators, for suitability in creating an osteocutaneous flap.

METHODS

Twenty fresh cadaveric knees were studied using computed tomographic angiography combined with anatomical dissection. Three-dimensional angiography was used to develop an overview, and multiplanar two-dimension angiography was used for detailed data collection. Anatomical dissection verified by angiography was used to locate skin perforators of the proximal part of the anterior tibial artery.

RESULTS

Proximal fibular bone perforators from the anterior tibial artery were found to arise either from the anterior tibial recurrent artery, the posterior tibial recurrent artery or the circumflex fibular artery in every specimen (100%), whereas perforators from the inferolateral genicular artery met those criteria in 12 of 18 specimens (66.7%). In the proximal half of 20 anterior tibial arteries, 129 skin perforators with a diameter larger than 0.5 mm were found. There were 54 potential septocutaneous skin perforators between the extensor digitorum longus and the peroneus longus muscles (EDL/PL), and 18 between the extensor digitorum longus and the tibialis anterior muscles (TA/EDL). Skin perforators from the inferolateral genicular artery emerging from the posterolateral corner of the knee had a diameter of < 0.5 mm.

CONCLUSION

Based on this cadaveric study, the reverse flow anterior tibial artery pedicle and the EDL/PL or TA/EDL skin perforators can be considered as options for osteocutaneous proximal fibular transfers.

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.

Wrist Arthrodesis and Osteoarticular Reconstruction in Giant Cell Tumor of the Distal Radius

PURPOSE

The aim of this multi-institutional retrospective study was to compare osteoarticular graft reconstruction (OA) and wrist arthrodesis (WA) after distal radius resection for giant cell tumor.

MATERIAL AND METHODS

Sixty-seven patients affected by giant cell tumor of the distal radius underwent resection and reconstruction with OA (47 patients) or WA (20 patients). The mean age was 40 years (range, 13-74 years). Grafts included fresh-frozen allograft or nonvascularized fibular autograft. Complications requiring surgical revision were recorded. Clinical outcome was assessed with the Musculoskeletal Tumour Society Score (MSTS) and Disabilities of the Arm, Shoulder, and Hand (DASH) score.

RESULTS

Fifteen patients developed a local recurrence after a median of 12 months (range, 6-137 months). Sixteen patients required revision surgery for complications. Of these, 10 were graft-related complications (7 in the OA group and 3 in the WA group). Among OA, 2 patients with painful instabilities and 4 with severe arthritis required conversion into WA after a mean of 26 months (range, 13-38 months) At a median follow-up of 105 months (range, 12-395 months), similar functional outcome (MSTS and DASH score) was observed between OA and WA.

CONCLUSIONS

Our results did not show any advantage of OA or WA over the other technique. A patient-by-patient decision should be taken both regarding the type of reconstruction (OA or WA) and the type of graft (allograft or autograft). The reconstructive choice should also consider the patient's functional expectations.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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.

[Specific intraoperative and secondary complications of biological reconstructions following extralesional tumour resections of malignant bone tumours]

BACKGROUND

The treatment of primary malignant bone tumours is interdisciplinary and individually adapted to the patient. Nowadays, limb salvage surgery is usually possible, and the subsequent reconstruction is carried out either by implantation of modular tumour megaprostheses or by biological reconstruction procedures. Special surgical and secondary complications have to be considered.

OBJECTIVES

Indication and explanation of various biological reconstruction procedures and presentation of specific peri- and postoperative complications.

MATERIALS AND METHODS

An adapted literature review and the contribution of our own therapy experiences and case studies for the presentation of biological reconstructions and their complication management was performed.

RESULTS

In biological reconstructions, autografts, allografts or a combination of autografts and allografts are used. Stabilization is achieved with screw and plate osteosyntheses. The most common secondary complications are pseudarthrosis, interponate fracture, graft necrosis and secondary malpositions.

CONCLUSION

In selected cases, particularly at the upper extremities and in dia- or metaphyseal tumour sites, biological reconstruction after extralesional tumor resection is the surgical therapy of choice. The rate of long-term revision interventions is significantly lower compared to modular tumour megaprostheses. Biological reconstructions and the treatment of specific complications have to be performed in specialized centres for musculoskeletal surgical oncology/tumor orthopedics.

Reversed vascularized second metatarsal flap for reconstruction of Manske type IIIB and IV thumb hypoplasia with reduced donor site morbidity

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Background:

The predominant method for Manske type IIIB and IV thumb hypoplasia is pollicization. However, for those who are not willing to sacrifice the index finger, a method that could reconstruct a functionally capable and aesthetically acceptable thumb remains desirable. This study aimed to investigate and assess the functional and radiographic outcomes of utilizing a reversed vascularized second metatarsal composite flap for thumb reconstruction as a new alternative.

Methods:

From May 2014 to January 2017, 15 patients with Manske type IIIB or IV thumb hypoplasia who were admitted to the Department of Hand Surgery, Beijing Jishuitan Hospital were included in this study. An osteocutaneous flap containing a section of second metatarsal and its distal head was transferred in reversed position to reconstruct carpometacarpal joint. The donor site was reconstructed by a split half of the third metatarsal. Various functional reconstructions were commenced at second stage. The reconstructed thumbs were evaluated using the Kapandji score, pinch force, and the capacities of performing daily activities through a detailed questionnaire.

Results:

Among these 15 patients (seven type IIIB and eight type IV), there were ten boys and five girls with median age of 4.2 years (range: 2.0–7.0 years). There were seven right, three left, and five bilateral thumbs for whom only the right thumb received surgery. There were 14 metatarsal flaps survived (14/15). With an average follow-up of 19.2 months, the reconstructed thumbs had acceptable functional and aesthetic outcomes and the donor foot presented in decent appearance without signs of impaired function. All 15 children have improved the Kapandji score (from 0 to an average of 6.7), pinch force (from 0 to an average of 1.5 kg), with ability of grip and pen holding. X-ray indicated continuous bone growth. Patients and parents had good acceptance of the new thumb.

Conclusions:

Reconstruction of an unstable hypoplastic thumb (Manske type IIIB and IV) with use of a vascularized metatarsal is an effective strategy. It offers an alternative solution for parents insisting on saving the thumb.

Vascularity of the Proximal Fibula and Its Implications in Vascularized Epiphyseal Transfer: An Anatomical and High-Resolution Computed Tomographic Angiography Study

BACKGROUND

Various vascular pedicles have been used to supply the proximal fibula for vascularized epiphyseal transfer. The optimal pedicle has, however, not been agreed on. This study aimed to describe the detailed vascular anatomy of the proximal fibula to assist the surgeon in choosing the optimal pedicle.

METHODS

Twenty-eight lower extremities were injected with latex or a mixture of latex and barium sulfate. Vessels supplying the proximal fibula were identified and dissected, and the course, diameter, anatomical relations, length, and branches were documented. In the barium group, high-resolution computed tomographic scanning was conducted before dissection. In seven specimens, branches of the deep peroneal nerve to the tibialis anterior muscle were carefully preserved, and their relation to the proximal fibular vascularity was noted.

RESULTS

An anastomotic vascular network supplied the proximal fibula. This was formed superiorly by branches of the inferior lateral genicular artery, and inferiorly by branches of the anterior tibial artery, the most important of which were the first and second recurrent epiphyseal arteries. One or more deep peroneal nerve branches passed deep to the first recurrent epiphyseal artery in all specimens examined. In five specimens, all of the branches were superficial to the second recurrent epiphyseal artery, whereas two had branches deep to it.

CONCLUSIONS

The proximal fibula can be transferred using the inferior lateral genicular or anterior tibial artery because of the existing anastomosis. Factors including length of pedicle, potential for nerve injury, and diaphyseal portion to be harvested should be considered in the pedicle choice.

Microsurgery in musculoskeletal oncology

Sarcomas are rare mesenchymal bone and soft tissue tumors of the musculoskeletal system. In the past, the primary treatment modality was amputation of the involved limb and the 5-year survival was very low for high-grade tumors. During the last three decades, limb salvage has become the rule rather than the exception and the use of neoadjuvant and adjuvant therapies (radiation and chemotherapy) has dramatically increased disease-free survival. Reconstruction of large bone and soft tissue defects, though, still remains a significant challenge in sarcoma patients. In particular, vascularized tissue transfer has proved extremely helpful in dealing with complex bone and soft tissue or functional defects that are frequently encountered as a result of the tumor or as a complication of surgery and adjuvant therapies. The principles, indications and results of microsurgical reconstruction differ from trauma patients and are directly related not only to the underlying disease process, but also to the local and systemic therapeutic modalities applied to the individual patient. Although plastic reconstruction in the oncological patients is not free of complications, usually these complications are manageable and do not jeopardize oncological outcome. The overall treatment strategy should be tailored to the patient's and sarcoma profile.

Vascularized second metatarsophalangeal joint transfer for radial deficiency - an update

Vascularized second metatarsophalangeal joint transfer offers a possibility to reconstruct the radial support which is lacking in radial dysplasia. Our experience from 1987 to 2017 with 34 congenital radial club hand reconstructions have allowed a possibility for long-term evaluation of the method. Compared with conventional methods, second metatarsophalangeal joint transfer results in better wrist mobility and does not restrict typical ulnar growth. The balance of the wrist remains good until age 11. Thereafter, the growth of the vascularized bone graft transfer matches only partially the distal ulnar growth in adolescence, resulting in mild recurrence of radial deviation. A new option to create a two-bone forearm in selected Bayne-Klug Type III radial dysplasia cases will allow a relatively good pro-supination ability. Potentially, a proximal fibular epiphyseal transfer could be a future solution. Currently, a safe harvest of the proximal fibula at childhood remains controversial.

[Progress of reconstruction in bone tumor surgery]

Bone tumor surgery involves tumor resection and subsequent reconstruction. With the development of surgical technique and new material, there is a great step toward bone and joint reconstruction in bone tumor surgery. Generally speaking, there are two major reconstructive methods including bio-reconstruction and mechanical reconstruction. In addition, three-dimensional printed prosthesis has been widely applied in the field of bone tumor surgery. The short-term result is encouraged; however, long-term results and related complications are seldom reported.

Free vascularized fibula grafting in the operative treatment of malignant bone tumors of the upper extremity: A systematic review of outcomes and complications

BACKGROUND AND OBJECTIVES

Vascularized bone grafting after tumor resection can be an important component in the treatment of bony neoplasms of the upper extremity. The purpose of this study was to determine the outcomes of free vascularized fibula grafting (FVFG) in the treatment of upper extremity sarcomas.

METHODS

A systematic review of the literature of FVFG used in the treatment of upper extremity sarcomas was performed.

RESULTS

A total of 56 studies were included in final analysis. The most common diagnosis was osteosarcoma (35.1%) and the most common recipient site was the humerus (57.3%). FVFG had a median union rate of 93.3%, with the median time to union being 5.0 months. The most common complications were fracture (11.7%), nerve injury (7.5%), infection (5.7%), and hammer toe deformity (3.3%). The reoperation rate was 34.5%. The most commonly reported standardized assessment of clinical outcomes following treatment was the Musculoskeletal Tumor Society Score, which had a median of 80% postoperatively.

CONCLUSIONS

FVFG in the treatment of malignant bony neoplasms of the upper extremity has a high rate of union and good overall outcomes; however, postoperative complication rates are high. A greater degree of standardization is needed in the reporting of patient-centered outcomes to facilitate future comparative studies.

Vascularized Fibula-Based Physis Transfer: A Follow-Up Study of Longitudinal Bone Growth and Complications

Background:

The vascularized free fibula epiphyseal transfer provides an option for the preservation of limb lengthening after resection of the proximal humerus in pediatric sarcoma patients. The purpose of this study was to provide a long-term follow-up of longitudinal growth patterns and outcomes after free fibula epiphyseal transfer in upper extremity reconstruction.

Methods:

A retrospective review of 4 patients who underwent free fibula epiphyseal transfer after oncologic resection of the proximal humerus for osteosarcoma was performed. Oncologic details that could affect outcomes were included in the review: primary tumor pathology, location of malignancy, and presence of recurrence. Details on the reconstruction included longitudinal growth of the flap from the time of implantation to the most recently available radiograph and postoperative complications. The length of the fibula over time was measured from the humeral head to the olecranon process.

Results:

All patients were alive at the start of this study. The average longitudinal growth rate of the free fibula epiphyseal transfer was 0.54 ± 0.18 cm/y, and patients demonstrated satisfactory and consistent longitudinal bone growth and hypertrophy over time. All 4 patients suffered from a complication of postoperative fibula graft fracture, and 1 of 4 patients experienced unremitting peroneal nerve damage. All patients demonstrated normal wrist and hand motion with a normal arc of elbow flexion and extension.

Conclusion:

This study demonstrates that the vascularized fibula epiphyseal transfer offers the ability to preserve longitudinal limb growth and hypertrophy throughout adolescence.

What are the Functional Results, Complications, and Outcomes of Using a Custom Unipolar Wrist Hemiarthroplasty for Treatment of Grade III Giant Cell Tumors of the Distal Radius?

PURPOSE

A giant cell tumor (GCT) of bone presenting in the distal radius is rare, however, when they occur, Campanacci Grade III tumors can present formidable reconstructive challenges. They are associated with a high local recurrence rate with intralesional treatment, therefore approaches to reconstruct the wrist after en bloc resection warrant study.

QUESTIONS

We asked: (1) What are the functional outcomes after en bloc resection and reconstruction of the wrist with a unipolar prosthesis in patients with Grade III GCT of the distal radius? (2) What complications occur with use of a unipolar prosthesis in these patients? (3) What are the oncologic outcomes with using en bloc resection and reconstruction with a custom unipolar wrist hemiarthroplasty for Grade III GCTs of the distal radius?

METHODS

We retrospectively analyzed 10 patients with Campanacci Grade III GCTs of the distal radius treated by a unipolar prosthesis after wide resection of the tumor between January 2008 and October 2013. During that period, all patients at our medical group who presented with a Grade III GCT of the distal radius were treated with wide resection and reconstruction using a custom unipolar implant. Pre- and postoperative pain at rest were assessed according to a 10-cm VAS score. The functional outcomes of the wrist were assessed using the modified Mayo wrist score, and the degenerative changes were evaluated radiographically by a new rating system based on the Knirk and Jupiter scale. We also analyzed tumor recurrence, metastases, and complications associated with the reconstruction procedure. All patients were available for followup at a mean of 52 months (range, 24-90 months).

RESULTS

Although the complication rate associated with prosthetic arthroplasty was relatively high (six of 10), none of our patients experienced severe complications. Two patients reported having occasional pain of the involved wrist at the time of final followup (VAS, preoperative versus postoperative: 0 versus 3; 5 versus 2, respectively). The mean modified Mayo wrist score was 68 (range, 45-90). Degenerative changes were found in three wrists (Grade 1, two patients; Grade 2, one patient). Aseptic loosening occurred in one patient and wrist subluxation occurred in two patients. Lung metastases or local tumor recurrence were not observed.

CONCLUSIONS

Because of the proportion of patients who had complications and progressive degeneration with this approach, we recommend first exploring alternatives to reconstruction with custom unipolar wrist hemiarthroplasty after resection of Grade III GCTs of the distal radius, such as fibular autografting. However, this technique provides an alternative for patients with concerns regarding possible morbidity associated with autografting, and for situations when allograft is not available.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

[Pediatric lower extremity reconstruction]

Lower limb multi-tissular injuries are rare in children but require elaborate surgical care considering the child's growth potential, donor-site morbidity and the psychological consequences for the child and his family. This review outlines the various coverage options, from simple to more complex, developing their principles and their results. Technical features of wound repair of the lower limb in children will be detailed. An efficient and ambitious care can give excellent functional outcomes in children, even when extended, multi-tissue lesions members are involved.

Topographic matching of distal radius and proximal fibula articular surface for distal radius osteoarticular reconstruction

During osteoarticular reconstruction of the distal radius with the proximal fibula, congruity between the two articular surfaces is an important factor in determining the quality of the outcome. In this study, a three-dimensional model and a coordinate transformation algorithm were developed on computed tomography scanning. Articular surface matching was performed and parameters for the optimal position were determined quantitatively. The mean radii of best-fit spheres of the articular surfaces of the distal radius and proximal fibula were compared quantitatively. The radial inclination and volar tilt following reconstruction by an ipsilateral fibula graft, rather than the contralateral, best resembles the values of the native distal radius. Additionally, the ipsilateral fibula graft reconstructed a larger proportion of the distal radius articular surface than did the contralateral. The ipsilateral proximal fibula graft provides a better match for the reconstruction of the distal radius articular surface than the contralateral, and the optimal position for graft placement is quantitatively determined.

Unicompartmental isoelastic resurfacing prosthesis for malignant tumor of the distal radius: A case report with a 3-year follow-up

We report a case of 74-year-old man in whom a unicompartmental isoelastic resurfacing prosthesis was used to reconstruct the distal radius after en-bloc resection of a malignant tumor. Thirty-nine months after the operation, on a visual analogic scale, pain score was 0/10 and range of motion was 25° of flexion, 5° of extension, 70° of pronation, 45° of supination, 20° of radial deviation, and 30° of ulnar deviation. The Quick DASH functional score was 72.72/100. With radiographic finding, the prosthesis was well-aligned, with no evidence of loosening but with slightly implant conflict with the lunate. This case report indicates that unicompartmental isoelastic resurfacing prosthesis seems a simple and reliable technique for distal radius reconstruction after en-bloc resection of malignant tumor.

Reconstruction of the Pediatric Lateral Malleolus and Physis by Free Microvascular Transfer of the Proximal Fibular Physis

Traumatic injury to the pediatric growth plate can result in growth disturbances, late angular deformity, and limb length inequalities. Complete traumatic loss the entire growth plate complex (physis, epiphysis, and distal metaphysis) of the ankle can lead to severe joint instability and loss of function. In the growing child, physeal preservation is paramount; however, the reconstructive options are limited. We report a case of post-traumatic loss of the distal fibular physis resulting in severe ankle valgus in a pediatric patient after a Gustilo grade 3B open injury. Ankle valgus secondary to post-traumatic necrosis of the lateral ankle physeal complex was successfully managed by microvascular free transfer of the ipsilateral proximal fibula physis. The 24-month follow-up examination demonstrated continued growth of the free vascularized physeal graft and a stable ankle. The donor site had healed without incident. The patient was able to return to age-appropriate play, sports, and social integration.

New options for vascularized bone reconstruction in the upper extremity

Originally described in the 1970s, vascularized bone grafting has become a critical component in the treatment of bony defects and non-unions. Although well established in the lower extremity, recent years have seen many novel techniques described to treat a variety of challenging upper extremity pathologies. Here the authors review the use of different techniques of vascularized bone grafts for the upper extremity bone pathologies. The vascularized fibula remains the gold standard for the treatment of large bone defects of the humerus and forearm, while also playing a role in carpal reconstruction; however, two other important options for larger defects include the vascularized scapula graft and the Capanna technique. Smaller upper extremity bone defects and non-unions can be treated with the medial femoral condyle (MFC) free flap or a vascularized rib transfer. In carpal non-unions, both pedicled distal radius flaps and free MFC flaps are viable options. Finally, in skeletally immature patients, vascularized fibular head epiphyseal transfer can provide growth potential in addition to skeletal reconstruction.

Embryology, diagnosis, and evaluation of congenital hand anomalies

Although congenital hand anomalies are rare, musculoskeletal clinicians should have a basic understanding of their clinical manifestations and the possibility of concurrent anomalies and syndromes. In this review, we provide a brief overview of the embryology of limb development and the molecular pathways involved. We also summarize the clinical manifestations, diagnostic evaluation, and principles of surgical treatment for radial longitudinal deficiency, thumb hypoplasia, ulnar longitudinal deficiency, central deficiency, syndactyly, polydactyly, and amniotic constriction band. Although one of the main goals of treatment is to provide a functional upper extremity, musculoskeletal clinicians should be aware of the clinical findings that should trigger referral to evaluate for life-threatening syndromes.

Free vascularised fibular grafts in orthopaedics

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 graft from the metatarsal base for reconstructing major osteochondral distal radius defects

PURPOSE

To present our experience of reconstructing distal radius articular defects with a vascularized osteochondral graft from the metatarsal base and to present the mid-term outcomes.

METHODS

Seven patients (average age, 36 y; range, 26-55 y) who had reconstruction of major defects of the articular surface of the radius are presented. In 5, the lunate facet and sigmoid notch were reconstructed; in 1, an isolated defect on the surface of the lunate facet was reconstructed; and in 1, the scaphoid facet was reconstructed. In 6, the base of the third metatarsal was transferred, and in 1, the base of the second was transferred.

RESULTS

All flaps survived without complications. At the latest follow-up (range, 20 mo to 8 y), the flexion-extension arc improved an average of 50°, and the pain on a visual analog scale decreased from 8 to 1 on average. Disabilities of the Arm, Shoulder, and Hand score improved from 54 to 11 on average. One patient did not improve. No major complaints related to the donor site were mentioned (average American Orthopedic Foot and Ankle Society score of 96/100).

CONCLUSIONS

Our mid-term results are promising; however, the decision-making process and the operation are complex. The operation is not indicated when the carpals are devoid of cartilage or when the defect involves the whole radius surface.

Management of congenital radial longitudinal deficiency: controversies and current concepts

SUMMARY

Radial longitudinal deficiency is a spectrum of upper extremity dysplasia and hypoplasia affecting the proximal arm and the radial aspect of the forearm, wrist, and hand. Often, the hand surgeon is the first to evaluate a patient with radial longitudinal deficiency and thus must be aware of its common associated syndromes. Specific evaluation, including clinical examination and laboratory testing, is necessary. At this time, there are many surgical approaches that can be used for treatment of radial longitudinal deficiency. The procedures should be specifically tailored to the patient and family to improve overall function and clinical outcome.

Massive wrist prosthesis for giant cell tumour of the distal radius: a case report with a 3-year follow-up

We report the case of a 72-year-old woman in whom a mega wrist prosthesis was used to reconstruct the distal radius after en-bloc resection of a giant cell tumour. Three years later, her pain score was 2/10 and motion ranges were 20° of flexion, 70° of extension, 70° of pronation, 60° of supination, 20° of radial deviation, and 20° of ulnar deviation. The QuickDASH score was 52.27/100 and the Enneking score was 83%. Radiographically, the prosthesis was well aligned, with no evidence of loosening but with dorsal subluxation of the ulnar head. The outcome in this patient, together with published data, indicate that mega prosthesis use is among the treatment options for distal radius reconstruction after en-bloc resection of a giant cell tumour, provided a biocompatible, bipolar, unconstrained prosthesis is used.

Vascularized proximal fibular epiphyseal transfer: two cases

Vascularized proximal fibular epiphyseal transfer in children enables reconstruction of long-bone epiphyseal defect, while conserving axial growth potential. This technique was applied in two children for diaphyseal-epiphyseal reconstruction of the proximal humerus and distal radius respectively, using a graft vascularized only by the anterior tibial artery. There were no major complications during harvesting. Both cases showed transplant growth, of a mean 0.5cm/year. Joint function in the proximal humerus reconstruction was satisfactory, with functional range of motion. In the distal radius reconstruction, range of motion was almost zero; insufficient transplant growth induced radial club hand, requiring partial correction by progressive lengthening using an external fixator. In case of severe bone loss, fibular epiphyseal-diaphyseal graft vascularized only by the anterior tibial artery is a feasible attitude.

Femoral bone transport by a monolateral external fixator with or without the use of intramedullary nail: a single-department retrospective study

BACKGROUNDS

Treatment for bone defect remains a challenge for orthopedists. Bone transport gives an effective alternative, which can be performed with an external fixator alone or combined with an intramedullary nail. Each has its advantages and disadvantages. We present a retrospective study to find out the optimal choice by evaluating the outcomes of treatment for femoral bone defect with two methods.

METHODS

Two groups of patients, the monolateral external fixator alone (group A, n = 13) and the monolateral external fixator combined with intramedullary nail (group B, n = 15), were compared. Duration of the external fixator, external fixator index, radiographic consolidation index, complication, and total cost for treatment was also recorded. A modified classification of the Association for the Study and Application of the Method of Ilizarov (ASAMI) was used to assess results in two groups of patients; another SF-36 health survey questionnaire was used to assess the life qualities patients of two groups.

RESULTS

Healing was achieved in 13/13 and 13/15 of the two groups, respectively. The rates of complications were significantly higher in the group A. Two patients performed amputations because of persistent deep infections in group B. Statistically significant difference was found when comparing ASAMI scores and categories of the SF-36 health survey.

CONCLUSIONS

Bone transport by monolateral external fixator with the use of intramedullary nail reduces the incidence of complication and the duration of external fixator time that give patients a better life quality in both physical and emotional. However, if chronic osteitis exists, bone transport should be treated with monolateral external fixator alone due to a lower rate of amputations.

Assessment of epiphyseal plate allograft viability and function after ex vivo storage in University of Wisconsin Solution

BACKGROUND

Compromised epiphyseal plate function can result in limb deformities. Microvascular transplantation of an epiphyseal plate allograft is a potentially effective approach to reestablish longitudinal limb growth. For this procedure to become clinically useful, the technique for temporary ex vivo storage of allografts must be reliable. The goal of this study was to determine a time frame for which proximal tibial epiphyseal plate allografts could be stored in University of Wisconsin Preservation Solution (UWPS) and remain functional in vivo after microvascular transplantation.

METHODS

Proximal tibial epiphyseal plate allografts from skeletally immature female New Zealand White rabbits (10 to 12 wk of age) were used. Allografts (isolated on the popliteal arteriovenous pedicle) were stored ex vivo in cold UWPS for periods of up to 21 days. Chondrocyte viability, phenotype, and extracellular matrix composition of growth plate cartilage was assessed. Microvascular transplantations of nonstored or prestored (3 d) allografts were performed and analysis of bromodeoxyuridine and calcein incorporation was done to determine chondrocyte proliferation and new bone growth, respectively.

RESULTS

In vitro analysis showed that, compared with control tissue, epiphyseal plate chondrocyte viability (P>0.05), organization, and collagen extracellular matrix was preserved up to 4 days in cold UWPS. Microvascular transplantation of nonstored epiphyseal plate allografts was successful. Despite care being taken to ensure vascular patency during the microvascular procedure, transplantation of prestored allografts failed due to absent flow in the larger vessels and in the allograft based upon the visualization of organized thrombus within the vascular pedicle, and absent flow within the composite graft itself. However, growth plate viability and function was detected in a peripheral region of a single allograft where partial blood flow had been maintained during the transplantation period.

CONCLUSIONS

Ex vivo storage in cold UWPS for 3 days maintains growth plate chondrocyte viability and function in vivo. However, future studies must be directed toward investigating the direct effect of ex vivo storage on the integrity and function of the vascular pedicles.

Distal radius reconstruction using a split vascularized fibula. Two cases following giant cell tumor resection

We propose a distal radius reconstruction technique that provides a strong stable wrist while preserving mediocarpal range of motion. Two cases of giant cell tumor of the distal end of the radius were treated. The technique included en bloc resection of the lesion followed by wrist reconstruction with partial arthrodesis. A vascularized fibular graft was used. With 4 years of follow-up for patient 1 and 1 year for patient 2, range of movement in flexion was, respectively, 20°and 20°; in extension, 20 and 30°; in pronation, 80 and 30°; and in supination, 20 and 15°. Strength reached 68 and 57% of the strength of the opposite side. The time to union of the radial graft and the carpal graft was 2 months in both cases. This technique provided cosmetic and functional results matching the results reported in the literature. It increases the reliability of the procedure and the recovery process.

Bone quality and growth characteristics of growth plates following limb transplantation between animals of different ages--results of an experimental study in male syngeneic rats

INTRODUCTION

The purpose of this study was to identify graft osteoporosis post transplantation by micro-CT analysis, and the growth potential of growth plates in the transplanted limb.

METHODS

Ten juvenile to juvenile and five juvenile to adult hind limb transplants were performed in male syngeneic Lewis rats. Upper tibial bone density in isochronograft and heterochronograft limbs was measured by 3D micro-CT and compared with that of the opposite non-operated limbs.

RESULTS

We observed inferior bone quality (p < 0.05) in heterochronografts compared to isochronografts. After transplantation, isochronografts did not exhibit increases in tibial lengths compared to opposite juvenile non-operated tibias (p = 0.66) or heterochronograft tibias (p = 0.61). However, significant differences were observed between heterochrongraft tibial lengths when and opposite adult non operated tibial lengths (p < 0.001).

CONCLUSIONS

Age dependent alterations affect bone quality, resulting in post transplantation osteoporosis in heterochronografts, but not isochronografts. However, the growth plates of transplanted limbs retain their properties of longitudinal growth and continue to grow at the same rate.

Biological reconstruction of bone defects: the role of the free fibula flap

This review describes the kinds of skeletal bone defects in bones which develop through enchondral ossification. It focuses on the biological reconstruction of those defects according to the two main subtypes, intercalary and osteoarticular. We list the causes of bone defects and outline the different types and configurations that result from them. We then review the currently available reconstructive options according to the patient's age and describe the theoretical options as well. Finally, the history, surgical anatomy and clinical use of the free fibula flap will be reviewed. From our own clinical experience and review of the literature, we conclude that biological reconstruction is, in many ways, superior to alloplastic materials, especially in children, adolescents and young adults.