Free Fibula Long Bone Reconstruction in Orthopedic
Oncology: A Surgical Algorithm for Reconstructive
Options
Arik Zaretski, MD, Aharon Amir, MD, Isaac Meller, MD, David
Leshem, MD, Yehuda Kollender, MD, Yoav Barnea, MD, Jacob
Bickels, MD, Tomas Shpizer, MD, Dean Ad-El, MD, Jerry Weiss,
MD, and Eyal Gur, MD.
The fibula free flap became popular in orthopedic oncology,
for limb sparing long bone tumor resection. It is particularly
suitable for intercalary or resection arthrodesis options. In
the present series we used a surgical reconstruction algorithm
enabling each patient to receive a personalized technique.
During the years 1998 – 2002, 30 patients underwent limbsparing surgery (LSS) for long bone sarcoma. There were 18
males and 12 females. Their mean age was 23 years (9-70
years). The diagnoses were Ewing’s sarcoma (11 patients),
osteogenic sarcoma (8 patients), chondrosarcoma (5), giant
cell tumor of bone (3), high-grade soft tissue sarcoma (2) and
lieomyosarcoma of bone (1). The majority of tumors where
located in the lower extremity (23), most of them in the femur
(15 patients, subdivided to: 4 in the proximal femoral shaft,
5 in the distal femoral shaft, whole femoral shaft in 5 and
just one in the proximal femoral head). In 7 patients the
upper extremity was involved, six in the radius and in one the
humerus was involved. The free fibula flap was used in three
types of approaches: vascularized fibula as an osseous flap
only (18 patients), a combination of a vascularized fibula
flap in conjunction with an allograft (Capanna’s technique)
(10 patients) and a free double-barreled fibula (2 patients).
Up to date, all flaps survived (100%). Post operatively; all
patients were monitored clinically, radiologically and by
radioisotope bone scan studies. Callus formation and union
were shown 2.6 to 8 months post operatively. Patients who
underwent lower extremity reconstruction were non weight
bearing (NWB) for 3 - 9 months with a transition period in
which they used a brace and gradually increased weight bearing
until full weight-bearing (FWB). Eight patients had 11
recipient site complications: Two patients (6.7%) had
hematomas, three patients (10%) had infection and dehiscence
of the surgical wound with bone exposure in one, all resolved
using conservative treatment only. Failure of the hardware
fixation system occurred in 2 patients mandating surgical
correction. No fibula donor site complications were recorded.
In intercalary resections, the use of the vascularized fibula
flap as an isolated osseous flap might be insufficient.
Different body sites have different stress loads to carry,
depending also on the age of the patient and on his individual
physical status. In order to achieve initial strength in the
early period, we combined the free fibula flap with an
allograft (Capanna’s method), or augmented it as a doublebarreled fibula. We propose, a surgical algorithm to assist
the surgeon with the preferred method for reconstruction of
various long bone defects in different body locations at
childhood or adulthood. Long bone reconstruction using a
vascularized fibula flap, alone or in combination with an
allograft, autogenous bone graft or double-barreled fibula for
limb sparing surgery is a safe and reliable method with a
predictable bony union, good functional outcome and a low
complication rate.
Tumor of long bone
Staging studies
Biopsy
Bone sarcoma
Neoadjuvant chemotherapy
Chondrosarcoma
Osteosarcoma
Oncological resection
Primary biological reconstruction
Ewing’s sarcoma
No R.T.*
Radiation therapy
Oncological resection
Spacer reconstruction
2 years follow-up
Favorable prognosis
Definitive biological reconstruction
Figure 1 – Immediate versus late reconstruction: Secondary definitive
reconstruction is advised in patients scheduled for postoperative
radiation treatment.
* Patients with Ewing’s sarcoma and a favorable prognosis did not
receive radiation therapy.
Figure 4
–
Immedia
te versus
late
reconstr
uction:
Secondar
y
definitive
reconstru
ction is
advised
in
patients
scheduled
for
postopera
tive
radiation
treatment.
* Patients
with
Ewing’s
sarcoma
and
a
favorable
prognosis
did not
receive
radiation
therapy.
Lower extremity long bone sarcoma
Segmental resection
Partial longitudinal bone
defect or bone weakness*
Fibula only
Periarticular
Prosthesis
complication**
Intercalary
Mid tibia
Fibula only
Femur/
Proximal tibia
Allograft & fibula
Double barrel fibula***
Resection arthrodesis
Figure 2 - Lower extremity reconstruction: Autogenous reconstruction
is indicated primarily in cases that are not periarticular. The
decision about type of fibular reconstruction depends no the
mechanical load expected according to the anatomical site.
*
Avscular necrosis, osteoradionecrosis, pathological fracture.
** Infectious complication, implant failure.
***When there is enough fibula bone source, the bony defect is not to
big and not a heavy patient.
Upper extremity long bone sarcoma
Radius
Intercalary
Fibula flap
Fibula
arthrodesis
Humerus
Periarticular
Adult
Fibula
arthroplasty
Intercalary
Child*
Fibula flap
Periarticular
Fibula
arthrodesis
Fibula
arthroplasty**
Fibula arthroplasty
with the growth plate***
Figure 3 – Upper extremity reconstruction: In upper extremity
reconstruction the fibula flap is adequate to be used as the sole
bony replacement. In a growing child with a periarticular defect of
the radius it is recommended to harvest the fibula flap with the
proximal fibula head and the vascularized growth plate.
*With active epiphysial plate.
**With or without active epiphysial plate – depending on the patients
age.
***When significant growth is still expected.