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PubMed2002

Complications of vascularized fibula graft for reconstruction of long bones.

The clinical results and complications of the vascularized fibular graft for the reconstruction of various long bone defects were reviewed in 60 cases. Bony reconstruction was achieved in 57 of the 60 cases; however, various postoperative complications occurred in 54 percent of the cases. One case of arterial thrombosis of an anastomosed vessel and nine cases of venous congestion of the monitoring flap occurred in the early postoperative periods. The authors managed the nine cases of venous congestion of the flap conservatively, and all flaps survived. Partial necrosis of the flap was noted in eight of these nine cases, but additional surgical intervention was required in only four cases. Treatment included a gastrocnemius musculocutaneous flap in one case and a full-thickness skin graft in three cases. The vascularized fibula survived and bony fusion was achieved in all of these cases. The one case of arterial thrombosis resulted in graft failure due to a delay in the decision to perform a thrombectomy. Graft fracture occurred in 13 cases as the mechanical stress to the graft increased. In two cases of femoral reconstruction, graft fracture occurred during dynamization of the graft, despite the use of an Ilizarov external fixator. Correct alignment between the recipient bone and the external fixator is a prerequisite to preventing graft fracture. Vascularized fibular grafting offers the patient a great deal of benefit; however, this graft has a concomitant high risk of complications. Great attention to detail must be paid to prevent postoperative complications.

Adolescent↗
PubMed1985

Free vascularized fibula transfer for stabilization of the thoracolumbar spine. A case report.

Anterior strut grafting for kyphosis has become an accepted procedure. High stresses are placed across these grafts, however, and it would seem advisable to use a living bone graft that could remodel in response to these stresses, rather than an avascular graft of fibula or rib such as is commonly employed. This case report demonstrates the use of a free, vascularized living bone graft in the treatment of a post-traumatic kyphosis, with successful subsequent incorporation into the anterior fusion mass.

Adult↗
PubMed2003

The role of anterior spinal instrumentation and allograft fibula for the treatment of pott disease.

STUDY DESIGN: The authors retrospectively reviewed 28 patients with multilevel Pott disease who underwent anterior radical débridement, decompression, and fusion with anterior spinal instrumentation and fibular allograft replacement. OBJECTIVES: To assess the efficacy of allograft fibular fusion and anterior spinal stabilization as an alternative treatment of spinal tuberculosis. SUMMARY OF BACKGROUND DATA: The results of anterior surgery in preventing late or early spinal deformity from Pott disease have been closely related to the status of the segmental stability and graft materials, especially in cases of multisegmental involvement. The use of allograft and anterior spinal instrumentation in tuberculous spondylitis remains controversial because of the risk of persistence and recurrence of infection in the presence of devitalized bone graft, which may also be prone to poor incorporation. METHODS: Between 1993 and 1998, a total of 28 patients with Pott disease (two or more segments involved) underwent anterior débridement, allograft fusion, and stabilization. The patients were given antituberculosis treatment in the postoperative period according to a standardized protocol. The authors retrospectively analyzed their experience in tuberculous spondylitis, with particular attention to method, allograft incorporation, and anterior spinal instrumentation. Incorporation of the allograft was evaluated by either static or dynamic (flexion/extension) radiographs. RESULTS: None of the patients used external support in the postoperative period. A minimum of 3 years' follow-up was achieved in 26 patients. The overall fusion rate was 96%. There were no graft problems. Two patients died in the early postoperative period as a result of multiorgan failure. One patient suffered from an instrumentation failure. No other complications were observed. The segmental correction was maintained successfully in all of the patients. The mean correction loss was 6 degrees. CONCLUSION: The use of anterior spinal stabilization accompanied with a structural allograft fibula is effective after proper radical débridement for interbody fusion, deformity correction, and maintenance in cases of multisegment-involved Pott disease.

Adult↗
PubMed2004

Asymptomatic massive dural ectasia associated with neurofibromatosis type 1 threatening spinal column support: treatment by anterior vascularized fibula graft.

We report the case of a girl with a dystrophic neurofibromatosis lumbar scoliosis with asymptomatic progression and spread of dystrophic characteristics over 18 years. Resorption of almost the entire anterior column of L1-L4 had occurred despite a previous posterior instrumentation and fusion. A vascularized fibula bone graft wrapped in titanium mesh was used as an anterior structural graft. With close follow-up, the need for this type of salvage surgery might have been averted. Further follow-up showed no graft resorption and unchanged sagittal alignment after 3 years.

Adolescent↗
PubMed2005

Indications and rationale for use of vascularized fibula bone flaps in cervical spine arthrodeses.

BACKGROUND: Anterior cervical spine arthrodesis for large defects using autograft or allograft fibula for anterior structural support is a widely accepted procedure. In unique demand situations, a vascularized fibular flap is regarded as an "improvement" to the standard procedure. While a vascularized flap does deliver living tissue to the region, it does so with added potential morbidity and increased technical demand. The indications in the literature for this procedure have not been clearly defined. In this article, the authors review specific high-demand situations where they believe a vascularized flap is indicated. They also review patient outcomes after this procedure. METHODS: Fibular free flaps were used in six patients with failed previous cervical spine arthrodeses. Three of the six patients had preoperative radiation therapy, and one received postoperative radiation treatment. All six patients had tumor and/or osteomyelitis present. RESULTS: One patient died of intraoperative hypotension 3 days after a successful free flap transfer during an elective posterior spine instrumentation procedure. One flap was lost from a venous thrombosis, and the patient was then treated successfully with a second fibular free flap. Clinical and radio-graphic evidence of fusion was obtained at 3 months in the five surviving patients, and neurologic function remained stable or improved. CONCLUSIONS: Analyzing their results and the literature, the authors propose that fibular free flaps are indeed a useful adjunct in difficult cervical spine stabilization procedures. Indications for this flap include combinations of the following situations: failed prior attempts at fusion, anterior cervical arthrodeses of three or more vertebral levels, osteomyelitis of the spine, and tumor cases when the spine has been or will be radiated.

Aged↗
PubMed2006

Lower extremity trauma: trends in the management of soft-tissue reconstruction of open tibia-fibula fractures.

BACKGROUND: Open lower leg fractures with exposed bone or tendon continue to be challenging for plastic surgeons. Microvascular free-tissue transfer increases the ability to close wounds, transfer vascularized bone, and prevent amputation, yet remains a complex, invasive procedure with significant complication rates, donor-site morbidity, and failure rates. This review documents the changing treatment protocol in the authors' institution for these injuries. METHODS: Two hundred ninety consecutive open tibia-fibula fractures over a 12-year period (1992 to 2003) were retrospectively reviewed and methods and outcomes were compared by grouping the fractures into 4-year intervals. RESULTS: The number of open lower extremity fractures increased, whereas the distribution of Gustilo grade I to III fractures remained unchanged. Overall, free-tissue transfer was performed less frequently and constituted 20 percent of reconstructions in period 1 (1992 to 1995), 11 percent in period 2 (1996 to 1999), and 5 percent in period 3 (2000 to 2003). For the most severe fractures, Gustilo grade III, free-flap reconstruction has decreased significantly, constituting 42 percent, 26 percent, and 11 percent of procedures in periods 1, 2, and 3, respectively. Local flaps for grade III fractures have remained relatively constant throughout the study. In contrast, local wound care for grade III fractures, including skin grafts, delayed primary closures, and secondary intention closures has significantly increased from 22 percent to 49 percent of reconstructions from periods 1 through 3. In 1997, the authors began to use the vacuum-assisted closure device and now use it in nearly half of all open fractures. Despite this trend, there has been no change in infection, amputation, or malunion/nonunion rates and a decrease in reoperation rate with at least 1-year follow-up. CONCLUSIONS: These results demonstrate a change in practice, with a trend down the reconstructive ladder, currently using fewer free flaps and more delayed closures and skin grafts with frequent use of the vacuum-assisted closure sponge. Possible reasons for this change are a better understanding of lower leg vascular anatomy and better use of improved wound care technology.

Adult↗
PubMed1996

Congenital hypoplasia of the fibula: clinical manifestations.

We describe five cases of congenital hypoplasia of the fibula and the clinical appearance of the patients. The more relevant clinical manifestation is leg length discrepancy, which is usually < 6 cm. The management of this problem has been approached with predictive tables and timing of the epiphyseodesis. Some cases have been treated with tibial lengthening to correct the associated valgus deformity simultaneously. The valgus deformity is secondary to the hypoplasia of the lateral femoral condyle, which can be treated with medial hemiepiphysiodesis of the distal femur. Anterior instability of the knee usually exists due to congenital absence of the anterior cruciate ligament and can complicate lengthening procedures. The hip joint is not involved, but mild shortening of the femur was observed in four cases. Ball and socket joint at the ankle and tarsal coalitions with absent lateral rays of the foot can occur. Management of the leg length discrepancy must be considered in light of all these possible associated defects.

Child↗
PubMedDate not supplied

Rotational osteotomy of the distal tibia and fibula.

A surgical technique for distal transverse osteotomy of the tibia and fibula to correct torsional malalignment of the leg is described. Thirty-two derotation osteotomies have been performed on 19 patients, whose average age at the time of surgery was 12 years; average follow-up was 2 years. Average torsional change following surgery was 38 degrees. Ninety-four percent of the patients available for follow-up (16 or 17) had a successful outcome. The two small incisions required in this procedure are cosmetically acceptable, and the location of the osteotomy in metaphyseal bone provides stability. We conclude that this osteotomy is a simple, safe, and effective procedure for correction of torsional malalignment in carefully selected patients.

Adolescent↗
PubMedDate not supplied

Longitudinal growth of the distal fibula in children with slipped capital femoral epiphysis.

The longitudinal growth rates of the distal fibula were measured, using a roentgen stereophotogrammetric method, in 32 children treated for slipped capital femoral epiphysis and compared with growth rates in a series of normal children. The growth rates in patients were similar to the growth rates in normal children, in both boys and girls. However, at the time of slippage, 13 patients had a body height exceeding the normal value by greater than 1 SD, indicating an above-average growth rate before slippage. This pattern was found in one boy whose distal fibular growth rates were measured both before and after slippage. In conclusion, there are indications that the skeletal growth rate is slightly accelerated before slippage and more normal after slippage.

Adolescent↗
PubMedDate not supplied

Congenital pseudarthrosis of the fibula.

Three cases of congenital pseudarthrosis of the fibula are reported, all with prepseudarthrotic involvement of the omolateral tibia. In patients with this condition, correction of valgus deformity should be deferred until puberty, and the occurrence of tibial fractures should be prevented by means of leg splints.

Child↗
PubMedDate not supplied

Treatment of genu valgus deformity in congenital absence of the fibula.

Twenty patients with Syme amputation for congenital absence of the fibula and genu valgus deformity were followed until skeletal maturity. Radiographs were analyzed for genu valgus, mechanical axis, tibial angulation, and the condylar height ratio. This ratio was determined by measuring the greatest perpendicular height from the physis to the joint line and dividing the lateral height by the medial height. A smaller value represented more marked lateral condylar hypoplasia. The presence of medial tibial angulation and the degree of lateral femoral condylar hypoplasia correlated with the degree of genu valgus. Two of three patients who had proximal tibial osteotomies required multiple procedures for recurrent deformity. Medial distal femoral physeal stapling corrected the deformity in five of six limbs. The procedure is simple, allows immediate weightbearing in the prosthesis postoperatively, and has low morbidity. Patients should be followed closely until skeletal maturity. Osteotomy performed before skeletal maturity can result in recurrence of genu valgus deformity.

Adolescent↗
PubMedDate not supplied

Rotational osteotomies of the leg: tibia alone versus both tibia and fibula.

From a chart review of 45 consecutive cases (mean age 8.9 years) of patients who had rotational osteotomies of the tibia alone (group 1, 27 cases) or of both the tibia and fibula (group 2, 18 cases) for torsional deformities of the leg, we compared the length of surgery and postoperative complications. We also describe the surgical technique for tibial osteotomy alone. The most common complication, posterior and varus/valgus angulation at the osteotomy site, was significantly higher in group 2 than in group 1 (p < 0.05). The mean operative time was 21% faster for tibial osteotomy alone. One case of chronic lateral compartment syndrome occurred in group 2. When indicated, tibial osteotomy alone is a simple, safe, fast, and stable surgical procedure for correcting excessive tibial torsion.

Adolescent↗
PubMed1990

Brachy/ectrodactyly and absence or hypoplasia of the fibula: an autosomal dominant condition with low penetrance and variable expressivity.

A complex dysostosis characterized by brachy- and/or ectrodactyly and fibular hypoplasia was found in two distantly related individuals. The proposita, aged 25 years, showed metacarpal and phalangeal hypoplasia on both hands, ectrodactyly on both feet, and nearly complete bilateral absence of the fibula. Only milder acromelic defects were detected in a second cousin. A similar pattern of skeletal involvement had been previously described in an unrelated Italian family. The peculiar segregation pattern can be explained by autosomal dominant inheritance with low penetrance and variable expressivity.

Abnormalities, Multiple↗
PubMed2006

Primary intraosseous melanotic schwannoma of the fibula associated with the Carney complex.

Described herein is a rare case of intraosseous melanotic schwannoma (MS) occurring in a long bone of a 13-year-old girl with a loss of heterozygosity (LOH) at 17q22-24, which contains the PRKAR1A gene encoding the protein kinase A regulatory subunit 1-a. Plain radiography and magnetic resonance imaging revealed a 10 cm expansile osteolytic lesion involving the proximal fibula. An excisional biopsy revealed a cellular tumor consisting of mildly pleomorphic spindle or oval to polygonal cells with frequent intranuclear pseudoinclusions, intracytoplasmic melanin pigments, nuclear palisades, Verocay body-like structures, and psammomatous calcifications. The tumor cells showed strong immunoreactivity for S-100 protein, HMB-45, and neuron-specific enolase. Ultrastructurally, the tumor cells were invested by continuous, multiplied external lamina and conspicuous melanosomes in various stages of maturation. These observations were compatible with psammomatous melanotic schwannoma (PMS). In addition, the detection of LOH for PRKAR1A strongly suggests that PMS in the present case is a manifestation of the Carney complex (CNC).

Adolescent↗
PubMed2004

Primary osteochondrorhabdomyosarcoma (malignant mesenchymoma) of the fibula: a rare tumour in an unusual site -- case report and review of the literature.

Malignant mesenchymoma, defined by Stout as sarcomas comprising two or more unrelated differentiated tissue elements other than a fibrosarcoma component, is rare. We report a case of primary malignant mesenchymoma of the proximal fibula in a 10-year-old female student who presented with pain and swelling of the right knee for 2 months. Initial biopsy showed features of rhabdomyosarcoma only, but the resected specimen revealed additional osteosarcomatous and chondrosarcomatous elements. The patient remained well more than 5 years after initial presentation. Including our present patient, 16 cases of primary malignant mesenchymoma of bone are found in the English literature, affecting mainly adolescents and young adults, with a slight male predominance and predilection for the metaphysis of long bones, especially around the knee. More than 60% of the patients develop metastasis, almost invariably to the lung, but occasionally to the brain. About 60% of the patients, all with metastasis, died mostly within one year of diagnosis. The clinical features of primary malignant mesenchymoma of bone thus resemble those of conventional osteosarcoma. Moreover, our case illustrates that, with combination chemotherapy targeted for individual elements, the prognosis of this rare tumour might be much improved, as in osteosarcoma.

Antineoplastic Combined Chemotherapy Protocols↗