RECONSTRUCTIVE

Use of the Vascularized Free Fibula Graft withan Arteriovenous Loop for Fusion of Cervicaland Thoracic Spinal Defects in PreviouslyIrradiated Pediatric Patients

Shareef Jandali, M.D.Michael L. Diluna, M.D.

Phillip B. Storm, M.D.David W. Low, M.D.

Philadelphia, Pa.

Background: Extensive spinal neoplasms are difficult to manage. Followingresection, arthrodesis of the spine can be performed with instrumentation,but this often fails in the setting of radiation therapy. Use of the free fibulaflap for anterior spinal fusion to correct deformities has been described inmultiple studies, but its use for posterior spinal fusion has been limited. Inaddition, its use in the pediatric population for this purpose has not beenreported.Methods: A retrospective review was performed of three pediatric casesof cervical and thoracic spine tumor resection with posterior fusion of thespine with a microvascular fibula flap over a 2-year period. Data recordedincluded patient demographics, medical/surgical history, indications forsurgery, length of free fibula flap, recipient vessels, ischemic time, numberof osteotomies performed on the fibula, complications, and time to com-puted tomography– documented fusion of the fibula to the remaining spinalcolumn.Results: All three microvascular anastomoses were successfully performedusing an arteriovenous loop of saphenous vein graft to the anterior neck orsubscapular vessels. The average length of fibula harvested was 23.7 cm, theaverage length of ischemic time was 220 minutes, the number of osteotomiesin all cases was two, and there was bony fusion at an average of 15.7 weekspostoperatively.Conclusions: The free fibula flap is ideally suited for accelerated posteriorspinal fusion after extensive resection of cervical or thoracic spinal neo-plasms. An arteriovenous saphenous vein loop facilitates the microvascularanastomosis in this anatomical region that lacks suitable recipientvessels. (Plast. Reconstr. Surg. 127: 1932, 2011.)

Extensive spinal neoplasms are often difficultto manage because many of the patients haveundergone preoperative radiation therapy

and require radical resection and then stabiliza-tion of the spine. Arthrodesis of the spine can beperformed with instrumentation, but this oftenfails in cases of multilevel corpectomies and ver-tebrectomies, and in the setting of poor tissue bedssecondary to radiation therapy. In these situations,

bone grafting is performed to obtain a bony fusionof the axial skeleton.

Conventional allografts and nonvascularizedautografts can be used for short segments of boneloss, but these are often inadequate for more ex-tensive defects, especially after radiation ther-apy. Vascularized bone grafting results in accel-erated healing, earlier fusion, and increasedstrength. Cell viability is maintained in the bonegraft, and primary bone healing occurs at thefusion site as opposed to the creeping substitutionFrom the Division of Plastic Surgery, University of Pennsyl-

vania Health System, and the Divisions of Plastic Surgeryand Neurosurgery, Children’s Hospital of Philadelphia.Received for publication August 31, 2010; accepted Novem-ber 22, 2010.Copyright ©2011 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e31820cf4a6

Disclosure: The authors have no financial interestto declare in relation to the content of this article.

www.PRSJournal.com1932

into the scaffold of necrotic nonvascularized bonegraft. Therefore, extensive bone remodeling, in-cluding revascularization, resorption, and pro-duction of new bone, does not occur as it doeswith nonvascularized bone grafts. Structural vi-ability and strength is maintained throughoutthe healing process.1–5 The combination of spi-nal fusion with instrumentation and vascular-ized bone autografting allows for early structuralstabilization and late osseous union. Osseousunion rates with vascularized bone grafts havebeen reported to be as high as 82 to 90 percentafter tumor resection.6 – 8

There are three good options for vascularizedbone grafts for spinal reconstruction: pedicled ribgraft, free iliac crest bone graft, and the free fibulaflap.1,6,9 The pedicled rib graft can be used foranterior or posterior spinal fusions and is suitablefor thoracolumbar defects. The downsides to therib graft are that it is weaker than the fibula or iliaccrest graft and requires additional spinal fixation,it is curved, and it is limited to reconstructing thethoracolumbar spine because of its arc ofrotation.1 The iliac crest is more stable but is lim-ited in length and is not a straight bone graft likethe fibula.10 The vascularized fibula graft has mul-tiple advantages: it can be harvested up to 25 cmin length; it has no angulation; it has a thick,strong cortex; and it can be used anywhere on thevertebral column.10

Use of the free fibula flap for anterior spinalfusion to correct deformities has been describedin multiple studies.9,11–16 However, its use for pos-terior spinal fusion has been limited.17 In addition,reports of its use in poor fusion environments arealso rare, with most reports being concernedwith patients with osteomyelitis.6,17,18 We presentthree cases of cervical and thoracic spinal neo-plasms in a pediatric population. All three pa-tients underwent preoperative radiation therapyand subsequently underwent posterior spinal fu-sion with a vascularized fibula bone graft withuse of an arteriovenous saphenous vein loopover a 2-year period from 2008 to 2010.

OPERATIVE TECHNIQUEIn these cases, the operative team included the

neurosurgical spine surgeon and the plastic sur-geon. Typically, the neurosurgical team performsthe tumor resection and insertion of the posteriorspinal fusion hardware. The patient is then usuallyplaced in the left lateral decubitus position with abeanbag, to give access to the right neck, the pos-

terior midline spine, the left saphenous vein, andthe right fibula.

Because of the absence of any suitable re-cipient vessels in the midline of the back for thefibula anastomosis, a saphenous vein graft isused to connect to the closest recipient vessels,which are usually in the neck. We first performthe saphenous vein harvest from the left leg,extending from the ankle to the proximal thigh.A small submandibular incision is made in theright neck to find suitable recipient vessels, usu-ally the facial vessels, which are dissected free. Ifthe back incision is exposed, it is opened at thelevel where the fibular pedicle will likely lie. Anample subcutaneous tunnel is made between theneck incision and either the opened back inci-sion or an area just lateral to it if it is not ex-posed. The saphenous vein graft is reversed andthe loop is tunneled so that the middle can beseen through the back incision and the two endsin the neck field. Particular attention is paid tomake sure that the marked side of the vein isfacing upward and there are no kinks or twistsin the subcutaneous tunnel. The venous andarterial anastomoses are performed in that or-der under the microscope. After the clamps arereleased, the loop of the graft in the back inci-sion should be pulsatile with a thrill (Fig. 1).Both the neck and back incisions are closed andattention is turned to the right leg for fibulaharvest, which is then performed in standardfashion.

Fig. 1. An arteriovenous loop of saphenous vein graft can beseen through the midline back incision.

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The patient is usually flipped to the proneposition at this time and the entire back incisionis reopened. The fibula is placed in the locationof planned fusion. The saphenous vein isclamped at two spots at the apex of the loop andthen divided between these clamps so that thevenous and then arterial anastomoses can beperformed. After restoration of arterial inflow,the fibula is then osteotomized at one or twolocations to better conform it to the curve of thespine. The lateral periosteum is then elevatedwith a periosteal elevator and the underlyinglateral cortex is burred off with a pineappleburr. The neurosurgical team decorticates theapposing lamina on which the fibula is going torest. The fibula is placed alongside the decor-ticated lamina and bone dust and osteoinduc-tive material are packed around the bony inter-faces to facilitate rapid and proper fusion(Fig. 2). Occasionally, a few loose sutures areapplied over the fibula from one fusion rod tothe other fusion rod. However, this is usually notnecessary because the soft-tissue closure holdsthe fibula in place. Therefore, the fibula is notfixated in place with any hardware, is not load-bearing, and is not acting as a strut graft. A CookDoppler probe is only applied if a surface Dopp-ler signal cannot be easily found over the sub-cutaneous tunnel with the underlying saphe-

nous vein graft. The patient is sent to theintensive care unit postoperatively for frequentneurologic assessments and flap checks. The pa-tient is allowed to lie supine but cannot haveanything compressive placed over the area ofthe arteriovenous loop. No special brace is nec-essary because the patient’s vertebral column isstable with the hardware.

CASE REPORTSCase 1

Patient 1 was a 17-year-old girl with a malignant paraspinalperipheral nerve sheath tumor extending from T5 to T10.She had undergone subtotal debulking of the tumor bymeans of a left thoracotomy, followed by radiation therapy,additional debulking, and then chemotherapy. She finallyunderwent a radical resection that included a left hemilam-inectomy from T4 to T11 and removal of the left posteriorribs from T5 to T10. At this time, she underwent thoracicspinal fusion with pedicle screws and rods, chest wall recon-struction with a methylmethacrylate mesh sandwich, andlocal pedicled left latissimus and trapezius muscle coverage.She developed wound complications requiring multipledebridements, which included the prosthetic methylmeth-acrylate mesh patch. She then required partial hardwareremoval on two separate occasions. She subsequently devel-oped a bronchopleural fistula on her left posterior chestsecondary to the radiation therapy. Her remaining hardwarewas felt to be contaminated and needed to be removed. Sheunderwent complete hardware removal and harvesting of aright latissimus myocutaneous flap (anastomosed to the leftthoracodorsal vessels), which was used in an attempt to sealoff the bronchopleural fistula. The pulmonary service laterplaced endobronchial valves to attempt to seal off the in-volved lung segments and allow the muscle flap to seal theleak. Postoperatively, she continued to have a persistentbronchopleural air leak and developed rapidly progressivekyphoscoliosis, with loss of approximately 2.5 inches ofheight over 2 weeks. She was taken to the operating room forrevision of the latissimus flap to seal off the bronchopleuralfistula, reinsertion of lower profile posterior spinal hardware(T2 to L2 pedicle screw and rod fusion), and autograft fusionof the spine with a free fibula flap. A saphenous vein graftfrom her left leg was anastomosed as an arteriovenous loopfrom the residual stumps of her right subscapular vessels andtunneled subcutaneously to her back incision. The free fibulaflap from her right leg was 24 cm in length and anastomosedto the divided arteriovenous loop in her back after 5.5 hoursof ischemia. Two fibular osteotomies were performed tobetter conform the fibula to the fusion site along the rightside of her spine (Fig. 3). Postoperatively, she required in-sertion of additional endobronchial valves, but ultimately herbronchopleural fistula healed, as did all of her surgicalwounds (Fig. 4). A computed tomographic scan of her chest13 weeks postoperatively showed fusion of the fibula to thespine. She remains tumor-free 2 years postoperatively andthere is no clinical evidence of instability.

Case 2Patient 2 was a 13-year-old boy with a malignant peripheral

nerve sheath tumor of the skull base and upper cervicalspine. He had already undergone radiation therapy and che-motherapy, but a positron emission tomographic scan still

Fig. 2. A fibula flap alongside the decorticated lamina of the ver-tebral column. The vascular pedicle is seen anastomosed to thedivided arteriovenous loop of saphenous vein. Two fibular os-teotomies can be visualized.

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showed increased uptake in the region of the tumor, andbiopsy showed residual tumor. He was taken to the operatingroom for resection and reconstruction with posterior hard-ware and a vascularized fibula flap. Both anterior and pos-terior approaches were used for tumor resection, followed bya C1 laminectomy, removal of the C1 lateral mass and theoccipital condyle, and placement of posterior hardware fromthe occiput to C4. A saphenous vein graft was harvested fromthe left leg and anastomosed as an arteriovenous loop to abranch of the internal jugular vein and the external carotid

artery. This was tunneled subcutaneously to the posteriorneck and used for the anastomosis to the free fibula pedicle,which was harvested from the right leg. The fibula flap was24 cm in length, and two osteotomies were made to formthree struts that were set to stabilize the upper cervical spine.The anastomosis was performed without difficulty to thedivided arteriovenous saphenous loop after approximately30 minutes of ischemia. Postoperatively, the patient did welland there was radiographic evidence of bony fusion on acomputed tomographic scan of the cervical spine at 23 weekspostoperatively (Fig. 5). There was never any clinical evi-dence of instability. Fifteen months postoperatively, the cer-vical hardware started to erode through the irradiated skinand he was taken back to the operating room for hardwareremoval. The fibula was viable and the three struts were fusedas a sheet of bone to the cervical spinal column.

Case 3A 15-year-old boy with a C6 to T2 pilocytic astrocytoma and

a holocord syrinx underwent a C7 to T1 laminoplasty andneedle biopsy and was irradiated at an outside hospital. Hecontinued to have progressive kyphoscoliosis and deterio-rating neurologic symptoms. He underwent aggressive deb-ulking of the tumor to decompress the spinal cord and thesyrinx above and below the tumor. He was then taken backto the operating room for posterior spinal fusion to correcthis deformity and for a vascularized free fibula flap for bonyfusion. The patient underwent T6 and T7 vertebrectomieswith titanium cage placement, resection of multiple poste-rior ribs, and rod fusion from T1 to L2. Our team thenharvested the saphenous vein from the left leg and anasto-mosed it to the right facial artery and external jugular veinto form an arteriovenous loop, which was tunneled subcu-taneously to the posterior neck. Next, the right fibula washarvested as a 23-cm vascularized bone graft and anasto-mosed to the divided arteriovenous loop after approximately5 hours of ischemia. Two osteotomies were performed tobetter conform the fibula to the thoracic spine. Postopera-tively, the patient did well and showed radiographic evidenceof bony fusion on a computed tomographic scan of thecervical and thoracic spine at 11 weeks postoperatively.

DISCUSSIONStabilization and fusion of the spine after tu-

mor resection with multilevel partial or completevertebrectomies is of utmost importance. Fusioncan be achieved with instrumentation and allo-graft or nonvascularized autograft. However,this often fails in an irradiated environment, notonly because of poor osseous and soft-tissuehealing beds but also because of the increasedrisk of infection. Therefore, our indications forvascularized fibula grafting to the spine includemultilevel partial or complete vertebrectomies,poor osseous or soft-tissue bed secondary to ra-diation, or previous failed spine arthrodesis dueto infection. Vascularized bone grafting with afree fibula flap is performed in addition to spi-

Fig. 3. Diagrammatic illustration showing the free latissimusflap on the left sealing off the bronchopleural fistula, two fusionrods with pedicle screws in place, and the free fibula graft alongthe lamina on the right side of the vertebral column. The vascularpedicle is visualized, anastomosed to the saphenous vein graftsto the subscapular artery and vein.

Fig. 4. Case 1. Postoperative view of the patient showing well-healed incisions, no hardware exposure, and a stable spine with-out kyphoscoliosis.

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nal fusion with instrumentation. This allows forearlier and stronger osseous union. If the hard-ware erodes through the soft tissue or becomesinfected or painful, it can be removed, leavinga stable vertebral column because of the solidbony fusion, as evidenced in case 2.

The microvascular free fibula flap, with useof an arteriovenous saphenous vein loop to ei-ther the neck or the axilla, is our preferredmethod of reconstruction for posterior spinalstabilization and fusion. This vascularized flapworks especially well in an irradiated environ-ment, as was the case in all three of the pre-sented cases. The fibula provides a straight, longsegment of strong, bicortical bone. It can beeasily osteotomized at multiple intervals to bet-ter conform it to the curve of the spine.19 In eachof the three reported patients, it was necessaryto perform two osteotomies to form three seg-ments. These osteotomies do not weaken thebone or risk devascularization, provided thatthey are not closely spaced within a few centi-meters of each other (where a small segmentwould not be supplied by its own perforator)and do not disrupt the vascular pedicle on themedial side of the bone. A skin island can beharvested along with the bone (osteoseptocuta-neous fibula flap), but positioning the skin is-land would be difficult in these cases where thebone is buried against the vertebral column andcovered by paraspinous muscle and tissue.20

However, we often take a portion of the flexorhallucis longus muscle to fill in any soft-tissue

defect adjacent to the vertebral column. Post-operative monitoring of the pedicle is made easyby the nature of the saphenous vein graft pediclein the subcutaneous tunnel. A skin suture isapplied over the pedicle for examination usinga handheld Doppler probe by the nursing staff.If the pedicle is not easily examined with a Dopp-ler probe because of positioning of the patient,a Cook implantable Doppler device is applied tothe artery.21

The vascular anatomy of the lower leg is com-monly variable, with multiple different patternsof arterial branching.20,22 However, routine an-giographic evaluation of the vasculature in everypatient undergoing free fibula flap surgery isprobably not necessary or cost-effective, nordoes it have benefits that outweigh the risks.23

No preoperative angiographic imaging was ob-tained in any of the patients presented here. Allwere young and otherwise healthy, and had pre-operative palpable dorsalis pedis and posteriortibial pulses. However, during harvest of thefibula flap, before ligation of the distal peronealartery, a microvascular clamp is applied to theartery and pulses in the foot are again palpated.If both dorsalis pedis and posterior tibial pulsesin the foot are lost and cannot be palpated orexamined with the Doppler device while theperoneal artery is clamped, this may signify therare case of peroneus magnus, which would ne-cessitate bridging of the peroneal defect withanother saphenous vein graft.

In our series of three patients, there wascomputed tomography– documented bony fu-

Fig. 5. Case 2. (Left) Axial cross-section of the computed tomographic scan of the cervical spine of the patientshowing three struts of fibula graft with bony fusion to the apposing vertebral column. The fusion rods can also beseen on both sides of the vertebral body. (Right) Coronal cross-section of the patient showing fusion at the cephalicand caudal ends.

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sion of the fibula to the adjacent spinal columnat an average of 15.7 weeks (range, 11 to 23weeks) postoperatively. Considering that sur-veillance computed tomographic scans were notobtained on any regular basis, this time untilbony consolidation is not necessarily the earliesttime at which fusion occurred, but rather theearliest documented fusion in these three indi-vidual cases. This compares favorably with pre-vious reports on osseous consolidation after freefibula transfers.12,24 –26 We believe the key to suc-cessful fusion is based on our and the neuro-surgical team’s technique of insetting the fibulaonto the posterior vertebral column. The peri-osteum of the lateral fibula is elevated and theunderlying cortex is removed with a burr. Theapposing lamina on which the fibula is going torest is decorticated and the fibula is set in place.At the bony interfaces, demineralized bone ma-trix was applied in case 1, bone dust was appliedin case 2, and nothing was applied in case 3.Considering that the physis of the fibula is notincluded in the flap, we did not see longitudinalgrowth of the fibula with time along the spinalcolumn. In addition, because the fibula is notload-bearing in its position along the spine,there is stress shielding of the graft and there-fore no hypertrophy of the bone with time.

Our limited number of these procedures hasbeen successful, with no postoperative complica-tions, reoperations, or infections after fibula flapsurgery. Given the high rate of pseudoarthroseswith allograft and nonvascularized autograft,along with the relatively low morbidity of the freefibula flap, we now advocate using the vascularizedfibula graft at the time of the initial arthrodesis inpatients with extensive resections and a history ofprior radiation therapy.

CONCLUSIONSThe free fibula flap is ideally suited for accel-

erated posterior spinal fusion after extensive re-section of cervical or thoracic spinal neoplasms.Because of the high rate of failure of fusion in anirradiated field and the relatively low morbidity ofthe free fibula flap, the vascularized fibula onlaygraft is performed at the time of the radical re-section and instrumentation. This technique re-sults in a robust arthrodesis in a previously irra-diated vertebral column. An arteriovenoussaphenous vein loop facilitates the microvascularanastomosis in this anatomical region that lackssuitable recipient vessels.

CODING PERSPECTIVEThis information prepared by Dr. RaymondJanevicius is intended to provide codingguidance.

20955 Free fibula flap35231-51 Saphenous vein graft-artery35231-59 Saphenous vein graft-vein69990-59 Use of operating microscope

(for vein grafts)

• A fibular free flap is reported with code20955. This includes harvest and inset ofthe flap, closure of the donor and recipientsites, and microvascular anastomosis of theartery and vein.

• Code 20955 does not include vein grafting.Each saphenous vein graft is reported sep-arately with code 35231.

• Code 35231 is a macrovascular code. Useof the operating microscope for microvas-cular technique is reported with code69990.

• Since all free flap codes include the use ofthe operating microscope (69990), ap-pend modifier 59 to indicate that code69990 is not being used with code 20955,but is used to indicate use of the operatingmicroscope with code 35231.

Shareef Jandali, M.D.Division of Plastic Surgery

University of Pennsylvania Health System3400 Spruce Street

10 Penn TowerPhiladelphia, Pa. 19104

shareef.jandali@uphs.upenn.edu

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