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Vascularised fibula
Rodolfo Capanna M.D.
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206 VASCULARIZED BONE GRAFTS
AGE 2 - 65 (average 24)
ONCOLOGY: 148 (71%)
TRAUMATOLOGY: 58 (29%)
SITE: humerus 38
radius 10
ulna 7
metacarpal 1
femur 57
tibia 82
mandibolar 8
calcaneum 3
3838
77
8282
5757 11
33
1010
88
BONE LOSS: 6-23 Cm.
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DONOR SITES
Fibula: 196
Iliac crest: 7
Metatarsal: 1
M.F. joint : 1
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Male, 29 y
Osteoblastoma
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Follow-up
6 years
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Our experience with vascularized iliac crest graft
after calcanectomy for calcaneus tumors
3 cases (1999, 2001, 2005)
Age at surgery 18 - 29
Diagnosis:
No surgical complications
Free weight-bearing at 6 months Follow-up: average 60.3 months (20 89)
ISOLS/MSTS score: average 80% (53,3 93,3)
B. F. HistiocytomaOsteoblastoma
Giant Cell Tumor
2 total - 1 subtotal calcanectomy
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FIBULA
Taylor G. I. The free vascularized bone graft: a clinical extension of
microsurgical technique
Plast Recon Surg 1975
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V. FIBULA ALONE Good matching of diaphyseal diameter for upper limb
Sufficient mechanical resistance
Adequate length for intercalary defects
INDICATIONS
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FIBULA + ALLOGRAFT
Biologic potential of V.F. + allograft mechanical resistance
Very stable assembling for segments under weight bearing Fusion between two components at medium term
INDICATIONS
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AllograftVascularised fibula
Inadequate SizeLiving Tissue
HypertrophyFracturesBone Repair and Hypertrophy
Appropriate SizeMechanical Strenght
Creeping SubstitutionFracturesBone Resorption
Combination V.F. + Allograft
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march 1988
The history
Jenni .. 11 yrs..
osteosarcoma of the
meta-diaphyseal tibia
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1 m 2 y 5 y
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1 m
2 yr
5 yr
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november 1988
The history
Sara 8 yrsEwing sarcoma of the
meta-diaphyseal tibia
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3 m 2 y
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1993
The technique
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I i h l i
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Intra-epiphyseal resection
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I i h l i
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Intra-epiphyseal resection
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I t i h l ti
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Intraepiphyseal resection
11 y11 y1 y1 y
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3 m 7 y
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COMPLICATIONS
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COMPLICATIONS
Valgus deformity
of the ankle: 3 (2.6%)
Flexor tendons
retraction: 6 (5.2%)
Extensor tendons
retraction: 1 (0.8%)
DONOR SITE
Vascularized fibular diaphysis
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V l d f it 2 6%
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Valgus deformity 2.6%
Distal 6 cm. should
be preserved
T.F. synostosis is not able
to prevent valgus def.(Kanaya 2002)
Due to: - Proximal migration of the fibula
- Valgus ankle instability
- Inhibition of the growth of the
lateral part of tibial epiphysis
*
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Fl t d t ti 5 2%
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Flexor tendons retraction 5.2%
Early complication (2-3 m.)
Treatment: lengthening of
involved tendons
Due to: - Adhesion of F.H.L. to the musclesof posterior compartment
- Ischemic retraction of F.H.L.
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DIAPHYSIS
COMPLICATIONS
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Fracture: 20 (17,5%) Non Union: 12 (10,5%)
Infection: 5 (4,3%)
Soft T. necrosis: 4 (3,5%)
Microvascular failure: 4 (3,5%)
Peroneal nerve palsy: 1 (0,8%)
DIAPHYSISCOMPLICATIONS
RECIPIENT SITE
Vascularized fibular diaphysis
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Fractures Lower Extremity 1
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Fractures Lower Extremity 1
VFG Alone
29 CASES : 9 FRACTURES (31%)all healed conservatively
2 m2 m 1 y1 y 2 y2 y 4 y4 y 10 y10 y
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Fractures Lower Extremity 2
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y
VFG + Massive Allograft
61 CASES: 6 FRACTURES (9.8 %)4 healed conservatively2 surgery
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Biologic properties of vascularized bone allow an early
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healing of fracture when a stable osteosynthesis is present
3 m.
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FRACTURES
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FRACTURES
20/114 17,5 %
20 healed 100 % 3 secondary procedures 15 %
Overall
fracture rate17,5%
Upper limb
29%
Lower limb
17%
VF alone
31 %
VF + allograft
9.8 %
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COMPLICATIONS RECIPIENT SITE
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NON UNION: 12 (10,5%)
All healed after secondary procedures
COMPLICATIONS RECIPIENT SITE
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COMPLICATIONS DIAPHYSIS
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COMPLICATIONS
Soft tissue necrosis: 4 (3,5%)
DIAPHYSIS
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COMPLICATIONS DIAPHYSIS
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COMPLICATIONS
Microvascular failure: 4 (3,5%)
DIAPHYSIS
3 amputations
1 Ilizarov
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COMPLICATIONS DIAPHYSIS
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COMPLICATIONS
Microvascular failure: 4 (3,5%)
3 amputations
1 Ilizarov
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BLOOD SUPPLY
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Taylor:
A.T.A. is able to supply the
epiphysis by an epiphyseal
branch and the proximal 2/3 of
the diaphysis by means of tiny
musculoperiosteal branches
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Reconstruction of the radius
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Osteosynthesis: platesOsteosynthesis: plates
Anastomosis: R.A./A.I.A.Anastomosis: R.A./A.I.A.
Ligaments reconstructionLigaments reconstruction
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Results: radius
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Female Osteosarcoma
8 yrs. at surgery
7 yrs. F.U.
1 yr
4 yrs
TOTAL GROWTH: 5.2 cm
GROWTH RATE: 0.75 cm/yr
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FUNCTIONAL OUTCOME
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Reconstruction of the humerus
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Reconstruction of the humerus
Osteosynthesis: platesOsteosynthesis: plates
Anastomosis: D.B.A./B.A.Anastomosis: D.B.A./B.A.
Ligaments reconstructionLigaments reconstruction
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Results: humerus
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3 yrs.
Male
5 yrs at surgery
3 yrs F.U.
Total growth: 3.2cm.
Growth rate: 1.06
cm/y
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COMPLICATIONS
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Temporary palsy peroneal n. : (56%)
Permanent deficit E.H.L., E.D.C : (8%)
Permanent deficit T.A.: (4%)
Ankle instability : (4%) Knee instability : 0
Premature closure of the G.P.: (20%)
Fractures : (20%)
Subacromial displacement : (16%)
Non union : 0
Infection : 0
DONOR
SITE
RECIPIENT
SITE
VF with growth plate
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Premature closure of growth plate 20%
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Postop
F.U. 8 y.
2 cases supplied by peroneal A. 3 cases with damage to rec. branch A.T.A.
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Fracture 20%
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Torsion stress Break point: proximal
screw
Excessive stiffness of
implant
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S l ti
Fracture 5
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Solution:
Elastic implant Reconstruction plates
Long plates, few screws
Locking Compression Plate
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Subacromial displacement 16%
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EVOLUTION OF
VASCULARIZED BONE GRAFTS
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VASCULARIZED BONE GRAFTS
Fusion
Hypertrophy
Remodelling
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FUSION
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Vascularized bone preserves more than double
vital osteocytes than a non vascularized bone
Arata, J Recon Micro 1994
Vascularized bone preserves endostal and periosteal
vascularization favouring fusion by a mechanism similar
to common fracture healing
Zdeblick T.A. Clin Orthop 1988
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FUSION
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IntraopIntraop.. 3 m3 m 8 m8 m 12 m12 m
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FUSION
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1 m. 5 m.
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FUSION
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FUSION
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3 m. 12 m.
Vascularized fibula and its periosteum promotes allograftfusion even in case of insufficient contact
(osteotomy gap > 2mm)
18 m.
Fibula
Allograft
Femur
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Vascularized Fibula
Fractures
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20/114 (17,5 %)
20 fusion (100 %)
3 surgical revision (15 %)
Firenze
114 cases
Kasashima
62 cases
Arai
60 cases
Lee
46 cases
El Gammal
25 cases
Fracture Tot 17,5 % 24 % 22% 39 % 12 %
Upper limb 29 % 14% 11 % / /
Lower limb 17 % 40 % 24.5 % 39 % 12 %
The introduction of combined technique (allograft+ V.F.)
markedly decreased the incidence of fractures in weight bearing segments
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EVOLUTION OF
VASCULARIZED BONE GRAFTS
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VASCULARIZED BONE GRAFTS
Fusion
Hypertrophy
Remodelling
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Hypertrophy
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HYPERTROPHY
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6 m 5 aa
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In a long bone hypertrophy
occurs expecially at cortical level
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Osteogenic action
of vascularized periosteum
Biologic response to theincreasing mechanical stress
Hypertrophy up to reach
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HYPERTROPHY
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1 m1 a 4 a
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HYPERTROPHY
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Stress fractures are relatively common and
proportional to weight bearing
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2 m2 m 1 y1 y 2 y2 y 4 y4 y 10 y10 y
Their healing with hypertrophyc callus contributes
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Combination V.F. + Allograft
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Progressive fibular hypertrophy
favours a gradual integration between two components
3 y 7 y
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3 y. 7 y
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Open allograft, unstable osteosynthesis
Postop. 3 y. . 8 y.
1
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Early fusion with host bone Progressive allograft resorption
Fibular hypertrophy and allograft internal repair
Postop. 6 y.
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Early fusion with host bone Progressive allograft resorption
Fibular hypertrophy and allograft internal repair
Postop. 6 y.
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Open allograft , stable osteosynthesis2
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No allograft resorption Slow fibular hypertrophy and fusion with allograft
Postop. 2 y.
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No allograft resorption Slow fibular hypertrophy and fusion with allograft
2 y. 5 y.
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EVOLUTION OF
VASCULARIZED GRAFTS
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Fusion
Hypertrophy
Remodelling
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Morphologic remodelling potential
is very high in pediatric age
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2 m. 4 m. 12 m.
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9 years old
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4 m4 yrs
Osteosarcoma
Resection: 7 cm.
F.U. 4 years
TOTAL GROWTH : 3.3 cm.AVERAGE GROWTH : 0.82 cm/yr
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Proportional growth
of neoradius with omolateral ulna
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7 y. 3 y. 5 y.
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Eterotopic fibula Ortotopic fibula
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R G : 4 years oldR G : 4 years old
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R.G.: 4 years oldR.G.: 4 years old
Ewing SarcomaEwing Sarcoma
proximal femurproximal femur
IntraIntra--articular resectionarticular resection
Reconstructive objectives
Articular function recovery
Growth potential recovery
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R G : 4 years oldR G : 4 years old
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R.G.: 4 years oldR.G.: 4 years old
Ewing SarcomaEwing Sarcoma
proximal femurproximal femur
IntraIntra--articular resectionarticular resection
Reconstructive objectives
Articular function recovery
Growth potential recovery
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1. Allograft epiphysis resection
2. A groove is created on theallograft
3. Fibular osteotomy
4. Concentric assembling
5. Step-cut osteotomy
6. Stable osteosynthesis
7. Circumflex vessels anastomosis
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1. Allograft epiphysis resection
2. A groove is created on theallograft
3. Fibular osteotomy
4. Concentric assembling
5. Step-cut osteotomy
6. Stable osteosynthesis
7. Circumflex vessels anastomosis
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1. Allograft epiphysis resection
2. A groove is created on theallograft
3. Fibular osteotomy
4. Concentric assembling
5. Step-cut osteotomy
6. Stable osteosynthesis
7. Circumflex vessels anastomosis
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Fast healing Allograft V.F. integration
Longitudinal growth
Epiphyseal remodelling
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Postop.2 m.
8 m.
18 m.
4 Yrs.Postop.
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POSSIBLE FUTURE
PROSPECTIVES
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Stem cells
Periostium
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VASCULARIZED FIBULA +TIBIAL PERIOSTEUM
Male 22 years
Femoral open fracture with 18 cm bone loss
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Comminuted open fracture of omolateral tibia and fibula
Reconstruction with controlateral V.F. + tibial periosteum + chronOS + stem cells
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VASCULARIZED FIBULA +TIBIAL PERIOSTEUM
Male 22 years
Femoral open fracture with 18 cm bone loss
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Comminuted open fracture of omolateral tibia and fibula Reconstruction with controlateral V.F. + tibial periosteum + chronOS + stem cells
Tibia
Perone
M. Interossea
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VASCULARIZED FIBULA +TIBIAL PERIOSTEUM
Male 22 years
Femoral open fracture with 18 cm bone loss
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Comminuted open fracture of omolateral tibia and fibula Reconstruction with controlateral V.F. + tibial periosteum + chronOS + stem cells
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VASCULARIZED FIBULA +TIBIAL PERIOSTEUM
Male 22 years
Femoral open fracture with 18 cm bone loss
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Comminuted open fracture of omolateral tibia and fibula Reconstruction with controlateral V.F. + tibial periosteum + chronOS + stem cells
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VASCULARIZED FIBULA +TIBIAL PERIOSTEUM
Male 22 years
Femoral open fracture with 18 cm bone loss
C i d f f l l ibi d fib l
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Comminuted open fracture of omolateral tibia and fibula Reconstruction with controlateral V.F. + tibial periosteum + chronOS + stem cells
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VASCULARIZED FIBULA +TIBIAL PERIOSTEUM
Male 22 years
Femoral open fracture with 18 cm bone loss
C i t d f t f l t l tibi d fib l
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Comminuted open fracture of omolateral tibia and fibula Reconstruction with controlateral V.F. + tibial periosteum + chronOS + stem cells
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VASCULARIZED FIBULA +TIBIAL PERIOSTEUM
Male 22 years
Femoral open fracture with 18 cm bone loss
Commin ted open fract re of omolateral tibia and fib la
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Comminuted open fracture of omolateral tibia and fibula Reconstruction with controlateral V.F. + tibial periosteum + chronOS + stem cells
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VASCULARIZED FIBULA +TIBIAL PERIOSTEUM
Male 22 years
Femoral open fracture with 18 cm bone loss
Comminuted open fracture of omolateral tibia and fibula
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Comminuted open fracture of omolateral tibia and fibula Reconstruction with controlateral V.F. + tibial periosteum + chronOS + stem cells
F.U. 7 m
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