We present our experience with reconstruction after resection of tumors around the knee, using free vascularized fibular grafting. The study included 23 patients. The lower femur was involved in 17 cases, the upper tibia in 6. The cases included giant cell tumor of the lower femur (2 patients), giant cell tumor of the upper tibia (1 patient), malignant fibrous histiocytoma of the lower femur (1 patient), parosteal osteosarcoma (1 patient), and periosteal osteosarcoma (1 patient). The remaining patients suffered from conventional osteogenic sarcomas. The size of the defect ranged from 12 to 16 cm in length. Skin flap necrosis after tumor resection was the most common complication encountered. Other complications included peroneal nerve involvement in one case and rupture of the arterial anastomosis in another. All transferred fibulas progressed to union within 7–9 months. Union time of both upper and lower ends of the fibula and time of appearance of periosteal reaction were identical. In evaluating periosteal hypertrophy of the fibula, the hypertrophy (de Boer) index (de Boer HD, Wood MB, J Bone Joint Surg 1989;71B:374–378) proved unreliable. False positive results are obtained, when callus formation around the lower end of the femur is far more abundant than at the upper end of the fibula. For this reason, we introduced the graft index. The latter is the ratio between the diameter of the graft at its thinnest portion at latest follow‐up to its diameter on the day of operation, as calculated on plain radiographs. Two of the viable fibulas developed stress fractures after plate removal. Functional and quality‐of ‐life results were satisfactory. It is concluded that the free vascularized fibular graft remains a valuable reconstruction option after the resection of tumors around the knee, provided certain precautions are followed. First, before closure of the wound, the skin flaps should be assessed for their viability. Necrotic parts should be excised. Stable fixation is a necessary prerequisite at the time of operation. Removal of the fixation device should not be guided by union or periosteal hypertrophy, but by true widening of the medullary canal. © 2000 Wiley‐Liss, Inc. MICROSURGERY 20:233–251 2000

Rolando fracture is one of the most difficult fractures facing hand surgeons. It can be described as a Y- or T-shaped fracture line that runs longitudinally through the metaphyseal area, with an intra-articular fracture splitting the metacarpal base fragment into a volar and a dorsal fragment. In this study, we introduce our technique used in the management of 7 cases, which were treated by our dynamic external fixation. The results were found to be promising, with an excellent range of motion and power grip postoperative. The joints spaces were restored. No patients in our series developed arthritic changes. All patients are pain free in 3 months.

The potentialities, limitations, and technical pitfalls of the vascularized fibular grafting in infected nonunions of the tibia are outlined on the basis of 14 patients approached anteriorly or posteriorly. An infected nonunion of the tibia together with a large exposed area over the shin of the tibia is better approached anteriorly. The anastomosis is placed in an end-to-end or end-to-side fashion onto the anterior tibial vessels. To locate the site of the nonunion, the tibialis anterior muscle should be retracted laterally and the proximal and distal ends of the site of the nonunion debrided up to healthy bleeding bone. All the scarred skin over the anterior tibia should be excised, because it becomes devitalized as a result of the exposure. To cover the exposed area, the fibula has to be harvested with a large skin paddle, incorporating the first septocutaneous branch originating from the peroneal vessels before they gain the upper end of the flexor hallucis longus muscle. A disadvantage of harvesting the free fibula together with a skin paddle is that its pedicle is short. The skin paddle lies at the antimesenteric border of the graft, the site of incising and stripping the periosteum. In addition, it has to be sutured to the skin at the recipient site, so the soft tissues (together with the peroneal vessels), cannot be stripped off the graft to prolong its pedicle. Vein grafts should be resorted to, if the pedicle does not reach a healthy segment of the anterior tibial vessels. Defects with limited exposed areas of skin, especially in questionable patency of the vessels of the leg, require primarily a fibula with a long pedicle that could easily reach the popliteal vessels and are thus better approached posteriorly. In this approach, the site of the nonunion is exposed medial to the flexor digitorum muscle and the proximal and distal ends of the site of the nonunion debrided up to healthy bleeding bone. No attempt should be made to strip the scarred skin off the anterior aspect of the bone lest it should become devitalized. Any exposed bone on the anterior aspect should be left to granulate alone. This occurs readily when stability has been regained at the fracture site after transfer of the free fibula. The popliteal and posterior tibial vessels are exposed, and the microvascular anastomosis placed in an end-to-side fashion onto either of them, depending on the length of the pedicle and the condition of the vessels themselves. To obtain the maximal length of the pedicle of the graft, the proximal osteotomy is placed at the neck of the fibula after decompressing the peroneal nerve. The distal osteotomy is placed as distally as possible. After detaching the fibula from the donor site, the proximal part of the graft is stripped subperiosteally, osteotomized, and discarded. Thus, a relatively long pedicle could be obtained. To facilitate subperiosteal stripping, the free fibula is harvested without a skin paddle. In this way, the use of a vein graft could be avoided. Patients presenting with infected nonunions ...

We are presenting our experience with vascularized epiphyseal transplantation of the upper end of the fibula, based distally on the anterior tibial artery in two patients, one suffering from septic epiphysitis of the hip with complete loss of the head and neck of the femur, the other suffering from radial club hand following septic loss of the radius, excluding its proximal and distal articular segments. In the first patient, the fibular epiphysis bridged the bone defect and provided growth at the neck of the femur. This restored hip stability, reduced limb-length discrepancy, initiated some degree of acetabular development, and maintained a functional range of hip motion. In the second patient, transplantation of the upper end of the fibula was used to bridge a gap resulting from complete resorption of the right radius and provide for growth of the radius. At follow-up, complete union of the graft was noted. The club-hand appearance improved markedly. Pronation and supination were regained. However, donor-site morbidity was a problem. It included sloughing of part of the peroneal muscles and the skin edge of the incision. This was due to loss of the anterior tibial artery as well as injury to the peroneal vessel collaterals supplying the skin and peroneal muscles. The latter occurred due to opening of the posterior compartment of the leg in an attempt to locate the anterior tibial artery at its origin from the popliteal artery. It is therefore concluded, that transplantation of the upper end of the fibula is a valuable reconstructive alternative for septic epiphysitis with complete loss of the head and neck of the femur as well as for septic loss of the radius. However, whenever an extended part of the upper end of the fibula needs being harvested, this should be performed through an anterior approach, in order to avoid sloughing of the skin and muscles of the anterior and lateral compartments of the leg.