Composite-Free Vascularized Fibular Epiphyseal Flap and Proximal Humeral Allograft for Proximal Humerus Reconstruction in a Pediatric Patient

Abstract

Tumors involving the epiphysis in children present a reconstructive challenge. A free vascularized fibula epiphyseal transfer offers a means for biological reconstruction and longitudinal growth; however, it is often complicated by graft fracture and limited shoulder motion. Here, we present a case of a composite structural allograft with free vascularized fibula epiphyseal transfer for proximal humeral reconstruction. At 27-month follow-up, there was longitudinal growth, hypertrophy of the epiphysis, shoulder function which allowed activities of daily living, and no graft fracture.

Vascularized Fibular Epiphyseal Transfer for Pediatric Limb Salvage: Review of Applications and Outcomes

“…Oncologic indications most commonly included osteosarcoma and Ewing sarcoma. 2,3,5,6,[8][9][10][12][13][14][16][17][18][19]21,[23][24][25]27,[31][32][33][36][37][38]40 Congenital deformities included radial longitudinal deficiency and ulnar pseudarthrosis. 19,22,23,27,30,35 Traumatic injuries involved the lateral malleolus, calcaneus, radius, and ulna.…”

“…The anterior tibial artery (ATA), which supplies the proximal two-thirds of the fibula as detailed by Taylor et al, 43 was the predominant vascular pedicle harvested. 2,3,7,10,[12][13][14][15][16][17][19][20][21]24,26,31,35,36,40,42 Dissection of the ATA was challenging due to its close relation with the deep peroneal nerve and the fragility of its short recurrent epiphyseal branch that supplies the fibular head. The ATA was often applied in a reverse flow manner to provide a longer pedicle during flap inset without necessitating a vein graft.…”

“…3,8,17,20 To prevent secondary knee instability after fibula harvest, the lateral collateral ligament and remaining biceps femoris tendon were reinserted to the proximal lateral tibia. 10,13,[15][16][17] To maintain ankle stability after VFET harvest, a general guideline is to preserve the distal 6 cm of fibula. 46 In addition, a syndesmotic screw to secure the remaining fibula to the tibia distally can be used to prevent and/or delay valgus deformity of the ankle.…”

“…The predominant method of fixation was the combined use of plates and screws. 9,[12][13][14]17,20,23,29,30,32,33,36,37,40 Although a plate bridging the flap may provide stable fixation to maintain postoperative alignment, there has been concern that it can interrupt the blood supply and prevent flap thickening over time. 29 Several cases therefore involved fixation with screws alone.…”

“…5,25,26 Following inset of VFET at the recipient site, muscle reattachment and soft tissue reconstruction were performed to support the reconstructed joint. 13,18,37 Examples of ligamentous reconstruction using the biceps femoral tendon included wrapping it around the coracoid process of the scapula or anchoring it to the glenoid capsule for shoulder stabilization, 3,10,14 weaving it into the residual capsule to stabilize the radiocarpal joint in distal radius and ulna reconstruction, 8,22,23 helping reconstruct calcaneal ligaments in ankle reconstruction, 15,20,31 and suturing it into the remaining capsular ligament of the TMJ in mandible reconstruction. 17 Postoperative protocols entailed immobilization followed by rehabilitation with progressive range of motion…”