Free vascularised fibular grafts in orthopaedics

Abstract

Bony defects caused by trauma, tumors, infection or congenital anomalies can present a significant surgical challenge. Free vascularised fibular bone grafts (FVFGs) have proven to be extremely effective in managing larger defects (longer than 6 cm) where other conventional grafts have failed. FVFGs also have a role in the treatment of avascular necrosis (AVN) of the femoral head, failed spinal fusions and complex arthrodeses. Due to the fact that they have their own blood supply, FVFGs are effective even in cases where there is poor vascularity at the recipient site, such as in infection and following radiotherapy. This article discusses the versatility of the FVFG and its successful application to a variety of different pathologies. It also covers the applied anatomy, indications, operative techniques, complications and donor-site morbidity. Though technically challenging and demanding, the FVFG is an extremely useful salvage option and can facilitate limb reconstruction in the most complex of cases.

Vascularized versus Nonvascularized Bone Grafts: What Is the Evidence?

“…It is our understanding that a statement by Weiland et al [53] in the 1983 article on 41 VBGs to long bone defects in which VBGs were said to ''offer significant advantages… [for] defects greater than 6 cm'' has been interpreted to mean that VBGs have been proven to be superior to NVBGs at those lengths. The 6-cm rule has proliferated from that point and modern reviews of grafts for long-bone and large-joint reconstructions decades later still quote the rule [9,44]. This rule may have biased subsequent studies that examine length, by encouraging the use of length categories that use 6 cm as a boundary, rather than analyzing the data without prejudice.…”

“…This may translate to a longer or incomplete recovery. In practice and in modern research studies, defects larger than 5 to 7 cm generally have not been considered candidates for NVBGs [9,20,44]. However, the origin of the 6-cm rule is not readily apparent in those studies, which point to an array of articles that do not present relevant evidence (Fig.…”

“…1). A review of fibular VBGs published in 2014 recommends that defects greater than 6 cm be treated with VBGs [9]. However, the two references in the article used to support that argument [21,57] reveal no origin for this recommendation.…”

“…In seeking evidence for the need for VBGs greater than a specific length, two obstacles frequently are encountered: the citation of secondary sources and qualitative descriptors of length. Similar to a 2014 review [9], a 2013 review of VBGs states that defects greater than 5 to 6 cm require VBGs [44]. However the source, a review article does not mention a centimeter-based rule for bone grafts [28].…”

Free Vascularized Fibular Graft Transfer in the Reconstruction of Defects for Premalignant and Malignant Musculoskeletal Conditions of the Femur in a Tertiary Care Setting in Pakistan: A Series of Six Cases

“…In 1975, Taylor et al introduced the first FVFG in a limb salvage procedure after a trauma, which revolutionized the procedure worldwide thereafter [2]. Since then, over 600 published articles have been cited on PubMed pertaining to FVFG being the most commonly used free vascularized bone graft [3]. Currently, FVFG has been utilized for the treatment of bony defects resulting from congenital anomalies, infection, tumors, avascular necrosis of the femoral head, and traumatic salvage procedures [3].…”