Pediatric extremity bone sarcoma reconstruction with the vascularized fibula flap: Observational study assessing long-term functional outcomes, complications, and survival

Ruiz-Moya, Alejandro; Lagares-Borrego, Araceli; Sicilia-Castro, Domingo; Barrera-Pulido, Fernando; Gallo-Ayala, J.M.; Santos-Rodas, A.; Hernández-Beneit, J.M.; Carvajo-Perez, Francisco; Gómez-Ciriza, Gorka; Gómez-Cía, Tomás

doi:10.1016/j.bjps.2019.08.009

Cited by 14 publications

(9 citation statements)

References 25 publications

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“…Our 44.8% overall complication rate is similar to that reported by other studies within the pediatric population (25-100%). 4,7,12,14,17,[20][21][22][23][24][25][26][27][29][30][31][32][33][34][35][36][37] One exception is our rate of neurologic injury (3.4%), which is much lower than other published reports. While most frequently seen as a donor-site complication, the single neurologic complication in our series was in the recipient site, where the patient experienced a deep peroneal nerve palsy secondary to postoperative swelling.…”

Section: Discussionmentioning

confidence: 91%

Surgical Outcomes, Complications, and Long-Term Functionality for Free Vascularized Fibula Grafts in the Pediatric Population: A 17-Year Experience and Systematic Review of the Literature

McCullough

Arkader

Ariani

et al. 2020

J Reconstr Microsurg

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Background In the pediatric population, bony defects of the extremities pose a significant challenge for which free vascularized fibular grafts (FVFGs) represent a valuable reconstructive option. The purpose of this study was to explore surgical outcomes, complications, and long-term functionality of FVFG for this patient group. Methods Using MEDLINE and PubMed databases, studies were identified of pediatric extremity reconstruction using FVFG which reported functional outcomes and/or complications. The operative logs at a tertiary pediatric center were then reviewed for cases of FVFG between January 2000 and 2017. Demographic characteristics, surgical indications, operative details, graft survival, bony union, complications, and functionality of the reconstruction were recorded. Results A total of 366 studies were identified with 23 ultimately meeting inclusion criteria in the systematic review. In the institutional series, 29 patients were included with mean age of 9.7 years (1–17 years). Indications for reconstruction included malignant bone tumor (n = 11), osteomyelitis (n = 9), congenital pseudoarthrosis (n = 6), and osteofibrous dysplasia (n = 3). Major postoperative complications included graft nonunion (24.1%), fracture (17.2%), and hardware failure (17.2%). Thirteen patients (44.8%) experienced delayed complications, while two (6.8%) experienced an immediate complication. Complications occurred in the donor site in 2 cases and the recipient site in all 13 cases. Long-term graft survival was achieved in 27 patients (93.1%), and 23 (79.3%) had full functional recovery, with an average Musculoskeletal Tumor Society score of 90% (60–100%). Mean follow-up was 5.17 years (2–12 years). Conclusion This review and institutional series demonstrate the versatility of FVFG to facilitate limb reconstruction in large defects or serve as a salvage option in complex cases. While immediate and donor-site complications are uncommon, delayed recipient-site complications are frequent, and patients and families should be counseled regarding this expectation. Though technically challenging, excellent long-term graft viability and functional recovery can be achieved in the large majority of patients.

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Section: Discussionmentioning

confidence: 91%

Surgical Outcomes, Complications, and Long-Term Functionality for Free Vascularized Fibula Grafts in the Pediatric Population: A 17-Year Experience and Systematic Review of the Literature

McCullough

Arkader

Ariani

et al. 2020

J Reconstr Microsurg

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“…Other smaller series reported less consistent union rates, ranging from 60% to 100%, with the use of traditional treatment methods for non-complex cases (Adamczyk and Riley, 2005; Ballal et al., 2009; Looi et al., 2017). For difficult scenarios, including nonunion related to bone tumours, large bone defects, infection, long-standing nonunions and previous failed treatment, the use of vascularized bone grafts have significantly enhanced union rates (Cano-Luís et al., 2018; Ruiz-Moya et al., 2019). Similar to bone grafts, the use of vascularized periosteal grafts in our series achieved a union rate of 100%, even when encountering difficult cases involving long-standing nonunion or following open fractures or malignant tumour resection.…”

Section: Discussionmentioning

confidence: 99%

“…Although several methods have been described to treat nonunions, the rate of complications remain significant, including radioulnar synostosis, radial nerve palsy, myositis ossificans, olecranon bursitis and residual elbow stiffness (Di Gennaro et al., 2017; Ruiz-Moya et al., 2019). In our series, we achieved pain relief associated with excellent functional outcomes, indicating statistically and clinically significant improvements in patients’ QuickDASH score and grip strength.…”

Section: Discussionmentioning

confidence: 99%

Vascularized ulnar periosteal pedicled flap for forearm nonunion in children

Sapage

Alabau-Rodriguez

Muñoz-Perdomo

et al. 2021

J Hand Surg Eur Vol

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We report our experience with the use of a vascularized ulnar periosteal pedicled flap to treat forearm nonunion in children. Seven children underwent surgical treatment of radial diaphysis nonunion with this technique. The mean duration of nonunion prior to the flap was 9 months. Significant postoperative improvements were observed in pain severity (mean visual analogue scale score of 0.6), Quick Disabilities of the Arm, Shoulder, and Hand (mean score of 7.1) and grip strength (89% higher than preoperative status). Union was achieved in all patients, with a mean time to union of 3 months. One patient developed distal radioulnar synostosis as a postoperative complication. A vascularized ulnar periosteal pedicled flap is a reliable and versatile technique for treating forearm nonunion in children, associated with both good outcomes and low donor morbidity. Level of evidence: IV

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“…These cases often require staged and time-consuming procedures such as the inducedmembrane technique developed by Masquelet [3,4] or distraction osteogenesis (DO) pioneered by Ilizarov [5][6][7][8]. In addition, other options including autogenous vascularized fibula grafts [9], intercalary endoprostheses [10], and structural allografts [11][12][13][14][15] are associated with unique complications that limit patient outcomes and lead to re-operation or failure of limb-salvage.…”

Section: Introductionmentioning

confidence: 99%

Mechanical strain induces ex vivo expansion of periosteum

et al. 2022

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Segmental bone defects present complex clinical challenges. Nonunion, malunion, and infection are common sequalae of autogenous bone grafts, allografts, and synthetic bone implants due to poor incorporation with the patient’s bone. The current project explores the osteogenic properties of periosteum to facilitate graft incorporation. As tissue area is a natural limitation of autografting, mechanical strain was implemented to expand the periosteum. Freshly harvested, porcine periosteum was strained at 5 and 10% per day for 10 days with non-strained and free-floating samples serving as controls. Total tissue size, viability and histologic examination revealed that strain increased area to a maximum of 1.6-fold in the 10% daily strain. No change in tissue anatomy or viability via MTT or Ki67 staining and quantification was observed among groups. The osteogenic potential of the mechanical expanded periosteum was then examined in vivo. Human cancellous allografts were wrapped with 10% per day strained, fresh, free-floating, or no porcine periosteum and implanted subcutaneously into female, athymic mice. Tissue was collected at 8- and 16-weeks. Gene expression analysis revealed a significant increase in alkaline phosphatase and osteocalcin in the fresh periosteum group at 8-weeks post implantation compared to all other groups. Values among all groups were similar at week 16. Additionally, histological assessment with H&E and Masson-Goldner Trichrome staining showed that all periosteal groups outperformed the non-periosteal allograft, with fresh periosteum demonstrating the highest levels of new tissue mineralization at the periosteum-bone interface. Overall, mechanical expansion of the periosteum can provide increased area for segmental healing via autograft strategies, though further studies are needed to explore culture methodology to optimize osteogenic potential.

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Pediatric extremity bone sarcoma reconstruction with the vascularized fibula flap: Observational study assessing long-term functional outcomes, complications, and survival

Cited by 14 publications

References 25 publications

Surgical Outcomes, Complications, and Long-Term Functionality for Free Vascularized Fibula Grafts in the Pediatric Population: A 17-Year Experience and Systematic Review of the Literature

Surgical Outcomes, Complications, and Long-Term Functionality for Free Vascularized Fibula Grafts in the Pediatric Population: A 17-Year Experience and Systematic Review of the Literature

Vascularized ulnar periosteal pedicled flap for forearm nonunion in children

Mechanical strain induces ex vivo expansion of periosteum

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