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10 Year Experience of Composite Trunk and Extremity Reconstruction with Vascularized Fibula Flap
Mark W. Clemens, MD, Edward I. Chang, MD, Scott D. Oates, MD, David W. Chang, MD.
MD Anderson Cancer Center, Houston, TX, USA.
Purpose: Reconstruction after resection of primary bone sarcomas of the trunk and extremities has been traditionally associated with significant challenges in obtaining reliable long-term functional outcomes. At our institution, vascularized fibula flap transfer has been used as a standard of care for reconstruction in patients following resection of bone sarcomas of the trunk and extremities, particularly in patients receiving adjunct chemotherapy and/or radiation, to improve bone healing and to optimize functional return.
Methods: From 2001 to 2010, 52 consecutive patients received vascularized fibula flaps for trunk and extremity reconstruction. Indications and outcomes were assessed including preoperative and postoperative adjunct therapy, co-morbidities, complications, bone union, functional assessment of reconstructions, local recurrence, metastasis, and survival.
Results: 52 patients (mean age 32, range 7 to 69, 25 females, 27 males) received 53 vascularized fibula flaps for trunk (n=19), lower (n=21) and upper (n=13) extremity composite reconstructions immediately following tumor extirpative surgery. Indications included sarcoma (n =47), allograft nonunion (n =7), osteomyelitis (n=1), congenital (n=1), and lymphoma (n=1). Spinal defects were reconstructed using an onlay technique (n=3), extremity segmental bone defects were reconstructed using either an intramedullary (n=14) or an onlay technique (n=20), and pelvic ring defects were reconstructed with double barrel struts (n=16). Growth plate transfer with vascularized fibula were used for pediatric patients (n=5). Adjunct therapy included preoperative (n=40) and postoperative (n=30) chemotherapy and preoperative (n=7) and postoperative (n=5) radiation treatment. Reconstructed areas included femur, tibia, humerus, ulna, spine, sacrum and iliac bone. Pedicled flaps (n=5) were utilized for tibia defects. Fibular flaps were either harvested as bone only (n=44) or osteocutaneous (n=9). Flap survival was 100 percent. Three patients required emergent reexploration (5.6%), one for hematoma (1.8%) and two for thrombosis (3.8%). Mean follow-up time was 36.8 months. Complications included delayed wound healing (7.5%), infection (1.8%), hardware failure (1.8%), and bony non-union (5.6%). Local disease recurrence was 1.8%, with pulmonary metastases (5.6%), and seven patients died of disease (13.4%). Bony unions were achieved in 94.4% of patients with mean-time for bone union of 3 months (range, 1.5 to 4 months). In trunk (spine/pelvis) patients, 100% of patients were able to ambulate, although 5 patients required support. In the upper extremity patients, 100% of patients were able to use their reconstructed limb; in lower extremity patients, 19/21 (90.5%) patients were ambulating with full-weight bearing at the time of the study.
Conclusions: We present our 10-year experience utilizing the free fibula flap for limb salvage and composite tissue reconstruction. The unique characteristics of the vascularized fibula flap afford a diverse number of applications for complex composite defects. Within this difficult patient population, reconstructions with vascularized fibula flaps can result in a high rate of bone union, decreased time of healing, good functional outcomes, while sparing debilitating amputations, facilitating early ambulation, and improving patient quality of life.
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