Vascularized Fibula-Based Physis Transfer: A Follow-Up Study of Longitudinal Bone Growth and Complications

Abstract

Background: The vascularized free fibula epiphyseal transfer provides an option for the preservation of limb lengthening after resection of the proximal humerus in pediatric sarcoma patients. The purpose of this study was to provide a long-term follow-up of longitudinal growth patterns and outcomes after free fibula epiphyseal transfer in upper extremity reconstruction.

Methods: A retrospective review of 4 patients who underwent free fibula epiphyseal transfer after oncologic resection of the proximal humerus for osteosarcoma was performed. Oncologic details that could affect outcomes were included in the review: primary tumor pathology, location of malignancy, and presence of recurrence. Details on the reconstruction included longitudinal growth of the flap from the time of implantation to the most recently available radiograph and postoperative complications. The length of the fibula over time was measured from the humeral head to the olecranon process.

Results: All patients were alive at the start of this study. The average longitudinal growth rate of the free fibula epiphyseal transfer was 0.54 ± 0.18 cm/y, and patients demonstrated satisfactory and consistent longitudinal bone growth and hypertrophy over time. All 4 patients suffered from a complication of postoperative fibula graft fracture, and 1 of 4 patients experienced unremitting peroneal nerve damage. All patients demonstrated normal wrist and hand motion with a normal arc of elbow flexion and extension.

Conclusion: This study demonstrates that the vascularized fibula epiphyseal transfer offers the ability to preserve longitudinal limb growth and hypertrophy throughout adolescence.

Figures

Fig. 1.

Representative radiographs from case number 1. Preoperative films displaying the oncologic lesions are shown (A). After resection, a vascularized fibula physis transfer was performed on the same operative day (B). Approximately 8 months after the fibula transfer, the patient suffered a fracture through the graft (C). After nonoperative management, sufficient healing bony union and graft survival was observed at 5 months’ post fracture (D) and 11 years postoperatively (E).

Fig. 2.

Representative radiographs from case number 2. A, The transplanted fibula flap after oncologic resection of proximal humeral osteosarcoma. B, A transverse fracture suffered 8 years after the initial operation.

Fig. 3.

Representative images from case number 3. The patient underwent emergent oncologic resection of proximal humeral osteosarcoma (A), followed by a vascularized fibula physis flap 11 months after the initial oncologic resection (B). After nonoperative management, films demonstrated adequate bone remodeling and callus formation at 1 year (C). Six weeks after humeral reconstruction, the patient sustained a fracture through the fibula graft (D).

Fig. 4.

Representative images from case number 4. Four years after the initial operation utilizing the vascularized free fibula physis transfer, the patient sustained a transverse fracture of the mid fibula shaft (A). The patient’s films demonstrated continued healing and callus formation (B). At her most recent clinic appointment, the patient’s films displayed a healed fibula graft, with no evidence of the previously seen fracture line (C).

Fig. 5.

The longitudinal growth of the vascularized fibula epiphyseal transfer for reconstruction of the proximal humerus. Radiographs were obtained at each consecutive year post transplant, and fibula length was measured from the humeral head to the olecranon process. Overall, patients demonstrated steady and continued growth of the transplanted fibula. Patient 1 did not have radiographs available for analysis between years 2 and 8. Patients 3 and 4 were followed until their most recent clinical visit, which was 4 years postoperatively. The average growth rate per year was 0.54 cm.

Fig. 6.

Patients’ height as a function of time. The overall linear association between the patients’ height and the vascularized fibula-based epiphyseal transfer was very strong.