Complication of osteo reconstruction by utilizing free vascularized fibular bone graft

Abstract

The success of free vascularized fibular bone graft (FVFBG) has accelerated the osteo reconstruction which results from trauma, resection of a tumor or an infectious bone segment, or correction of congenital deformity. But the complication behind should not be overlooked. The failure could necessitate a second surgery, which prolong the rehabilitation period and produce further health cost. Worst, the patients may suffer a permanent impaired ankle function, or a sustained morpho-functional loss on reconstructive area which are hard to save. To provide an overview of the complication related to reconstruction by FVFBG, a narrative review is conducted to identify the complications including their types and rates, the contributing factors, the approaches to measure and the techniques to avoid. Methodologically, by quick research on Pubmed and abstract reading of reviews, we characterize five reconstructive areas where FVFBG were most frequently applied: extremities, mandible, spine, osteonecrosis of femoral head, and penile. Following, the complications on different reconstructive areas are retrieved, studied and presented in five (or more specifically, six) separate sections. By the way, meaningful difference between FVFBG and other bone flap was presented in a few words if necessary. Donor-site morbidities were studied and summarized as a whole. In these literatures, the evidences documented on limb and mandibular reconstruction have the fullest detail, followed by the spine and lastly the penile. In conclusion, FVFBG, though a mature technique, needs further deep and comprehensive study and maybe device-based assistance to achieve better reconstructive effect and minimize donor-site damage.

Strategies for large bone defect reconstruction after trauma, infections or tumour excision: a comprehensive review of the literature

“…Viable bone material was considered the gold standard for reconstruction of post-traumatic bone defects from non-union or malunion, given its properties of osteogenesis, osteoinduction, osteoconduction, and histocompatibility, given its low risk of immunological rejection and a high rate of neoformation of bone [ 12 , 13 , 30 ]. Vascularized fibular graft, vascularized iliac bone graft, bone lengthening utilizing external fixation, and the induced-membrane technique are all examples of reconstruction techniques using viable bone [ 9 – 11 ]. Allograft, a biological reconstruction technique through non-viable bone, is used in reconstruction after resection of a bone tumour [ 6 , 20 , 21 ].…”

“…In adult patients, a fibular graft up to 25–26 cm can be harvested [ 21 , 37 ]. The proximal fibula and the lateral malleolus should be spared to maintain knee and ankle joint stability, protect the common peroneal nerve, and preserve weight-bearing capacity [ 9 , 21 , 33 , 35 , 37 ]. A classical single vascularized fibular graft (Fig.…”

“…A common complication associated with this technique is thrombosis of the anastomosed vessels, which can lead to failure of the graft [ 48 ]. Uncontrolled bleeding, stress fractures, delayed or failed bone consolidation, delayed bone growth, persistence of deformity, infections, and compartment syndrome are complications associated with the technique [ 9 , 33 , 50 , 53 , 54 ]. The overall limb salvage rate was 94%, hybrid graft fractures occurred in 23%, and infection in 6% [ 54 ].…”

“…Furthermore, freezing can also cause thrombosis of the microcirculation, inducing ischaemic necrosis of the tumour [ 4 , 96 , 98 ]. The technique involves three steps: the bone fragment is immersed for 20 min, thawed for 15 min at room temperature, and rinsed with distilled water for 10–15 min [ 4 , 9 , 99 , 100 ]. There are two different procedures to manage the affected bone segment: free freezing and pedicle freezing technique [ 99 ] (Fig.…”

“…Reconstructive management for large bone defects can involve autograft, allograft and non-biological materials [ 8 ]. Autografts such as vascularized fibular graft [ 9 ] or vascularized iliac bone graft [ 10 , 11 ] are considered the gold standard for reconstruction of post-traumatic bone defects with non-union or malunion, given their properties of osteogenesis, osteoinduction, osteoconduction, and histocompatibility, leading to a low risk of immunological rejection [ 12 – 14 ]. Disadvantages are the limited amount of bone graft available, infection, prolonged wound drainage, and reoperation of the donor site [ 15 , 16 ].…”