Long-term effect on foot and ankle donor site following vascularized fibular graft resection in children

Abstract

This study was carried out to evaluate the long-term effect on the donor side of the foot and ankle following vascularized fibular graft resection in children. Eight patients underwent resection of the fibula for the purpose of a vascularized fibular graft by a surgical team who practiced leaving at least 6 cm residual distal fibula. The age of these children at the time of surgery was between 3 and 12 years. They were reviewed between 3 and 12 years after surgery. Two patients who underwent resection of the middle shaft of the fibula at 3 and 5 years of age developed abnormal growth of the distal tibia, leading to ankle valgus. They were treated with growth modulation of the distal tibial physis and supramalleolar osteotomy with tibiofibular synostosis. Another patient who underwent the entire proximal fibula resection at the age of 6 years had developed hindfoot valgus because of weakness of the tibialis posterior muscle. He required talonavicular fusion and flexor hallucis to tibialis posterior muscle transfer. Patients operated at the age of older than 8 years neither had ankle nor hindfoot deformity. We concluded that resection of the middle shaft of the fibula for the purpose of a vascularized fibula graft, leaving a 6 cm distal fibular stump in children younger than 6 years old, may give rise to abnormal growth of the distal tibial physis, leading to valgus ankle. The entire proximal fibular resection for the similar purpose in a 6-year-old child may give rise to weakness of tibialis posterior and hindfoot valgus.

Fibula regeneration following non-vascularized graft harvest in children

“…Common complications of donor region reported are surgical scar, pain, ankle instability, motor-neural weaknesses, proximal migration of fibula, ankle valgus and deformities of the tibial shaft and ankle [11][12][13][14][15][16][17]. The recommendations of leaving a distal fibular remnant greater than 5-6 cm, distal tibiofibular arthodesis, and scheduling surgical harvest at age older than eight years emerged from these findings [11][12][13][14]. A close examination of literature on the subject showed that a majority of these results surfaced from vascularized fibula graft series where regeneration of donor fibula did not occur.…”

“…There are only a few studies in the pediatric population to testify for above inferences. Moreover, the main literature for donor site follow-up in the paediatric group has emerged from the vascularized fibular graft technique [11][12][13][14][15][16][17]. An important difference between vascularized and non-vascularized fibular graft is that the donor site following the latter regenerates new bone provided periosteum is preserved, and it can even be used for reharvest.…”

Single-cortex is better than double-cortex in fibula grafts for large tibia bone defect in a 2-year-old child

“…However, for other patients older than 8 years, no one has ankle or hindfoot deformity. [ 1 ] This strongly indicates that double-cortex fibular graft resection will cause obvious growth deformity in small patients and should not be used in patients younger than 6 years.…”

“…The conventional double-cortex fibula graft for adult usually causes severe complications in small patients. [ 1 ] And the studies about effective methods for large bone defect in patients younger than 3 years are rare in literature. In this article, we report a case of 2-year-old boy with a large tibia bone defect treated by ipsilateral single-cortex fibula graft, and it achieves a satisfactory result.…”

Bone Allograft Segment Covered with a Vascularized Fibular Periosteal Flap: A New Technique for Pediatric Mandibular Reconstruction

“…In this regard, an additional advantage of our technique is the avoidance of the potential ankle instability and valgus deformity associated with the fibula resection. 11 In addition, by preserving the entire fibula, the longitudinal growth of the fibula is likely to be maintained because the proximal and distal fibular physes are preserved together with the epiphyseal periosteal and endosteal vessels. In fact, after a temporary contraction of the flexor hallucis longus, our patient has shown optimal lower limb function and growth remains symmetrical.…”