Long-term Outcomes Following Free Vascularized Fibula Physeal Transfer for Proximal Humerus Oncologic Reconstruction in Children: An International Multi-Institutional Study

Abstract

Background: Vascularized fibula epiphyseal flap was first described in 1998 for proximal humeral reconstruction in children/infants. The authors aim to review their international, multi-institutional, long-term outcomes. Methods: An international, multi-institutional review (2004 to 2020) was conducted of patients younger than 18 years undergoing free vascularized fibula epiphyseal transfer for proximal humeral reconstruction. Donor- and recipient-site complications, pain, and final ambulatory status were reviewed. Growth of the transferred bone was assessed under the guidance of a pediatric musculoskeletal radiologist. Results: Twenty-seven patients were included with a median age of 7 years (range, 2 to 13 years). Average follow-up was 120 ± 87.4 months. There were two flap failures (7.4%). Recipient-site complications included fracture [n = 11 (40.7%)], avascular necrosis of the fibula head [n = 1 (3.7%)], fibular head avulsion [n = 1 (3.7%)], infection [n = 1 (3.7%)], and hardware failure [n = 1 (3.7%)]. Operative fixation was necessary in one patient with a fracture. The case of infection necessitated fibula explantation 2 years postoperatively, and ultimately, prosthetic reconstruction. Sixteen patients developed peroneal nerve palsy (59.3%): 13 of these cases resolved within 1 year (81% recovery), and three were permanent (11.1%). One patient (3.7%) complained of upper extremity pain. Longitudinal growth was confirmed in all but three cases [n = 24 (88.9%)] at an average rate of 0.83 ± 0.25 cm/year. Conclusions: The vascularized fibula epiphysis for proximal humerus reconstruction in children preserves the potential for future growth and an articular surface for motion. Peroneal nerve palsy is common following harvest, although this is often transient. Future efforts should be geared toward reducing postoperative morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

From replantation to transplantation: The evolution of orthoplastic extremity reconstruction

“…The ability to transfer a growing physis has revolutionized pediatric tumor reconstruction. Our experience has demonstrated growth of the humerus in all patients 67 . Donor morbidity in cases of epiphyseal transfer includes transient peroneal nerve palsy due to the division of branches of the motor nerve during harvest.…”

“…Our experience has demonstrated growth of the humerus in all patients. 67 These nerves are repaired. All patients had recovery of foot eversion (Figure 4).…”

Oncology

“…In answer to the longstanding mystery regarding the outcomes after a vascularized fibula epiphyseal flap for humeral reconstruction, a team from Philadelphia (Pennsylvania, USA) has carried out an international, multi-institutional review of patients aged < 18 years who have undergone just that. 3 A total of 27 patients with a median age of seven years were included, which represents a large series given the nature of the diagnosis and treatment. Follow-up was reported out to a mean of ten years (standard deviation (SD) 87.4 months), during which time there were two flap failures.…”

Pediatric Microsurgery and Free-Tissue Transfer

“…13,15 Vascularized fibula transfer has been successfully used for upper extremity (humerus, radius, ulna), lower extremity (femur, tibia), trunk (spine, pelvis), and craniofacial (maxilla, mandible) bony defects in children. [50][51][52][53] Anesthesia Since its application in surgical practice, general anesthesia has been a remarkable achievement in modern medicine, enabling immobilization and pain control during operations with seemingly safe implications. Nevertheless, recent evidence from studies involving nonhuman primates has established a link between commonly used anesthetic agents and brain neurotoxicity.…”