Clinical Outcome of Free Vascularized Fibula Graft for Nonunion of Garden IV Femoral Neck Fracture of 13 Years Duration: A Case Report.

BACKGROUND: Femoral neck fractures in young patients are mostly caused by high-energy trauma and demonstrate more displacement and vertical fracture surfaces, which increase nonunion and osteonecrosis risks. Free vascularized fibula graft (FVFG) is effective in treating old femoral neck fractures and nonunion; however, available data are limited to patients within 2 years after injury or revision surgery. We present the case of a patient who was diagnosed with femoral neck fracture at the age 9 and treated with FVFG 13 years later. CASE PRESENTATION: A 9-year-old Asian girl who experienced left hip pain after an injury was diagnosed with Garden IV left femoral neck fracture, which was treated through manipulation reduction and fixed with splints. At age 16, the pain worsened after another injury and was considered to be in the physical development stage. She refused surgical treatment; hence, the fracture was fixed externally with splints. At age 22, she was hospitalized owing to a 12-day left hip pain with restricted movement caused by a fall. She was diagnosed with old Garden IV femoral neck fracture nonunion and treated with FVFG. Seven years postoperatively, imaging showed that the left femoral neck was internally fixed, the fracture had healed, and the Harris score was 90 points. The 36-Item Short Form Health Survey responses revealed that the patient's physiological functioning, emotional well-being, energy, and mental health were normal. She achieved satisfactory functional results and resumed her normal daily life. CONCLUSION: FVFG could provide satisfactory outcomes for long-term old femoral neck fractures.

Management of Massive Mandibular Fibrous Dysplasia with Radical Excision and Different Immediate Reconstructive Modalities: Case Series Report.

Purpose: To review and represent three different mandibular reconstruction modalities following surgical treatment of massive mandibular fibrous Dysplasia (MMFD). Methods: The present retrospective case series study was conducted on 24 patients who had MMFD and treated via resection and immediate reconstruction at Al-Azhar University Hospitals, Egypt. Patients were divided into three groups according to the grafting procedure. Group I patients were grafted with iliac bone graft (IBG), group II patients were grafted with IBG and bone marrow aspirate concentrate (BMAC), while group III patients were grafted with free vascularized fibula graft (FVFG). Postoperative clinical and radiographic assessments were performed immediately, at 6 months, 12 months and 2 years to evaluate lesion recurrence and bone graft resorption. Other study variables included assessment of postoperative wound dehiscence, infection rate, amount of edema, and facial bone contour. Results: The parameters of the clinical analysis showed non-statistically significant differences among all groups. Postoperative wound healing was clinically uneventful in all groups, except for two cases of wound dehiscence in group I (8.3%) and one case in group III (4.2%). Most patients had appropriate postoperative facial contour, and adequate facial symmetry. The radiographic measurements revealed a highly statistically significant difference between group I and II at 12 months, and two years, without any statistically significant difference between group II and III. Conclusion: MMFD surgical defect should be repaired for function and cosmetics aims especially in young adult patients. The findings of the present study have shown that when compared to traditional IBG alone or FVFG, the use of autogenous IBG with BMAC injection produces a favorable outcome with few difficulties.

Thirty-eight-year follow-up of the first patient of mandibular reconstruction with free vascularized fibula flap.

BACKGROUND: The mandible is responsible for vital functions of the stomatognathic system, and its loss results in functional and aesthetic impairment. Mandibular reconstruction with free fibula flap is considered the gold standard for mandibular reconstruction. CASE PRESENTATION: We describe here the 38-year follow-up of the patient who was the first case of mandibular reconstruction with free fibula flap reported in the literature. The original report describes a 27-year-old woman who had undergone extensive mandibulectomy due to an osteosarcoma. A microvascularized fibula flap was used for mandibular reconstruction in 1983. Two years later, a vestibulo-lingual sulcoplasty with skin graft was performed to allow the construction of a total dental prosthesis. Fifteen years after the initial treatment, an autologous iliac crest graft was placed in the fibula flap, aimed at increasing bone thickness and height for rehabilitation with implant supported prosthesis. In 2015, a rib graft was positioned in the mental region, enhancing the support to the soft tissues of the face and improving the oral function. A recent review of the patient shows well-balanced facial morphology and optimal functional results of the procedure. CONCLUSIONS: The fibula flap method, described in 1975 and first reported for mandibular reconstruction in 1985, continues to be applied as originally described, especially where soft tissue damage is not extensive. Its use in reconstructive surgery was expanded by advancements in surgery and techniques such as virtual surgical planning. However, there is still a lack of evidence related to the long-term evaluation of outcomes. The present work represents the longest-term follow-up of a patient undergoing mandibular reconstruction with free vascularized fibula flap, presenting results showing that, even after 38 years, the procedure continues to provide excellent results.

Biomechanical analysis of fibular graft techniques for nontraumatic osteonecrosis of the femoral head: a finite element analysis.

BACKGROUND: Free vascularized fibula graft (FVFG) techniques have most consistently demonstrated beneficial effects in young patients diagnosed with nontraumatic osteonecrosis of the femoral head (NONFH), and the core track technique (CTT) in particular is the most commonly used technique. As an alternative to CTT, the modified light bulb technique (LBT) has been reported to have a higher success rate. However, its biomechanical outcomes are poorly understood. This study aimed to compare the biomechanical properties of modified LBT with those of CTT in treating NONFH. METHODS: Two types (C1 and C2) of NONFH finite element models were established on the basis of a healthy subject and the Japanese Investigation Committee (JIC) classification system, and the CTT and LBT procedures were simulated in each type of model. The average von Mises stresses and stiffness of the proximal femur were calculated by applying a load of 250% of the body weight on the femoral head to simulate walking conditions. In addition, two patient-specific models were built and simulated under the same boundary conditions to further validate the LBT. RESULTS: In the healthy subject-derived models, both the LBT and CTT resulted in reduced stresses in the weight-bearing area, central femoral head, femoral neck, and trochanteric and subtrochanteric regions and increased structural stiffness after surgery. In the weight-bearing area, the CTT reduced the stress more than the LBT did (36.19% vs 31.45%) for type C1 NONFH and less than the LBT did (23.63% vs 26.76%) for type C2 NONFH. In the patient-specific models, the stiffness and stresses also increased and decreased, respectively, from before to after surgery, which is consistent with the results of healthy subject-derived models. CONCLUSION: The biomechanical effects of the LBT and CTT differ by the JIC type of NONFH. In terms of preventing the collapse of the femoral head, the LBT may be more effective for JIC type C2 NONFH and may be a suitable alternative to the CTT, while for JIC type C1 NONFH, the CTT is still a better choice. Both techniques can improve the biomechanical properties of NONFH by reducing the proximal femoral stress and increasing the structural stiffness.

Clinical Outcome of Free Vascularized Fibula Graft in the Surgical Treatment of Extremity Osteosarcoma.

OBJECTIVE: To determine the clinical outcome and complications associated with use of free vascularized fibular graft (FVFG) in the resection and reconstruction of extremity osteosarcoma (OS). METHODS: This is a retrospective study recruiting a consecutive series of 18 patients who had undergone resection of extremity OS between May 2009 and June 2017 in our clinic center. Reconstruction of the bone defect with FVFG was performed for each patient. Surgery-related complications and time of bone union were recorded at the follow-up visit. The functional outcome of the reconstructed limb was assessed with the musculoskeletal tumor society (MSTS) scoring system. Patients were further classified into low extremity group and upper extremity group according to the tumor location. The Student t-test was used to compare the surgical outcome between the two subgroups. RESULTS: There were 11 males and seven females with an average age of 25.9 ± 14.2 years. The mean length of the bone resection was 11.9 ± 4.1 cm. The mean follow-up duration was 3.1 ± 1.2 years. As for tumor location, six cases were located in the femur, five in the tibia, four in the humerus, two in the ulna, and one in the radius. All the patients had successful graft healing at an average of 4.9 months after surgery. At the 2-year follow-up, an excellent functional outcome was observed in 88.9% of the patients (n = 16). The mean score of MSTS was 27.0 ± 4.6. Screw loosening and autograft fracture were observed in one patient with femur tumor, who had a low MSTS score of 11. Besides, there were three cases with delayed incision healing. Patients with lower extremity OS were found to have significantly longer duration of hospital stay and more blood loss than those with upper extremity OS. The incidence of postoperative complication was higher in the lower extremity group but with marginal significance (0% vs 36.3%, P = 0.1). There was no significant difference regarding time to bone union and the functional outcome as indicated by MSTS score. CONCLUSIONS: FVFG technique can be effectively applied to the reconstruction of bone defects after OS resection with satisfactory functional outcome and low incidence of complications.

Reconstruction of Large Femur and Tibia Defect with Free Vascularized Fibula Graft and Locking Plate

PURPOSE: The reconstruction of femur and tibia defects following tumor resection remains a surgical challenge. The clinical outcome of free vascularized fibula graft (VFG) reconstruction with locking plate for massive femur and tibia defects of more than 10 cm that were secondary to skeletal tumor resection is reported. MATERIALS AND METHODS: Thirteen patients with a mean follow-up of 3.3 years were reviewed. Seven patients received vascularized fibula grafts in the femur and six in the tibia. The mean bony defect of the femur and tibia was more than 10 cm and the length of the grafted fibula was more than 15 cm. All defects were stabilized with long locking plates. RESULTS: All patients were free of disease at final follow-up; All VFGs were transferred successfully. All patients had a successful outcome with bony union. Stress fractures of the grafted fibula had occurred but the locking plate stabilized the fracture and healed until the last follow-up. All patients were able to walk without a brace after a mean of 9 months postoperatively. CONCLUSIONS: VFG with locking plate is a reliable reconstructive procedure for massive femur and tibia defects.