Manual and Device-Assisted Hamstring Autograft Tensioning Yield Similar Outcomes following ACL Reconstruction.

The optimal initial graft tension during ACL reconstruction is still a matter of debate. Manual tension is commonly applied to the graft during tibial fixation. However, this has been associated with a greater graft failure rate than that associated with device-assisted tensioning. This study aims to compare the clinical outcomes between the application of manual tension and the use of the ConMed Linvatec SE™ Graft Tensioning System during graft fixation while performing anatomic single-bundle ACL reconstruction. METHODS: A prospective comparative study was conducted between September 2015 and May 2017. Sixty-four patients (mean age 29.3 years, range 14-45) with isolated ACL injuries (and who would be subjected to ACL reconstruction with a quadruple hamstring tendon graft) were divided into two groups. In Group A (n = 29), common tension was applied manually to both grafts. In Group B (n = 35), specific tension was applied to the grafts with the use of a tensioner device (ConMed Linvatec SE™ (Stress Equalization) Graft Tensioning System). A total of 60 N was applied to the semitendinosus, and 40 N was applied to the gracilis. Clinical outcomes were assessed at 6, 12, and 24 months. RESULTS: There were no significant differences between the baseline demographic and clinical data among the patients of the two groups (all p > 0.05). The patients were followed up for a minimum of 24 months (mean ± SD). There were no significant differences in the side-to-side anterior knee laxity, the IKDC, the Lysholm Knee, and the Tegner Activity Scale scores for up to 24 months after operation. The pivot shift test was negative in all cases, and no graft failure was reported at a 2-year follow-up. CONCLUSION: No significant differences were found with respect to postoperative anterior knee laxity, clinical outcomes, activity level, and patient satisfaction between the application of manual tension and the use of the graft-tensioning system during tibial fixation while performing anatomic single-bundle ACL reconstruction with a quadruple hamstring tendon graft. Further high-quality clinical studies are required to elucidate whether device-assisted tension is superior to manual tension.

Effect of laterality and fatigue in peroneal electromechanical delay.

INTRODUCTION: Extremity dominance is one of the intrinsic factors that have been identified for ankle sprains. Electromechanical delay (EMD) is an integral part of the peroneal motor response and, therefore, substantial in preventing ankle sprains. This study aimed to investigate the effect of laterality on EMD times before and after fatigue. METHODS: Fifteen healthy male volunteers participated in the study. Measurements were taken with the ankle in a neutral (0°) position, and all subjects followed an isokinetic fatigue protocol. Repeated ANOVA was used for statistical analysis, and the α level was set a priori at p ≤ 0.05. RESULTS: No significant difference was noted in EMD times between the dominant and non-dominant legs of the volunteers (p = 0.940). Fatigue caused a significant increase in EMD by 10-15 ms (p = 0.003), while the leg × fatigue interaction was not significant (p = 0.893). CONCLUSIONS: In a non-injured athlete, both ankles seem to be under the same protection of the reactive response of the peroneal muscles. Therefore, athletes should be aware that both their extremities are equally exposed to the danger of an ankle injury. Also, fatigued ankles demonstrate longer EMD times, implying that improving resistance to fatigue may add another layer of protection that has the potential to prevent ankle sprain recurrence.

Neonatal brachial plexus injuries and their impact on growing bone. An experimental study.

Neonatal brachial plexus palsy remains a problem, even in light of current advances in perinatal care. While many cases resolve spontaneously, the concern remains on the best means of surgical management for restoration of elbow flexion and shoulder reanimation. The present experimental study in an animal model examines the evidence that supports that neonatal brachial plexus injuries result in structural changes in the affected bone. The study suggests that if the microsurgical reinnervation takes place early enough, these changes may be diminished. On the other hand there is no way to identify at birth, which injuries will be permanent and will need surgical repair and which will spontaneously improve.

Current Concepts in Intradiscal Percutaneous Minimally Invasive Procedures for Chronic Low Back Pain.

STUDY DESIGN: A systemic review of thermal annular procedures (TAPs) and percutaneous disk decompression procedures (PDDPs) for the treatment of discogenic chronic low back pain (CLBP) was conducted. OBJECTIVE: The objective of this review is to evaluate and to compare the effectiveness of TAPs and PDDPs in treating discogenic CLBP and to assess the frequency of complications associated with those procedures. MATERIALS AND METHODS: English-language journal articles were identified through computerized searches of the PubMed database and bibliographies of identified articles and review papers. Articles were selected for inclusion if percutaneous minimally invasive procedures were the treatment options for patients with CLBP and if follow-up outcome data included evaluations of back pain severity, functional improvement, and/or incidence of complications. For this review, 27 studies were included. RESULTS: Intradiscal electrothermal therapy (IDET) procedure in properly selected patients may eliminate or delay the need for surgical intervention for an extended period, whereas few adverse effects have been reported. In contrast to IDET, there is far less literature on the effectiveness of radiofrequency annuloplasty and intradiscal biacuplasty procedures. Nucleoplasty is a potentially effective treatment option for patients with contained disc herniation, while the procedure is well tolerated. Increased success rates have been found for percutaneous laser disc decompression and automated percutaneous lumbar discectomy in strictly selected patients. CONCLUSIONS: These procedures can be effective and may obviate the need for surgery completely. Further prospective randomized sham-controlled trials with higher quality of evidence are necessary to confirm the efficacy of these procedures.

The effect of peripheral nervous system in growing bone biomechanics. An experimental study.

OBJECTIVE: There are several factors which affect bone growth. One of them is the peripheralnervous system whose effect on the biomechanics has not been extensively studied. The purpose of this study is to assess the effect of peripheral nervous system in bone biomechanics in an experimental rat model. MATERIALS & METHODS: 27 male Wistar rats were used. In all animals, the roots of the right brachial plexus were dissected and after that the animals were divided into three groups A, B and C. The animals were sacrificed six, nine, and twelve months respectively after the denervation. Both humerus were resected and biomechanical analysis was performed. RESULTS: According to the findings of the present study the denervated bones sustain less loading before fracture and they become also more elastic. Additionally, in greater time after denervation plastic deformity is noticed. CONCLUSION: Apart from structural changes, the peripheral nerves are responsible for biomechanic changes in the bones such the greater elasticity of the bone and the reduced strength.

The Efficacy of Vascularized Bone Grafts in the Treatment of Scaphoid Nonunions and Kienbock Disease: A Systematic Review in 917 Patients.

Background Vascularized bone grafts have become one of the first treatment options for scaphoid nonunions and Kienböck's disease. The aim of this study is to review the current body of the literature regarding the use of four vascularized bone grafts (1,2 ICSRA [1,2 intercompartmental supraretinacular artery] graft, 4+5 ECA [4+5 extracompartmental artery] graft, volar radial graft, and free medial femoral condyle graft) in these pathologies. Patients and Methods A search on MEDLINE and Google Scholar was performed. Exclusion criteria included language other than English, studies with no full text available, case reports, letters, editorials, and review articles. The primary outcomes included consolidation rate of the grafts and time to union regarding scaphoid nonunion, as well as the clinical outcomes (pain, grip strength, range of motion), revascularization of the lunate, and progression of the disease regarding Kienböck's disease. Results A total of 37 articles were included in the study enrolling 917 patients. Regarding scaphoid nonunion, the consolidation rate was 86.3% for the 1,2 ICSRA graft, 93.9% for the volar radial bone graft, and 88.8% for the free medial femoral condyle graft. In patients with Kienböck's disease, progression of the disease was observed in 13% of patients, and grip strength and pain were substantially improved whereas range of motion did not demonstrate statistically significant improvement ( p < 0.05). Conclusion Vascularized bone grafts yield successful outcomes in patients with scaphoid nonunions demonstrating a high union rate. In patients with Kienböck's disease, vascularized grafts lead to revascularization of the lunate in most of the cases with concomitant improvement of the clinical parameters.

Secondary procedures for restoration of upper limb function in late cases of neonatal brachial plexus palsy.

Neonatal brachial plexus palsy is a devastating complication after a difficult delivery. The incidence of this injury has not significantly decreased over the past decades, despite all the advances in perinatal care. Although primary repair of the nerves with microsurgical techniques is the common treatment strategy nowadays, there are late cases in which secondary procedures in tendons or bones are necessary. Moreover, secondary procedures may be needed to improve the results of primary repair. A careful preoperative assessment of all the residual defects and deformities in upper limbs of these patients is essential. The aim of these procedures is usually to restore the deficient shoulder abduction and external rotation, release of any elbow flexion contracture or to correct a weak elbow flexion. More distally a supination or pronation deformity is usually apparent, and available options include tendon transfers or radial osteotomy. The wrist of these patients may be ulnarly deviated or may has absent extension, so tendon transfers or free muscle transfers can also be used for correction of these deformities. In severe cases, wrist fusion is an alternative option. The clinical presentation of the hand is highly variable due to complex deformities including thumb adduction deformity, metacarpophalangeal joints drop, and weak finger flexion or extension depending on the level of the injury. Each of these deformities can be restored with a combination of soft tissue procedures like local or free muscle transfer and bony procedures like arthrodesis.

Traumatic upper plexus palsy: Is the exploration of brachial plexus necessary?

Brachial plexus injuries are major injuries of the upper limb resulting in severe dysfunction usually in young patients. Upper trunk injuries of the brachial plexus account for approximately 45% of brachial plexus injuries. Treatment options for upper trunk brachial plexus injuries include exploration of the plexus and microsurgical repair using nerve grafts or nerve transfers. Several published studies presented the results of both techniques, but there are few studies which compared these two techniques. This article summarizes the treatment options for upper trunk brachial plexus injuries, discusses the merits and demerits of each technique, and presents authors' proposed treatment for these injuries.

Clinical outcomes after lumbar spine microdiscectomy: a 5-year follow-up prospective study in 100 patients.

BACKGROUND: To evaluate the effect of lumbar microdiscectomy (LM) in pain, disability and quality of life in a 5-year period and to identify potential demographic and clinical risk factors. METHODS: One hundred patients who underwent LM by the same surgeon participated in this prospective study. Clinical assessment was made with validated questionnaires preoperatively and up to 5 years postoperatively. Subsequently, associations between clinical outcomes and demographic data were recorded. RESULTS: In every assessment questionnaire, there was a significant improvement in the first postoperative month, which lasted up to 1 year post-discectomy. After that, improvement was statistically significant (p < 0.05) but without clinical importance. Women reported more pain preoperatively and 1 month after surgery. Urban residents also presented more pain preoperatively. Older patients had more pain, disability and worse quality of life 1-5 years postoperatively. Similarly, patients with lower education presented the worst scores in every questionnaire at the same time. Smokers reported less pain 1.5-4 postoperative years. Higher alcohol consumption and obesity were associated with lower levels of preoperative pain. However, obese patients had worse SF-36 and ODI scores after the 6th postoperative month. Patients with heavy jobs presented the worst preoperative ODI scores. CONCLUSION: Significant clinical improvement was recorded from the first postoperative month to the first postoperative year; stabilization was noticed later on. Feminine gender, urban residency, older age, low level of education, obesity and heavy physical occupation were negative prognostic factors. Oddly smoking and alcohol were correlated with less pain.

Calcific deposit needling in combination with extracorporeal shock wave therapy (ESWT): A proposed treatment for supraspinatus calcified tendinopathy.

BACKGROUND: Calcified tendinopathy of the rotator cuff is one of the most common conditions concerning the shoulder pathology. It is characterized by a reactive calcification that affects the tendons being part of the rotator cuff. The reported prevalence varies from 2.7% to 22%. Most of the patients can be treated effectively with non-operative measures such as anti-inflammatory drugs, subacromial injection of steroid, physiotherapy, extracorporeal shock wave therapy (ESWT) and needle aspiration irrigation. Results of a treatment combining some of these methods have not been reported. OBJECTIVES: The purpose of this study is to present the radiological as well as the clinical results of our proposed protocol which combines drilling of the calcium deposits with xylocaine under ultrasound guidance, with a specific program of physiotherapy for 1 month without the use of NSAIDs. METHODS: Sixty-six consecutive patients (68 shoulders) were treated for calcified tendinitis of supraspinatus, which was diagnosed clinically and radiologically, with needle drilling using xylocaine under ultrasound guidance. After the drilling the patient followed a physiotherapy protocol with ESWT which included five visits within a month. After the end of the physiotherapy, the patients were evaluated clinically and radiologically. The Visual Analogue Scale (VAS) for pain and the Disabilities of the Arm, Shoulder, and Hand (DASH) score were measured before and after the end of the therapy. RESULTS: All the patients showed clinical improvement of the symptoms at the follow-up. The mean VAS score showed improvement from 8.1 to 3.3 whereas the mean DASH score was 27 and after the end of the therapy 5. Radiologically all but one calcific deposits were disappeared. CONCLUSIONS: The ultrasound-guided drilling of the calcific deposit using xylocaine, in combination with physiotherapy using ESWT provides a reliable alternative treatment for the calcific tendinitis of the supraspinatus.

Bifid Median Nerve Complete Transection at the Wrist.

A 17-yr-old male patient was admitted with a transverse sharp transection caused by broken glass at the volar aspect of his left wrist. Clinical examination showed loss of sensation at the distribution of the median nerve to the thumb, index, and middle finger and an inability to flex the middle finger. Under regional anesthesia and a high humerus tourniquet, surgical exploration of the wound with binocular loupe magnification showed a bifid median nerve with a persistent thin median artery running between the two nerve trunks. The bifid median nerve was sharply and transversely transected, slightly proximal to the transverse carpal ligament. The palmaris longus tendon and the flexor digitorum superficialis tendon of the middle finger were also cut. The flexor digitorum tendon was sutured with a two-strand technique augmented with a running epitendinous suture. The two trunks of the bifid median nerve were repaired separately using microsurgical technique and 8-0 nylon epineural sutures. Postoperatively, the hand was immobilized in a palmar short-arm splint that was removed at 40 d. A progressive Tinel sign was evident 30 d postoperatively. At 3 mo, the patient experienced light touch sensation at the tip of the index and middle fingers. At the last follow-up, 2.5 yr after his injury, the patient has complete nerve functional recovery without atrophy of the thenar muscles and with strong thumb opposition.

A new, low cost, locking plate for the long-term fixation of a critical size bone defect in the ratfemur: in vivo performance, biomechanical and finite element analysis.

BACKGROUND: The optimum fixation device for the critical size bone defect is not established yet. OBJECTIVE: A reliable, feasible and low-cost fixation device for the long-term maintenance of a critical bone defect. METHODS: A custom-made plate made of poly-methyl-methacrylate was used for the fixation of a critical defect of rats' femurs. The screws were securely fixing both on the plate and the bone. A three point bending test, aimed to resemble the in vivo loading pattern, a Finite Element Analysis and a 24-week in vivo monitoring of the integrity of the plate fixation were utilized. RESULTS: The plate has linear and reproducible behavior. It presents no discontinuities in the stress field of the fixation. Its properties are attributed to the material and the locking principle. It fails beyond the level of magnitude of the normal ambulatory loads. In vivo, 100% of the plates maintained the bone defect intact up to 12 weeks and 85% of them at 24 weeks. CONCLUSION: This novel locking plate shows optimal biomechanical performance and reliability with high long-term in vivo survival rate. It is fully implantable, inexpensive and easily manufactured. It can be qualified for long term critical defect fixation in bone regeneration studies.

Digital ray reconstruction through distraction osteogenesis: a retrospective study of 82 rays with long-term follow-up.

PURPOSE: The aim of the present study was to present the long-term radiographic results with distraction osteogenesis in traumatic or congenital length discrepancies of long bones of the hand. METHODS: The medical records and radiographs of 65 consecutive patients (27 metacarpals and 55 phalanges) with either traumatic or congenital digital length discrepancies were retrospectively reviewed. The mean follow-up was 8.2 years. The mean distraction period was 21 days with a distraction rate of 4×0.25mm/day. Callus consolidation was obtained in all patients. RESULTS: The bones were lengthened by a mean amount of 17.5mm, with a mean increase in bone length of 68±17.3%. The mean healing index was 28.57 days/cm. Ray reconstruction with callus distraction can be applied effectively in skeletally immature or mature patients with congenital differences of the hand or amputated fingers. CONCLUSION: A distraction rate of 1mm/day proved to be a safe rate of lengthening in both metacarpals and phalanges.

Use of intercostal nerves for different target neurotization in brachial plexus reconstruction.

Intercostal nerve transfer is a valuable procedure in devastating plexopathies. Intercostal nerves are a very good choice for elbow flexion or extension and shoulder abduction when the intraplexus donor nerves are not available. The best results are obtained in obstetric brachial plexus palsy patients, when direct nerve transfer is performed within six months from the injury. Unlike the adult posttraumatic patients after median and ulnar nerve neurotization with intercostal nerves, almost all obstetric brachial plexus palsy patients achieve protective sensation in the hand and some of them achieve active wrist and finger flexion. Use in combination with proper muscles, intercostal nerve transfer can yield adequate power to the paretic upper limb. Reinnervation of native muscles (i.e., latissimus dorsi) should always be sought as they can successfully be transferred later on for further functional restoration.

Approach to radial nerve palsy caused by humerus shaft fracture: is primary exploration necessary?

INTRODUCTION: While recommendations for early exploration and nerve repair in cases of open fractures of the humeral shaft associated with radial nerve palsy are clear, the therapeutic algorithm for the management of closed humeral shaft fractures complicated by radial nerve palsy is still uncertain. The purpose of this study was to determine whether patients with complete sensory and motor radial nerve palsy following a closed fracture of the humeral shaft should be surgically explored. PATIENTS AND METHODS: Twenty-five patients with closed humeral shaft fractures complicated by complete radial nerve palsy were retrospectively reviewed during a 12-year period. Surgical intervention was indicated if functional recovery of the radial nerve was not present after 16 weeks of expectant management. RESULTS: Surgical exploration was performed in 12 patients (48%) after a mean period of expectant management of 16.8 weeks (range: 16-18 weeks). In 2 of them (10%) total nerve transection was found. In the rest 10 patients underwent surgical exploration the radial nerve was found to be macroscopically intact. All intact nerves were fully recovered after a mean time of 21.6 weeks (range: 20-24 weeks) post-injury. In 13 patients (52%) in whom surgical exploration was not performed the mean time to full nerve recovery was 12 weeks (range: 7-14 weeks) post-injury. CONCLUSIONS: We proposed immediate exploration of the radial nerve in case of open fractures of the humeral shaft, irreducible fractures or unacceptable reduction, associated vascular injuries, radial nerve palsy after manipulation or intractable neurogenic pain. Due to high rate of spontaneous recovery of the radial nerve after closed humeral shaft fractures we recommend 16-18 weeks of expectant management followed by surgical intervention.

Management of acute acromioclavicular joint dislocation with a double-button fixation system.

INTRODUCTION: Numerous static and dynamic techniques have been described for the management of acute acromioclavicular (AC) joint dislocation. To date, no standard technique has been established and several complications have been described for each of these techniques. The purpose of the present study was to evaluate the functional and radiographic outcomes of acute AC joint reconstruction after a mini-open technique using the double-button fixation system. PATIENTS AND METHODS: Twelve patients with acute AC joint dislocation treated with the double-button fixation system by one surgeon were retrospectively reviewed. Functional assessment was performed by an independent reviewer using the DASH, Constant and the VAS scores. The coracoclavicular (CC) distance of the affected shoulder was assessed on a standard radiograph and compared with the contralateral normal one. RESULTS: Eight patients were operated on for grade III AC joint dislocation and 4 for grade IV. The mean age of the patients at the time of surgery was 27.5 years. The mean follow-up was 18.25 months (range: 12-30 months). At the most recent follow-up, the mean Constant score was 94.8 (range: 84-100) showing a significant increase compared with the mean pre-operative value of 34.4 (range: 25-52) (p<0.001). The mean DASH score was significantly decreased from 19.6 (range: 14-28) preoperatively to 0.25 (range: 0-3) at the last follow-up (p<0.001). The mean VAS score showed a significant decrease from 5.75 (range: 4-7) to 0.2 (range: 0-2) (p<0.001). The mean CC distance on the operated shoulder was found to have no significant difference from the CC distance on the contralateral normal side (10.5 vs. 10mm) (p>0.05). There was no evidence of AC joint osteoarthrosis, CC calcification or osteolysis of the distal clavicle or the coracoid process. CONCLUSIONS: The proposed mini-open technique provides adequate exposure of the base of the coracoid with minimal damage to the soft tissues surrounding the CC ligaments while ensures an excellent cosmetic result. We recommend this fast and relatively simple technique for all type IV injuries and for type III injuries in heavy manual workers and high-demand upper extremities athletes.

Shoulder abduction and external rotation restoration with nerve transfer.

INTRODUCTION: In upper brachial plexus palsy patients, loss of shoulder function and elbow flexion is obvious as the result of paralysed muscles innervated by the suprascapular, axillary and musculocutaneus nerve. Shoulder stabilisation, restoration of abduction and external rotation are important as more distal functions will be affected by the shoulder situation. PATIENTS AND METHODS: Between 2005 and 2011, eleven patients with upper type brachial plexus palsy were operated on with triceps nerve branch transfer to anterior axillary nerve branch and spinal accessory nerve transfer to the suprascapular nerve for shoulder abduction and external rotation restoration. Nine patients met the inclusion criteria for the study. All patients were men with ages ranged from 21 to 35 years (average, 27.4 years). The interval between injury and surgery ranged from 4 to 11 months (average, 7.2 months). Atrophy of the supraspinatus, infraspinatus and deltoid muscle and subluxation at the glenohumeral joint was obvious in all patients preoperatively. During the pre-op examination all patients had at least muscle grading 4 on the triceps muscle. RESULTS: The mean post-operative value of shoulder abduction was 112.2° (range: 60-170°) while preoperatively none of the patients was able for abduction (p<0.001). The mean post-operative value of shoulder external rotation was 66° (range: 35-110°) while preoperatively none of them was able for external rotation (p<0.001). Postoperative values of shoulder abduction were significantly better that those of external rotation (p=0.0004). The postoperative average muscle grading for shoulder abduction according the MRC scale was 3.6±0.5 and for the shoulder external rotation was 3.2±0.4. CONCLUSIONS: Combined nerve transfer by using the spinal accessory nerve for suprascapular nerve neurotisation and one of the triceps nerve branches for axillary nerve and teres minor branch neurotisation is an excellent choice for shoulder abduction and external rotation restoration.

Diagnostic and treatment modalities in nonunions of the femoral shaft: a review.

Nonunions of the femoral shaft represent a treatment challenge for the orthopaedic surgeon and a serious socioeconomic problem for the patient. Inadequate fracture stability, insufficient blood supply, bone loss or presence of infection are the main reasons for the development of a nonunion. Careful classification and exclusion of infection are crucial for the choice of the proper treatment alternative. Nail dynamization, primary intramedullary nailing or nail exchange, plate osteosynthesis and external fixation along with bone grafting, usage of bone substitutes and electrical stimulation can stimulate osseous union. A review of the aetiology, classification and treatment should prove helpful managing this serious complication.

Proximal screws placement in intertrochanteric fractures treated with external fixation: comparison of two different techniques.

BACKGROUND: To compare two different techniques of proximal pin placement for the treatment of intertrochanteric fractures in elderly patients utilizing the Orthofix Pertrochanteric Fixator. METHODS: Seventy elderly high-risk patients with an average age of 81 years were treated surgically for intertrochanteric fracture, resulting from a low energy trauma. Patients were randomly divided in two groups regarding to the proximal pin placement technique. In Group A the proximal pins were inserted in a convergent way, while in Group B were inserted in parallel. RESULTS: All fractures healed uneventfully after a mean time of 98 days. The fixator was well accepted and no patient had significant difficulties while sitting or lying. The mean VAS score was 5.4 in group A and 5.7 in group B. At 12 months after surgery, in group A the average Harris Hip Score and the Palmer and Parker mobility score was 67 and 5.8, respectively. In group B, the average Harris Hip Score and the Palmer and Parker mobility score was 62 and 5.6, respectively. No statistically significant difference was found regarding the functional outcome. The mean radiographic exposure during pin insertion in Group A and Group B was 15 and 6 seconds, respectively. The difference between the two groups, regarding the radiographic exposure, was found to be significant. CONCLUSION: Proximal screw placement in a parallel way is simple, with significant less radiation exposure and shorter intraoperative duration. In addition, fixation stability is equal compared to convergent pin placement.

Recent updates of surgical techniques and applications of free vascularized fibular graft in extremity and trunk reconstruction.

Successful free vascularized bone transfers have revolutionized the limb salvage and musculoskeletal reconstruction. The free vascularized fibula remains the mainstay in bone reconstruction combines the benefits of blood supply, biological potential, and callus formation with its unique biomechanical characteristics offering a supreme candidate for various dissolvable issues. Especially in conditions where there was lack of other applicable method and the free vascularized fibular graft was introduced as the only alternative. Extensive traumatic bone loss, tumor resection, femoral head osteonecrosis and congenital defects have been managed with exceptional results beyond expectations. The present manuscript updates several issues in application of free vascularized fibular graft in extremity and trunk reconstruction. It also highlights tips and pearls of surgical technique in some crucial steps of harvesting the vascularized fibular graft in order to offer a vascularized bone with safety and low donor site morbidity.