Summary

This paper compares allograft alone and in combination with vascularised free fibular flaps (FFF) to reconstruct long bone defects after tumour excision.

We present 33 cases, 21 of these patients had reconstruction with an allograft alone as the initial procedure. Nine patients underwent reconstruction with FFF plus allograft plus iliac crest bone graft (ICG), two patients underwent reconstruction with a FFF and ICG and one patient underwent reconstruction with an allograft, a pedicled fibular flap and a FFF. The allograft was obtained from the Queensland Bone Bank and had been irradiated to 25 000 Gy.

In our experience (N=21) the complication rates with allograft alone were: delayed union 3, nonunion 7, fractured allograft 6, infection requiring resection of the allograft 3, other infections 2. The revision rate was 48% (10 cases of which five required a free fibular flap) and an average of 1.8 revision procedures were required. In the lower limb cases, the mean time to full weightbearing was 20 months and 40% were full weightbearing at 18 months. We felt that the high complication rate compared with other series may have been related to the irradiation of the graft.

FFFs were used in 18 cases, 12 cases were primary reconstructions and six were revision reconstructions. The mean fibular length was 19.4 cm (range 10–29 cm).

There were no flap losses and the FFF united at both ends of 11 of 12 primary reconstruction cases. One case had nonunion at one end, giving a union rate of 96% (23 of 24 junctions). When a FFF was used in combination with an allograft as a primary reconstruction, the allograft nonunion rate was 50% (five of 10 cases). The mean time to full weightbearing in the lower limb cases was 7.5 months and 100% were full weightbearing at 18 months.

The FFF hastens time to full weightbearing but does not appear to affect the complication rates of allograft. The number of revision procedures required is reduced in the presence of a FFF and is the latter is a useful technique for the salvage of refractory cases.

Keywords: Allograft; Free fibular flap; Lower limb reconstruction

Article Outline

Patients and methods

Results

Allograft experience

Reconstruction using free fibular flap

Complications with primary reconstructions using free fibular flaps

Revision with free fibular flap

Discussion

Acknowledgements

References

This paper has been presented in a preliminary form at the Centenary Surgical Oncology Conference 2001 Meeting, at the Princess Alexandra Hospital, Brisbane, Queensland, Australia, in August 2001. This paper in its current form was presented at the Royal Australasian College of Surgeons Annual Scientific Congress in Brisbane in May 2003.