Classification of vascularized fibular flap hypertrophy based on X-ray evaluation
Classification of vascularized fibular flap hypertrophy based on X-ray evaluation
Objective: The aim of this study was to analyze and classify hypertrophy seen in vascularized fibula flaps used for reconstruction of tubular bone defects. Methods: Thirty-three patients who underwent a vascularized fibula flap for the reconstruction of massive bone defects of the upper or lower extremity long bones were retrospectively reviewed and included in this study. There were 24 lower extremities (21 tibial and 3 femoral) and 9 upper extremities (4 humeral, 2 radial and 3 ulnar) reconstructions in this series. The mean age was 32.7 (range= 10– 59) years. The mean length of bony defect following initial debridement was 10.3 (range= 4–25) cm. The fibula was inserted as a single strut in 29 patients, and as a double barrel construct in 4 patients. The degree of fibular hypertrophy was calculated based on anteroposterior (AP) and lateral X-ray measurements of fibular flaps at an average postoperative period of 52 months. The difference in thickness between the initial and final x- ray measurements were expressed as percentage of hypertrophy. The variances seen in this period were defined and classified. Results: When bony consolidation of the 33 cases were examined in detail, 4 different modes of flap hypertrophy were defined: type 0- absence of hypertrophy, type 1- limited hypertrophy, type 2- marked hypertrophy triggered by stress fracture, and type 3- massive hypertrophy enhanced by peripheral bone production. Conclusion: Fibular hypertrophy follows different modes based on vascularity of the flap, amount of stress imparted on the flap, site of reconstruction, and whether the periosteal sleeve is retained at the reconstruction site. Determination of these factors at the initial period may help the surgeons to predict the final hypertrophy that will be seen at the end of flap maturation
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- 1. El-Gammal TA, El-Sayed A, Kotb MM. Hypertrophy after free vascularized fibular transfer to the lower limb. Microsurgery. 2002;22(8):367-370. 10.1002/ micr.10066
- 2. El-Sherbiny M. Long term behavior of pedicled vascularized fibular grafts in reconstruction of middle and distal tibia after resection of malignant bone tumors. J Egypt Natl Canc Inst. 2008;20(2):187-195.
- 3. Falder S, Sinclair JS, Rogers CA, Townsend PL. Long-term behaviour of the free vascularised fibula following reconstruction of large bony defects. Br J Plast Surg. 2003;56(6):571-584. 10.1016/S0007-1226(03)00186-3
- 4. de Boer HH, Wood MB. Bone changes in the vascularised fibular graft. J Bone Joint Surg Br. 1989;71(3):374-378. 10.1302/0301-620X.71B3.2722923
- 5. El-Gammal TA, El-Sayed A, Kotb MM. Reconstruction of lower limb bone defects after sarcoma resection in children and adolescents using free vascu- larized fibular transfer. J Pediatr Orthop B. 2003;12(4):233-243.10.1097/01.bpb. 0000049577.53117.e7
- 6. Fujimaki A, Suda H. Experimental study and clinical observations on hyper- trophy of vascularized bone grafts. Microsurgery. 1994;15(10):726-732. 10. 1002/micr.1920151012
- 7. Ikeda K, Tomita K, Hashimoto F, Morikawa S. Long-termfollow-up of vascular- ized bone grafts for the reconstruction of tibial nonunion: Evaluation with computed tomographic scanning. J Trauma. 1992;32(6):693-697. 10.1097/ 00005373-199206000-00004
- 8. Lazar E, Rosenthal DI, Jupiter J. Free vascularized fibular grafts: Radiographic evidence of remodeling and hypertrophy. AJR Am J Roentgenol. 1993;161 (3):613-615. 10.2214/ajr.161.3.8352118
- 9. Jones HH, Priest JD, Hayes WC, Tichenor CC, Nagel DA. Humeral hypertrophy in response to exercise. J Bone Joint Surg Am. 1977;59(2):204-208. 10.2106/ 00004623-197759020-00012
- 10. Woo SL, Kuei SC, Amiel D, et al. The effect of prolonged physical training on the properties of long bone: A study of Wolff’s Law. J Bone Joint Surg Am. 1981;63(5):780-787. 10.2106/00004623-198163050-00013
- 11. Muramatsu K, Ihara K, Shigetomi M, Kawai S. Femoral reconstruction by single, folded or double free vascularised fibular grafts. Br J Plast Surg. 2004;57(6):550-555. 10.1016/j.bjps.2003.08.021
- 12. Bos KE, Besselaar PP, Vd Eijken LW, Raaymakers EL. Failure of hypertrophy in revascularized fibula grafts due to stress protection. Microsurgery. 1996;17 (7):366-370. 10.1002/(SICI)1098-2752(1996)17:7<366::AID-MICR4>3.0.CO;2-E
- 13. Wada T, Naito T, Usui M, Tsuchida Y, Kanaya K, Tsuji H. Free vascularized fibular grafts for reconstruction of large femoral defects involving the knee joint: Report of two cases. J Reconstr Microsurg. 1998;14(3):205-209. 10.1055/s- 2007-1000169
- 14. Sun Y, Zhang C, Jin D, Sheng J, Cheng X, Zeng B. Treatment of large skeletal defects by free vascularized fibular graft combined with locking plate. Arch Orthop Trauma Surg. 2010;130(4):473-479. 10.1007/s00402-009- 0898-5
- 15. Qi Y, Sun HT, Fan YG, Li FM, Lin ZS. Do stress fractures induce hypertrophy of the grafted fibula? A report of three cases received free vascularized fibular graft treatment for tibial defects. Chin J Traumatol. 2016;19(3):179-181. 10. 1016/j.cjtee.2016.04.003
- 16. Enneking WF, Eady JL, Burchardt H. Autogenous cortical bone grafts in the reconstruction of segmental skeletal defects. J Bone Joint Surg Am. 1980;62 (7):1039-1057. 10.2106/00004623-198062070-00001