Management of upper limb bone defects using free vascularized osteoseptocutaneous fibular bone graft

Sixteen patients (11 men and 5 women), who formed the basis of the study, underwent surgery in the Hand and Reconstruction Microsurgical Unit, Orthopedic Department, Sohag Faculty of Medicine, from January 2001 to January 2009.The right side was involved in 7 cases and the left side in 9 cases. Average age was 35.2 years. The causes of bone defects were infected nonunion of both bone forearms in 5 cases, infected nonunion of the middle part of radius in 4 cases, posttraumatic bone loss of distal radius in 4 cases, and tumor of shaft humerus in 3 cases (aneurysmal bone cyst in 1 and osteosarcoma in 2 patients).The principle of treatment was debridement and excision of either infected unhealthy bone or tumor tissues with wide safety margin.The average bone defect was 8 cm (range, 6-14 cm). The defect was bridged by osteoseptocutaneous vascularized fibular bone graft. The donor bone was the right fibula in 7 cases and the left fibula in 10 cases. Two grafts were used in 1 patient because of soft tissue injuries, which included the peroneal vessels during osteotomy. The vascularized fibula was fixed by small dynamic compression plate. The operative time ranged between 7 and 11 hours. Blood transfusion was indicated in all the cases and its average transfusion was 1000 mL. The average follow-up was 84 months. Bone union was ultimately obtained in 15 patients except 1 who had failure of the graft. Arthrodesis of the distal ulna with the wrist joint was done during the follow-up. Arthrodesis of the wrist joint was also performed for 1 patient who had loss of carpal bones, distal radius, and wrist and finger extensors. The average time for union was 3.5 months. The hand function was normal in all cases. Stress fracture and fibular donor-site morbidity did not occur in this series. Neither shoulders nor elbows were affected postoperatively. There was no recurrence for either infection or tumor.