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Outcomes following Free Fibula Physeal Transfer for Pediatric Proximal Humerus Reconstruction: An International
Saïd C Azoury1, Ronnie L Shammas2, Sammy Othman3,4
1From the Division of Plastic Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center.
Insights
Vascularized fibula epiphyseal transfer for pediatric proximal humerus reconstruction shows good growth potential but common peroneal nerve palsy. Further research should focus on minimizing complications for better patient outcomes.
Area of Science:
- Orthopedic Surgery
- Pediatric Orthopedics
- Musculoskeletal Reconstruction
Background:
- The vascularized fibula epiphyseal flap, introduced in 1998, is utilized for proximal humeral reconstruction in pediatric patients.
- This study reviews long-term outcomes of this technique across multiple international institutions.
Purpose of the Study:
- To evaluate the long-term efficacy and complications of free vascularized fibula epiphyseal transfer for proximal humeral reconstruction in patients under 18 years old.
- To assess graft growth, recipient-site issues, and functional recovery.
Main Methods:
- An international, multi-institutional review of patients younger than 18 years who underwent the procedure between 2004 and 2020.
- Data collected included donor- and recipient-site complications, pain, ambulatory status, and bone growth assessed radiographically.
Main Results:
- Twenty-seven patients (median age 7 years) were analyzed with an average follow-up of 120 months.
- Flap failure occurred in 7.4% of cases. Recipient-site complications included fractures (40.7%) and peroneal nerve palsy (59.3%, often transient).
- Longitudinal growth was achieved in 88.9% of cases at an average rate of 0.83 cm/year.
Conclusions:
- Free vascularized fibula epiphysis transfer for proximal humerus reconstruction in children preserves growth potential and joint function.
- While peroneal nerve palsy is frequent, it is often temporary. Reducing postoperative morbidity remains a key objective.
Background:
Vascularized fibula epiphyseal flap was first described in 1998 for proximal humeral reconstruction in children/infants. The authors aim to review their international, multi-institutional, long-term outcomes.
Methods:
An international, multi-institutional review (2004 to 2020) was conducted of patients younger than 18 years undergoing free vascularized fibula epiphyseal transfer for proximal humeral reconstruction. Donor- and recipient-site complications, pain, and final ambulatory status were reviewed. Growth of the transferred bone was assessed under the guidance of a pediatric musculoskeletal radiologist.
Results:
Twenty-seven patients were included with a median age of 7 years (range, 2 to 13 years). Average follow-up was 120 ± 87.4 months. There were two flap failures (7.4%). Recipient-site complications included fracture [ n = 11 (40.7%)], avascular necrosis of the fibula head [ n = 1 (3.7%)], fibular head avulsion [ n = 1 (3.7%)], infection [ n = 1 (3.7%)], and hardware failure [ n = 1 (3.7%)]. Operative fixation was necessary in one patient with a fracture. The case of infection necessitated fibula explantation 2 years postoperatively, and ultimately, prosthetic reconstruction. Sixteen patients developed peroneal nerve palsy (59.3%): 13 of these cases resolved within 1 year (81% recovery), and three were permanent (11.1%). One patient (3.7%) complained of upper extremity pain. Longitudinal growth was confirmed in all but three cases [ n = 24 (88.9%)] at an average rate of 0.83 ± 0.25 cm/year.
Conclusions:
The vascularized fibula epiphysis for proximal humerus reconstruction in children preserves the potential for future growth and an articular surface for motion. Peroneal nerve palsy is common following harvest, although this is often transient. Future efforts should be geared toward reducing postoperative morbidity.
Clinical Question/Level Of Evidence:
Therapeutic, IV.
