Assessing nonunion and morbidity in pediatric clavicula pro humero reconstruction with vascularized fibular grafts

The proximal humerus is a common site for pediatric malignant bone tumors, often necessitating complex surgical approaches when the tumor extends into the glenohumeral joint. Limb-salvage techniques like clavicula pro humero (CPH) reconstruction aim to balance limb function with oncological safety. However, nonunion and functional limitations remain significant challenges. This study evaluates whether adding a vascularized fibular graft (VFG) reduces nonunion in CPH reconstructions following proximal humeral tumor resection. A retrospective review of six pediatric patients (mean age 12 years) treated between 2006 and 2021 for malignant bone tumors in the proximal humerus was performed. All underwent CPH reconstruction combined with a VFG. Primary outcomes included nonunion rates, time to bone healing, and complications like infections and fractures. Secondary outcomes assessed morbidity related to fibular graft harvesting, including lower limb alignment and peroneal nerve injury. Of the six patients, four (66%) experienced proximal nonunion, all requiring revision surgery. The average time to proximal union (21 months) was significantly longer than distal union (11.5 months; P  < 0.05). Fibular graft complications included transient common peroneal nerve deficiency in two cases (33%). No infections or local tumor recurrences were observed during follow-up. VFG improves distal junction consolidation, but provides limited benefit for proximal union. This may be influenced by factors such as the length of the harvested clavicle or the vascularization quality of the clavicular graft.