Free Vascularized Fibular Graft for Congenital Pseudarthrosis Tibia: A Case Series

Introduction: Congenital pseudarthrosis tibia (CPT) probably one of the most difficult to treat among all diseases in the children. There are several surgical approaches that have been used to treat CPT including on-lay graft, double on-lay grafts, pedicle grafts, osteotomy, bypass graft and intramedullary rods. Prognosis of CPT has changed considerably with the use of Free Vascularized Fibular Graft (FVFG). Despite these advances, several operations are often necessary to obtain union of CPT and the risk of amputation is never entirely eliminated Case presentation: We presented 2 case with CPT. The first case is a 4 year old girl with CPT-Associated Neurofibromatosis, patient was brought to orthopedic polyclinic complaining bend on her right leg since she was born, the parent also complained her child has abnormality when walking since she was 14 months old. The second case is a 3 year old girl with CPT complaining bend on her right leg, abnormalities and pain when walking since she was aged 1 years 11 months. We performed free vascularized fibular graft for both of the patient. Result: The results in our cases showed bone union in 14 weeks, 16 weeks and 18 weeks respectively. The optimal of technique options should be adapted to the type of pseudarthrosis and especially to the extent of the bone defects. good results can be found with intramedullary nailing with a bone graft or the Ilizarov technique Conclusion: The optimal of technique options should be adapted to the type of pseudarthrosis and especially to the extent of the bone defects Keywords: Congenital pseudarthrosis tibia, Free vascularized fibular graft, case series.

Free Vascularized Fibular Graft

Background: Free Vascularized Fibular Grafts (FVFGs) are currently a mainstay for extreme case reconstruction mainly due to their anatomical characteristics, reliability, and versatility in managing all bone defects cases. Method: This paper is a review article of the journal found by the author suitable for our reference in search engines with the keywords "Free Vascularized Fibular Graft" "surgery" "postoperative" and "complications". Results: FVFG can be used as management of bone defects such as post-trauma, infection or tumor, treatment of congenital abnormalities, avascular necrosis (AVN), arthrodesis, and pediatric pathology. Position Placement, Intercalary Resection, Bone Tumor Resection, Fibula Flap Retrieval, Allograft Preparation, Reconstruction at Recipient Site, and Intra-articular Resection need to be considered in the surgical procedure. Postoperative Monitoring in the ICU is necessary to evaluate Vital signs, flap viability, axle well as complications in patients. Conclusion: FVFG is a choice of bone defect reconstruction techniques with good results to be considered by orthopedic surgeons. Keywords: Free Vascularized Fibular Grafts, FVFG, Surgery post-operative, complication.

Massive Ameloblastoma and Reconstruction with Free Fibular Graft

Aims: To report a case of massive ameloblastoma in mandible with wide excision and reconstruction with free vascularized fibular graft and titanium plate. Case Description: A 49- year-old male patient complained right facial mass since 5 years ago. Patient underwent right hemimandibulectomy with general anesthesia and pathologic examination revealed folliculare ameloblastoma. The large defect after resection reconstructed with free fibular graft. Fibula was osteotomised and resembled with mandible shape and reconstructed by plate with intact pedicle. Care was taken to protect the periosteal branch of the peroneal artery before performing an osteotomy. Shaping of the resected fibula was done according to the preoperative template. A titanium miniplate with locking screws was used to secure the osteotomized fibula and the mandible. To secure the airway, we performed tracheostomy. Followup after operation, patient still got a defect facial asymmetry in right mandible. Discussion: Ameloblastoma is histologically benign but locally aggressive tumor originating from odontogenic epithelium. After hemimandibulectomy, reconstruction continued with microvascular free fibular graft and titanium plate. Osteotomies were performed with the pedicle still attached. Conclusions: Free vascularized fibular graft with titanium plate is preferrably reconstruction option for large defect after wide excision of mandibular ameloblastoma.

Treatment options for infected bone defects in the lower extremities: free vascularized fibular graft or Ilizarov bone transport?

Objective The objective was to explore the relative indications of free vascularized fibular graft (FVFG) and Ilizarov bone transport (IBT) in the treatment of infected bone defects of lower extremities via comparative analysis on the clinical characteristics and efficacies. Methods The clinical data of 66 cases with post-traumatic infected bone defects of the lower extremities who underwent FVFG (n = 23) or IBT (n = 43) from July 2014 to June 2018 were retrieved and retrospectively analyzed. Clinical characteristics, operation time, and intraoperative blood loss were statistically compared between two groups. Specifically, the clinical efficacies of two methods were statistically evaluated according to the external fixation time/index, recurrence rate of deep infection, incidence of complications, the times of reoperation, and final functional score of the affected extremities. Results Gender, age, cause of injury, Gustilo grade of initial injury, proportion of complicated injuries in other parts of the affected extremities, and numbers of femoral/tibial defect cases did not differ significantly between treatment groups, while infection site distribution after debridement (shaft/metaphysis) differed moderately, with metaphysis infection little more frequent in the FVFG group (P = 0.068). Femoral/tibial defect length was longer in the FVFG group (9.96 ± 2.27 vs. 8.74 ± 2.52 cm, P = 0.014). More patients in the FVFG group presented with moderate or complex wounds with soft-tissue defects. FVFG treatment required a longer surgical time (6.60 ± 1.34 vs. 3.12 ± 0.99 h) and resulted in greater intraoperative blood loss (873.91 ± 183.94 vs. 386.08 ± 131.98 ml; both P < 0.05) than the IBT group, while average follow-up time, recurrence rate of postoperative osteomyelitis, degree of bony union, and final functional scores did not differ between treatment groups. However, FVFG required a shorter external fixation time (7.04 ± 1.72 vs. 13.16 ± 2.92 months), yielded a lower external fixation index (0.73 ± 0.28 vs. 1.55 ± 0.28), and resulted in a lower incidence of postoperative complications (0.87 ± 0.76 vs. 2.21±1.78, times/case, P < 0.05). The times of reoperation in the two groups did not differ (0.78 ± 0.60 vs. 0.98 ± 0.99 times/case, P = 0.615). Conclusion Both FVFG and IBT are effective methods for repairing and reconstructing infected bone defects of the lower extremities, with unique advantages and limitations. Generally, FVFG is recommended for patients with soft tissue defects, bone defects adjacent to joints, large bone defects (particularly monocortical defects), and those who can tolerate microsurgery.

Possible Novel Treatment Modality for Non Ossifying Fibroma Neck of Femur

Nonossifying fibromas (NOFs) are benign bone tumors occurring in the second decade of life. Most of the NOFs are diagnosed incidentally on the basis of its presentation on plain radiographs where they typically appear as small, cortical osteolytic lesions with sclerotic margin. They are mostly asymptomatic but can result in pathologic fractures if the lesion involves more than 50% of bone diameter. They are mostly treated with curettage and bone grafting. But in challenging situations where the classical surgery has failed or there is impending fracture of the neck of femur, bone structural support is needed. We are discussing two cases diagnosed as NOFs of intracapsular femoral neck. Both cases underwent curettage of tumor followed by free vascularized fibular graft. Results in both the cases were very gratifying, with complete resolution of symptoms during 1 year of follow-up.

Free vascularized fibular graft in patient with skeletal defect after neurofibroma surgical excision of forearm

The free vascularized fibular graft has been successfully applied as a reconstruction option in patient with large secondary skeletal defects result from excision of pathologic tissue after neurofibroma surgical excision. It provides a strong cortical strut for reconstruction of defects, so that the free vascularized fibular graft is ideal for ulna reconstruction. A 22-year-old male with lump in his right forearm for 3 months previously which become bigger and more painful. There was also sings of ulnar nerve disfunction. From the CPC result, we diagnosed forearm neurofibroma. We performed wide excision and reconstruction using free vascularized fibular graft. On the last follow up, the active and passive ranges of motion (ROM) of 4th and 5th metacarpal was measured with the help of a goniometer. The ulnar neurological state was tested by manual testing and graded on the Medical research council (MRC) scale. Four weeks after surgery, the operation wound at the right forearm and right lower leg was good and no infection signs. The graft viability was good with compromised vascularity. The post-operative passive and active ROM of the 4th and 5th metacarpal able did full extend. The post-operative sensoris level of the ulnar area improved from pre-operative sensoris level.Post-operative follow-up, in the early period (up to 6 weeks) we monitor the graft viability. Our case reported good result in the operation wound, the graft viability, the passive and active ROM of the 4th and 5th metacarpal and the sensoris level of the ulnar area.