Injury, Int. J. Care Injured 44 (2013) S1, S70–S75
Vascularized bone grafts for the management of skeletal defects in orthopaedic
trauma and reconstructive surgery
Panayotis N. Soucacosa,*, Zinon T. Kokkalisa, Mara Piagkoub, Elizabeth O. Johnsonb
aOrthopaedic Research and Education Center (OREC), Attikon University Hospital, University of Athens, School of Medicine, Athens, Greece
bDepartment of Anatomy, University of Athens, School of Medicine, Athens, Greece
A R T I C L EI N F O A B S T R A C T
Vascularized fibular graft
Bone lossfromtrauma, neoplasia, reconstructivesurgery and congenital defects remains a major health prob-
lem. The long-term clinical goal is to reconstructbony tissue in an anatomically functional three-dimensional
morphology. In the extremities, bone grafts are used for the treatment of non-unions and necrotic lesions,
for skeletal structural support and for the reconstruction of defects resulting from trauma, tumor excision,
osteomyelitis, congenital pseudarthrosis, or radiation necrosis. In all cases their use is successful provided
that the host bed has adequate vascularization. In cases of decreased blood supply, a vascularized bone graft
should be applied. The intrinsic blood supply of the vascularized bone grafts leads to higher success rates and
to acceleration of the repair process in the reconstruction of defects and necrotic lesions of the skeleton.
© 2013 Elsevier Ltd. All rights reserved.
Large bone defects can be primary, related to high energy trauma
with extensive bone loss, or result secondarily from the excision of
pathological tissue from atrophic non-union, chronic osteomyelitis,
congenital pseudarthrosis, or resection of bone tumours.1,2Bone
loss related to disease or trauma has been traditionally managed
with bone grafts, including allografts and autografts. Recent ad-
vances regarding their application reflect current understanding of
osteoconduction; the ability of a bone graft to act as a scaffold and
host osteoblasts to synthesize bone through the process of creeping
substitution. Fresh autologous bone grafts, particularly cancellous
bone, have osteogenetic properties provided by osteoinductive
growth factors, osteogenic cells and structural scaffold.3Autologous
grafts support all aspects of bone regeneration (osteoinduction, os-
teoconduction and osteogenesis) at the recipient site, and as such,
are considered superior for promoting bony healing.4Bridging large
bone defects by avascular grafts involves creeping substitution,
with cells migrating from the well-perfused resection and junction
area into an almost acellular matrix. This is related to the fact that
osteobalsts are not able to survive in biological surroundings with
low oxygen tension. Thus, the use of avascular grafts requires not
only time, but also bears a high risk for complications, including
bone atrophy, transplant fracture and non-union.3,5
Avascularity of the remaining environment is now recognized
as a central component of the pathogenesis following large bony
* Corresponding author: Professor Panayotis N. Soucacos, MD, FACS, Orthopaedic
Research and Education Center (OREC), Attikon University Hospital, University of
Athens, School of Medicine, 1 Rimini Street 12462, Chaidari, Athens, Greece. Fax:
E-mail address: firstname.lastname@example.org ().
0020-1383/$ – see front matter © 2013 Elsevier Ltd. All rights reserved.
defects induced by high energy trauma, chronic osteomyelitis, tu-
mor resection and bony non-union.6Successful bone grafting is
dependent upon the host bed having adequate vascularization. Vas-
cularity has been identified as a central component of influencing
bone healing, and hence, plays a key role to achieve good graft
repair. In cases of decreased blood supply, the choice of a vascular-
ized bone graft seems inevitable, as bone grafts with intrinsic blood
supply lead to higher success rates and to acceleration of the repair
process in the reconstruction of defects and necrotic lesions of the
With the advancement of microsurgical techniques, the trans-
plantation of bony tissue with its nutritional vascular pedicle has
become a reliable option as effective bone void fillers. Free mi-
crovascular bone transfers are used to cover large bony defects
from a variety of factors that cannot be bridged by conventional
techniques. In contrast to non-vascularized bone grafts, the blood
supply is preserved with vascularized grafts by the anastomosis
of the feeding artery of the graft to a host artery. It is believed
that preserving the arterial blood supply of the periosteum and en-
dostium enables primary healing as induced by vital osteoblasts.7
Thus, the graft does not undergo necrosis and revascularization
takes place both by anastomosing the vascular bundle of the host to
the recipient vessels and by support from the surrounding vascula-
ture. Vascularized and cancellous autografts show optimal skeletal
incorporation. The additional advantage of harvesting vascularized
bone grafts in combination to skin and/or muscle offers solution to
complex problems in skeletal/soft-tissue defect reconstruction.
Donor sites of vascularized bone grafts include the iliac crest,
the ribs and the fibula. In the herein study we report on the use
of vascularised fibula graft in clinical conditions related to the
discipline of trauma and orthopaedic surgery.
P.N. Soucacos et al. / Injury, Int. J. Care Injured 44 (2013) S70–S75
Vascularized fibular graft
The fibula is one of the most frequently used donor bones
for free vascularized bone transfers. Because of its size (up to
26 cm),configuration and ability to promote early remodeling and
hypertrophy, it lends well to reconstruction of long bones large
defects. In addition to segmental bony defects,8the vascular fibular
graft has been applied for the treatment of osteomyelytis,9bone
loss after resection of tumors,10,11kyphosis,12and congenital
pseudarthrosis of the tibia.9
The vascularized fibular graft provides an anatomically favorable
substrate for bridging large gaps particularly in the upper extremity.
In particular, the size and shape of the free fibula graft are favorable
for defects of the humerus and forearm bones. The anatomic
shape and size of the fibula matches the radius and ulna almost
exactly, while it fits into the medullary canal of the humerus. This
anatomical match results in less need for hypertrophy and early
return of function, as once both junction sites have healed, the arm
is immediately functional.
The graft can be free or pedicled, with the peroneal artery and
veins providing an adequate vascular pedicle. The length of the
pedicle can range from 3 to 5 cm, and the diameter of these vessels
(peroneal artery – 1.5–2.2 mm) and dominant veins (2.5–4.0 mm)
allows for good anastomses. The fibular graft has a dual vascularity.
The double vascularity of fibula with endosteal and periosteal
vessels, enhances the biology at the recipient site and significantly
improves healing.The endosteal vascular supply is provided by the
nutrient artery, which typically enters the posterior fibular cortex
at the junction of the proximal one-third and distal two-thirds. The
nutrient artery is a branch of the peroneal artery that runs along
the posterior aspect of the fibular diaphysis. The periosteal supply
is provided numerous musculo-periosteal vessels that also branch
off from the peroneal artery.
The vascularized fibular graft also has a unique versatility, and
can be used as an osseous flap or as a composite flap with skin and
fascia, with muscle or with the growth plate.
The vascularized fibular graft presents several advantages to
the biology of bone healing. First the vascularity and viability of
the graft is maintained. Creeping substitution is bypassed, and the
stronger mechanical properties allows for faster incorporation and
graft hypertrophy. In cases where it is applied for neoplasms etc,
it allows for the radical excision of the pathological tissue, which
prevents recurrence and improves prognosis. Vascularized fibular
grafting for bone defects is also associated with several disadvan-
tages. The microsurgical technique is demanding and the procedure
is time-consuming. Vessels are sacrificed, and the progress of bony
healing and vascular viability are both difficult to monitor.
Remodelling of the graft, incorporation and hypertrophy are
dependent on the immediate restoration of the vascular supply
after anastomosis. Hypertrophy of the vascularized bone graft is
frequent finding has distinctive radiographic features. Vascularized
autografts are more likely to achieve union, less likely to undergo
cortical bone resorption, and less likely to sustain stress frac-
tures than avascular autografts are. These properties are especially
important when it is necessary to bridge a gap greater than 6 cm.13
Reconstruction of large bone defects in the upper extremity
with the use of vascularized fibular graft has been shown to be
associated with graft healing in up to 92% of the junction sites
after an average of 3 months, and excellent functional outcome is
observed in 83.3% of the cases.14Overall, large skeletal defects in
the upper extremity were found to be effectively reconstructed with
the free vascularized fibular grafts, even in the presence of poor
vascularity of the surrounding soft tissue envelope or infection,
which would compromise alternative methods.14
An important modification of the free vascularized fibular graft
involves a transverse osteotomy made from the anterolateral aspect
of the fibular shaft just distal to the entry of the nutrient artery.15
This produces two vascularized bone struts that may be folded
parallel to each other but that remain connected by the periosteum
and muscle cuff surrounding the peroneal artery and vein. The
proximal strut is vascularized by both a periosteal and an endosteal
blood supply, whereas the distal strut is vascularized by a periosteal
blood supply alone. This so-called “double barrel” free vascularized
fibular graft can be employed in patients with segmental bone
defects with adjacent bony defects of the radius and ulna, or for
large bones such as the femur or tibia.
Skeletal defects are a major challenge, especially when combined
with soft tissue loss. The question of salvage versus amputation
is hard to resolve for the upper extremity. As on the on hand,
amputation will result in the total loss of function, and prostheses
for the upper extremity have not been as satisfactory as for the
Gustlilo’s types IIIB and IIIC open fractures of the lower extrem-
ity are often associated with combined bony and soft tissue defects
that cannot be reconstructed with conventional methods.16,17Sec-
ondary defects may also result after wide excision of pathologic
tissue in case of septic or aseptic non-union. The reconstruc-
tion of these lesions involves aggressive debridement of infected
and devitalized tissue, primary stabilization with external fixation,
early soft-tissue coverage with local muscle flaps or free muscle
transfers, and delayed bone grafting. Skeletal reconstruction can
be accomplished by several methods including Papineau grafting,
non-vascularized and vascularized autografts, and bone transport
For patients with bone defects larger than 6 cm vascularized
fibular grafting is indicated. When massive bone loss is associated
with small or large skin defect, an osteoseptocutaneous fibular flap
simultaneously, or latissimus dorsi myocutaneous flap first followed
by a vascularized fibular graft are indicated, respectively.18
The timing of bone grafting remains controversial. According to
some, large open fractures are contaminated with bacteria.19Thus,
the defect should be reconstructed after wound control to ensure
a non-infected soft-tissue envelope, capable of providing adequate
vascular support. This entails a two-stage reconstruction, where the
bony defect is reconstructed 6 to 8 weeks after successful soft-tissue
management. In contrast, the advocates of a one-stage procedure
believe that patients with combined bone and soft-tissue defects
can be treated with an osteoseptocutaneous or osteomuscular
fibular graft immediately after radical debridement of the lesion
site.20The advantages of this procedure include simultaneous bone
and soft-tissue reconstruction, early bone stability, stimulation of
bone union and decreased time for bone healing, prevention of
soft-tissue and vessel scarring, and increased rate of infection
Delayed union is defined as an abnormal slowing of the fracture
healing process, which nonetheless will continue to completion
with time. Non-union is defined as a complete ceasation of the
healing process after about 6–9 months. Assuming that mechanical
stability is optimal, an inadequate blood supply of the fracture
site is considered as the primary contributor to the development
of delayed union and non-union.5,21Once the normal fracture
healing process has been slowed or stopped, two conditions
are necessary in order to establish union. One requirement is
stability, and the second prerequisite is a biological stimulus for
the fibrocartilagenous callus to finish the healing process. One such
biologic stimulus is bone graft material, such as fresh autologous
P.N. Soucacos et al. / Injury, Int. J. Care Injured 44 (2013) S70–S75
bone grafts, particularly cancellous bone, which have osteogenetic
properties from the cells that survive the procedure.22
The factors that contribute to delayed union or non-union are
complex can be divided into three major categories: deficiencies
in vascularity, deficiencies in the robustness of the chondroosseous
response, and deficiencies in stability. For a bone graft to enhance
bone healing, it must help alleviate the primary causing factor.
The various types of grafts used today, ranging from autogenous
fresh cancellous to cortical bone and free vascularized grafts, have
demonstrated varying capacities to induce active bone formation
or to serve as a substrate for bone formation. These capacities are
tightly dependent upon the surrounding environment, particularly
the mechanical and vascular environment.23
Vacularized bone grafts have been used to manage recalcitrant
posttraumatic shaft non-union of long bones. The vascularized
fibular graft can be effectively used for patients with large bony
defects and with poor intrinsic stability of the non-union site.1,8
Pedicled vascularized bone grafts enables the transfer of bone with
preserved circulation and viable osteoclasts and osteoblasts. This
type of grafting procedure allows for primary bone healing without
creeping substitution within the dead bony tissue, and assists in
promoting the healing process, replacing deficient bony tissue and
revascularizing ischemic bone.
Free vascularized fibular grafting has been proven a valuable tool
in managing aspectic or infected non-unions with an impressive
success rate.1,8In most cases, these non-unions are complicated
with previous surgical procedures, bone atrophy, damage to the
surrounding soft tissues, as well as focal infection. These prob-
lematic cases require thorough bone and soft tissue debridement,
before bridging of the bony defect with the vascularized fibula graft
Osteonecrosis of the femoral head is a particularly recalcitrant
disease of the human skeleton in which bone death usually
progresses to structural failure leading to collapse of the femoral
head. It has the tendency to affect young adults between 20 and
Fig. 1. A. Malunion and nonunion of distal third of both bones of the forearm in female patient. B. Solid healing of both bones of the forearm was achieved following the
use of a double-barrel vascularized free fibular graft. C, D. Satisfactory functional results were achieved in terms of pronation, supination, flexion and extension of the wrist.
50 years of age and it shows a devastating progression, despite
treatment, which in most cases results in degenerative arthritis
of the hip.24,25Today, treatment is based not on knowledge of
the pathogenesis and disease prevention, but rather on end-stage
changes of the bone.
It is well recognized that without specific treatment approxi-
mately 75% of hips with clinically established osteonecrosis will
show radiologic and clinical progression. Among the several pro-
phylactic procedures, which have been used in the earlier stages
of the disease in an attempt to impede progression and stimulate
repair, is the free vascularized fibular graft. Several studies have
evaluated microsurgical salvage of the hip joint by implantation of
a vascularized fibular graft, augmented with cancellous bone, into
the curetted core of the femoral head, which has been affected
by aseptic necrosis.24,25The microsurgical procedure was found to
induce new bone formation, which fused with affected subchondral
bone, preventing the collapse of the articular surface. The free
vascular fibular graft was shown to be an excellent alternative
for salvage of the hip in the management of osteonecrosis of the
Management of osteonecrosis of the femoral head with a free
vascularized fibular graft accomplishes several objectives. It allows
for decompression of the femoral head, which in turn may interrupt
the cycle of ischemia and interosseous hypertension believed to be
primary etiologic factors. This microsurgical procedure also removes
the necrotic bone, which may inhibit revascularization, as well as
fills the defect with cancellous bone, which is osteoinductive. With
the nutrient blood supply preserve, osteocytes and osteoblasts with
the graft can survive, and incorportaion of the graft to the recipient
bone is facilitated without the usual replacement of the graft by
creeping substitution. Finally, the procedure places a viable cortical
bone strut which supports the subchondral surface and enhances
We have described 228 hips in 187 patients who underwent
fibula grafting for osteonecrosis of the femoral head, of which 184
were assessed at a mean follow-up of 4.7 years using the Steinberg
classification system. A total of 101 hips (55%) did not progress,
while 69 (38%) demonstrated progression. Only 14 hips (8%) were
P.N. Soucacos et al. / Injury, Int. J. Care Injured 44 (2013) S70–S75
Fig. 2. Characteristic examples of the successful application of vascularized free fibular graft for the management of avascular necrosis of the femoral head. A. 19 year
post-operative radiograph shows no further subchondral plate collapse after without narrowing of the joint space following treatment of bilateral avascular necrosis (Stage
1) in a young male patient with vascularized fibular grafting. B. 21 year postoperative radiograph showing no further deterioration of the osteonecrotic area in a female
patient with Stage II avascular necrosis treated with a vascularized fibular graft.
converted to total hip replacement. Patients who had stage 2
osteonecrosis had signigicatnly better results than those with stage
5 disease. Specifically, 95% of the hips with stage 2 osteonecrosis
did not progress, compared to 39% of the stage 5 hips25(Fig. 2).
The success of free fibular grafting in the management of
osteonecrosis may be related to decompression of the femoral
head, which in turn may halt the ishaemia caused by increased
intraosseous pressure; excision of the necrotic bone beneath the
weight-bearing region that might inhibit revascularisation of the
femoral head; and buttressing the articular surface with the vascu-
larised graft by primary callus formation, augmented by cancellous
bone graft which has both osseoinductive and osseoconductive
Management of chronic osteomyelitis remains a challenge,
mainly because of alterations in bacterial flora and appearance of
resistant bacteria. Systematically delivered antibiotic cannot easily
reach the septic area due to the presence of a biologically inactive
bone surrounding by scarred tissue. Radical debridement of the
infected foci is the mainstay of treatment of osteomyelitis.26
A staged procedure should be performed in case of infection. The
first stage includes removal of all hardware, if any, and extensive
debridement of infected and devitalized bone back to bleeding one.
Bone curettage should be followed by resection of surrounding
scar and granulation tissue to healthy bleeding soft-tissue. Samples
of all tissues should be sent for aerobic, anaerobic, fungal, and
mycobacterial cultures. The resulting bony defect is filled with
antibiotic-impregnated polymethylmethacrylate beads or spacer.
Stabilization is accomplished with external fixation at the same
time. Intravenous antibiotics are administered according to the
microbiological sensitivity tests, usually for 3 to 6 weeks, and the
patients are monitored for subsidence of the inflammation. Free
vascularized fibular grafting is performed in a second stage, after
1 to 3 weeks, when clinical and laboratory signs of infection are
absent, combined with flexor hallucis longus or soleus muscle flap
in patients with large skin defects after radical debridement.
Free fibula transfer allows the surgeon to perform complete
resection of the infected tissue with the confidence that union
can be achieved regardless of the length of the subsequent defect.
Incorporation of the graft may be accomplished irrespective of the
presence of avascular soft-tissue bed. In addition, by increasing
vascularity and blood supply, vascularized fibular graft enhances
antibiotic and immune components delivery to the recipient site.27
Congenital pseudarthrosis of the tibia is characterized by an-
terolateral bowing of the tibia and recurrent fractures of the tibia
and/or fibula. Treatment alternatives for this difficult paediatric
condition include bone electric stimulation, intramedullary fixation,
vascularized or non-vascularized grafts, Ilizarov technique, and re-
combinant bone morphogenetic proteins. Free vascularized fibula
transfer is considered an adequate method for both correction of
the tibial deformity and recurrence prevention in a single operation.
It combines complete excision of the abnormal tissue and primary
lengthening of the tibia. It is the most acceptable treatment modal-
ity for Boyd type II pseudarthrosis in which extensive bone and
soft-tissue resection is required. While some suthors propose the
use of fibular grafting for defects greater than 3 cm, or when pre-
vious techniques have failed,28others propose that the vasculared
fibular graft should be the primary treatment as it avoids residual
limb-length discrepancy and ankle pain resulting from multiple
Although rare, bone sarcomas, such as osteosarcoma and Ew-
ing’s sarcoma, are most often highly malignant. New improved
treatment regimens have now increased the five-year survival rate
in patients with non-metastatic disease to above 70%.30Today,
it is possible to perform bone tumour resections as limb-sparing
surgery in more than 80% of all cases, and without increased
mortality.31Reconstruction of bony defects after tumor excision
is challenging, particularly since en bloc resection can potentially
lead to pathological fractures and articular surface’s collapse. Re-
construction procedures after lower extremity long bone sarcoma
resection include massive allografts, endoprosthesis, bone transport
techniques, vascularized and non-vascularized bone autografts. The
two most acceptable biological reconstructive techniques for large
intercalary defects caused by primary malignancy resection include
the use of massive allografts and free fibular flaps (Fig. 3). Massive
allografts have a high complication rate including infection, frac-
ture, and non-union.32Although fibular flaps had the advantage of
increasing hypertrophy and high rate of bone union, inadequate
P.N. Soucacos et al. / Injury, Int. J. Care Injured 44 (2013) S70–S75
Fig. 3. A. Recurrence of giant cell tumor following multiple previous unsuccessful attempts at management using cementation and wide local resection. B. Satisfactory
results were achieved with vascularized free fibular grafting following wide excision of the distal third of the radius.
fixation between the fibula and host bone and subsequent stress
fracture during remodelling were reported.33The trend towards
higher chemotherapy doses in patients with sarcoma, has been
associated with healing problems, fractures and infection,34all of
which are related to the avascularity of the bone.35In contrast to
non-vascularized autografts and allografts, graft–host union can be
achieved even in the presence of an irradiated bed or in patients
treated with chemotherapy.36
To reconstruct large bony defects, Capanna proposed combining
allograft with a free fibular flap,37to produce a construct with the
immediate mechanical strength of the allograft, and the potential
for revascularization and remodelling of the vascularized fibula.
In cases of femur or proximal tibia reconstruction, both double
barreled fibula and hybrid graft are the preferred methods of
treatment. Double-barreled fibula is the method of choice when the
expected stress loads are intermediate and the bony defect is less
than 13 cm. Otherwise, the combination of a vascularized fibular
graft with a massive allograft is indicated. The combination of the
mechanical properties of the allograft with the biological properties
of the vascularized fibular graft is a very promising technique.
In a series of 144 reconstructions after resection of malignant
bone tumor of limbs, 103 patients were treated with combination
of free fibular graft with massive bone allograft.38The overall
functional results were excellent in 48% of the patients (69/144),
good in 27% (36/144), and fair or poor in 25% (39/144). Our results
of limb-sparing surgery and reconstruction of bone defects with
vascularized fibula grafts in patients with neoplasms have also been
encouraging with acceptable clinical results.14
In the extremities, bone grafts are used for the treatment of
non-unions and necrotic lesions, for skeletal structural support and
for the reconstruction of defects resulting from trauma, tumor exci-
sion, osteomyelitis, congenital pseudarthrosis, or radiation necrosis.
The success of the free vascularized fibula is related to its unique
vascularity, morphology and composition of the graft. The applica-
tion of the free vascularized fibular graft is technically demanding,
requiring meticulous microsurgical technique. Nonetheless it can
provide a useful solution for the reconstruction of skeletal defects
of more than 6 cm, especially in cases of scarred and avascular
recipient sites, or in patients with combined bone and soft-tissue
defects. The ability to fold the free fibula into two segments or to
combine it with massive allografts is a useful technique for recon-
struction of massive bone defects of the femur or proximal tibia. It
can also be transferred with skin, fascia, or muscle as a composite
flap. Overall, the intrinsic blood supply of the vascularized bone
grafts leads to higher success rates and to acceleration of the repair
process in the reconstruction of defects and necrotic lesions of the
Conflict of interest
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