Free fibula flap for humerus segmental reconstruction: report on 13 cases.

Abstract

In the period between 1994 and 2004, 13 patients (10 male, 3 female) presenting with post-traumatic defects to the humerus were treated with vascularised fibula graft. Age ranged from 21 to 62 (mean 37) years. Length of the bony defect ranged from 6 to 16 cm. Graft fixation was performed with plates in 12 cases, and in one case only screws were used. All patients were clinically reviewed between 120 days and 14 months after surgery. In one patient the flap was lost and a second free fibula flap was performed to achieve the reconstructive goal. Mean time for segmental bony union was 6 months (range from 3 to 13 months). Vascularised fibula graft allows for a successful humerus reconstruction when traditional techniques provide unsatisfactory results.

Full text

Page 1

Abstract In the period between 1994 and 2004, 13
patients (10 male, 3 female) presenting with post-trau-
matic defects to the humerus were treated with vascu-
larised fibula graft. Age ranged from 21 to 62 (mean 37)
years. Length of the bony defect ranged from 6 to 16 cm.
Graft fixation was performed with plates in 12 cases, and
in one case only screws were used. All patients were clin-
ically reviewed between 120 days and 14 months after
surgery. In one patient the flap was lost and a second free
fibula flap was performed to achieve the reconstructive
goal. Mean time for segmental bony union was 6 months
(range from 3 to 13 months). Vascularised fibula graft
allows for a successful humerus reconstruction when tra-
ditional techniques provide unsatisfactory results.
Keywords Humerus · Segmental bony defects ·
Vascularised fibula graft
Introduction
Humerus fractures account for 5%–8% of all skeletal
fractures, and for about 10% of long bone fractures [1].
Despite recent significant progress in the management of
those fractures, the incidence of non-union to the diaphy-
seal shaft remains fairly high, being 2%–10% after a con-
servative approach and up to 15% after surgical manage-
ment [1–9].
Fracture non-union or delayed union frequently occur
after high-energy traumas associated to significant bony
tissue loss, or when infection is not avoided (open fracture,
inadequate debridement, etc.). Inappropriate fixation is
also associated to a high incidence of skeletal non-union
[6, 10–15]. Overweight, abuse of drugs, alcohol, smoke,
bone osteoporosis and immunodepression are to be con-
sidered risk factors for impaired bone union [6, 13, 15].
A number of surgical options for the treatment of
humerus diaphyseal bony non-union have been described
over the years. Among those, bone nailing [11, 16, 17],
use of external fixators such as Ilizarov apparatus [13,
18–21] and compression plates associated to non-vascu-
larised bone graft represent the standard armamentarium
for the orthopaedic surgeon [9, 14, 22]. In many circum-
stances the aforementioned techniques provide satisfac-
tory results, and bone healing is achieved in 82%–95% of
cases according to different series [12]. However in a
number of cases fracture healing does not occur, often
because of technical errors determining inadequate
reduction and or fixation. Persistent infection [13] and
especially bony defects greater than 6 cm [23, 24] repre-
sent critical factors in suggesting different technical
approaches. This study investigates the role of vascu-
larised fibula graft for reconstructing the humerus dia-
physeal shaft.
Chir Organi Mov (2008) 91:21–26
DOI 10.1007/s12306-007-0004-5
O R I G I NA L A RT I C L E
Free fibula flap for humerus segmental reconstruction:
report on 13 cases
Roberto Adani • Luca Delcroix •
Marco Innocenti • Luigi Tarallo •
Alessio Baccarani
Received: 18 April 2007 / Accepted: 09 November 2007
© Springer-Verlag 2008
R. Adani (?) · L. Tarallo · A. Baccarani
Dipartimento Integrato di Emergenza-Urgenza
Clinica Ortopedica e Traumatologica
Azienda Ospedaliera Universitaria Policlinico di Modena
Università degli Studi di Modena e Reggio Emilia
Largo del Pozzo 71, 41100 Modena, Italy
e-mail: adani.roberto@unimo.it
L. Delcroix · M. Innocenti
SODS Microchirurgia
Azienda Ospedaliero-Universitaria Careggi
Florence, Italy

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Methods
From January 1994 to December 2004, 13 patients
underwent microsurgical reconstruction of the humerus
diaphyseal shaft with free fibula. Ten patients were male
and 3 were female. Mean age was 37 (range from 21–62).
In 7 cases the left upper extremity was involved. Car
accident (Table 1) was the main aetiology for humeral
fractures (11 cases out of 13). One case was a press
injury and one was a gunshot. Open reduction and inter-
nal fixation (ORIF) with plates was performed in 5 cases;
patient 2 had a bone nailing and patient 3 had a close
reduction and external fixation (CREF). Two patients had
conservative treatment with immobilisation and in one
case a “minimal” fixation with wiring was performed.
All patients developed a bone non-union and as a con-
sequence underwent additional surgical procedures either
to debride the fracture site or to resolve the non-union.
The number of surgeries varied from 2 to 5, with a mean
of almost 3 procedures per patient. Regardless of the dif-
ferent possible aetiologies, 8 patients developed
osteomyelitis. Time delay from the initial trauma to the
reconstructive procedure varied from 4 months to 130
months (mean 37.2 months). The humerus was recon-
structed in 1 case at the proximal third, in 8 cases at the
middle third and in 4 cases at the distal third. The length
of the bony defect to be restored was from 6 to 16 cm
(mean 10.5) (Table 2). In only 1 case a skin island was
harvested together with the fibula flap to reconstruct a
soft tissue defect to the injured arm.
22Chir Organi Mov (2008)
Table 1 Preoperative evaluation
Case Age (years)SexMechanism of injuryInitial treatmentPrevious operationsInfection
1
2
3
4
5
6
7
8
9
10
11
12
13
62
41
25
35
46
35
31
51
30
26
21
28
53
M
M
M
M
M
M
F
F
M
M
M
M
F
RTA (car)
Crush trauma
RTA (car)
RTA (car)
RTA (motorcycle)
RTA (car)
RTA (car)
RTA (motorcycle)
RTA (motorcycle)
Gun shot lesion
RTA (car)
RTA (car)
RTA (car)
Plaster cast
ORIF
ORIF
ORIF
Intramedullary nail
ORIF
Intramedullary nail
ORIF
Plaster cast
External fixator
External fixator
External fixator
Cerclage wire
2
5
4
3
3
4
2
2
2
2
2
2
4
No
Yes
Yes
Yes
No
Yes
No
No
No
Yes
Yes
Yes
Yes
RTA, road traffic accident
Table 2 Preoperative evaluation
CaseInjury/
VFG
(months)
Level
of bone
defect
(thirds)
Graft
length
(cm)
Graft fixationAnastomosesAdditional
procedures
Prox Dist
1
2
3
36
30
23
27
L middle
L middle
R middle
L middle
7
14
10
10
LCP
Reconstruction plate+screws
DCP
LCP
End-to-end deep brachial a.
End-to-side brachial a.
End-to-end deep brachial a.
End-to-side brachial a.
New plate 4
+ bone graft
5
6
7
8
33
34
50
48
L middle
R middle
L middle
L middle
9
12
7.5
8
DCP+screws
LCP
DCP
DCP
End-to-end deep brachial a.
End-to-side brachial a.
End-to-end elbow a.
End-to-side brachial a.
Distal bone graft
New plate
+ bone graft
9
10
11
12
130
26
5
4
R distal
R proximal
L distal
R distal
6
11
15
16
Reconstruction plate+screws
Reconstruction plate
DCP
Reconstruction plate+screws
+ext. fixator
Screws
End-to-end elbow a.
End-to-side brachial a.
Reconstruction plate a.
End-to-end elbow a.
End-to-end ulnar
New VFG
13 38 R distal11 End-to-side brachial a.
L, left; R, right

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23Chir Organi Mov (2008)
Fibula fixation was carried out with bridging plates in
11 cases: Dynamic Compression Plate (DCP) in 4 patients
and Locking Compression Plate (LCP) in 3 patients. In 4
cases reconstruction plates were used. Patient 11 had a
DCP plate proximally and a reconstruction plate distally.
In patient 13 bone fixation was achieved only with screws
both proximally and distally. Microvascular anastomoses
were performed using as a recipient vessel the deep
humeral artery (end to end – 3 cases), the humeral artery
(end to side – 6 cases), the recurrent ulnar artery (end to
end – 3 cases) or ulnar artery (end to end – 1 case).
Results
All 13 patients were reviewed between 120 days and 14
months after surgery. In 4 cases additional surgeries were
required to achieve fracture consolidation at the interface
between the graft and the humeral stumps. In patient 6 a
cancellous bone graft was performed at the distal interface
5 months after the initial surgery. Also in patient 8 a cancel-
lous bone graft was inserted at the distal interface together
with plate removal and new osteosynthesis (Table 2).
Patient 3 developed a fracture to the fibular shaft
associated to plate rupture 10 months postoperatively,
after apparent consolidation. In this case surgery implied
hardware removal, new synthesis with an LCP plate and
cancellous bone grafting. Bone healing was achieved
after 3 months (Table 2).
In patient 12 the free fibula flap failed because of vascu-
lar impairment to the pedicle. A second fibula flap was thus
harvested and a successful reconstruction was achieved, after
performing a non-vascularised bone graft at the distal inter-
face,where a delayed union occurred. In all the other patients
a stable fracture consolidation was achieved both proximally
and distally between 3 and 6 months postoperatively with no
need for additional surgeries (Table 3). Mean time for bone
healing was 6 months in this series (range 3–13 months).
Patients were reviewed according to Tang’s scoring
system, which evaluates both clinical and radiological
outcome (Table 3) [25].
According to Tang’s scoring system the following
results were obtained:
–Excellent clinical evaluation in 7 patients, good in 6.
No patient showed fair or poor results.
–Excellent radiographic evaluation in 8 patients, good
in 1, fair in 4. No patient had a poor result.
Discussion
Bony defects of the humerus can be treated by a number
of traditional surgical options: bone nailing [16], com-
pression plates with or without non-vascularised bone
grafts [14] and external fixation [13]. Non-vascularised
iliac crest bone grafts are qualified in the management of
defects smaller than 5–6 cm in length, in the presence of
well perfused soft tissue with no active infection [26, 27].
With advancements in microsurgical techniques, vascu-
larised bone grafts have become well established techni-
cal resources capable of providing solutions to difficult
reconstructive challenges. The use of free fibula flap in
the treatment of humerus diaphyseal non-unions has also
gained increased popularity over the last few decades
[28]. The reason for this is twofold. First, an increased
vascularity at the fracture site is essential in promoting a
faster bone healing process and in antagonising infections
[14]. Second, a vascularised bone provides higher biome-
chanical strength than a non-vascularised bone [27].
Free fibula flap in humeral shaft reconstruction is a
useful and versatile procedure for defects greater than
6–8 cm [29]. It has been demonstrated that, when appro-
Table 3 Postoperative evaluation
CaseGraft union Time of bone union
(months)
Functional recovery
(Tang criteria)
X-ray evaluation
(Tang criteria)
Prox Dist
1
2
3
4
5
6
7
8
9
10
11
12
13
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
3
3.5
13
6
5
9
3
8
4
3
3
12
3.5
Excellent
Excellent
Excellent
Good
Good
Good
Excellent
Good
Excellent
Excellent
Excellent
Good
Good
Excellent
Excellent
Fair
Good
Excellent
Fair
Excellent
Fair
Excellent
Excellent
Excellent
Fair
Excellent

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24Chir Organi Mov (2008)
priate blood perfusion is restored to the flap, the proxi-
mal and distal fracture sites have the same healing poten-
tial of a bifocal fracture with no bone tissue loss, and
with no vascular impairment to the central segment.
Accurate patient selection with a careful clinical eval-
uation is essential in order to reduce the complication rate.
Chronic infections,diabetes,
(patients 6 and 12), alcohol, tobacco, drug abuse and obe-
sity (patient 3) are to some extent relative contraindica-
tions to the procedure [6]. Furthermore, the local wound
conditions, the aetiology of trauma and the outcome of
previous surgeries should also be carefully considered.
We consider the standard indication for a humerus
reconstruction with a free fibula graft to be a patient pre-
senting with chronic non-union, associated to bone atro-
phy, soft tissue scars and uneffective hardware [29]
(Figs. 1 and 2).
Because of its constant vascular anatomy, length and
diameters the fibula allows for an ideal humeral shaft
reconstruction. Moreover, donor site morbidity is insi-
gnificant if the harvest is properly performed.
As there is still controversy regarding the opportuni-
ty of performing a one-stage procedure [27, 29], it is our
immunosuppression
contention that the free flap should not be inset before
having accurately debrided the recipient site, in case of
infection [30] (Fig. 2).
The overall success rate of the procedure estimated
from the literature varies from 76% to 100% , with a
healing time ranging from 3.5 to 9 months [31]. From a
meta-analysis of 13 different series involving 317 recon-
structions [29], the mean time for fracture consolidation
appeared to be 5.5 months in 87% of patients. In cases of
severely injured limbs complicated by infection and
large bony defects the success rate of the reconstruction
was lowered to 71.5%. Our results do not differ much
from the data reported in the literature, as our mean heal-
ing time turned out to be 6 months.
Once positioned into the recipient site, the fibula is
capable of undergoing a remodelling process which
allow the new functional load to be sustained. This trans-
lates radiographically into a hypertrophy. A number of
parameters such as the age of the patient, vascular con-
dition and the type of hardware used for fixation may
influence this process [32].
Among different possible complications, stress fractures
to the graft represent quite a common event, which may be
Fig. 1 Clinical case no. 1. a,b Clinical and X-ray aspect preop. c Intraoperative view: arterial anastomosis between the peroneal artery and
the deep brachial artery. d X-ray result at the end of operation. e,f,g Clinical and radiological aspect at the follow-up
a
defg
bc

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a
defg
bc
Fig. 2 Clinical case no. 2. a X-ray aspect at the preop. b,c Intraoperative view: a fibular osteoseptocutaneous flap was harvested and bone
reconstruction was achieved using a reconstruction plate. d,e Aspect of the reconstructed arm and donor site result two weeks after surgery.
f, g Clinical and radiological result at the follow-up
abc
Fig. 3 Clinical case no. 13. a,b,c Recurrent fracture of the reconstructed arm treated with cast
associated with hardware rupture in 15%–20% of the cases
[10, 30, 33, 34]. Those events usually occur within the first
12 months after surgery. Patient 3 had a traumatic fracture of
the graft and of the plate 10 months postoperatively. A new
fixation was achieved using an LCP reconstruction plate,
and a cancellous bone graft was also applied to the fracture.
Definitive consolidation occurred in 3 months.
Patient 13 had a double fracture to the fibula treated
conservatively with immobilisation (Fig. 3). This fracture
was determined by an inappropriate fixation with screws
only. The successful final outcome demonstrates the
osteogenic potential of the vascularised fibula [35].
It is currently our conviction that the fixation of the graft
should be performed when possible with a single bridging
reconstruction plate to ensure maximal stability [36]. New
generation LCP plates adequately fulfil this requirement.
Other complications associated to the procedure are:
secondary infections, delayed unions, recurrent non-
25 Chir Organi Mov (2008)

Page 6

unions, transitory palsy to the radial nerve and vascular
impairments to the flap pedicle. These complications
occur in 7–10% of cases [33, 34]. Complications to the
donor site are rare and of little impact [29].
In conclusion, vascularised fibula graft represents a
valid reconstructive option to be considered once tradi-
tional management has proven to be ineffective.
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