Introduction and Aims: The treatment of bone defects secondary to congenital pseudoarthrosis of the tibia, infections and tumors is problematic. The vascularised fibular graft has been used for many years as a way to improve blood supply and successfully achieve union. Lengthening the limb prior to grafting can improve outcomes. Method: Forty-one patients with major bone defects secondary to tumor resections, infections and congenital pseudoarthroses had reconstruction with a vascularised fibular graft. Of these, 10 patients had limb length discrepancies, which were treated by application of an external fixater for lengthening through the bone gap. Following restoration of length with an external fixater, a vascularised fibular graft was inserted to bridge the bone defect. The external fixater was not removed until union of the graft to the host bone and initial hypertrophy occurred. Results: The 10 patients (five males and five females) were aged 2.5 to 14.5 years (mean 7.6 years). The affected bones included eight tibias, one humerus and one ulna. The limb length discrepancies ranged from three to 20cm (mean 6.44cm). The duration of lengthening prior to definitive vascularised fibular graft ranged between one to 15 weeks (mean seven weeks) in nine patients. In the patient with a discrepancy of 20cm, lengthening spanned 52 weeks. At the time of the definitive vascularised fibular graft procedure, the fixater was partially disassembled to facilitate surgery and microvascular anastomosis. The frame was then reassembled and used as the fixation device to protect the graft. The fixater was removed from seven to 24 weeks (mean 16 weeks) after definitive surgery. There were no complications during the lengthening process. However, two patients experienced non-unions, which were successfully treated by autologous bone grafts. One patient had a fracture of the vascularosed fibular graft, which healed uneventfully. Conclusion: A staged approach to reconstruction of major long bone deficiencies leads to a better outcome than insertion of vascularised fibular grafts without addressing the limb length discrepancy. In this type of procedure, the patients not only bridged their bone defect, but achieved limb length equality as well

Introduction: Osteochondral reconstruction following tumour resections has a high complication rate. We hypothesized that the vascularised fibular graft as a supplement to the allograft reconstruction following tumour resections would provide a biological solution. Purpose of the study: A prospective study of the results of patients receiving large fragment allografts and vascularised fibular grafts following tumour resections around the hip and the knee. Patients and methods: 18 patients underwent resection of primary malignant bone tumors followed by reconstruction with large fragment allograft and vascularised fibular graft. 8 patients underwent resection arthrodesis of the hip, six underwent resection arthrodesis of the knee and five underwent intercalary resections around the knee followed by a large fragment allograft and vascularised fibular graft reconstruction to span the gap left by resection. The patients were assessed clinically (MSTS scoring system) and radiologically at regular intervals. Results: There were 14 males and 4 females, with a mean age of 26 years (12–70). Mean follow-up was 65 months (8–144). Five patients died of metastatic disease but without local recurrence. In six of the patients with resection arthrodesis of the hip, there was evidence of fracture of the allograft but without the failure of the construct. One fibula fractured but eventually healed uneventfully. There were no cases of non-union in cases of intercalary resections. All the patients scored good or excellent in the MSTS scoring system. Discussion: Our experience clearly indicates that tumour resection followed by reconstruction with large fragment allograft and vascularised fibular graft is a useful limb salvage procedure providing a biological long-term solution with superior results when compared to prosthetic reconstruction

This is a prospective study assessing the results of patients receiving large fragment allograft and a vascularised fibular graft following primary malignant tumour resections around the hip and the knee. 18 patients underwent tumor resection followed by reconstruction with large fragment allograft and vascularised fibular graft. Eight patients underwent resection arthrodesis of the hip, four underwent resection arthrodesis of the knee and six underwent intercalary resections. Following tumour resection with adequate margins, an appropriate sized allograft fragment was internally fixed with either a plate or an intramedullary nail. A vascularised fibular graft was used to span the gap between the remaining host bones. Osteosarcoma was the commonest diagnosis. The patients were clinically assessed by MSTS functional scoring system and radiologically assessed at regular intervals. The mean age was 26 years (range12–70) and majority of the patients was men. 11 patients received preoperative chemotherapy. Mean follow-up was 85 months (range 8–153). Six patients have died of metastatic disease at a mean of 33 months. Complications included local recurrence in two, deep infection in one and stress fracture of the fibula in two cases. One patient with local recurrence and the other with deep infection underwent an amputation. Majority of the patients had good or excellent MSTS scores at final follow-up and 75% of the patients are engaged in physically active occupations. Graft hypertrophy was evident in majority of the patients. Our experience clearly indicates that reconstruction with large fragment allograft and vascularised fibular graft is a useful limb salvage procedure with the fibula hypertrophying slowly with time. The eventual fracture of the allograft or failure of the allograft-plate composite is to be expected but is not deleterious due to the physiological response of the vascularised fibula to the weight bearing stresses over time. We feel that this biological solution is likely to demonstrate superior long-term results compared to a prosthetic reconstruction

The August 2015 Children’s orthopaedics Roundup. 360 . looks at: Learning the Pavlik; MRI and patellar instability; Cerebral palsy and hip dysplasia; ‘Pick your poison’: elastic nailing under the spotlight; Club feet and surgery; Donor site morbidity in vascularised fibular grafting; Cartilage biochemistry with hip dysplasia; SUFE and hip decompression: a good option?

The October 2015 Oncology Roundup. 360 . looks at: Radiotherapy for the radioresistant; Multiple hereditary exostosis; The total femur as a limb salvage option; Survival prediction in osteosarcoma; What happens when chondrosarcoma recurs?; Thumbs up for vascularised fibular graft; Radiotherapy and survival; Musculoskeletal tumours in pregnancy

The October 2012 Oncology Roundup. 360. looks at: the causes of primary bone tumours; adjuvant chemotherapy in the longer term; vascularised fibular grafts to salvage massive femoral allografts; a new look at old risks; reconstruction with excised irradiated bone; predicting chemosensitivity in osteosarcoma ; and chemotherapy, osteoporosis and the risk of fracture

The aetiology, pathogenesis and clinical staging of osteonecrosis of the femoral head have been the subject of considerable discussion. The same is true regarding the treatment of such conditions, which could be non-operative (shockwaves, no traction, PEMFs) or operative (conservative methods or prosthetic substitution), depending on the age of the patient and the degree of compromise of the femoral head. During the period between 1972 and 2003 at the CTO Hospital of Turin, Italy, 54 patients underwent surgery. We used core decompression (forage biopsy) in 39 cases and in the other 15 cases free vascularised fibular grafting (microsurgical techniques). All the patients were at the initial stages of the condition (Steinberg I–IIIa), stages in which subchondral collapse had not yet occurred. Follow up average 125.6 months. The results were estimated according to the Harris Hip Score, which allows for a score in relation to pain upon motional, functional and clinical deformity. In light of our data, we can confirm that the advantage of the result is secondary to the appropriate use of surgical techniques in relation to the clinical staging of the pathology. We have, in fact, established a treatment protocol that calls for core decompression at stage 0 – IA and free vascularised fibular grafting at the more advanced stages that go from IB to IIIA

Objective and Purpose: Pilon fractures are complex fractures of the tibial articular surface usually associated with high energy trauma and major soft tissue injury. We investigated the effectiveness of Ilizarov external fixator in such cases. At our hospital, we obtain excellent results performing reconstruction using vascularised fibular grafts for the infectious non-union. Methods and Materials: We examined 21 cases treated with the Ilizarov apparatus for the fresh pilon fracture from 1999. There were 13 males and 8 females, with an average of 44 years. The AO classification was A2 type in 2 cases, B1 in 4, C1 in 3, C2 in 3, and C3 in 9, with open fractures of Gustilo type?Uor ?Va in 7 cases. 11 cases were treated by the Ilizarov technique only. 10 cases were treated by the additional limited open reduction with screw, K-wire and fibular plating. The average time between injury and surgery was 4 days. We examined 6 cases treated with the vascularised fibular graft for the infectious non-union cases after internal fixation. Age at the surgery was from 19 to 70 (mean 46). Results: All fractures were united and removed at an average of 10 weeks (range 8–12 weeks). Complications included 5 cases of superficial pin tract infections. There is no deep infections and no pseudarthrosies. Conclusion: The use of Ilizarov fixator is a safer method of treatment of pilon fractures, especially for the severe soft tissue injury and we don ft delay surgery for soft tissue considerations

The June 2013 Hip & Pelvis Roundup. 360 . looks at: failure in metal-on-metal arthroplasty; minimal hip approaches; whether bisphosphonates improve femoral bone stock following arthroplasty; whether more fat means more operative time; surgical infection; vascularised fibular graft for osteonecrosis; subclinical SUFE; and dentists, hips and antibiotics

Aim. To compare the functional outcome of proximal femoral reconstruction using endoprosthetic replacement and hip arthrodesis using a vascularised fibular graft. Material and Methods. The study included thirty-five patients who had proximal femoral reconstruction following resection of a malignant bone tumour. Patients were divided into 2 groups according to the reconstructive modality used. Group 1 (15 patients) reconstructed by hip arthrodesis using a vascularised fibular graft. Group 2 (20 patients) reconstructed by endoprosthesis. The mean age of group I was 14.9 years (range, 7-25). 8 patients had Ewing's sarcoma, 5 osteogenic sarcoma, and 2 chondrosarcoma. In group 2, the mean age was 35 years (range, 14-61). Eight patients had osteogenic sarcoma, 2 chondrosarcoma, 2 Ewing's sarcoma, 1 lymphoma, 1 MFH, 1 synovial sarcoma, 1 parosteal osteosarcoma, and 4 metastatic carcinomas. Results. In group 1 failure of the fixation occurred in two patients, and deep infection developed in one patient. These patients were managed with revision of internal fixation and debridement respectively. The mean MSTS functional score was 87% (range 70 – 96%) at the time of the latest follow-up (mean = 64 months). The average limb length discrepancy was 2 cm (range 1 to 4). In group 2, two patients developed deep infection, one patient had a dislocation, and one had loosening of the implant with a re-operation rate of 20%. After a mean follow up of 49.1 months, the mean MSTS functional score was 79% (range 60 – 93%). Conclusion. The functional outcome of hip arthrodesis using a vascularized fibular graft is comparable to endoprosthetic replacement after proximal femoral resections. It should be considered as a durable reconstructive modality in children and young active patients with long life expectancy

Autografts produced by recycling of tumor-bearing bone have been used for bridging intercalary bone defects but they are known to act as massive allografts after recycling procedures due to devitalisation. Recycled bone is superior to massive allografts since it allows anatomical reconstruction. Vascularised fibular grafts are inserted into recycled bone segments to provide biological support and to promote healing. Twelve patients with a mean age of 13.3 years (6–31), who had undergone curative resection of malignant bone tumor followed by biological reconstruction comprised of recycled bone combined with vascularised fibula, were followed up for a mean period of 16.8 (6–46). The tumor was located in distal femur in 7 patients, proximal femur in 2, proximal tibia in 2 and mid-diaphyseal tibia in 1. Cryopreservation with liquid nitrogen was employed for all patients. Contralateral single strut vascularised fibular grafts were used in all except one patient for whom bilateral fibula grafts were harvested to span a longer defect. Plates were used for fixation in 11 patients, and intramedullary nailing in one case. Mean length of bony defect was 16.1 cm (9.0–25.0). Mean fibular graft length was 17.5 cm (10.0–23.0 cm). Complete union and full weight bearing was achieved in 6 patients, and mean time to detect the commencement of union was 6 months (4–8). Incomplete union was detected in 4 patients and no union in 2. Five patients were complicated by implant failure, 1 with deep infection and 1 with drop foot. In order to fill large defects after resection of bone tumors, recyled bone combined with vascularised fibular graft is an effective reconstructive tool. Union rate of this technique is quite satisfactory with good functional results

Vascularised bone grafts have been most commonly applied in reconstructions of the lower extremities. However, the indications for vascularised bone grafts in the upper extremities have now been expanded, as this technique is becoming more widely appreciated. Between 1993 and 2000, 12 patients who had segmental bone defects following trauma of the forearm received vascularised fibular grafts, among them six men and six women. The average age was 39 years (range 16–65 years). The reconstructed sites were the radius in eight patients and the ulna in four. The length of the bone defect ranged from 6 to 13 cm. In four cases the fibular graft was raised as a vascular osteoseptocutaneous fibular graft. For fixation of the grafted fibula, plates were used in ten cases, screws and Kirschner wires in two. In these two cases an external skeletal fixator was used for immobilisation of the extremity. The follow-up period ranged from 93 to 10 months. In 11 patients grafting was successful. There were no instances of fractures of the grafted bone; however, non-union occurred at the proximal site in one case and only one patient required an additional bone graft. No patient showed evidence of resorption of the graft or symptoms related to the donor leg. No recurrence of local infection was encountered in the patients with previous osteomyelitis. The mean period to obtain radiographic bone union was 4.8 months (range 2.5–8 months). With the use of fibular grafts a segment of diaphyseal bone can be transferred that is structurally similar to the radius and ulna and that is of sufficient length for the reconstruction of most skeletal defects in the forearm. A vascularised fibular graft is indicated in patients with intractable non-unions, where conventional bone grafting has failed or for large bone defects (in excess of 6 cm) in the radius or ulna

Extracorporeal Irradiation and Reimplantation (EIR) of tumor bearing bone segments is an alternative reconstruction method for major osseous resections. In contrast with endoprosthetic reconstruction, EIR is a biologic solution and after a prolonged healing and remodeling period it is expected to create a structural and metabolic almost normal bone. After oncologic resection the bone segment is cleaned from adhered soft tissues and send to irradiation which kills malignant and normal cells. Reimplantation consists of fixation, mostly by plates, vascularised fibular graft insertion in the medullary canal, iliac bone graft in critical sites and ligamentous sutures. Since 2001 fifteen patients were submitted to EIR in our institution. Resections affected seven distal femurs, four proximal tibias, one acetabulum, one iliac bone and the proximal forehand bones once which bear 11 osteosarcomas, 2 Ewing’s sarcomas, 1 chondrosarcoma and 1 rhabdomyosarcoma. There were six males and nine females with age ranging from five to 55 years. Ten patients were submitted to osteoarticular reconstructions, three to intercalary and two to partial pelvis reconstructions. Local recurrence leading to amputation occurred in one patient and resection of an infected innominate bone occurred once. Three patients died two to nine months after surgery because of their disease. Five patients had metaphyseal fractures after one to 14 months after surgery. Four patients had no fracture; three of them had intercalary resections. The patient with osteoarticular resection and no fracture had his metaphyseal region injected with cement which prevented fracture and after 23 months have not developed osteoarthritis. All the cases in which a vascularised fibular graft was implanted progressive fusion of the living and dead bones were observed. As a conclusion EIR is a good alternative for intercalary resections. For osteoarticular resections improvement of the method are necessary to prevent fracture and ligamentous laxity

Free, vascularised fibular grafting is well described in limb salvage surgery. The mechanical properties of the fibula make it ideal for replacement of bony defects after tumour resection and it can be sacrificed with minimal morbidity. We review the outcome of a consecutive series of 24 patients. Between 1993 and 2002 we performed free vascularised fibular grafts in 24 patients as part of a limb salvage procedure following tumour excision. Pre-operatively patients were staged using the Musculoskeletal Tumour Society (MSTS) system. Post-operatively patients were followed up with radiographs and clinical examination. From the radiographs graft hypertrophy and time to bony union was documented. Functional outcome was assessed using the MSTS scoring system. Complications were recorded. There were 15 women and 9 men with a mean age of 26 years (6–52). Mean follow up was 51 months (12–106). There were 19 malignant tumours, all stage 2b, and 5 giant cell tumours. The mean length of graft was 12.5 cm. (4.5–25). 16 grafts were used in the upper limb and 8 in the lower limb. Arthrodesis was performed in 8 cases and intercalary reconstruction in 16 cases. Fixation of grafts was achieved with a plate and screws in 21, a blade plate in 2 and an IM nail in 1. In 6 cases the resected tumour bone was reinserted as autograft after extracorporeal irradiation. In all but one patient the tumour margins were clear. Primary bony union was achieved in 22 patients (92%) at a mean of 35 weeks (12–78). Graft hypertrophy was seen in 7/29 cases (24%). Complications included 2 wound breakdowns, 3 stress fractures, 1 muscle contracture, 1 malunion and 1 painful plate. Overall 8 patients (33%) required second operation. 2 patients died of recurrent disease and one has metastases. The mean MSTS functional score was 87% (80–93). Free vascularised fibula grafts offer a reliable method of reconstruction after excision of bone tumours. The complication rate appears high and some patients require a revision procedure. However, the problems are relatively easy to correct, bony union is achieved in the majority and functional outcome is good

Introduction Free, vascularised fibular grafting is well described in limb salvage surgery. The mechanical properties of the fibula make it ideal for replacement of bony defects after tumour resection and it can be sacrificed with minimal morbidity. We review the outcome of a consecutive series of 24 patients. Methods Between 1993 and 2002 we performed free vascularised fibular grafts in 24 patients as part of a limb salvage procedure following tumour excision. Pre-operatively patients were staged using the Musculoskeletal Tumour Society (MSTS) system. Post-operatively patients were followed-up with radiographs and clinical examination. From the radiographs graft hypertrophy and time to bony union was documented. Functional outcome was assessed using the MSTS scoring system. Complications were recorded. There were 15 women and nine men with a mean age of 26 years (6 to 52). Mean follow-up was 51 months (12 to 106). There were 19 malignant tumours, all stage 2b, and five giant cell tumours. The mean length of graft was 12.5 cm (4.5 to25). Sixteen grafts were used in the upper limb and eight in the lower limb. Arthrodesis was performed in eight cases and intercalary reconstruction in 16 cases. Fixation of grafts was achieved with a plate and screws in 21, a blade plate in two and an IM nail in one. In six cases the resected tumour bone was reinserted as autograft after extracorporeal irradiation. Results In all but one patient the tumour margins were clear. Primary bony union was achieved in 22 patients (92%) at a mean of 35 weeks (12 to 78). Graft hypertrophy was seen in 7/29 cases (24%). Complications included two wound breakdowns, three stress fractures, one muscle contracture, one malunion and one painful plate. Overall eight patients (33%) required second operation. Two patients died of recurrent disease and one has metastases. The mean MSTS functional score was 87% (80 to 93). Conclusions Free vascularised fibula grafts offer a reliable method of reconstruction after excision of bone tumours. The complication rate appears high and some patients require a revision procedure. However, the problems are relatively easy to correct, bony union is achieved in the majority and functional outcome is good

Purpose: Reconstruction after resection of malignant bone tumours remains a major challenge. Free vascularised fibular grafts may be a useful alternative in this indication. Material: Thirty children (nine girls, twenty-one boys) were treated between 1993 and 2000. Mean age was eleven years. Tumour histology was: osteogenic osteo-sarcoma (n=20), Ewing tumour (n=5), justacortical osteosarcoma (n=3), synovialosarcoma (n=1), and chondrosarcoma (n=1). Tumours were located in the femur (n=17), the tibia (n=6), the humerus (n=5), the radius (n=1), and the distal fibular (n=1). The length of resection varied from 100 mm to 260 mm (mean 160 mm). Internal fixation was used in 27 cases and external fixation in three. The adjacent epiphysis was preserved in 22 cases and initial arthrodesis was performed in eight. Method: Patients were followed clinically and radiographically. A bone scintigram was obtained in all patients at least once during the postoperative period. Radiological assessment was based on the hypertrophy index of the graft using the method described by DeBoer and Wood. Functional outcome was assessed using the Enneking criteria. Results: Mean follow-up was 51 months (range 2 – 9 years). Early amputation was required in two patients due to local ocological complications. One patient died at eight months follow-up due to lung metastasis. Among the remaining 27 patients, primary bone healing was achieved in 22. The five other patients exhibited clear signs of non-vascularisation. Successful healing was achieved in four of these patients after a complementary autologous graft. All cases of stress fracture healed after simple immobilisation. The twenty-two patients who achieved primary bone healing developed a hypertrophic graft (mean 61%, range 22 – 190%). Graft hypertrophy was not observed in the five cases requiring a secondary graft after the scintigram demonstrated lack of vascularisation. Hypertrophy of the vascularised fibular graft was more marked for lower limb reconstructions than for upper limb reconstructions. Functional outcome was satisfactory in all cases. On the 30-point Enneking scale as modified, our patients achieved a mean 26 points (range 19 – 30). Discussion: Outcome was directly related to patency of the vascular anastomoses. Bone scintigraphy, performed one month after reconstruction surgery, was an important element for assessing prognosis. In case of unsuccessful vascularisation, a complementary cortico-cancellous graft should be used. Early weight-bearing is advisable using adequate protective devices. Dynamic osteosynthesis systems should be helpful in improving graft hypertrophy

Unstable slipped capital femoral epiphysis (SCFE) has an increased incidence of avascular necrosis (AVN). The purpose of this study was to determine if early identification and intervention for AVN may help preserve the femoral head. We retrospectively reviewed 48 patients (50 hips) with unstable SCFE managed between 2000 and 2014. Based on two different protocols during the same time period, 17 patients (17 hips) had a scheduled MRI between 1 and 6 months from initial surgery, with closed bone graft epiphysiodesis (CBGE) or free vascularised fibular graft (FVFG) if AVN was diagnosed. Thirty-one patients (33 hips) were evaluated by plain radiographs. Outcomes analysed were Steinberg classification and subsequent surgical intervention. We defined Steinberg class IVC as failure in treatment because all of the patients referred for osteotomy, arthoplasty, or arthrodesis in our study were grade IVC or higher. Overall, 13 hips (26%) with unstable SCFE developed AVN. MRI revealed AVN in 7 of 17 hips (41%) at a mean of 2.5 months postoperatively (range, 1.0 to 5.2 months). Six hips diagnosed by MRI received surgical intervention (4 CBGE, 1 FVFG, and 1 repinning due to screw cutout) at a mean of 4.1 months (range, 1.3 to 7.2 months) postoperatively. None of the 4 patients treated with CBGE within two months postoperatively progressed to stage IVC AVN. The two patients treated after four months postoperatively both progressed to stage VC AVN. Radiographically diagnosed AVN occurred in 6 of 33 hips (18%) at a mean of 6.8 months postoperatively (range, 2.1 to 21.1 months). One patient diagnosed with stage IVB AVN at 2.4 months had screw cutout and received CBGE at 2.5 months from initial pinning. The remaining 5 were not offered surgical intervention. Five of the 6 radiographically diagnosed AVN, including the one treated with CBGE, progressed to stage IVC AVN or greater. None of the 4 patients with unstable SCFE treated with CBGE within 2 months post pinning developed grade IVC AVN, while all patients treated with other procedures after 2 months developed IVC or greater AVN. Early detection and treatment of AVN after SCFE may alter the clinical and radiographic progression

Aims: Free vascularized fibular graft for osteonecrosis of the femoral head is a well established procedure based on the assumption that the graft will provide mechanical support, blood supply to the osteonecrotic head and to introduce mesenchymal stem cells into the affected area of the femoral head. Methods: We reviewed 25 cases to delineate the pathological features of femoral heads with AVN treated by vascularised fibular grafts which were retrieved at revision surgery when the construct was deemed clinically to have failed. Results: Review of the patients’ records disclosed that 60.8% were on steroid therapy when the AVN was diagnosed. The recorded time from first symptoms of failure to conversion to total hip arthroplasty was an average of 55 months. The length of the graft was divided into three zones : zone 3 the femoral neck; zone 2 the lower femoral head or “metaphysis”; zone 1 the more apical or epiphyseal component of the femoral head. The intention was to follow the vascularization of the pedicle and the changes in the three diverse areas of the specimen. The graft showed incorporation with the host bone. In the pedicle there was preservation of vascular patency and tissue viability. Conclusion: However, this healing process involved a slow reparative resorptive activity which undermined the joint surface. This could suggest that non-resorbable materials in place of tissue grafts can be expected to avoid the negative effect of creeping substitution as an undermining force in the repair and revascularisation of the necrotic area in the head

We did a retrospective comparative analysis of twenty five patients treated with Ilizarov bone transport [IBT] and twenty one patients treated with vascularised fibular graft [VFG] from 1994 to 2003 in one institution, for post traumatic tibial bone defects of more than six centimetres. The aim of the study was to find out if there were any differences in achieving radiological end points, bone and functional score and return to work (final outcome), hospital stay and operating time (logistic factors) and complication rates. The mean defect size in the IBT group was 11.9 centimetres and in the VFG group 14.6 centimetres. Twenty one and sixteen patients in the IBT and VFG group respectively achieved the radiological end point that is union of the defect and graft hypertrophy [p 0.5]. Nineteen patients in the IBT group and fifteen in the VFG group returned to productive work [p 0.72]. Bone and functional results were analyzed by Paley's evaluation system and there were no significant differences in the two groups of patients [bone result p 0.97 and functional result p 0.1]. The logistic factors were significantly less of IBT group [p < 0.05]. Two patients in the IBT group and one patient in the VFG group had amputation and one patient in VFG group died. Three cases in the VFG group had flap loss. Stress fracture of the graft occurred in eight patients in the VFG group [p 0.0007]. The final outcome was same in both groups. Hospital stay, operating time and refractures were significantly less in IBT group

Several methods have been used for proximal humeral reconstruction following tumour resection. None of these modalities allow the patient to regain his normal shoulder range of motion. Moreover, every modality has its advantages and disadvantages. The aim of this study was to compare the functional outcome of 2 reconstructive modalities that we are using in our institution for proximal humeral reconstruction; endoprosthesis and shoulder arthrodesis using a vascularised autograft This study included 48 patients diagnosed with malignant or benign aggressive tumours that required resection of their proximal humerus. They were divided into 2 groups according to the method of reconstruction. Group 1 included 22 patients with an average age of 20 years were reconstructed by shoulder arthrodesis using a free vascularised fibular graft (6) or a pedicled scapular crest graft (16). Group 2 included 26 patients with an average age of 26 years were reconstructed with an endoprosthesis. In group 1 the average follow up period was 88 months (range 12 to 184 months). The average functional outcome (according to the MSTS scoring system) was 25 points (range 19 – 28). The average abduction and forward flexion range of motion (scapulothoracic) was 40 degrees (range 20 -60). Complications included failed fixation (2), non union (1), infection (1) and temporary radial nerve palsy (2). In group 2 the average follow up period was 36 months (range 12 – 110). The average functional outcome was 24 points (range 20 – 27). The average abduction and forward flexion range of motion was 40 (range 30 –70). Complications included sublaxation (2), loosening (1) and infection (1). Reconstruction of the proximal humerus by arthrodesis or endoprosthesis yield similar functional outcome. Although endoprosthesis is a much more expensive modality, it does not provide any superior functional outcome over shoulder arthrodesis