In order to understand the role and efficacy of vascularized fibular graft and massive allograft in reconstruction of the knee, we have analyzed and review 25 patients of primary malignant bone tumours within 5 cm around the knee, that were managed primarily by this technique. In 4 patients the distal femur was affected while the proximal tibia was affected in 21 patients. There were 16 male and 9 female with an average age at the time of surgery of 19.7 years (range; 5 to 52), 17 patients (68%) were skeletally immature. The pathology was mostly represented by Osteosarcoma and Ewing sarcoma (15) and 18 patients (72%) received pre-operative chemotherapy. The resection of the tumor was transepiphyseal in 13 patients (52%) and intercalary in 12 patients (48%). The method of reconstruction was mainly concentric (allograft and fibula inside in 22 patients, 88%), while fixation was done principally by diaphyseal plate and metaphyseal screws (14 patients, 56%). Only three flaps failed (12%) detected by postoperative bone scan and confirmed by the clinical follow up. Twelve patients (48%) had 17 local complications (68%). Management of these complications succeeded to control them in nine patients (75%). The average time of union of fibula was 5.6 month (range: 3–10). The average time of union of allograft was 19.6 month (range: 10–34). All allograft united primarily (92%) except two cases; one case required bone graft and re-platting at 13 month postoperative after implant failure to achieve union 2 months later ; the other had infected non-union of allograft and amputation was done. Functional results were evaluated using the modified 30-points Musculoskeletal Tumor Society rating score (MTSRS) at final follow up of average 143 month (range; 28–213): the average total score was 27.4 (range; 18 to 30). All patients had good functional range of motion of the knee with stable knee at final follow up and were able to perform sport. Long term results of this study clearly indicates that allograft and vascularized fibular graft is a useful limb salvage procedure providing a biological long-term solution especially in skeletally immature. This technique provides single stage life long reconstruction. The allograft shell provide early stability and fixation to support a small epiphyseal fragment to preserve the articular surface and the vascularized fibula provides revascularization and osteointgration with the allograft to finally offer a long lasting durable reconstruction with full rang of motion of the knee.

Fibula autograft reconstruction, both vascularised (v) and non-vascularised (nv), has been established as a standard method in limb salvage surgery of bone and soft tissue tumours of the extremities. This study retrospectively analyses the results of fibula autograft procedures in general and in relation to vascular reconstruction or simple bone grafting.

Since the implementation of the Vienna Tumour Registry in 1969, 26 vascularised and 27 non-vascularised fibula transfers have been performed at our institution in 53 patients, 26 males and 27 females with an average age of 21 years (range 4 to 62 years). Indications included osteosarcoma in 18, Ewing’s Sarcoma in 15, adamantinoma in 5, leiomyosarcoma in 3 and others in 12. Thirty patients were operated for reconstruction of the tibia (8v/22 nv), 7 for the femur (6v/1nv), 7 for defects of the forearm (4v/3nv), 5 for metarsal defects (all v), 3 for the humerus (1v/2nv) and one patient was treated for a pelvic defect (nv).

Average follow-up was 63 months (range 2 to 259 months). 43 patients showed successful primary bony union of the autograft. In 12 cases pseudarthrosis indicated further surgical revision, 9 of these patients were primarily reconstructed by use of a nv autograft. 4 patients, 2 with v and 2 with nv reconstruction, suffered a fracture of the transplant and were operated for secondary osteosynthesis. 10 patients with v bone graft developed wound healing disturbances which led to surgery, 2 patients with nv grafts suffered such complications. In 2 patients recurrent infection of a nv and a v fibula transfer led to the implantation of a modular tumour prostheses or amputation, retrospectively. Function of all patients with primary bone healing was rated satisfactory.

The use of fibula autograft in limb-salvage surgery under oncological conditions allows biological reconstruction with good functional outcome, especially when primary bone healing is achieved. Vascularised bone grafting seems to have a better outcome in terms of primary bone healing than simple fibula bone grafting, and thus represents a feasible choice in the reconstruction of bone defects from tumour resection.