Annals of Surgical Oncology Sign the Guestbook
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
10.1245/ASO.2005.03.018
Annals of Surgical Oncology 12:57-64 (2005)
© 2005 Society of Surgical Oncology
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Nathan, S. S.
Right arrow Articles by Healey, J. H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Nathan, S. S.
Right arrow Articles by Healey, J. H.

Original Article

Ankle Instability After Vascularized Fibular Harvest for Tumor Reconstruction

Saminathan S. Nathan, MD1, Lee Hung-Yi, MD2, Joseph J. Disa, MD2, Edward Athanasian, MD1, Patrick Boland, MD1, Peter G. Cordeiro, MD2 and John H. Healey, MD1

1 Orthopaedic Surgery Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, New York 10021
2 Plastic Surgery Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, New York 10021

Correspondence: Address correspondence and reprint requests to: John H. Healey, MD; E-mail: healeyj{at}mskcc.org


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: The vascularized fibular graft is an important tool in the reconstruction of defects caused by resections of orthopedic tumors. Children often undergo this form of reconstruction, but there is little information about the complications after vascularized fibular graft harvest in this age group.

Methods: We present a series of 32 patients who underwent this procedure to reconstruct an extremity in our institution. There were 12 children and 20 adults.

Results: The residual distal fibula was significantly longer in adults as compared with children (P < .048). Among children, 3 of 11 undergoing the procedure developed ankle instability, in distinction to adults, none of whom developed this complication (P < .041). This reflects a disruption of normal ankle function that develops in skeletally immature patients with a short residual fibula but not in patients with a longer residual fibula (P < .008). When the sum of patient age in years and residual fibula length in centimeters was less than 16, 3 of 6 patients developed deformity, in contrast to no deformity developing in the remaining 23 when the sum was >16 (P < .004). Adults were more likely to develop pain than instability.

Conclusions: Our series suggests that children with an age-length sum <16 should be considered for prophylactic tibiofibular synostosis creation.

Key Words: Vascularized fibular graft • Ankle instability • Orthopedic tumors • Children


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The vascularized fibular graft has become a versatile instrument for reconstructing defects left by resections for various bone tumors.1,2 Most series on reconstructions involving this modality are dominated by cases pertaining to trauma or infections, which statistically implicate adults.3–10 Series involving children are rare.11 We present a series of tumors that were resected and reconstructed with vascularized fibular grafts.

The group involving tumors is characterized by certain specific features. Bone tumors occur frequently in children. Children are prone to secondary changes that result from removal of the fibula, including valgus deformity.12–14 Children, being of small stature, have less tissue for donation, and the residual fibula is typically very small. This would potentially result in relatively greater ankle instability than in adults.

Few publications address this issue in the younger population.15,16 We believe that this is the largest series of its kind to date.17–19 Only one other series has dealt with the specific clinical situation of vascularized fibula grafts to reconstruct defects from extremity tumor resections.20 In that series, patients were generally older, and ankle complications were not found. Additionally, a study on donor site morbidity highlighted the occurrence of ankle symptoms and gait analysis changes.21 These were all adults and, again, did not show ankle instability. In the largest known series on vascularized fibular grafts used to reconstruct defects in children left from resections of congenital pseudoarthrosis of the tibia,22 prophylactic donor site tibiofibular stabilization was performed in all donor ankles. Consequently, only one case of valgus ankle instability resulted. More recently, other studies have been conducted to attempt to quantify the risk of developing ankle instability at the donor site after a vascularized fibular graft procedure.23–28 These studies provide compelling evidence for the occurrence of this complication after the procedure. However, because age and the degree of skeletal maturity were not well characterized, it is difficult to draw conclusions on the risk factors for development of ankle instability. We sought to compare the prevalence of ankle instability in children with that in adults and to formulate a treatment algorithm given the results of this study and the available literature on the pathogenesis of valgus ankle deformity after vascularized fibular harvest.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
This study was a retrospective review of all cases of tumors reconstructed with vascularized fibular grafts after resection between 1991 and 2002 at the Memorial Sloan-Kettering Cancer Center. The study was approved by the institutional review board. Data was gleaned from an ongoing department-owned database, clinical charts, and radiological examinations. "Children" were defined as individuals with significant remaining growth potential. This was confirmed radiologically by the presence of unfused physes. The length of the defect, residual fibular length, and functional outcome were analyzed in relation to patient demographic and clinical data. Clinical data included the presence or absence of pain or discomfort and the subjective sensation of increased valgus stress deformation relative to the contralateral ankle. Ankle instability was diagnosed according to the presence of valgus stress deformation and radiographical data. Radiographical data were based on anteroposterior films of the ankle. Valgus angles were measured between the horizontal and valgus distortions of the tibial plafond, as shown in Fig. 1aGo. Talar tilt was measured between the axis of the tibia and the tangent off the talar dome, as shown in Fig. 1bGo. Results were recorded as valgus deviations from the horizontal or talar tilt minus 90°. Angles were measured with Pathspeed Workstation 8.1 software (General Electric, Waukesha, WI).



View larger version (23K):
[in this window]
[in a new window]
  		FIG. 1. Technique of measuring (a) lateral tibial lysis and (b) talar tilt.

 
Fisher’s exact test was used to assess for significance in categorical variables, and Student’s t-test was used to assess for significance with continuous variables. All statistical analysis was performed with SPSS version 11.5 for Windows NT (SPSS Inc., Chicago, IL). For purposes of comparisons with respect to ankle instability, only patients with a minimum follow-up of 1 year were included in the analysis, because ankle instability did not manifest before this time.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Between October 1991 and August 2002, 32 patients underwent tumor excision and reconstruction of their extremity with vascularized fibular grafts (Table 1Go). There were 17 male and 15 female patients. The mean patient age at surgery was 26.8 years (range, 5–74 years). There were 12 children (5–14 years) and 20 adults (17–74 years). The reconstructed areas included nine humeri, nine radii, nine tibiae, three femora, and two ulnae. There were nine patients with osteogenic sarcoma and eight with Ewing’s tumor. Others included chondrosarcoma in five patients, giant cell tumor in four, liposarcoma in one, leiomyosarcoma in one, clear cell sarcoma in one, desmoid tumor in one, and malignant fibrous histiocytoma in two. The mean bone defect was 12.4 cm (range, 6–18 cm), and the mean corresponding donor length was 16.4 cm (range, 7.7–27 cm). There were no significant differences (P < .52) between the donor fibula lengths among adults, with a mean of 16.0 cm (range, 7.7–26 cm), and those in children, with a mean of 17.1 cm (range, 13–27 cm). There were significant differences (P < .048) between the distal remnant fibula lengths among adults, with a mean of 9.4 cm (range, 6–15 cm), and those in children, with a mean of 7.2 cm (range, 4.5–15 cm).


View this table:
[in this window]
[in a new window]
  		TABLE 1. Details of 32 patients who had free vascularized fibular transfers
 
Two patients died within a year of their operations. One was an adult, and the other was a child. Neither patient had pain or ankle instability. They were excluded in the analyses concerning ankle instability and pain. Excluding these 2, 30 patients were followed up for a mean of 5.0 years (range, 1.1–11.9 years) from the time of operation.

Nine patients developed ankle complications. Six patients developed chronic pain that was self limiting. Three patients developed valgus ankle instability. There were four male and five female patients in this group, with an age range of 6 to 49 years. The more severe cases involving deformities occurred in patients in the younger age group. There were three cases of osteogenic sarcoma, two Ewing’s tumors, two giant cell tumors, one desmoid tumor, and one patient with chondrosarcoma. Patients without ankle donor site complications had the analogous distribution of diagnoses.

There were 12 children in this population—1 died within a year of surgery, 1 had pain, and 3 developed ankle instability. Three of 11 children, as opposed to no adults, undergoing the procedure developed ankle instability. They were first noted to have ankle instability an average of 27.3 months (range, 20–38 months) after their surgical procedures. Two of these required corrective surgery in the form of a fibular osteotomy and lengthening and tibiofibular synostosis. The incidence of ankle instability was significantly higher among children as compared with adults as assessed by Fisher’s exact test (P < .041).

Patients who developed valgus instability were younger, with a mean age of 7.6 years (6, 7, and 10 years), as compared with those without instability (P < .000004), with a mean age of 29 years (range, 5–74 years). Among all children, this trend continued, with younger patients (mean age, 7.6 years; range, 6–10 years) developing instability and older children (mean, 9.8 years; range, 5–14 years) remaining stable (P < .28).

There was a significant association between ankle instability and residual fibula lengths. Patients with instability had mean residual fibula lengths of 6 cm (range, 5–7 cm), as opposed to those without instability (P < .008), with a residual length of 8.9 cm (range, 4.5–15 cm). Among all children, patients with unstable ankles had mean remnant distal fibula lengths of 6 cm (range, 5–7 cm), and those with stable ankles had mean lengths of 7.9 cm (range, 4.5–15 cm). This was not statistically significant (P < .16). Patients with residual fibula lengths of <7 cm had a greater tendency to develop instability in the ankle (P < .078).

This apparent relationship between age (and, hence, future growth), residual fibular length, and the frequency of valgus deformity was further investigated with an index incorporating age in years and length in centimeters (distal fibular donor index). When the sum of age and length was <16, then 3 of 6 patients developed deformity; when this was ≥ 16, none of the remaining 23 developed deformity (P < .004).

There was no significant association between harvested donor fibula lengths and instability. Donor fibula lengths among patients with instability (mean, 15.6 cm; range, 13–19 cm) were not significantly different (P < .77) from those without instability (mean, 16.3 cm; range, 7.7–27 cm). Among all children, donor fibula lengths were not significantly different (P < .66) between those without instability (mean, 16.7 cm; range, 14–27 cm) and those with instability (mean, 15.6 cm; range, 13–19 cm).

Six patients developed pain without deformity (one child and five adults). The one child with pain had sustained a Salter-Harris type II fracture of the distal tibia. The patient was noted to be osteoporotic in the area, and this was ascribed to the chemotherapy the patient underwent for treatment of her osteogenic sarcoma. This was treated in a cast and resolved without incident. The other five patients were all adults. These experienced pain generally as aches in the calves. These were self-limiting and lasted on average 7.4 months from the time of surgery (range, 3–19 months). For purposes of statistical analysis of pain, this child’s pain was not considered representative of the kind of pain the adults felt and was excluded from subsequent assessment.

Patients who developed pain without deformity tended to be older. Although all patients with pain without deformity were adults, this relationship was not significant (P < .13). These had a mean age of 33 years (range, 20–49 years), as compared with those without pain (P < .30), who had a mean age of 26 years (range, 5–74 years).

There was a significant association between residual fibula lengths and pain. Patients with residual fibula lengths of >7 cm were more likely to develop pain in the ankle (P < .05). Patients with pain had mean residual fibula lengths of 10.2 cm (range, 8–15 cm), as opposed to those without pain (P < .21), who had residual lengths of 8.3 cm (range, 4.5–15 cm). Among all adults, patients with painful ankles had mean remnant distal fibula lengths of 10.2 cm (range, 8–15 cm), and those without pain had mean lengths of 9.0 cm (range, 6–15 cm). This was not statistically significant (P < .45).

Similarly, donor fibula length among patients with pain (mean, 13.5 cm; range, 7.7–20 cm) was not significantly different (P < .22) from that of those without pain (mean, 16.8 cm; range, 11–27 cm). Among all adults, donor fibula lengths were not significantly different (P < .20) between those without pain (mean, 17 cm; range, 11–26 cm) and those with pain (mean, 13.5 cm; range, 7.7–20 cm).

Radiological data were available in the three patients with valgus instability. Figures 2aGo, 3aGo, and 4cGo show lateral tibial plafond valgus distortions of 28°, 38°, and 38°, respectively. Talar tilt measured 3°, 13°, and 2°, respectively. There was corresponding distortion of the ankle mortise. Consequently, there was a tendency for the ankles to deform in the direction of valgus and external rotation. This was not seen in stable ankles. Two patients underwent tibiofibular synostosis procedures and functioned well afterward, as shown in Figs. 2bGo and 3bGo. They both developed stable ankles without pain and had full activity after the procedure. The third patient is presently under observation (Fig. 4Go).



View larger version (129K):
[in this window]
[in a new window]
  		FIG. 2. Case 2: a 6-year-old girl with a Ewing’s tumor of the contralateral tibia resected and reconstructed with a vascularized fibular graft. She developed valgus ankle instability (a), which was stabilized by creation of a tibiofibular synostosis (b).

 


View larger version (107K):
[in this window]
[in a new window]
  		FIG. 3. Case 5: a 7-year-old boy with osteogenic sarcoma of the humerus resected and reconstructed with a vascularized fibular graft. He developed valgus ankle instability (a), which was stabilized by creation of a tibiofibular synostosis (b).

 


View larger version (101K):
[in this window]
[in a new window]
  		FIG. 4. Case 7: an 11-year-old boy with a Ewing’s tumor resected and reconstructed with a vascularized fibular graft. The radiographs performed before the procedure did not show any hint of the deformity (a). He developed a valgus ankle deformity 20 months after the operation (b). The characteristic radiological changes (arrows) with lateral tibial physeal lysis (c) and anterior rotation of the fibula (d) are evident. The patient led an apparently unencumbered life and was treated conservatively.

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
We present here the largest published series to date studying the risk for developing ankle instability after vascularized fibular graft donation for reconstruction of bone tumor resections.29–31 This series is unique for its good representation of adults and children. Orthopedic tumors often occur in children. This group of patients is smaller and has less tissue for donation than adults. This group would therefore be more susceptible to the ill effects of vascularized fibular graft donation than are adults. Reviews of complications of this procedure therefore cannot highlight this specific complication if the population in question is predominantly adult.32,33 Children with tumors are generally on long-term follow-up and hence will not be lost to follow-up. This represents a valuable captive population. Ankle complications in vascularized fibular grafts have been highlighted in the past.1 Recent studies have reported ankle instability in children.25,26,34–36

In our series, it was found that harvested donor fibular lengths were not significantly different between adults and children. The length of the residual fibula was, however, significantly longer in adults as compared with children (P < .048). Hence, the grafts, although not absolutely different, were relatively longer in children than in adults, with their attendant morbidity.

As many as 27% of children undergoing the procedure are at risk of developing ankle instability, as opposed to adults, who are at virtually no risk of developing this complication (P < .041). This is a reflection of the disruption of the normal ankle articulation that develops in skeletally immature patients with short residual fibulae but not in older patients or those with longer residual fibulae (P < .008). Patients who lack this lateral post are believed to be at increased risk of developing this deformity.26,37 That said, a review of the data in Table 1Go shows that of the children in this series, three of eight with residual fibular lengths of ≤7 cm, two of six with lengths of <6 cm, and one of three with lengths <5 cm developed this complication. The absence of a strong direct relationship may be an artifact of the sample size, yet it suggests that other factors are involved in the pathogenesis of ankle instability. The simple sum of patient age and residual fibular length being <16 had the highest correlation with the development of deformity (P < .004).

The deformities noted were proximal migration of the fibula, anteromedial rotation of the proximal part of the remnant distal fibula, impaction of this tip onto the tibial diaphysis, and lateral tibial physeal lysis, as shown in Fig. 5Go. There was also a suggestion of anteromedial arrest of the distal fibular physis. Ankle instability has not been demonstrated in adults after a vascularized fibular graft procedure. This is probably because of the limited potential for remodeling in the adult metaphysis. This is supported by a recent study that suggests that in adults, only 10% of the fibula length is needed distally to maintain stability.38 Children naturally have greater ligamentous laxity than adults. This would allow more instability than would otherwise be possible with the stiffer ligaments seen in adults. This instability could conceivably result in increased pressure and, ultimately, necrosis of the lateral tibial growth plate, as demonstrated in Fig. 5Go. The valgus instability therefore evolves into a permanent deformity because of the relative overgrowth of the medial versus the lateral tibial physis. In addition, because of the propensity to develop the secondary changes demonstrated here in the talar dome, this is likely to evolve into a permanent state of valgus deformity in adulthood.26



View larger version (121K):
[in this window]
[in a new window]
  		FIG. 5. Typical changes seen in the ankle after occurrence of ankle instability secondary to vascularized fibular graft harvest, as shown by the (a) anteroposterior and (b) lateral views of the ankle in case 5.

 
Our series suggests that children with distal residual fibulae of <7 cm should be considered for prophylactic tibiofibular synostosis creation. Although significance could not be demonstrated (P < .078), this is likely due to the small patient population here. There may be some cases in which this is valuable, but we cannot prove that it is absolutely necessary in all cases on the basis of our reported data. Given that the number of these rare cases is small, the conclusion should be viewed as suggestive and our recommendations as provisional. Extrapolating the data, we see that these patients have only been followed up for a minimum duration of 1 year. The mean duration before development of clinically significant instability was 27.3 months (range, 20–38 months) after surgery, even though mild changes were routinely seen by 1 year. In our series, four more children have been followed up for <38 months. It isconceivable that additional cases developing instability within this group could dramatically increase the frequency of this complication.

Pain as a complication has been described in the past.25,39–41 In our series, this was a self-limiting phenomenon. Although pain occurred more frequently in adults, this trend was not significant. What was interesting was that pain occurred in patients in whom residual fibular lengths were >7 cm (P < .05). This suggests that the pain is not related to ankle instability, where, conceivably, residual fibular lengths should be shorter. Similar series on donor site morbidity show similar complications in adult tumor cases reconstructed with vascularized fibular grafts.42 This complication has been recorded up to 2 to 7 years after the procedure. In our series, the patients had pain for 3 to 19 months after the procedure.

In conclusion, the vascularized fibular graft is a key tool for the orthopedic oncologist and may need to be used in children, in whom bone tumors are more common and for whom biological reconstructive measures are preferred. Although excessive shortening of the remnant distal fibula during this procedure is not desirable, it may not be avoidable, given the requirements of the specific reconstructions. The vascularized fibular graft is a double-edged sword—this should be considered before surgery. A primary synostosis of the distal tibia and fibula might be advisable for patients when the sum of age and residual fibular lengths is <16. Otherwise, radiological and clinical surveillance is suggested for early diagnosis.


   FOOTNOTES
 
Presented at the 12th International Symposium of Limb Salvage, Rio de Janeiro, Brazil, September 15–17, 2003.

Received for publication March 15, 2004. Accepted for publication September 20, 2004.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Weiland AJ. Vascularized bone transfers. Instr Course Lect 1984;33:446–60.[Medline]
  2. Taylor GI, Miller GD, Ham FJ. The free vascularized bone graft. A clinical extension of microvascular techniques. Plast Reconstr Surg 1975;55:533–44.[Medline]
  3. Hsu RW, Wood MB, Sim FH, Chao EY. Free vascularised fibular grafting for reconstruction after tumour resection. J Bone Joint Surg Br 1997;79:36–42.
  4. Minami A, Kasashima T, Iwasaki N, Kato H, Kaneda K. Vascularised fibular grafts. An experience of 102 patients. J Bone Joint Surg Br 2000;82:1022–5.
  5. Wada T, Usui M, Nagoya S, Isu K, Yamawaki S, Ishii S. Resection arthrodesis of the knee with a vascularised fibular graft. Medium- to long-term results. J Bone Joint Surg Br 2000;82:489–93.
  6. Yuceturk A, Tuncay C, Isiklar U, Tandogan R. Vascularised bone graft applications in upper extremity problems. Microsurgery 1998;18:160–2.[CrossRef][Medline]
  7. Coghlan BA, Townsend PL. The morbidity of the free vascularised fibula flap. Br J Plast Surg 1993;46:466–9.[CrossRef][Medline]
  8. Yajima H, Tamai S, Mizumoto S, Ono H. Vascularised fibular grafts for reconstruction of the femur. J Bone Joint Surg Br 1993;75:123–8.
  9. Lee EH, Goh JC, Helm R, Pho RW. Donor site morbidity following resection of the fibula. J Bone Joint Surg Br 1990;72:129–31.
  10. Boer HH, Wood MB. Bone changes in the vascularised fibular graft. J Bone Joint Surg Br 1989;71:374–8.
  11. Weiland AJ, Weiss AP, Moore JR, Tolo VT. Vascularized fibular grafts in the treatment of congenital pseudarthrosis of the tibia. J Bone Joint Surg Am 1990;72:654–62.[Abstract/Free Full Text]
  12. Pho RW, Levack B, Satku K, Patradul A. Free vascularised fibular graft in the treatment of congenital pseudarthrosis of the tibia. J Bone Joint Surg Br 1985;67:64–70.
  13. Paluska DJ, Blount WP. Ankle valgus after the Grice subtalar stabilization: the late evaluation of a personal series with a modified technic. Clin Orthop 1968;59:137–46.[Medline]
  14. Hsu LC, Yau AC, O’Brien JP, Hodgson AR. Valgus deformity of the ankle resulting from fibular resection for a graft in subtalar fusion in children. J Bone Joint Surg Am 1972;54:585–94.[Abstract/Free Full Text]
  15. Lee EH, Goh JC, Helm R, Pho RW. Donor site morbidity following resection of the fibula. J Bone Joint Surg Br 1990;72:129–31.
  16. Coghlan BA, Townsend PL. The morbidity of the free vascularised fibula flap. Br J Plast Surg 1993;46:466–9.
  17. Hsu RW, Wood MB, Sim FH, Chao EY. Free vascularised fibular grafting for reconstruction after tumour resection. J Bone Joint Surg Br 1997;79:36–42.
  18. Moore JR, Weiland AJ, Daniel RK. Use of free vascularized bone grafts in the treatment of bone tumors. Clin Orthop 1983;175:37–44.
  19. Han CS, Wood MB, Bishop AT, Cooney WP III. Vascularized bone transfer. J Bone Joint Surg Am 1992;74:1441–9.[Abstract/Free Full Text]
  20. Hsu RW, Wood MB, Sim FH, Chao EY. Free vascularised fibular grafting for reconstruction after tumour resection. J Bone Joint Surg Br 1997;79:36–42.
  21. Lee EH, Goh JC, Helm R, Pho RW. Donor site morbidity following resection of the fibula. J Bone Joint Surg Br 1990;72:129–31.
  22. Weiland AJ, Weiss AP, Moore JR, Tolo VT. Vascularized fibular grafts in the treatment of congenital pseudarthrosis of the tibia. J Bone Joint Surg Am 1990;72:654–62.
  23. Bodde EW, de Visser E, Duysens JE, Hartman EH. Donor-site morbidity after free vascularized autogenous fibular transfer: subjective and quantitative analyses. Plast Reconstr Surg 2003;111:2237–42.[CrossRef][Medline]
  24. Pacelli LL, Gillard J, McLoughlin SW, Buehler MJ. A biomechanical analysis of donor-site ankle instability following free fibular graft harvest. J Bone Joint Surg Am 2003;85:597–603.[Abstract/Free Full Text]
  25. Tang CL, Mahoney JL, McKee MD, Richards RR, Waddell JP, Louie B. Donor site morbidity following vascularized fibular grafting. Microsurgery 1998;18:383–6.[CrossRef][Medline]
  26. Omokawa S, Tamai S, Takakura Y, Yajima H, Kawanishi K. A long-term study of the donor-site ankle after vascularized fibula grafts in children. Microsurgery 1996;17:162–6.[CrossRef][Medline]
  27. Babhulkar SS, Pande KC, Babhulkar S. Ankle instability after fibular resection. J Bone Joint Surg Br 1995;77:258–61.
  28. Ganel A, Yaffe B. Ankle instability of the donor site following removal of vascularized fibula bone graft. Ann Plast Surg 1990;24:7–9.[CrossRef][Medline]
  29. Hsu RW, Wood MB, Sim FH, Chao EY. Free vascularised fibular grafting for reconstruction after tumour resection. J Bone Joint Surg Br 1997;79:36–42.
  30. Moore JR, Weiland AJ, Daniel RK. Use of free vascularized bone grafts in the treatment of bone tumors. Clin Orthop 1983;175:37–44.
  31. Han CS, Wood MB, Bishop AT, Cooney WP III. Vascularized bone transfer. J Bone Joint Surg Am 1992;74:1441–9.
  32. Lee EH, Goh JC, Helm R, Pho RW. Donor site morbidity following resection of the fibula. J Bone Joint Surg Br 1990;72:129–31.
  33. Coghlan BA, Townsend PL. The morbidity of the free vascularised fibula flap. Br J Plast Surg 1993;46:466–9.
  34. Bodde EW, Visser E, Duysens JE, Hartman EH. Donor-site morbidity after free vascularized autogenous fibular transfer: subjective and quantitative analyses. Plast Reconstr Surg 2003;111:2237–42.
  35. Babhulkar SS, Pande KC, Babhulkar S. Ankle instability after fibular resection. J Bone Joint Surg Br 1995;77:258–61.
  36. Ganel A, Yaffe B. Ankle instability of the donor site following removal of vascularized fibula bone graft. Ann Plast Surg 1990;24:7–9.
  37. Lee EH, Goh JC, Helm R, Pho RW. Donor site morbidity following resection of the fibula. J Bone Joint Surg Br 1990;72:129–31.
  38. Pacelli LL, Gillard J, McLoughlin SW, Buehler MJ. A biomechanical analysis of donor-site ankle instability following free fibular graft harvest. J Bone Joint Surg Am 2003;85:597–603.
  39. Lee EH, Goh JC, Helm R, Pho RW. Donor site morbidity following resection of the fibula. J Bone Joint Surg Br 1990;72:129–31.
  40. Lee EH, Goh JC, Helm R, Pho RW. Donor site morbidity following resection of the fibula. J Bone Joint Surg Br 1990;72:129–31.
  41. Bodde EW, Visser E, Duysens JE, Hartman EH. Donor-site morbidity after free vascularized autogenous fibular transfer: subjective and quantitative analyses. Plast Reconstr Surg 2003;111:2237–42.
  42. Lee EH, Goh JC, Helm R, Pho RW. Donor site morbidity following resection of the fibula. J Bone Joint Surg Br 1990;72:129–31.



This article has been cited by other articles:


Home page
 J Am Acad Orthop SurgHome page
M. Ghert, N. Colterjohn, and M. Manfrini
The Use of Free Vascularized Fibular Grafts in Skeletal Reconstruction for Bone Tumors in Children
J. Am. Acad. Ortho. Surg., October 1, 2007; 15(10): 577 - 587.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Nathan, S. S.
Right arrow Articles by Healey, J. H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Nathan, S. S.
Right arrow Articles by Healey, J. H.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS