The fibula free flap became popular in orthopedic oncology, for limb sparing long bone tumor resection. It is particularly suitable for intercalary or resection arthrodesis options. In the present series we used a surgical reconstruction algorithm enabling each patient to receive a personalized technique. During the years 1998 – 2002, 30 patients underwent limb-sparing surgery (LSS) for long bone sarcoma. There were 18 males and 12 females. Their mean age was 23 years (9-70 years). The diagnoses were Ewing’s sarcoma (11 patients), osteogenic sarcoma (8 patients), chondrosarcoma (5), giant cell tumor of bone (3), high-grade soft tissue sarcoma (2) and lieomyosarcoma of bone (1). The majority of tumors where located in the lower extremity (23), most of them in the femur (15 patients, subdivided to: 4 in the proximal femoral shaft, 5 in the distal femoral shaft, whole femoral shaft in 5 and just one in the proximal femoral head). In 7 patients the upper extremity was involved, six in the radius and in one the humerus was involved. The free fibula flap was used in three types of approaches: vascularized fibula as an osseous flap only (18 patients), a combination of a vascularized fibula flap in conjunction with an allograft (Capanna’s technique) (10 patients) and a free double-barreled fibula (2 patients). Up to date, all flaps survived (100%). Post operatively; all patients were monitored clinically, radiologically and by radioisotope bone scan studies. Callus formation and union were shown 2.6 to 8 months post operatively. Patients who underwent lower extremity reconstruction were non weight bearing (NWB) for 3 - 9 months with a transition period in which they used a brace and gradually increased weight bearing until full weight-bearing (FWB). Eight patients had 11 recipient site complications: Two patients (6.7%) had hematomas, three patients (10%) had infection and dehiscence of the surgical wound with bone exposure in one, all resolved using conservative treatment only. Failure of the hardware fixation system occurred in 2 patients mandating surgical correction. No fibula donor site complications were recorded. In intercalary resections, the use of the vascularized fibula flap as an isolated osseous flap might be insufficient. Different body sites have different stress loads to carry, depending also on the age of the patient and on his individual physical status. In order to achieve initial strength in the early period, we combined the free fibula flap with an allograft (Capanna’s method), or augmented it as a double-barreled fibula. We propose, a surgical algorithm to assist the surgeon with the preferred method for reconstruction of various long bone defects in different body locations at childhood or adulthood. Long bone reconstruction using a vascularized fibula flap, alone or in combination with an allograft, autogenous bone graft or double-barreled fibula for limb sparing surgery is a safe and reliable method with a predictable bony union, good functional outcome and a low complication rate.
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