Sufficiency of Isolated Vascularised Fibular Free Flaps for Pediatric Intercalary Lower Limb Reconstruction

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Background: For intercalary defects after resection of pediatric sarcoma, an isolated vascularized free fibular graft (VFFG) offers a living bone option with the potential for durability but is underutilized due to concerns about mechanical sufficiency. By contrast, structural allograft is initially strong but is associated with a high complication profile with or without a composite VFFG (Capanna). Our aim was to compare the complications associated with allograft/VFFG composites to isolated VFFG. Methods: This is a retrospective comparison of 32 pediatric patients with primary femoral or tibial sarcoma. Reconstructions were categorized into 2 groups: allografts + VFFG (Capanna) (Group 1, n = 9) and "single barrel" isolated VFFG (Group 2, n = 23). Descriptive and inferential statistical analyses were performed. Results: No significant differences between the 2 groups were observed in age, sex, diagnosis, length of reconstruction, or follow-up (56 months (SD 29) for Group 1 and 53 months (SD 24) for Group 2). Group 1 participants exhibited a higher number of complications including the need for unplanned surgery (mean 2.9) compared with those in Group 2 (mean 1.6, p < 0.01). Disparities in bone healing were notable. At the final follow-up, 46% in Group 1 had achieved full consolidation compared with 96% in Group 2 (p = 0.002). Graft fractures and hardware failures were not different between the groups despite full weight-bearing among all subjects, suggesting mechanical equivalency within the follow-up period. The mean numbers of unplanned surgeries per participant were 4.2 ± SD 4.4 and 2.3 ± SD 2.5 for Groups 1 and 2, respectively (p = 0.149). Conclusions: Isolated single barrel VFFG reconstructions are structurally sound and had fewer complications and faster union than composite allograft/VFFG composites. Level of Evidence: Retrospective cohort study Level III. See Instructions for Authors for a complete description of levels of evidence.

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