CORRInsights®: Is There Benefit to Free Over Pedicled Vascularized Grafts in Augmenting Tibial Intercalary Allograft Constructs?

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Limb-salvage surgery following resections of bone tumors in the tibia can be complex and difficult. Fortunately, treatment options for limb preservation have benefited greatly from innovations in both surgical techniques and advances in three-dimensional imaging.
In the current study, Manfrini and colleagues compared the effectiveness of vascularized fibular autografts with pedicled vascularized fibular autografts. By concentrating their review on a single area of reconstruction, and limiting their comparison to two specific techniques, the authors demonstrated the overall utility (and noninferiority) of the pedicled fibular graft compared to the contralateral, free-fibula-transfer method. Their findings suggest that when appropriately selected for specific reconstructions of the tibia, pedicled vascularized fibular autografts are the simpler, and presumably, more cost-effective and time-efficient technique. The authors also note, however, that there are situations where the pedicled graft was not the best choice such as previous radiation, fracture of the fibula infection or vascular compromise, and they continue to use the free vascularized technique.
Although massive allograft reconstructions usually unite to the host bone and provide structural support for the limb [2, 6], mechanical failures can complicate intercalary reconstructions requiring revision surgery [1]. Enneking and Mindell [5] demonstrated histologically that in retrieved allograft samples, large allografts often heal only partially with limited penetration and remodeling of the new bone into the nonviable allograft. Used alone as an intercalary construct [8], for repair of failed grafts [3], or occasionally in conjunction with large autografts [7], the addition of a vascularized fibula has been shown to increase the healing and long-term effectiveness of allografts when used to reconstruct intercalary defects of the tibia [4]. Vascularized bone reconstructions (either pedicle grafts rotated on their blood supply) or free-tissue transfers (such as the contralateral fibula grafts) can hypertrophy over time, which in theory, could provide greater durability over the long run.
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