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Minimally invasive harvesting of nonvascularized fibular graft in children
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ARTICLE IN PRESS Orthopaedics & Traumatology: Surgery & Research xxx (2015) xxx–xxx
Available online at
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Technical note
Minimally invasive harvesting of nonvascularized fibular graft in children G. Lucas a,b , J. Lopez a,b , B. Fraisse a,b , S. Marleix a,b , P. Violas a,∗,b a b
Service de chirurgie pédiatrique, CHU de Rennes, 35033 Rennes, France Faculté de médecine, université Rennes 1, 35043 Rennes, France
a r t i c l e
i n f o
Article history: Received 27 December 2013 Accepted 19 February 2015 Keywords: Bone defect Nonvascularized fibular graft Minimally invasive
a b s t r a c t Using a nonvascularized fibular graft is part of the therapeutic arsenal for filling bone loss defects. It is conventionally performed by open surgery. The authors propose a minimally invasive technique for harvesting a free fibular graft. The fibula was removed subperiosteally by two or three small incisions in five patients with a mean age of nine years and nine months. The mean surgical time was 21 min and 40.5% of the length of the fibula was harvested. At the donor site, we found no removal-related complications, regeneration of the fibula was observed in 80% of cases, and the cosmetic result was considered excellent by all patients with a mean 4.3 years follow-up. This minimally invasive technique is simple and fast, with very low morbidity in our experience. © 2015 Elsevier Masson SAS. All rights reserved.
1. Introduction The nonvascularized autologous bone graft has been used for more than 100 years, most particularly for reconstruction after resection of bone tumors [1], with the first use of a fibular graft described by Walter in 1911 [2]. The vascularized fibular grafting technique appeared in 1975 [3]. Using a nonvascularized fibular graft can provide an autograft for a variety of reconstruction surgeries [1,4,5]. Classically, nonvascularized fibula has been harvested via a large lateral approach of the leg. Herein we propose a minimally invasive technique.
incision of the periosteum and step-by-step subperiosteal detachment performed cautiously on each of the fibula surfaces using a spatula (Fig. 2a). Then the osteotomy was performed proximally and distally using an oscillating saw (Fig. 2b). The graft was grasped with clamps (Fig. 2c), then the graft was mobilized on its axis by rotating it, allowing the periosteum to be completely detached and the bone graft extracted (Fig. 2d). Postoperatively, crutches were prescribed with partial weight-bearing allowed as well as daily physical therapy with passive and active mobilization of the toes to prevent muscle and tendon retractions. 3. Preliminary series
2. Technique Bone was harvested surgically on patients in the supine position with a pillow under the buttocks, with a tourniquet cuff in place. The site planned for the osteotomy (Fig. 1a) was at least 8 cm from the distal fibula (Fig. 1b) so as not to risk destabilizing the ankle. The proximal end of the fibula was at least 6 cm from the site to remain sufficiently distant from the fibular nerve (Fig. 1c). Two or three 2to 3-cm incisions were required depending on the length of graft material needed, at least 10 cm apart (Fig. 1d). The fibular diaphysis approach was used after opening the crural fascia and identifying the space between the soleus and fibular muscles, followed by an
∗ Corresponding author. Service de chirurgie pédiatrique, CHU de Rennes, 35033 Rennes, France. Tel.: +29 9284 321. E-mail address: [email protected] (P. Violas).
Six nonvascularized fibula samples per minimally invasive approach were harvested between 2001 and 2012. One patient was excluded because her growth cartilages were closed. This series included five patients (three girls and two boys), with a mean age of nine years and nine months (range, 3–14 years). The indications were the following: two pelvic Ewing sarcomas, one ballistic injury to the proximal tibia (Fig. 3), one epiphysiodesis of the femoral neck in a case of epiphysiolysis, and one anterior vertebral bone graft (Pott’s cervicothoracic abscess with kyphosis). The mean followup was 4.3 years (range, 1.3–10.5 years). The mean length of the grafts was 12.4 cm (range, 5–21 cm), a mean 40.5% (range, 27–60) of the total length of the fibula. The mean duration of harvesting was 21 min (range, 17–30 min). No complications related to bone harvesting or surgical problems were noted. The esthetic aspect was deemed excellent by all the patients. No valgus ankle deformity or superior or inferior tibiofibular instability was recorded,
http://dx.doi.org/10.1016/j.otsr.2015.02.006 1877-0568/© 2015 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Lucas G, et al. Minimally invasive harvesting of nonvascularized fibular graft in children. Orthop Traumatol Surg Res (2015), http://dx.doi.org/10.1016/j.otsr.2015.02.006
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ARTICLE IN PRESS G. Lucas et al. / Orthopaedics & Traumatology: Surgery & Research xxx (2015) xxx–xxx
Fig. 1. 1a–c: identification of proximal and distal osteotomy areas; d: 2- to 3-cm incisions at least 10 cm apart.
including in one patient presenting 4.5 mm ascension of the lateral malleolus. In four cases (80%), donor site regeneration was complete, within a mean five months (range, 1.5–8 months) (Fig. 4). In one case, regeneration occurred along the entire length of the fibula in 22 months but with nonunion at the proximal extremity, with the distal extremity achieving bone union after three years. At the last follow-up, in three cases, the width of the newly formed fibula was greater than it had been initially. The small number of patients examined in the study made it impossible to demonstrate a significant relation between the quality of fibular regeneration and patient age.
4. Discussion The minimally invasive harvesting of nonvascularized fibula is a simple and rapid technique and appears to have very low morbidity. After bone harvest, complete regeneration was obtained in 80% of the cases, with one case evolving toward nonunion. In the literature, after open nonvascularized bone harvesting, Bettin et al. [6] found 49% complete regeneration in 8–16 months, with age seeming to be the only factor predicting regeneration. Setting the age limit at 15 years, prediction of regeneration reached 96% sensitivity and 74% specificity. Krieg et al. [1] found 69% complete
Fig. 2. a: detachment of the periosteum; b: osteotomy with the oscillating saw; c: rotational movement with a clamp to complete periosteum detachment; d: graft extraction.
Please cite this article in press as: Lucas G, et al. Minimally invasive harvesting of nonvascularized fibular graft in children. Orthop Traumatol Surg Res (2015), http://dx.doi.org/10.1016/j.otsr.2015.02.006
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ARTICLE IN PRESS G. Lucas et al. / Orthopaedics & Traumatology: Surgery & Research xxx (2015) xxx–xxx
3
Fig. 3. Ballistic injury, proximal tibia: a,b: postoperative; c,d: at 16 months of follow-up. Note the reconstitution of the fibula (thicker on lateral view).
or partial regeneration. They also showed that patients with fibular regeneration were significantly younger, with a mean age of 16 years. Steinlechner et al. [7] found 86% fibular regeneration in eight children treated with sequestrectomy for chronic osteomyelitis. In view of the present results, a technical improvement could be suggested: using Liston forceps for the fibular osteotomy rather than an oscillating saw to prevent heating the bone, a possible cause
of nonunion. Although Krieg et al. [1] reported 3.5% ankle instability with valgus deformity, we did not observe this complication, including in the case presenting a slight ascension of the lateral malleolus. In a series of 20 children, Fragnière et al. [8] found 45% valgus deformity and 100% lateral malleolus ascension, but these were vascularized fibula bone harvests. Only age was retained as a factor of valgus deviation. They therefore proposed prevention
Fig. 4. Fibula regeneration after minimally invasive bone harvesting: a,b: at 2 months of follow-up; c,d: at 10.5 years of follow-up.
Please cite this article in press as: Lucas G, et al. Minimally invasive harvesting of nonvascularized fibular graft in children. Orthop Traumatol Surg Res (2015), http://dx.doi.org/10.1016/j.otsr.2015.02.006
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ARTICLE IN PRESS G. Lucas et al. / Orthopaedics & Traumatology: Surgery & Research xxx (2015) xxx–xxx
4
using syndesmosis screws before 10–12 years of age. However, Hsu et al. [9] estimated that subperiosteal resection of nonvascularized fibula resulted in bone regeneration protecting from valgus deformity, which seems correlated with the results reported herein. In addition, several authors recommended preserving 6–8 cm of distal fibula to prevent destabilization of the ankle [3,10,11], despite the biomechanical work reported by Pacelli et al. [12] demonstrating that only 10% of the fibula length could be preserved. Bettin et al. [6] reported three cases of moderate laxity of the lateral collateral ligament at the knee. Although no neurological complications were demonstrated, they have been reported in the literature. Shingade et al. [13] studied weakness in the extensor hallucis longus muscle after nonvascularized fibular harvest: 38% of the patients experienced postoperative weakness that resolved secondarily. Although it is often accepted that this weakness may result from disinsertion of the muscle origins after fibulectomy [14], Shingade et al. [13] showed that this weakness was isolated and related to impairment of the extensor hallucis longus nerve. After a cadaver study, they described several anatomic variants of the position of this nerve, sometimes very close to the periosteum of the fibula, which could therefore be injured during bone harvesting. Krieg et al. [1] reported 6.5% nerve lesions and Basarir et al. [15] described 10% paralysis of the fibular nerve that resolved spontaneously in four months. Scarring complications after open harvesting have been reported. Bettin et al. [6] described 5.7% of patients with moderate pain, Krieg et al. [1] reported 3.5% muscle adherences related to scarring and 3.5% decreased ankle joint amplitudes. In 163 patients, Nassr et al. [16] found 15% experienced pain at the scar more than 3 months after surgery. Minimally invasive harvesting seems to prevent this complication. 5. Conclusion If the option of a nonvascularized fibula graft is chosen, the minimally invasive bone harvesting procedure seems to be an elegant method with a good number of advantages, making it possible to harvest long grafts while reducing the procedure time, reducing intra- and postoperative bleeding as well as scarring complications with a clear esthetic benefit. Moreover, compared to the technique via a large lateral approach, we have encountered good results even
if the number of cases studied has been small. Nevertheless, this technique requires thick periosteum that can be easily detached. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Krieg AH, Hefti F. Reconstruction with non-vascularised fibular grafts after resection of bone tumours. J Bone Joint Surg Br 2007;89:215–21. [2] Walter M. Résection de l’extrémité inferieure du radius pour ostéosarcome : greffe de l’extrémité supérieure du péroné. Bull Mem Soc Chir Paris 1911;37:739–47. [3] Taylor GI, Miller GD, Ham FJ. The free vascularized bone graft: a clinical extension of microvascular techniques. Plast Reconstr Surg 1975;55:533–44. [4] Enneking WF, Eady JL, Burchardt H. Autogenous cortical bone grafts in the reconstruction of segmental skeletal defects. J Bone Joint Surg Am 1980;62A:1039–58. [5] Yadav SS. Dual-fibular grafting for massive bone gaps in the lower extremity. J Bone Joint Surg Am 1990;72-A:486–94. [6] Bettin D, Böhm H, Clatworthy M, Zurakowski D, Link TM. Regeneration of the donor side after autogenous fibula transplantation in 53 patients: evaluation by dual x-ray absorptiometry. Acta Orthop Scand 2003;74:332–6. [7] Steinlechner CW, Mkandawire NC. Non-vascularised fibular transfer in the management of defects of long bones after sequestrectomy in children. J Bone Joint Surg Br 2005;87:1259–63. [8] Fragnière B, Wicart P, Mascard E, Dubousset J. Prevention of ankle valgus after vascularized fibular grafts in children. Clin Orthop Relat Res 2003;408:245–51. [9] 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. [10] Weiland AJ, Moore JR, Daniel RK. Vascularized bone autografts. Experience with 41 cases. Clin Orthop Relat Res 1983;174:87–95. [11] Vail TP, Urbaniak JR. Donor-site morbidity with use of vascularized autogenous fibular grafts. J Bone Joint Surg Am 1996;78:204–11. [12] 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. [13] Shingade VU, Jagtap SM, Ranade AB. Weakness of extensor hallucis longus after removal of non-vascularised fibula as an autograft. J Bone Joint Surg Br 2004;86:384–7. [14] Gore DR, Gardner GM, Sepic SB, Mollinger LA, Murray MP. Function following partial fibulectomy. Clin Orthop Relat Res 1987;220:206–10. [15] Basarir K, Selek H, Yildiz Y, Saglik Y. Nonvascularized fibular grafts in the reconstruction of bone defects in orthopedic oncology. Acta Orthop Traumatol Turc 2005;39:300–6. [16] Nassr A, Khan MH, Ali MH, Espiritu MT, Hanks SE, Lee JY, et al. Donor-site complications of autogenous nonvascularized fibula strut graft harvest for anterior cervical corpectomy and fusion surgery: experience with 163 consecutive cases. Spine J 2009;9:893–8.
Please cite this article in press as: Lucas G, et al. Minimally invasive harvesting of nonvascularized fibular graft in children. Orthop Traumatol Surg Res (2015), http://dx.doi.org/10.1016/j.otsr.2015.02.006
ARTICLE IN PRESS Orthopaedics & Traumatology: Surgery & Research xxx (2015) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Technical note
Minimally invasive harvesting of nonvascularized fibular graft in children G. Lucas a,b , J. Lopez a,b , B. Fraisse a,b , S. Marleix a,b , P. Violas a,∗,b a b
Service de chirurgie pédiatrique, CHU de Rennes, 35033 Rennes, France Faculté de médecine, université Rennes 1, 35043 Rennes, France
a r t i c l e
i n f o
Article history: Received 27 December 2013 Accepted 19 February 2015 Keywords: Bone defect Nonvascularized fibular graft Minimally invasive
a b s t r a c t Using a nonvascularized fibular graft is part of the therapeutic arsenal for filling bone loss defects. It is conventionally performed by open surgery. The authors propose a minimally invasive technique for harvesting a free fibular graft. The fibula was removed subperiosteally by two or three small incisions in five patients with a mean age of nine years and nine months. The mean surgical time was 21 min and 40.5% of the length of the fibula was harvested. At the donor site, we found no removal-related complications, regeneration of the fibula was observed in 80% of cases, and the cosmetic result was considered excellent by all patients with a mean 4.3 years follow-up. This minimally invasive technique is simple and fast, with very low morbidity in our experience. © 2015 Elsevier Masson SAS. All rights reserved.
1. Introduction The nonvascularized autologous bone graft has been used for more than 100 years, most particularly for reconstruction after resection of bone tumors [1], with the first use of a fibular graft described by Walter in 1911 [2]. The vascularized fibular grafting technique appeared in 1975 [3]. Using a nonvascularized fibular graft can provide an autograft for a variety of reconstruction surgeries [1,4,5]. Classically, nonvascularized fibula has been harvested via a large lateral approach of the leg. Herein we propose a minimally invasive technique.
incision of the periosteum and step-by-step subperiosteal detachment performed cautiously on each of the fibula surfaces using a spatula (Fig. 2a). Then the osteotomy was performed proximally and distally using an oscillating saw (Fig. 2b). The graft was grasped with clamps (Fig. 2c), then the graft was mobilized on its axis by rotating it, allowing the periosteum to be completely detached and the bone graft extracted (Fig. 2d). Postoperatively, crutches were prescribed with partial weight-bearing allowed as well as daily physical therapy with passive and active mobilization of the toes to prevent muscle and tendon retractions. 3. Preliminary series
2. Technique Bone was harvested surgically on patients in the supine position with a pillow under the buttocks, with a tourniquet cuff in place. The site planned for the osteotomy (Fig. 1a) was at least 8 cm from the distal fibula (Fig. 1b) so as not to risk destabilizing the ankle. The proximal end of the fibula was at least 6 cm from the site to remain sufficiently distant from the fibular nerve (Fig. 1c). Two or three 2to 3-cm incisions were required depending on the length of graft material needed, at least 10 cm apart (Fig. 1d). The fibular diaphysis approach was used after opening the crural fascia and identifying the space between the soleus and fibular muscles, followed by an
∗ Corresponding author. Service de chirurgie pédiatrique, CHU de Rennes, 35033 Rennes, France. Tel.: +29 9284 321. E-mail address: [email protected] (P. Violas).
Six nonvascularized fibula samples per minimally invasive approach were harvested between 2001 and 2012. One patient was excluded because her growth cartilages were closed. This series included five patients (three girls and two boys), with a mean age of nine years and nine months (range, 3–14 years). The indications were the following: two pelvic Ewing sarcomas, one ballistic injury to the proximal tibia (Fig. 3), one epiphysiodesis of the femoral neck in a case of epiphysiolysis, and one anterior vertebral bone graft (Pott’s cervicothoracic abscess with kyphosis). The mean followup was 4.3 years (range, 1.3–10.5 years). The mean length of the grafts was 12.4 cm (range, 5–21 cm), a mean 40.5% (range, 27–60) of the total length of the fibula. The mean duration of harvesting was 21 min (range, 17–30 min). No complications related to bone harvesting or surgical problems were noted. The esthetic aspect was deemed excellent by all the patients. No valgus ankle deformity or superior or inferior tibiofibular instability was recorded,
http://dx.doi.org/10.1016/j.otsr.2015.02.006 1877-0568/© 2015 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Lucas G, et al. Minimally invasive harvesting of nonvascularized fibular graft in children. Orthop Traumatol Surg Res (2015), http://dx.doi.org/10.1016/j.otsr.2015.02.006
G Model OTSR-1216; No. of Pages 4 2
ARTICLE IN PRESS G. Lucas et al. / Orthopaedics & Traumatology: Surgery & Research xxx (2015) xxx–xxx
Fig. 1. 1a–c: identification of proximal and distal osteotomy areas; d: 2- to 3-cm incisions at least 10 cm apart.
including in one patient presenting 4.5 mm ascension of the lateral malleolus. In four cases (80%), donor site regeneration was complete, within a mean five months (range, 1.5–8 months) (Fig. 4). In one case, regeneration occurred along the entire length of the fibula in 22 months but with nonunion at the proximal extremity, with the distal extremity achieving bone union after three years. At the last follow-up, in three cases, the width of the newly formed fibula was greater than it had been initially. The small number of patients examined in the study made it impossible to demonstrate a significant relation between the quality of fibular regeneration and patient age.
4. Discussion The minimally invasive harvesting of nonvascularized fibula is a simple and rapid technique and appears to have very low morbidity. After bone harvest, complete regeneration was obtained in 80% of the cases, with one case evolving toward nonunion. In the literature, after open nonvascularized bone harvesting, Bettin et al. [6] found 49% complete regeneration in 8–16 months, with age seeming to be the only factor predicting regeneration. Setting the age limit at 15 years, prediction of regeneration reached 96% sensitivity and 74% specificity. Krieg et al. [1] found 69% complete
Fig. 2. a: detachment of the periosteum; b: osteotomy with the oscillating saw; c: rotational movement with a clamp to complete periosteum detachment; d: graft extraction.
Please cite this article in press as: Lucas G, et al. Minimally invasive harvesting of nonvascularized fibular graft in children. Orthop Traumatol Surg Res (2015), http://dx.doi.org/10.1016/j.otsr.2015.02.006
G Model OTSR-1216; No. of Pages 4
ARTICLE IN PRESS G. Lucas et al. / Orthopaedics & Traumatology: Surgery & Research xxx (2015) xxx–xxx
3
Fig. 3. Ballistic injury, proximal tibia: a,b: postoperative; c,d: at 16 months of follow-up. Note the reconstitution of the fibula (thicker on lateral view).
or partial regeneration. They also showed that patients with fibular regeneration were significantly younger, with a mean age of 16 years. Steinlechner et al. [7] found 86% fibular regeneration in eight children treated with sequestrectomy for chronic osteomyelitis. In view of the present results, a technical improvement could be suggested: using Liston forceps for the fibular osteotomy rather than an oscillating saw to prevent heating the bone, a possible cause
of nonunion. Although Krieg et al. [1] reported 3.5% ankle instability with valgus deformity, we did not observe this complication, including in the case presenting a slight ascension of the lateral malleolus. In a series of 20 children, Fragnière et al. [8] found 45% valgus deformity and 100% lateral malleolus ascension, but these were vascularized fibula bone harvests. Only age was retained as a factor of valgus deviation. They therefore proposed prevention
Fig. 4. Fibula regeneration after minimally invasive bone harvesting: a,b: at 2 months of follow-up; c,d: at 10.5 years of follow-up.
Please cite this article in press as: Lucas G, et al. Minimally invasive harvesting of nonvascularized fibular graft in children. Orthop Traumatol Surg Res (2015), http://dx.doi.org/10.1016/j.otsr.2015.02.006
G Model OTSR-1216; No. of Pages 4
ARTICLE IN PRESS G. Lucas et al. / Orthopaedics & Traumatology: Surgery & Research xxx (2015) xxx–xxx
4
using syndesmosis screws before 10–12 years of age. However, Hsu et al. [9] estimated that subperiosteal resection of nonvascularized fibula resulted in bone regeneration protecting from valgus deformity, which seems correlated with the results reported herein. In addition, several authors recommended preserving 6–8 cm of distal fibula to prevent destabilization of the ankle [3,10,11], despite the biomechanical work reported by Pacelli et al. [12] demonstrating that only 10% of the fibula length could be preserved. Bettin et al. [6] reported three cases of moderate laxity of the lateral collateral ligament at the knee. Although no neurological complications were demonstrated, they have been reported in the literature. Shingade et al. [13] studied weakness in the extensor hallucis longus muscle after nonvascularized fibular harvest: 38% of the patients experienced postoperative weakness that resolved secondarily. Although it is often accepted that this weakness may result from disinsertion of the muscle origins after fibulectomy [14], Shingade et al. [13] showed that this weakness was isolated and related to impairment of the extensor hallucis longus nerve. After a cadaver study, they described several anatomic variants of the position of this nerve, sometimes very close to the periosteum of the fibula, which could therefore be injured during bone harvesting. Krieg et al. [1] reported 6.5% nerve lesions and Basarir et al. [15] described 10% paralysis of the fibular nerve that resolved spontaneously in four months. Scarring complications after open harvesting have been reported. Bettin et al. [6] described 5.7% of patients with moderate pain, Krieg et al. [1] reported 3.5% muscle adherences related to scarring and 3.5% decreased ankle joint amplitudes. In 163 patients, Nassr et al. [16] found 15% experienced pain at the scar more than 3 months after surgery. Minimally invasive harvesting seems to prevent this complication. 5. Conclusion If the option of a nonvascularized fibula graft is chosen, the minimally invasive bone harvesting procedure seems to be an elegant method with a good number of advantages, making it possible to harvest long grafts while reducing the procedure time, reducing intra- and postoperative bleeding as well as scarring complications with a clear esthetic benefit. Moreover, compared to the technique via a large lateral approach, we have encountered good results even
if the number of cases studied has been small. Nevertheless, this technique requires thick periosteum that can be easily detached. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Krieg AH, Hefti F. Reconstruction with non-vascularised fibular grafts after resection of bone tumours. J Bone Joint Surg Br 2007;89:215–21. [2] Walter M. Résection de l’extrémité inferieure du radius pour ostéosarcome : greffe de l’extrémité supérieure du péroné. Bull Mem Soc Chir Paris 1911;37:739–47. [3] Taylor GI, Miller GD, Ham FJ. The free vascularized bone graft: a clinical extension of microvascular techniques. Plast Reconstr Surg 1975;55:533–44. [4] Enneking WF, Eady JL, Burchardt H. Autogenous cortical bone grafts in the reconstruction of segmental skeletal defects. J Bone Joint Surg Am 1980;62A:1039–58. [5] Yadav SS. Dual-fibular grafting for massive bone gaps in the lower extremity. J Bone Joint Surg Am 1990;72-A:486–94. [6] Bettin D, Böhm H, Clatworthy M, Zurakowski D, Link TM. Regeneration of the donor side after autogenous fibula transplantation in 53 patients: evaluation by dual x-ray absorptiometry. Acta Orthop Scand 2003;74:332–6. [7] Steinlechner CW, Mkandawire NC. Non-vascularised fibular transfer in the management of defects of long bones after sequestrectomy in children. J Bone Joint Surg Br 2005;87:1259–63. [8] Fragnière B, Wicart P, Mascard E, Dubousset J. Prevention of ankle valgus after vascularized fibular grafts in children. Clin Orthop Relat Res 2003;408:245–51. [9] 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. [10] Weiland AJ, Moore JR, Daniel RK. Vascularized bone autografts. Experience with 41 cases. Clin Orthop Relat Res 1983;174:87–95. [11] Vail TP, Urbaniak JR. Donor-site morbidity with use of vascularized autogenous fibular grafts. J Bone Joint Surg Am 1996;78:204–11. [12] 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. [13] Shingade VU, Jagtap SM, Ranade AB. Weakness of extensor hallucis longus after removal of non-vascularised fibula as an autograft. J Bone Joint Surg Br 2004;86:384–7. [14] Gore DR, Gardner GM, Sepic SB, Mollinger LA, Murray MP. Function following partial fibulectomy. Clin Orthop Relat Res 1987;220:206–10. [15] Basarir K, Selek H, Yildiz Y, Saglik Y. Nonvascularized fibular grafts in the reconstruction of bone defects in orthopedic oncology. Acta Orthop Traumatol Turc 2005;39:300–6. [16] Nassr A, Khan MH, Ali MH, Espiritu MT, Hanks SE, Lee JY, et al. Donor-site complications of autogenous nonvascularized fibula strut graft harvest for anterior cervical corpectomy and fusion surgery: experience with 163 consecutive cases. Spine J 2009;9:893–8.
Please cite this article in press as: Lucas G, et al. Minimally invasive harvesting of nonvascularized fibular graft in children. Orthop Traumatol Surg Res (2015), http://dx.doi.org/10.1016/j.otsr.2015.02.006