Vascularized free fibular transfer combined with autografting for the management of fracture nonunions associated with radiation therapy

Background: The purpose of this study was to evaluate the functional results, rates of union, and complications associated with vascularized free fibular transfer combined with autografting for the treatment of nonunions in previously irradiated bone. Methods: Seventeen patients who had had eighteen vascularized free fibular transfers combined with autografting for the treatment of nonunion of a fracture in previously irradiated bone were included in this study. There were eleven female patients and six male patients. Eight patients had a bone neoplasm and nine, a soft-tissue neoplasm. The diagnosis was Ewing sarcoma in four patients; lymphoma, malignant fibrous histiocytoma, and rhabdomyosarcoma in two patients each; and cavernous hemangioma, metastatic breast carcinoma, reticulum-cell sarcoma, myxosarcoma, hemangiopericytoma, and fibrosarcoma in one patient each. The remaining patient had a soft-tissue tumor for which the diagnosis was not known. All patients received radiation therapy. The average dose was 5564 centigray. There were no recurrent tumors. The average interval between the radiation therapy and the original fracture was 111 months. The fracture was in the femur in thirteen patients, in the humerus in three, and in the tibia in one. All patients had operative or nonoperative treatment, or both, of the initial fracture, and two had iliac-crest bone-grafting after the initial open reduction and internal fixation procedure. The ages of the patients ranged from thirteen to eighty-two years at the time of the vascularized free fibular transfer. All fibular transfers were applied as onlay grafts because no nonunion was associated with a large segmental defect. Cancellous autogenous bone graft from the iliac crest was used as an additional graft at the proximal and distal junctions of the graft with the bone and at the fracture site in all patients. The average duration of follow-up after the vascularized free fibular transfer was fifty-seven months (range, twenty-eight to 112 months). Results: Sixteen of the eighteen fracture sites united, after an average of 9.4 months (range, three to twenty-four months). Thirteen patients had an excellent result, one had a good result, two had a fair result, and one had a failure of treatment. Four patients had an infection, including one who continued to have a nonunion. The of her three patients had union after treatment with antibiotics, debridement, and removal of the hardware. Another patient who had a recalcitrant nonunion eventually required an above-the-knee amputation. Conclusions: On the basis of this review, we suggest that microvascular fibular transfer combined with autografting is an appropriate treatment: option for difficult nonunions associated with previously irradiated bone.