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 result s, rates of union, and complications associated with vascularized free fibu lar transfer combined with autografting for the treatment of nonunions in p reviously irradiated bone. Methods: Seventeen patients who had had eighteen vascularized free fibular transfers combined with autografting for the treatment of nonunion of a fra cture in previously irradiated bone were included in this study. There were eleven female patients and six male patients. Eight patients had a bone ne oplasm and nine, a soft-tissue neoplasm. The diagnosis was Ewing sarcoma in four patients; lymphoma, malignant fibrous histiocytoma, and rhabdomyosarc oma in two patients each; and cavernous hemangioma, metastatic breast carci noma, reticulum-cell sarcoma, myxosarcoma, hemangiopericytoma, and fibrosar coma 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 centigra y. There were no recurrent tumors. The average interval between the radiati on therapy and the original fracture was 111 months. The fracture was in th e 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 o pen reduction and internal fixation procedure. The ages of the patients ranged from thirteen to eighty-two years at the ti me of the vascularized free fibular transfer. All fibular transfers were ap plied as onlay grafts because no nonunion was associated with a large segme ntal defect. Cancellous autogenous bone graft from the iliac crest was used as an additional graft at the proximal and distal junctions of the graft w ith 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 tre atment with antibiotics, debridement, and removal of the hardware. Another patient who had a recalcitrant nonunion eventually required an above-the-kn ee amputation. Conclusions: On the basis of this review, we suggest that microvascular fib ular transfer combined with autografting is an appropriate treatment: optio n for difficult nonunions associated with previously irradiated bone.