Clinical Outcomes of Vascularized Fibular Graft Reconstruction for Treatment of Late Radiation-Induced Complications in Long Bones

Introduction: High dose radiation therapy leads to significant local tissue compromise including low vascularity, fibrosis and infection. There are several surgical reconstruction options for high dose radiation fractures non unions or repeat resection of tumor recurrence. Reconstruction with vascularized fibular graft (VFG) addresses the bone loss and the vascular compromise. We sought to describe the difficulties and prognosis of implementing this surgical technique in high dose radiated tissue for better patient counseling and surgical planning.

Methods: A retrospective chart review of patients surgically treated with VFG reconstruction for post radiation complication from 1986 to 2014 was conducted. Data on demographics, anatomical location, union rate, complications, functional outcome and soft tissue changes was collected.

Results: 13 patients (9 fracture nonunion, 3 local recurrences and 1 radiation induced sarcoma) were identified. Median age was 44 years with median follow-up of 75 months. Humerus was the most common location (n=6) followed by femur (n=4). Median radiation dose was 5000 cGy with median interval between RT and VFG surgery of 5 years. 12 flaps (92%) survived and one patient had above knee amputation for osteomyelitis. Radiological union was achieved in 9 patients (70%) with median time to union of 18 months (range: 8-29). The most common complications were infection (n=4) and non union (n=4); 7 (54%) patients had re-operation. In 6 patients (46%) union was delayed (more than 24 months), 3 required bone grafting. Extensive soft tissue fibrosis was found in longer time interval from radiation to surgery (p=0.04)

Discussion: VFG is good salvage procedure following local radiation long term complication with 92% clinical success. The surgeon should anticipate a long union time of 1.5 years and difficult soft tissue dissection during surgery. Frequent surgical wound inspection and bone grafting should be planned to reduce the high complication rate of infection and non union.