Vascularised fibula
Rodolfo Capanna M.D.
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206 VASCULARIZED BONE GRAFTS
AGE 2 - 65 (average 24) 8
ONCOLOGY: 148 (71%)
38
TRAUMATOLOGY: 58 (29%) 7
10
SITE: BONE LOSS: 6-23
humerus 38 Cm.
radius 10
ulna 7 57 1
metacarpal 1
femur 57
tibia 82 82
mandibolar 8
calcaneum 3
3
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DONOR SITES
• Fibula: 196
• Iliac crest: 7
• Metatarsal: 1
• M.F. joint : 1
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Male, 29 y
Osteoblastoma
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Male, 29 y
Osteoblastoma
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Follow-up
6 years
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Our experience with vascularized iliac crest graft
after calcanectomy for calcaneus tumors
3 cases (1999, 2001, 2005)
2 total - 1 subtotal calcanectomy
• Age at surgery 18 - 29
• Diagnosis: B. F. Histiocytoma
Osteoblastoma
Giant Cell Tumor
• No surgical complications
• Free weight-bearing at 6 months
• Follow-up: average 60.3 months (20 – 89)
• ISOLS/MSTS score: average 80% (53,3 – 93,3)
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FIBULA
Taylor G. I. “The free vascularized bone graft: a clinical extension of
microsurgical technique”
Plast Recon Surg 1975
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V. FIBULA ALONE
• Good matching of diaphyseal diameter for upper limb
• Sufficient mechanical resistance
• Adequate length for intercalary defects
INDICATIONS
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Knee arthrodesis
1.5 y 4y 12 y
3m
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FIBULA + ALLOGRAFT
• Biologic potential of V.F. + allograft mechanical resistance
• Very stable assembling for segments under weight bearing
• Fusion between two components at medium term
INDICATIONS
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Combination V.F. + Allograft
Allograft Vascularised fibula
üAppropriate Size üInadequate Size
üMechanical Strenght üLiving Tissue
üCreeping Substitution üHypertrophy
üFractures üFractures
üBone Resorption üBone Repair and Hypertrophy
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The history
… march 1988
Jenni .. 11 yrs..
osteosarcoma of the
meta-diaphyseal tibia
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1m 2y 5y
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1m
2 yr
5 yr
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The history
… november 1988
Sara… 8 yrs…
Ewing sarcoma of the
meta-diaphyseal tibia
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3m 2y
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The technique
…1993
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Intra-epiphyseal resection
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Intra-epiphyseal resection
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Intra-epiphyseal resection
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2y 5y 10 y
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Intraepiphyseal resection
1y 11 y
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Male, 13 y.o., hemorragic OS of the meta-diaphyseal
femur, by concentrical assembling of VFG + MA
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3m 7y
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COMPLICATIONS
DONOR SITE
Vascularized fibular diaphysis
ØValgus deformity
of the ankle: 3 (2.6%)
ØFlexor tendons
retraction: 6 (5.2%)
ØExtensor tendons
retraction: 1 (0.8%)
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Valgus deformity 2.6%
Due to: - Proximal migration of the fibula
- Valgus ankle instability
- Inhibition of the growth of the
lateral part of tibial epiphysis
üDistal 6 cm. should
be preserved
üT.F. synostosis is not able
to prevent valgus def.
(Kanaya 2002)
*
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Flexor tendons retraction 5.2%
Due to: - Adhesion of F.H.L. to the muscles
of posterior compartment
- Ischemic retraction of F.H.L.
üEarly complication (2-3 m.)
üTreatment: lengthening of
involved tendons
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COMPLICATIONS
DIAPHYSIS
RECIPIENT SITE
Vascularized fibular diaphysis
Ø Fracture: 20 (17,5%)
Ø Non Union: 12 (10,5%)
Ø Infection: 5 (4,3%)
Ø Soft T. necrosis: 4 (3,5%)
Ø Microvascular failure: 4 (3,5%)
Ø Peroneal nerve palsy: 1 (0,8%)
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Fractures Lower Extremity 1
VFG Alone
29 CASES : 9 FRACTURES (31%)
all healed conservatively
2m 1y 2y 4y 10 y
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Fractures Lower Extremity 2
VFG + Massive Allograft
61 CASES: 6 FRACTURES (9.8 %)
4 healed conservatively
2 surgery
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Biologic properties of vascularized bone allow an early
healing of fracture when a stable osteosynthesis is present
3 m.
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FRACTURES
• 20/114 17,5 %
• 20 healed 100 %
• 3 secondary procedures 15 %
Upper limb
Overall 29%
fracture rate VF alone
17,5% 31 %
Lower limb
17%
VF + allograft
9.8 %
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COMPLICATIONS RECIPIENT SITE
NON UNION: 12 (10,5%)
All healed after secondary procedures
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COMPLICATIONS DIAPHYSIS
ØSoft tissue necrosis: 4 (3,5%)
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COMPLICATIONS DIAPHYSIS
3 amputations
ØMicrovascular failure: 4 (3,5%)
1 Ilizarov
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COMPLICATIONS DIAPHYSIS
3 amputations
ØMicrovascular failure: 4 (3,5%)
1 Ilizarov
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COMPLICATIONS DIAPHYSIS
3 amputations
ØMicrovascular failure: 4 (3,5%)
1 Ilizarov
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FIBULA: EPIPHYSIS
• Epiphyseal reconstruction in pediatric age
• Preservation of longitudinal growth
• Restoring of joint function
INDICATIONS
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BLOOD SUPPLY
Taylor:
A.T.A. is able to supply the
epiphysis by an epiphyseal
branch and the proximal 2/3 of
the diaphysis by means of tiny
musculoperiosteal branches
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BLOOD SUPPLY
A.T.A.
Recurrent branch of the
Anterior Tibial Artery
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Harvesting technique
The peroneal nerve and the anterior
tibial vessels are identified on the
interosseous membrane
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Reconstruction of the radius
•Osteosynthesis: plates
•Anastomosis: R.A./A.I.A.
•Ligaments reconstruction
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Results: radius
• Female
• Osteosarcoma
• 8 yrs. at surgery
• 7 yrs. F.U. 4 yrs
2m 7 yrs
1 yr
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Results: radius
• Female
• Osteosarcoma
• 8 yrs. at surgery
• 7 yrs. F.U. 4 yrs
1 yr
üTOTAL GROWTH: 5.2 cm
üGROWTH RATE: 0.75 cm/yr
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FUNCTIONAL OUTCOME
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Reconstruction of the humerus
•Osteosynthesis: plates
•Anastomosis: D.B.A./B.A.
•Ligaments reconstruction
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Results: humerus
• Male
• 5 yrs at surgery
• 3 yrs F.U.
• Total growth: 3.2 3 yrs.
cm.
• Growth rate: 1.06
cm/y
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FUNCTIONAL OUTCOME
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COMPLICATIONS
VF with growth plate
• Temporary palsy peroneal n. : (56%)
DONOR • Permanent deficit E.H.L., E.D.C : (8%)
• Permanent deficit T.A.: (4%)
SITE
• Ankle instability : (4%)
• Knee instability : 0
• Premature closure of the G.P.: (20%)
• Fractures : (20%)
RECIPIENT
• Subacromial displacement : (16%)
SITE • Non union : 0
• Infection : 0
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Premature closure of growth plate 20%
Postop
F.U. 8 y.
• 2 cases supplied by peroneal A.
• 3 cases with damage to rec. branch A.T.A.
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Fracture 20%
• Torsion stress
• Break point: proximal
screw
• Excessive stiffness of
implant
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Fracture 5
Solution:
• Elastic implant
• Reconstruction plates
• Long plates, few screws
• Locking Compression Plate
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Subacromial displacement 16%
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EVOLUTION OF
VASCULARIZED BONE GRAFTS
• Fusion
• Hypertrophy
• Remodelling
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FUSION
Vascularized bone preserves more than double
vital osteocytes than a non vascularized bone
Arata, J Recon Micro 1994
Vascularized bone preserves endostal and periosteal
vascularization favouring fusion by a mechanism similar
to common fracture healing
Zdeblick T.A. Clin Orthop 1988
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FUSION
Intraop. 3m 8m 12 m
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FUSION
V.F.
V.F.
Humerus Allograft
Allograft
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FUSION
1 m. 5 m.
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FUSION
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FUSION
6 m.
6 m. 24 m. 24 m.
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FUSION
At osteotomy line fusion occurs even
in case of “minimal” osteosynthesis
A periosteal flap
improves fusion rate
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FUSION
Fibula
Allograft
3 m. 12 m. 18 m.
Femur
Vascularized fibula and its periosteum promotes allograft
fusion even in case of insufficient contact
(osteotomy gap > 2mm)
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Vascularized Fibula
Fractures
• 20/114 (17,5 %)
• 20 fusion (100 %)
• 3 surgical revision (15 %)
Firenze Kasashima Arai Lee El Gammal
114 cases 62 cases 60 cases 46 cases 25 cases
Fracture Tot 17,5 % 24 % 22% 39 % 12 %
Upper limb 29 % 14% 11 % / /
Lower limb 17 % 40 % 24.5 % 39 % 12 %
The introduction of combined technique (allograft+ V.F.)
markedly decreased the incidence of fractures in weight bearing segments
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EVOLUTION OF
VASCULARIZED BONE GRAFTS
• Fusion
• Hypertrophy
• Remodelling
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Hypertrophy
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HYPERTROPHY
6m 5 aa
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HYPERTROPHY
pania tc
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In a long bone hypertrophy
occurs expecially at cortical level
• Osteogenic action
of vascularized periosteum
• Biologic response to the
increasing mechanical stress
• Hypertrophy up to reach
the host diameter,
but never overcoming it
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HYPERTROPHY
1a
4a
1m
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HYPERTROPHY
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Stress fractures are relatively common and
proportional to weight bearing
2m 1y 2y 4y 10 y
Their healing with hypertrophyc callus contributes
to accelerate the hypertrophy process
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Combination V.F. + Allograft
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Progressive fibular hypertrophy
favours a gradual integration between two components
3 y. 7y
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1 Open allograft, unstable osteosynthesis
Postop. 3 y. . 8 y.
Postop. 6 y.
• Early fusion with host bone
• Progressive allograft resorption
• Fibular hypertrophy and allograft internal repair
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Postop. 6 y.
• Early fusion with host bone
• Progressive allograft resorption
• Fibular hypertrophy and allograft internal repair
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2 Open allograft , stable osteosynthesis
Postop. 2 y.
• No allograft resorption
• Slow fibular hypertrophy and fusion with allograft
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2 y. 5 y.
• No allograft resorption
• Slow fibular hypertrophy and fusion with allograft
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EVOLUTION OF
VASCULARIZED GRAFTS
• Fusion
• Hypertrophy
• Remodelling
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Morphologic remodelling potential
is very high in pediatric age
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2 m. 4 m. 12 m.
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• 9 years old
• Osteosarcoma
• Resection: 7 cm.
• F.U. 4 years
4m
1,5 a
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• 9 years old
• Osteosarcoma
• Resection: 7 cm.
• F.U. 4 years
4 yrs
4m
üTOTAL GROWTH : 3.3 cm.
üAVERAGE GROWTH : 0.82 cm/yr
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ü Proportional growth
of neoradius with omolateral ulna
7 y. 3 y. 5 y.
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F.U. 4 y.
Fibular articular surface has progressively developed a concavity
corresponding to convexity of first carpal row
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Eterotopic fibula Ortotopic fibula
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• R.G.: 4 years old
• Ewing Sarcoma
proximal femur
• Intra-articular resection
Reconstructive objectives
• Articular function recovery
• Growth potential recovery
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• R.G.: 4 years old
• Ewing Sarcoma
proximal femur
• Intra-articular resection
Reconstructive objectives
• Articular function recovery
• Growth potential recovery
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1. Allograft epiphysis resection
2. A groove is created on the
allograft
3. Fibular osteotomy
4. Concentric assembling
5. Step-cut osteotomy
6. Stable osteosynthesis
7. Circumflex vessels anastomosis
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1. Allograft epiphysis resection
2. A groove is created on the
allograft
3. Fibular osteotomy
4. Concentric assembling
5. Step-cut osteotomy
6. Stable osteosynthesis
7. Circumflex vessels anastomosis
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1. Allograft epiphysis resection
2. A groove is created on the
allograft
3. Fibular osteotomy
4. Concentric assembling
5. Step-cut osteotomy
6. Stable osteosynthesis
7. Circumflex vessels anastomosis
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• Fast healing
• Allograft V.F. integration
• Longitudinal growth
• Epiphyseal remodelling
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Postop. 4 Yrs.
18 m.
8 m.
2 m.
Postop.
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POSSIBLE FUTURE
PROSPECTIVES
• Stem cells
• Periostium
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VASCULARIZED FIBULA +
TIBIAL PERIOSTEUM
• Male 22 years
• Femoral open fracture with 18 cm bone loss
• Comminuted open fracture of omolateral tibia and fibula
• Reconstruction with controlateral V.F. + tibial periosteum + chronOS + stem cells
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VASCULARIZED FIBULA +
TIBIAL PERIOSTEUM
• Male 22 years
• Femoral open fracture with 18 cm bone loss
• Comminuted open fracture of omolateral tibia and fibula
• Reconstruction with controlateral V.F. + tibial periosteum + chronOS + stem cells
Tibia
M. Interossea
Perone
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VASCULARIZED FIBULA +
TIBIAL PERIOSTEUM
• Male 22 years
• Femoral open fracture with 18 cm bone loss
• Comminuted open fracture of omolateral tibia and fibula
• Reconstruction with controlateral V.F. + tibial periosteum + chronOS + stem cells
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VASCULARIZED FIBULA +
TIBIAL PERIOSTEUM
• Male 22 years
• Femoral open fracture with 18 cm bone loss
• Comminuted open fracture of omolateral tibia and fibula
• Reconstruction with controlateral V.F. + tibial periosteum + chronOS + stem cells
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VASCULARIZED FIBULA +
TIBIAL PERIOSTEUM
• Male 22 years
• Femoral open fracture with 18 cm bone loss
• Comminuted open fracture of omolateral tibia and fibula
• Reconstruction with controlateral V.F. + tibial periosteum + chronOS + stem cells
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VASCULARIZED FIBULA +
TIBIAL PERIOSTEUM
• Male 22 years
• Femoral open fracture with 18 cm bone loss
• Comminuted open fracture of omolateral tibia and fibula
• Reconstruction with controlateral V.F. + tibial periosteum + chronOS + stem cells
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VASCULARIZED FIBULA +
TIBIAL PERIOSTEUM
• Male 22 years
• Femoral open fracture with 18 cm bone loss
• Comminuted open fracture of omolateral tibia and fibula
• Reconstruction with controlateral V.F. + tibial periosteum + chronOS + stem cells
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VASCULARIZED FIBULA +
TIBIAL PERIOSTEUM
• Male 22 years
• Femoral open fracture with 18 cm bone loss
• Comminuted open fracture of omolateral tibia and fibula
• Reconstruction with controlateral V.F. + tibial periosteum + chronOS + stem cells
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VASCULARIZED FIBULA +
TIBIAL PERIOSTEUM
• Male 22 years
• Femoral open fracture with 18 cm bone loss
• Comminuted open fracture of omolateral tibia and fibula
• Reconstruction with controlateral V.F. + tibial periosteum + chronOS + stem cells
F.U. 7 m
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CONCLUSIONS
• Vascularized bone grafts behave biologically
and biomechanically as “normal” viable bone
• Due to this property, their are an important
option in reconstruction of large intercalary
bone loss
• Complex surgery requiring human and
technical resources
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