Free fibula osteoseptocutaneous graft for reconstruction of segmental femoral shaft defects.

Seventeen major reconstructions of the femoral shaft using vascularized fibula osteoseptocutaneous grafts were performed from August 1984 to September 1993. Patients were 14 males and 3 females, with an average age of 34 years. All patients had sustained high-energy trauma in motor vehicle crashes and had bone defects averaging 10 cm. The skeletal defect was primary attributable to bone loss at the time of injury (2 cases) or secondary after infection and sequestrectomy (15 cases). Vascularized fibular transfer was performed at an average of 6 months after trauma. The fibular graft was inserted as a single strut in 10 cases and as a double-barrel composite in 7 cases. Patients were evaluated at an average of 43 months after surgery. All grafts eventually united, and no patient showed evidence of recurrent or persistent infection. The average time to radiologic union was 8 months, and the average time to full weight bearing was 14 months. Secondary bone grafting and internal fixation were required in five cases because of delayed union, stress fracture, or screw loosening. All cases of delayed union and stress fracture were in those reconstructed by single-strut fibular graft. Four cases (24%) required quadriceps plasty and arthrolysis. The final average arc of active knee motion was from 0 to 80 degrees. Limb length discrepancy ranged from 0 to 7 cm (average, 3 cm). Five cases (29%) had varus deformity averaging 30 degrees. The fibular graft hypertrophied to 100% of the femoral circumference in cases followed for 3 years. Donor site morbidity was negligible. At the time of final follow-up, 13 patients had returned to their original jobs, two were permanently disabled because of below-knee amputation, and two were retired. The study suggests that vascularized fibula osteoseptocutaneous transfer is a valuable procedure for reconstruction of large, previously infected femoral shaft defects.