Free Vascularized Fibula Graft with Femoral Allograft Sleeve for Lumbar Spine Defects After Spondylectomy of Malignant Tumors: A Case Report

The Use of Free Vascularized Fibula Graft in Spinal Reconstruction: A Comprehensive Systematic Review

Reconstructive surgeons frequently face large structural abnormalities after spine resection. Unlike defects in the mandible or long bone, where a free vascularized fibular graft (FVFG) is a popular alternative for segmental osseous reconstruction, data on the use of an FVFG in the spine are still limited. The purpose of this study was to comprehensively describe and analyze the outcome of spinal reconstruction utilizing FVFG.

Methods

The extensive search included the following databases: PubMed, ScienceDirect, Web of Science, Cumulative Index to Nursing and Allied Health Literature, and Cochrane for relevant studies published up to January 20, 2023, according to PRISMA 2020 guidelines. Demographic data, flap success, recipient vessels, and flap-related complications were evaluated.

Results

We identified 25 eligible studies involving 150 patients, consisting of 82 men and 68 women. Spinal reconstruction utilizing FVFG is mostly reported in the case of spinal neoplasm, followed by spinal infection (osteomyelitis and spinal tuberculosis) and spinal deformities. The cervical spine is the most common vertebral defect reported in the studies. All studies summarized in the present study reported successful spinal reconstruction, while wound infection was the most reported postoperative complication after spinal reconstruction utilizing FVFG.

Conclusions

The results of the current study highlight the ability and superiority of using FVFG in spinal reconstruction. Despite being technically challenging, this strategy provides enormous benefits to patients. However, a further additional large-scale study is required to corroborate these findings.

Anterior Column Reconstruction with Vascularized Rib After Thoracic Spondylectomy: A Case Report

CASE

A 35-year-old man with a chondrosarcoma of the thoracic spine was treated with neoadjuvant proton radiotherapy (RT), total en bloc spondylectomy (TES), and adjuvant RT. Multiple vertebrae were removed to ensure negative margins, which created a sizable midthoracic defect. A vascularized rib autograft was harvested and intussuscepted within a femoral allograft for reconstruction of the anterior column and supplemented with posterior and lateral instrumentation.

CONCLUSION

This report demonstrates the feasibility of using a rib autograft within a femoral allograft sleeve to achieve immediate robust biomechanical support and eventual osseous union after thoracic TES for malignant tumors.

The use of autologous free vascularized fibula grafts in reconstruction of the mobile spine following tumor resection: surgical technique and outcomes

OBJECTIVE

Reconstruction of the mobile spine following total en bloc spondylectomy (TES) of one or multiple vertebral bodies in patients with malignant spinal tumors is a challenging procedure with high failure rates. A common reason for reconstructive failure is nonunion, which becomes more problematic when using local radiation therapy. Radiotherapy is an integral part of the management of primary malignant osseous tumors in the spine. Vascularized grafts may help prevent nonunion in the radiotherapy setting. The authors have utilized free vascularized fibular grafts (FVFGs) for reconstruction of the spine following TES. The purpose of this article is to describe the surgical technique for vascularized reconstruction of defects after TES. Additionally, the outcomes of consecutive cases treated with this technique are reported.

METHODS

Thirty-nine patients were treated at the authors' tertiary care institution for malignant tumors in the mobile spine using FVFG following TES between 2010 and 2018. Postoperative union, reoperations, complications, neurological outcome, and survival were reported. The median follow-up duration was 50 months (range 14-109 months).

RESULTS

The cohort consisted of 26 males (67%), and the median age was 58 years. Chordoma was the most prevalent tumor (67%), and the lumbar spine was most affected (46%). Complete union was seen in 26 patients (76%), the overall complication rate was 54%, and implant failure was the most common complication, with 13 patients (33%) affected. In 18 patients (46%), one or more reoperations were needed, and the fixation was surgically revised 15 times (42% of reoperations) in 10 patients (26%). A reconstruction below the L1 vertebra had a higher proportion of implant failure (67%; 8 of 12 patients) compared with higher resections (21%; 5 of 24 patients) (p = 0.011). Graft length, number of resected vertebrae, and docking the FVFG on the endplate or cancellous bone was not associated with union or implant failure on univariate analysis.

CONCLUSIONS

The FVFG is an effective reconstruction technique, particularly in the cervicothoracic spine. However, high implant failure rates in the lumbar spine have been seen, which occurred even in cases in which the graft completely healed. Methods to increase the weight-bearing capacity of the graft in the lumbar spine should be considered in these reconstructions. Overall, the rates of failure and revision surgery for FVFG compare with previous reports on reconstruction after TES.