Dolph Houben

42 CHAPTER 2 Figure 4: pre-operative X-ray of a bone tumor in the tibia while planning the margins of the resection (A), post-operative X-ray a large segmental defect of the tibia treated by a free vascularized contra-lateral fibula (B), large defect of the tibia reconstructed with a large allograft to obtain union an ipsilateral pedicled fibula was used as an onlay graft (C), conventional x-rays demonstrating hypertrophy of a pedicled ipsilateral fibula used for the reconstruction of a large segmental defect in the tibia. Femur Femoral reconstructions oppose a considerably more challenging problem, compared to the tibia. The femur presents an array of technical difficulties particular to this bone because of greater difficulties with bony stabilization and vascular access. The greatest challenge in this type of reconstruction is to achieve a strong and stable situation with rigid internal fixation. Strong muscle forces across the bone can result in instability and fractures resulting in poorer outcomes. Appropriate pre-operative planning in these cases is essential so initial vessel dissection, flap harvest, bony fixation, and anastomosis can be performed in an orderly and efficient way. A multi- disciplinary approach is therefore advised. For femoral reconstruction, the ipsilateral fibula is the preferred donor site, unless other contraindications exist. In most cases two incisions can be used, one medially for vascular access and one laterally for bony access. Due to the greater cross-sectional size of the femoral shaft, the fibula can be placed within the intramedullary canal with a spanning plate and screws (Fig. 5), alongside an IM nail, with direct end-to-end contact, as an onlay graft spanning a defect reconstructed with a structural allograft and an IM nail.