Dolph Houben

67 Combined massive allograft and intramedullary vascularized fibula 3 Ozaki et al. [19] modified this technique in 1997 by using the ipsilateral fibula as a pedicled fibular graft. They modified the Capanna technique in order to reduce the risks and complications of a free flap, operation time and donor site morbidity. The Ozaki technique has inspired others to follow. Manfrini et al. [25] showed in a case-control study that there was no significant difference in outcome between a pedicled or free fibular flap combined with a massive allograft. Although there was a significant reduction in operation time in the pedicled group, as there was no need for microvascular anastomosis. Capanna et al. suggested in 1993 that a minimal fixation method with small fragment screws combined with a long plate which did not span the entire defect was sufficient to achieve a stable reconstruction [21] . However, presentation of their long-term results in 2007, showed plate fixation to be more stable and achieve better union rates [18] . A rigid fixation with large plates and screws and even dual-plating have been thought to result in better union rates, lower fracture rates and less deformity related complications [13, 18, 19, 25] . Venkatramani et al. [7] published a case series of six cases reconstructed with the Capanna technique after post-traumatic defects in femurs. Their cases progressed into primary union (mean 6 months) without any additional surgical intervention to achieve union. Only one case of a deep infection occurred which was successfully treated with antibiotics. The authors claim that the reconstructions in traumatic cases have different challenges than those in oncologic cases. The problems associated with adjuvant chemotherapy and radiotherapy are absent, but the risk and incidence of infection are higher. Traumatic cases are often associated with open wounds, thus more susceptible to infection [7] . Vascularized bone autografts are well known for their biological activity, high hypertrophy and union potential [2, 13, 14] . Long-term radiographic studies of vascularized fibula autografts placed inside a massive allograft have shown progressive hypertrophy starting one month after reconstruction extending to 24 months [15, 27, 33] . Manfrini, Vanel, De Paolis, Malagutiet al. [33] showed that the ongoing fibula hypertrophy inside of the allograft results in an endosteal reaction of the allograft. This indicates the ability of the allograft to adapt to stress due to revascularization of the allograft [33] . According to our results, fractures still frequently occur but successful fracture healing after ORIF or conservative treatment is the result of a process similar to normal fracture healing. This reflects the biological activity of the vascularized fibular autograft [13, 27, 33-35] . In addition, Innocenti, Abed, Beltrami, Delcroixet al. [27] showed the correlation between union of both allograft and fibula and the extent of fibular hypertrophy, reflecting the mechanical role of the fibula in the weight-bearing beside its biological role in union of the allograft. The insertion of a vascularized fibula into a massive structural allograft possesses several downsides. For example, the structural allograft has to be adjusted to fit the vascularized fibula graft and allow hypertrophy which may reduce the strength of the allograft. Transfer of a vascularized portion of the fibular is associated donor site morbidity, such as motor weakness and sensory deficits in the foot, and ankle instability. Rare donor site complications reported are flexion contracture of the great toe, valgus deformity of the ankle, and stress fracture of the tibia. However, donor site morbidity is often acceptable in the majority of the patients due to preserved function in the reconstructed limb and low prevalence [21, 36] .