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Combined Massive Allograft and Intramedullary Vascularized Fibula as the Primary Reconstruction Method for Segmental Bone Loss in the Lower Extremity

A Systematic Review and Meta-Analysis

Houben, Rudolph H. MD1; Rots, Mathijs MD1,*; van den Heuvel, Stefanie C.M. MD1,*; Winters, Henri A.H. MD, PhD1

doi: 10.2106/JBJS.RVW.18.00166
Evidence-Based Systematic Reviews

Background: Reconstruction of segmental bone loss due to malignancy, infection, or trauma is a challenge for the reconstructive surgeon. The combination of a vascularized fibular flap with a cortical allograft provides a reliable reconstructive option in the lower extremity. In this systematic review, we describe the outcome of this technique for the treatment of segmental bone loss.

Methods: A systematic review was performed on the use of a combined massive allograft and intramedullary vascularized fibula as a reconstruction method for large bone defects. We used PubMed, Embase, and the Wiley Cochrane Library.

Results: Seventeen clinical articles were included between 1997 and 2017, reporting 329 cases of lower-extremity reconstructions. A meta-analysis was performed on primary union rates. The main outcome measures were primary union rate, complication rate, reintervention rate, and function after reconstruction. All publications showed relatively high complication (5.9% to 85.7%) and reintervention rates (10% to 91.7%) with good primary union rates (66.7% to 100%) and functional outcome (range of mean Musculoskeletal Tumor Society [MSTS] scores, 24 to 29 points).

Conclusions: The combination of a massive allograft with intramedullary vascularized fibula provides a single-step reconstruction method for large bone defects (>6 cm) in the lower extremity, with good long-term outcomes.

Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

1VU Medisch Centrum, Amsterdam, the Netherlands

E-mail address for R.H. Houben:

*Mathijs Rots, MD, and Stefanie C.M. van den Heuvel, MD, contributed equally to this work.

Investigation performed at the VU Medisch Centrum, Amsterdam, the Netherlands

Disclosure: The authors indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (

Copyright © 2019 by The Journal of Bone and Joint Surgery, Incorporated
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