title: Dual-fibular reconstruction of a massive tibial defect after Ewing's sarcoma resection in a pediatric patient with a vascular variation.
abstract: BACKGROUND
  In the management of malignancies of the extremities, limb salvage procedures have recently taken on greater significance. For those patients under intense adjuvant chemotherapy and with massive bone loss, free vascularized fibular grafting is currently advocated as a reliable reconstructive option, maybe because of the controversial results of bone transport in similar situations. However, when there is a vascular abnormality of either the recipient or donor extremity, microsurgical procedures are not feasible, further limiting potential reconstructive alternatives.
  
  
  METHODS
  We present the case of a 13-year-old female patient with Ewing's sarcoma of the right tibia. Preoperative angiography showed that vascularity of the affected side depended totally on a single peroneal artery. The patient was treated initially with multiagent chemotherapy, followed by an excision of 23 cm. The defect was bridged by a gradual medial transportation of the ipsilateral fibula with the Ilizarov technique and strengthened by nonvascularized transfer of the contralateral fibula.
  
  
  RESULTS
  Total external fixation time was 162 days. After the removal of the Ilizarov frame a walking cast was applied for another month. At 5 years postoperatively there was no recurrence of the malignancy. The patient had full weight-bearing ability on the affected limb, with preservation of the ankle and knee joints motion and without any limb length discrepancy or axial deformity. The functional outcome that was visible was graded excellent.
  
  
  CONCLUSIONS
  Transverse distraction osteogenesis of the ipsilateral fibula performed well under chemotherapy, showing unproblematic callus formation. Supplemented with nonvascularized transfer of the contralateral fibula, provided a reconstructive option with biological affinity, sufficient biomechanical strength and durability, and with a decreased complication rate. This case report presents a viable option, especially in cases in which vascular abnormalities of either the donor or the recipient limb, combined with multiagent chemotherapy, restrict potential reconstructive alternatives. It also highlights why vascularized bone graft should not be regarded as a panacea for all situations in which a fibular graft is required.
  
  
  METHODS
  Level IV, case report.
authors.affiliation: Department of Orthopaedic Surgery, Medical School, University of Patras, Rio, Greece. alkisaridis@hotmail.com
authors.forename: Alkis G
authors.initials: AG
authors.lastname: Saridis
authors.forename: Panagiotis D
authors.initials: PD
authors.lastname: Megas
authors.forename: Christos S
authors.initials: CS
authors.lastname: Georgiou
authors.forename: Georgios M
authors.initials: GM
authors.lastname: Diamantakis
authors.forename: Minos E
authors.initials: ME
authors.lastname: Tyllianakis
mesh_terms: D000293:Adolescent; D000792:Angiography; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D001859:Bone Neoplasms / Q000188:drug therapy / Q000473:pathology / Q000601:surgery*; D016025:Bone Transplantation / Q000379:methods; D003131:Combined Modality Therapy; D005260:Female; D005360:Fibula / Q000098:blood supply / Q000637:transplantation*; D005500:Follow-Up Studies; D006801:Humans; D018889:Ilizarov Technique; D023821:Limb Salvage / Q000379:methods; D020127:Recovery of Function; D012512:Sarcoma, Ewing / Q000188:drug therapy / Q000473:pathology / Q000601:surgery*; D013977:Tibia / Q000098:blood supply / Q000473:pathology / Q000601:surgery*; D016896:Treatment Outcome