title: Vascularized fibular periosteal graft:  a new technique to enhance bone union in children.
abstract: BACKGROUND
  The periosteum in children has strong osteogenic power and is quite thick, facilitating procurement. However, it has been rarely used as a vascularized flap to enhance bone union in this age range. The purpose of this study is to assess the effectiveness of a new vascularized periosteal flap harvested from the fibula for the enhancement of bone union in the pediatric age.
  
  
  METHODS
  Thirteen vascularized fibular periosteal grafts were used in 12 children, mean age 12.6 years. Indications included the prevention of bone allograft-host junction nonunion and treatment of recalcitrant bone nonunion. In 9 instances, the periosteal flap was harvested as a free flap and in 4 as a pedicled flap. Serial radiographs and computed tomography scans were used to evaluate the progression of callus formation and bone healing.
  
  
  RESULTS
  All flaps were successful in promoting bone healing and achieving bone union in a mean time of 2.8 months for metaphyseal junctions and 7.1 months for diaphyseal ones, except for 1 case, which initially failed due to a pedicle torsion. It was then resolved with a second vascularized fibular periosteal grafts, with complete union after 5 months.
  
  
  CONCLUSIONS
  Transfer of a vascularized fibular periosteal flap, either pedicled or as a free flap, is an effective treatment to enhance bone union in children in biologically unfavorable scenarios. The properties of periosteal tissue in the pediatric age are unique and its use in bone union enhancement permits new reconstructive strategies in children different from those described in adults.
  
  
  METHODS
  IV.
authors.affiliation: Paediatric Orthopaedic Surgery Unit, Orthopaedic Surgery Department, Hospital Universitari Vall Hebron, Institut de Recerca Vall Hebron (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain. xsoldado@gmail.com
authors.forename: Francisco
authors.initials: F
authors.lastname: Soldado
authors.forename: Cesar G
authors.initials: CG
authors.lastname: Fontecha
authors.forename: Ignasi
authors.initials: I
authors.lastname: Barber
authors.forename: Roberto
authors.initials: R
authors.lastname: Velez
authors.forename: Manel
authors.initials: M
authors.lastname: Llusa
authors.forename: Diego
authors.initials: D
authors.lastname: Collado
authors.forename: Alfonso
authors.initials: A
authors.lastname: Rodriguez-Baeza
authors.forename: Vicens
authors.initials: V
authors.lastname: Martinez-Ibañez
mesh_terms: D000293:Adolescent; D016025:Bone Transplantation / Q000379:methods*; D002648:Child; D002675:Child, Preschool; D005360:Fibula / Q000637:transplantation*; D005500:Follow-Up Studies; D006801:Humans; D010521:Periosteum / Q000098:blood supply / Q000637:transplantation*; D013524:Surgical Flaps / Q000098:blood supply; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome