Outcomes of free vascularized fibular flaps for the treatment of radiation-associated femoral nonunions

Introduction: Nonunion is a known complication following fracture in the setting of radiotherapy. Free vascularized fibular (FVF) flaps have been used successfully in the treatment of segmental bone defects; however, their efficacy in the treatment of radiated nonunions is limited. The purpose of the study was to evaluate the outcome following FVFG for radiation-associated femoral fracture nonunions.Methods: 23 (11 male and 12 female; mean age 60 +/- 12 years) patients underwent FVF for radiation-associated femoral fracture nonunions. The most common indication for radiotherapy was soft tissue sarcomas (n = 16). The mean follow-up was 5 +/- 4 years. Mean radiation dose was 51 +/- 14 Gy at a mean of 11 +/- 3 years prior to FVF. The mean FVF length was 17 +/- 4 cm and placed commonly with an intramedullary nail (n = 18).Results: First time union was 52% (n = 12) following additional bone grafting, the overall union was 78% (n = 18) at a mean of 13 +/- 6 months. Musculoskeletal Tumor Society scores improved from 30% preoperatively to 73% at latest follow-up (p < 0.0001). Five fractures failed to unite; 3 were converted to proximal femoral replacements.Conclusions: FVF are a reasonable treatment option for radiation-associated femoral fracture nonunions, providing a union rate of 78% and an improvement in functional outcome. Level of Evidence: Therapeutic Level IV. (C) 2020 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.