Skeletal reconstruction after large tumor resection is challenging. The free vascularized fibular graft (FVFG) offers the potential for rapid autograft incorporation as well as growing physeal transfer in pediatric patients. We retrospectively reviewed eleven pediatric patients treated with FVFG reconstructions of the upper extremity after tumor resection. Eight male and three female patients were identified, including four who underwent epiphyseal transfer. All eleven patients retained a functional salvaged limb. Nonunion and graft fracture were the most common complications relating to graft site (27%). Peroneal nerve palsy occurred in 4/11 patients, all of whom received epiphyseal transfer. Patients receiving epiphyseal transplant had a mean annual growth of 1.7？cm/year. Mean graft hypertrophy index increased by more than 10% in all cases. Although a high complication rate may be anticipated, the free vascularized fibula may be used to reconstruct large skeletal defects in the pediatric upper extremity after oncologic resection. Transferring the vascularized physis is a viable option when longitudinal growth is desired. 1. Introduction Many patients who undergo resection of primary malignant bone tumors of the extremity are skeletally immature [1]. Current adjuvant chemotherapy and radiation regimens have increased the survival of many of these patients such that any reconstruction performed must be durable over time [2]. Limb salvage surgery has replaced amputation as the standard of care in most of these patients [3]. The high functional demands, need for longitudinal growth, and expected longevity of a salvaged pediatric limb pose unique problems to the reconstructive orthopaedic surgeon. There are a number of techniques which have the potential for success including endoprosthesis, allografts, and autografts—both avascular or vascular [4]. The decision of which technique to utilize depends on tumor-related factors such as size and location, as well as patient and surgeon related factors [4]. The goals of long term fixation and the need for high functionality render conventional endoprostheses suboptimal in the pediatric patient. Additionally, many endoprostheses are not available in sizes to fit small children. Osteoarticular allografts and endoprostheses also may be more susceptible to complications such as infection, aseptic loosening, and implant failure [5–9]. Avascular autografts heal by creeping substitution—a simultaneous process of osteoclastic and osteogenic activity—which weakens grafts and makes them susceptible to nonunion, delayed
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