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Pediatric free tissue transfer for limb salvage: case series and review of vascularized fibular epiphyseal transfer
Christine J. Lee, MD1; Ekaterina Tiourin, BS1; Nima Khoshab, MS1; Amber R. Leis, MD, FACS1,2; Nader A. Nassif, MD3; Raj M. Vyas, MD, FACS1,2 1 Department of Plastic Surgery, University of California, Irvine Medical Center, Orange, California 2 Division of Plastic Surgery, Childrens Hospital Orange County, Orange, California 3 Newport Orthopedic Institute, Newport Beach, California

Background: Pediatric microsurgery is now considered part of the repertoire of the reconstructive plastic surgeon. With recent success rates ranging from 89-95%, concerns regarding free flap feasibility and survival have now shifted to the functionality of these transferred parts into adulthood. Vascularized fibular epiphyseal transfer (VFET) is widely accepted to offer a functional advantage in pediatric reconstruction due to the preservation of growth potential in skeletally immature patients. It is less understood how patient characteristics and surgical-related factors influence the degree of function restoration and donor site morbidity following VFET.

Methods: We present a case series of successful pediatric microsurgical limb salvage with different techniques including VFET at Children's Hospital Orange County. To better determine the variables that influence functional outcomes of VFET, we performed a literature review using the PubMed database. Studies were evaluated for individualized patient surgery-related factors and functional outcomes including limb growth, donor site morbidity, and recipient site complications following VFET in pediatric patients. Statistical analysis was conducted across the pooled data to identify any significant associations among patient and surgical factors on clinical outcomes.

Results: Thirteen studies representing 36 patients who underwent vascularized fibular epiphyseal transfer to either the radius, ulna, humerus, or femur were included. The average patient age was 7 years and 67 percent of patients were male. Patients were followed for an average of 6 years after the VFET surgery. The average limb growth per year was 0.82 cm and average limb length discrepancy was 2.19 cm. After conducting statistical analysis, we found that the use of peroneal vessels as the pedicle was associated with less limb growth per year compared to anterior tibial or inferior lateral genicular vessels (p<0.05). The radius as a recipient site was associated with a statistically significantly lower limb length discrepancy compared to the humerus or femur. We found that the harvest of anterior tibial vessels as the pedicle was associated with a higher incidence of postoperative foot drop (p<0.05). Chemotherapy and the defect at the recipient site (malignancy, trauma, congenital deformity) did not influence outcomes.

Conclusion: This data can help guide surgical planning to best restore limb function utilizing pediatric microsurgical limb salvage with VFET as a surgical option. We believe flap and limb long-term functional outcomes are optimized when the pediatric microsurgeon and pediatric orthopedic oncologist work as a team to strategize flap inset, pedicle positioning, and muscle and joint preservation.

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