Biological reconstruction in the growing child after tumour resection: long-term outcomes of vascularized fibular epiphyseal transfer

Abstract

PURPOSE: Paediatric limb-salvage surgery after tumour resection is challenging because reconstruction must account for small skeletal dimensions, immature bone, and residual growth. This study aimed to evaluate the long-term clinical, radiological, functional, and oncological outcomes of vascularized fibular epiphyseal transfer (VFET) after paediatric oncological resection. METHODS: We retrospectively reviewed nine children who underwent VFET between 1995 and 2025 at two institutions. Surgical techniques, bone union, graft hypertrophy, neo-joint remodelling, growth-related changes, complications, functional outcomes, and oncological status were analysed. RESULTS: The mean age at surgery was 6.8 years (range, 2-14), and the mean follow-up was 105 months (range, 7-330). Reconstruction sites included the proximal humerus, proximal radius, proximal femur, and distal tibia. Mean resection length was 12.25 cm. Bone union was achieved in seven patients after a mean of 22 months. Graft hypertrophy was observed in all patients at one year, with a mean increase of 34%. Neo-joint remodelling occurred in three patients. Two patients developed proximal humeral graft overgrowth with instability and dislocation. Mechanical complications occurred in eight patients, mainly non-union and graft fracture. One-year complication-free survival was 33 ± 16%. Functional outcomes were better in the upper limb than in the lower limb. Three-year overall survival was 71 ± 18%. CONCLUSIONS: VFET is a demanding biological reconstruction option in growing children after tumour resection. Although graft hypertrophy and selected joint remodelling may occur, growth behaviour is unpredictable and mechanical complications are frequent.