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Wee et al. Plast Aesthet Res 2019;6:12 I http://dx.doi.org/10.20517/2347-9264.2019.02 Page 5 of 12

A B

C D

Figure 4. A: fracture separating radial head and neck with large bone gap; B: removal of bony fragment from biceps tendon; C: suture
anchors used to attach biceps tendon to fibula graft; D: intact posterior interosseous nerve noted over fibula graft

been found in other reports to reliably achieve union at approximately 6 months . A recent systematic review
[4]
of free fibula flap reconstruction of humeral bone defects after oncologic resection found 93% union in an
average of 5 months . VBGs in the oncologic setting have the additional advantage of increased durability
[5]
in the face of adjuvant chemotherapy and radiation . While allografts were previously utilized in oncologic
[6]
reconstruction, these reconstructions were associated with a high fracture and nonunion rate of over 15%,
with over 80% of grafts failing in the setting of infection, and approximately 50% failing in the setting
of fracture . In a series of 20 patients who underwent both upper and lower extremity reconstruction
[7-9]
with allograft after tumor resection, 60% required removal of their allograft followed by replacement with
allograft of endoprosthesis due to failure . While fibula grafts are also prone to complications such as
[10]
fracture, they possess higher healing potential without the need for a major reoperation in comparison to
allograft. Houdek et al. reports a success rate of 100% after VBG fracture, with some patients undergoing
[11]
operative fixation and others responding to conservative management alone. For the pediatric population,
fibula VBGs have another advantage: the fibular head can be included to allow for bone growth while also
replacing the humeral head in the glenohumeral joint for reconstruction of the humeral head and diaphysis
in pediatric tumor resections. While classically, a proximal and distal segment are preserved at the donor
site to protect the common peroneal nerve and maintain ankle stability, Shuck et al. did not report any
[12]
peroneal nerve deficits or instability with walking after removing the fibular head. This patient is currently
one year out from surgery and has resumed participation in competitive athletics without significant
functional upper extremity limitations or impairment.

Case 4. A 56-year-old female presented with chondrosarcoma of the humerus [Figure 6], which after necessary
resection resulted in a large bony defect. We reconstructed this extensive defect with a free fibula bone flap
using the Capanna technique [Figure 7]. The Capanna technique combines methods of bony reconstruction,
using a VBG in conjunction with allograft bone. Variations of the technique have been described with regard
to the specific placement of the VBG with respect to the allograft: it can be placed completely within the