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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 11 of 12

Allograft reconstruction can provide a shorter, less technically demanding reconstruction, but its success
may be limited to well-vascularized wound beds of a smaller size. Current data suggests that larger defects
with compromised vascularity may lead to a significantly higher rate of major complications in bony
defects reconstructed with allograft when compared to autograft . However, further study is required to
[21]
explore the outcomes of different classes of allograft as the age and processing of the allograft may allow
it to retain more osteoinductive properties. Autologous reconstruction can be performed in several ways
and is also subject to its own limitations. The major reasons for the failure of traditional non-vascularized
reconstructive techniques are large size of defect, residual nonviable bone secondary to avascularity or
infection, and inadeqate soft tissue coverage . In such challenging cases, fibula VBGs - in the form of bone
[17]
flaps and osteocutaneous flaps - provide reconstructive options that incorporate stable vascularity and supply
osteoinductive, osteoconductive and osteoprogenitor elements . We found these properties of fibula VBGs
[20]
to be useful in cases of severe trauma and composite tissue injuries, where the zone of injury often extends
beyond what is perceived clinically or radiographically. In our oncologic and degenerative disease cohorts,
fibula VBGs provide reliable blood flow to the bone as vascularity is often compromised in these situations
due to chronic disease and/or radiation. Additionally, the use of the Capanna technique capitalizes on the
ability of fibula VBGs to be used in combination with allografts to enhance vascular perfusion, allograft
incorporation, and restoration of long bone osseous defects.

In conclusion, at our respective institutions, the orthoplastic surgeons have achieved excellent surgical
outcomes, the most notable of which is high rates of successful bony union in patients with extremity bone
defects and osseous nonunion cases from traumatic, oncologic, degenerative and congenital etiologies. The
major disadvantages of fibula VBGs include longer operative times and higher technical demand, prolonged
immobilization following surgery, and risk of early fracture. Fibula VBGs nonetheless provide an excellent
reconstructive option for segmental bony defects and to address cases of failed nonvascularized nonunion
grafting attempts in the extremities, and they offer promise in the efforts to improve outcomes and success
in limb salvage. Our knowledge of the subject and our mastery of the techniques are continually expanding,
fueled in part by multidisciplinary collaboration among trauma, oncologic, orthopaedic and plastic and
reconstructive surgeons. It is our hope that this growing experience will lead to improved care for patients
affected by limb-threatening bony pathology.

DECLARATIONS
Acknowledgments
The faculty and staff of the Departments of Plastic and Reconstructive Surgery and Orthopedic Surgery at
the authors’ institutions involved for supporting the orthoplastic surgery programs.

Authors’ contributions
All authors made substantial contributions to conception and design of the study, performed data analysis
and interpretation, as well as provided administrative, technical, and material support: Wee C, Ruter D,
Schulz S, Sisk G, West J, Tintle S, Valerio I

Availability of data and materials
Not applicable.

Financial support and sponsorship
This work was supported by the IRB Protocol (2018E0888 and 2018E0350).

Conflicts of interest
All authors declared that there are no conflicts of interest.