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Treatment of Chronic Nonunions of the Humerus with Free Vascularized

Fibula Transfer: A Report of Thirteen Cases

Article in Journal of Reconstructive Microsurgery · November 2008

DOI: 10.1055/s-0028-1090624 · Source: PubMed

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Treatment of Chronic Nonunions of the
Humerus with Free Vascularized Fibula
Transfer: A Report of Thirteen Cases
A. Bobby Chhabra, M.D.,1,2 S. Raymond Golish, M.D., Ph.D.,1,2
Michael E. Pannunzio, M.D.,3 Thomas E. Butler Jr., M.D.,4 Luis E. Bolano, M.D.,5
and William C. Pederson, M.D.6

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ABSTRACT

Chronic nonunions of the humerus remain a challenging problem. We reviewed

13 cases of chronic nonunion of the humerus resulting from trauma or osteomyelitis treated
with vascularized fibula transfer after failure of conventional treatment. Patient averages
were 35 years of age, follow-up of 19 months, and 4.2 prior operations. Healing was
obtained in 12 of 13 (92%) patients with an average healing time of 18 weeks and graft
length of 12.5 cm. In total, 11 of 12 (91%) patients who united had good to excellent range
of motion of their shoulder and elbow. There were eight complications in 7 of 13 patients
(54%). Two patients developed fractures of the graft, and three had superficial infections at
the harvest site requiring operative debridement. Two patients had median neurapraxia
that resolved by 4 months. Two patients complained of intermittent pain at the donor site.
No significant correlations were found between time to heal and other covariates.

KEYWORDS: Humerus, nonunion, vascularized bone graft

H umerus fractures account for 3% of all frac-
tures treated by orthopaedic surgeons. Fortunately,
current treatment methods for these fractures often
result in primary healing. Humeral nonunions are
uncommon but pose a very challenging treatment
problem. Most humeral nonunions are successfully
treated by compression plating, intramedullary fixation,
corticocancellous bone grafting, the Ilizarov method,
electrical stimulation, or a combination of these tech-
niques.1–7 Union rates vary from 46% with electrical
stimulation alone to > 90% with a combination of
compression plating and cancellous bone grafting.4,6
Traumatic fractures with bone loss or comminu-
tion, open fractures, fractures complicated by infection,
and multiply operated fractures may not respond to
conventional attempts at union. Pseudoarthrosis and
chronic osteomyelitis require extensive debridement of
bone and can result in large defects not suitable to
standard techniques. In these complex cases, the soft
tissue envelope is frequently dysvascular, and nonvascu-
larized bone grafting may fail.
Free autogenous vascularized bone grafting (rib,
iliac crest, and fibula) has been used successfully for the
treatment of several challenging problems including
mandibular reconstruction, avascular necrosis of the
hip, congenital pseudoarthrosis of the tibia and forearm,
traumatic defects in the lower and upper extremity,
chronic osteomyelitis, recalcitrant nonunions, and limb

1
Department of Orthopaedics, University of Virginia; 2University of
Virginia Hand Center, Charlottesville, Virginia; 3Reconstructive Hand
Surgeons of Indiana, Carmel, Indiana; 4Southwest Shoulder and
Elbow Surgery, Tucson, Arizona; 5Scott Orthopaedic Center,
Huntigton, West Virginia; 6Hand Center of San Antonio, San
Antonio, Texas.
Address for correspondence and reprint requests: A. Bobby
Chhabra, M.D., Department of Orthopaedic Surgery, University
of Virginia Health System, Box 800159, Charlottesville, VA 22908
(e-mail: ac2h@virginia.edu).
J Reconstr Microsurg 2009;25:117–124. Copyright # 2009 by
Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York,
NY 10001, USA. Tel: +1(212) 584-4662.
Received: May 2, 2007. Accepted: June 8, 2007. Published online:
October 15, 2008.
DOI 10.1055/s-0028-1090624. ISSN 0743-684X.
117
118 JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 25, NUMBER 2
salvage after tumor excision.8–22 Treatment of humerus
nonunions by vascularized bone grafting is most often
indicated following multiple failed operations, for
chronic infections, when vascularity of the humeral soft
tissue envelope is poor, and when a large bony defect is
unlikely to heal by other means. Vascularized cortical
bone transfer provides immediate structural stability and
has been used in the humerus to bridge bony gaps
> 15 cm.12,17,23 Because the vascularized graft relies
solely on its pedicle circulation and not on the surround-
ing soft tissue for viability, it is uniquely suited for use in
salvage surgery.
Since Taylor et al first reported the technique of
vascularized fibular transfer in 1974, the fibula has
emerged as the preferred graft for long bone reconstruc-
tion in the upper extremity.24 Although the ilium,
scapula, rib, radius, and femur have also been used as
bone grafts for long bone defects, the fibula is often the
most suitable for reconstruction.21 The triangular cross
section of the fibula resists angular and rotational stress,
giving it exceptional strength. Furthermore, the fibula is
a straight cortical bone, with sufficient length and a
predictable vascular pedicle that can be harvested with
minimal donor site morbidity, making it a prime candi-
date for grafting.9,21,25 Free vascularized fibula transfer
to the humerus has been reported following tumor
resection, trauma, infection, and soft tissue lengthen-
ing.18–20,26–28 Harvest of the fibular graft is demanding,
but the pedicle is consistently large in caliber and reliable
in location. There is minimal associated donor site
morbidity if 6 cm of fibula is preserved both proximally
and distally.29–31
This study reports our experience with the treat-
ment of recalcitrant humeral nonunions with free vascu-
larized fibula bone grafting in 13 patients who were
referred to the senior authors (W.C.P. and L.E.B.).
MATERIALS AND METHODS
This study retrospectively reviews 13 cases of chronic
nonunions of the humerus treated with free vascularized
fibula transfer between 1989 and 2000. Data were
collected by chart review. In all cases, fibula transfer
was not performed unless conventional treatment op-
tions had failed. All patients were referred to the senior
authors for the treatment of the recalcitrant nonunion.
Seven males and six females with an average age of
35 years (range, 11 to 76 years) were included in the
study. The nonunion site was in the dominant extremity
in eight patients and in the nondominant extremity in
five patients. The average follow-up was 19 months
(range, 12 to 32 months). The initial humerus fracture
resulted from a motor vehicle accident in seven patients,
a gunshot wound in two patients, a plane crash in one
patient, and a fall in one patient. The remaining two
patients developed a proximal humeral shaft nonunion
2009
after multifocal osteomyelitis as children. Four patients
had open fractures. Four patients were morbidly obese
and one patient was a diabetic. The nonunion site was
the proximal third humeral shaft in four patients, the
midhumerus in five patients and the distal humeral shaft
in four patients. The average number of failed conven-
tional attempts at union prior to free fibula transfer was
4.2 (range, 2 to 9). All patients had at least one attempt
at union with compression plating and bone grafting.
Electrical stimulation was used in five patients without
success. Five patients (38%) had infected nonunions. In
these nonunions, aggressive surgical debridement and
antibiotic therapy was instituted to control the infection
before free vascularized fibula transfer.
Before free fibula transfer, each patient’s vascular
status was assessed by pulse examination. A Doppler was
used if pulses were not palpable. The donor and recipient
site were examined in this manner. An arteriogram was
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not obtained preoperatively if a noninvasive vascular
examination was normal. All patients in this series had
a normal vascular examination by palpation or Doppler
exam. The operations were performed by one of two
experienced microsurgeons.
OPERATIVE PROCEDURE
In all cases, the patient was placed in a supine position
and the contralateral fibula harvested extraperiosteally on
the peroneal pedicle through a lateral approach using a
standard technique that has been described in detail
elsewhere.12,17,23 A small skin island (osteocutaneous
fibula) was harvested in four patients for the purpose
of postoperative vascular monitoring.32 At least 6 cm of
fibula was preserved proximally and distally as recom-
mended to avoid knee or ankle instability. In children, a
distal tibiofibular syndesmosis was established to prevent
valgus alignment of the ankle as recommended by
Weiland.17,23 The fibula harvest was performed under
tourniquet control, but the tourniquet was deflated to
allow reperfusion before transfer to the recipient site.
The length of fibula harvested was determined by the
size of the recipient defect, adding an additional 2 to
4 cm to allow for insetting of the bone graft. The
proximal and distal periosteum was elevated off the
ends of the fibula prior to final trimming of the graft.
This extra vascularized periosteum was sutured both
proximally and distally across the fibular–humerus junc-
tion site after insetting of the graft. The average graft
length was 12.5 cm (range, 9 to 16 cm).
The recipient site was prepared prior to fibular
harvest. Gross infection was ruled out before proceeding
with vascularized fibula transfer. Aggressive debride-
ment of devascularized bone ends and necrotic tissue
was performed. This was done through previous surgical
incisions when possible. A dynamic compression plate
was used to stabilize the humerus in nine patients (69%),
 CHRONIC NONUNIONS OF THE HUMERUS WITH FREE VASCULARIZED FIBULA TRANSFER/CHHABRA ET AL
and an Ilizarov external fixator was used in the remaining
four patients. The plate was placed on the anterolateral
or anterior aspect of the humerus. Rigid stabilization was
obtained so that early shoulder and elbow motion could
be initiated. Intraoperative radiographs or fluoroscopic
images were obtained to confirm adequate reduction and
appropriate position of the hardware. The free vascular-
ized fibula was placed within a longitudinal trough
created in the proximal and distal humerus segments
such that the graft would traverse the nonunion site as
described by Jupiter.27 The graft was placed either
anteriorly or medially depending on the placement of
the plate. The plate was not placed on the graft. One-
centimeter step cuts were made at the proximal and
distal ends of the fibula graft, and one or two screws were
placed at each end only to protect the vascularity of the
graft. If the nonunion was in the proximal or distal third
of the humerus, the fibula graft was impacted into the
medullary canal of the humerus at one end and stabilized
with one screw at the other end. Intraoperative radio-
graphs were obtained after insetting of the fibula to
confirm the position of the graft.
Through a medial or posteromedial approach, the
brachial artery or a branch of the profunda brachii artery
and a superficial vein were exposed. After the fibula graft
was secured, arterial and venous vascular anastomosis
were performed to the pedicle of the fibula using an
operating microscope. An end-side anastomosis was
performed between the peroneal artery of the fibula
and the brachial artery in eleven patients. An end-end
anastomosis was performed to a branch of the profunda
brachii artery in the remaining two patients. An end-end
venous anastomosis was performed between the venae
comitantes of the fibula pedicle and a superficial vein in
the arm in all cases. The fibular vascular pedicle was
adequate in length in each case, and no interposition vein
grafts were required.
In all cases, the excess vascularized periosteum on
both sides of the graft was sutured across the junction to
enhance the healing potential. The fibula graft was also
supplemented with autogenous corticancellous and can-
cellous bone graft harvested from the ilium and packed
around the proximal and distal fibular–humerus junc-
tions. The graft was monitored with an implanted
Doppler probe (Cook Inc., Bloomington, IN) placed
distal to the arterial anastomosis or with a skin paddle.
Skin closure was performed and the extremity immobi-
lized securely in a bulky splint to protect the vascular
anastomosis. If a skin paddle was used for vascular
monitoring, it was kept visible. For the donor site, a
split-thickness skin graft was used to cover the defect left
from harvesting of the skin paddle if primary closure was
not possible.
Postoperative care included strict bedrest until
postoperative day 4 or 5. Thorazine was used to provide
vascular dilation as well as sedation. Each patient was
119
started on an aspirin on postoperative day 1 that was
continued for 1 month. Vascular monitoring was per-
formed every hour for the first 5 days. Heparin or
dextran was used routinely for the first 5 days in all cases.
After discharge from the hospital, the patient was
kept immobilized in a coaptation splint for 2 weeks until
suture removal. Pendulum exercises for the shoulder and
range of motion exercise for the elbow were encouraged
after healing of the operative wound. A protective
humeral splint was maintained until clinical or radio-
graphic union. Supervised therapy was initiated for each
patient for shoulder and elbow exercises after 4 weeks.
Strengthening exercises were not started until evidence
of radiographic healing.
The donor leg was maintained in a short leg cast
postoperatively. Weightbearing was allowed in the cast
after discharge from the hospital. The cast was discon-
tinued at 2 weeks postoperatively.
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Radiographs were obtained at each clinic visit and
compared with previous films to document progression
of healing. Healing time was based on radiographic
evidence of healing at both the proximal and distal
fibular–humeral junction. Full activity was allowed after
radiographic evidence of healing and acceptable return of
range of motion of the shoulder and elbow.
RESULTS
Healing of the chronic humerus nonunion was obtained
in 92% (12 of 13) of the patients. Figure 1 is a
representative case. Average healing time determined
by radiographic analysis was 18 weeks (range, 12 to
32 weeks). There was no evidence of graft resorption
on radiographs. There were eight complications in seven
patients (54%). One patient required emergent venous
anastomosis revision 12 hours postoperatively secondary
to flap compromise. Two patients had fractures of the
fibula graft after healing. One healed with fracture
bracing, and the other required open reduction internal
fixation. There were two superficial infections at the
fibula harvest site and one at the iliac crest bone graft
harvest site. These three infections required operative
debridement or antibiotics but healed without further
complications. There were two cases of median nerve
neurapraxia. Both resolved entirely by 4 months post-
operatively. A total of six additional procedures were
performed in four patients.
Two patients complained of intermittent leg pain
at the donor site with activity. Eleven patients who
healed had a good to excellent range of motion of their
shoulder and elbow after union. No patient lost motion
as a result of the procedure. Six patients obtained full
range of motion of both the elbow and shoulder post-
operatively. All twelve patients denied shoulder or
elbow pain. The six patients who had shoulder stiffness
denied significant functional deficits. Five patients who
120 JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 25, NUMBER 2 2009

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Figure 1 Radiographs of a single patient who underwent free fibula transfer for infected nonunion. (A) Preoperatively.
(B) Intraoperatively after debridement and provisional fixation. (C) Immediately postoperatively, showing position of fibular
graft. (D) Nineteen weeks postoperatively, demonstrating union. The patient experienced venous thrombosis requiring
revision of anastomosis at 12 hours postoperatively.

had elbow stiffness obtained a functional range of
motion (30 to 130 degrees) with therapy. Only one
patient who healed did not achieve a functional range of
motion of the elbow postoperatively (30 to 90 degrees).
The one patient who failed to heal was the oldest
patient in the study (76 years). Figure 2 demonstrates
loss of fixation at the proximal fibular-humerus junc-
tion at 5 months. She refused additional surgical
intervention and was lost to follow-up at 7 months.
Table 1 summarizes the results of the series. Figure 3
demonstrates a freshly harvested fibular graft with
pedicle and skin flap.
In this series, no significant correlations were
found by parametric or nonparametric statistics. There
was no correlation between graft length and time to heal
by Pearson correlation (p ¼ 0.36) or Spearman correla-
tion (p ¼ 0.98). There was no difference in time to heal
between patients with osteomyelitis and atrophic non-
union by t test (p ¼ 0.068) or Wilcoxon rank sum test
(p ¼ 0.064). There was no difference in time to heal
 CHRONIC NONUNIONS OF THE HUMERUS WITH FREE VASCULARIZED FIBULA TRANSFER/CHHABRA ET AL 121

Table 1 Summary of Results*

Age (mean) 35.3 y (range, 11–76 y)
Prior operations (mean) 4.2 (range, 2–9)
Infection (n) Osteomyelitis ¼ 5 (38%)
Atrophic nonunion ¼ 8 (62%)
Graft size (mean) 12.5 cm (range, 9–18 cm)
Hardware (n) Plate ¼ 9 (69%)
Ilizarov ¼ 4 (31%)
Union 12 (92%)
Time to healing (mean) 17.75 wk (range, 12–32 wk)
Complications (n) 8 in 7 patients (54%)
Subsequent operations (n) 4 in 2 patients
Follow-up (mean) 19 mo (range, 12–32 mo)
Mechanism (n) Motor vehicle accident ¼ 7
Gunshot wound ¼ 2
Osteomyelitis ¼ 2
Figure 2 Radiographs of a single patient who underwent Plane crash ¼ 1
free-fibula transfer that did not unite. The figure is at 5 months Fall ¼ 1

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postoperatively, demonstrating nonunion at the proximal end Donor site pain (n) 2 (15%)
of the fibular graft. The patient refused additional surgery and Iliac crest bone graft usage (n) 13 (100%)
was lost to follow-up at 7 months. Stiffness (n) 1 (7.6%)
Complications (n) Fracture of fibula graft ¼ 2
Superficial infection ¼ 3
between patients with or without a bone stimulator by Neurapraxia ¼ 2
t test (p ¼ 0.79) or Wilcoxon rank sum test (p ¼ 0.86). End-to-side anastomosis 10 (77%)
There was no correlation between age and time to heal with brachial artery (n)
by Pearson correlation (p ¼ 0.087) or Spearman correla- End-to-end anastomosis 3 (23%)
tion (p ¼ 0.32). with profunda brachii (n)
Open fractures (n) 4 (30%)
Osteomyelitis as a child (n) 2 (15%)
DISCUSSION
*All percentages are based on 13 patients total.
Although nonvascularized cortical bone grafts have been
used successfully in the humerus for the treatment of
nonunions and following tumor resection, use of vascu-
larized bone grafts provides certain biological advan- resorption and revascularization.37,38 The reason for
tages.33,34 Vascularized bone grafts maintain their this ‘‘weak period’’ is the mechanism of graft incorpo-
structural characteristics by remaining viable and being ration. In standard cortical bone graft implants, integra-
incorporated into the graft site in a mechanism similar to tion occurs via ‘‘creeping substitution,’’ in which the graft
acute fracture healing, as opposed to the ‘‘creeping is slowly broken down and replaced by the bone remod-
substitution’’ seen in nonvascularized grafts.9,32,35,36 eling process. In contrast, union and remodeling of
Nonvascularized cortical bone grafts, although initially vascularized grafts occurs rapidly at the host–graft in-
as strong as vascularized grafts, undergo a period of terfaces similar to normal bone, eliminating the period of
progressive weakening over the first 6 weeks due to weakness seen with creeping substitution. Dell et al

Figure 3 A photograph of a freshly harvested fibular graft with pedicle and skin flap.
122 JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 25, NUMBER 2
reported that 6 to 12 months after transplant there is
little difference in strength between vascularized and
nonvascularized grafts, but the decreased strength of
nonvascularized grafts leading up to this point may result
in increased mortality and failure to obtain union.37
Vascularized bone grafts also offer several other
distinct advantages over nonvascularized grafts for the
treatment of nonunions. Most authors agree that the
number of remaining viable osteogenic cells is greater
and the repair of nonviable bone is accelerated in
vascularized bone grafts when compared with nonvascu-
larized ones.11,39–42 Combined with the method of graft
incorporation, these observations likely account for the
improved mechanical strength and stiffness of vascular-
ized grafts, especially during the interval from 6 weeks to
6 months after surgery, a time when Enneking has
shown nonvascularized bone to be the weakest.38 Other
reported advantages of a vascularized bone graft include
a faster healing rate, a higher rate of union and graft
hypertrophy, and a lower incidence of fatigue frac-
ture.40,42,43 Accordingly, we believe the use of a vascu-
larized bone graft should be considered when structural
stability depends primarily on the graft, such as in the
treatment of segmental bone defects. In addition, the
vascularized graft has an independent circulation and
will heal and hypertrophy within a relatively avascular
soft tissue envelope. We believe that maintaining the
viability of the periosteum is critical to success. The
fibula harvest should be atraumatic, and an excess peri-
osteal sleeve should be preserved and sutured over the
repair site.
Because vascularized fibula grafting is a difficult
procedure with long anesthetic times that places the
patient at risk for complications, the indications for its
use in the treatment of humeral nonunions must be
scrutinized. Most authors agree that segmental bone
losses > 6 cm is an indication for vascularized fibula
transfer. The majority of failures in conventional bone
grafting occur in defects > 6 to 8 cm.14 For bone defects
in > 12 cm, Gazdag reported nonvascularized grafts
failed twice as often as vascularized grafts, with failure
rates of 50% and 25%, respectively.44 In this series,
vascularized fibula grafting was considered only after
conventional attempts at union had failed. Jupiter re-
ported successful treatment of five humeral nonunions
with this technique.27 In the two largest published
general series of upper extremity reconstruction by
vascularized bone transfer, the overall success rate was
> 80%.17,20 Healing appeared to be enhanced following
tumor resection presumably because the nonresected
tissues and vessels are normal.8,19 Urbaniak reported
that in traumatic long bone nonunions, the healing
rate was lower and the complication rate was higher
compared with tumor resection.15
Heitmann et al published a study in 2002 report-
ing their experience with vascularized fibula graft for
2009
segmental defects of the humerus in 15 patients (eight
males and seven females; average age, 41 years).25
Surgical indications included segmental nonunion in
nine patients, gunshot wounds in three, tumor resection
in two, and one failure of an allograft-prosthesis recon-
struction. The average humeral defect measured 9.3 cm;
the mean fibular graft size was 16.1 cm. Of the
15 patients, 11 achieved primary osseous union (73%)
with all 15 ultimately being successfully treated. Three
patients had an early failure of graft fixation within the
first two postoperative months. Each was successfully
treated with open reduction, internal fixation with a
compression plate, and additional bone grafting at the
nonunion site. The final patient presented for follow-up
at 2 months with graft resorption and signs of infection
at the site of proximal nonunion. Union was ultimately
achieved with a second osteoseptocutaneous vascularized
fibula graft.
Downloaded by: University of Virginia Libraries. Copyrighted material.
Other studies have also supported the success of
this procedure. Muramatsu et al reported primary union
after vascularized bone grafting in 21 of 23 patients who
had previously undergone at least one surgical procedure
for humeral nonunion, with the two remaining patients
achieving union following additional bone grafting and
alteration in internal fixation.45 Grafts were harvested
from the femur in 10 cases, scapula in 3, and the fibula in
the remaining 10. Nine of the 10 fibula graft patients
obtained primary union with the last patient obtaining
union following a second operation. Judet et al reported
that a free vascularized fibula graft treated 70% of
humeral nonunions in 10 patients.46 Similar success
was noted by Wright et al, who reported successful
treating eight of nine patients with humeral nonunion
by placing a vascularized fibular graft in the medullary
canal.47 Recently, vascularized bone grafting with the
free fibula graft has been gaining acceptance for a variety
of indications in the upper extremity.48–51
Currently, we do not attempt vascularized fibula
transfer unless three previous surgical procedures have
failed. The harvest is performed carefully to protect
the vascularity of the graft and preserve periosteum. We
agree with Jones and others, who feel that preoperative
angiography should be considered only for the patient
with an abnormal vascular examination, significant
symptoms of peripheral vascular disease, a history of
severe trauma to the leg, or previous reconstructive
vascular surgery.52 We do acknowledge the work of
Rosson et al, however, who reported complications of
fibula flap harvest due to variant anatomy. They found
the prevalence of peronea arteria magna to be 5.3% in
an urban population and therefore believe that mag-
netic resonance arteriography imaging of the donor
limb, being minimally invasive, is cost effective and
indicated for free fibula transfers to minimize the
chance of devascularizing complications with fibular
harvest.53
 CHRONIC NONUNIONS OF THE HUMERUS WITH FREE VASCULARIZED FIBULA TRANSFER/CHHABRA ET AL
Rigid fixation is obtained with a dynamic com-
pression plate if possible to allow for early range of
motion. Hardware should be placed in the proximal
and distal aspects of the fibula only, and the plate should
not be placed on the graft. This technique protects the
vascularity of the graft. Autogenous cancellous graft
should be used liberally at each junction site, and the
extremity should be protected until radiographic union.
Currently, we monitor all grafts with an implantable
Doppler probe placed intraoperatively. In four of our
thirteen cases, an osteocutaneous fibular graft was used,
which allows a twofold advantage. First, the skin paddle
harvested with the fibular graft allows better closure of
the soft tissue envelope. Given that vascularized fibula
transfer is not a first-line treatment, there is a significant
length of time before surgery, allowing for scarring and
contraction of the soft tissue envelope. This problem can
be further exacerbated by the swelling from the surgical
dissection and graft placement, making closure very
challenging.25 Furthermore, the skin paddle serves as a
convenient way to monitor graft survival by providing a
reliable long-term indicator of blood flow to the fibular
graft. We believe the approach outlined here for the
treatment of recalcitrant nonunions of the humerus will
result in a high union rate.
CONCLUSIONS
Based on the results of this study, free vascularized fibula
transfer is a reliable treatment for chronic humerus
nonunions that have failed to heal with conventional
surgical techniques. This procedure offers hope of union
to patients who have failed other therapies and can even
preserve the extremity of a patient with a significant long
bone defect facing a potential amputation. However, it is
not without risk. Extended operative time and potential
morbidity secondary to graft harvest may further stress
the patient. Postoperative complications, such as throm-
bosis of the anastomosed vessel, fracture, malunion,
nonunion, and potential infection, should also be con-
sidered.54 Failed surgery not only leaves the patient with
a humerus nonunion but also with morbidity associated
with the harvest of normal tissue at the graft site. Despite
these potential drawbacks, it is our firm opinion that the
benefits of free vascularized fibula graft for humerus
nonunion in select patients who have failed alternative
therapies outweigh the risks when performed by experi-
enced surgeons.
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