The advantages of vascularized bone transfer versus conventional nonvascularized autograft are well known. The ability to heal according to physiological rules, the possibility to reconstruct long bone defects even in scarred or infected beds, the bone remodeling and hypertrophy under the influence of loading are some of the most remarkable features of vascularized autografts. In skeletally immature patients, the harvest of vascularized epiphysis along with a variable amount of adjoining dia-physis may provide the potential for growth of the graft. Such a procedure results to be highly valuable when an active growth plate, included in oncological resection or involved in destruction for traumatic or infective reasons, has to be biologically reconstructed. The aim of the procedure is the reconstruction of bone loss and simultaneous restoration of growth potential preventing future limb discrepancy.

Autologous epiphiseal plate transfer have been pioneered by several surgeons since the beginning of this century.1-3 The reported results referring to premicrosurgical era are disappointing in the majority of cases and the sporadic successful cases are probably related to the small dimension of the transferred physes and subsequent possible neovascularization from the adjoining recipient bone. The experimental investigations carried out by several authors in the past 30 years4-13 seem to agree that the feasibility of the technique depends on adequate blood supply both to the growth plate and to the diaphysis ; thus a failure in revascularization leads to premature fusion of the growth plate and possible nonunion with the host bone.

In the eighties, the vascularized epiphyseal transfer left its experimental dimension to enter the clinical scenario.14-17 The developing of reliable microsurgical technique allowed to apply in the clinical practice the vascularized transfer improving the success rate of such a procedure.

Three donor sites have been suggested in order to reconstruct epiphyseal defects in children: the iliac crest, the inferior portion of the scapula and the proximal fibular epiphysis. All the above mentioned segments can be harvested with minimal morbidity in the donor area and all them contain active growth plates. However, the iliac crest and the scapula can be anatomically classified as apophysis and they do

Fig. 10D.1. A preoperative arteriography is routinely performed in order to detect the recurrent epiphyseal branch of the anterior tibial artery (arrow). The epiphyseal vessel raises from the anterior tibial artery approximately 2 cm after its emergence in the anterior compartment of the leg.

not have the features of a true epiphysis.18 In particular, they fail in providing a true articular surface with unpredictable functional outcome after the transfer. By contrast, the proximal fibular epiphysis satisfies all the biological and biomechanical requirements in case of replacement of the epiphyseal portion of a long bone and for this reason the proximal fibula became the most popular graft in order to reconstruct the distal radius and the proximal humerus in the pediatric age.

The blood supply of the fibula has been extensively studied.19,20 The anterior tibial artery provides a constant recurrent branch to the proximal fibular physis (Fig. 10D.1) and therefore it may be used as the vascular pedicle for a distant transfer of such a graft. The peroneal artery (with or without the lateral inferior genicular artery) has also been used as the vascular pedicle for such physeal transfers, but with inconsistent results. Taylor's anatomical investigations21 confirmed the role of the anterior tibial artery in the vascularity of the fibular growth plate and also demon-

strated that sufficient blood supply can be provided to the proximal diaphysis by small musculo periosteal branches raising from the same artery. Thus, the anterior tibial artery is able to supply the graft, provided that both the epiphyseal vessel and the diaphyseal periosteal vascular network are preserved during the dissection.

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