Free vascularized iliac periosteal graft for bilateral forearm nonunion reconstruction in a child with bilateral transfemoral amputation

Vascularized periosteal flaps have been reported as very effective for treating biologically complex bone nonunion in pediatric patients, owing to their high angiogenic and osteogenic potentials. The purpose of this article is to report a case of a 6-year-old patient with nonunion involving both forearms and a very limited bone flap donor site in the context of prior bilateral transfemoral amputation due to meningococcal sepsis. Two free vascularized iliac periosteal flaps (VIPF), supplied by the deep circumflex iliac vessels, were used in two stages to reconstruct the forearms. In the first stage, the left forearm, which had a diaphyseal bone defect of 5 cm diameter in the ulna and 4 cm in the radius, was combined with an iliac-crest bone allograft, fixed with two longitudinal 1.8 mm Kirschner wires and surrounded with a free VIPF of 24 cm(2). Consolidation was achieved 3 months after left forearm surgery, while complete allograft revascularization and remodeling was observed at 12 months. In the second stage, the right forearm, which had a diaphyseal bone defect of 3 cm diameter in the ulna and 1 cm in the radius, was fixed the radius with a 2.7 mm plate and surrounded with a free VIPF of 24 cm2. The radius nonunion healed 6 weeks after surgery. There were no postoperative complications. Two years postoperatively, the patient had again resumed his arm gait painlessly and without a splint. VIPF may be considered a valuable and reliable surgical option for nonunion reconstruction in complex clinical scenarios in children.