Free vascularized proximal fibular grafting is a common procedure for replacing bony defects and for reconstruc- tion after resections of tumours (Aberg et al., 1988). The proximal fibula is vascularized by a double blood supply, metaphyseal and epiphyseal, arising from the peroneal and the anterior tibial arteries respectively. Previous studies have demonstrated that there is an extensive anastomosis between these two systems, so that each artery on its own should be able to provide an ade- quate blood supply to the fibular epiphysis (Gilbert and Razaboni, 1991). Most modern techniques use a single anastomosis with the peroneal artery (Tamai et al., 1980; Taylor et al., 1975). Nonetheless various surgical tech- niques have been developed to provide a double vascular supply to the grafted proximal fibula (Gilbert and Razaboni, 1991). In this study we had an opportunity to assess the vascularization and vitality of a grafted proxi- mal fibula 1 year after the initial surgery. This allowed us to compare noninvasive techniques for assessment of the vitality of the graft with the histological results. CASE REPORT An otherwise healthy 46-year-old male patient presented in August 1996 with a 1 year history of pain and swelling of the right wrist. There was no history of preceding trauma, musculoskeletal problems, or recent illness. Physical examination revealed localized tenderness on the flexor aspect of the right wrist. Initial imaging stud- ies, including standard radiographs and MRI of the dis- tal radius, showed characteristic features of a giant cell tumour (Fig 1). Subsequent exploration through a dorsal incision showed a thin cortical layer without apparent fracture. A cortical window exposed typical creme- caramel tissue with bony septa. The biopsy cavity was then packed with cement. Histology revealed a large number of giant cells and mature fibroblast-like cells with few mitotic figures, confirming the diagnosis of giant cell tumour of bone (GCT). The neoplasm was graded III based on the imaging studies. The patient sub- sequently underwent an en bloc excision of the distal radius with a vascularized distal fibula autograft stabi- lized proximally with an AO plate and distally with a K- wire passed from the proximal fibula into the distal ulna (Fig 2). Preoperative vascular imaging of the lower leg showed a normal fibular vascular pedicle and a normal continuation of the three major vessels of the lower leg. The graft was vascularized using an end-to-side anasto- mosis to the radial artery and as end-to-end anastomosis to the origin of the cephalic vein. Postoperatively the patient did well and 1 month later there was scant bridging callus proximally. The K-wire was then removed and he started a physiotherapy pro- gramme. Three months after surgery a technetium bone scan revealed a vascularized vital graft (Fig 3a). Six months after surgery, after a minor injury, he developed a posterior luxation and subsequent instability at the wrist. He was placed in a cast for another 2 months but nonoperative treatment for instability was unsuccessful. One year after the initial operation he underwent wrist arthrodesis. Before operation a second technetium bone scan demonstrated a viable autograft (Fig 3b). During the procedure a fragment of the fibular epiphysis was sampled to study the viability of the grafted bone. Histology showed a mixture of necrotic bone with scant isles of viable trabecular bone (Fig 4). After surgery he was treated in a cast for 2 months. He eventually resumed his occupation as a plumber and is now asymptomatic and free of disease. X-rays demonstrated fusion and cal- lus formation of the wrist arthrodesis 6 months postop- eratively, with marked hypertrophy of the graft. DISCUSSION Free vascularized fibular grafting is a common proce- dure for substitution of the distal radius for treatment of tumours (Aberg et al., 1988). The vitality of the peroneal graft is routinely assessed by bone scintigraphy, contrast enhanced MRI and X-ray (Itoh et al., 1989; Lisbona et al., 1980; Lomasney et al., 1994). Standard X-rays of a living graft show hypertrophy of the graft and bony cal- lus at the boundary with the host bone (Lazar et al., 497 ASSESSMENT OF VASCULARIZED FIBULAR GRAFT ONE YEAR AFTER RECONSTRUCTION OF THE WRIST AFTER EXCISION OF A GIANT-CELL TUMOUR R. FERRACINI, G. GINO, B. BATTISTON, A. LINARI, R. FRANZ and S. BERTOLO From the Istituto Chirurgico Regina Maria Adelaide, Turin, Italy We report a patient in whom the distal radius was resected for a giant cell tumour and the bone defect was replaced using a vascularized proximal fibular graft. The graft was viable and hypertrophied and normal callus formed on the distal radius. Due to chronic instability of the wrist the patient underwent revision arthrodesis 1 year after resection. Microscopic studies of the epishyseal region of the fibula showed wide necrosis of the graft with active creeping substitution. Despite the good technical result of the vascularized fibular graft, the vascularization was incomplete in the proximal epiphysis. We discuss possible reasons for this. Journal of Hand Surgery (British and European Volume, 1999) 24B: 4: 497–500