Osteosarcoma and Ewing Sarcoma usually occur in children in the lower limbs [1]. Over the last decades, the number of limb salvage procedures has evolved from rare to standard due to the surge of chemotherapy protocols. Consequently, interventions demanding bone reconstruction have increased [2]. Limb salvage surgery is currently the treatment of choice in pediatric patients with bone sarcomas [2].

Moreover, oncological procedures are not the only ones requiring complex reconstructions. Congenital deficiencies, bone necrosis, trauma, or infections are also examples of pathologies leading to bone deficiencies that could need further structural restoration.

While wide surgical resection is the cornerstone of local curative treatment of bone tumors, many reconstruction techniques have been proposed to obtain the best functional outcome for patients in who amputation can be avoided. Among these reconstructive techniques, the use of vascularized fibular autograft (VFA) is one of the most attractive alternatives for biological and mechanical reasons [3]. VFA can be added or incorporated into a massive bone allograft (MBA), providing vascular supply to an inherently avascular reconstruction to improve bone properties and promote osteo-inductive capabilities [4,5].

In fact, because of the avascular nature of MBA, creeping substitution does not usually occur further than 2 cm at the allograft–host osteotomy [4,6]. Therefore, MBA alone can be associated with complications such as fracture and host-allograft non-union, particularly in patients treated with chemotherapy that may delay bone healing [7]. Hence, VFA can be a valuable aid in reducing the risk of mechanical complications related to MBA alone, especially for diaphyseal resections greater than 10 cm [8].

Although VFA are increasingly performed in expert centers, the literature regarding the role of imaging in assessing those complex skeletal reconstructions remains scarce and focused on computed tomography (CT) only so far [4]. To the best of our knowledge, no studies analyzed the interest of conventional radiography (CR) to evaluate MBA integration. Yet, given the young age of patients undergoing VFA, limiting radiation dose exposure would be valuable. Hence, the objective of our study was to evaluate if early CR findings are correlated to the outcome (i.e. graft integration) of MBA skeletal reconstructions supplemented with VFA.