Figure 1: 26-year-old male with high-grade osteosarcoma and 3-level en bloc resection of the lumbar spine after external decompression for paraplegia and neoadjuvant chemotherapy (a–c). 2 years later, no evidence of recurrence or metastases. However, mechanical failure of the instrumentation (d). Implant removal, spino-pelvic/ilio-lumbar/thoraco-lumbar re-instrumentation from Th11/12/L1 to L5/S1 as well as bilateral ilium with triple rod construction, TLIF L5/S1, dorsal, bony spondylodesis using vascularized autologous fibula transfer (graft length 26 cm) from Th11 to sacrum, fixation of the graft using small fragment screw osteosynthesis thoracically to the processus spinosus LWK 2 lumbar/sacral to the lamina S1 (e/f). 2 years postoperatively consolidated fibula, stable instrumentation, no complaints, no recurrence or metastases (g/h).