Experience with the clinical use of demineralized bone autografts in traumatology and orthopedics

The authors analyse the results of clinical application of osseous allografts demineralized by 1, 2-2, 4-3, 6 N solutions of hydrochloric acid. Of 92 patients with various pathologies of the locomotor system the postoperative results were positive in 85 cases (92.4%) and negative in 7 cases (7.6%). The analysis has demonstrated that the negative results were not connected with the kind of the osteoplastic material.     

Urovaginal fistulas: Experience with the management of 41 cases

In a retrospective analysis the authors have evaluated their experience with the management of urovaginal fistulas in 41 patients. Of them 34 had vesicovaginal, 3 ureterovaginal, 2 urethrovaginal, 1 ureterovesicovaginal and 1 ileovasicorectovaginal fistula. Fistulas occurred most frequently after gynaecological operations for benign and malignant diseases and after radiotherapy. Reconstructive operations were performed in 37 patients, mostly from the vaginal approach. Primary repair of fistulas was successful in 35 patients. In 2 patients reoperation was required. Due to good experience the authors recommend the transvaginal approach, which in their opinion is suitable for repair of the prevailing part of vesicovaginal fistulas.     

Spontaneous bilio-digestive fistula of lithiasic etiology. Experience of 41 cases

Spontaneous biliary-digestive fistulas represent a rare pathology, but an important one given the diagnostic difficulties and high operative mortality that still characterise the obstructive forms in particular. Personal experience of 41 cases is reported with a discussion of the symptoms, diagnostic procedures and surgical indications. The complete clinical aspecificity of the fistulas and their frequent association with choledocholithiasis and stricturing odditis are emphasised.     

Vascularized autogenous canine coccygeal bone transfer.

Based on cadaver studies in dogs, the 8th, 9th, or 10th canine coccygeal vertebra with overlying skin was designed for free vascularized bone transfer. In six dogs the coccygeal osteocutaneous flap was transferred to fill a defect of the tibia, anastomosing the median caudal artery and one of the two caudal veins to the tibial vessels. The overlying skin provided a reliable monitoring system for the transferred tissue. The behavior of the vascularized coccygeal vertebrae was then evaluated with radiographic and histologic examination and compared with control vertebrae transferred without reconnection of the blood vessels. The results revealed that the canine coccygeal bone graft is a reliable vascularized osteocutaneous flap, which can be applied either in clinical veterinary surgery or in orthopedic microsurgical research.     

Tumors of the carotid body: Experience with 41 operative cases

Evaluation of a patient with a carotid body tumor requires a complete head and neck examination with special attention to the cranial nerves and careful search for additional paragangliomas in other sites. Angiography is very helpful in making the diagnosis and assessing the ipsilateral and contralateral carotid artery. Surgery should be performed early, since group I tumors are easily excised and are associated with a low surgical morbidity. Surgical excision should be performed by head and neck and vascular surgeons, applying shunting or reconstructive techniques when appropriate. With improved diagnostic and surgical techniques, the morbidity and mortality should continue to approach zero.     

Vascularized autografts for reconstruction of skeletal defects following lower extremity trauma. A review

Over the last 15 years, vascularized bone grafts have proved to be a valuable method of reconstructing skeletal defects in the extremities. Successful skeletal reconstruction has been reported following tumor resection, select traumatic skeletal defects, congenital pseudarthrosis, and both infected and uninfected skeletal nonunions unresponsive to conventional methodology. Incorporation of the graft into the recipient is not as dependent on an uninfected well-vascularized host as a conventional avascular autogenous graft is. Vascularized autografts are also capable of achieving union across large skeletal defects with fewer stress fractures than when avascular autografts are used to span a defect greater than 6 cm. With patency of the vascular anastomoses and union at both ends of the graft, hypertrophy of the segmental graft is not unusual. The overall success rate of ultimate bony union is approximately 80% and is mostly dependent on the recipient location. As discussed in this article, vascularized autografts are a salvage procedure to be used in reconstructing extremities in which conventional reconstructive techniques have failed or are not applicable.     

Vascularized free fibula transfer in the treatment of bone tumours. Report of three cases

The surgical treatment of two cases of bone tumours and one case of a tumour-like lesion are reported in this article. The tumours were resected radically and the massive bone defect or bone cavity were substituted by vascularized free fibula transfer. All of them were cured by early union. Neither atrophy nor non-union between the graft and the recipient bone occurred. Early restoration of function was observed. Our experiences of isolating the graft and the operative procedure are discussed. We believe that this method has prospects not only in the field of treatment of bone tumours but also in the management of bone defects or non-union due to various other causes.     

Vascularized tibial periosteal graft in complex cases of bone nonunion in children

Bone nonunion in the pediatric population usually occurs in the context of highly unfavorable biological conditions. Recently, the vascularized fibular periosteal flap has been reported as a very effective procedure for treating this condition. Even though a vascularized tibial periosteal graft (VTPG) was described long ago and has been successfully employed in one adult case, there has been no other report published on the use of this technique. We report on the use of VTPG, pedicled in the anterior tibial vessels, for the treatment of two complex pediatric bone nonunion case: a recalcitrant supracondylar femoral pseudarthrosis secondary to an infection in an 11‐year‐old girl, and a tibial nonunion secondary to a failed bone defect reconstruction in a 12‐year‐old girl. Rapid healing was obtained in both cases. In the light of the data presented, we consider VTPG as a valuable surgical option for the treatment of complex bone nonunions in children. © 2014 Wiley Periodicals, Inc. Microsurgery 35:239–243, 2015.     

Vascularized bone graft in carpal bone reconstruction

We report our experience of vascularized bone graft harvested from the volar aspect of the distal radius for carpal bone reconstruction. Thirty cadaveric dissections showed in all cases the volar carpal artery which born from the radial artery. Between 1994 to 2001, we treated 87 scaphoid non-unions with an average follow-up of 41 months (range 6 to 65 months). Union was obtained in 80 patients (92%) with an average delay of 8.6 weeks (range 6 to 24). Between 1994 to 2000 we treated 22 patients with a Kienbock's disease. A radius shortening was always added to the revascularization of lunate by this vascularized bone graft. Preoperative and postoperative MRI was systematically done. The average follow-up was 55 months (range 24 to 92 months). MRI showed healing with good revascularization in 16 cases (74%). Lesions of lunate were stabilized in five cases and we had one failure with secondary palliative procedure. This simple but meticulous technique needs only one approach and allows a sufficient revascularisation.     

Vascularized periosteum and bone regeneration

The osteogenic potential of periosteum is widely recognized. During development, it plays a prominent role in the radial growth of long bones. Similarly, it has a key role in the consolidation of fractures. The physiological function of periosteum in the healthy, mature skeleton remains relatively subtle; however, its detachment from the bone surface reactivates its potential for fibrogenic and osteochondrogenic regeneration. This discreet anatomical structure is actually a reservoir of mesenchymal progenitor cells capable of proliferating and differentiating, by reinitializing cellular and molecular cascades of embryogenesis in mesenchymal tissues. However, given the hitherto limited knowledge of the quantitative potential of periosteum and of the pathways regulating tissue differentiation during regeneration, human applications have remained anecdotal. The findings of several in vivo and in vitro experiments indicate that the maintenance of the periosteum's vascularization stimulates its quantitative potential. The structural organization of the regenerated material in vivo is governed by locoregional biological and mechanical regulatory mechanisms that serve to make it capable of performing its new functions. The increasing awareness of periosteum's potential is stimulating active research in the fields of cellular biology and tissue engineering. The demonstration of its regenerative potential in animals gives reason to believe that strips of vascularized periosteum could become part of the developing armamentarium of regenerative medicine.     

Vascularized bone grafts in children. Specifics and indications

The authors report on the vascularized bone grafts used in children. Some of them are the same as those used in adults, like the fibula free flap. Others are growth plate transfers as the proximal fibular epiphysis, the iliac crest or the lateral scapular crest. Finally, other transfers are periosteal vascularized grafts. The indications and results are discussed concerning the congenital pseudarthrosis of the tibia (43 cases treated by the first author), the congenital pseudarthrosis of the forearm, the tumors of the limb and the post-traumatic defects. The specific indications in children are the microsurgical growth plate transfers, especially the epiphyseal growth fibula for the upper limb and the iliac crest for the lower limb.     

Vascularized bone grafts for maxillofacial reconstruction

Vascularized bone transfers are the ideal bone graft since they provide their own blood supply and all necessary osteoinductive, osteoconductive, and osteoprogenitor elements. These attributes allow them to be used in compromised recipient sites. When used as onlay grafts to augment skeletal contour they provide the best opportunity to maintain volume. Vascularized bone grafts used to provide mechanical stability are most often used to reconstruct the mandible after portions of it have been removed for tumor and further treated with radiation therapy. The considerable number of free bone graft donor sites allows considerable flexibility in design for mandibular reconstruction. In instances in which complex composite defects in the mandible, and particularly the maxilla, exist, restoring a well-vascularized soft tissue milieu with a free soft tissue transfer allows successful skeletal reconstruction with nonvascularized bone grafts. Vascularized bone allografts are a theoretically appealing way to reconstruct large bone defects. At this time their benefits are outweighed by the toxicity of current immunosuppressive therapy.     

Vascularized bone transfer of scapula apophysis

The vascularized bone transfer of the scapular apophysis was described for the first time by Gilbert and Téot (1982) [1]. The growing pattern of this specific apophysis has large capacity and the plasticity during remodeling is unique. Primarily used for mandibular reconstruction, the scapular crest is also suitable for humeral or femoral reconstruction as well as for carpal stabilization in radial hand malformation, which is considered to be the main clinical indication. The radial hand malformation is characterized by an insufficient ulnar carpal stabilization which leads to luxation and radial deviation of the carpus. Using the vascularized scapular transfer in volar apposition to the ulnar, it enables enlarging the contact surface area with the carpus, thus stabilizing the wrist. Due to the preserved epiphyseal vascularization, good remodeling and integration of the scapular crest is achieved until consolidation takes place.     

Vascularized bone graft for scaphoid nonunion

The management of recalcitrant nonunion of the scaphoid can be frustrating. Recent understanding of the vascular anatomy of the distal radius has helped in the management of these problems. Vascularized bone grafting for scaphoid nonunion has improved the union rates. Consequently, familiarity with this procedure is an important tool for any surgeon who treats scaphoid nonunion. Although there are numerous publications discussing both the vascular anatomy of the distal radius and the scaphoid, little is written about the surgical technique. This study reviews the literature on scaphoid nonunion and outlines the authors' experience with this procedure.