Clinical applications of vascularized bone autografts

Our experience with microvascular transfer of fibular grafts and composite osteocutaneous iliac flaps has shown that massive autogenous bone grafting with an intact vascular pedicle decreases the time to bony union and the duration of immobilization required for functional reconstruction of an extremity. The technique has proven reliable (87 per cent success rate) in the reconstruction of bone defects of greater than 6 to 8 cm following tumor resection or defects existing in a fibrotic, avascular bed. More importantly, these techniques have been applied for limb salvage in patients with tumors or with severely traumatized extremities that were not candidates for more traditional methods of bone grafting. In many cases, amputation would have been the only alternative.     

骨外固定支架的应用现状

外固定支架在临床中经过不断地改进,成为骨科的一门基本技术。近几十年来,外固定理论的发展及各式外固定器的研制,使其用途呈现多样化。在肢体延长和畸形矫正方面的成绩,更显示其重要性,某些方面是内固定不可替代的。当然,该技术也有一定的并发症发生率,若应用不当会发生严重并发症甚至后遗症。本文从外固定支架的分类,在四肢骨折、胸腰椎骨折、肢体延长中的应用及在延长过程中需注意的问题,可能出现的并发症等几个方面进行了综述。     

Errors and complications of plastic surgery of defects and false joints of the humerus using free vascularized bone autografts

The authors analyse the errors and the complications in the plasty of defects and false joints of the humerus with free vascularized bone autografts in 20 patients aged 8-50 with the period of duration of the disease from 6 months to 9 years. The size of the defect was 3-20 cm (15 patients). In 17 cases a fibular bone graft on a vascular pedicle was used. In 8 patients 14 various kinds of complications occurred in different combinations. Non-union of one of the ends of the graft was observed most frequently (4) due to faults of osteosynthesis. In all patients consolidation was achieved. In this type of complications the authors advise to make an early repeated intervention with the aim of shortening the duration of treatment and subsequent rehabilitation. They stress the perspective character and the validity of this method of plasty, especially in extensive defects in association with poor vascularization of the injured segment of the extremity. Accurate performance of all stages of the intervention and the surgeon's personal experience play an important role in prevention of errors and complications in employing microsurgical technique in the treatment of this category of patients.     

跟骨撬拨外固定器的研制及临床应用

目的 研究能独立完成跟骨骨折整复与固定的外固定器具,方法 采用自行研制跟骨撬拨外固定器治疗跟骨骨折50例,57个跟骨,进行临床观察。结果 本组50例,43例得到平均14.5个月的随访,根据中医骨伤科病证诊断疗效标准,治愈好转率为97%。结论 跟骨撬拨外固定器结构设计合理、简单、完整、使用方便,可单独完成跟骨骨折整复与固定直至愈合,尤其适用皇舌状型骨折治疗。     

Improvement of Hoffmann external fixation apparatus

The resurgence of external fixators for the management of skeletal and joint injuries has generated an increasing number of reports. In addition, many types of fixators have been developed in the last ten years. Of these, the Hoffmann external fixator is the most popular one. Is it possible for the patient with a tibial comminuted fracture to walk with the fixator? This study has been pursued to investigate this question and to improve on the fixator. Bone models were made from tubed polyester resin strengthened by glass fiber (elastic module: 9.46 kg/mm2, outside diameter: 35 mm, inside diameter: 30 mm). Each bone model was transfixed by two Steinmann pins (phi: 4.5 mm) with 43 mm between, and a pair of models was framed with two straight bars, with 30 mm from model to bar. The Steinmann pins and straight bars were connected to each attachment. The experiment focused on four main studies: Measurement of the Young's modulus of the Steinmann pin. Compression load test and bending load test framed bone models with each attachment. Observation and measurement of the ground reaction force of ambulation on stilt framed with experimental external fixator. Determination of S-N curve of the Steinmann pin. Results were as follows: The Young's modulus of the Steinmann pin were 1.8 X 10(4) kg/mm2. 0.2% proof of the pin was 110 kg/mm2. The bone models framed with the conventional method were destructed at the universal ball joint at 68 kgf in the compression load test, and 6.8 kgf in the bending load test. The models framed with the conventional method fitted with spring washers at ball joints were not destructed until 203 kgf in compression load, but after several trials the spring washers were crushed. The models fabricated by using a vice with rods and articulation coupling were not damaged until 210 kgf in compression load and were not damaged until 15 kgf in bending load even after several trials. The displacement between the models were 2.8 mm at 80 kgf and 8.5 mm at 210 kgf in compression load. The models fabricated by experimental external fixators were not damaged until 250 kgf in compression load and were not damaged until 30 kgf in bending load, and the displacement between the models were 2.1 mm at 80 kgf and 6.9 mm at 210 kgf in compression load.(ABSTRACT TRUNCATED AT 400 WORDS)     

Fate of vascularized and nonvascularized autografts

Controlled laboratory data demonstrate biologic and mechanical characteristics of orthotopically placed canine ulnar autografts. The pattern of bone repair was similar in vascular and nonvascular ulnar grafts beginning with resorption followed by appositional reactive bone formation. The time intervals in the sequence were accelerated in the vascularized grafts. Both the strength and stiffness of the vascularized grafts were found to be significantly greater in Groups studied from six weeks to six months postoperation. There was no statistical difference between the grafts for mechanical testing performed on dogs either one week or one year postoperation. The vascularized ulnar bone grafts fared better than comparably sized nonvascularized grafts and were more rapidly repaired. The mechanical testing demonstrated superior strength and stiffness of the vascularized grafts throughout the repair process.     

Management of bone in digital replantation: free vascularized and composite bone grafts.

Microvascular surgical techniques have been applied to the problem of digital amputation, persistent nonunion and complicated extremity injuries with segmental bone and soft tissue loss. In replantations, adequate bone shortening and fixation with intramedullary pins or rods is mandatory. Proper patient selection, preoperative management of the amputated parts, application of microsurgical disciplines, employment of an organized surgical sequence, and rigid postoperative monitoring has resulted in an 80% viability rate in 121 replantations. Recent advances in the management of skeletal injuries using microvascular techniques include free vascularized bone grafting and salvage of the preamputation limb using free composite grafts of skin, subcutaneous tissue and bone. These free composite grafts techniques are exacting and time consuming. Meticulous planning, preoperative rehearsal and careful coordination between the operating teams make the functional restoration of a severely injured limb possible.     

The use of periosteally vascularized autografts to augment the fixation of large segmental allografts.

Large segmental bone grafts are a standard of reconstructing long bone defects. Nonunion or delayed union at the host-graft junction is a major complication of these procedures. In six patients, a nonunion was treated by locally available bone, vascularized by its periosteum as an onlay autograft to improve fixation and speed incorporation of the allograft into the host bone. At three months, all were pain free and using their allografts without limitation. By four months, all had roentgenographic evidence of allograft and autograft incorporation. During the follow-up period from two to four years, all have incorporated the allografts and are pain free.     

全程使用与分阶段使用外固定架和石膏外固定治疗胫腓骨开放性骨折疗效比较

目的　探讨分阶段使用单侧多功能外固定架 (UMEFA )和石膏外固定治疗胫腓骨开放性骨折的疗效。方法　 89例胫腓骨开放性骨折经清创、骨折复位后均予以UMEFA外固定。然后 ,将其分 2组。A组 5 3例为全程骨外固定组 ,其中 8例因并发症较严重 ,中途拆除外固定架 ,其余 45例外固定维持至骨折愈合。B组 36例为临时骨外固定组 ,伤口愈合、肿胀消退、骨折纤维连接时拆除外固定架 ,改用长腿管状石膏外固定。结果　B组并发症的发生率为 8% ,显著低于A组40 % ( P <0 .0 1)。B组患者骨折愈合的平均时间为 2 13.6d ,显著低于A组 2 68.4d( P <0 .0 5 )。B组患者骨折愈合的优良率为 83% ,显著高于A组 60 % (P <0 .0 5 )。结论　分阶段使用外固定架和石膏外固定治疗胫腓骨开放性骨折 ,具有治疗效果好、骨折愈合快、并发症少等优点。     

Rigid internal fixation and vascularized bone grafting in mandibular reconstruction

The technique of mandibular reconstruction utilizing rigid internal fixation and vascularized bone grafts has been described. This type of repair should be considered in all patients undergoing mandibular resection for head and neck malignancies. Although no ideal method of reconstruction has yet been described, it appears that rigid internal fixation combined with vascularized bone grafts most satisfactorily fulfills the requirements associated with reconstruction of jaw defects.     

The plastic repair of defects in the long tubular bones using vascularized bone autografts]

Free vascularized osseous autoplasty is an effective method of treatment of defects of long tubular bones and false joints. The microsurgical auto-osseous transplants are the source of osteogenesis in the recipient area since they are not objected to resorption and rearrangement and preserving its primary structure.     

Cost of external fixation vs external fixation then nailing in bone infection

AIM: To study the cost benefit of external fixation vs external fixation then nailing in treatment of bone infection by segment transfer.METHODS: Out of 71 patients with infected nonunion tibia treated between 2003 and 2006, 50 patients fitted the inclusion criteria (26 patients were treated by external fixation only, and 24 patients were treated by external fixation early removal after segment transfer and replacement by internal fixation). Cost of inpatient treatment, total cost of inpatient and outpatient treatment till full healing, and the weeks of absence from school or work were calculated and compared between both groups.RESULTS: The cost of hospital stay and surgery in the group of external fixation only was 22.6 ± 3.3 while the cost of hospital stay and surgery in the group of early external fixation removal and replacement by intramedullary nail was 26.0 ± 3.2. The difference was statistically significant regarding the cost of hospital stay and surgery in favor of the group of external fixation only. The total cost of medical care (surgery, hospital stay, treatment outside the hospital including medications, dressing, physical therapy, outpatient laboratory work, etc.) in group of external fixation only was 63.3 ± 15.1, and total absence from work was 38.6 ± 6.6 wk. While the group of early removal of external fixation and replacement by IM nail, total cost of medical care was 38.3 ± 6.4 and total absence from work or school was 22.7 ± 4.1. The difference was statistically significant regarding the total cost and absence from work in favor of the group of early removal and replacement by IM nail.CONCLUSION: Early removal of external fixation and replacement by intramedullary nail in treatment of infected nonunion showed more cost effectiveness. Orthopaedic society needs to show the cost effectiveness of different procedures to the community, insurance, and health authorities.     

Stress fracture of free vascularized bone grafts]

Three cases of stress fracture within free vascularized bone graft were found among 35 patients with completed treatment. In 32 years old male stress fracture of free vascularized fibular graft used for tibial reconstruction occurred after a dozen of one (operated) leg hops. In 29 years old female operated due to tibial pseudoarthrosis with free vascularized iliac wing graft the fracture appeared after couple of days of intense walking. In both cases fracture occurred after incorporation of the graft, several months after removal of the external fixator. Pain and swelling of the limb increased over couple of days. In the last case of 25 years old male vascularized fibula transferred to the femur fractured in the presence of external fixator one year after surgery in the course of remodeling of the graft. In all cases X-ray revealed transverse fracture line in the middle of the graft. Plaster cast immobilization has been used in one case only. Graft remodeling with marked hypertrophy was found 4 month later.     

The current status of free vascularized bone grafts

In the last decade, free vascularized bone transfer has become an established technique, with success rates above 90 per cent reported in most series. These operations have special application for those situations in which the bone defect is large, the recipient bed is poorly vascularized, and there is an associated soft tissue deficiency. The donor sites now include the fibula, iliac crest, rib, metatarsal, radius, and scapula. Because this is a rapidly expanding field of surgical endeavor, much of the work is unpublished and information in some instances has been obtained necessarily from recent clinical meetings and by personal communication with surgeons. Our experience of 41 bone transfers, using the fibula and the iliac crest as the donor grafts, over a 9-year period has been presented. In general, the fibula is recommended for the reconstruction of a long bone. In the lower extremity it should be placed within the medullary cavity of the recipient bone ends so as to be sited in the line of the weight-bearing stress. The iliac osteocutaneous graft is ideal for reconstructing the mandible and other curved bones but can be used also for shorter defects of the tibia. With appropriate osteotomies the curvature of this bone can be increased or straightened to satisfy the requirements of the recipient site. Stress fracture of a long graft is not uncommon in the lower extremity, especially in adults. Nevertheless, this is followed usually by rapid formation of callus at the fracture site and hypertrophy of the bone. The use of angiography, replica bone models, and trial operations on cadavers is recommended in planning. Operative refinements include a simpler dissection of the fibula with a thinner sleeve of muscle; shaping the iliac bone graft while it is still attached at the donor site; and the suture of vein grafts to the bone graft on a side table when the pedicle is too short. Finally, it must be remembered that these are still relatively sophisticated procedures that place demands on personnel and hospital routine. They do not replace conventional bone grafting techniques but offer an alternative solution for difficult situations (Fig. 19). John Hunter stated, "A surgeon must approach the victim of his operation with a sacred dread and reluctance." Although a century has passed this is still a sage message.     

Postoperative monitoring of free vascularized bone grafts in reconstruction of bone defects

Vascularized bone transfer is increasingly recognized as a very useful and versatile technique for reconstructing large bone defects. It is especially indicated in patients with challenging conditions, such as nonunions, postoncologic resections, severe trauma, and congenital defects. With increasing experience of reconstructive surgeons, improved microsurgical techniques, and more enhanced flaps, the failure rate of free flaps has been reduced in the last decades. Especially, the early‐postoperative period is decisive in the outcome of surgery. Several techniques have been described for monitoring the postoperative viability of microsurgical free vascularized graft, and their sensitivity and reliability continues to be the object of animal experiments and clinical trials. The qualities of an optimal monitoring device should be objective, continuous, noninvasive, safe, reproducible, easily managed, and interpretable for the nursing staff, inexpensive, and a clear indicator of changes in arterial and venous circulation. Presently, no one neither fulfills all of the criteria completely nor is uniformly accepted. In this article, relative advantages and disadvantages of these various postoperative monitoring techniques are discussed. © 2009 Wiley‐Liss, Inc. Microsurgery 2009.     

Transfer of vascularized grafts of iliac bone to the extremities

We treated sixteen patients, all of whom had a large segmental defect of bone in an extremity, with transfer of a vascularized graft of the iliac crest. Thirteen patients had an open defect that required an osteomuscular or osteocutaneous graft; the other three had a closed segmental osseous defect and the graft of the iliac crest was transferred without soft tissue. The average length of the osseous defect was seven centimeters. For the defects of the lower extremity, the average time to osseous union was 8.8 months. For the defects of the upper extremity, it was four months. Three patients had delayed union due to difficulty in positioning the graft on the tibia and maintaining circulation to the overlying skin; this led us to modify our method of transfer. In six patients, we used an osteomuscular graft and a separate skin graft instead of the osteocutaneous flap. When performing the transfers to the tibia, we tried to place the graft in the coronal plane against the fibula for better alignment and stability. For the transfers to the distal part of the forearm, we did a double microvascular anastomosis.     

外固定架治疗开放性胫腓骨骨折

目的 观察外固定架治疗开放性胫腓骨骨折的疗效。方法 自1994年7月到1999年12月,收治开放性胫腓骨骨折43例,男27例,女16例;年龄18-62岁。全部采用单侧多功能外固定架治疗。结果 43例全部随访,平均18个月,骨折均愈合,平均愈合时间86天,患肢恢复良好,无骨髓炎、骨不连等合并症。结论 该方法操作简单、创伤小、固定可靠、愈合率高,并发症少。为开放性胫腓骨骨折首选治疗方法。     

Aneurysmal cyst of the proximal radius: Resection and free vascularized fibular bone graft

We present the case of a 22-year-old woman with an aneurysmal cyst of the right proximal radius, treated by resection and a free bone graft (microvascular fibular transfer), without recurrence after 4 years. Over a 4 month period, there was a rapidly expanding and lytic lesion found in the radius. There were symptoms of elbow and wrist pain and early radially innervated muscle weakness. Radiological examination showed a localized tumour of the proximal radius, type 2, grade C, according to the classification of Campanacci. Biopsy led to the diagnosis of an aneurysmal bone cyst. Complete tumour resection was followed by a free vascularized fibular bone graft, resulting in good functional improvement, without local recurrence. Aneurysmal bone cysts are a rare condition, and the location in the radius has not previously been described. Vascularized bone grafts are mechanically and biologically superior in this type of case. © 1993 Wiley-Liss Inc.