Free vascularized bone grafting for large-gap nonunion of long bones

In conclusion, vascularized bone grafts provide a useful technique for difficult skeletal reconstructive problems. The advantages, indications, and method of this technique have been reviewed. The experience of the literature has been summarized, and our current experience with microvascular grafting was presented.     

Double-barrel free fibula flap for treatment of infected nonunion of both forearm bones

Free vascularized bone transfer is a viable treatment option for extensive bony defects greater than 6 to 8 cm involving scarred, poorly vascularized, or infected recipient beds, such as in chronically infected nonunion of the radius and ulna treated with a double-barrel free fibula flap. Both patients reported here experienced bony union with significant resolution of their symptoms. Although range of motion improved following an aggressive physical therapy regimen, pronation was adversely affected. Chronic infected nonunions or nonunions from radionecrosis involving large segmental defects of both forearm bones are a truly unique challenge and must be treated aggressively to ensure any useful long term function of the injured limb.     

Free vascularized bone graft for nonunion of the scaphoid

We used a free vascularized small periosteal bone graft to treat scaphoid nonunion. The graft consisted of periosteum, full-thickness cortex, and the underlying cancellous bone and was harvested from the supracondylar region of the femur. The graft was nourished by the articular branch of the descending geniculate artery and vein. Unlike the currently used vascularized bone grafts, this graft can be easily harvested and shaped to accommodate the bone defect of the scaphoid without disturbing its vascularity and can then be transferred with microvascular anastomosis of the nutrient vessels to the radial artery and its venae commitantes. Ten patients with longstanding nonunion of the scaphoid secondary to avascular necrosis, confirmed by radiologic and intraoperative findings, were treated with this vascularized bone graft. Union was achieved in all 10 patients at an average of 12 weeks after surgery. The average follow-up period for all fractures was 3.5 years. The scores for overall outcome, according to the Mayo wrist scoring system, were excellent in 4 patients, good in 4, and fair in 2. Two unsatisfied patients had preoperative signs of early periscaphoid osteoarthrosis. This free vascularized small bone graft from the supracondylar region of the femur is an attractive alternative to the conventional vascularized bone grafting procedures.     

Free vascularized fibula in traumatic long bone defects and in limb salvaging following tumor resection: Comparative study

In this retrospective analysis, we present our experience with two groups of patients who had long bone defects secondary to trauma or tumor resection and who were treated with a free vascularized fibular graft for skeletal reconstruction. Both groups were comparable in number and average age of patients, length of bone defect, and mean follow-up (average 3 years both groups). The number of surgical procedures prior to microvascular grafting was significantly higher for the traumatic defects. Primary bone union in a mean period of 6 months occurred at a higher rate in the tumor patients; the trauma patients had a significantly higher nonunion rate, which required multiple additional surgical procedures. The latter did not, significantly, improve the rate of success in the trauma group. Residual limb shortening was present in one-half of the patients with traumatic defects. On the basis of this review, it appears that the scarred and relatively avascular soft tissues surrounding the long bone defects secondary to trauma affect the course and the final outcome of the microvascular fibular grafting. A similar procedure applied for limb salvaging after tumor resection is better. © 1993 Wiley-Liss Inc.     

Free vascularized corticoperiosteal bone graft for the treatment of persistent nonunion of the clavicle

Radiation-induced necrosis or infection can result in a persistent nonunion of the clavicle. We describe 3 cases in which a free vascularized corticoperiosteal flap was harvested from the medial aspect of the femoral condyle and transferred to the fractured clavicle by use of microvascular anastomoses. Healing was confirmed by tomography in all 3 patients. The function of the upper extremity was remarkably improved at final follow-up. Vascularized free corticoperiosteal bone flaps are an option in clavicle fracture treatment. The technique of periosteal grafting is ideally suited to chronic nonunions with poor chances of healing on their own. Rapid subperiosteal new bone and improved local blood flow serve to correct many of those changes attributed to necrosis of bone.     

Free vascularized fibula and reconstruction of long bones in the child--our evolution

The aim is to show our evolution for reconstruction of long bones in the child with free vascularized fibula after tumoral resection. Between 1990 and 2004, 78 children were operated on for sarcoma of long bones and one girl with congenital pseudarthrosis. The main applications are illustrated: U-shaped fibular transplant, fibular epiphysis with growth plate and diaphysis transfer, fibular graft associated to massive allograft. Follow-up of the children was performed by clinical examination and standard X-ray. No post operative death occurred. Many benign complications for femoral reconstruction were observed. So our recent evolution is to use vascularized fibula associated with massive allograft; but resorption of allograft was observed 3 years later. Vascularized fibula for reconstruction of long bones is the ideal material. The result is definitive. The future for femur is perhaps vascularized fibula associated with osseous substitute.     

胫骨皮瓣游离移植治疗肱骨骨不连骨缺损

肱骨骨不连是骨科术后较为常见的并发症,治疗方法较多,效果较好。但对于一些复杂类型的肱骨骨不连,如合并感染的肱骨骨缺损,肱骨双节段骨不连等,治疗比较困难。2001年6月-2005年6月,采用胫骨皮瓣游离移植治疗13例肱骨骨不连骨缺损,取得良好效果。1临床资料本组13例,男9例,女4例;年龄14~56岁;左侧8例,右侧5例。肱骨粉碎性骨折术后骨不连、碎骨片坏死9例(开放性7例,闭合性2例),其中采用钢板固定5例;钢板加钢丝捆扎固定4例,有2例演变成骨髓炎。肱骨血源性骨髓炎形成慢性骨髓炎骨缺损合并窦道形成3例,肱骨骨折钢板固定术后骨不连再次摔伤致钢板…     

Free vascularized bone grafts for reconstruction of traumatic bony defects of mandible and maxilla

Small bone defects of the mandible and maxilla can be surgically treated with conventional bone grafts provided local conditions are optimal for bone healing. However, when the bone defect is large, is associated with soft tissue loss, or when conventional bone grafting fails, a free vascularized bone graft often becomes an important alternative to ensure adequate healing. As free vascularized bone grafting is today considered a more reliable procedure for bone reconstruction, with success rates over 96%, we prefer to treat even smaller segmental bone defects with this technique when local conditions are less than ideal. The technique also allows for simultaneous insertion of osteointegrated dental implants at the time of vascularized bone grafting, thereby facilitating earlier total oral rehabilitation.     

吻合血管的腓骨多术式移植重建肿瘤性骨关节缺损

目的:探讨吻合血管的腓骨多术式移植重建肿瘤性骨关节缺损的方法及疗效。方法:1996年10月至2005年1月应用多种吻合血管的腓骨移植术式治疗89例肿瘤性骨关节缺损,男48例,女41例;年龄12～67岁,平均35岁。其中病灶清除腔内嵌入植骨术35例;瘤段切除单节段或双节段腓骨植骨术15例;近关节肿瘤切除带腓骨头半关节移植术16例;病灶外科边缘切除双段腓骨、髂骨联合植骨术23例。结果:根据Enneking肢体功能评价标准,对术后功能评价:病灶清除腔内嵌入植骨术35例中29例获随访,优26例,良1例,可2例;瘤段切除单节段或双节段腓骨植骨术15例中12例获随访,优8例,良1例,可1例,差2例;近关节肿瘤关节切除带腓骨头半关节移植术16例中12例随访,优7例,良3例,可1例,差1例;病灶外科边缘切除双段腓骨髂骨联合支撑植骨术23例中17例获随访,优11例,良3例,可1例,差2例。结论:吻合血管的腓骨多术式移植重建骨关节缺损,极大地丰富了骨肿瘤的治疗方法,可以满足四肢多部位肿瘤切除后的功能重建,效果可靠。手术操作时,需要根据不同病变选择相应术式。     

Treatment of nonunion of the forearm bones with posterior interosseous bone flap

Background

Reconstructions of forearm fracture nonunions are frequently complex. A few studies that help guide the treatment of forearm nonunion have been reported. We offer a novel surgical technique to treat nonunion of the forearm using a regional vascularized bone graft.

Methods

Four females and 5 males ranging from 27 to 74 years of age with 7 ulna and 2 radius nonunions were surgically treated by pedicle grafting with a posterior interosseous bone flap (PIBF) and internal fixation with a plate. There were no cases with extensive soft tissue damage or infection. Pre- and postoperatively (mean 21 months), all patients were assessed by radiographs and for function by the Disabilities of the Arm, Shoulder and Hand (DASH) score.

Results

Function of the upper extremity was improved in all patients. DASH scores improved from 61.2 points pre-operatively to 12 points at final follow-up. All nonunions were united uneventfully.

Conclusions

Following debridement of the necrotic tissue, the bone defect can be filled with a vascularized graft from posterior interosseous pedicles. Pedicled PIBF is a safe and useful novel technique in cases of atrophic or hypertrophic nonunion of the middle third of the radius or proximal two-thirds of the ulna.     

Free fibula and corticocancellous bone grafting for salvage of a war-injured forearm

The treatment of a complex forearm injury inflicted by a wartime mine explosion is presented in this study. Apart from the soft tissue damage, a 4-part fracture of the radius and loss of 19 cm of the ulnar diaphysis were present along with lesions of the median and ulnar nerves. The radial pulse was intact. The first formal treatment of the wounding consisted of extensive soft tissue and bone debridement and external fixation of radius with an additional intramedullary K-wire. After wound closure was obtained, a free vascular fibula grafting of the ulna and corticocancellous bone grafting of the radius were performed. Bone union of both the radius and ulna was subsequently achieved and 9 years after the injury, the patient has full flexion and extension of the elbow, full pronation and 70% of supination. Motion of the wrist is limited because of an ulnar plus variant of the distal radioulnar joint. Hand function is still limited by chronic low-moderate median nerve palsy, but the ulnar nerve has recovered completely. The patient is able to pinch, has full finger extension and can make a fist. He is satisfied that he made the correct decision in not having an initial amputation for his injury.     

Vascularised bone transfer for defects and pseudarthroses of forearm bones.

During a five-year period, 15 patients with defects or pseudarthroses of the forearm bones were operated on. All had previously undergone one to six conventional operations. A vascularised fibular graft was used in ten cases, a radial graft in three cases and a humeral graft in two cases. Bone graft viability and healing were assessed clinically and patients have been observed for seven months to five years. 14 patients have finished treatment: 13 were cured and only two repeat osteosyntheses were required. In one case there was resorption of the central part of the fibular graft. Primary bony union was achieved in three to six months. Care must be taken in precise pre-operative assessment of the state of the forearm arteries. We advocate wider usage of vascularised radial and humeral grafts.     

Management of traumatic tibial defects using free vascularized fibula or Ilizarov bone transport: a comparative study

There are several options for the treatment of traumatic tibial defects. Among these options, free vascularized fibula and Ilizarov bone transport are well-known and effective techniques. The differences between both techniques and the indications for each of them are not well studied in the literature. Between September 1995 and December 2004, Ilizarov bone transport and free vascularized fibula were used to treat 25 traumatic bone. Patients were divided into two groups, Ilizarov group (12) and free fibula group (13). Preoperative data, operative data, duration of treatment, functional outcome, range of motion loss, number of secondary procedures, and type and rate of complications were compared in both groups. All the cases were ultimately united in both groups. Operative time and blood loss were significantly higher in the free fibula group. Although external fixation time was longer in the Ilizarov group, the overall duration of treatment was similar. Range of motion loss was less in the Ilizarov group, but the overall functional outcome was similar. There was no difference in complication rate, or number secondary procedures. Defect size was found to have the most significant effect on the results. Results were much better in the free fibula group when the defect length was 12 cm or more while the results were better in Ilizarov group when the defect length was less than 12 cm. We recommend using free vascularized fibula for traumatic tibial defects of 12 cm or more, whenever experience is available.     

One-bone forearm formation using vascularized fibula graft for massive bone defect of the forearm with infection: case report

Massive long-bone defects of greater than 6 cm are difficult to treat with conventional bone grafts, and other methods are sometimes recommended, such as vascularized bone grafts or bone transport using the Ilizarov external fixator. The combination of local infection with a massive bone defect exacerbates the problem, and provides an even more negative prognosis. The authors treated a large bone defect of the forearm with local infection, using a one-bone forearm formation with a large vascularized fibula graft. They attached an adequate amount of muscle fascia to the vascularized fibula, which was useful not only for coverage of the skin defect, but also for treatment of the local infection. Twenty months after surgery, elbow and hand functions were maintained, and the patient had no disturbance of hand function in daily activities, although rotation of the forearm was sacrificed.     

吻合血管的髂骨与腓骨移植修复四肢骨缺损疗效分析

目的探讨带血管腓骨和髂骨移植修复四肢骨缺损的临床效果。方法1992年1月～2004年1月,对49例四肢骨缺损患者采用带血管腓骨(33例)和带血管髂骨(16例)移植治疗。参照Enneking系统对患肢进行功能评价,移植骨转归参照国际挽救肢体专题讨论会制定的关于同种及带血管移植的放射学评价方法评定。结果所有患者术后随访1～12年,带血管腓骨移植组患肢功能恢复率为82.7%,移植腓骨愈合时间平均为16.8周,治愈率为87.9%。带血管髂骨移植组患肢功能恢复率为88%,移植髂骨愈合时间平均15.2周,治愈率为93.8%。两组骨愈合时间和患肢功能恢复率比较有统计学意义。结论带血管腓骨移植可用于修复下肢大段骨缺损和桡骨远端缺损,而带血管髂骨修复上肢骨缺损效果较好。     

Results of free vascularized fibula grafting for allograft nonunion after limb salvage surgery for malignant bone tumors

The purpose of this study was to assess the results of free vascularized fibula grafting (FVFG) in the treatment of allograft fracture nonunion after limb salvage surgery for malignant bone tumors.A retrospective study was performed on 8 patients who underwent FVFG for allograft fracture nonunions. All had prior tumor resection and allograft reconstruction for osteosarcoma (n = 6) or Ewing sarcoma (n = 2) of the femur (n = 3), tibia (n = 2), humerus (n = 2), or ulna (n = 1). All patients failed an initial course of immobilization; 4 patients failed prior open reduction and internal fixation with autogenous nonvascularized bone grafting. Average age at the time of FVFG was 14 years. Average follow-up was 44 months.The FVFG resulted in successful bony healing in 7 of 8 patients, providing pain relief, limb preservation, and restoration of function. One patient developed an infection requiring fibula removal and staged prosthetic reconstruction. Additional complications requiring further treatment included limb-length discrepancy, additional allograft fracture, and wound infection.The FVFG is an effective treatment option for allograft nonunion after limb salvage surgery because it provides both the mechanical stability and biological stimulus for bony healing. Attention to internal fixation, limb alignment, and microvascular principles is essential to prevent complications and allow for the best functional outcomes.     

Free vascularized fibula grafting for the treatment of osteonecrosis of the femoral head.

A variety of joint-preserving operations have been devised to preserve the necrotic femoral head with varying success. Since 1979, the authors studied the effectiveness of vascularized fibula grafting in the treatment of osteonecrosis of the femoral head (ONFH) for joint preservation. Eighty-one of 121 hips with a minimum follow-up period ranged from three years to ten years eight months (mean, five years two months). All patients were evaluated clinically and roentgenographically on the basis of the causes and the stages of the disease. In the clinical assessment, 60 (74%) of 81 hips were rated excellent, 14 (17%) were rated good, six (7%) were rated fair, and one (2%) was rated poor. Overall satisfactory results, including excellent and good, were seen in 74 hips (91%). In the roentgenographic assessment, 57 hips (71%) had improved radiologically, 15 (18%) were unchanged, and nine (11%) were worse. Seventy-two hips (89%) showed roentgenographic improvement or unchange. Roentgenographic results had no significant correlation with the etiologic factors. Vascularized fibula grafting is one of the better alternatives for treating ONFH. It is highly expected that vascularized fibula grafting can prevent the necrotic femoral head from progressing to collapse and promote directly restored vascularization and new bone formation.     

Free vascularized fibula grafts for salvage of failed oncologic long bone reconstruction and pathologic fractures

Vascularized bone grafts, particularly the free fibula transfer, have incited revolutionary changes in the field of skeletal reconstruction. In no place has this been more evident than in oncologic reconstruction. The free vascularized fibula graft has been used to good effect for primary long‐bone reconstruction, long‐bone allograft complication salvage, and pathologic fracture salvage of the long bones. Although many of these procedures often entail significant complications, limb salvage has been made possible in a majority of patients using transfers of free vascularized fibula grafts. The purpose of this review is to critically evaluate the technique of onlay free vascularized fibula grafts for salvage of allograft complications and pathologic fractures of the long bones. This will be accomplished by reviewing the problem of allograft complications and pathologic fractures, the current treatment modalities available, the outcomes of these treatments, and future directions of treatment for this particular problem. © 2009 Wiley‐Liss, Inc. Microsurgery, 2009.     

Reconstruction of traumatic tubular bone defects using vascularized fibular graft

Large segmental bone defects due to major trauma constitute a major challenge for the orthopaedic surgeon, especially when combined with poor or lost soft tissue envelope. Vascularized fibular transfer is considered as the gold standard for the reconstruction of such defects of the extremities due to its predictable vascular pedicle, long cylindrical shape, and tendency to hypertrophy, and resistance to infection. Vascularized bone grafts remain viable throughout the healing period and are capable of inducing rapid graft union without prolonged creeping substitution, osteogenesis and hypertrophy at the reconstruction site, and fight with infection.The fibular graft can be transferred solely, or as a composite flap including muscle, subcutaneous tissue, skin and even a nerve segment in order to reconstruct both bone and soft tissue components of the injury at single stage operation. Such a reconstruction can even be performed in the presence of local infection, since vascularized bone and adjacent soft tissue components enhances the blood flow at the traumatized zone, allowing for the delivery of antibiotics and immune components to the infection site.In an effort to preserve growth potential in pediatric patients; the fibular head and proximal growth plate can be included to the graft. This practice also enables to reconstruct the articular ends of various bones, including distal radius and proximal ulna. Apart from defect reconstruction, vascularized fibular grafts also proved to be a reliable in treating atrophic nonunions, reconstruction of osteomyelitic bone segments. These grafts are superior to alternative reconstructive techniques, as bone grafts with intrinsic blood supply lead to higher success rates in reconstruction and accelerate the repair process at the injury site in cases where blood supply to the injury zone is defective, poor soft tissue envelope, and local infection at the trauma zone.