Free vascularized fibula grafts in surgery of the upper limb

Twenty patients with intractable diseases in the upper extremity were treated using free vascularized fibula grafts. There were 13 men and seven women. Three patients had traumatic bone defects, five had post-traumatic nonunions, two had congenital pseudoarthroses, seven had defects after tumor resection, and three had other lesions. The reconstructed sites were the humerus in two patients, the radius and/or ulna in 17, and the metacarpal and phalangeal bones in one. The length of the bone defect ranged from 3 to 18 cm (mean: 8.4 cm). Follow-up periods ranged from 6 to 204 months. No patient required additional bone grafts. The mean period required to obtain radiographic bone union was 4.4 months. There were no cases with fractures of the grafted bone, but malunion occurred in four cases. The vascularized fibula graft is indicated in patients with large bone defects or intractable nonunions in the humerus, radius, and/or ulna.     

Upper limb salvage with microvascular bone transfer for major long-bone segmental tumor resections

A series of 14 young, active patients who underwent vascularized bone graft reconstructions of large (9-15 cm) segmental skeletal defects of the upper extremity resulting from resection of a variety of bony tumors is presented. Eight defects involved the proximal humerus and required shoulder joint reconstruction, two were mid humeral and four involved the distal radius. Surgical techniques for both distal radius reconstruction with vascularized iliac crest and vascularized fibular head and glenohumeral reconstruction using the vascularized fibula are described. Several cases are discussed in detail, including achievement of bony union, postoperative range of motion and pain, and each patient's ability to resume activities. The literature is reviewed, and other reconstructive options for large bony defects of the upper extremity after tumor resection are discussed: nonvascularized bone grafts, allograft transfer, and custom prosthetic devices. The authors think that vascularized bone grafting offers the most favorable method of upper extremity salvage with preservation of joint function, especially at the shoulder.     

Congenital pseudarthrosis of both forearm bones: long-term results of two cases managed by free vascularized fibular graft.

We analyzed the clinical and radiographic outcome of 2 cases of congenital pseudarthrosis of both forearm bones managed by free vascularized fibular grafts. The follow-up periods were 17 and 13 years, respectively. The first patient, a 4-year-old girl, had reconstruction of both the radius and ulna by a vascularized fibular graft, restoring pronation/supination to 110 degrees. The second patient, a 17-year-old boy, underwent a 1-bone forearm procedure using a vascularized fibular graft. After surgery, he had a stable forearm that was shortened by approximately 15 cm. In these 2 cases of congenital pseudarthrosis of both forearm bones, bone union was obtained by means of vascularized fibular graft.     

Free vascularized fibula for the treatment of traumatic bone defects and nonunion of the forearm bones

Eighteen infected nonunions and segmental defects of both the radius and ulna which had failed to resolve with conventional treatment were treated with a free vascularized fibular graft to restore radial, but not ulnar, continuity. In three patients there was destruction of the wrist joint and in two destruction of the elbow. The time from injury to referral ranged from 4 weeks to 3 months. The ipsilateral fibula was used as an osseous or osseocutaneous free flap to reconstruct the radius. All fractures united with good soft-tissue healing and resolution of infection. One patient required additional cancellous bone grafting. The mean period required for radiographic bone union was 4 months. Reconstruction of only the radius provided a stable forearm with a reasonable range of forearm rotation.     

Reconstruction of the bones and joints of the upper extremity by vascularized free fibular graft: report of 46 cases.

The vascularized free fibular graft was applied in reconstructing bone and joint structures of the upper extremity in 46 cases between August, 1977 and December, 1989. Among these, 30 were grafts of the fibular shaft and 16 were grafts of the fibular head. There were 19 bony defects after trauma or osteomyelitis, 18 bony or articular defects after resection of tumors, five congenital deformities or defects, and four replacements for fibrous dysplasia. The longest grafted fibula was 22 cm and the shortest, 5 cm. Thirty-one cases were followed for more than two years, and these were evaluated for functional ability in daily living, roentgenologic appearance, and 99mTc scan during follow-up. The results revealed quite sufficient functional restoration, solid bone healing, and adequate blood supply, in most cases. The vascularized free fibular head graft appears to be an ideal procedure for the reconstruction of defects of the lower end of the radius or the upper humerus, including the humeral head. The stability of the reconstructed wrist or shoulder joint was maintained by suturing the lateral collateral ligament, the palmar collateral ligament around the wrist, or by passing the long head of the biceps brachii through the grafted fibula at the shoulder. Methods for fixation of the fibular shaft to the recipient bone and the selection of vessels for anastomoses, both in the graft and at the recipient site, are discussed. The importance of postoperative functional exercise is emphasized.     

Limb reconstruction with vascularized fibular grafts after bone tumor resection

Limb-salvage operations are being used with increasing frequency for patients with malignant bone tumors. For children, when a biologic reconstruction is desired, the choice is often between conventional and vascularized fibular grafts. An experimental study was performed in dogs to compare the two types of fibular grafts for bridging segmental defects in the radius and ulna. Twenty-six adult dogs were divided into two groups and studied at intervals of two, three, four, six, and 12 months after transplantation. The conventional grafts healed by creeping substitution i.e., they were first partially resorbed before new bone was laid down. In contrast, the vascularized fibulae maintained their normal structure and hypertrophied by subperiosteal new bone formation. The conventional fibulae eventually hypertrophied but much later than the vascularized grafts. The vascularized grafts were stronger at four and six months. Between six and 12 months, both grafts remodeled to resemble the size and shape of the forearm bones they were replacing. These experimental results have influenced the treatment of patients. Vascularized fibular grafts are ideal for diaphyseal defects greater than 10 cm long, especially in very young children, a poorly vascularized bed, or when bone healing is delayed by chemotherapeutic agents. To maximize hypertrophy, an external fixator is used to immobilize the graft rather than a plate, which acts as a stress shield.     

The free vascularized fibular graft for bridging large skeletal defects of the upper extremity

Large skeletal defects of the upper extremity pose a serious clinical problem with potentially deleterious effects on both function and viability of the limb. Recent advances in the microsurgical techniques involved in free vascularized bone transfers for complex limb injuries have dramatically improved limb salvage and musculoskeletal reconstruction. This study evaluates the clinical and radiographic results of 18 patients who underwent reconstruction of large defects of the long bones of the upper extremity with free vascularized fibular bone grafts. Mean patient age was 27 years (7-43 years) and mean follow-up was 4 years (1-10 years). The results confirm the value of vascularized fibular grafts for bridging large bone defects in the upper extremity.     

Pseudarthrose congénitale de l’avant-bras. À propos de deux cas et revue de la littérature

Congenital pseudarthrosis of the forearm represents a rare entity which is often associated with neurofibromatosis type I. Isolated pseudarthrosis of the ulna is the most frequent deformity, followed by pseudarthrosis of the radius and both forearm bones. The treatment of these deformities remains difficult: conventional bone grafts rarely lead to complete fusion. The reconstruction by a vascularized fibular graft represents the treatment of choice if the radial head is not dislocated. This procedure allows restoration of a balance between radius and ulna during growth. The presence of a vascularized graft enhances the potential for bony fusion in a fibrous environment. In cases of isolated ulna pseudarthrosis, a luxation of the proximal radial epiphysis may occur when the ulnar deformity increases with time. The single-bone forearm represents a salvage procedure that creates a stable upper limb with a satisfactory wrist and elbow function. The two clinical cases of a pseudarthrosis of both forearm bones and of an ulna pseudarthrosis are presented.     

Use of free vascularized fibular graft for congenital ulnar pseudarthrosis: surgical decision making in the growing child

Congenital pseudarthrosis of the ulna may cause growth disturbance and progressive forearm deformity, leading to functional compromise of the upper extremity. Treatment is challenging, and surgical decision making must take into account three goals of treatment: bony healing, distal radioulnar joint (DRUJ) stability, and continued skeletal growth. Four cases of congenital ulnar pseudarthrosis treated with free vascularized fibular graft are presented here. In two cases, the vascularized fibular graft included the proximal fibular epiphysis to reconstruct the DRUJ and ulnocarpal joints. Average age of the four patients at time of vascularized fibular grafting was 10 years (range 3-16 years). Patients had undergone up to three previous failed operations. A step-cut osteotomy technique with rigid internal fixation was used in all patients. Donor-site distal tibiofibular arthrodesis was performed in skeletally immature patients when appropriate. At average follow-up of 60 months (range 33-83 months), all patients achieved bony union with full wrist range of motion compared with the contralateral extremity. The DRUJ was stable in all patients. Two skeletally immature patients with concomitant epiphyseal transfer showed continued skeletal growth. Two patients nearing skeletal maturity achieved revascularization of the distal ulna. Free vascularized fibular grafting is a successful option in the treatment of congenital ulnar pseudarthrosis. Reconstruction of the distal radioulnar and ulnocarpal joints using concomitant proximal fibular epiphyseal transfer should be considered in the skeletally immature patient with distal ulnar involvement.     

A modified induced membrane 2-stage technique using a thoracodorsal artery perforator free flap followed by vascularized or non-vascularized free fibular transfer for the treatment of complex bone infection with concomitant severe soft tissue lesion–A case series of 9 cases

Treatment of post-traumatic complex bone infection is very challenging. The two principal bone reconstruction approaches are the single-stage vascularized bone graft technique and the two-stage induced membrane technique (IMT). Here we introduce a modified 2-stage induced membrane technique (MIMT) for complex long bone infection with a major bone defect and a concomitant severe soft tissue lesion. The 2-stage procedure consists of bone debridement, placement of a PMMA spacer and soft tissue reconstruction with a thoracodorsal artery perforator free flap (“Tdap”) at stage 1. At stage 2, the thoracodorsal artery perforator flap is elevated and a fibular strut graft (either vascularized of non-vascularized) is placed for bone reconstruction.We retrospectively analyzed the extents of lower extremity, long bone, post-traumatic bone infection treated via MIMT from 2008 to 2020. There were nine such cases (eight males) of mean age 59.8 (range 31 to 79) years. The osteomyelitis durations ranged from 3 to 360 months (mean 53 months). The cortical bone defect sizes was ranged from 9 to 14 cm (mean10.7 cm). All skin resurfacing employed Tdap. Vascularized fibular grafts were placed in six patients and non-vascularized grafts were placed in three. The fibular graft size ranged from 12.5 to 19 cm (mean 16.2 cm). Non-vascularized iliac bone grafts served as the fibula docking sites.Unfortunately, all patients suffered complications before bone union was achieved. One case of plate stress fracture and one case of screw fracture required plate and screw change. In three cases of cellulitis, one resolved by use of intravenous antibiotics, others required plate and screw removal. Wound disruption required re-suture and distal skin flap partial necrosis was covered by perforator-based island flap. One case of fibular stress fracture needed cast for 4 weeks. A peroneal nerve palsy patient recovered spontaneously. Bone union was achieved after 6 months in five patients and after 8 months in three (mean 6.9 months). All patients were able to walk unaided. The follow-up period ranged from 2 to 14 years (mean 6.2 years).MIMT saves the limbs in cases with difficult post-traumatic bone infection. It is valid treatment option for complex bone infections with severe soft tissue lesions. However, even with this technique potential complication must be considered.     

带骨骺腓骨近段移植重建小儿尺骨远端骨骺2例

目的探讨吻合血管带骨骺腓骨近段移植重建小儿骨软骨瘤切除后尺骨远端骨骺、矫正腕关节畸形的临床效果。方法采用吻合血管带骨骺腓骨近段移植重建2例小儿骨软骨瘤切除后尺骨远端骨骺、矫正其腕关节畸形,并评价其临床效果。结果2例患儿的腕关节尺偏畸形得到矫正,术后2个月所有腓骨移植近段与受区骨端愈合良好．分别随访1年和6年,重建的尺骨远端与健侧肢体几乎同步生长,腕关节形态功能满意。结论吻合血管带骨骺腓骨近段移植能有效重建小儿骨软骨瘤切除后尺骨远端骨骺并长期矫正其腕关节尺偏畸形。     

Vascularized fibular graft for reconstruction after resection of aggressive benign and malignant bone tumors.

From 1982 to 1991, 19 patients at Nara Medical University, Kashihara, Japan, underwent resection of aggressive benign and malignant bone tumors, with limb salvage and reconstruction by free vascularized fibula grafts. The patients were followed up for an average of 54 months. The reconstructed site was the jaw in 6 cases, upper extremity in 3, spine in 1, pelvis in 2, and lower extremity in 7. Six patients had aggressive benign lesions, and 13 had malignant lesions. The sizes of the resultant bone defect ranged from 6 to 20 cm, and the lengths of fibular used ranged from 8 to 24 cm. The average time to union was 4.1 months (2-9 months) in the extremities and pelvis. Local recurrence was observed in 3 cases, for whom vascularized fibula grafts were performed for recurrent tumors. In cases of primary untreated tumors, no recurrences occurred. Therefore, this procedure should be performed at the time of primary operation after extensive resection of an aggressive benign or malignant bone tumor.     

带血管腓骨复合异体骨修复长骨肿瘤切除后骨缺损

目的 探讨带血管腓骨复合异体骨重建长骨恶性肿瘤切除后骨缺损的临床结果.方法 2006年4月至2009年10月对19例四肢长骨恶性骨肿瘤患者行保肢手术,男11例,女8例;年龄11～37岁,平均(18.5±7.6)岁.肱骨5例、股骨7例、胫骨7例.肿瘤切除后骨缺损长度(13.2±4.3)cm,采用带血管自体腓骨复合大段异体...     

应用带双皮岛的串式腓骨瓣游离移植修复前臂尺桡骨及皮肤联合缺损

目的 探讨带双皮岛的串式腓骨瓣游离移植修复前臂尺、桡骨及皮肤联合缺损的临床效果.方法自2005年6月至2009年7月,应用带双皮岛的串式腓骨瓣游离移植修复前臂尺、桡骨及皮肤联合缺损5例,修复尺骨的腓骨段长度4.5～7.5 cm,修复桡骨的腓骨段长度5.5～7.0 cm,皮瓣大小:5.0 cm×3.0 cm～8.0 cm×5.5 cm.术后12个月按Enneking评分系统测定患肢功能.结果 5例所应用的10块皮瓣全部成活,移植的腓骨段与尺、桡骨完全骨性愈合时间为4～6个月.术后随访时间14个月～2年,前臂旋转功能优2例、良2例、差1例,优良率为80%,按Enneking系统评分,平均为24.8分,平均恢复了肢体功能的81.3%.结论 带血供的骨移植,骨细胞保持活性,利于骨质愈合,同时,该术式可以一次手术完成前臂多部位、多组织缺损的修复,因此,应用带双皮岛的串式腓骨瓣游离移植修复前臂尺、桡骨及皮肤联合缺损,是一种比较理想的治疗方法.

Abstract：

Objective To investigate the outcome of the free double-skin paddle string-type composite fibular flap in the reconstruction of the combined defects of ulna and radium. Methods From June 2005 to July 2009, 5 cases with combined defects of ulna and radium were reconstructed using the free double-skin paddle string-type composite fibular flap. The length of fibular segment for the reconstruction of ulnar defect ranges from 4.5 to 7.5 cm. The length of fibular segment for the reconstruction of radial defect ranges from 5.5 to 7.0 cm. The size of the flap varies from 5.0 cm × 3.0 cm to 8.0 cm × 5.5 cm. At the 12 month follow-up, the function of reconstructed forearm was evaluated based upon Enneking scoring system.Results Ten flaps in the 5 cases all survived. The time for the transplanted fibula healed on the radium and ulna was 4-6 months. The 5 patients were followed up from 14 months to 2 years. The forearm rotation functions were excellent in 2 cases, good in 2 cases and poor in 1 case. The eligible rate was 80%. The average Enneking score was 24.8, which indicated an average of 81.3% recovery of limb function. Conclusion Bone graft with blood supply can ensure the activity of osteocytes, which facilitates the fracture union.Whilst, the procedure can reconstruct multi-location and multi-tissue defects in the forearm. Therefore, the double-skin paddle string-type composite fibular flap is an ideal alternative for the reconstruction of the combined defects of ulna and radium and the skin.     

Peroneal artery perforator chimeric flap for reconstruction of composite defects in extremities

Large bone defects of extremities, especially those associated with soft tissue defects, represent difficult reconstructive problems. Chimeric flap is a suitable option for reconstruction of complex bone and soft‐tissue defects. In this report, we present the experience on use of the peroneal artery perforator chimeric flap for the reconstruction of complex bone and soft tissue defects in the extremities in 16 patients. The bone defects were located in the tibia in 8 patients, in both tibia and fibula in 1 patient, in the ulna in 2 patients, in both ulna and radius in 2 patients, and the metatarsal bone in 3 patients. The flap was created with skin paddle and fibula bone segments based on independent perforators. The sizes of flap ranged from 8 × 6 to 20 × 11 cm², and the length of fibular grafts ranged from 6 to 22 cm. All flaps survived completely. Bone union was ultimately obtained in all cases at 5 to 11 months, while two cases suffered from stress fractures in 12 month and 18 month after operation, respectively, which eventually healed with external fixation treatment. The follow‐up time ranged from 12 to 37 months. The definite bone hypertrophy was observed from X‐ray at 18 months after operation. In conclusion, our results show that the peroneal artery perforator chimeric flap is a good option for reconstruction of complex bone and soft‐tissue defects of extremities, particularly for those with three‐dimensional defects and bone defects exceeding 6 cm in length. © 2010 Wiley‐Liss, Inc. Microsurgery, 2010.     

Vascularized fibula transfer for lower limb reconstruction

Massive bony defects of the lower extremity are usually the result of high-energy trauma, tumor resection, or severe sepsis. Vascularized fibular grafts are useful in the reconstruction of large skeletal defects, especially in cases of scarred and avascular recipient sites, or in patients with combined bone and soft-tissue defects. Microvascular free fibula transfer is considered the most suitable autograft for reconstruction of the middle tibia because of its long cylindrical straight shape, mechanical strength, predictable vascular pedicle, and hypertrophy potential. The ability to fold the free fibula into two segments or to combine it with massive allografts is a useful technique for reconstruction of massive bone defects of the femur or proximal tibia. It can also be transferred with skin, fascia, or muscle as a composite flap. Proximal epiphyseal fibula transfer has the potential for longitudinal growth and can be used in the hip joint remodeling procedures. Complications can be minimized by careful preoperative planning of the procedure, meticulous intraoperative microsurgical techniques, and strict postoperative rehabilitation protocols. This literature review highlights the different surgical techniques, indications, results, factors influencing the outcome, and major complications of free vascularized fibular graft for management of skeletal or composite defects of the lower limb.     

腓骨骨皮瓣移植修复肢体复合组织缺损

目的总结腓骨骨皮瓣移植修复肢体外伤性复合组织缺损的临床修复效果。方法依照患者肢体复合组织缺失情况及全身状况,采用腓骨骨皮瓣移植进行修复,其中男9例,女3例。年龄12～45岁。胫骨缺损伴腓骨骨折2例,单纯胫骨缺损2例,桡骨缺损2例,尺骨缺损3例,跟骨缺损1例,第1跖骨缺损2例;骨缺损长度4.2～10.6cm,平均7.8cm;皮肤缺损10.0cm×4.5cm～27.0cm×15.0cm。合并胫前和(或)胫后动脉损伤2例,胫后神经损伤2例,腓总神经损伤1例。一期修复4例,延期修复8例。骨皮瓣游离移植手术9例,推移手术2例,逆行移位手术1例。4例于术后3～6个月行二期肌腱移位动力重建术。行腕、踝关节融合术各1例。结果术后出现静脉危象及腓总神经牵拉性损伤各1例,经探查、大隐静脉移植等对症治疗,12例骨皮瓣全部成活。术后随访6～24个月,移植腓骨与受区断端均达骨性愈合,肢体功能均得到良好恢复。供区未出现膝及踝关节运动障碍。结论采用急诊或延期的腓骨骨皮瓣移植手术,可较好地修复肢体长管状骨干和软组织复合组织缺损。应注意受区移植腓骨皮瓣术后的感觉功能重建。     

Vascularized fibula transplantation in orthopedic oncology. Personal experience and review of the literature

Primary malignant bone tumors can be treated predominantly with limb salvage. After resection of large articular segments adjacent to the dia- or metaphysis of long bones modular endoprosthetic devices are most commonly used for reconstruction. In case non-vascularized corticocancellous bone is transplanted in order to bridge extensive bone defects, the risk of pseudarthrosis and fracture of the donor bone is significantly higher in comparison to a free vascularized transplant. From 1988 until 1999 we treated 20 patients with extensive bone defects after resection of tumors affecting the upper and lower extremity using a vascularized fibular graft. In this retrospective analysis we collected the data focusing on bone integration and functional outcome. The graft union was classified according to the standards of the "International Symposium of Limb Salvage". Evaluation of the functional outcome was quantified using the Enneking-score. The stabilisation of the transplant was obtained exclusively by plate fixation in the upper extremity. In 10 in a total of 12 patients the reconstruction using a vascularized fibula transfer was reinforced with an allograft in the lower extremity. The functional evaluation score reached 73% of normal function at the last follow-up. After 18 months the radiographic evaluation of graft union was "excellent" in 75%, "good" in 11%, "fair" in 6% and "poor" in 9% according to the criteria of the ISOLS. Main complications were graft fracture in of 15% and pseudarthrosis in 14.3%. Reconstruction of extensive bone defects using free vascularized fibula grafts are a demanding operative procedure. The procedure combines a biologic form of reconstruction with a legitimate expectation of good long term outcome and a relatively low rate of complications.     

Vascularized fibular graft for management of severe osteomyelitis of the upper extremity

The authors analyzed 14 patients with severe osteomyelitis of the upper extremity between 1985 and 1992, managed with the vascularized fibular graft. Eleven radii, two humeri and one ulna were reconstructed. Bone loss after resection ranged from 6 to 12 cm (mean 8.14 cm). Follow-up ranged from 8 months to 7 years and 10 months (mean 3 years and 3 months). The therapeutic applications of the vascularized fibular graft in severe bone infections of the upper extremity were discussed and the good results of this surgical procedure established it as a good option for treatment. Morbidity at the donor site was minimal. © 1994 Wiley-Liss, Inc.     

吻合血管腓骨移植的新术式

目的 探索扩大吻合血管腓骨移植修复骨缺损的应用范围。方法 应用吻合血管节段性腓骨移植修复骨肿瘤切除后骨缺损;吻合口管双节段腓骨或复合组织瓣移植－期修复尺,桡骨缺损;对于Ⅲ度胫骨粉碎性骨折,采用带血管或吻合血管腓骨移植,起到内夹板固定作用,并加速骨折的愈合。结果 所有被修复骨缺损均获良好愈合,其功能与外形均令人满意。结论 以上术式的开展,扩大了吻合血管腓骨移植的应用范围,为腓骨移植展示了良好的临床应