Vascularised fibula osteocutaneous flap for cervical spinal and posterior pharyngeal wall reconstruction

We report a case of vascularised fibula osteocutaneous flap used for composite cervical spinal and posterior pharyngeal wall reconstruction, in a patient with recurrent skull base chordoma, resected by an anterior approach via median labio-mandibular glossotomy approach. Bone stability and pharyngeal wall integrity were simultaneously restored     

Fibular flap reconstruction of the cervical spine for repair of osteoradionecrosis

Background contextAlthough cervical spine reconstruction with osteocutaneous fibular flap microvascular grafting has been described, simultaneous reconstruction of the cervical vertebral column and laryngectomy have not been described.PurposeTo present a unique case of combined cervical spine and laryngectomy reconstruction.Study designCase report.MethodsWe modified a previously reported procedure reconstituting the cervical spine and pharynx with a single fibular flap in a case of posterior pharyngeal ulceration and osteomyelitis/osteoradionecrosis without spinal deformity.ResultsWe present a case of simultaneous cervical stabilization and pharynx reconstruction with a fibular graft in a life-saving treatment of osteoradionecrosis complicated by acute cervical kyphosis and spinal cord compression in a 55-year-old patient with extensive head and neck cancer history and recent recurrence of hypopharyngeal cancer.ConclusionsRigid anterior plate fixation and subsequent posterior fixation were required after corpectomy and total laryngectomy in our patient with extensive surgical scarring and radiation history because of severe spinal deformity secondary to osteoradionecrosis. We achieved successful preservation of neurologic function and resolution of pain.     

Treatment of tibial defect with vascularized osteocutaneous pedicled transfer of fibula

Free osteocutaneous fibular flap transfer has been used for long bone and soft tissue defects in both the lower and upper extremity. Since July, 1984, two cases of tibial defect, with severe scar formation on the anteromedial aspect, have been treated. An ipsilateral, vascularized, osteocutaneous, pedicled flap of the fibula was used to bridge the bony defect and to resurface the wound, after scar excision and bony debridement. The peroneal vessels were severed, leaving one side intact. The entire fibular flap was shifted anteromedially through a tunnel between the anterior and posterior tibialis. In addition to screw fixation of both ends of the transfer, an external fixator was used for three months. This technique has the advantages of obviating the need for vessel anastomoses and of completing the whole procedure on a single leg.     

Donor side selection in mandibular reconstruction using a free fibular osteocutaneous flap

While the free fibular osteocutaneous flap is indispensable for mandibular reconstruction, reliable setting is often difficult because relative positions of the bone, skin island, and vascular pedicle are critical. We have an algorithm for donor-side selection of free fibular osteocutaneous flap.From July 2002 to March 2004, we performed 15 mandibular reconstructions using free fibular osteocutaneous flaps. We retrospectively classified these procedures as follows. In type I (flap harvested ipsilaterally to defect, n = 5), the skin island was fixed to the oral cavity, and the vascular pedicle emerged from the anterior aspect of the fibula. In type II (flap contralateral to defect, n = 5), the skin island was fixed to the oral cavity, and the vascular pedicle arose from the posterior aspect. In type III (flap contralateral to defect, n = 4), the skin island was fixed to the facial skin and the vascular pedicle arose from the anterior aspect. In type IV (flap ipsilateral to defect, n = 1), the skin island was fixed to the facial skin and the vascular pedicle arose from the posterior aspect. Flaps took completely except in 1 group II case with partial necrosis. Close attention to geometric characteristics of a free fibular osteocutaneous flap facilitates reconstruction of mandibular defects and selection of donor side.     

带监测皮岛游离腓骨复合组织瓣移植修复胫骨中上段Gustilo Ⅲ B和Ⅲ C型骨折

目的探讨小腿高能量损伤后应用移植带监测皮岛游离腓骨复合组织瓣早期修复胫骨中上段GustiloⅢB型和ⅢC型骨折的临床疗效。方法总结温州手足外科医院2004年12月至2010年6月采用带监测皮岛游离腓骨复合组织瓣联合外固定支架早期治疗胫骨中上段GustiloⅢB型和ⅢC开放性骨折10例,胫骨缺损长度4.1～6.5cm,软组织缺损面积3.2cm×5.2cm～5.1cm×8.3cm,单纯胫前血管损伤伴缺损4例,胫前与胫后血管同时损伤2例。损伤后行游离腓骨复合组织瓣移植中位时间8(7～11)d,复合组织瓣与受区血管直接吻合4例,腓动静脉桥接胫前动静脉6例。结果 10例中位随访时间15(12～24)个月,创面Ⅰ期愈合7例,Ⅱ期愈合2例;伤口不愈合并有死骨形成,经死骨摘除清创后愈合1例。中位住院时间29(25～42)d,X线摄片示术后18(12～24)周移植腓骨与胫骨骨愈合,患肢开始部分负重时间为术后12～24周,完全负重时间为48～72周。Enneking系统肢体功能评定结果:优4例、良3例、可2例、差1例。结论小腿高能量损伤后应用带监测皮岛的游离腓骨复合组织瓣早期修复胫骨中上段GustiloⅢB与ⅢC型骨折骨缺损可Ⅰ期完成带血运的骨移植及修复皮肤和软组织缺损,减少手术次数,早期封闭创面,促进骨折愈合,减少胫骨骨髓炎发生,有助于尽早恢复患者下肢功能。     

Fibula osteo‐adipofascial flap for reconstruction of a cervical spine and posterior pharyngeal wall defect

When reconstructing combined defects of the cervical spine and the posterior pharyngeal wall the goals are bone stability along with continuity of the aerodigestive tract. We present a case of a patient with a cervical spine defect, including C1 to C3, associated with a posterior pharyngeal wall defect after excision of a chordoma and postoperative radiotherapy. The situation was successfully solved with a free fibula osteo‐adipofascial flap. The reconstruction with a fibula osteo‐adipofascial flap provided several benefits in comparison with a fibula osteo‐cutaneous flap in our case, including an easier insetting of the soft tissue component at the pharyngeal level and less bulkiness of the flap allowing our patient to resume normal deglutition. © 2013 Wiley Periodicals, Inc. Microsurgery 34:314–318, 2014.     

Pharyngocutaneous fistula after anterior cervical spine surgery

Pharyngocutaneous fistulae are rare complications of anterior spine surgery occurring in less than 0.1% of all anterior surgery cases. We report a case of a 19 year old female who sustained a C6 burst fracture with complete quadriplegia. She was treated urgently with a C6 corpectomy with anterior cage and plating followed by posterior cervical stabilization at another institution. Post operatively she developed a pharyngocutaneous fistula that failed to heal despite several attempts of closure and esophageal exclusion with a Jpeg tube. The patient was eventually successfully treated with a three-stage procedure consisting of firstly a posterior approach to reinforce the posterior stabilization of the cervical spine that was felt to be inadequate, secondly an anterior approach with removal of all the anterior instrumentation followed by iliac crest bone graft and thirdly a superior based sternocleidomastoid flap that was interposed between the esophagus and the anterior cervical spine. The patient's fistula healed successfully. However, yet asymptomatic, the anterior iliac crest bone graft resorbed almost completely at 16 months follow up. In light of this complication, we discuss the surgical options for the treatment of pharyngocutaneous fistulae and the closure of this fistula using a superiorly based sternocleidomastoid muscle flap.     

Adopting 540-degree fusion to correct cervical kyphosis

BACKGROUND: Two cases of severe cervical spine kyphotic deformity resulting from late effects of infection were successfully corrected by combined anterior and posterior instrumentations in a single operative sitting. CASE DESCRIPTION: Case 1 is a 43-year-old man who developed severe cervical kyphosis from C5-6 discitis over a few months despite long-term antibiotic therapy. He was neurologically intact except for severe neck pain and obvious deformity. Case 2 is a 40-year-old woman who had a previous wound infection five years before presentation. There was gradual worsening of swan neck deformity at the C2-3 and C5-6 levels with some spinal cord compression worsening her baseline myelopathy. The patients were placed and maintained in cervical traction on the Stryker frame for the duration of the procedure. Both cases required anterior approach initially to achieve some release of dense scar tissue using a high-speed drill. The wounds were then closed and patients were rotated to the prone position for further release of fused bony elements, including the facets. Lateral mass screws and plates were placed. In Case 2, additional instrument to the occipital was performed to stabilize the C2 using a U-shaped cervical rod. Once adequate reduction had been achieved, the patients were rotated back to supine position for further corpectomy and fibular construct fusion with plates. CONCLUSION: In cases of severe kyphotic deformity complicating infectious vertebral destruction, the spinal alignment can be achieved safely by a multi-step technique combining the anterior as well as posterior surgical approaches.     

Combined free fibular osteocutaneous-lateral calcaneal fasciocutaneous flap for reconstruction of composite oromandibular defects

The free fibular osteocutaneous flap is often used in the reconstruction of composite oromandibular defects. In contrast, the lateral calcaneal flap has never been used in oromandibular reconstruction. On the basis of their anatomic continuity, the authors combined the free fibular osteocutaneous flap with the lateral calcaneal skin paddle to obtain 2 adjoining flaps in different anatomic areas with the same vascular axis. The authors report their experience in 3 patients with composite oromandibular defects. In 1 patient without an outer skin defect, only a sensory lateral calcaneal skin paddle with a fibular osseus flap was harvested. The lateral calcaneal flap carried the sural nerve as a sensory flap in 2 patients, and the result was passable. Only 1 patient encountered superficial flap tip necrosis at the lateral calcaneal skin paddle, and recovered well after wound care. In conclusion, a flap with many specific features is a feasible choice for reconstruction of composite oromandibular defects.     

游离腓骨(皮)瓣移植修复上肢长段骨缺损

目的 探讨游离腓骨(皮)瓣移植修复上肢长段骨缺损的临床应用及效果.方法 自2000年6月至2010年12月,应用游离腓骨骨瓣修复上肢长段骨缺损12例,其中携带皮瓣4例.男11例,女1例;年龄19～ 55岁,平均35岁.修复肱骨缺损2例,尺骨缺损6例,桡骨缺损4例.腓骨瓣切取范围1.5 cm× 2.0 cm～ 12.0 cm× 16.0 cm,腓骨移植长度6.0～ 20.0 cm.结果 12例均成功并获得随访,随访时间平均2年5个月.4例携带皮瓣全部存活;创面Ⅰ期愈合11例,Ⅱ期愈合1例,愈合时间12～18 d;腓骨移植骨愈合时间3～6个月,平均4个月.应用Enneking上肢功能标准评分为22～29分,平均27分;供区无功能障碍.结论 游离腓骨(皮)瓣移植修复上肢长段骨缺损可一期完成骨缺损修复,且可同时解决软组织缺损.虽难度大、风险高,但仍是一种很理想的治疗方法.     

Reconstruction of a Complex Foot Injury With Free Remodeled Fibular Osteocutaneous Flap: A Case Report and Literature Review

Management of complex foot injuries, which involve open fractures and severe trauma to soft tissues, represent a challenge to orthopedic clinicians. In the present case report, we treated a complex foot injury with a remodeled fibular osteocutaneous free flap to reconstruct the anterior and lateral areas of the foot. The flap survived completely. At the 9-month follow-up examination, bony union of the graft bone was identified by radiographic examination. The reconstructed foot could bear body weight, and the patient could maintain a bipedal gait without discomfort. The remodeled fibular osteocutaneous free flap provides an option for functional reconstruction of foot defects.     

Multiple revisions of a L2 burst fracture in a suicide jumper: a retrospective analysis of what went wrong

A 35-year-old female patient sustained three contiguous vertebral fractures at the thoracolumbar junction while jumping off the third floor in a suicide attempt. Initial fracture treatment occurred in the setting of a multiple injury scenario. While the Th12 and the L1 vertebral fractures were considered stable, the L2 fracture exhibited a complete burst configuration with 80% canal compromise due to a posterior wall fragment causing paraplegia. A posterior pedicle screw stabilisation with indirect fracture reduction was carried out initially from T12 to L3. At 1 year follow-up the patient presented to us for new onset radiculopathy L2, and loss of correction. A circumferential revision surgery with an expandable cage was carried out to restore the anterior and posterior columns. Unfortunately again loss of reduction with kyphosis occurred, this time at the upper instrumented vertebra, which made another revision necessary. In this situation a longer construct was chosen using a combined approach and a Mesh cage. This later procedure was complicated by a postoperative paraparesis believed to be vascular in origin. Six months later a further complication involving MSSA deep wound infection required a series of irrigation debridement for healing. At the 2.5 years follow up the spine was stable and the patient had a neurologic recovery allowing her to ambulate with crutches. This Grand Round Case raises the question on the initial management of multiply injured patients with spine fracture, the classification of these fractures, the optimal initial internal fixation, the need for complementary anterior column reconstruction and the strategy when all these fails. A comment on this article Grand Rounds is available at doi:.     

Repair of cervical esophageal perforation using longus colli muscle flap: a case report of a patient with cervical spinal cord injury

BACKGROUND CONTEXT: Perforation of the esophagus after anterior cervical spine surgery is a rare, but well-recognized complication. The management of esophageal perforation is controversial, and either nonoperative or operative treatment can be selected. PURPOSE: Several reports have described the use of a sternocleidomastoid muscle flap for esophageal repair. In this case report, we describe a longus colli muscle flap as a substitute for a sternocleidomastoid flap in a patient with an esophageal perforation. STUDY DESIGN: Case report. PATIENT SAMPLE: A 20-year-old man sustained cervical spinal cord injury, on diving and hitting his head against the bottom of a pool. A C6 burst fracture was observed with posterior displacement of a bone fragment into the spinal canal. The patient exhibited complete paralysis below the C8 spinal segment level. METHODS: The patient underwent subtotal corpectomy of the sixth cervical vertebra with the iliac bone graft and augmented posterior spinal fixation (C5-7) with pedicle screws. After the primary operation, the patient showed signs of infection such as throat pain, a high fever, and osteolytic change of the grafted bone by cervical radiograph. A second operation was performed to replace the graft bone using fibula. On the day after the operation, food residue was confirmed in the suction drainage tube, suggesting esophagus perforation. A third operation was immediately performed to confirm and treat esophagus perforation, although apparent esophageal perforation could not be detected at the second operation. Because the erosion around the perforation of the esophageal posterior wall was extensive, a longus colli muscle flap transposition was accordingly performed into the interspace between the esophageal posterior wall and the grafted bone in addition to simple suturing of the perforation. RESULTS: Neither high fever nor pharyngeal pain has recurred at latest follow-up, 5 years after surgery. CONCLUSIONS: To the best of our knowledge, this is the first report concerning the use of a longus colli muscle flap for esophageal perforation after anterior cervical spine surgery.     

Reconstruction of the middle and lower face with three simultaneous free flaps: combined use of bilateral fibular flaps for maxillomandibular reconstruction

A 23-year-old man sustained massive maxillofacial destruction from a close-range, high-velocity gunshot injury. The devastating nature of the injury led to extensive soft-tissue and bone loss involving nearly the total middle and lower portions of his face, including the deeper anatomic structures. Reconstruction of this extraordinarily extensive and three-dimensional defect was accomplished by simultaneous transfer of three free flaps during one session. A specially designed radial forearm flap replaced the internal lining and external cover of the nose, a large fibular osteocutaneous flap restored the lower face, and a second fibular osteocutaneous flap harvested from the other leg restored the midface. The second fibular flap was revascularized by combining it with the first one in a flow-through manner, and its pedicle vessels were anastomosed to the distal ends of the vessels of the first flap. Dorsal nasal reconstruction with an expanded paramedian forehead flap, commissurotomy, and intraoral flap debulking were additional procedures performed to improve cosmetic and functional outcome during the following 1-year period. Along with a radial forearm flap, combined use of bilateral osteocutaneous fibular flaps provided simultaneous, single-stage reconstruction of a huge facial defect involving both the lower and middle face with an acceptable result.     

Calcaneal reconstruction with free fibular osteocutaneous flap

Due to the role of the calcaneus in weight bearing, soft tissue coverage along with proper reduction of the fracture is the treatment following open calcaneal injury. Intra-articular calcaneal fractures present a very difficult management problem, as the lack of soft tissue and the intricate vascularity in this area pose a risk of complications. Coverage with local and free muscle flaps following excision of infected structures is a common approach for the treatment of chronic osteomyelitis. However, it is unknown which type of flap is optimal for the treatment of lateral foot wounds, especially when complicated by calcaneal osteomyelitis. A patient presented with an open wound over the lateral aspect of the heel with exposed hardware and chronic osteomyelitis of the calcaneus. Following multiple debridements, an ipsilateral osteocutaneous free fibular flap was transferred to the bony defect. Weight bearing was initiated at 2 months postoperatively, and he now ambulates with a normal gait, has normal plantar sensation, and has no difficulty maneuvering stairs. The patient has done well postoperatively and has recovered full range of motion and complete mobility. In this case report, an osteocutaneous free flap provided an excellent outcome for an active patient with a very complex and complicated condition.     

血管化游离腓骨肌皮瓣重建下颌骨缺损

目的：总结游离腓骨肌皮瓣修复下颌骨缺损的经验。方法：对25例应用游离腓骨肌皮瓣行下颌骨缺损修复的病例进行临床分析,探讨不同类型下颌骨缺损,所采用腓骨肌皮瓣的设计,复合组织瓣的成活情况及术后并发症的发生情况。结果：本组25例患者游离腓骨肌皮瓣成活率100%,最长的腓骨为16cm,分为三段者3例,两段者20例。结论：血管化的游离腓骨肌皮瓣修复下颌骨缺损血供丰富、抗感染力强、骨愈合快、塑形好、成活率高。     

急诊组织瓣移植(位)修复伴有严重血管损伤的上肢复杂性组织缺损

目的 介绍急诊组织瓣移植或移位一期修复伴有严重血管损伤的上肢复杂性组织缺损的手术疗效.方法 对10例伴有严重血管损伤的上肢复杂性组织缺损的患者,在修复血管重建肢体血运的同时,根据组织缺损需要采用皮瓣、肌皮瓣、骨皮瓣甚至组织瓣组合移植的方法急诊进行一期修复.其中上臂肱动、静脉长段缺损,合并肱二头肌及上臂内侧大面积皮肤缺损,血管修复后背阔肌皮瓣移位覆盖创面并重建屈肘功能3例;肘部血管损伤合并肘关节周围大面积皮肤撕脱缺损,血管修复后移植胸脐皮瓣覆盖创面2例;前臂尺、桡动脉损伤合并皮肤肌肉缺损,血管修复后移植股前外侧皮瓣覆盖创面3例;前臂尺桡动脉损伤并尺桡骨缺损,血管修复后移植腓骨皮瓣重建尺骨缺损,二期再移植腓骨皮瓣重建桡骨缺损1例;前臂尺、桡动脉损伤合并桡骨及大面积皮肤缺损,血管修复后股前外侧皮瓣加髂骨皮瓣组合移植1例.结果 术后10例患肢及移位组织瓣全部存活.术后随访3～6个月,3例上臂损伤患者,肘关节最大屈曲度为105,屈肘肌力为M_3～M_4地,手功能恢复基本正常;肘及前臂损伤的7例患者,肢体及移植皮瓣完全存活,骨皮瓣和腕部已达骨性愈合,并恢复部分手功能.结论 对严重血管损伤且合并有复杂组织缺损的上肢损伤,急诊在施行血管修复重建肢体血运的同时,采用组织瓣单独或组合移植一期有效覆盖创面,可提高复杂性患肢的成活率,并为二期功能重建术提供良好的软组织条件.     

Free vascularized osteocutaneous fibular graft to the tibia

We reviewed the clinical results of reconstruction performed for extensive tibial bone and soft tissue defect with a free vascularized osteocutaneous fibular graft in 46 patients (43 male and 3 female). The mean duration of follow-up was 30 months (range 13-76 months). The mean age at the time of reconstruction was 41 years (range 15-66 years). In the 46 consecutive procedures of free vascularized osteocutaneous fibular grafts, bony union was achieved in 43 grafted fibulae at an average of 3.75 months after operation. There were two delayed unions and one non-union. Forty-four cutaneous flaps survived, and two cutaneous flaps failed due to deep infection and venous insufficiency. One necrotized cutaneous flap was replaced with a latissimus dorsi free flap and the other with a soleus muscle rotational flap without replacing the grafted fibulae; unions were obtained without significance complications. All grafted fibulae hypertrophied during the follow-up periods. The most common complication was fracture of the grafted fibulae in 15 patients, and it occurred at an average of 9.7 months after the reconstruction. The fractured fibulae were treated with long leg above-the-knee cast immobilization or internal fixation with conventional cancellous bone graft. Free vascularized osteocutaneous fibular graft is a good treatment modality for the reconstruction of extensive bone and soft tissue defect in the leg. Fracture of the grafted fibula, one of the most common complications after this operation, can easily be treated with cast immobilization or internal fixation with conventional cancellous bone graft.     

Total pharyngeal reconstruction using a pectoralis major myocutaneous tunnel

Total pharyngeal reconstruction was performed using a pectoralis major myocutaneous flap. In this technique, the posterior wall of the neopharynx consists only of the prevertebral tissue, while the flap forms the anterior and lateral walls. The posterior wall heals by reepithelialization of the prevertebral fascia. Clinical experience with seven patients has shown that this technique provides a wide conduit and is not prone to develop stenosis.