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.     

Reconstruction with distraction osteogenesis for juxta-articular nonunions with bone loss

BACKGROUND: Nonunions of a juxta-articular lesion with bone loss, which represent a challenging therapeutic problem, were treated using external fixation and distraction osteogenesis. METHODS: Seven juxta-articular nonunions (five septic and two aseptic) were treated. The location of the nonunion was the distal femur in four patients, the proximal tibia in one patient, and the distal tibia in two patients. All of them were located within 5 cm from the affected joints. Preoperative limb shortening was present in six cases, averaging 2.9 cm (range, 1-7 cm). The reconstructive procedure consisted of refreshment of the nonunion site, deformity correction, stabilization by external fixation, and lengthening to eliminate leg length discrepancy or to fill the defect. Shortening-distraction was applied to six patients and bone transport to one patient for reconstruction. Intramedullary nailing to reduce the duration of external fixation was simultaneously performed in two cases. All the patients had at least 1 year of follow-up evaluation. RESULTS: Osseous union without angular deformity or leg length discrepancy greater than 1 cm was achieved in all patients. The mean amount of lengthening was 5.8 cm (range, 2.2-10.0 cm). The mean external fixation period was 219 days (range, 98-317 days), and the mean external fixation index was 34.4 days/cm (range, 24.5-47.6 days/cm). All patients reported excellent pain reduction. There were no recurrences of infection in five patients with prior history of osteomyelitis. The functional results were categorized as excellent in two, good in three, and fair in two. CONCLUSION: Despite the length of postoperative external fixation, distraction osteogenesis can be a valuable alternative for the treatment of juxta-articular nonunions.     

Reconstruction of posttraumatic bone defects of the humerus with vascularized fibular graft

Humeral nonunions still present a challenge to the orthopedic surgeon. Many methods of treating recalcitrant, posttraumatic humeral shaft nonunions have been described, with varying degrees of success. The present report reviews our experience with the use of vascularized fibular grafting for the treatment of large humeral defects. We treated 13 patients, with an average length of the humeral defect of 10.5 cm. Nine patients healed primarily, 3 required additional bone grafting, and 1 had a second fibular transplant. The mean period to radiographic bone union was 6 months. Only 5 patients regained full range of motion of the shoulder and elbow. The vascularized fibular graft is a reliable reconstructive procedure for recalcitrant pseudoarthrosis of the humerus in which the bony gap is greater than 6 to 7 cm, especially when traditional procedures have not provided the expected result.     

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。     

Reconstruction with a free vascularized fibular graft for malignant bone tumor

Seven patients with a bone tumor were operated on with local excision and a free vascularized fibular graft. Four of the patients received both chemotherapy and radiotherapy. The blood flow in the grafts was evaluated by scintigraphy within 1 week after the operation. The median follow-up time was 4 (1-5) years. All but one graft-host junction healed primarily. There were 5 graft fractures in 3 patients. Four of the fractures occurred in 2 patients who received preoperative and postoperative chemotherapy and radiotherapy. Three of these fractures healed without surgery. Resorption of the grafts was never seen, whereas hypertrophy was observed in 6 patients. None of the patients had any permanent morbidity at the donor site. One patient had tumor recurrence and died after 2 years. Our findings indicate that a vascularized bone graft is also a useful alternative for reconstruction of large bone defects in patients receiving both chemotherapy and radiotherapy.     

Reconstruction with a free vascularized fibular graft for malignant bone tumor

Seven patients with a bone tumor were operated on with local excision and a free vascularized fibular graft. Four of the patients received both chemotherapy and radiotherapy. The blood flow in the grafts was evaluated by scintigraphy within 1 week after the operation. The median follow-up time was 4 (1-5) years.

All but one graft-host junction healed primarily. There were 5 graft fractures in 3 patients. Four of the fractures occurred in 2 patients who received preoperative and postoperative chemotherapy and radiotherapy. Three of these fractures healed without surgery. Resorption of the grafts was never seen, whereas hypertrophy was observed in 6 patients. None of the patients had any permanent morbidity at the donor site. One patient had tumor recurrence and died after 2 years.

Our findings indicate that a vascularized bone graft is also a useful alternative for reconstruction of large bone defects in patients receiving both chemotherapy and radiotherapy.     

应用携带监测皮岛的腓骨移植重建股骨上段肿瘤术后骨缺损

目的报道应用携带监测皮岛的腓骨移植修复股骨上段骨肿瘤术后骨缺损的临床效果。方法对于7例股骨上段肿瘤切除术后的骨缺损采用携带监测皮岛的腓骨进行移植。根据骨缺损长度,设计带监测皮岛(3cm×5cm)的腓骨,切除腓骨长度比骨缺损长度多4cm,上下各2cm插入股骨髓腔后用滑动鹅头钢板(DHS)桥接固定腓骨。结果全部病例获得随访12—24个月,无复发。术后功能恢复良好,腓骨和受区骨均呈骨性愈合。结论采用带监测皮岛的腓骨移植复合DHS固定是治疗股骨上段骨肿瘤术后骨缺损的有效方法。     

Reconstruction of skeletal defects in the femur with 'two-strut' free vascularized fibular grafts.

Large skeletal defects of the femur caused by infected nonunions remain a challenge to orthopedic surgeons. Conventional bone grafting may not succeed when the recipient bed is not ideal. Single fibular grafts were proven very useful in bridging this type of defect, yet were complicated by the high incidence of refracture and the need for protection of long duration. By dividing the fibula into two struts connected by the nutrient vessels, we doubled the effective cross-sectional area of bone grafting with only one set of vascular anastomoses. Five cases of infected nonunion of the femur after a high-energy trauma were successfully managed with this technique. All the fractures healed in an average of 7 months. By 1 year the grafts hypertrophied to the size of the femur. A follow-up of at least 2 years recommends this technique in the management of certain chronic osseous defects of the femur.     

Reconstruction of defects following bone tumor resections by distraction osteogenesis

Introduction The authors present the results of nine patients (two females, seven males) who had bone tumors that were treated with en bloc resection and distraction osteogenesis between 1991–2000.Materials and methods The average age of the patients was 19.3 years (14–42 years). The histological diagnosis was osteosarcoma in four cases, Ewings sarcoma in two, giant cell tumor in one, osteofibrous dysplasia in one and osteoblastoma in one. A uniplanar external fixator was applied to one case and circular external fixator to the other eight cases.Results The average follow-up period was 59.1 months (27–129 months). The external fixator was removed at an average of 18.1 months (range, 4–19 months). The average bone defect after resection was 14 cm (8–24 cm) and the average external fixation index, distraction index, and maturation index were 31.5 (18.7–40.0), 11.2 (10.9–11.2) and 17.8 (7.5–32.7), respectively. The function of the affected leg was excellent in four patients, good in three, fair in one and poor in one according to the Enneking scoring system. We did not observe any early consolidation or osseous binding in the defect area in any patient. Frequent complications were pin tract infection and non-union at the docking site.Conclusion Our results indicate that the Ilizarov method allows effective restoration of bone defects in the treatment of bone tumors despite various disadvantages.This revised version was published online in April 2005 with corrections to the order of the figures.     

Reconstruction of large skeletal defects due to osteomyelitis with the vascularized fibular graft in children

BACKGROUND: Reconstruction of large skeletal defects secondary to osteomyelitis is a challenging problem. The purpose of this study was to evaluate the outcome of the use of a vascularized fibular graft to treat such defects in children. METHODS: Eight patients with a mean age of seven years and a skeletal defect with a mean length of 11.8 cm (range, 6 to 17 cm) were treated with a vascularized fibular graft. A staged protocol was used for the five patients with an active infection at the time of presentation. The first procedure consisted of radical débridement, and at the second stage a free (seven patients) or pedicled (one patient) vascularized fibular graft was used. The mean follow-up time was 5.7 years. RESULTS: Union of the graft occurred primarily in seven of the eight patients, at a mean of 3.5 months, and after iliac crest bone-grafting in the remaining patient. There was no recurrence of deep infection. Complications developed in two patients. The mean time to full weight-bearing by the seven patients with a lower-extremity reconstruction was 8.4 months, and all patients were pain-free and able to walk without supportive devices. CONCLUSIONS: A vascularized fibular graft is a viable option for the management of large skeletal defects resulting from osteomyelitis in children.     

Reconstruction of large posttraumatic skeletal defects of the forearm by vascularized free fibular graft

Vascularized bone graft is most commonly applied for reconstruction of the lower extremity; indications for its use in the reconstruction of the upper extremity have expanded in recent years. Between 1993-2000, 12 patients with segmental bone defects following forearm trauma were managed with vascularized fibular grafts: 6 males and 6 females, aged 39 years on average (range, 16-65 years). The reconstructed site was the radius in 8 patients and the ulna in 4. The length of bone defect ranged from 6-13 cm. In 4 cases, the fibular graft was harvested and used as a vascularized fibula osteoseptocutaneous flap. To achieve fixation of the grafted fibula, plates were used in 10 cases, and screws and Kirschner wires in 2. In the latter 2 cases, an external skeletal fixator was applied to ensure immobilization of the extremity. The follow-up period ranged from 10-93 months. Eleven grafts were successful. The mean period to obtain radiographic bone union was 4.8 months (range, 2.5-8 months). Fibular grafts allow the use of a segment of diaphyseal bone which is structurally similar to the radius and ulna and of sufficient length to reconstruct most skeletal defects of the forearm. The vascularized fibular graft is indicated in patients with intractable nonunions where conventional bone grafting has failed or large bone defects, exceeding 6 cm, are observed in the radius or ulna.     

锁定钢板结合游离腓骨移植治疗下肢长骨大段骨缺损的临床研究

目的 应用锁定钢板结合游离腓骨移植治疗下肢长骨大段骨缺损,并观察其疗效.方法 自2005年1月至2007年5月应用锁定钢板内固定结合游离腓骨移植治疗下肢长骨大段骨缺损10例,其中股骨2例,胫骨8例,病程6～96个月,平均27.9个月.结果 全部患者随访4～30个月,平均14.4个月;骨折均在4～6个月内牢固连接,平均愈合时间为4.5个月,无内固定松动及骨不连等并发症.结论 锁定钢板结合游离腓骨移植是治疗下肢长骨大段骨缺损的一种十分有效的方法.     

Osteosynthesis of infected and impaired growth of the femur with vascularized fibular graft]

The authors present the causes of difficulties arising during treatment of infected non-unions. Much attention was paid to the unique character of the infection in the thigh and the technical problems related to it. The role of vascularized bone grafts was emphasised. Different possibilities of surgical treatment of bone loss in different localisations were presented basing on clinical material of 7 patients. The authors used various osteosynthesis techniques, most frequently external fixators. Graft healing anf remodelling with different kind of fixators is discussed. The frequency of graft fractures was stressed. The differences in the healing of graft fractures and normal fractures was discussed. The need of suitable elasticity of the external fixator for the correct healing of the transplant and its remodelling was emphasised.     

Reconstruction of a large tibial defect with a free vascularized fibular graft

A successful reconstruction of a large tibial defect with a free vascularized fibular graft is presented. The fibular graft demonstrated a significant hypertrophy 2 years postoperatively.     

Reconstruction of a large tibial defect with a free vascularized fibular graft

Summary A successful reconstruction of a large tibial defect with a free vascularized fibular graft is presented. The fibular graft demonstrated a significant hypertrophy 2 years postoperatively.

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Zusammenfassung Die erfolgreiche Rekonstruktion eines ausgedehnten Tibiadefektes mit einem freien, vaskularisierten Fibulaspan wird vorgestellt. Der Fibulaspan zeigte 2 Jahre nach der Operation eine eindeutige Hypertrophie.

     

Vertical distraction osteogenesis of fibular bone flap in reconstructed mandible

Excellent functional and aesthetic results can be achieved in mandibular reconstructions with using free fibular bone flap. However, the vertical deficiency between the reconstructed segment and the occlusal plane made dental rehabilitation impossible in some cases. We encountered this problem in our 3 patients who had mandibular reconstruction with fibular flap due to extensive bone defect result from gunshot injury. To overcome this segmental vertical distraction of the reconstructed mandible was performed. Fibular bone segments (40-70 mm) were distracted with using extraoral distraction device after a latency period of 5-7 days. The rate of distraction was 1 mm/day, and the rhythm was 4 times (4 x 0.25 mm). Distraction was continued until the desired height was achieved, and the distractor left in place for 12 weeks for bony consolidation. No minor or major complications were encountered. The increase of vertical height was between 9 and 13 mm, and it was stable during the follow-up period (7-22 months). Following the vertical distraction and vestibuloplasty operations, the dental restoration of the patients was performed with mandibular removable partial dentures.