Free vascularized fibular grafts have a high union rate in atrophic nonunions

Medial Femoral Condyle Corticoperiosteal Flap for Failed Total Wrist Fusions

Background  Recalcitrant nonunion following total wrist arthrodesis is a rare but challenging problem. Most commonly, in the setting of failed fusion after multiple attempts of refixation and cancellous bone grafting, the underlying cause for the failure is invariably multifactorial and is often associated with a range of host issues in addition to poor local soft-tissue and bony vascularity. The vascularized medial femoral condyle corticoperiosteal (MFC-CP) flap has been shown to be a viable option in a variety of similar settings, which provides vascularity and rich osteogenic progenitor cells to a nonunion site, with relatively low morbidity. While its utility has been described for many other anatomical locations throughout the body, its use for the treatment of failed total wrist fusions has not been previously described in detail in the literature. Methods  In this article, we outline in detail the surgical technique for MFC-CP flap for the management of recalcitrant aseptic nonunions following failed total wrist arthrodesis. We discuss indications and contraindications, pearls and pitfalls, and potential complications of this technique. Results  Two illustrative cases are presented of patients with recalcitrant nonunions following multiple failed total wrist fusions. Conclusion  When all avenues have been exhausted, a free vascularized corticoperiosteal flap from the MFC is a sound alternative solution to achieve union, especially when biological healing has been compromised. We have been able to achieve good clinical outcomes and reliable fusion in this difficult patient population.

Multifactorial Analysis of Treatment of Long-Bone Nonunion with Vascularized and Nonvascularized Bone Grafts

Introduction  The purpose of the study was to evaluate the results of treatment of the nonunion of long bones using nonvascularized iliac crest grafts (ICGs) or vascularized bone grafts (VBGs), such as medial femoral condyle corticoperiosteal flaps (MFCFs) and fibula flaps (FFs). Although some studies have examined the results of these techniques, there are no reports that compare these treatments and perform a multifactorial analysis. Methods  The study retrospectively examined 28 patients comprising 9 women and 19 men with an average age of 49.8 years (range: 16-72 years) who were treated for nonunion of long bones between April 2007 and November 2018. The patients were divided into two cohorts: group A had 17 patients treated with VBGs (9 patients treated with MFCF and 8 with FF), while group B had 11 patients treated with ICG. The following parameters were analyzed: radiographic patterns of nonunion, trauma energy, fracture exposure, associated fractures, previous surgeries, diabetes, smoking, age, and donor-site morbidity. Results  VBGs improved the healing rate (HR) by 9.42 times more than the nonvascularized grafts. Treatment with VBGs showed a 25% decrease in healing time. Diabetes increased the infection rate by 4.25 times. Upper limbs showed 70% lower infection rate. Smoking among VBG patients was associated with a 75% decrease in the HR, and diabetes was associated with an 80% decrease. Conclusion  This study reports the highest success rates in VBGs. The MFCFs seem to allow better clinical and radiological outcomes with less donor-site morbidity than FFs.

Non-vascularized fibular autograft for resistant humeral diaphyseal nonunion: Retrospective case series

INTRODUCTION

There is a great surgical challenge when humeral diaphyseal fractures are initially open, complex, or associated with segmental bone loss. The challenge becomes even greater with previous multiple unsuccessful surgeries. The question of this study was: Does combining locked compression plating with non-vascularized fibular autograft in cases of resistant humeral diaphyseal nonunion yield reliable bony union and satisfactory functional outcome?

HYPOTHESIS

The use of non-vascularized fibular autograft in conjunction with locked compression plating will provide stable construct, enhance bony union and improve functional outcome in cases of resistant humeral diaphyseal nonunion.

MATERIALS AND METHODS

Thirty-three patients with resistant humeral diaphyseal nonunion who were surgically managed combining non-vascularized fibular autograft fixed with locked compression plating in the period from January 2011 to June 2017, were retrospectively studied. All patients were followed-up for a minimum of 24 months. The time to union, the postoperative disability of arm, shoulder and hand (DASH) score, in addition to the possible complications including infection or nonunion were reported and analyzed.

RESULTS

Twenty-nine patients have achieved union at the final follow-up with a mean time to radiological union of 7.5±2.6 months (range: 3-12). The mean postoperative DASH score was 7.7±8.9 (range: 0-38.8) which was significantly better than the preoperative value (p<0.001) and superior in the patients of aseptic nonunion (p=0.04). Eight patients showed complications in the form of infection (four), nonunion (two cases), transient radial nerve palsy (one case) and one case of septic nonunion that was managed by two-stage reconstruction using vascularized fibular autograft. There were comparable results in patients with either open or closed fractures. However, patients with septic nonunion experienced more significant complications (p=0.02).

DISCUSSION

The use of non-vascularized fibula autograft in cases of resistant humeral diaphyseal nonunion provides adequate fracture stability, quadrilateral screw purchase, enhances bony union in addition to promoting satisfactory functional outcome particularly in aseptic nonunion.

LEVEL OF EVIDENCE

IV; retrospective case series.

Periosteal medial femoral condyle free flap for metacarpal nonunion

Background

Metacarpal nonunion is a rare condition. The osteogenic capacity of periosteal free flap was investigated in five patients with metacarpal nonunion and impaired bone vascularization.

Patients and methods

Surgery was performed between 64 and 499 days after the initial bone osteosynthesis. The average age was 27.6 (range 16–32) years. Nonunion was caused by excessive periosteal removal in two patients, extensive open trauma in three. Four nonunions were diaphyseal, one metaphyseal. A periosteal medial femoral condyle free flap was raised on the descending genicular artery for four patients, the superomedial genicular artery for one. After osteosynthesis with a plate, the flap was wrapped around the metacarpal, overlapping the bone proximally and distally. The recipient vessel were the dorsal branch of the radial artery and a vena comitans in the anatomical snuffbox in four patients, at the base of the first webspace in one.

Results

The flap size ranged from 5 × 3.5 cm to 8 × 4 cm. No postoperative complication occurred. Radiological bone union was achieved 3 to 8 months after surgery. One patient had a full range of motion, one a slight extension lag of the proximal interphalangeal joint, two moderate joint stiffness of the proximal interphalangeal or metacarpophalangeal joint (one requiring plate removal and extensor tenolysis), one severe stiffness that allowed using a hook grip which was the aim of the surgery.

Conclusion

In case of metacarpal nonunion with impaired bone vascularization, the periosteal medial femoral condyle free flap provides an effective and biomimetic approach to bone healing.

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.

Surgical Solution for Total Carpectomy due to Destructive Wrist Pan-Osteomyelitis Using a Free Femoral Condyle Osteocutaneous Flap for Wrist Arthrodesis

Osteomyelitis of the hand is rare, even more so in the carpal bones. Patients with rheumatoid arthritis (RA) have a higher infection rate overall, and up to a 14-fold increase in the incidence of septic arthritis of the hand. The destruction of immunologic barriers, such as cartilage and joint capsules, as well as the use of immunosuppressive medications will have an impact on the higher incidence of articular infections and osteomyelitis in these patients. Infection in these cases is often overlooked because of the similarity of presentation to an acute event of RA. When osteomyelitis is present, rapid and aggressive treatment should be given. Surgical debridement, lavage, and excision of necrotic bone is the best choice, followed by cemented antibiotic impregnated spacer to resolve the acute scenario. Vascularized bone grafts (VBG) can then be used for a definitive solution, as these have great biologic properties that increase the possibility of a good outcome. We hereby present a report of a wrist arthrodesis, using a free medial femoral condyle VBG for the treatment of destructive osteomyelitis of the carpal bones in a female patient with RA.

Tips to secure healing at the free vascularised fibular graft-to-host bone junction

The most commonly used vascularized bone graft in Orthopedics for difficult reconstructive problems requiring biological augmentation properties is the fibula. It provides immediate structure and with a patent pedicle, increases blood flow at the recipient site, promoting healing and hypertrophy in response to mechanical stress. The vascular supply from the nutrient branch and the periosteal vessels allows a variety of graft harvesting configurations for a broad spectrum of reconstructive challenges. We present the details on how to optimize healing and graft incorporation at the junction sites.

Healing physiology following delayed surgery for femoral midshaft fracture caused by high-energy injury: an in vivo study in dogs

Objective

An experimental model of severe soft tissue damage was designed to simulate high-energy fracture and observe the fracture healing process following early surgery and surgery delayed by 1 week.

Methods

Forty dogs were randomized to Group A (immediate surgery) and B (delayed surgery). The femur was broken, and the two ends were forcefully stabbed to damage the surrounding soft tissues. The fracture was repaired using a custom six-hole steel plate. Four dogs were killed on day 3 and weeks 1, 2, 4, and 8 following bone fracture. Soft tissue and bone were examined by light and electron microscopy.

Results

In Group A, no callus was present at 1, 2, 4, and 8 weeks following fracture, resulting in atrophic nonunion. In Group B, visible weak external callus was present 1 week following fracture, and good external callus growth was present at 2, 4, and 8 weeks, leading to callus healing.

Conclusion

These findings suggest that the first week is critical for fracture healing. Absence of callus in the early stage is indicative of absence of callus growth throughout the entire healing process, while the presence of callus in the early stage is indicative of vigorous callus growth thereafter.

Medial femoral condyle vascularised corticoperiosteal graft: A suitable choice for scaphoid non-union

Introduction

Scaphoid fractures are not very common and frequently remain undiagnosed, presenting in non-union and persistent wrist pain. Options for scaphoid fracture treatment have been described over several decades, however, none with an optimal solution to achieve union along with good hand function. We describe here, the use of vascularised corticoperiosteal bone grafts from the medial femoral condyle (MFC) as a solution for the difficult problem of scaphoid fracture non-union.

Materials and Methods

This series has 11 patients with non-union following a scaphoid fracture treated over 18 months ranging from January 2014 to January 2016 using a vascularised corticoperiosteal graft from the MFC. Bone graft fixation was done using K-wires and anastomosis was done with the radial vessels.

Results

There were no cases of flap loss. Time of union was an average 3 months. All patients had a full range of movements.

Discussion

MFC is an ideal site for harvesting vascularised corticoperiosteal grafts providing a large surface of tissue supplied by a rich periosteal plexus from the descending genicular artery. No significant donor site morbidities have been reported in any series in the past. The well-defined anatomy helps in a rather simple dissection. Corticoperiosteal grafts have a high osteogenic potential and hence, this vascularised graft seems ideal for small bone non-unions.

Conclusion

Thin, pliable and highly vascularised corticocancellous grafts can be obtained from the MFC as an optimal treatment option for scaphoid non-unions.

Wrist arthrodesis with the medial femoral condyle flap: Outcomes of vascularized bone grafting for osteomyelitis

BACKGROUND

Osteomyelitis of the wrist is rare but destructive. Subsequent bone defects often require vascularized bone for successful healing. Recent literature has pointed to the successful use of the medial femoral condylar (MFC) flap for difficult non-unions, yet it has not been specifically described for wrist fusion. We present our experience with this technique for limited and complete wrist arthrodesis.

PATIENTS AND METHODS

We reviewed 4 cases of radiocarpal bone loss from osteomyelitis. All cases utilized debridement of nonviable tissues, and at least 6 weeks of intravenous antibiotics, followed by vascularized bone grafting with a MFC flap. The flap was based on the horizontal periosteal branch of the descending geniculate artery, and utilized to directly bridge the bony defects following resection.

RESULTS

Three patients healed primarily, and 1 patient required secondary cancellous bone grafting to reach union. One patient required revision of the donor site closure. None of the patients had a recurrence of infection or other complications. Average follow up was 8.5 months after reconstruction. Average time to union was 11.5 weeks. Three patients demonstrated full composite fist, and 1 patient had incomplete finger range of motion following several flexor and extensor tendon grafts.

CONCLUSIONS

These cases illustrate the use of the MFC in wrist arthrodesis after osteomyelitis defects. In all cases, there was complete union in a short time, no recurrence of infection, and low donor-site morbidity.

Intercalary reconstruction after wide resection of malignant bone tumors of the lower extremity using a composite graft with a devitalized autograft and a vascularized fibula

Introduction. Although several intercalary reconstructions after resection of a lower extremity malignant bone tumor are reported, there are no optimal methods which can provide a long-term reconstruction with fewest complications. We present the outcome of reconstruction using a devitalized autograft and a vascularized fibula graft composite. Materials and Methods. We conducted a retrospective review of 11 patients (7 males, 4 females; median age 27 years) undergoing reconstruction using a devitalized autograft (pasteurization (n = 6), deep freezing (n = 5)) and a vascularized fibula graft composite for lower extremity malignant bone tumors (femur (n = 10), tibia (n = 1)). Results. The mean period required for callus formation and bone union was 4.4 months and 9.9 months, respectively. Four postoperative complications occurred in 3 patients: 2 infections (1 pasteurized autograft, 1 frozen autograft) and 1 fracture and 1 implant failure (both in pasteurized autografts). Graft removal was required in 2 patients with infections. The mean MSTS score was 81% at last follow-up. Conclusions. Although some complications were noted in early cases involving a pasteurized autograft, our novel method involving a combination of a frozen autograft with a vascularized fibula graft and rigid fixation with a locking plate may offer better outcomes than previously reported allografts or devitalized autografts.

Outcomes of free adipofascial flaps combined with tenolysis in scarred beds

PURPOSE

To review our outcomes of transferring vascularized free adipofascial flaps used to change the local tissue conditions at the time of tenolysis in adhesion-prone beds.

METHODS

Eleven free adipofascial flaps were transplanted in 10 patients after tenolysis on the forearm (3 cases), the dorsum of the hand (5 cases), or the dorsum of the proximal phalanx (3 cases). All recipient areas had badly scarred beds, 7 of which had previously failed tenolyses. In addition to tenolysis (10) or the insertion of bridging tendon grafts (1), arthrolysis of several involved joints and bone fixation for nonunion (3 cases) were carried out simultaneously. The adipofascial flap was then wrapped around the tendons or interposed between the scarred tissue and the freed tendons. In 8 cases, the flap was the lateral arm adipofascial flap, whereas adipose flaps from the toes were used for the fingers.

RESULTS

All flaps survived without vascular crisis. In all cases, total active motion was similar to the passive motion obtained at surgery. Average Disabilities of the Arm, Shoulder, and Hand score improved from 69 to 10, and average Patient-Rated Wrist Hand Evaluation score improved from 65 to 9. Secondary surgery was needed to reduce the bulk of the flap in 3 patients. One patient required an additional procedure to obtain an optimum result.

CONCLUSIONS

Free adipofascial flaps provided satisfying results in this group of patients. The flaps should be considered when the bed is scarred or after a failed tenolysis.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Free vascularised fibular graft in multi-operated patients for an aseptic non-union of the humerus with segmental defect: Surgical technique and results

In cases of non-union of the humerus with segmental bone defect, if a conventional treatment has failed, free fibular transfer should be considered as a reliable option to allow satisfactory bone union. We reported five cases of aseptic and multi-operated non-union of the humerus from trauma. In each case, a free fibular flap was performed after failure of a conventional treatment and bony union was demonstrable radiologically within six months. Some technical points such as harvesting of the fibula, humerus approach, fibula placement and fixation are highlighted in order to simplify the transfer and to standardise the technique.

Recent updates of surgical techniques and applications of free vascularized fibular graft in extremity and trunk reconstruction

Successful free vascularized bone transfers have revolutionized the limb salvage and musculoskeletal reconstruction. The free vascularized fibula remains the mainstay in bone reconstruction combines the benefits of blood supply, biological potential, and callus formation with its unique biomechanical characteristics offering a supreme candidate for various dissolvable issues. Especially in conditions where there was lack of other applicable method and the free vascularized fibular graft was introduced as the only alternative. Extensive traumatic bone loss, tumor resection, femoral head osteonecrosis and congenital defects have been managed with exceptional results beyond expectations. The present manuscript updates several issues in application of free vascularized fibular graft in extremity and trunk reconstruction. It also highlights tips and pearls of surgical technique in some crucial steps of harvesting the vascularized fibular graft in order to offer a vascularized bone with safety and low donor site morbidity.

Using segmental renal artery as recipient artery for spinal reconstructive surgery

STUDY DESIGN

Report of the use of one segmental artery from the left renal artery as inflow source for reconstructing a spine with recalcitrant osteomyelitis.

OBJECTIVE

To describe one difficult case of spinal osteomyelitis and our reconstruction procedure.

SUMMARY OF BACKGROUND DATA

The use of a vascularized fibular flap for spinal osteomyelitis has been reported previously, with vascular graft having a higher successful rate of bone union and overcoming poor perfusion beds. Because repeated spinal surgery may lead to severe scarring, the choice of recipient vessels may become a difficult issue.

METHODS

A 49-year-old man with T12-L1 vertebral osteomyelitis experienced progressive spinal cord involvement. Because previous multiple sessions of antibiotic treatment and surgery proved unsuccessful, a 2-stage surgery was planned. Posterior lateral fusion from T9 to L3 with MOSS Miami spine system (DePuy, Spine Inc, Raynham, MA) and allogenous bone graft were performed, followed by anterior debridement and reconstruction with free vascularized fibular graft 1 week later. End-to-side vascular anastomosis was performed between the peroneal artery and the upper anterior segment artery of the left renal artery.

RESULTS

After more than 50 months follow-up, the patient was able to walk smoothly without the aid of a brace, walker, or crutches. There were no complications, and the radiograph showed good bony union. Furthermore, renal function was normal.

CONCLUSION

The segmental renal artery can be selected as one of the recipient vessels in spinal reconstruction surgery without detrimental effect on renal function in our case. The use of vascularized fibular flap is preferable in cases of recalcitrant spinal osteomyelitis. Staged surgery in the presence of spinal infection can offer good spinal stability and good bony union with lower infection risk.

Modified free vascularized fibular grafting for the treatment of femoral neck nonunion

OBJECTIVE

To evaluate a modified free vascularized fibular grafting procedure with an anterior approach to the hip as a treatment for femoral neck nonunions.

DESIGN

Retrospective radiographic and clinical review.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

Twenty-six femoral neck nonunions treated between November 2000 and December 2005.

MAIN OUTCOME MEASUREMENTS

Harris Hip scoring system and radiographic standard evaluation for bone union.

RESULTS

The average follow-up period was 29.3 months (range, 12-63 months). The average duration of the surgery was 2.5 hours (range, 2-4 hours). Average blood loss was 300 mL (range, 200-400 mL). The neck-shaft angle was improved by 2.3 degrees on average. Twenty-four of 26 femoral neck nonunions healed without any severe complications. Average union time was 5.3 months (range, 3-9 months). Twenty-four patients had well-functioning hips with an average Harris hip score of 87.9 as compared with the average preoperative Harris hip score of 57.8. One case developed osteonecrosis of the femoral head requiring total hip arthroplasty 2 years after the index procedure. One case developed an immediate postoperative infection.

CONCLUSION

The clinical result indicates that the anterior approach modification of free vascularized fibular grafting is a valuable procedure in the treatment of femoral neck nonunions.

Salvage of a hip following pathological fracture through a large aneurysmal bone cyst: a case report

A young lady aged 20 presented to us in 2004 with a pathological fracture of the left femoral neck through a large aneurysmal bone cyst. Instead of total hip arthroplasty, we performed one-stage reconstruction surgery combining internal fixation and free vascularized fibular grafting. At 4 years the structure and function of the hip had been preserved.

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.

Early experience and results of bone graft enriched with autologous platelet gel for recalcitrant nonunions of lower extremity

BACKGROUND

Refractory nonunions of the tibia or femur are physically and mentally devastating conditions for the patients, and the treatment is challenging for orthopedic surgeons. The goal of this study was to assess the feasibility and outcome of surgical treatment in recalcitrant nonunions of a lower extremity with bone graft enriched with autologous platelet gel (APG).

METHODS

Twelve patients with four femoral and eight tibial atrophic nonunions after multiple prior procedures were included. All of them were treated with the bone grafting procedures with autograft complex enriched with APG. They were evaluated with radiographs, bone mineral density for bony healing process, and the Short-Form 36 Health Survey for functional outcome.

RESULTS

Of the 12 patients, 11 healed at an average of 19.7 weeks after the first attempt and 1 healed after the second attempt at 21 weeks. The bone mineral density continued to increase steadily from early healing to the remodeling phase. Functional status was greatly improved at an average follow-up of 32.4 months.

CONCLUSIONS

The results of this preliminary study implied the possible potential of bone graft enriched with APG in the treatment of recalcitrant nonunions of the lower extremity. More research is necessary to clarify its role in augmentation of bone graft to enhance healing of nonunion.

The fate of elbow arthrodesis: indications, techniques, and outcome in fourteen patients

Arthrodesis of the elbow remains a salvage procedure. In elbow surgery, it is indicated in cases of painful loss of motion, instability, and infection due to various causes. The literature lacks comprehensive clinical series concerning indications, techniques, and, particularly, outcome in elbow arthrodesis. We retrospectively reviewed our results of elbow arthrodesis in 14 patients. At final follow-up, the chart data of all patients showed favorable results with solid union of the fused elbows, no pain in 8 patients, and moderate pain in 4. In those patients in whom clinical follow-up was possible, after an average 62 months (4-132), noteworthy functional results were observed because of compensatory motion of adjacent joints. The authors outline decisive factors in the decision making process for patients with salvage elbows, as well as the techniques for elbow arthrodesis. Our indications, favorable results, and complications are discussed. A comprehensive review of literature highlights the technical steps necessary for successful elbow arthrodesis.

Evolving concepts in the management of the bone gap in the upper limb. Long and small defects

Vascularised bone graft is a well accepted technique when dealing with long defects. Its role in refractory nonunion, in small defects and in the growing patient is rarely discussed. In this paper the authors review the different alternatives to deal with bone defects in the upper extremity. The indications of vascularised corticoperiosteal graft for solving small defects harbouring refractory nonunion, and the use of vascularised bone phalanx and metatarsal for complex - but small - defects in the fingers is presented. The ability of the bone to grow and remodel when a living epiphysis is included, and to maintain the cartilage viability when a composite osteochondral graft is transferred are also discussed.

Vascularised corticoperiosteal grafts from the medial femoral condyle for difficult non-unions of the upper limb

The vascularised corticoperiosteal graft was introduced by Sakai and Doi, in 1991, as a means to achieve bony union under unfavourable conditions. We present our experience with this vascularised graft, taken from the femoral condyle, in six patients with difficult non-unions (5) or other bony problems (1) in the upper limb. In five cases, a long bone defect--two humeral, two ulnar and one radial--was involved. All had had between three and seven previous operations. Two of the non-unions were secondary to infection. The others had had conventional grafting on two or three previous occasions each. In the sixth case, a corticoperiosteal graft was used to promote healing in a combined carpometacarpal and intercarpal dislocation with a very poor bed. All of the grafts survived without complications and all of the bones healed radiologically in less than three months. Three patients achieved a normal range of motion and two obtained a functional range of motion with only slight limitations. The carpometacarpal arthrodesis was healed soundly at five weeks.

Pasteurized intercalary autogenous bone graft combined with vascularized fibula

The optimal reconstruction procedure after wide resection of bone tumors is debatable. We reviewed pasteurized intercalary autogenous bone graft combined with a vascularized fibula graft in 15 patients with malignant bone tumors, and assessed whether this procedure would improve bone union and function. The mean duration until bone union of the pasteurized autogenous bone was 13.5 months and duration until union of the vascularized fibula was 7.7 months. Complete bone union between the pasteurized autogenous bone and the vascularized fibula eventually was achieved in 13 patients (86.7%). In the remaining two patients, fibula union was achieved but union of the pasteurized autogenous bone was not attributable to infection. Postoperative complications included two fractures and two infections. Three patients with delayed union eventually achieved bone union using an autogenous cancellous bone graft. The mean Musculoskeletal Tumor Society score was 80.6% and it was comparable to scores from other procedures. Our results suggest a pasteurized autogenous bone graft combined with a vascularized fibula graft can be a useful reconstruction method in selected patients with large bone defects after wide resection of malignant bone tumors.

Internal thoracic vessels used as pedicle graft for anastomosis with vascularized bone graft to reconstruct C7-T3 spinal defects: a new technique

STUDY DESIGN

A report of 4 cases of primary bone tumors (3 cases) or infection (1 case) at the cervicothoracic junction treated with resection-reconstruction.

OBJECTIVES

To document a new technique using the internal thoracic vessels as recipient vessels for reconstruction of the cervicothoracic spine with free vascularized fibula grafts.

SUMMARY OF BACKGROUND DATA

The cervicothoracic junction is a difficult region in reconstructive spinal surgery. Although nonvascularized fibula grafts can be used to reconstruct the osseous defect, compared with free vascularized fibula grafts they are biomechanical weaker, incorporate less well, are less resistant to infection, and remodel incomplete in time. However, when using free vascularized bone grafts, the selection of suitable recipient vessels remains one of the most critical decisions.

MATERIALS AND METHODS

Four patients who had a primary tumor (3 cases) or a severe progressive kyphotic deformity and progressive neurologic symptoms due to tuberculosis (1 case) were treated by resection and vascularized reconstruction. In 3 patients, a staged anteroposterior en bloc resection of T1-T3 (2 cases) or T1-T2 (1 case) was performed; the ventral reconstruction of the osseous defect consisted of a vascularized fibula graft interposition between C7-T4 (2 cases) or C7-T3 (1 case). In another case, an axial slot was milled through the T1-T2 vertebral bodies to accept an osteotomized vascularized fibular graft. In all cases, a free vascularized fibula graft was used: the vascular anastomosis was performed between the peroneal and the dissected and rerouted internal thoracic vessels. The anterior construction was strengthened by a ventral plate-screw system.

RESULTS

The resection-reconstruction procedures, including the dissection, rerouting, and anastomosis between the internal thoracic vessels and the peroneal vessels, were successfully performed. At present, all patients are alive, and there is no evidence of recurrent disease, unchanged, or improved neurologic with a mean follow-up of 28 months. All grafts are well incorporated. CONCLUSIONS.: A combined low anterolateral cervical and midsternal approach or a midline sternotomy allows not only a safe and excellent exposure to the cervicothoracic junction but also to the internal thoracic vessels. The internal thoracic vessels are appropriate donor vessels: its longevity, diameter, length, and rerouting capacity allow vascularized graft reconstruction of vertebral column defects of the low cervical (C6-C7) and/or upper thoracic (T1-T3) region.

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.

Vascularized bone blocks from the toe phalanx to solve complex intercalated defects in the fingers

PURPOSE

Vascularized bone transplants resist infection and allow rapid healing but keeping small bony segments vascularized, as needed for a finger defect, is a challenge. The purpose of this article is to present a cohort of patients with traumatic intercalated compound bony defects in the fingers that were reconstructed by a vascularized toe phalanx (or part of a phalanx) in a single stage.

METHODS

Eight patients were treated with an intercalary vascularized bone graft that included a part of the proximal phalanx (3 patients), most of the middle phalanx (4 patients), or a portion of each phalanx (1 patient) of a second toe (totaling 9 bone blocks). There was an associated soft-tissue defect in each patient, an infection in 6 patients, and cartilage loss in 4 patients. The toes were pedicled on the proper digital artery (6 patients) or a segment of the first dorsal metatarsal artery (2 patients). A mean length of 12 mm of vascularized bone was transferred. The associated skin island varied from a minimum of 2 x 1 cm to a maximum of 5 x 3 cm. Bleeding from all of the bone surfaces was evidenced once the clamps were released. The homolateral digital nerve and the contralateral neurovascular pedicle of the toe were kept in place. The toe defect was treated by soft-tissue arthroplasty or arthrodesis. No toe was amputated.

RESULTS

Radiologic bony union was evident at 4 to 6 weeks, except in 1 patient with an acute infection whose distal union failed to unite at 6 weeks because the infection recurred. Finger length loss averaged 3 mm. All patients returned to their preoperative occupation.

CONCLUSIONS

In this group of patients the toe phalanx reliably maintained its vascularization, allowing us to solve compound osteocutaneous defects in the fingers in a single stage. Donor site morbidity was minimal.

Early return to function in young adults with neglected femoral neck fractures

Neglected femoral fractures in young adults are a challenge to the orthopaedic surgeon, requiring prolonged treatment and with attendant risks of nonunion. We postulated treatment in this group by accurate reduction, two cannulated screws, and whole free fibular autograft would allow early mobilization and provide good bony union. Thirty-two patients aged 18 to 50 years were treated at our center in this manner. They presented to our center 3 to 6 months after injury, and had Garden's Grade III/IV fractures with varying degrees of neck resorption, but no avascular necrosis. No plaster was applied, and early return to function was encouraged. Bony union was achieved in 29 (90.6%) patients at a mean of 19.2 weeks (range, 16-24 weeks). All patients with union had good function at long-term followup at an average of 6.1 years postoperatively (range, 2-12 years), and the average Harris hip score was 87.1 points (range, 74.5-94 points). Our procedure allows early return of function in young, active patients disabled by old femoral neck fractures compounded by lack of early treatment.

Vascularised bone grafts for the management of non-union

Non-union of the long bones may have severe consequences, particularly when combined with other post-traumatic sequelae, such as tendon adhesions, reflex sympathetic dystrophy and infection, among others. In these cases, it is important to treat the delayed union or non-union first or at the same time with the other problems in order to achieve adequate function. Once the normal bony healing process has been slowed or stopped, it is necessary to provide both stability to the fracture site, as well as a biological stimulus for the fibrocartilagenous callus to finish the healing process. Vascularised grafts, such as the free fibula, offer not only structural support, but also promote bone healing. The later is achieved by trabecular bone formation, as well as vascular sprouting from pedicle vessels.

Early healing pattern of autogenous bone grafts with and without e-PTFE membranes: A histomorphometric study in rats

OBJECTIVE

The aim of this study was to perform quantitative and qualitative analyses of the initial repair pattern of an autogenous bone block graft when covered or not with e-PTFE membranes.

STUDY DESIGN

Sixty male Wistar rats received a bone graft plus an e-PTFE membrane (MB) or just the graft (B). A block graft was harvested from the animal's calvarium and was laid and stabilized on the external cortical area near the angle of the mandible. Descriptive histology and histomorphometric analyses were carried out and the data were analyzed statistically by ANOVA and the Tukey test, with the level of significance set at 5%.

RESULTS

The results for group B showed that there was bone loss during the healing period (B0 = 1.38, B45 = 1.05, F = 7.91 > F(C) = 3.02), that is, the initial volume of the graft decreased in time. Bone tissue loss was about 24%. In contrast, the MB group showed bone tissue gain along the observation period (MB0 = 1.54, MB45 = 2.40, F = 7.91 > F(C) = 3.02), meaning that the total volume of newly formed bone was greater than the original graft area. Bone tissue gain was approximately 55%. MB showed significantly greater bone gain when compared to B (B45 = 1.05, MB45 = 2.40, F = 39.86 > F(C) = 1.90). These significant differences between B and MB could already be observed after 21 days.

CONCLUSIONS

The bone block graft underwent resorption at an early healing stage, while additional new bone formation was observed when the bone graft was covered with an e-PTFE membrane.