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Yang S, Morton Z, Colcord M, Jackson RS, Moore EJ, Thuener J, Bewley AF, Coughlin A, Khariwala SS, Richmon JD, Pipkorn P, Winters R, Militsakh ON, Zender CA, Wright J, Wax MK. Fibula Free Flap Reconstruction of Cervical Spine Defects: A Multi-Institutional Study. Laryngoscope 2024. [PMID: 38984420 DOI: 10.1002/lary.31625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/03/2024] [Accepted: 06/25/2024] [Indexed: 07/11/2024]
Abstract
INTRODUCTION Cervical spine defects result in spinal instability, putting the spinal cord and vertebral arteries at risk of damage and possibly devastating neurological injuries. The fibula free flap can span the spinal defects for stability. There is a paucity of literature on this technique. METHOD Multi-institutional retrospective case series reviewing patients who underwent cervical spine reconstruction with a fibula free flap. Patient demographic information, comorbidities, characteristics of cervical spine defects, and free flap complications were collected. RESULTS A total of 1187 fibula free flaps across 10 different institutions were reviewed. Thirteen patients (1.09%) underwent cervical spine reconstruction with a fibula free flap. Average age was 52.3 years old with an age range of 12-79 years. There were six males (46.1%) and seven females (53.8%). The most common defect etiology was infection (n = 6, 46.1%). Most commonly involved cervical spine level of the defect was C5 (n = 10) followed by C6 (n = 9) and C4 (n = 8). The majority of reconstructed defects spanned three or more cervical levels, (n = 9, 69.2%). Facial artery was the most common arterial anastomosis (n = 8). Eight patients (61.5%) required a tracheostomy during their postoperative course. None of the patients had symptomatic or radiographic nonunion. CONCLUSION This case series demonstrates that a vascularized fibula flap is a potential reconstructive option for cervical spine defects, especially in defects greater than three cervical levels, in the setting of infection, and previously radiated patients. LEVEL OF EVIDENCE Level 4 Laryngoscope, 2024.
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Affiliation(s)
- Sara Yang
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - Zoey Morton
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Maddie Colcord
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - Ryan S Jackson
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St. Louis, St Louis, Missouri, U.S.A
| | - Eric J Moore
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Jason Thuener
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals, Cleveland, Ohio, U.S.A
| | - Arnaud F Bewley
- Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Sacramento, California, U.S.A
| | - Andrew Coughlin
- Department of Surgery, Creighton University School of Medicine, Nebraska Methodist Hospital, Omaha, Nebraska, U.S.A
| | - Samir S Khariwala
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota, U.S.A
| | - Jeremy D Richmon
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, U.S.A
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St. Louis, St Louis, Missouri, U.S.A
| | - Ryan Winters
- Department of Otolaryngology-Head and Neck Surgery, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Oleg N Militsakh
- Department of Surgery, Creighton University School of Medicine, Nebraska Methodist Hospital, Omaha, Nebraska, U.S.A
| | - Chad A Zender
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, U.S.A
| | - James Wright
- Department of Neurosurgery, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - Mark K Wax
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A
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2
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Vermoet NCW, Weijs WLJ, van Bilsen MWT, Honings J. Pharyngo-cervicospinal fistula with destructive osteomyelitis after laryngopharyngectomy and radiotherapy, managed successfully with a vascularized fibula free flap. Int J Oral Maxillofac Surg 2024; 53:282-285. [PMID: 37813806 DOI: 10.1016/j.ijom.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 09/12/2023] [Accepted: 09/25/2023] [Indexed: 10/11/2023]
Abstract
Total laryngectomy is an operation mainly employed in recurrent laryngeal and hypopharyngeal carcinoma after previous radiotherapy. The most feared complication after this procedure is a pharyngocutaneous fistula. An extremely rare complication is the development of osteomyelitis of the cervical spine, which is associated with high rates of neurological impairment and epidural empyema, often requiring surgical treatment. This report describes the case of a patient with neck and shoulder pain and progressive motor weakness of the left deltoid and biceps muscle, caused by a pharyngo-cervicospinal fistula with spinal empyema. This condition resulted in destructive osteomyelitis of the cervical spine. A successful reconstruction of the cervical spine and neopharynx was performed using a free vascularized fibula bone and skin graft in a complex area because of previous treatments. It appears that no similar case has been described previously.
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Affiliation(s)
- N C W Vermoet
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands.
| | - W L J Weijs
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - M W T van Bilsen
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - J Honings
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
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Riasa INP, Kawilarang B. The Use of Free Vascularized Fibula Graft in Spinal Reconstruction: A Comprehensive Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5079. [PMID: 37334392 PMCID: PMC10270507 DOI: 10.1097/gox.0000000000005079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 05/02/2023] [Indexed: 06/20/2023]
Abstract
Reconstructive surgeons frequently face large structural abnormalities after spine resection. Unlike defects in the mandible or long bone, where a free vascularized fibular graft (FVFG) is a popular alternative for segmental osseous reconstruction, data on the use of an FVFG in the spine are still limited. The purpose of this study was to comprehensively describe and analyze the outcome of spinal reconstruction utilizing FVFG. Methods The extensive search included the following databases: PubMed, ScienceDirect, Web of Science, Cumulative Index to Nursing and Allied Health Literature, and Cochrane for relevant studies published up to January 20, 2023, according to PRISMA 2020 guidelines. Demographic data, flap success, recipient vessels, and flap-related complications were evaluated. Results We identified 25 eligible studies involving 150 patients, consisting of 82 men and 68 women. Spinal reconstruction utilizing FVFG is mostly reported in the case of spinal neoplasm, followed by spinal infection (osteomyelitis and spinal tuberculosis) and spinal deformities. The cervical spine is the most common vertebral defect reported in the studies. All studies summarized in the present study reported successful spinal reconstruction, while wound infection was the most reported postoperative complication after spinal reconstruction utilizing FVFG. Conclusions The results of the current study highlight the ability and superiority of using FVFG in spinal reconstruction. Despite being technically challenging, this strategy provides enormous benefits to patients. However, a further additional large-scale study is required to corroborate these findings.
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Affiliation(s)
- I Nyoman P Riasa
- From the Plastic Reconstructive and Aesthetic Surgery IGNG Prof Ngoerah Hospital, Udayana University, Denpasar, Bali, Indonesia
| | - Bertha Kawilarang
- From the Plastic Reconstructive and Aesthetic Surgery IGNG Prof Ngoerah Hospital, Udayana University, Denpasar, Bali, Indonesia
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4
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Levin LS. From replantation to transplantation: The evolution of orthoplastic extremity reconstruction. J Orthop Res 2022. [PMID: 36413095 DOI: 10.1002/jor.25488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/20/2022] [Accepted: 11/15/2022] [Indexed: 11/23/2022]
Abstract
For more than six decades, the use of the operating microscope for extremity surgery has led to remarkable advances in the management of orthopedic trauma, tumors, infections, and congenital differences. The microsurgical reconstructive ladder ascends from basic microsurgical procedures such as a digital artery or nerve repair to more complex procedures such as autologous tissue transplantation. Functional muscle transfers, toe-to-hand transfers, and recently vascularized composite allotransplantation are the highest rungs on this ladder that help restore extremity function. The development of the orthoplastic approach over the last three decades simultaneously integrates the principles and practices of both orthopedic surgery and plastic surgery for optimal care and salvage of extremities. Clinical, anatomic, and basic science research in reconstructive microsurgery has resulted in significant improvements in extremity salvage, reconstruction, and restoration.
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Affiliation(s)
- L Scott Levin
- Department of Orthopaedic Surgery, Department of Surgery, Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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5
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Long segment spinal reconstruction of C3-T1 utilizing single strut fibula free flap following debridement and corpectomy for chronic osteomyelitis. Am J Otolaryngol 2022; 43:103310. [PMID: 34894445 DOI: 10.1016/j.amjoto.2021.103310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 11/28/2021] [Indexed: 11/24/2022]
Abstract
Cervical vertebral osteomyelitis (CVO) is a complex destructive pathology that presents as a significant challenge to reconstructive surgeons. Advanced cases of CVO involving neurologic deficits, spinal column instability, or refractory infection require surgical intervention with bony debridement and decompression followed by spinal reconstruction, realignment, and stabilization. Reconstruction of the spine is typically performed through an anterior approach with or without posterior instrumentation. Restoration of the anterior spinal column can be performed with titanium or PEEK cages, allograft bone or vascularized autograft bone. Anterior spine reconstruction using vascularized osseous free flaps has been well documented in the medical literature; however, to our knowledge, we report the largest osteomyelitic anterior cervical spine defect that has been reconstructed using a single strut osseous free flap. This was a complex case of cervical osteomyelitis in a patient with prior C4-C7 anterior cervical corpectomy and fusion who presented with instrumentation failure and septicemia. Anterior column reconstruction required a vascularized fibular strut spanning six vertebral levels from C3-T1, as well as a trapezius myocutaneous pedicled flap for posterior soft tissue coverage.
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6
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Vascularized Bone Grafts in Orthopaedic Surgery: A Review of Options and Indications. J Am Acad Orthop Surg 2022; 30:60-69. [PMID: 34932501 DOI: 10.5435/jaaos-d-20-01200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 10/31/2021] [Indexed: 02/01/2023] Open
Abstract
Vascularized bone grafts have demonstrated increased perfusion, structural integrity, and ability to achieve good outcomes in challenging clinical situations when compared with nonvascularized grafts. These grafts may be pedicled or free, and bring perfused, viable bone into areas of impaired healing. Although numerous grafts have been described, a few grafts have demonstrated particular usefulness and versatility. Pedicled grafts from the distal radius, medial femoral condyle, ribs, and fibula have improved outcomes in challenging situations without the need for microsurgery. Free grafts from the fibula and medial femoral condyle/trochlea, although they require microsurgical anastomosis, can be transferred to virtually any site in the body and have expanding indications. The capacity of these grafts to achieve favorable outcomes in difficult cases make them a powerful tool for orthopaedic surgeons to have in their armamentarium.
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Addressing common orthopaedic calamities with microsurgical solutions. Injury 2021; 52:3561-3572. [PMID: 34030865 DOI: 10.1016/j.injury.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 05/04/2021] [Indexed: 02/02/2023]
Abstract
Reconstructive microsurgery has been an essential aspect of orthopaedic surgery and extremity reconstruction since the introduction of the operating microscope in the mid-20th century. The reconstructive ladder ranges from simple healing by secondary intention to complex procedures such as free tissue transfer and vascularized composite allotransplantation. As orthopaedic surgery has evolved over the past 60 years, so too have the reconstructive microsurgical skills that are often needed to address common orthopaedic surgery problems. In this article, we will discuss a variety of complex orthopaedic surgery scenarios ranging from trauma to infection to tumor resection as well as the spectrum of microsurgical solutions that can aid in their management.
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Hamati FJ, Siotos C, Terhune EB, Williams JC, Dorafshar AH. Free Fibular Flap and Fibular Graft Double-Strut Tunneling to Fill a Large Tibial Plateau Defect. EPLASTY 2021; 21:e9. [PMID: 35652082 PMCID: PMC9129069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Introduction Bony defects resulting from trauma, osteomyelitis, and tumor resection pose significant reconstructive challenges. Free fibular flaps (FFFs) are an excellent option, especially for large defects in the tibia. Case presentation In this article, the authors review a case of a 60-year-old male who underwent FFF and fibular graft double-strut tunneling to fill a large tibial plateau defect. Conclusion The use of the FFF provides an excellent option for reconstructing long bone large defects (defects > 6 cm). The case presented in this report indicates an expanded application of this technique in treating defects secondary to chronic osteomyelitis in infected tibial plateau nonunion.
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Affiliation(s)
- Fadi J. Hamati
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL
| | - Charalampos Siotos
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL
| | - E. Bailey Terhune
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL
| | - Joel C. Williams
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL
| | - Amir H. Dorafshar
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL
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Erol B, Sofulu O, Sirin E, Saglam F, Baysal O, Tetik C. Pelvic Ring Reconstruction After Iliac or Iliosacral Resection of Pediatric Pelvic Ewing Sarcoma: Use of a Double-Barreled Free Vascularized Fibular Graft and Minimal Spinal Instrumentation. J Bone Joint Surg Am 2021; 103:1000-1008. [PMID: 33770022 DOI: 10.2106/jbjs.20.01332] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In patients undergoing iliosacral resections, pelvic ring reconstruction can maintain stability of the pelvis and spinal column, which is expected to achieve good functional outcomes. However, no optimal reconstruction method has been established. We aimed to analyze the outcome of pelvic ring reconstruction using double-barreled free vascularized fibular graft (FVFG) and internal fixation after iliosacral resections in children. METHODS We retrospectively reviewed 16 children with pelvic Ewing sarcoma who underwent pelvic ring reconstruction using double-barreled FVFG after iliosacral resection. The fibular graft was placed between the supraacetabular region distally and the remaining ilium or sacrum proximally. The stability of the remaining pelvis and spinal column was provided by minimal spinal instrumentation. RESULTS Eleven Type-I and 5 Type-I+IV resections were performed for 10 boys and 6 girls, who had a mean age of 13.4 years (range, 10 to 18 years). The mean follow-up was 49.8 months (range, 28 to 96 months). At the time of the final follow-up, 14 patients were alive and 2 patients had died of disease. The mean time for bone union was 9 months (range, 6 to 12 months). Graft hypertrophy was evident in all patients at 12 months. The median Musculoskeletal Tumor Society (MSTS) score at the time of the final follow-up was 80% (range, 60% to 96.6%). Seven patients had complications. Three complications required reoperation: 1 deep infection, 1 hematoma, and 1 wound dehiscence. Three patients had disease relapse in terms of lung metastases. CONCLUSIONS This reconstruction method can achieve a high rate of bone union and can provide good functional outcomes following resection of pediatric pelvic Ewing sarcomas with iliosacral involvement. Complications are usually manageable without a need for revision surgical procedures. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Bulent Erol
- Department of Orthopaedic Surgery and Traumatology, Marmara University School of Medicine, Istanbul, Turkey
| | - Omer Sofulu
- Department of Orthopaedic Surgery and Traumatology, Marmara University School of Medicine, Istanbul, Turkey
| | - Evrim Sirin
- Department of Orthopaedic Surgery and Traumatology, Marmara University School of Medicine, Istanbul, Turkey
| | - Fevzi Saglam
- Department of Orthopaedic Surgery and Traumatology, Marmara University School of Medicine, Istanbul, Turkey
| | - Ozgur Baysal
- Department of Orthopaedic Surgery and Traumatology, Marmara University School of Medicine, Istanbul, Turkey
| | - Cihangir Tetik
- Departments of Orthopaedics and Traumatology, Acıbadem University Hospital, Istanbul, Turkey
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10
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Goldman JJ, Huynh KA, Elfallal W, Chaiyasate K, Fahim DK. Cervical Spine and Craniocervical Junction Reconstruction with a Vascularized Fibula Free Flap. World Neurosurg 2020; 144:34-38. [DOI: 10.1016/j.wneu.2020.08.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 10/23/2022]
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Ou Q, Wu P, Zhou Z, Pan D, Tang JY. Complication of osteo reconstruction by utilizing free vascularized fibular bone graft. BMC Surg 2020; 20:216. [PMID: 33008361 PMCID: PMC7531124 DOI: 10.1186/s12893-020-00875-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 09/21/2020] [Indexed: 12/19/2022] Open
Abstract
The success of free vascularized fibular bone graft (FVFBG) has accelerated the osteo reconstruction which results from trauma, resection of a tumor or an infectious bone segment, or correction of congenital deformity. But the complication behind should not be overlooked. The failure could necessitate a second surgery, which prolong the rehabilitation period and produce further health cost. Worst, the patients may suffer a permanent impaired ankle function, or a sustained morpho-functional loss on reconstructive area which are hard to save. To provide an overview of the complication related to reconstruction by FVFBG, a narrative review is conducted to identify the complications including their types and rates, the contributing factors, the approaches to measure and the techniques to avoid. Methodologically, by quick research on Pubmed and abstract reading of reviews, we characterize five reconstructive areas where FVFBG were most frequently applied: extremities, mandible, spine, osteonecrosis of femoral head, and penile. Following, the complications on different reconstructive areas are retrieved, studied and presented in five (or more specifically, six) separate sections. By the way, meaningful difference between FVFBG and other bone flap was presented in a few words if necessary. Donor-site morbidities were studied and summarized as a whole. In these literatures, the evidences documented on limb and mandibular reconstruction have the fullest detail, followed by the spine and lastly the penile. In conclusion, FVFBG, though a mature technique, needs further deep and comprehensive study and maybe device-based assistance to achieve better reconstructive effect and minimize donor-site damage.
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Affiliation(s)
- Qifeng Ou
- Department of Orthopedics, Hand and Microsurgery, Xiangya Hospital, Central South University, No.87 XiangYa Road, Changsha, 410008, Hunan, China
| | - Panfeng Wu
- Department of Orthopedics, Hand and Microsurgery, Xiangya Hospital, Central South University, No.87 XiangYa Road, Changsha, 410008, Hunan, China
| | - Zhengbing Zhou
- Department of Orthopedics, Hand and Microsurgery, Xiangya Hospital, Central South University, No.87 XiangYa Road, Changsha, 410008, Hunan, China
| | - Ding Pan
- Department of Orthopedics, Hand and Microsurgery, Xiangya Hospital, Central South University, No.87 XiangYa Road, Changsha, 410008, Hunan, China
| | - Ju-Yu Tang
- Department of Orthopedics, Hand and Microsurgery, Xiangya Hospital, Central South University, No.87 XiangYa Road, Changsha, 410008, Hunan, China.
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12
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Restoration of Spinopelvic Continuity with the Free Fibula Flap after Limb-Sparing Oncologic Resection Is Associated with a High Union Rate and Superior Functional Outcomes. Plast Reconstr Surg 2020; 146:650-662. [DOI: 10.1097/prs.0000000000007095] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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13
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Free Fibula Flap for Restoration of Spinal Stability after Oncologic Vertebrectomy Is Predictive of Bony Union. Plast Reconstr Surg 2020; 145:219-229. [DOI: 10.1097/prs.0000000000006382] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Bohl MA, Hlubek RJ, Turner JD, Reece EM, Kakarla UK, Chang SW. Novel Surgical Treatment Strategies for Unstable Lumbar Osteodiscitis: A 3-Patient Case Series. Oper Neurosurg (Hagerstown) 2019; 14:639-646. [PMID: 28961732 DOI: 10.1093/ons/opx162] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 06/27/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Lumbar osteomyelitis frequently affects patients with medical comorbidities and poor preoperative health. Surgery is indicated when medical management fails or patients present with spinal instability or neural compromise. Successful arthrodesis can be difficult and sometimes requires alternative surgical techniques. OBJECTIVE To report 3 novel methods, each illustrated by a case, for achieving arthrodesis for lumbar osteomyelitis. METHODS A retrospective review was performed of 3 cases of surgical treatment of lumbar osteomyelitis. Novel aspects of the surgical techniques are reported, as are perioperative clinical details and imaging results. RESULTS In the first patient, a vascularized iliac crest graft on a quadratus lumborum pedicle was rotated into the posterolateral fusion bed of the affected level. In the second, an anterior approach with debridement of affected lumbar levels was followed by rotation of a vascularized iliac crest graft on an iliacus muscle pedicle into the anterior lumbar defect. In the third, a structural, nonvascularized iliac crest graft was harvested via a lateral approach to provide better surgical access, and an autologous tricortical bone graft was obtained for placement in the debridement defect. Follow-up imaging suggested successful early incorporation of all the grafts in the fusion beds. CONCLUSION Patients with multiple risk factors for pseudarthrosis and recurrent infection often require alternative surgical strategies to augment fusion. These 3 novel methods for lumbar debridement, fixation, and fusion using vascularized or nonvascularized autograft accommodate posterior, anterior, and lateral surgical approaches. Further experience with these techniques is required to compare outcomes with those of traditional techniques.
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Affiliation(s)
- Michael A Bohl
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Randall J Hlubek
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Jay D Turner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Edward M Reece
- Arizona Center for Hand Surgery-Reconstructive Plastic Surgery, Phoenix, Arizona
| | - U Kumar Kakarla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Steve W Chang
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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15
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An Interdisciplinary Approach to Treatment of Adult Facial Arteriovenous Malformations. J Craniofac Surg 2019; 30:1635-1639. [DOI: 10.1097/scs.0000000000005423] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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16
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Abellan Lopez M, Iniesta A, Brioude G, Farah K, Fuentes S. Osteocutaneous free transfer of vascularized fibula in cervico-thoracic spinal reconstruction with filling of an esophageal fistula: A case report. Neurochirurgie 2018; 64:434-438. [PMID: 30243465 DOI: 10.1016/j.neuchi.2018.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 06/10/2018] [Accepted: 06/22/2018] [Indexed: 10/28/2022]
Abstract
The case under review is a 60-year-old patient with a vertebral plasmocytoma treated by cervico-thoracic fusion 2 years previously. He presented a thoracic spinal septic non-union complicated by esophagospinal fistula. We performed vascularized fibula transplant with cutaneous pad to fill the esophageal fistula. Control CT at day 5 confirmed vascular anastomosis permeability and bone transplant position. Osseointegration was achieved at 18 months postoperatively. The patient was alive 3 years after the last procedure (5 years after tumorectomy). A systematic review of the literature on spinal reconstruction by vascularized fibula transplant showed the diversity of surgical techniques available. In view of the multiplicity of possible organ and soft tissue defects involving the spine, reminders are provided of the different approaches and recipient vessels in this type of reconstruction depending on location.
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Affiliation(s)
- M Abellan Lopez
- Hand Surgery and Limb Reconstructive Surgery Department, La Timone Hospital, 13005 Marseille, France.
| | - A Iniesta
- Hand Surgery and Limb Reconstructive Surgery Department, La Timone Hospital, 13005 Marseille, France.
| | - G Brioude
- Department of Thoracic Surgery, Lung Transplantation and Diseases of the Esophagus, North University Hospital, 13015 Marseille, France.
| | - K Farah
- Department of Neurosurgery, La Timone Hospital, 13005 Marseille, France.
| | - S Fuentes
- Department of Neurosurgery, La Timone Hospital, 13005 Marseille, France.
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17
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Zhang J, He WS, Wang C, Yan YG, Ouyang ZH, Xue JB, Li XL, Wang WJ. Application of vascularized fibular graft for reconstruction and stabilization of multilevel cervical tuberculosis: A case report. Medicine (Baltimore) 2018; 97:e9382. [PMID: 29504970 PMCID: PMC5779739 DOI: 10.1097/md.0000000000009382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Multilevel cervical reconstruction and fusion after cervical tuberculosis has always been a challenge. The current implantation materials for cervical fusion, including titanium mesh, cage, and plate are limited by its inferior biological mechanical characteristics and the properties of the metallic material. This has led to the increased risk of recurrent infection after surgery. In addition, the unique nature of tuberculosis infection results in the low rate of cervical fusion and high risk of recurrence. This case report presents 1 patient who suffered from long segmental cervical tuberculosis and had reconstruction surgery using a vascularized fibula graft. The patient had successful graft incorporation 3 months postsurgery and was followed-up for 30 months. In this review, we detail the advantages of using vascularized fibular grafts and compare it with other types of grafts.
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Affiliation(s)
| | - Wen-Si He
- Department of Spine Surgery, the First Affiliated Hospital, University of South China, Hengyang, Hunan, China
| | - Cheng Wang
- Department of Spine Surgery, the First Affiliated Hospital, University of South China, Hengyang, Hunan, China
| | - Yi-Guo Yan
- Department of Spine Surgery, the First Affiliated Hospital, University of South China, Hengyang, Hunan, China
| | - Zhi-Hua Ouyang
- Department of Spine Surgery, the First Affiliated Hospital, University of South China, Hengyang, Hunan, China
| | - Jing-bo Xue
- Department of Spine Surgery, the First Affiliated Hospital, University of South China, Hengyang, Hunan, China
| | - Xue-Lin Li
- Department of Spine Surgery, the First Affiliated Hospital, University of South China, Hengyang, Hunan, China
| | - Wen-Jun Wang
- Department of Spine Surgery, the First Affiliated Hospital, University of South China, Hengyang, Hunan, China
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Houdek MT, Rose PS, Bakri K, Wagner ER, Yaszemski MJ, Sim FH, Moran SL. Outcomes and Complications of Reconstruction with Use of Free Vascularized Fibular Graft for Spinal and Pelvic Defects Following Resection of a Malignant Tumor. J Bone Joint Surg Am 2017; 99:e69. [PMID: 28678130 DOI: 10.2106/jbjs.16.01458] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Following resection of malignant tumors of the spine and pelvis, reconstructive surgeons often face large structural defects. Unlike reconstruction in the extremities, wherein a free vascularized fibular graft (FVFG) is a highly utilized option for segmental osseous reconstruction, there are limited data on the use of an FVFG in the spine and pelvis. The aim of this study was to review our institution's experience with reconstruction with use of an FVFG following oncological resection in the spine and pelvis. METHODS We reviewed 24 cases involving the use of an FVFG in reconstruction of segmental osseous defects of the spine and pelvis following oncological resection from 2000 to 2015. The cohort consisted of 12 male and 12 female patients with a mean age of 37 years and a mean follow-up of 5 years. Fifty-four percent of the reconstructions were spinopelvic or sacropelvic. RESULTS The overall 2, 5, and 10-year rate of survival was 76%, 55%, and 37%, respectively. With regard to disease-free survival, the overall 2, 5, and 10-year rate was 81%, 72%, and 48%. The overall rate of union was 86%, with a mean time to union of 7 months. Complications were common, with 83% of the patients sustaining at least 1 postoperative complication. Following the procedure, the mean Musculoskeletal Tumor Society rating was 53%. CONCLUSIONS An FVFG provides a durable means of reconstruction of osseous defects in the spine and pelvis. Although patient function was acceptable following these large reconstructions, the rate of postoperative complications was high. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Matthew T Houdek
- 1Department of Orthopedic Surgery (M.T.H., P.S.R., K.B., E.R.W., M.J.Y., F.H.S., and S.L.M.) and Division of Plastic and Reconstructive Surgery (K.B. and S.L.M.), Mayo Clinic, Rochester, Minnesota
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Fibula osteo-adipofascial flap for reconstruction of a cervical spine and posterior pharyngeal wall defect. Microsurgery 2013; 34:314-8. [DOI: 10.1002/micr.22217] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2013] [Revised: 12/04/2013] [Accepted: 12/12/2013] [Indexed: 11/07/2022]
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Winters HAH, Kraak J, Oosterhuis JWA, de Kleuver M. Spinal reconstruction with free vascularised bone grafts; approaches and selection of acceptor vessels. Scand J Surg 2013; 102:42-8. [PMID: 23628636 DOI: 10.1177/145749691310200109] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The use of free vascularised bone grafts is an infrequently performed surgical technique for the reconstruction of spinal defects. This field of surgery brings many challenges concerning the choice of free vascularised bone graft, planning of the operative procedure and selection of recipient vessels. This study aims to report our experience with free vascularised bone grafts, with special emphasis on the surgical approach and the selection of recipient vessels. Over a period of 17 years (1994-2011), we used these grafts for anterior spinal reconstruction in 30 patients. In 28 patients, a free vascularised fibular graft was used, and in two cases a free vascularised iliac crest graft was used. The spinal segments reconstructed involved the cervical or cervicothoracic spine (6 cases), the thoracic spine (11 cases) and the thoracolumbar and lumbosacral spine (13 cases). Revascularisation of the free vascularised bone graft proved to be technically feasible in 30 patients, but failed in one fibular graft due to difficulties with recipient vessels in the lumbar region. Technical challenges were met with respect to the choice of the recipient vessel at various anatomical sites. Availability of acceptor vessels was highly de-pendant of the type of surgery (resection or stabilisation) and the selected surgical approach. Based on these findings, a preferred approach is given for each region. The use of free vascularised bone grafts is a valuable technique for the reconstruction of complex spinal disorders. Successful execution requires microvascular expertise with respect to graft harvesting and appropriate choice of recipient vessels. Adequate preoperative planning in a multidisciplinary setting and adherence to the basic principles for spinal reconstruction are required.
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Affiliation(s)
- H A H Winters
- Department of Plastic and Reconstructive Surgery, VU University Medical Center, Amsterdam, The Netherlands.
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Aliano KA, Agulnick M, Cohen B, Gonya G, Low C, Stavrides S, Addona T, Goncalves J, Shin D, Kilgo MS, Davenport TA. Spinal reconstruction for osteomyelitis with free vascularized fibular grafts using intra-abdominal recipient vessels: A series of three cases. Microsurgery 2013; 33:560-6. [DOI: 10.1002/micr.22150] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Revised: 05/15/2013] [Accepted: 05/28/2013] [Indexed: 11/11/2022]
Affiliation(s)
| | | | | | | | | | | | | | - John Goncalves
- Division of Cardiothoracic Surgery; Winthrop University Hospital; Mineola NY
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Abstract
Since the advent of the operating microscope by Julius Jacobson in 1960, reconstructive microsurgery has become an integral part of extremity reconstruction and orthopaedics. During World War I, with the influx of severe extremity trauma Harold Gillies introduced the concept of the reconstructive ladder for wound closure. The concept of the reconstructive ladder goes from simple to complex means of attaining wound closure. Over the last half century microsurgery has continued to evolve and progress. We now have a microsurgical reconstructive ladder. The microsurgical reconstruction ladder is based upon the early work on revascularization and replantation extending through the procedures that are described in this article.
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Affiliation(s)
- Scott M Tintle
- University of Pennsylvania, Philadelphia, PA, United States
| | - L Scott Levin
- University of Pennsylvania, Philadelphia, PA, United States.
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Abstract
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.
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Thankappan K, Duarah S, Trivedi NP, Panikar D, Kuriakose MA, Iyer S. Vascularised fibula osteocutaneous flap for cervical spinal and posterior pharyngeal wall reconstruction. Indian J Plast Surg 2010; 42:252-4. [PMID: 20368870 PMCID: PMC2845377 DOI: 10.4103/0970-0358.59294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Krishnakumar Thankappan
- Department of Head and Neck Surgery, Amrita Institute of Medical Sciences, Elamakkara, Kochi, India
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Winters H, van Engeland A, Jiya T, van Royen B. The use of free vascularised bone grafts in spinal reconstruction. J Plast Reconstr Aesthet Surg 2010; 63:516-23. [DOI: 10.1016/j.bjps.2008.11.037] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2008] [Revised: 09/19/2008] [Accepted: 11/07/2008] [Indexed: 11/24/2022]
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Moran SL, Bakri K, Mardini S, Shin AY, Bishop AT. The use of vascularized fibular grafts for the reconstruction of spinal and sacral defects. Microsurgery 2009; 29:393-400. [DOI: 10.1002/micr.20655] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Bourdais L, Hamel A, Hamel O, Pannier M, Duteille F. Intérêt d’un péroné vascularisé pour la reconstruction du rachis dans le cadre d’une neurofibromatose de type 1. ANN CHIR PLAST ESTH 2008; 53:293-7. [DOI: 10.1016/j.anplas.2007.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2007] [Accepted: 05/11/2007] [Indexed: 11/24/2022]
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[Anterior cervical fusion in the lower cervical spine. Locked vs nonlocked screw plate, pure cancellous bone vs tricortical strut]. Chirurg 2008; 79:461-73. [PMID: 18214399 DOI: 10.1007/s00104-007-1454-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Physical alterations in cervical fusions endanger healing. Experimentally we determined less stability loss in fixations using cancellous bone grafts than in those using tricortical grafts. Four hundred eighty-five Patients underwent anterior cervical fusion, for a total of 700 Segments. Patients were divided into four groups: (1) nonlocked H plate with autogenous cancellous bone, (2) nonlocked H plate with autogenous tricortical graft, (3) locked cervical plate with tricortical graft, and (4) stand-alone cage with cancellous bone. Evaluations included X-ray and random CT scan examinations. Our results suggest that anterior cervical fusions using nonlocked H screw plate systems with pure autogenous cancellous bone grafts provide the fastest (6 weeks) and most secure bone healing (P=0.00001), whereas fixations using nonlocked or locked screw plate systems and tricortical autograft require prolonged healing and develop nonunions more frequently. Complete consolidation was achieved using stand-alone cages filled with pure autogenous cancellous bone, but bony healing was delayed due to the cage. Rate of nonunions were: groups 1 and 4 0%, and groups 2 and 3 4.5% and 21%, respectively.
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Abstract
The use of vascularized bone grafts in complex spine reconstruction is particularly attractive in situations that involve large segmental bone defects, failed previous attempts at arthrodesis, poor soft tissue beds secondary to infection or radiation exposure necrosis or failed arthrodesis in neuromuscular disease processes. This article details the indications and rationale for vascularized bone grafting as well as the results of vascularized bone grafting of the spine.
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Affiliation(s)
- Alexander Y Shin
- Department of Orthopedic Surgery, Division of Hand Surgery, Mayo Clinic, Clinic 200 1st Street SW, Rochester, MN 55905, USA.
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