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Agnihotri I, Nayak BB, Lakhotia P, Patnaik A, Mohanty RR. Comparative Study of Degree of Great Toe Movement after Complete and Partial Flexor Hallucis Longus Harvest in Free Fibula Flap. Indian J Plast Surg 2024; 57:192-200. [PMID: 39139694 PMCID: PMC11319024 DOI: 10.1055/s-0044-1786989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2024] Open
Abstract
Background The flexor hallucis longus (FHL) muscle is crucial in fine motor control of the great toe but the muscle is often sacrificed in free fibula flap (FFF) reconstruction. The aim of this study was to compare great toe movement between complete and partial FHL resection during FFF harvest to see if FHL can be left behind (without undergoing fibrosis) in situ when bulk is not required at the recipient site. Methods A prospective, cross-sectional, observational study was performed including patients undergoing FFF harvest over a 2-year period. Movement of great toe interphalangeal joint was recorded of operated and unoperated legs in patients undergoing partial and complete FHL harvest and data analyzed. Results There was a statistically significant ( p < 0.05) difference between the two groups of patients. Conclusion FHL can be safely left in situ in patients not requiring bulk at the recipient site as blood supply, nerve supply, and muscle function are not compromised in partial FHL harvest. Further image-based and dye-based studies are warranted.
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Affiliation(s)
- Ishan Agnihotri
- Department of Plastic and Reconstructive Surgery, S.C.B. Medical College, Cuttack, Odisha, India
| | - Bibhuti Bhusan Nayak
- Department of Plastic and Reconstructive Surgery, S.C.B. Medical College, Cuttack, Odisha, India
| | - Puja Lakhotia
- Department of ENT, SUM Ultimate Medicare, Bhubaneswar, Odisha, India
| | - Aashish Patnaik
- Department of Plastic and Reconstructive Surgery, S.C.B. Medical College, Cuttack, Odisha, India
| | - Rasmi Ranjan Mohanty
- Department of Plastic and Reconstructive Surgery, S.C.B. Medical College, Cuttack, Odisha, India
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Warmerdam E, Horn D, Filip R, Freier K, Ganse B, Classen C. Gait asymmetries after fibular free flap harvest: A cross-sectional observational study. Clin Biomech (Bristol, Avon) 2024; 115:106259. [PMID: 38714110 DOI: 10.1016/j.clinbiomech.2024.106259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 04/23/2024] [Accepted: 04/30/2024] [Indexed: 05/09/2024]
Abstract
BACKGROUND The ability to walk safely after head and neck reconstruction with fibular free flaps in tumor surgery is a high priority for patients. In addition, surgeons and patients require objective knowledge of the functional donor-site morbidity. However, the effects of fibular free flap surgery on gait asymmetries have only been studied for step length and stance duration. This study analyses whether patients who have undergone fibular free flap reconstruction have enduring gait asymmetries compared to age-matched controls. METHODS Patients who underwent head and neck reconstruction with fibular free flaps between 2019 and 2023 were recruited, as well as age-matched controls. Participants walked on an instrumented treadmill at 3 km/h. The primary outcome measures were 22 gait asymmetry metrics. Secondary outcome measures were the associations of gait asymmetry with the length of the harvested fibula, and with the time after surgery. FINDINGS Nine out of 13 recruited patients completed the full assessment without holding on to the handrail on the treadmill. In addition, nine age-matched controls were enrolled. Twenty out of the 22 gait asymmetry parameters of patients were similar to healthy controls, while push-off peak force (p = 0.008) and medial impulse differed (p = 0.003). Gait asymmetry did not correlate with the length of the fibula harvested. Seven gait asymmetry parameters had a strong correlation with the time after surgery. INTERPRETATION On the long-term, fibular free flap reconstruction has only a limited effect on the asymmetry of force-related and temporal gait parameters while walking on a treadmill.
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Affiliation(s)
- Elke Warmerdam
- Werner Siemens-Endowed Chair for Innovative Implant Development (Fracture Healing), Clinics and Institutes of Surgery, Saarland University, 66421 Homburg, Germany.
| | - Dominik Horn
- Department of Maxillo-Facial-Surgery, Saarland University, 66421 Homburg, Germany
| | - Ramona Filip
- Department of Maxillo-Facial-Surgery, Saarland University, 66421 Homburg, Germany
| | - Kolja Freier
- Department of Maxillo-Facial-Surgery, Saarland University, 66421 Homburg, Germany
| | - Bergita Ganse
- Werner Siemens-Endowed Chair for Innovative Implant Development (Fracture Healing), Clinics and Institutes of Surgery, Saarland University, 66421 Homburg, Germany
| | - Carolina Classen
- Department of Maxillo-Facial-Surgery, Saarland University, 66421 Homburg, Germany
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Kim MB, Kim KW, Lee SH, Lee YH. Use of Three-Column Reconstruction and Free Vascularized Fibular Grafts for the Repair of Large Tibial Defects after Tumor Resection. Clin Orthop Surg 2023; 15:1029-1035. [PMID: 38045591 PMCID: PMC10689222 DOI: 10.4055/cios22298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 06/09/2023] [Accepted: 06/09/2023] [Indexed: 12/05/2023] Open
Abstract
Background This study aimed to evaluate the clinical outcomes of three-column reconstruction of the lower leg using a single-barrel contralateral vascularized fibular graft (VFG), medial locking plate, and the ipsilateral fibula for the repair of large tibial defects after tumor resection. Methods In this retrospective study, we reviewed 12 patients who underwent three-column reconstruction using a single-barrel contralateral VFG, medial locking plate, and the ipsilateral fibula between June 1996 and May 2020. These patients had large tibial bone defects following tumor resection. The mean age of the patients was 26.3 years (range, 11-63 years), and 7 of them were women. The mean follow-up period was 104.8 months (range, 26-284 months). The mean size of the tibial bone defect after tumor resection was 17.8 cm (range, 11-26.8 cm). The clinical and radiological outcomes were evaluated at the final follow-up. Results All patients survived beyond the final follow-up without recurrence of the primary bone tumor. The mean time from reconstruction to bony union at both host-graft junctions was 12.9 months (range, 4-36 months). The mean Musculoskeletal Tumor Society score was 82.3% (range, 60%-97%). All tibial defects were reconstructed with adequate bone healing. There were 4 cases of stress fracture and graft failure; these were resolved by using longer plates and more screws. All patients were ambulatory without assistance and showed no permanent complications. Conclusions Large tibial defects that occur after tumoral resection can be effectively reconstructed by three-column reconstruction using a medial locking plate, an inlay single-barrel VFG harvested from the contralateral side, and the intact ipsilateral fibula. This technique permits early weight-bearing before fibular hypertrophy and bony union.
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Affiliation(s)
- Min Bom Kim
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung Wook Kim
- Department of Orthopaedic Surgery, Dankook University Hospital, Cheonan, Korea
| | - Seung Hoo Lee
- Department of Orthopaedic Surgery, Chungnam National University Sejong Hospital, Chungnam National University College of Medicine, Sejong, Korea
| | - Young Ho Lee
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Russell J, Volker G, McGarvey D, Sharpe C, Breik O, Borgna SC, Pateman K, Batstone M. An objective analysis of composite free flap donor site morbidity in head and neck surgery: Prospective series. Head Neck 2023; 45:398-408. [PMID: 36437486 PMCID: PMC10098479 DOI: 10.1002/hed.27254] [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: 09/07/2022] [Revised: 10/25/2022] [Accepted: 11/09/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND A poor evidence basis exists regarding the objective donor site morbidity associated with osseous free flap harvest. This study prospectively assessed the objective donor site morbidity associated with osseous free flap harvest for the fibula, scapula, and iliac crest (DCIA) donor sites. METHODS A single-site, prospective cohort clinical research study was conducted. Sixty-four patients were recruited between 2017 and 2021. Patients were assessed using a donor site specific assessment tool pre-operatively, and again >12 months post-operatively. RESULTS There was a significant reduction post-operatively in assessment tool scores compared to the pre-operative period for the fibula, scapula and DCIA. Females were more likely to report a greater reduction in Harris Hip Score post-operatively compared to males. CONCLUSIONS The fibula, scapula, and DCIA donor sites are associated with reduced objective function post-operatively compared to patient's pre-operative baseline. The implications are least pronounced for the fibula.
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Affiliation(s)
- Joshua Russell
- Faculty of MedicineThe University of QueenslandHerstonQueenslandAustralia
| | - Glen Volker
- Department of PhysiotherapyRoyal Brisbane and Women's HospitalHerstonQueenslandAustralia
| | - Declan McGarvey
- Department of PhysiotherapyRoyal Brisbane and Women's HospitalHerstonQueenslandAustralia
| | - Catherine Sharpe
- Department of PhysiotherapyRoyal Brisbane and Women's HospitalHerstonQueenslandAustralia
| | - Omar Breik
- Maxillofacial DepartmentRoyal Brisbane and Women's HospitalHerstonQueenslandAustralia
| | - Scott C. Borgna
- Maxillofacial DepartmentRoyal Brisbane and Women's HospitalHerstonQueenslandAustralia
| | - Kelsey Pateman
- The University of QueenslandSchool of DentistryHerstonQueenslandAustralia
| | - Martin Batstone
- Maxillofacial DepartmentRoyal Brisbane and Women's HospitalHerstonQueenslandAustralia
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Raguse JD, Trampuz A, Boehm MS, Nahles S, Beck-Broichsitter B, Heiland M, Neckel N. Replacing one evil with another: Is the fibula really a dispensable spare part available for transfer in patients with medication-related osteonecrosis of the jaws? Oral Surg Oral Med Oral Pathol Oral Radiol 2020; 129:e257-e263. [PMID: 32102764 DOI: 10.1016/j.oooo.2019.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/18/2019] [Accepted: 10/15/2019] [Indexed: 11/26/2022]
Abstract
Because of the long-term and consecutive use of different causative agents, clinicians are increasingly encountering patients needing restoration of the stomatognathic system after surgical resection of highly advanced necroses of the jaw. For plastic restoration in these cases, microvascular reconstruction seems to represent the most viable option. According to the limited data available, the risks of this operation are considered comparable with those faced by other patient cohorts. We report here the case of a patient who suffered 2 successive pathologic fractures of the tibia after microsurgical reconstruction of the mandible with a free fibula flap. This exemplifies a general problem, especially because the patient also suffered from a treatment-refractory infection of the transplanted bone. Although the present literature indicates otherwise, fibula transplants might not be the gold standard in these cases. Therefore, alternatives to transplants from the weight-bearing parts of the body need to be considered until more data are available.
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Affiliation(s)
- Jan-Dirk Raguse
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Oral and Maxillofacial Surgery, Germany
| | - Andrej Trampuz
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Infectiology and Septic Surgery, Germany
| | | | - Susanne Nahles
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Oral and Maxillofacial Surgery, Germany
| | - Benedicta Beck-Broichsitter
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Oral and Maxillofacial Surgery, Germany
| | - Max Heiland
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Oral and Maxillofacial Surgery, Germany
| | - Norbert Neckel
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Oral and Maxillofacial Surgery, Germany.
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Maben D, Anehosur V, Kumar N. Assessment of Donor Site Morbidity Following Fibula Flap Transfer. J Maxillofac Oral Surg 2020; 20:258-263. [PMID: 33927495 DOI: 10.1007/s12663-020-01337-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 02/04/2020] [Indexed: 11/27/2022] Open
Abstract
Purpose To assess donor site morbidity for patients who underwent mandibular reconstruction by fibula free flap. Patients and Methods The data were recorded from medical records and clinical questioner of patients from 2013 to 2016. Predictor variables were drawn from demographics of patients who had mandible defect reconstructed with free fibula flap. The outcome variables were drawn from point evaluation system for pain, walking ability, activities of daily living, gait alteration, cosmetic appearance using validated 10-point self-assessment scale. The assessment was done postoperatively at intervals of 15 days, 1 month, 3 months and 6 months. ANOVA test was used to measure the statistical significance. Results There was significant reduction in perception of pain, significant improvement in walking ability, activities of daily living, gait and cosmetic appearance postoperatively after 6 months (P < 0.005). Conclusion Point evaluation system is a simple and effective tool to understand the postoperative morbidity. Donor site morbidity following fibula harvest was low without any major complications.
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Affiliation(s)
- Daniel Maben
- SDM Craniofacial Unit and Research Centre, SDM College of Dental Sciences and Hospital, Shri Dharmasthala Manjunatheshwara University, Sattur, Dharwad, Karnataka 580009 India
| | - Venkatesh Anehosur
- SDM Craniofacial Unit and Research Centre, SDM College of Dental Sciences and Hospital, Shri Dharmasthala Manjunatheshwara University, Sattur, Dharwad, Karnataka 580009 India
| | - Niranjan Kumar
- Department of Plastic Surgery, SDM Craniofacial Unit and Research Centre, SDM College of Medical Sciences and Hospital, Shri Dharmasthala Manjunatheshwara University, Sattur, Dharwad, Karnataka 580009 India
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Ni Y, Zhang X, Zhang Z, Liang W, Zhao L, Li Z, Li S, Lu P, Xu Z, Dai W, Duan W, Tan X, Sun C, Liu F. Assessment of fibula flap with flexor hallucis longus's effect on head & neck tumor patients' quality of life and function of donor site. Oral Oncol 2019; 100:104489. [PMID: 31785451 DOI: 10.1016/j.oraloncology.2019.104489] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 11/04/2019] [Accepted: 11/21/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Free fibular flaps (FFFs) have been widely used in mandibular reconstruction. It is still unclear whether retaining flexor hallucis longus (FHL) is needed for flaps. This study introduces a comparison in quality of life and donor-site function between those who have and haven't harvested FHL with FFF. METHODS Patients with FFFs were single-blind-randomly assigned into the FHL group or nFHL group. Patients were followed up preoperatively and 1, 3 and 6 months postoperatively via subjective evaluations (SF-36/AOFAS) and objective evaluation s(muscle strength and range of motion). Patients' hospitalization and intraoperative information, donor site morbidity were recorded. RESULTS Each group had 15 patients. The flap harvesting time in FHL group was shorter significantly than nFHL group (125.9 ± 24.8 min vs 146.7 ± 29.9 min, P = 0.048). There were no significant differences in hospitalization information such as operation time, hospitalization days and cost. Donor site morbidities at 1, 3 and 6 months postoperatively showed no significant differences except for the presence of claw toes (nFHL group > FHL group, 40% vs 0, P = 0.017; 53.3% vs 6.7%, P = 0.014; 60.0% vs 13.3%, P = 0.021). There were no significant differences in SF-36 and AOFAS scores. There were no significant differences in muscle strength and range of motion. CONCLUSION Excision of the FHL lowered the flap harvesting time. It did not increase donor site morbidity. The impacts on patients' quality of life and foot function were the same. The surgeons can use the FHL without considering the influence on patients if not retaining the FHL.
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Affiliation(s)
- Youkang Ni
- Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Xuedi Zhang
- Department of Anesthesiology, School of Stomatology, China Medical University, Shenyang, People's Republic of China
| | - Zhiqiang Zhang
- Department of Rehabilitation Medicine, Shengjing Hospital of China Medical University, Shenyang, People's Republic of China.
| | - Weidi Liang
- Department of Rehabilitation Medicine, Shengjing Hospital of China Medical University, Shenyang, People's Republic of China.
| | - Lina Zhao
- Department of Rehabilitation Medicine, Shengjing Hospital of China Medical University, Shenyang, People's Republic of China
| | - Zijia Li
- Department of Oromaxillofacial-Head and Neck Surgery, School of Stomatology, China Medical University, Shenyang, People's Republic of China
| | - Siqi Li
- Department of Oromaxillofacial-Head and Neck Surgery, School of Stomatology, China Medical University, Shenyang, People's Republic of China
| | - Ping Lu
- Department of Oromaxillofacial-Head and Neck Surgery, School of Stomatology, China Medical University, Shenyang, People's Republic of China
| | - Zhongfei Xu
- Department of Oromaxillofacial-Head and Neck Surgery, School of Stomatology, China Medical University, Shenyang, People's Republic of China
| | - Wei Dai
- Department of Oromaxillofacial-Head and Neck Surgery, School of Stomatology, China Medical University, Shenyang, People's Republic of China
| | - Weiyi Duan
- Department of Oromaxillofacial-Head and Neck Surgery, School of Stomatology, China Medical University, Shenyang, People's Republic of China
| | - Xuexin Tan
- Department of Oromaxillofacial-Head and Neck Surgery, School of Stomatology, China Medical University, Shenyang, People's Republic of China
| | - Changfu Sun
- Department of Oromaxillofacial-Head and Neck Surgery, School of Stomatology, China Medical University, Shenyang, People's Republic of China.
| | - Fayu Liu
- Department of Oromaxillofacial-Head and Neck Surgery, School of Stomatology, China Medical University, Shenyang, People's Republic of China.
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Osteocutaneous flaps for head and neck reconstruction: A focused evaluation of donor site morbidity and patient reported outcome measures in different reconstruction options. Arch Plast Surg 2018; 45:495-503. [PMID: 30466228 PMCID: PMC6258970 DOI: 10.5999/aps.2017.01592] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 03/15/2018] [Indexed: 11/08/2022] Open
Abstract
With significant improvements in success rates for free flap reconstruction of the head and neck, attention has turned to donor site morbidity associated with osteocutaneous free flaps. In this review, we address the morbidity associated with harvest of the four most commonly used osteocutaneous flaps; the free fibula flap, the scapula flap, the iliac crest flap and the radial forearm flap. A comprehensive literature search was performed to identify articles relevant to donor site morbidity for these flaps. We assessed morbidity in terms of incidence of delayed healing, chronic pain, aesthetic outcomes, site specific complications and patient satisfaction/quality of life. Weighted means were calculated when sufficient studies were available for review. The radial forearm and free fibula flaps are associated with high rates of delayed healing of approximately 20% compared to the scapular (<10%) and iliac flaps (5%). The radial forearm flap has higher rates of chronic pain (16.7%) and dissatisfaction with scar appearance (33%). For the majority of these patients harvest of one of these four osteocutaneous does not limit daily function at long-term follow-up. The scapular osteocutaneous flap is associated with the lowest relative morbidity and should be strongly considered when the recipient defect allows. The radial forearm is associated with higher morbidity in terms of scarring, fractures, chronic pain and wrist function and should not be considered as first choice when other flap options are available.
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Abstract
PURPOSE To investigate morbidity related to harversting of bilateral fibula free flap for head and neck reconstruction using subjective and functional tests. METHODS Patients were retrospectively evaluated using point evaluation system (PES) and balance evaluation systems test (BESTest) questionnaires to assess morbidity related to surgery. RESULTS Five patients were enrolled in the study. Mean PES scores was 22.2 over 24. Mean overall function assessed with BESTest was 77.6%, and the results were poorest for section I. Sections V and VI had scores of 88% and 83%, respectively, indicating that the sensory balance and gait stability of the patients were compromised only minimally. CONCLUSION Bilateral harvesting of the fibula free flap is not associated with an increase in long-term morbidity and does not lead to significant functional impairments. Therefore, this procedure should be considered safe, and can be performed without concern regarding morbidity, when bone reconstruction with a fibula free flap is indicated.
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Lin P, Shao Y, Lu H, Zhang Z, Lin H, Wang S, Li B, Li H, Wang Z, Lin N, Ye Z. Pelvic reconstruction with different rod-screw systems following Enneking type I/I + IV resection: a clinical study. Oncotarget 2018; 8:38978-38989. [PMID: 28465495 PMCID: PMC5503588 DOI: 10.18632/oncotarget.17164] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 04/03/2017] [Indexed: 11/29/2022] Open
Abstract
The mechanical outcomes of patients with pelvic bone tumors involving zone I or zone I + IV who received resection and different reconstructions are not clear. Therefore, the purpose of this study was to compare the outcomes of different rod-screw systems in reconstruction for these patients, and evaluate the relative risk of mechanical failure for them. We reviewed 30 patients for a mean duration of 40.4 months of follow-up (range, 13.1–162.2 months), five patients had mechanical complications. The mechanical survival rate of two-rod and four-screw (TRFS) group was significantly higher than one-rod and two-screw (ORTS) group (p = 0.000). The implant survival rate was correlated with ages (p = 0.010), younger people are more likely to fail. Thus, TRFS fixation for pelvic reconstruction after Enneking type I/I + IV resection can provide better short to long-term mechanical stability compared with ORTS fixation, the strength of ORTS fixation is not enough. In addition, biological reconstruction such as autologous bone graft is recommended for the patients who are younger or suffered from benign tumor. As for the patients who are older, with malignant tumors, underwent adjuvant radiotherapy or chemotherapy, functional reconstruction with bone cement is a good choice.
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Affiliation(s)
- Peng Lin
- Department of Orthopaedics, The Second Affiliated Hospital of Zhejiang University School of Medicine/Orthopedics Research Institute of Zhejiang University, Hangzhou 310009, China.,Department of Orthopaedics, Taizhou Hospital of Zhejiang Province, Linhai 317000, China
| | - Youyou Shao
- Department of Pediatric Pulmonology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou 325027, China
| | - Huigen Lu
- Department of Orthopaedics, The Second Affiliated Hospital of Zhejiang University School of Medicine/Orthopedics Research Institute of Zhejiang University, Hangzhou 310009, China.,Department of Orthopaedics, The Second Hospital of Jiaxing, Jiaxing 314000, China
| | - Zhengliang Zhang
- Department of Orthopaedics, The Second Affiliated Hospital of Zhejiang University School of Medicine/Orthopedics Research Institute of Zhejiang University, Hangzhou 310009, China.,Department of Orthopaedics, Dongyang People's Hospital, Jinhua 322100, China
| | - Haiqing Lin
- Department of Orthopaedics, The Second Affiliated Hospital of Zhejiang University School of Medicine/Orthopedics Research Institute of Zhejiang University, Hangzhou 310009, China.,Department of Orthopaedics, The Second Hospital of Jiaxing, Jiaxing 314000, China
| | - Shengdong Wang
- Department of Orthopaedics, The Second Affiliated Hospital of Zhejiang University School of Medicine/Orthopedics Research Institute of Zhejiang University, Hangzhou 310009, China
| | - Binghao Li
- Department of Orthopaedics, The Second Affiliated Hospital of Zhejiang University School of Medicine/Orthopedics Research Institute of Zhejiang University, Hangzhou 310009, China
| | - Hengyuan Li
- Department of Orthopaedics, The Second Affiliated Hospital of Zhejiang University School of Medicine/Orthopedics Research Institute of Zhejiang University, Hangzhou 310009, China
| | - Zhan Wang
- Department of Orthopaedics, The Second Affiliated Hospital of Zhejiang University School of Medicine/Orthopedics Research Institute of Zhejiang University, Hangzhou 310009, China
| | - Nong Lin
- Department of Orthopaedics, The Second Affiliated Hospital of Zhejiang University School of Medicine/Orthopedics Research Institute of Zhejiang University, Hangzhou 310009, China
| | - Zhaoming Ye
- Department of Orthopaedics, The Second Affiliated Hospital of Zhejiang University School of Medicine/Orthopedics Research Institute of Zhejiang University, Hangzhou 310009, China
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Nie Y, Huang Z, Xu B, Shen B, Kraus VB, Pei F. Evidence and mechanism by which upper partial fibulectomy improves knee biomechanics and decreases knee pain of osteoarthritis. J Orthop Res 2018; 36:10.1002/jor.23867. [PMID: 29424452 PMCID: PMC7480762 DOI: 10.1002/jor.23867] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 02/07/2018] [Indexed: 02/05/2023]
Abstract
To investigate the change in short-term clinical outcomes and biomechanical properties of the knee in response to upper partial fibulectomy and to probe into the biomechanical mechanism underlying the clinical benefits of upper partial fibulectomy for medial compartment knee osteoarthritis (KOA). A total of 29 patients with medial compartment KOA underwent upper partial fibulectomy. Visual analog scale (VAS) pain, the hospital for special surgery knee score (HSS), hip-knee-ankle (HKA) angle (measured in the frontal plane), and flexion/extension range of motion of the knee were assessed before and up to 6 months after surgery. Patients and 20 healthy controls were evaluated by 3D gait analysis and dynamic lower limb musculoskeletal analysis. Both VAS pain and HSS score were significantly improved (p < 0.001) one day after surgery and steadily improved during the subsequent 6 months. HKA angle improved (p = 0.025) immediately and remained stable by 3 months after surgery. The decreased overall peak KAM (decreased by 11.1%) and increased HKA angle (increased by 1.80 degrees from a more varus to more neutral alignment) of affected and operated side by 6 months after surgery were observed. Muscle activity of biceps femoris caput longum of affected and operated side increased immediately and was equivalent to healthy controls by 6 months after surgery (p = 0.007). This pilot study provides biomechanical evidence of benefit from partial upper fibulectomy and indicates a plausible rationale for the improvement in clinical symptoms. Long-term clinical outcomes and precise biomechanical mechanism of partial upper fibulectomy should be further investigated. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 9999:1-10, 2018.
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Affiliation(s)
- Yong Nie
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, SiChuan University, ChengDu, SiChuan Province, People’s Republic of China
| | - ZeYu Huang
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, SiChuan University, ChengDu, SiChuan Province, People’s Republic of China
- Duke Molecular Physiology Institute, Duke University School of Medicine, Duke University, Durham, NC, United States
| | - Bin Xu
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, SiChuan University, ChengDu, SiChuan Province, People’s Republic of China
| | - Bin Shen
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, SiChuan University, ChengDu, SiChuan Province, People’s Republic of China
| | - Virginia Byers Kraus
- Duke Molecular Physiology Institute, Duke University School of Medicine, Duke University, Durham, NC, United States
- Department of Medicine, Division of Rheumatology, Duke University School of Medicine, Duke University, Durham, NC, United States
| | - FuXing Pei
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, SiChuan University, ChengDu, SiChuan Province, People’s Republic of China
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12
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Nie Y, Ma J, Huang Z, Xu B, Tang S, Shen B, Kraus VB, Pei F. Upper partial fibulectomy improves knee biomechanics and function and decreases knee pain of osteoarthritis: A pilot and biomechanical study. J Biomech 2017; 71:22-29. [PMID: 29449003 DOI: 10.1016/j.jbiomech.2017.12.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 11/30/2017] [Accepted: 12/04/2017] [Indexed: 02/05/2023]
Abstract
To investigate the change in clinical outcomes and biomechanical properties of the knee in response to upper partial fibulectomy. Sixteen patients with medial compartment knee osteoarthritis (KOA) underwent upper partial fibulectomy. Visual analog scale (VAS) pain, the hospital for special surgery knee score (HSS), hip-knee-ankle (HKA) angle (measured in the frontal plane), and flexion/extension range of motion of the knee were assessed before and up to 6 months after surgery. Patients were evaluated for gait parameters and overall peak knee adduction moment (KAM). Patient-specific finite element knee models were developed to investigate changes in load in response to fibulectomy. Both VAS pain and HSS score were significantly improved (P < .001) one day after surgery and steadily improved during the subsequent 6 months. HKA angle improved (P = .006) immediately and remained stable by 3 months after surgery. A significant inverse relationship (R = -0.528, P = .012) between the overall peak KAM (decreased by 19.1%) and the HKA (increased by 1.24° from a more varus to more neutral alignment) angle was observed. The minor load supported by the fibula preoperatively was spread post-operatively over the cortical bone of the tibial shaft. The mean stress in the medial tibial plateau was significantly decreased (P < .001), with a portion of the stress transferred to the posterior-lateral region of the tibial plateau after upper partial fibulectomy. This pilot study provides objective 3D gait and plausible biomechanical evidence for the improvement in clinical symptoms from partial upper fibulectomy.
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Affiliation(s)
- Yong Nie
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, SiChuan University, ChengDu, SiChuan Province, People's Republic of China.
| | - Jun Ma
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, SiChuan University, ChengDu, SiChuan Province, People's Republic of China.
| | - ZeYu Huang
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, SiChuan University, ChengDu, SiChuan Province, People's Republic of China; Duke Molecular Physiology Institute, Duke University School of Medicine, Duke University, Durham, NC, United States.
| | - Bin Xu
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, SiChuan University, ChengDu, SiChuan Province, People's Republic of China.
| | - Shuo Tang
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, SiChuan University, ChengDu, SiChuan Province, People's Republic of China.
| | - Bin Shen
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, SiChuan University, ChengDu, SiChuan Province, People's Republic of China.
| | - Virginia Byers Kraus
- Duke Molecular Physiology Institute, Duke University School of Medicine, Duke University, Durham, NC, United States; Department of Medicine, Division of Rheumatology, Duke University School of Medicine, Duke University, Durham, NC, United States.
| | - FuXing Pei
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, SiChuan University, ChengDu, SiChuan Province, People's Republic of China.
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Spalthoff S, Zimmerer R, Dittmann J, Kokemüller H, Tiede M, Flohr L, Korn P, Gellrich NC, Jehn P. Heterotopic bone formation in the musculus latissimus dorsi of sheep using β-tricalcium phosphate scaffolds: evaluation of different seeding techniques. Regen Biomater 2017; 5:77-84. [PMID: 29644089 PMCID: PMC5888254 DOI: 10.1093/rb/rbx029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 09/27/2017] [Accepted: 09/28/2017] [Indexed: 12/21/2022] Open
Abstract
Osseous reconstruction of large bone defects remains a challenge in oral and maxillofacial surgery. In addition to autogenous bone grafts, which despite potential donor-site mobility still represent the gold standard in reconstructive surgery, many studies have investigated less invasive alternatives such as in vitro cultivation techniques. This study compared different types of seeding techniques on pure β-tricalcium phosphate scaffolds in terms of bone formation and ceramic resorption in vivo. Cylindrical scaffolds loaded with autologous cancellous bone, venous blood, bone marrow aspirate concentrate or extracorporeal in vitro cultivated bone marrow stromal cells were cultured in sheep on a perforator vessel of the musculus latissimus dorsi over a 6-month period. Histological and histomorphometric analyses revealed that scaffolds loaded with cancellous bone were superior at promoting heterotopic bone formation and ceramic degradation, with autogenous bone and bone marrow aspirate concentrate inducing in vivo formation of vital bone tissue. These results confirm that autologous bone constitutes the preferred source of osteoinductive and osteogenic material that can reliably induce heterotopic bone formation in vivo.
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Affiliation(s)
- Simon Spalthoff
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany and
- Correspondence address. Department of Oral and Maxillofacial Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany. Tel: +49-511-532-4879; Fax: +49-511-532-18598; E-mail:
| | - Rüdiger Zimmerer
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany and
| | - Jan Dittmann
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany and
| | - Horst Kokemüller
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany and
| | - Marco Tiede
- Department of Conservative Dentistry, Periodontology and Preventive Dentistry, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany
| | - Laura Flohr
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany and
| | - Philippe Korn
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany and
| | - Nils-Claudius Gellrich
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany and
| | - Philipp Jehn
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany and
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Rendenbach C, Rashad A, Hansen L, Kohlmeier C, Dyck ML, Suling A, Assaf AT, Amling M, Heiland M, Wikner J, Riecke B, Kreutzer K. Functional donor site morbidity longer than one year after fibula free flap: A prospective biomechanical analysis. Microsurgery 2017; 38:395-401. [PMID: 28745438 DOI: 10.1002/micr.30205] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 06/16/2017] [Accepted: 07/12/2017] [Indexed: 11/10/2022]
Abstract
OBJECTIVES The fibula free flap is the workhorse procedure for osseous reconstruction. The objective of this study was to investigate long-term functional outcomes of the harvesting site. PATIENTS AND METHODS About 19 patients (10 male, 9 female, mean age 58.1 years) were available for the long-term analysis 13-51 months after surgery. Jumping mechanography and balance testing on a ground force reaction plate (Leonardo Mechanograph GFRP) were performed before and surgery. The Esslinger Fitness Index (EFI, maximum peak power in W/kg normalized for age and gender) was considered as primary endpoint. Secondary outcomes were maximum force, range of motion in the ankle joint, sensory limitations, the American Orthopedic Foot and Ankle Society Score (AOFAS-Score), and subjective perceptions. RESULTS We found no significant difference between pre- and postoperative EFI (70.4% versus 66.0%, P = 0.07) and body sway (1.72 cm2 versus 2.60 cm2 , P = 0.093). The AOFAS-Score was reduced by 8.8 points (99.1 points versus 90.3 points, P < 0.001). Dorsal extenstion (31.6° versus 24.1°, P < 0.001) and flexion (32.3 versus 25.6° flexion, P = 0.011) were significantly reduced and 6 patients had chronic pain. CONCLUSIONS Reduced peak power and balance ability seem to be reversible short-term effects after fibula harvesting. We recommend preoperative patient education and standardized protocols for physiotherapy.
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Affiliation(s)
- Carsten Rendenbach
- Department of Oral & Maxillofacial Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Ashkan Rashad
- Department of Oral & Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, Hamburg, 20246, Germany
| | - Lara Hansen
- Department of Oral & Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, Hamburg, 20246, Germany
| | - Carsten Kohlmeier
- Department of Oral & Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, Hamburg, 20246, Germany
| | - Moritz L Dyck
- Department of Oral & Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, Hamburg, 20246, Germany
| | - Anna Suling
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, Hamburg, 20246, Germany
| | - Alexandre T Assaf
- Department of Oral & Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, Hamburg, 20246, Germany
| | - Michael Amling
- Institute of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, Hamburg, 20246, Germany
| | - Max Heiland
- Department of Oral & Maxillofacial Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Johannes Wikner
- Department of Oral & Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, Hamburg, 20246, Germany
| | - Bjoern Riecke
- Department of Oral & Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, Hamburg, 20246, Germany
| | - Kilian Kreutzer
- Department of Oral & Maxillofacial Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, Berlin, 13353, Germany
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Schardt C, Schmid A, Bodem J, Krisam J, Hoffmann J, Mertens C. Donor site morbidity and quality of life after microvascular head and neck reconstruction with free fibula and deep-circumflex iliac artery flaps. J Craniomaxillofac Surg 2017; 45:304-311. [DOI: 10.1016/j.jcms.2016.11.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 10/10/2016] [Accepted: 11/22/2016] [Indexed: 12/31/2022] Open
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16
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Carli A, Albers A, Séguin C, Harvey EJ. The Medical and Surgical Treatment of ARCO Stage-I and II Osteonecrosis of the Femoral Head: A Critical Analysis Review. JBJS Rev 2016; 2:01874474-201402000-00002. [PMID: 27490931 DOI: 10.2106/jbjs.rvw.m.00066] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Alberto Carli
- McGill University Health Center, Shriners Hospital for Children, 1529 Cedar Avenue, Montreal, Quebec, Canada H3G 1A6
| | - Anthony Albers
- McGill University Health Center, Shriners Hospital for Children, 1529 Cedar Avenue, Montreal, Quebec, Canada H3G 1A6
| | - Chantal Séguin
- McGill University Health Center, Department of Hematology and Oncology, Montreal General Hospital B7, 1650 Cedar Avenue, Montreal, Quebec, Canada H3G 1A4
| | - Edward J Harvey
- McGill University Health Center, Montreal General Hospital B5, 1650 Cedar Avenue, Montreal, Quebec, Canada H3G 1A4
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17
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Rendenbach C, Kohlmeier C, Suling A, Assaf AT, Catala-Lehnen P, Amling M, Heiland M, Riecke B. Prospective biomechanical analysis of donor-site morbidity after fibula free flap. J Craniomaxillofac Surg 2016; 44:155-9. [DOI: 10.1016/j.jcms.2015.10.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 09/29/2015] [Accepted: 10/26/2015] [Indexed: 11/16/2022] Open
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18
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Feuvrier D, Sagawa Y, Béliard S, Pauchot J, Decavel P. Long-term donor-site morbidity after vascularized free fibula flap harvesting: Clinical and gait analysis. J Plast Reconstr Aesthet Surg 2015; 69:262-9. [PMID: 26602741 DOI: 10.1016/j.bjps.2015.10.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 10/01/2015] [Accepted: 10/05/2015] [Indexed: 11/16/2022]
Abstract
The aim of this study was to determine the clinical morbidity and changes in gait temporal spatial parameters after harvesting of a vascularized free fibula flap. This study included 11 patients (mean age: 52 ± 17 years) and 11 healthy controls (mean age: 50 ± 14 years). The patients were assessed between 5 and 104 months post surgery. The study consisted of a subjective functional evaluation with two validated clinical scores (Kitaoka Score and Point Evaluation System (PES) score), clinical and neurological examination of the legs, and evaluation of gait temporal spatial parameters while walking at a comfortable speed. The mean functional Kitaoka score was 78/100, and the mean PES score of 12.18 was considered average. At the time of the review, five patients had sensory disorders, two had toe deformities, and eight had pain at the donor site. The gait analysis showed that the patient's comfortable walking speed was significantly lower in comparison to that of the controls, and that stride length and cadence were reduced. In addition, most of the gait-specific parameters were significantly different. The donor leg displayed greater variability during walking. To reduce the risk of falling, this study revealed that the patients' gait pattern had changed as they took a more cautious approach during walking. Early rehabilitation is expected to help improve and/or restore the physical abilities of patients after harvesting of the vascularized free fibula flap.
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Affiliation(s)
- Damien Feuvrier
- Service chirurgie orthopédique et traumatologique, chirurgie plastique, esthétique et reconstructrice, chirurgie de la main, CHRU Jean Minjoz, Besançon, France.
| | - Yoshimasa Sagawa
- Laboratoire d'Exploration Fonctionnelle Clinique du Mouvement, CHRU de Besançon, Besançon, France
| | - Samuel Béliard
- Service de Cardiologie, Angiologie, CH Louis Pasteur, Dole, France; Université de Franche Comté, EA 4267 Fonctions et Dysfonctions Epithéliales, Besançon, France
| | - Julien Pauchot
- Service chirurgie orthopédique et traumatologique, chirurgie plastique, esthétique et reconstructrice, chirurgie de la main, CHRU Jean Minjoz, Besançon, France
| | - Pierre Decavel
- Laboratoire d'Exploration Fonctionnelle Clinique du Mouvement, CHRU de Besançon, Besançon, France
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19
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Paul J, Barg A, Horisberger M, Herrera M, Henninger HB, Valderrabano V. Tibiotalocalcaneal Arthrodesis With an Intramedullary Hindfoot Nail and Pillar Fibula Augmentation: Technical Tip. Foot Ankle Int 2015; 36:984-7. [PMID: 25848135 DOI: 10.1177/1071100715579264] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Jochen Paul
- Orthopaedic Department, University Hospital Basel, Basel, Switzerland
| | - Alexej Barg
- Orthopaedic Department, University Hospital Basel, Basel, Switzerland
| | | | - Mario Herrera
- Orthopaedic Department, University Hospital of Canary Island, Tenerife, Spain
| | - Heath B Henninger
- Harold K. Dunn Orthopaedic Research Laboratory, University Orthopaedic Center, University of Utah, Salt Lake City, USA
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20
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Palmanovich E, Brin YS, Ben David D, Massarwe S, Stern A, Nyska M, Hetsroni I. Use of a spinal cage for creating stable constructs in ankle and subtalar fusion. J Foot Ankle Surg 2015; 54:254-7. [PMID: 25631194 DOI: 10.1053/j.jfas.2014.12.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Indexed: 02/03/2023]
Abstract
In complicated foot surgery with reconstruction of the hindfoot, a gap will sometimes be present between the bones that must be filled and stabilized. Bone grafting with structural bone graft is 1 alternative; however, it can collapse and must be stabilized with screws or a nail. A locking intramedullary nail can be used but could lead to nonunion owing to distraction. Newer nails include a compression device but that can result in shortening. We developed a technique that includes distraction of the fusion area with a spinal cage and then compression of the construct by inserting a compression screw through the cage. We present our experience with this technique.We reviewed the data from 7 patients who had undergone surgery using this technique. The technique included distraction of the fusion area and insertion of a titanium cylindrical spinal cage filled with autologous cancellous bone graft. A cannulated compression screw was then inserted through the cage, creating compression of the fusion area against the cage and achieving stabilization of the fusion area. Postoperatively, a non-weightbearing cast was applied for 3 months, followed by a full weightbearing cast until radiographic fusion was apparent. Complete radiographic union was observed in all 7 patients within 6 to 12 months postoperatively. At the latest follow-up visit, the mean American Orthopaedic Foot and Ankle Society scale score was 54 ± 16 (range 30 to 71) points. The use of a cylindrical titanium cage with a local bone graft and stabilization by distraction and compression provided a stable construct, avoided shortening, and led to good fusion. In addition, donor site complications and unpredictable strength loss and lysis of bone allograft were avoided.
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Affiliation(s)
- Ezequiel Palmanovich
- Orthopedic Surgeon, Department of Orthopaedic Surgery, Meir General Hospital, Kfar-Saba, Israel; Orthopedic Surgeon, Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel.
| | - Yaron S Brin
- Orthopedic Surgeon, Department of Orthopaedic Surgery, Meir General Hospital, Kfar-Saba, Israel; Orthopedic Surgeon, Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Dror Ben David
- Orthopedic Surgeon, Department of Orthopaedic Surgery, Meir General Hospital, Kfar-Saba, Israel; Orthopedic Surgeon, Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Sabri Massarwe
- Orthopedic Surgeon, Department of Orthopaedic Surgery, Meir General Hospital, Kfar-Saba, Israel; Orthopedic Surgeon, Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Abraham Stern
- Orthopedic Surgeon, Department of Orthopaedic Surgery, Meir General Hospital, Kfar-Saba, Israel; Orthopedic Surgeon, Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Meir Nyska
- Orthopedic Surgeon, Department of Orthopaedic Surgery, Meir General Hospital, Kfar-Saba, Israel; Orthopedic Surgeon, Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Iftach Hetsroni
- Orthopedic Surgeon, Department of Orthopaedic Surgery, Meir General Hospital, Kfar-Saba, Israel; Orthopedic Surgeon, Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
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21
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Anđelković SZ, Vučković ČĐ, Palibrk TD, Milutinović SM, Bumbaširević MŽ. Open Dislocation of the High Ankle Joint After Fibular Graft Harvesting. J Foot Ankle Surg 2014; 54:1158-61. [PMID: 25458439 DOI: 10.1053/j.jfas.2014.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Indexed: 02/03/2023]
Abstract
The free microvascular fibula and soft tissue transfer has become a widely used method for reconstruction of different regions. Donor site morbidity for free fibula microvascular flaps has generally been reported to be low, or at least acceptable. We describe the case of a patient who underwent vascularized free fibula graft harvest for mandibular reconstruction. After 21 months, he had sustained an open dislocation of the left high ankle joint during recreational sports activity. We did not found such case in the published data.
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Affiliation(s)
- Slađana Z Anđelković
- Clinical Assistant, Orthopedic and Traumatology Clinic, Clinical Center of Serbia, and Belgrade University School of Medicine, Belgrade, Serbia
| | - Čedo Đ Vučković
- Primarius, Orthopedic and Traumatology Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | - Tomislav D Palibrk
- Orthopedic and Traumatology Clinic, Clinical Center of Serbia, Belgrade, Serbia.
| | | | - Marko Ž Bumbaširević
- Professor, Orthopedic and Traumatology Clinic, Clinical Center of Serbia, and Belgrade University School of Medicine, Belgrade, Serbia
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22
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Li X, Zhu K, Liu F, Li H. Assessment of quality of life in giant ameloblastoma adolescent patients who have had mandible defects reconstructed with a free fibula flap. World J Surg Oncol 2014; 12:201. [PMID: 25004805 PMCID: PMC4113126 DOI: 10.1186/1477-7819-12-201] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 06/29/2014] [Indexed: 12/01/2022] Open
Abstract
Background The reconstruction of mandibular defects after giant ameloblastoma resection is one of the most challenging problems facing reconstructive surgeons. Mandibular resection has been associated with a poor quality of life (QOL), particularly in adolescent patients reconstructed with a free fibula flap. This study aims to evaluate QOL outcomes in adolescent patients who have had mandibular resections of giant ameloblastoma and reconstruction with a free fibula flap and to collect information about their socio-cultural situation. Methods The present study assessed 45 adolescent patients who had undergone immediate mandible reconstruction with a free fibula flap for faint ameloblastoma using University of Washington Quality of Life (UW-QOL) and 14-item Oral Health Impact Profile (OHIP-14) questionnaires. Results Thirty-five of the 54 questionnaires were returned (64.81%). In the UW-QOL, of the twelve disease-specific domains, the best three scores from the patients related to pain, shoulder and appearance and the worst three scores related to chewing, anxiety and saliva. In the OHIP-14, the lowest-scoring domain was handicap, followed by physical pain and social disability. Conclusions Mandibular reconstruction with a free fibular flap significantly influenced the adolescent patients’ QOL. Adolescent patients pay more attention to postoperative facial appearance; this should be considered in surgical planning.
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Affiliation(s)
| | | | | | - Hongwen Li
- Dermatology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou university, Zhengzhou, Henan 450052, China.
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23
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Paul J, Barg A, Horisberger M, Herrera M, Henninger HB, Valderrabano V. Ankle salvage surgery with autologous circular pillar fibula augmentation and intramedullary hindfoot nail. J Foot Ankle Surg 2014; 53:601-5. [PMID: 24795205 DOI: 10.1053/j.jfas.2014.03.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Indexed: 02/03/2023]
Abstract
Tibiotalocalcaneal arthrodesis with an intramedullary hindfoot nail is an established procedure for fusion of the ankle and subtalar joints. In cases involving ankle bone loss, such as in failed total ankle replacement, it can be difficult to salvage with sufficient bone restoration stability and a physiologic leg length and avoiding below the knee amputation. In addition to the alternatives of using a structural allograft or metal bone substitution, we describe the use of autologous ipsilateral circular pillar fibula augmentation in tibiotalocalcaneal retrograde nail arthrodesis combined with a ventral (anterior) plate in a prospective series of 6 consecutive cases with a mean follow-up duration of 26 ± 9.95 (range 12 to 34) months. The 6 patients (3 female and 3 male), with a mean age of 55 ± 13.89 (range 38 to 73) years were treated with revision surgery of the ankle (1 after talectomy, 5 [83.33%] after failed ankle replacement). The visual analog scale for pain and the American Orthopaedic Foot and Ankle Society hindfoot score were used to assess functional outcome, and radiographs and computed tomography scans were used to determine the presence of fusion. All patients improved clinically from pre- to postoperatively in regard to the mean pain visual analog scale score (from 7.5 to 2.0) and American Orthopaedic Foot and Ankle Society hindfoot score (from 29 to 65 points, of an 86-point maximum for fused joints). Radiologically, no loss in the reduction or misalignment of the hindfoot was detected, and all cases fused solid. One patient (16.67%) required hardware removal. The fixation construct provided good clinical and radiologic outcomes, and we recommend it as an alternative to structural allografts or metallic bone grafts for revision ankle surgery with severe bone loss.
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Affiliation(s)
- Jochen Paul
- Orthopaedic Department, University Hospital Basel, Basel, Switzerland
| | - Alexej Barg
- Orthopaedic Department, University Hospital Basel, Basel, Switzerland
| | | | - Mario Herrera
- Orthopaedic Department, University Hospital of Canary Island, Tenerife, Spain
| | - Heath B Henninger
- Harold K. Dunn Orthopaedic Research Laboratory, University Orthopaedic Center, University of Utah, Salt Lake City, UT
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Zhu J, Yang Y, Li W. Assessment of quality of life and sociocultural aspects in patients with ameloblastoma after immediate mandibular reconstruction with a fibular free flap. Br J Oral Maxillofac Surg 2014; 52:163-7. [DOI: 10.1016/j.bjoms.2013.10.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 10/31/2013] [Indexed: 12/01/2022]
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25
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Gebert C, Wessling M, Gosheger G, Aach M, Streitbürger A, Henrichs MP, Dirksen U, Hardes J. Pelvic reconstruction with compound osteosynthesis following hemipelvectomy: A clinical study. Bone Joint J 2013; 95-B:1410-6. [PMID: 24078542 DOI: 10.1302/0301-620x.95b10.31123] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
To date, all surgical techniques used for reconstruction of the pelvic ring following supra-acetabular tumour resection produce high complication rates. We evaluated the clinical, oncological and functional outcomes of a cohort of 35 patients (15 men and 20 women), including 21 Ewing's sarcomas, six chondrosarcomas, three sarcomas not otherwise specified, one osteosarcoma, two osseous malignant fibrous histiocytomas, one synovial cell sarcoma and one metastasis. The mean age of the patients was 31 years (8 to 79) and the latest follow-up was carried out at a mean of 46 months (1.9 to 139.5) post-operatively. We undertook a functional reconstruction of the pelvic ring using polyaxial screws and titanium rods. In 31 patients (89%) the construct was encased in antibiotic-impregnated polymethylmethacrylate. Preservation of the extremities was possible for all patients. The survival rate at three years was 93.9% (95% confidence interval (CI) 77.9 to 98.4), at five years it was 82.4% (95% CI 57.6 to 93.4). For the 21 patients with Ewing's sarcoma it was 95.2% (95% CI 70.7 to 99.3) and 81.5% (95% CI 52.0 to 93.8), respectively. Wound healing problems were observed in eight patients, deep infection in five and clinically asymptomatic breakage of the screws in six. The five-year implant survival was 93.3% (95% CI 57.8 to 95.7). Patients were mobilised at a mean of 3.5 weeks (1 to 7) post-operatively. A post-operative neurological defect occurred in 12 patients. The mean Musculoskeletal Tumor Society score at last available follow-up was 21.2 (10 to 27). This reconstruction technique is characterised by simple and oncologically appropriate applicability, achieving high primary stability that allows early mobilisation, good functional results and relatively low complication rates.
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Affiliation(s)
- C Gebert
- Orthopaedic Hospital Volmarstein, Department of Tumour & Revision Surgery, Lothar-Gau-Str. 11, D-58300 Wetter, and The University of Muenster, Germany
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Yazdi H, Mallakzadeh M, Mohtajeb M, Farshidfar SS, Baghery A, Givehchian B. The effect of partial fibulectomy on contact pressure of the knee: a cadaveric study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2013; 24:1285-9. [PMID: 24318306 DOI: 10.1007/s00590-013-1381-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 11/22/2013] [Indexed: 12/18/2022]
Abstract
PURPOSE The fibula is a valuable source of bone graft and partial or total fibulectomy is done in some procedures, such as upper tibial osteotomy and treatment of tibial nonunion. Previous studies emphasized donor-site morbidity after fibulectomy. The aim of our study was to quantitatively survey joint reaction forces in the medial and lateral compartments of the ipsilateral knee, after partial fibulectomy. METHODS Using left knees of six cadavers, after medial and lateral arthrotomy and total meniscectomy, Fuji pressure-sensitive film was inserted to both lateral and medial knee compartments. Weight bearing was simulated using a novel device that allowed a defined axial force to be applied to the left lower limbs of supine cadavers. The axial force of half the body weight of each specimen was applied to the plantar surface of the foot. After removing the films, fibulectomy was done 12 cm proximal to lateral malleolus and 2 cm of fibula harvested. The examination was repeated again in the same manner with new films. The resulting Fuji films were scanned using HP Scanjet (G3110) with resolution of 4,800 × 9,600 dpi. Films interpreted using software for Fuji pressure-sensitive film analysis. RESULTS Joint reaction force was decreased in the medial compartment (P = 0.028) and increased in the lateral compartment (P = 0.027) after partial fibulectomy. Our study also showed that pressure changes over the medial and lateral compartments of the knee were not dependent on body weight (P = 0.787 for the medial compartment and P = 0.872 for the lateral compartment) and decreasing pressure in medial compartment was not depended on increasing pressure in lateral compartment (P = 0.208 and correlation coefficient were 0.6). CONCLUSIONS The current study demonstrated partial fibulectomy at 12 cm above lateral malleolus results in decreasing pressure in knee medial compartment and increasing pressure in knee lateral compartment. Further studies are needed to evaluate the clinical importance of partial fibulectomy.
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Affiliation(s)
- Hamidreza Yazdi
- Department of Knee Surgery, Firoozgar Hospital, School of Medicine, Iran University of Medical Science, 1968945914, Tehran, Iran,
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Zhu J, Xiao Y, Liu F, Wang J, Yang W, Xie W. Measures of health-related quality of life and socio-cultural aspects in young patients who after mandible primary reconstruction with free fibula flap. World J Surg Oncol 2013; 11:250. [PMID: 24083617 PMCID: PMC3850790 DOI: 10.1186/1477-7819-11-250] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 09/22/2013] [Indexed: 11/25/2022] Open
Abstract
Background The reconstruction of mandibular defects after trauma or tumor resection is one of the most challenging problems facing reconstructive surgeons. Although the primary intended outcome of surgery to treat head-and-neck malignancies is still the disease-free survival of the patient, health-related quality of life (HRQOL) is now seen as an essential secondary outcome. This study aims to evaluate HRQOL outcomes in young patients undergoing primary mandible reconstruction with free fibula flap and to collect information about their socio-cultural situation. Methods The HRQOL outcomes of 25 young patients after primary mandible reconstruction with free fibula flap for mandible malignancies were assessed using the Medical Outcomes Study-Short Form-36 (MOS SF-36) and University of Washington Quality of Life (UW-QOL) questionnaires 12 months postoperatively. Results Using the UW-QOL questionnaire, the best-scoring domain was ‘pain’, whereas ‘chewing’ and ‘anxiety’ were given the lowest scores. Using the MOS SF-36 questionnaire, the best-scoring domain was ‘physical functioning’, while ‘bodily pain’ and ‘general health’ also scored well. Conclusions Mandible reconstruction with fibula flap will significantly influence a young patient’s HRQOL. Young patients pay more attention to postoperative facial appearance; this should be considered in surgical planning. The socio-cultural data show a fairly low level of education for the majority of patients.
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Affiliation(s)
- Juanfang Zhu
- Department of Stomatolagy, the First Affiliated Hospital of Zhengzhou University, No,1 Jianshe East Road, Zhengzhou, Henan 450052, China.
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Ling XF, Peng X, Samman N. Donor-site morbidity of free fibula and DCIA flaps. J Oral Maxillofac Surg 2013; 71:1604-12. [PMID: 23810616 DOI: 10.1016/j.joms.2013.03.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Revised: 02/18/2013] [Accepted: 03/05/2013] [Indexed: 11/18/2022]
Abstract
PURPOSE This study evaluated and compared the long-term donor-site morbidity of the free fibula flap with the deep circumflex iliac artery (DCIA) flap in maxillofacial reconstruction. MATERIALS AND METHODS Thirty-four patients (19 in the fibula group and 15 in the DCIA group) were evaluated for long-term morbidity. All clinical data were analyzed, including primary disease, type of defect, type of flap, length of bone harvested, total blood loss, operating time, length of hospitalization, and postoperative unaided gait. Subjective evaluation included cosmesis, function, and pain. Objective evaluation included physical examination, neurosensory assessment, Stony Brook Scar Evaluation, gait assessment, and goniometric measurement of range of movement. RESULTS In the subjective evaluation, no significant differences in cosmetic outcome, functional loss, wound healing, or pain between the 2 groups were noted (P > .05). However, neurosensory deficit was worse in the DCIA group (P ≤ .05). In the objective evaluation, 4 patients (27%) in the DCIA group had neurosensory deficit in the lateral thigh region. The DCIA group had a better Stony Brook Scar score (median, 5) than the fibula group (median, 4; P ≤ .05). However, there was no difference in walking ability between the 2 groups (P > .05). Goniometric measurement showed a significant difference between the operated and unoperated sites in the 2 groups; however, it was not severe enough in either group to affect patients' function. In the fibula group, 7 patients (38.9%) had claw toe deformity and 2 patients (12.1%) had weakness of the great toe, and the mean American Orthopedic Foot and Ankle Society score was 96.89. In the DCIA group, 1 patient (8.3%) had a hernia and the mean Harris Hip score was 98.33. CONCLUSION Given that these 2 options present donor-site concerns, the authors consider the fibula free flap the first choice for maxillofacial reconstruction in most cases and the DCIA free flap a reliable complementary flap in selected patients.
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Affiliation(s)
- Xiao Feng Ling
- Oral Surgery, Hospital Kulim, Ministry of Health, Kedah, Malaysia
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Vittayakittipong P. Donor-site morbidity after fibula free flap transfer: a comparison of subjective evaluation using a visual analogue scale and point evaluation system. Int J Oral Maxillofac Surg 2013; 42:956-61. [PMID: 23684077 DOI: 10.1016/j.ijom.2013.04.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 02/21/2013] [Accepted: 04/04/2013] [Indexed: 11/18/2022]
Abstract
The aims of this study were: (1) to compare the visual analogue scale (VAS) with the point evaluation system (PES) in the subjective evaluation of donor-site morbidity after fibula free flap transfer; (2) to compare the functional outcomes of fibula free flap surgery between patients with a normal body mass index (BMI) and patients with a high BMI, and between skin paddle and non-skin paddle harvesting; and (3) to determine the correlation between functional outcomes and related factors. This study included 15 patients who underwent a vascularized fibula free flap transfer for oral and maxillofacial reconstruction. Demographic data, preoperative, intraoperative, and postoperative data were collected. Subjective self-evaluation of functional outcomes was done using a VAS followed by a PES. Comparison of the VAS and PES scores was assessed with Pearson's correlation coefficient. The statistical significance was set at P<0.05. The VAS score was significantly correlated with the PES score (r=0.63, P=0.01). The tourniquet times for the skin paddle group were longer than for the non-skin paddle group (P=0.02), while the satisfaction score of the non-skin paddle group was higher than that of the skin paddle group (P=0.03). The VAS is a potential option for the subjective evaluation of donor-site morbidity after fibula free flap transfer.
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Affiliation(s)
- P Vittayakittipong
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Prince of Songkla University, Songkhla, Thailand.
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Fujiki M, Miyamoto S, Sakuraba M, Nagamatsu S, Hayashi R. A comparison of perioperative complications following transfer of fibular and scapular flaps for immediate mandibular reconstruction. J Plast Reconstr Aesthet Surg 2012; 66:372-5. [PMID: 23102764 DOI: 10.1016/j.bjps.2012.10.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Revised: 10/05/2012] [Accepted: 10/05/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND The fibular flap and the scapular flap are widely used for immediate reconstruction after segmental mandibulectomy. The aim of this study was to compare perioperative complications between the fibular flap and the scapular flap in immediate mandibular reconstruction. METHODS Data were retrospectively collected on 56 patients who had undergone immediate mandibular reconstruction with a fibular flap (38 patients) or a scapular flap (18 patients) after segmental mandibulectomy from 2005 to 2011. The rates of perioperative recipient-site and donor-site complications were compared between the groups. RESULTS The overall rate of recipient-site complications did not differ significantly between the fibula group and the scapula flap. However, the rate of donor-site complications was significantly higher in the fibula group than in the scapula group. Partial skin-graft loss in the fibula group occurred in as high as 13 out of 38 patients. DISCUSSION For immediate mandibular reconstruction, a scapular flap provides short-term results equivalent to those with a fibular flap but with less donor-site morbidity. The major drawbacks of the fibular flap include prolonged healing of the donor site and the delayed mobilisation of patients. Although our first choice of vascularised bone graft is the fibular flap, the scapular flap in an alternative for those patients, especially elderly patients, in whom fibula harvest can result in significant morbidity.
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Affiliation(s)
- Masahide Fujiki
- Division of Plastic and Reconstructive Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba 277-8577, Japan.
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Catalá-Lehnen P, Rendenbach C, Heiland M, Khakpour P, Rueger JM, Schmelzle R, Blake F. Long-Term Donor-Site Morbidity After Microsurgical Fibular Graft: Is There a Difference Between the Medial Approach and the Lateral Approach? J Oral Maxillofac Surg 2012; 70:2198-204. [DOI: 10.1016/j.joms.2011.09.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Revised: 09/29/2011] [Accepted: 09/29/2011] [Indexed: 10/14/2022]
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Pohlenz P, Atac A, Catala-Lehnen P, Khakpour P, Li L, Klatt J, Schmelzle R. RETRACTED ARTICLE: Donor site morbidity of the vascularized fibula: the Hamburg experience. Clin Oral Investig 2012; 16:1333. [DOI: 10.1007/s00784-012-0717-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Accepted: 03/05/2012] [Indexed: 11/29/2022]
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Yang L, Xu HZ, Liang DZ, Lu W, Zhong SZ, Ouyang J. Biomechanical analysis of the impact of fibular osteotomies at tibiotalar joint: A cadaveric study. Indian J Orthop 2012; 46:520-4. [PMID: 23162143 PMCID: PMC3491784 DOI: 10.4103/0019-5413.101043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Osteotomy of the fibula is a common orthopedic procedure performed for various indications, including harvesting fibula for grafting purposes. The effect of fibular osteotomy and need for tibiofibular syndesmotic fixation fusion at different levels on tibiotalar joint is matter of debate. We performed a biomechanical analysis of the impact of fibular osteotomies at different levels and whether the fixation of distal tibiofibular joint mitigates instability caused by the osteotomy. MATERIALS AND METHODS Six lower limb specimens from fresh adult cadavers were used to prepare leg-foot models. The specimens were assigned to six status according to the level of osteotomy and whether fixation of distal tibiofibular joint was performed or not. Each specimen was then loaded axially to 700 N by the material testing machine, and the tibiotalar joint contact area and peak pressure were measured using an electronic pressure sensor. RESULTS The contact area and the pressure of tibiotalar joint showed significant changes when compared to the normal specimen. All osteotomy specimens had a decreased tibiotalar contact area and an increased peak pressure. This positively correlated with proximity of level of osteotomy to the lateral malleolus. CONCLUSIONS Through this study, we found that fibular osteotomy had an adverse effect in terms of decreasing the contact surface of tibiotalar joint that led to increased peak pressure in the joint. However, bone fusion and screw fixation of the distal tibiofibular joint reduced these adverse effects.
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Affiliation(s)
- Lin Yang
- Department of Anatomy, Guangdong Provincial Medical Biomechanical Key Laboratory, Southern Medical University, Guangzhou, China
| | - Hong-Zhang Xu
- Department of Orthopaedics, Hospital of Integrated Traditional and Western Medicine, Southern Medical University, Guangzhou, China
| | - Dong-Zhu Liang
- Department of Anatomy, Guangdong Provincial Medical Biomechanical Key Laboratory, Southern Medical University, Guangzhou, China
| | - Wei Lu
- Department of Anatomy, Guangdong Provincial Medical Biomechanical Key Laboratory, Southern Medical University, Guangzhou, China
| | - Shi-Zheng Zhong
- Department of Anatomy, Guangdong Provincial Medical Biomechanical Key Laboratory, Southern Medical University, Guangzhou, China
| | - Jun Ouyang
- Department of Anatomy, Guangdong Provincial Medical Biomechanical Key Laboratory, Southern Medical University, Guangzhou, China,Address for correspondence: Dr. Jun Ouyang, Department of Anatomy, Guangdong Provincial Medical Biomechanical Key Laboratory, Southern Medical University, Guangzhou 510515, China. E-mail:
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Lin PY, Lin KC, Jeng SF. Oromandibular reconstruction: the history, operative options and strategies, and our experience. ISRN SURGERY 2011; 2011:824251. [PMID: 22229103 PMCID: PMC3246309 DOI: 10.5402/2011/824251] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Accepted: 09/18/2011] [Indexed: 11/23/2022]
Abstract
Oromandibular reconstruction resulting from resection of benign tumor, malignant cancer, osteomyelitic or osteoradionecrotic mandible remains a challenge for plastic surgeons today. At present, fibula osteocutaneous flap is the perhaps most commonly used technique for oromandibular reconstruction because of its potential for contouring, immediate dental implant placement, and favorable donor site morbidity. In this study, we review the history of oromandibular reconstruction, summarize the characteristics of different osteocutaneous flaps, offer surgical options of different osteocutaneous flaps, and provide reconstructive strategies for different locations of mandibular defects. Furthermore, we give a detailed description of various modifications in oromandibular reconstruction: (1) the myoosseous flap for lateral segmental defect repair may reduce donor site complication; (2) to improve the function of oral commissure in patients with obscure recipient vessels, we modify the fibula osteocutaneous flap with anterolateral thigh flap and combine the tensor fascia lata using one set of recipient vessel for composite oromandibular reconstruction; (3) to decrease the likelihood of neck infection and improve aesthetic result, we add the segmental soleus muscle to the fibula osteocutaneous flap to obliterate and augment submandibular dead space. Lastly, dental rehabilitation considerations associated with mandibular reconstruction have been given to help assist in surgical treatment planning.
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Affiliation(s)
- Pao-Yuan Lin
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 83301, Taiwan
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Huang YC, Leong CP, Pong YP, Liu TY, Kuo YR. Functional assessment of donor-site morbidity after harvest of a fibula chimeric flap with a sheet of soleus muscle for mandibular composite defect reconstruction. Microsurgery 2011; 32:20-5. [DOI: 10.1002/micr.20955] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Revised: 08/09/2011] [Accepted: 08/11/2011] [Indexed: 11/06/2022]
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Chen YC, Valerio IL, Chien CY, Jeng SF. Pedicled mandible myo-osseous flaps combined with free skin flaps for reconstruction of complex lateral mandibular defects. Head Neck 2011; 34:384-92. [PMID: 21584895 DOI: 10.1002/hed.21740] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2010] [Revised: 12/10/2010] [Accepted: 01/04/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study presents an alternative in reconstruction, using free skin flaps in combination with pedicled mandible bone flaps for complex lateral mandibular defects. METHODS In all, 13 patients were included in this prospective study. Pedicled mandible myo-osseous flaps were used for reconstruction of bone defects of the lateral mandible in combination with free skin flaps, including radial forearm flaps (n = 3), anterolateral thigh (ALT) flaps (n = 9), and local tongue flap (n = 1). Postoperatively, a (99m)Tc-methyl diphosphonate bone scan was performed to assess bone flap viability. RESULTS All patients had acceptably contoured mandibles. The major complications consisted of 1 failed ALT flap and 2 nonviable bone flaps. The bone scan confirmed viable bone flaps in 11 cases. Ten patients (77%) were able to resume soft to full diets. CONCLUSIONS For complex lateral mandibular defects (≤6 cm), a combination of the pedicled mandible myo-osseous flaps and free skin flaps is an alternative in reconstruction.
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Affiliation(s)
- Yen-Chou Chen
- Department of Plastic and Reconstructive Surgery, and Department of Otolaryngology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Wolff KD, Hölzle F, Kolk A, Hohlweg-Majert B, Steiner T, Kesting MR. Raising the osteocutaneous fibular flap for oral reconstruction with reduced tissue alteration. J Oral Maxillofac Surg 2011; 69:e260-7. [PMID: 21398008 DOI: 10.1016/j.joms.2010.11.040] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Revised: 10/19/2010] [Accepted: 11/23/2010] [Indexed: 10/18/2022]
Abstract
Raising the osteocutaneous fibular flap offers excellent possibilities for oral reconstructive surgery but is associated with specific donor-site risks. Moreover, with inadequate surgical technique, flap-specific complications can occur, such as loss of the skin paddle or inadequate pedicle length. A flap-raising technique has been used to decrease surgical damage but provide maximal pedicle length. Sixty-six osteocutaneous fibular flaps were raised by the lateral approach with the following modifications: 1) flap-raising was carried out without a tourniquet, 2) only the amount of bone needed was removed, leaving the rest of the fibula intact, 3) only a minimal muscle cuff was included, and 4) the complete pedicle was dissected along the posterior intermuscular septum without opening the interosseous membrane and without touching the deep flexor muscles proximal to the osteotomized fibular segment. The skin paddle was placed distally in the leg, perfused by only 1 perforator in most cases. Medical records were analyzed and patients were examined postoperatively for up to 32 months to evaluate the above-mentioned complications. Of the 66 reconstructions, 44 were performed in a previously operated or irradiated neck. Three flaps and 1 skin paddle were lost. The most common donor-site complications were temporary wound-healing disturbances of the skin graft (n = 17) and transient pain or sensory alterations (n = 12). No compartment syndrome, ankle instability, or need for walking aids was recorded. A hammertoe deformity developed in 1 patient. On average, pedicle length was 9 cm and flap-raising took 130 minutes. In conclusion, maximal pedicle length and minimal bone and muscle resections can be achieved with a small number of donor-site complications. The skin paddle is highly reliable based on only 1 perforator. Perforators can be precisely controlled when raising the flap in the perfused leg.
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Affiliation(s)
- Klaus D Wolff
- Department of Oral and Maxillofacial Surgery, Technische Universität München, Munich, Germany
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Scherberich A, Müller AM, Schäfer DJ, Banfi A, Martin I. Adipose tissue-derived progenitors for engineering osteogenic and vasculogenic grafts. J Cell Physiol 2010; 225:348-53. [PMID: 20626000 DOI: 10.1002/jcp.22313] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The current need for bone grafts in orthopedic and reconstructive surgery cannot be satisfied by autologous tissue transplant due to its limited availability and significant associated morbidity. Tissue engineering approaches could supply sufficient amounts of bone substitutes by exploiting the ability to harvest autologous osteogenic progenitors associated with suitable porous materials. However, the generation of clinically relevant-sized constructs is critically hampered by limited vascularization, with consequent engraftment and survival only of a thin outer shell, upon in vivo implantation. To overcome this limitation, different non-mutually exclusive approaches have recently been developed to promote or accelerate graft vascularization, from angiogenic growth factor gene delivery to surgical pre-vascularization of the construct before implantation. A simple, promising strategy involves the co-culture of vasculogenic cells to form an intrinsic vascular network inside the graft in vitro, which can rapidly anastomose with the host blood vessels in vivo. Recent data have shown that adipose tissue-derived stromal vascular fraction (SVF) may provide an efficient, convenient, and autologous source for both osteogenic and endothelial cells. When SVF progenitors were cultured in appropriate bioreactor systems and ectopically implanted, a functional vascular network connected to the host was formed concomitantly to bone formation. Future studies should aim at demonstrating that this approach effectively supports survival of scaled up cell-based bone grafts at an orthotopic site. The procedure should also be adapted to become compatible with an intra-operative timeline and complemented with the definition of suitable potency markers, to facilitate its development into a simplified, reproducible, and cost-effective clinical treatment.
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Affiliation(s)
- Arnaud Scherberich
- Tissue Engineering, Department of Biomedicine, Basel University Hospital, Basel, Switzerland
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Hsieh CH, Cheung SM, Sun CK, Huang YC, Lan GS, Chang HW, Jeng SF. Evaluation of the ankle function following reconstruction of the donor defect with a split fibular bone after a vascularized fibular flap transfer. Arch Orthop Trauma Surg 2010; 130:781-6. [PMID: 20063103 DOI: 10.1007/s00402-009-1042-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2009] [Indexed: 11/24/2022]
Abstract
INTRODUCTION To validate the hypothesis that the reconstruction of the missing segment of the fibula using a redundant split fibular graft after a vascularized fibular flap transfer may have a better effect on ankle function. MATERIALS AND METHODS Of the 24 head and neck cancer patients who received a free fibula flap for mandible reconstruction, 14 patients underwent the conventional method of donor site closure, in which the redundant fibular bone was discarded (Group I). Ten patients underwent longitudinal osteotomy of the redundant non-vascularized fibular portion to bridge the donor site defect (Group II). Postoperative subjective satisfaction level was evaluated with a self-constructed questionnaire in 10 parameters (ambulation with assistance, ankle instability, ankle stiffness, muscle weakness, leg edema, foot numbness, ankle pain, other sites of pain besides the ankle, and restriction to run) and the 4 voluntary motions (dorsiflexion, plantar flexion, eversion, and inversion) of both ankles were measured using a CYBEX II dynamometer. RESULTS The muscle peak torque of the donor leg was significantly lower at ankle plantar flexion (P = 0.002), eversion (P = 0.002), and inversion (P = 0.0002) in Group I as well as at dorsiflexion (P = 0.031), plantar flexion (P = 0.016), and inversion (P = 0.002) in Group II against the contralateral non-operated leg. The muscle power was significantly greater when performing ankle eversion (P = 0.049) in those who underwent split fibular bone reconstruction. There was no difference in the subjective satisfaction score between these two groups. CONCLUSION The reconstruction of the donor site with a split fibular bone graft led only a slight improvement in ankle eversion.
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Affiliation(s)
- Ching-Hua Hsieh
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Radiographic and functional outcomes of the ankle joint after free vascularized fibular graft resection procedure: assessment after 15 months. CURRENT ORTHOPAEDIC PRACTICE 2010. [DOI: 10.1097/bco.0b013e3181bf2558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Chu CH, Jou IM, Shieh SJ. Reconstruction of a massive femoral bone defect using a double-barreled free vascularized fibular bone graft after wide resection of femoral chondrosarcoma. Kaohsiung J Med Sci 2010; 25:552-8. [PMID: 19767261 DOI: 10.1016/s1607-551x(09)70548-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Salvaging the limb after malignant bone tumor ablation is a tough challenge for a reconstructive surgeon confronting such extensive bone defects. A 40-year-old male without any underlying disease was incidentally diagnosed with a chondrosarcoma over his left femoral bone. An orthopedic surgeon did a wide resection of the malignant bone tumor, leaving a massive bone defect about 11.3 cm in length. A double-barreled free vascularized fibular bone was designed to reconstruct the femoral bone defect. The maximal fibular bone graft harvested was 19 cm long; after the osteotomy, one barrel was 11 cm and the other was 8 cm. An iliac crest cancellous bone graft was harvested to fill the residual space. The pathology report showed a grade 1 well-differentiated conventional chondrosarcoma, and further adjuvant therapy was not suggested. At a 3-year follow-up, plain radiography showed a good bony union of the graft, and the patient could easily tolerate daily activity. A vascularized double-barreled fibular graft is an ideal option for reconstructing a massive defect in weight-bearing bone: it provides not only sufficient mechanical strength but also good union for early rehabilitation. We describe the long-term results after reconstruction and provide a literature review of long-bone chondrosarcoma.
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Affiliation(s)
- Chun-Hui Chu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Chaine A, Pitak-Arnnop P, Hivelin M, Dhanuthai K, Bertrand JC, Bertolus C. Postoperative complications of fibular free flaps in mandibular reconstruction: an analysis of 25 consecutive cases. ACTA ACUST UNITED AC 2009; 108:488-95. [DOI: 10.1016/j.tripleo.2009.05.043] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Revised: 05/01/2009] [Accepted: 05/22/2009] [Indexed: 10/20/2022]
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Long-term evaluation of donor site morbidity after free fibula transfer. Br J Oral Maxillofac Surg 2009; 48:267-70. [PMID: 19716215 DOI: 10.1016/j.bjoms.2009.07.019] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2009] [Indexed: 11/20/2022]
Abstract
Our aim was to evaluate the long-term morbidity at the donor site after harvest of free fibular flaps. From a total of 165 patients, we were able to examine (not randomly) 62 donor regions in 57 patients (33 men and 24 women) 2-167 months (mean 45 months) after fibular transfer. Patients' individual risk factors and any disturbances of healing, and dysfunction of the toes, were recorded. The Kitaoka ankle-hindfoot score was used for evaluation of functional impairment. Thirteen donor regions displayed prolonged wound healing, eight of which needed revision of the wounds. Eight (14%) had abnormalities of gait. The median Kitaoka ankle-hindfoot score was 93 (range: 14-100). In 17 patients (27%) after a follow-up period of 4 months, hammer and claw toes and deficits in dorsal extension of the hallux were assessed. Thirty patients (48%) had sensory deficits of the calf and toes. Neither the risk factors recorded nor the factors that indicated disturbance of wound healing or deformities of the toe were significantly associated with the development of functional impairment. In more than three-quarters of the cases healing was uneventful, but in a small number the morbidity at the donor site was severe, forcing the patient to use walking aids. We were not able to identify any risk factors for the development of long-term malfunction.
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Gaskill TR, Urbaniak JR, Aldridge JM. Free vascularized fibular transfer for femoral head osteonecrosis: donor and graft site morbidity. J Bone Joint Surg Am 2009; 91:1861-7. [PMID: 19651942 DOI: 10.2106/jbjs.h.01105] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Autogenous vascularized fibular transfer is used effectively for a variety of complex reconstructive procedures. Published series demonstrating the morbidity associated with its harvest have, understandably, been relatively small, and graft site (hip) complications have not been reported. This report describes both the donor and the graft site morbidity associated with use of vascularized fibular transfer to treat osteonecrosis of the femoral head. METHODS Between 1990 and 2006, 1270 free vascularized fibular grafts were used to treat osteonecrosis of the femoral head in 946 consecutive patients. All procedures and follow-up examinations were performed by one of two surgeons. Subjective and objective findings were recorded on standardized examination sheets at routine postoperative intervals. Data were analyzed to determine the morbidity associated with donor and graft sites. RESULTS There were 215 complications (a 16.9% rate) at the time of follow-up, at an average of 8.3 years, after the 1270 procedures. Of these complications, 146 (11.5%) and sixty-nine (5.4%) were referable to the donor and graft sites, respectively. A major complication requiring an additional surgical procedure or chronic pain management occurred after fifty-four (4.3%) of the 1270 procedures. CONCLUSIONS A measurable but acceptable morbidity risk is associated with vascularized fibular transfer for the treatment of osteonecrosis of the hip. Major complications are not frequent, and many minor complications are transient and improve over time. Risks can be minimized when specific technical principles are followed.
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Affiliation(s)
- Trevor R Gaskill
- Division of Orthopaedic Surgery, Duke University Medical Center, Box 3000, Durham, NC 27710, USA.
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Taddei F, Balestri M, Rimondi E, Viceconti M, Manfrini M. Tibia adaptation after fibula harvesting: an in vivo quantitative study. Clin Orthop Relat Res 2009; 467:2149-58. [PMID: 19277801 PMCID: PMC2706351 DOI: 10.1007/s11999-009-0776-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2008] [Accepted: 02/23/2009] [Indexed: 01/31/2023]
Abstract
UNLABELLED Absence of the fibula after harvesting to reconstruct an upper-limb segment increases loads on the donor-side tibia and thereby provides a unique opportunity to analyze the bone adaptation process in humans. We therefore quantified densitometric and morphologic changes of the donor-side tibia in three young patients (ages 8, 13, 16 years), on the basis of computed tomography (CT) examinations of both legs (one preoperatively and two postoperatively). The range of final followup was 27-43 months. Three-dimensional models of shank bones were generated from CT data and used to measure cross-sectional area, diaphyseal cortical thickness, and cross-sectional moment of inertia. In addition, density of the newly formed bone was evaluated. The donor-side tibia showed morphologic and density adaptation with time. New bone was deposited predominantly in the interosseous space and almost replaced the bone area lost by excision of the fibula. The second moment of area grew more in the donor-side tibia than in the intact one, without fully recovering the contralateral tibia-fibula complex values, and the principal axes rotated toward the preoperative direction. Thus, while considerable adaptation had occurred by 27-43 months in these young patients, the adaptation was incomplete; the mineral density of the newly formed bone recovered normal cortical bone values only in the patient with the longest followup (43 months). LEVEL OF EVIDENCE Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Fulvia Taddei
- Laboratorio di Tecnologia Medica, Istituto Ortopedico Rizzoli, Via di Barbiano, 1/10, 40136 Bologna, Italy
| | - Matteo Balestri
- Laboratorio di Tecnologia Medica, Istituto Ortopedico Rizzoli, Via di Barbiano, 1/10, 40136 Bologna, Italy
| | - Eugenio Rimondi
- Radiology Department, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Marco Viceconti
- Laboratorio di Tecnologia Medica, Istituto Ortopedico Rizzoli, Via di Barbiano, 1/10, 40136 Bologna, Italy
| | - Marco Manfrini
- Oncology Department, Istituto Ortopedico Rizzoli, Bologna, Italy
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Breuls RGM, Jiya TU, Smit TH. Scaffold stiffness influences cell behavior: opportunities for skeletal tissue engineering. Open Orthop J 2008; 2:103-9. [PMID: 19478934 PMCID: PMC2687114 DOI: 10.2174/1874325000802010103] [Citation(s) in RCA: 134] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2008] [Revised: 04/21/2008] [Accepted: 05/14/2008] [Indexed: 01/19/2023] Open
Abstract
Skeletal defects resulting from trauma, tumors, or abnormal development frequently require surgical treatment to restore normal tissue function. To overcome the limitations associated with conventional surgical treatments, several tissue engineering approaches have been developed. In particular, the use of scaffolds enriched with stem cells appears to be a very promising strategy. A crucial issue in this approach is how to control stem cell behavior. In this respect, the effects of growth factors, scaffold surface characteristics, and external ‘active’ loading conditions on stem cell behavior have been investigated. Recently, it has become clear that the stiffness of a scaffold is a highly potent regulator of stem cell differentiation. In addition, the stiffness of a scaffold affects cell migration, which is important for the infiltration of host tissue cells. This review summarizes current knowledge on the role of the scaffold stiffness in the regulation of cell behavior. Furthermore, we discuss how this knowledge can be incorporated in scaffold design which may provide new opportunities in the context of orthopedic tissue engineering.
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Affiliation(s)
- Roel G M Breuls
- Department of Physics and Medical Technology, VU University Medical Center, Research Institute MOVE, Amsterdam, The Netherlands
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