FREE VASCULARISED FIBULAR STRUT GRAFT FOR ANTERIOR SPINAL FUSION

Multipoint fixation with vascularised fibular bone graft and myotomy for atlanto-axial instability in cervical dystonia: a case report

Spinal instability is a challenging condition to manage in patients with cervical dystonia. Standard surgical stabilisation approaches may fail to cope with additional stress forces created by spasmodic muscles leading to construct failure either in the immediate or late post-operative period. Long-term stabilisation relies on the management of dystonic symptoms and adjunctive strategies to increase fusion success rate. We discuss the management of a challenging patient with translational C1/2 instability who had three metalwork failures with standard occipito-cervical fixation techniques within a 12 month period. A combined surgical approach using multipoint fixation, sternocleidomastoid myotomy and a vascularised fibular occiput-C2 bone graft successfully prevented further metalwork failure at over 2 years follow up.

Vascularized Occipital Bone Grafting: Indications, Techniques, Clinical Outcomes, and Alternatives

Successful arthrodesis at the craniocervical junction and atlantoaxial joint can be more challenging than in other segments of the cervical spine. Different techniques for spinal fixation in this region have been well described, along with auxiliary methods to improve fusion rates. The occipital vascularized bone graft is a novel technique that can be used to augment bony arthrodesis in the supra-axial cervical spine. It provides the benefits of a vascularized autologous graft, such as accelerated healing, earlier fusion, and increased strength. This technique can be learned with relative ease and may be particularly helpful in cases with high risk of nonunion or pseudoarthrosis in the upper cervical spine.

Free Vascularized Fibula Graft with Femoral Allograft Sleeve for Lumbar Spine Defects After Spondylectomy of Malignant Tumors: A Case Report

CASE

We present a 65-year-old man with an L4 conventional chordoma. Total en bloc spondylectomy (TES) of the involved vertebral bodies and surrounding soft tissues with reconstruction of the spine using a free vascularized fibula autograft (FVFG) is a proven technique, limiting complications and recurrence. However, graft fracture has occurred only in the lumbar spine in our institutional cases. We used a technique in our patient to ensure extra stability and support, with the addition of a femoral allograft sleeve encasing the FVFG.

CONCLUSIONS

Our technique for the reconstruction of the lumbar spine after TES of primary malignant spinal disease using a femoral allograft sleeve encasing the FVFG is viable to consider.

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

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

Vascularized Fibular Strut Autografts in Spinal Reconstruction after Resection of Vertebral Chordoma or Chondrosarcoma: A Retrospective Series

BACKGROUND

Margin-free en bloc resection is the best medical practice for primary vertebral chordoma and chondrosarcoma. Spinal reconstruction following total spondylectomy requires reconstructive interbody graft (allograft, devascularized autograft, vascularized autograft, or cage constructs) and instrumentation. An important consideration when choosing grafts and instrumentation is the durability and the long-term success of the fusion without subsidence.

OBJECTIVE

To evaluate the potential use of vascularized fibular autograft as a reconstructive strategy after en bloc resection.

METHODS

We present a series of 16 patients who underwent spondylectomy for primary vertebral chordoma or chondrosarcoma with reconstruction using a vascularized fibular autograft and anterior/posterior instrumentation between January 2011 and April 2014. We report postoperative neurological outcome, 6-mo rates of fusion and graft subsidence, and other complications.

RESULTS

Two patients passed away prior to 6-mo follow-up, and 1 patient was lost to follow-up. The mean follow-up time for the remaining 13 patients was 32 mo. Of these patients, 9 (69%) had evidence of fusion on the 6-mo follow-up computed tomography (CT) scan. Of the 4 patients who did not fuse, 2 had undergone surgery for new tumor diagnoses, 1 for hardware failure, and 1 for graft nonunion. Two patients (15%) had eventual graft subsidence along with hardware failure.

CONCLUSIONS

Vascularized fibular strut grafts are a viable method for reconstruction following spondylectomy. We present the largest series of patients to date utilizing this technique. Further comparative studies examining vascularized grafts vs nonvascularized grafts or metallic cage constructs will be important in choosing the best reconstructive strategy.

Vascularized pedicled rib graft: a technique for posterior placement in spinal reconstruction

The purpose of this paper is to provide a detailed description of the method to harvest a vascularized pedicled rib graft, transpose it to the posterior spine, and to straighten it to facilitate posterior spine fusion in patients undergoing complex spinal reconstruction.