Free vascularised fibular strut graft for anterior spinal fusion

The Use of Free Fibula Flap in Different Extremities and Our Clinical Results

Background and objectives Plastic, orthopedic, otolaryngology, and oromaxillofacial surgery specialists rely on fibula grafts to solve reconstructive problems. The aim of this study is to discuss the use and results of vascular fibula flaps in the treatment of bone and soft tissue defects in various regions with different etiologies. Materials and methods In our clinic, we treated 32 patients with osteocutaneous fibular flaps due to bone and soft tissue defects of different etiologies and varying anatomical regions. In our study, age, gender, side, cause of injury, surgical technique, treatment results, and complications were evaluated for each patient. Results Of the 32 patients, 25 were male, and 7 were female. The average age is 37.2 (27-56). The mean bone defect size was 10.45 cm. Bone defect occurred in eight patients due to osteomyelitis, eleven patients due to gunshot wounds, nine patients due to pseudoarthrosis, and four patients due to a giant cell tumor. We applied osteocutaneous fibula flap in 27 patients and vascularized fibular flap in five patients. Bone union could not be achieved in four patients, and bone grafting was performed as a secondary surgery. Local infection occurred in five patients, and their treatment was completed with debridement and antibiotic administration. Wound complications occurred in three patients at the donor site, which were treated with debridement and skin grafting. The mean duration of radiological union was three months, and complete union was achieved in the seventh month. Conclusions We have shown in our case series that free vascularized fibula transfer has gained an important place in the field of skeletal reconstruction and is a reliable method for various bone reconstructions.

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.

Microsurgery in musculoskeletal oncology

Sarcomas are rare mesenchymal bone and soft tissue tumors of the musculoskeletal system. In the past, the primary treatment modality was amputation of the involved limb and the 5-year survival was very low for high-grade tumors. During the last three decades, limb salvage has become the rule rather than the exception and the use of neoadjuvant and adjuvant therapies (radiation and chemotherapy) has dramatically increased disease-free survival. Reconstruction of large bone and soft tissue defects, though, still remains a significant challenge in sarcoma patients. In particular, vascularized tissue transfer has proved extremely helpful in dealing with complex bone and soft tissue or functional defects that are frequently encountered as a result of the tumor or as a complication of surgery and adjuvant therapies. The principles, indications and results of microsurgical reconstruction differ from trauma patients and are directly related not only to the underlying disease process, but also to the local and systemic therapeutic modalities applied to the individual patient. Although plastic reconstruction in the oncological patients is not free of complications, usually these complications are manageable and do not jeopardize oncological outcome. The overall treatment strategy should be tailored to the patient's and sarcoma profile.

Bone graft options for spinal fusion following resection of spinal column tumors: systematic review and meta-analysis

OBJECTIVE With the advent of new adjunctive therapy, the overall survival of patients harboring spinal column tumors has improved. However, there is limited knowledge regarding the optimal bone graft options following resection of spinal column tumors, due to their relative rarity and because fusion outcomes in this cohort are affected by various factors, such as radiation therapy (RT) and chemotherapy. Furthermore, bone graft options are often limited following tumor resection because the use of local bone grafts and bone morphogenetic proteins (BMPs) are usually avoided in light of microscopic infiltration of tumors into local bone and potential carcinogenicity of BMP. The objective of this study was to review and meta-analyze the relevant clinical literature to provide further clinical insight regarding bone graft options. METHODS A web-based MEDLINE search was conducted in accordance with preferred reporting items for systematic review and meta-analysis (PRISMA) guidelines, which yielded 27 articles with 383 patients. Information on baseline characteristics, tumor histology, adjunctive treatments, reconstruction methods, bone graft options, fusion rates, and time to fusion were collected. Pooled fusion rates (PFRs) and I² values were calculated in meta-analysis. Meta-regression analyses were also performed if each variable appeared to affect fusion outcomes. Furthermore, data on 272 individual patients were available, which were additionally reviewed and statistically analyzed. RESULTS Overall, fusion rates varied widely from 36.0% to 100.0% due to both inter- and intrastudy heterogeneity, with a PFR of 85.7% (I² = 36.4). The studies in which cages were filled with morselized iliac crest autogenic bone graft (ICABG) and/or other bone graft options were used for anterior fusion showed a significantly higher PFR of 92.8, compared with the other studies (83.3%, p = 0.04). In per-patient analysis, anterior plus posterior fusion resulted in a higher fusion rate than anterior fusion only (98.8% vs 86.4%, p < 0.001). Although unmodifiable, RT (90.3% vs 98.6%, p = 0.03) and lumbosacral tumors (74.6% vs 97.9%, p < 0.001) were associated with lower fusion rates in univariate analysis. The mean time to fusion was 5.4 ± 1.4 months (range 3-9 months), whereas 16 of 272 patients died before the confirmation of solid fusion with a mean survival of 3.1 ± 2.1 months (range 0.5-6 months). The average time to fusion of patients who received RT and chemotherapy were significantly longer than those who did not receive these adjunctive treatments (RT: 6.1 months vs 4.3 months, p < 0.001; chemotherapy: 6.0 months vs 4.3 months, p = 0.02). CONCLUSIONS Due to inter- and intrastudy heterogeneity in patient, disease, fusion criteria, and treatment characteristics, the optimal surgical techniques and factors predictive of fusion remain unclear. Clearly, future prospective, randomized studies will be necessary to better understand the issues surrounding bone graft selection following resection of spinal column tumors.

Free Vascularized Fibular Strut Autografts to the Lumbar Spine in Complex Revision Surgery: A Report of Two Cases

This case report presents two patients who underwent fibular strut grafting for complex revisions of previous lumbar spine arthrodeses. A case review of the Electronic Medical Record at the index institution was performed to evaluate the timeline of events of the two patients who underwent fibular strut grafting for complex revisions of previous lumbar spine arthrodesis, including imaging studies, progress notes, and laboratory results. One patient had developed chronic L3 vertebral body osteomyelitis from a prior fibular allograft and instrumentation placed for a traumatic burst fracture. The second patient had a severe scoliosis recalcitrant to prior arthrodeses in the context of Marfan syndrome and a persistent L4-5 pseudarthrosis. Both patients underwent free vascularized fibular autograft revision arthrodeses. At most recent long-term follow-up, both patients had improved clinically and neither had required further revision. The use of free vascularized fibular grafting is an excellent option for a variety of spinal indications, and these two reports indicate that the technology may have an indication for use after multiple failed surgeries for osteomyelitis or correction of a multi-level large spinal deformity secondary to Marfan syndrome.

Free vascularised fibular grafts in orthopaedics

Bony defects caused by trauma, tumors, infection or congenital anomalies can present a significant surgical challenge. Free vascularised fibular bone grafts (FVFGs) have proven to be extremely effective in managing larger defects (longer than 6 cm) where other conventional grafts have failed. FVFGs also have a role in the treatment of avascular necrosis (AVN) of the femoral head, failed spinal fusions and complex arthrodeses. Due to the fact that they have their own blood supply, FVFGs are effective even in cases where there is poor vascularity at the recipient site, such as in infection and following radiotherapy. This article discusses the versatility of the FVFG and its successful application to a variety of different pathologies. It also covers the applied anatomy, indications, operative techniques, complications and donor-site morbidity. Though technically challenging and demanding, the FVFG is an extremely useful salvage option and can facilitate limb reconstruction in the most complex of cases.

Fibular flap reconstruction of the cervical spine for repair of osteoradionecrosis

BACKGROUND CONTEXT

Although cervical spine reconstruction with osteocutaneous fibular flap microvascular grafting has been described, simultaneous reconstruction of the cervical vertebral column and laryngectomy have not been described.

PURPOSE

To present a unique case of combined cervical spine and laryngectomy reconstruction.

STUDY DESIGN

Case report.

METHODS

We modified a previously reported procedure reconstituting the cervical spine and pharynx with a single fibular flap in a case of posterior pharyngeal ulceration and osteomyelitis/osteoradionecrosis without spinal deformity.

RESULTS

We present a case of simultaneous cervical stabilization and pharynx reconstruction with a fibular graft in a life-saving treatment of osteoradionecrosis complicated by acute cervical kyphosis and spinal cord compression in a 55-year-old patient with extensive head and neck cancer history and recent recurrence of hypopharyngeal cancer.

CONCLUSIONS

Rigid anterior plate fixation and subsequent posterior fixation were required after corpectomy and total laryngectomy in our patient with extensive surgical scarring and radiation history because of severe spinal deformity secondary to osteoradionecrosis. We achieved successful preservation of neurologic function and resolution of pain.

The reconstructive microsurgery ladder in orthopaedics

Since the advent of the operating microscope by Julius Jacobson in 1960, reconstructive microsurgery has become an integral part of extremity reconstruction and orthopaedics. During World War I, with the influx of severe extremity trauma Harold Gillies introduced the concept of the reconstructive ladder for wound closure. The concept of the reconstructive ladder goes from simple to complex means of attaining wound closure. Over the last half century microsurgery has continued to evolve and progress. We now have a microsurgical reconstructive ladder. The microsurgical reconstruction ladder is based upon the early work on revascularization and replantation extending through the procedures that are described in this article.

Surgical management of cervical spine manifestations of neurofibromatosis Type 1: long-term clinical and radiological follow-up in 22 cases

Object

Patients with neurofibromatosis Type 1 (NF-1) at the cervical spine present significant surgical challenges due to neural compression, multiplicity of tumors, and complex spinal deformities. Iatrogenic instability following resection of tumors is underappreciated in the literature. The focus of this study was to understand the indications for stabilization in this specific group of patients.

Methods

The authors performed a retrospective review of 20 cases involving NF-1 patients with symptomatic cervical spine neurofibromas who underwent surgical decompression and tumor resection, with or without instrumentation, between 1991 and 2008. They also included 2 additional cases involving patients treated before 1991. Imaging findings and data pertaining to clinical presentation, intraoperative management, and postoperative assessment were compiled to clarify the indications for stabilization. An ordinal pain scale based on patient self-assessment was used. Neurological function was evaluated using American Spinal Injury Association Impairment Scale scores.

Results

The patient group comprised 13 men and 9 women. Their median age at presentation was 42.5 years; their median age at initial diagnosis of NF-1 was 30 years (range 8–74 years). The median duration of follow-up (since presentation) was 7 years (range 1–32 years). Progressive myelopathy was the main presenting symptom. Spinal cord compression was identified in 13 patients on presentation. Complete removal of the symptomatic tumors was performed in 11 patients. Ten patients underwent instrumented fusion during their first surgery. Six of these 10 required a second surgery—with fixation in 4 cases and without in 2. Of the 12 patients who did not receive instrumented fusion in their first surgery, 8 required a second surgery—with fixation in 5 cases and without in 3. Neurological deterioration due to progressive deformity was the indication for the second surgery in 3 of the 5 patients who required instrumented fusion only in their second surgery; the other 2 patients presented with neurological deterioration secondary to tumor progression. Four patients needed a third operation and instrumented fusion: 3 for deformity-related deficit and 1 for tumor progression. Based on the latest follow-up, 21 patients were stable clinically and radiologically, and 1 patient had died.

Conclusions

This specific group of patients represents a significant surgical challenge. In this retrospective analysis, emphasis is placed on early stabilization of the cervical spine to prevent late deformity as part of the comprehensive management of patients with NF-1.

Using segmental renal artery as recipient artery for spinal reconstructive surgery

STUDY DESIGN

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

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSION

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

Donor-site complications of autogenous nonvascularized fibula strut graft harvest for anterior cervical corpectomy and fusion surgery: experience with 163 consecutive cases

BACKGROUND CONTEXT

The fibula is a source of bone graft for reconstruction of the appendicular and axial skeleton.

PURPOSE

The aim of this study is to determine donor-site complications and morbidity in a large series of patients who underwent autogenous fibula harvesting for anterior cervical corpectomy and fusion (ACCF) surgery.

STUDY DESIGN/SETTING

Retrospective review (Level III).

PATIENT SAMPLE

One hundred sixty-three patients over an eight-year period who underwent ACCF with autogenous fibula.

OUTCOME MEASURES

Donor site complications (such as infection, cellulitis, pain, damage to the superficial peroneal nerve, ankle instability, tibial stress fracture, and so forth), treatment, and final outcome were determined from patient records.

METHODS

Retrospective study of patients who underwent ACCF with autogenous nonvascularized fibula strut graft over an eight-year period (from 1995 to 2002) was conducted. Donor site complications (such as infection, cellulitis, pain, damage to the superficial peroneal nerve, ankle instability, tibial stress fracture, and so forth), treatment, and final outcome were determined from patient records.

RESULTS

One hundred sixty-three patients underwent ACCF with autogenous fibula graft during the study period. The most common short-term complication (lasting <3 months) was incisional pain, present in 86 of 163 patients (53%). Incisional pain lasted longer than 3 months in 25 of 163 patients (15%) but resolved in all but two patients by 24 months. Two patients (1.2%) developed superficial peroneal neuromas. Five patients (3%) developed tibial stress fractures. Two patients (1.2%) developed ankle instability. Fifteen (9%) patients developed cellulitis that resolved in all patients after a short course of oral antibiotics, with one additional patient developing a deep infection requiring surgical debridement and intravenous antibiotics.

CONCLUSIONS

Although autogenous fibula is an excellent graft for multilevel ACCF reconstruction, surgeons should carefully consider the associated morbidity of fibular harvest before surgery. In this series, most complications were of short duration. However, nine patients with long-term complications required five additional surgical procedures. Therefore, patients who are scheduled to undergo autogenous fibula harvest should be advised about these potential complications.

The role of vascularized bone grafts in spine surgery

The use of vascularized bone grafts in complex spine reconstruction is particularly attractive in situations that involve large segmental bone defects, failed previous attempts at arthrodesis, poor soft tissue beds secondary to infection or radiation exposure necrosis or failed arthrodesis in neuromuscular disease processes. This article details the indications and rationale for vascularized bone grafting as well as the results of vascularized bone grafting of the spine.

Anterior thoracic spine reconstruction using a titanium mesh cage and pedicled rib flap

STUDY DESIGN

A retrospective clinical study.

OBJECTIVES

To evaluate the safety and efficacy of using an integrated titanium mesh cage and pedicled rib flap for thoracic spine reconstruction in patients at high risk of pseudarthrosis.

SUMMARY OF BACKGROUND DATA

A variety of materials are available for interbody thoracic reconstruction; however, the optimal treatment of patients at high risk of pseudarthrosis remains a challenging problem. Free or pedicled bone flaps have been shown to be highly effective in terms of promoting fusion and titanium mesh cages provide excellent structural support.

METHODS

Eleven patients who underwent anterior thoracic corpectomy and spinal reconstruction using an integrated titanium mesh cage and pedicled rib flap were analyzed with a mean follow-up of 37 months (range, 25-55 months). The etiology of spinal disease was infection in 7 (64%) patients and tumor in the remaining 4 (36%) patients. Seven (64%) patients were treated with only an anterior approach while the remaining 4 (36%) patients underwent circumferential spinal reconstruction.

RESULTS

All patients demonstrated clinical and radiographic evidence of spinal fusion at the time of follow-up. All patients had stable or improved Frankel grades after surgery. There was a mean kyphosis correction of 7 degrees for both the focal and regional thoracic kyphosis. There were three significant postoperative complications: bilateral pleural effusion, gram-negative bacteremia, and transient right lower extremity weakness requiring reoperation and pedicle screw revision. Two patients died after surgery: one from aneurysmal subarachnoid hemorrhage and the other from complications of breast cancer.

CONCLUSIONS

The use of an integrated rib flap and titanium mesh cage construct appears to be a safe and effective means of providing immediate and substantial anterior column support as well as achieving arthrodesis in challenging fusion candidates.

Use of the Microvascular Free Fibula Transfer as a Salvage Reconstruction for Failed Anterior Spine Surgery due to Chronic Osteomyelitis

BACKGROUND

Several factors influence the osseous union of spinal fusions, including the substrate used for arthrodesis, the biology of the fusion bed, as well as local host factors. While cancellous bone grafting is useful in simple cases with no major bony defects, corticocancellous strut grafts are indicated in reconstructions requiring mechanical support. The size and location of the spinal defect to be reconstructed determine what type of vascularized bone graft is indicated. According to the literature, locations suitable for reconstruction using a microvascular free fibula graft include the cervical spine and, less frequently, the cervicothoracic, thoracic, thoracolumbar, and lumbar spine. Using the microvascular free vascularized fibula graft as a salvage procedure for failed anterior spine surgery due to bacterial spinal osteomyelitis has not been reported.

METHODS AND RESULTS

Four cases of spinal osteomyelitis after attempted spinal fusion are presented. In all cases, a microvascular free fibula graft was successfully used for secondary spinal fusion and clearance of documented bacterial osteomyelitis. The operative approach is described.

CONCLUSIONS

Use of the vascularized free fibula graft for correction of primary and secondary spinal deformities, as well as for reconstruction after excision of malignant spine tumors, has been well documented. On the basis of their experience, the authors also recommend microvascular fibula transplantation as a salvage procedure for failed anterior spine surgery due to chronic osteomyelitis.

Indications and rationale for use of vascularized fibula bone flaps in cervical spine arthrodeses

BACKGROUND

Anterior cervical spine arthrodesis for large defects using autograft or allograft fibula for anterior structural support is a widely accepted procedure. In unique demand situations, a vascularized fibular flap is regarded as an "improvement" to the standard procedure. While a vascularized flap does deliver living tissue to the region, it does so with added potential morbidity and increased technical demand. The indications in the literature for this procedure have not been clearly defined. In this article, the authors review specific high-demand situations where they believe a vascularized flap is indicated. They also review patient outcomes after this procedure.

METHODS

Fibular free flaps were used in six patients with failed previous cervical spine arthrodeses. Three of the six patients had preoperative radiation therapy, and one received postoperative radiation treatment. All six patients had tumor and/or osteomyelitis present.

RESULTS

One patient died of intraoperative hypotension 3 days after a successful free flap transfer during an elective posterior spine instrumentation procedure. One flap was lost from a venous thrombosis, and the patient was then treated successfully with a second fibular free flap. Clinical and radio-graphic evidence of fusion was obtained at 3 months in the five surviving patients, and neurologic function remained stable or improved.

CONCLUSIONS

Analyzing their results and the literature, the authors propose that fibular free flaps are indeed a useful adjunct in difficult cervical spine stabilization procedures. Indications for this flap include combinations of the following situations: failed prior attempts at fusion, anterior cervical arthrodeses of three or more vertebral levels, osteomyelitis of the spine, and tumor cases when the spine has been or will be radiated.

Osteoradionecrosis of the cervical spine resulting from radiotherapy for primary head and neck malignancies: operative and nonoperative management

✓ Osteoradionecrosis is a process of dysvascular bone necrosis and fibrous replacement following exposure to high doses of radiation. The poorly vascularized necrotic tissue may cause pain and/or instability, and it cannot resist infection well, which may result in secondary osteomyelitis. When these processes affect the cervical spine, the resulting instability and neurological deficits can be devastating, and immediate reestablishment of spinal stability is paramount. Reconstruction of the cervical spine can be particularly challenging in this subgroup of patients in whom the spine is poorly vascularized after radical surgery, high-dose irradiation, and infection. The authors report three cases of cervical spine osteoradionecrosis following radiotherapy for primary head and neck malignancies. Two patients suffered secondary osteomyelitis, severe spinal deformity, and spinal cord compression. These patients underwent surgery in which a vascularized fibular graft and instrumentation were used to reconstruct the cervical spine; subsequently hyperbaric oxygen (HBO) therapy was instituted. Fusion occurred, spinal stability was restored, and neurological dysfunction resolved at the 2- and 4-year follow-up examinations, respectively. The third patient experienced pain and dysphagia but did not have osteomyelitis, spinal instability, or neurological deficits. He underwent HBO therapy alone, with improved symptoms and imaging findings. Hyperbaric oxygen is an essential part of treatment for osteoradionecrosis and may be sufficient by itself for uncomplicated cases, but surgery is required for patients with spinal instability, spinal cord compression, and/or infection. A vascularized fibular bone graft is a very helpful adjunct in these patients because it adds little morbidity and may increase the rate of spinal fusion.

Computed tomography validating bony ingrowth into fibula strut allograft: a criterion for fusion

BACKGROUND CONTEXT

Static and dynamic X-ray studies routinely determine whether or not fusion of a fibula strut allograft has occurred after multilevel anterior corpectomy with fusion (ACF) combined with posterior wiring and fusion (PWF).

PURPOSE

Two-dimensional (2D) computed tomography (CT) studies were assessed for documentation of bony ingrowth into fresh frozen fibula strut allograft to constitute an additional sign of fusion.

STUDY DESIGN/SETTING

This was a prospective, nonrandomized study, which was conducted at a university medical center.

PATIENT SAMPLE

Eighteen patients with moderate to severe myelopathy undergoing circumferential cervical surgery for ossification of the posterior longitudinal ligament and spondylostenosis were evaluated.

OUTCOME MEASURES

Static and dynamic X-rays and 2D CT examinations were performed in 18 patients 3 and 6 months after circumferential cervical procedures.

METHODS

Fusion was assessed on static and dynamic X-rays, and 2D CT studies performed in 18 patients following average 2.9 level anterior corpectomy with fusion (ACF) with posterior wiring and fusion (PWF) (C2-T1) with halo application. Routine fusion criteria on static radiographs included the documentation of bony trabeculation and absence of bony lucency at the graft/vertebral end plate interface. Routine dynamic X-ray criteria of fusion mandated that less than 3.5 mm of translation, less than 20 degrees of angulation, and less than 1 mm of motion be observed between adjacent spinous processes. Here, a potential additional 2D CT criterion for fusion, progressive bony ingrowth into the central shaft of a fibula strut allograft, was investigated on 3 and 6 month postoperative 2D CT examinations using direct measurement of Hounsfield units. Telescoping (mm) was also differentiated from ingrowth into the bony shaft based on a comparison of immediate, 3 and 6 month postoperative CT studies.

RESULTS

Immediate postoperative baseline 2D CT studies revealed no bone within the central canal but an average of less than 1 mm of cephalad and 2.3 mm of caudad graft telescoping. Within 6 postoperative months, 2D CT studies demonstrated an average of 3.5 mm of superior and 4.6 mm of inferior bony ingrowth (confirmed by measuring 500 to 900 Hounsfield units) into the central fibula canal of 17 of 18 patients (94%). Seventeen had routine/dynamic X-ray and CT studies confirming fusion.

CONCLUSIONS

Two-dimensional CT evidence of bony ingrowth into the central canal of fibula strut allografts after multilevel ACF/PWF provided an additional means of quantifying the extent of fusion.

Use of vascularized fibular grafts as a salvage procedure for previously failed spinal arthrodesis

STUDY DESIGN

A case series of spinal arthrodesis performed with vascularized fibular grafts is presented.

OBJECTIVES

The use of vascularized fibular grafts to obtain anterior spinal fusion in patients with complex spinal disorders and poor fusion environments is described.

SUMMARY OF BACKGROUND DATA

The fusion success of spinal arthrodesis is dependent on numerous factors, such as the substrate used for arthrodesis (i.e., graft), the biology of the fusion bed, and local host factors. Vascularized grafts have higher success rates for union and can better overcome a poor fusion bed than nonvascular grafts. However, they are associated with higher donor site morbidity and greater technical difficulty.

METHODS

Three patients with complex medical histories portending a difficult spinal fusion were treated with anterior arthrodesis using vascularized fibular autografts. Vascular patency was confirmed by bone scintigraphy, and osseous union by radiography and computed tomography.

RESULTS

All patients had successful osseous fusion in 3 to 6 months. Deformity was improved. Patients reported decreased pain and resumption to previous activities at 24 months follow-up. There were no complications.

CONCLUSIONS

A vascularized fibular graft is a useful alternative to standard grafts for spinal arthrodesis. Vascularized fibular grafts provide high fusion rates, rapid incorporation, and increased mechanical strength, and thus heal better in a suboptimal graft bed. The procedure is technically demanding, often requiring the expertise of a microvascular surgeon for obtaining the graft and achieving anastomosis. It is best suited in cases where significant difficulty in obtaining a spinal fusion is anticipated.

Use of folded vascularized rib graft in anterior fusion after treatment of thoracic and upper lumbar lesions. Technical note

For lesions involving the anterior and/or middle column of the spine, an anterior approach is adequate for curetting the lesion and restoring spinal stability. Materials such as autogenous bone grafts, cages with bone chips, some artificial materials, or allografts are used as strut materials. Rib material is usually removed when the anterior approach is conducted for thoracic or thoracolumbar lesions. A rib itself is not rigid enough to support the load, and a bone union is not easily obtained. The purpose of this paper is to describe a method of grafting vascularized rib in folded form to fill the defects left after removal of a spinal lesion. The rib, with the artery and vein at two levels cranial to the involved vertebral body, was isolated from surrounding tissues such as the intercostal nerve, muscles, and pleura. After curetting the lesion, the rib was folded into three or four pieces to a length adequate to fill the defect and inserted as a pedicled vascularized graft. A total of 23 cases, including 14 men and nine women, underwent surgery in which this grafting technique was used. The pathological conditions requiring anterior decompression and fusion were spinal trauma in nine cases, spinal infection in six cases, osteoporotic fracture in seven cases, and spinal metastasis in one case. In all cases a solid bone union was obtained and all infections resolved. With vascularized rib graft folded into three to four pieces, solid bone union can be obtained without use of any other grafted materials even in cases of infection and osteoporosis.

Severe progressive osteoporotic spine deformity with cardiopulmonary impairment in a young patient. A case report

STUDY DESIGN

This report describes a young patient with a rapidly progressive kyphosis caused by collapse of a severely osteoporotic thoracolumbar spine, which led to impairment of cardiopulmonary function.

OBJECTIVES

To highlight the treatment strategy, difficulty of diagnosis, operative stabilization, and outcome.

SUMMARY OF BACKGROUND DATA

Little is known about natural history, treatment options, and results of this condition.

METHODS

The magnitude of bone loss was measured by dual-energy x-ray absorptiometry, and the deformity was visualized by computed tomography and magnetic resonance imaging. Laboratory investigations also were performed before and during halotraction in an attempt to establish a diagnosis. These data constituted the preoperation information required to assess later results of medical and surgical intervention.

RESULTS

An extensive evaluation of possible underlying etiologies failed to identify a specific etiology. Before and during halotraction, bone mineral substitutes were given, partially correcting the bone mineral content as measured on repeated dual-energy x-ray absorptiometry scans. In addition, the thoracic kyphosis was partially corrected, from 100 degrees to 70 degrees Cobb's angle. Subsequently, a combined anterior and posterior stabilization was performed from C7 to S1 using a vascularized fibula graft, a double Isola rod system (AcroMed, Cleveland, OH), and a carbonate apatite cancellous bone cement to reinforce the pedicle screws. At follow-up assessment 40 months surgery, the patient was asymptomatic and fully mobilized, with radiographs showing complete incorporation of the grafts and no loosening of the fixation device.

CONCLUSIONS

The diagnostic and therapeutic difficulties of progressive spine deformity caused by severe osteoporosis in young patients emphasizes the importance of a thoroughly planned treatment strategy. Halotraction is recommended to stop progression of the deformity, or even partially correct it, and to allow time to search for the diagnosis and bone mineral substitution. Surgical treatment using vascularized fibular strut grafts and a strong fixation device was successful. Biocompatible carbonated apatite cancellous bone cement was successfully used to reinforce pedicle screw fixation.

Complex cervical spine neoplastic disease: reconstruction after surgery by using a vascularized fibular strut graft. Case report

The authors report a case of an aggressive chordoma in the cervical spine of a 15-year-old girl who underwent radical resection followed by reconstruction using an anterior vascularized fibular strut graft and posterior arthrodesis prior to receiving immediate postoperative radiation therapy. The patient had successful graft incorporation 4 months postoperatively. The authors review the advantages of using vascularized fibular strut grafts for the treatment of multilevel cervical spine neoplastic disease and discuss the theoretical advantages of using vascularized grafts that tolerate therapeutic levels of radiation.