Late fracture of vascularized fibular grafts

Is liquid nitrogen recycled bone and vascular fibula combination the biological reconstruction of choice in lower extremity long bone tumor-related defects?

INTRODUCTION

Combination techniques, which encompass the combined use of vascularized bone grafts with massive allografts or autografts (recycled bone grafts), are especially important in the biological reconstruction of tumor-related lower extremity long bone defects. Liquid nitrogen recycled bone (frozen autograft) and free vascular fibula graft (FVFG) combination, which was coined as the "frozen hotdog (FH)" method by the authors, has not been as widely used nor its outcomes reported for significantly sized patient groups. This study aims to provide an answer to whether FH is a safe and effective reconstructive tool for limb salvage in malignant tumors of the lower extremity regarding radiological, functional, and oncological outcomes.

PATIENTS AND METHODS

Sixty-six (male/female: 33/33) patients, who underwent FH reconstruction for tumor-related massive defects of lower extremity long bones between 2006 and 2020, were retrospectively analyzed. The mean age was 15.8 (3.8-46.7) years. The most common tumor localizations were distal femur (42.4%) and proximal tibia (21.2%) while classic osteosarcoma and Ewing's sarcoma were the most common pathologies (60.6% and 22.7%, respectively). Mean resection and FVFG lengths were 160 (90-320) mm and 192 (125-350) mm, respectively. The mean follow-up was 73.9 (24-192) months.

RESULTS

The mean MSTS score was 25.4 (15-30) and the mean ISOLS radiographic score was 22.6 (13-24). Mean time to full weight bearing without any assistive devices was 15.4 (6-40) months and the median time was 12 months. MSTS score negatively correlated with resected segment length and vascular fibula length (p < 0.001; p = 0.006). Although full contact apposition of the FH segment correlated with earlier full weight bearing compared to partial apposition (mean 13.7 vs. 17.9 months) (p = 0.042), the quality of reduction did not affect the ISOLS radiographic score at LFU. Overall limb survival rate was 96.3% at 5 and 10 years while FH survival rate was 91.0% and 88.1% at 5 and 10 years. Local recurrence-free survival rates were 88.8% and 85.9%, and overall survival was 89.9% and 86.1% at 5 and 10 years, respectively. Limb length discrepancy was the most common complication with 34 (51.5%) patients while shell nonunion was seen in 21 (31.8%) patients and graft fracture in 6 (9.1%).

CONCLUSION

The "FH" method is a safe, effective, and extremely cost-efficient reconstructive tool for tumor-related lower extremity long bone defects. Patient compliance to protracted weight-bearing, ensuring the vitality of the FVFG, and achieving an oncologically safe resection are key factors for a successful outcome.

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.

Ilizarov technique for treatment of distal radius deformity and bone defect after trauma

Objective

To investigate the effectiveness on the distal radius deformity and bone defect after trauma by using Ilizarov external fixator.

Methods

The clinical data of 9 patients of post-traumatic distal radius deformity with bone defect treated by Ilizarov technique between January 2012 and December 2016 were retrospectively analyzed. There were 7 males and 2 females with an average age of 25.6 years (range, 11-46 years). Of the 9 cases, 4 were radial baseball hand deformity with large bone defect, 4 were short deformity of distal radius, 1 was distal radius deformity with radial deflection and pronation deformity, all with distal dislocation of the distant radial-ulnar joint. The time from injury to operation was 6 months to 6.2 years (mean, 1.5 years). The bone defect was 1.4-6.8 cm (mean, 3.6 cm). After complete debridement, the forearm was fixed with Ilizarov external fixator. At 7 days after operation, bone transport or bone lengthening was performed at the rate of 0.8-1 mm/d, 4 times a day, the deformity was slowly corrected and the bone defect was repaired. According to the loss of palmar tilt angle and ulnar tilt angle measured before operation, the position of distal radial articular surface was gradually adjusted in the course of moving or prolonging, so as to restore palmar tilt angle and ulnar tilt angle as far as possible.

Results

All wounds healed by first intention and no leakage or rupture occurred. All the 9 patients were followed up 15-36 months (mean, 23 months). All the radius defects healed and the distal deformity was corrected, the healing time was 92.4-138.6 days (mean, 104.7 days); the external fixation index was 32.6-51.1 days/cm (mean, 40.2 days/cm). After 2 months of external fixator removal, the wrist joint flexion was (42.6±3.1)°, the wrist dorsum extension was (48.5±4.7)°, the palm inclination angle was (11.5±1.3)°, and the ulnar deviation angle was (21.2±3.7)°; the elbow flexion was (128.2±6.4)°, the elbow extension was (3.2±2.1)°, the forearm pronation was (71.5±4.3)°, and the forearm rotation was (38.2±6.5)°; the wrist and elbow joint extension and forearm rotation were significantly improved when compared with preoperative values ( P<0.05). At last follow-up, wrist function was assessed according to Gartland-Werley standard, the results were excellent in 3 cases, good in 5 cases, and fair in 1 case. Four cases had pinhole infection, and were cured after anti inflammatory dressing change or replacement of needles; 3 cases did not heal at the bone junction, and were healed after bone grafting; 4 cases deviated from the radial force line, and the deformity was corrected after adjusting the needle.

Conclusion

Ilizarov technique can correct deformity and reconstruct bone defect of the post-traumatic distal radius simultaneously, so it is a good method to treat this kind of disease.

Acute Limb Shortening for Major Near and Complete Upper Extremity Amputations with Associated Neurovascular Injury: A Review of the Literature

In the setting a near or complete upper extremity amputations with significant soft tissue loss and neurovascular compromise, upper extremity surgeons are faced with the challenge of limb salvage. There are a multitude of treatment options for managing skeletal and soft tissue injuries including provisional fixation, staged reconstruction, and an acute shortening osteotomy with primary rigid internal fixation. However, many complications are associated with these techniques. Complications of provisional fixation include pin tract infection and loosening, tethering of musculotendinous units, nonunion, and additional surgeries. Staged reconstruction includes a variety of techniques: distraction osteogenesis, bone transport, or vascularized and non-vascularized structural autograft or allograft, but the risks often outweigh the benefits. Risks include nonunion, postoperative vascular complications necessitating reoperation, and the inability to return to the previous level of function at an average of 24 months. Acute shortening osteotomy with internal fixation offers the advantage of a single-stage procedure that provides for decreasing the soft tissue loss, provides a rigid platform to protect the delicate neurovascular repair, and alleviates unwanted tension at the repair sites. This review discusses the literature on the surgical treatment of severe upper extremity trauma with associated neurovascular injury over the past 75 years, and aims to evaluate the indications, surgical techniques, clinical and functional outcomes, and complications associated with acute shortening osteotomy with rigid internal fixation. Although this technique is not without risks, it is well-tolerated in the acute setting with a complication profile comparable to other techniques of fixation while remaining a single procedure.

Combined rib-latissimus flap; the "picket fence" concept for reconstruction of upper tibia defects

Background:

Upper tibia defects ,type3b Gustilo, due to huge size and volume are very difficult to reconstruct; usually several operations are needed for bone and soft tissue defects and the definite one stage reconstruction is yet to be found.

Objectives:

In this article we reintroduce the rib- latissimus flap as an acceptable method to reconstruct tibia defects in selected cases.

Materials and Methods:

The latissimus muscle with one or two ribs revascualrized by reverse flow from perforators is harvested; the ribs are bisected after harvest yielding four to six struts of vascularized bone to fill the huge upper tibia defect. Internal fixation is very important and we favor LCP plates for long bone fixation and the rib struts are fixed in place by small titanium screws to maintain the “picket fence” design. The muscle is then wrapped around the ribs and the defect is completely reconstructed.

Results:

During the past 9 years we have used the rib-latissimus dorsi (RLD) muscle flap, without serratus muscle, in 7 patients with combined bone and soft tissue defects of the upper tibia. All the flaps healed without any major complications and only one stress fracture was seen and treated. The ribs healed and in a median of 14 months hypertrophied to the size of the upper tibia. Nonunion was not observed and patients with lower extremity defects were able to bear full weight within an average of seven months.

Conclusions:

The fractures of tibia type 3a and 3b Gustilo are devastating injuries requiring several operations. Several combinations of RLD-Serratus have already been reported but a rib-LD muscle with “picket fence” design has not been reported .The RLD transfer with two ribs divided into four struts for bone coverage and muscle to cover all the upper tibia soft tissue defect can be a useful tool in the armamentarium of the surgeon treating combined defects in a single stage.

Case reports: lengthening of a vascularized free fibular graft

Wide bone resection is sometimes necessary for bone tumors, and reconstruction is a major challenge. Vascularized fibular graft is one alternative but may result in progressive limb-length discrepancy (LLD) in children with substantial growth left. Progressive distraction lengthening with an external fixator is now a standard procedure to generally correct LLD. However, lengthening of free vascularized fibular grafts for lower limb reconstruction has not been reported frequently and then only in small series or case reports. We report our experience with three patients with lengthening after tibial reconstruction with a free vascularized fibular graft and review the literature.

Impact of radiation therapy on healing and stability of vascularized bone grafts in a dog model

The purpose of the study was to observe the impact of radiation therapy on healing and biomechanical properties of vascularized bone grafts, and thus to establish an appropriate large animal model. Ten male beagles were divided into two experimental groups: radiation (R) and control (C). The left 5th to 7th ribs of the animals of group R were irradiated 3 and 2 weeks preoperatively, using a dose of 8 Gy each time. Each animal of both groups underwent the following operative procedures. The 5th and 7th ribs were removed, and the 5th rib was replaced by a vascularized pedicle transfer of the 4th rib. The 7th rib was reconstructed using a pedicle transplant of the 8th rib. The 5th and 7th ribs were used as nonvascularized bone grafts to replace the donor sites of the 4th and 8th ribs, respectively. Group R received two further irradiation cycles 2 and 3 weeks postoperatively. The vascularized rib grafts of group R demonstrated a higher number of delayed unions in plain x-rays and avascular bone segments in microangiography than the control group. The presence of vital osteocytes in histology was not significantly different between groups. Biomechanical tests focusing on the durability of vascularized ribs against bending and torsion forces demonstrated a reduction of average maximum bending moments by 56.6% after radiation compared to controls (P < 0.05). Twisting moments were reduced by 47.6% (P < 0.05). The data demonstrate a significant worsening in bone healing and stability after pre- and postoperative radiation therapy to the wound bed and bone grafts. Thus, a large animal model is established for further determination of different strategies of radiotherapy in combination with vascularized bone transfers.

Case reports: management of large segmental tibial defects using a cylindrical mesh cage

We report a case series of three patients who sustained open Gustilo-Anderson Type IIIB tibia fractures associated with extensive segmental bone and soft tissue loss. The patients initially were treated with serial wound irrigations, débridements, and external fixation. After the soft tissue envelope was reconstructed successfully, each large segmental bone defect was reconstructed with a cylindrical titanium mesh cage packed with a composite of cancellous allograft and demineralized bone matrix putty and stabilized with a statically locked intramedullary nail. The mean segmental bone loss was 12.2 cm, and all patients had a minimum 1-year followup. One year after reconstruction, radiographs showed stable, well-aligned, healed constructs, and computed tomography images verified the presence of bony ingrowth throughout the cages. All patients were able to ambulate with full weightbearing, and had good ipsilateral knee, hip, and ankle range of motion. This technique seems to be a reasonable alternative for treating large segmental tibial bone defects.

Surgical management of a long segmental defect of the humerus using a cylindrical titanium mesh cage and plates: a case report

This is a case report of a patient who sustained multiple gunshots resulting in a Gustilo Anderson type IIIB mid-shaft humeral fracture associated with extensive segmental bone and soft-tissue loss. The patient was treated initially by multiple irrigations, wound debridement, and a unilateral external fixator. After the soft tissue healed without infection, the mid-shaft humeral defect of approximately 8 cm segmental bone loss was reconstructed with a cylindrical titanium mesh cage packed with a composite of cancellous allograft and demineralized bone matrix putty and stabilized with limited contact dynamic compression plates. At 13 months follow-up, plain radiographs demonstrated a healed construct with good alignment, and computed tomography images demonstrated bony in-growth through the cage. The patient had full range of motion at the shoulder and the elbow. This technique may be a reasonable alternative when treating large segmental bone defects of the humerus.

Comparison of internal bone transport and vascularized fibular grafting for femoral bone defects

OBJECTIVE

To compare results between vascularized fibular grafting and internal bone transport for large bone defects of the femur.

DESIGN

Retrospective review of patients.

SETTING

University teaching hospitals.

PATIENTS

This study included 37 patients with femoral bone loss: 20 patients were treated with internal bone transport and seventeen patients were treated with vascularized fibular grafting.

MAIN OUTCOME MEASUREMENTS

The outcomes investigated were external fixation time, external fixation index, bone results (union, infection, deformity, leg length discrepancy), and functional results.

RESULTS

The mean amount of filled defect was 8.4 cm with internal bone transport and 8.9 cm with vascularized fibular grafting. The external fixation index was 1.4 months/cm with internal bone transport and 1 month/cm with vascularized fibular grafting. The bone results and functional results of the internal bone transport were excellent in 65% and 0%, good in 5% and 45%, fair in 5% and 40%, poor in 25% and 15%, respectively, whereas those of the vascularized fibular grafting were excellent in 35% and 0%, good in 25% and 47%, fair in 5% and 35%, and poor in 35% and 18%.

CONCLUSION

With vascularized fibular grafting, careful monitoring of circulation and early intervention surgery is necessary to avoid vascular failure. With internal bone transport, repeated radical debridement until control of infection is achieved, bone grafting at the docking site for early union, and avoiding stress fracture are recommended to improve bone results.