Pedicled Vascularized Bone Grafts for Posterior Lumbosacral Fusion: A Cadaveric Feasibility Study and Case Report

A Comparative Analysis of Quadriceps Tendon, Patellar Tendon Bone Allograft, and Cadaver Graft in Anterior Cruciate Ligament (ACL) Repair and Reconstructive Surgery

Anterior cruciate ligament (ACL) injuries are a common occurrence among athletes and active individuals, often necessitating surgical intervention for optimal recovery. The choice of graft material for ACL reconstruction remains a topic of debate, with various options available, including quadriceps tendon (QT), patellar tendon bone allograft (PTBA), and cadaver graft (CG). This paper aims to provide an extensive review and comparison of the efficacy, outcomes, and complications associated with these graft types based on recent research. A systematic literature search following PRISMA guidelines was conducted to identify relevant studies published in the past six years. The findings suggest that while each graft type has its advantages and limitations, there is no definitive superior choice. Factors such as patient age, activity level, comorbidities, and surgeon preference should be considered when selecting the most appropriate graft for ACL repair surgery. QT grafts are associated with lower donor-site morbidity compared to patellar tendon grafts. However, QT grafts may have a higher risk of graft rupture and decreased knee flexion strength. PTBA grafts, compared to QT grafts, have a higher risk of donor-site morbidity but a lower risk of graft rupture and improved knee stability. CG grafts have lower donor-site morbidity compared to PTBA grafts but may have a higher risk of graft rupture and decreased knee flexion strength compared to PTBA grafts. In conclusion, the choice of graft material for ACL reconstruction is a complex decision that requires careful consideration of various factors, including patient age, activity level, comorbidities, and surgeon preference. While each graft type has its advantages and limitations, there is no definitive superior choice. Therefore, it is essential to carefully weigh the risks and benefits of each graft type to ensure optimal outcomes for patients undergoing ACL repair surgery.

Vascularized Bone Grafts for Spinal Fusion-Part 3: The Occiput

BACKGROUND

Obtaining successful arthrodesis at the craniocervical junction and atlantoaxial joint can be more challenging than in other segments of the cervical spine. This challenge stems from the relatively hypermobile joints between the occipital condyles, the motion that occurs at C1 and C2, as well as the paucity of dorsal bony surfaces for posterior arthrodesis. While multiple different techniques for spinal fixation in this region have been well described, there has been little investigation into auxiliary methods to improve fusion rates.

OBJECTIVE

To describe the use of an occipital bone graft to augment bony arthrodesis in the supraaxial cervical spine using a multidisciplinary approach.

METHODS

We review the technique for harvesting and placing a vascularized occipital bone graft in 2 patients undergoing revision surgery at the craniocervical junction.

RESULTS

The differentiation from nonvascularized bone graft, either allograft or autograft, to a bone graft using vascularized tissue is a key principle of this technique. It has been well established that vascularized bone heals and fuses in the spine better than structural autogenous grafts. However, the morbidity and added operative time of harvesting a vascularized flap, such as from the fibula or rib, precludes its utility in most degenerative spine surgeries.

CONCLUSION

By adapting the standard neurosurgical procedure for a suboccipital craniectomy and utilizing the tenets of flap-based reconstructive surgery to maintain the periosteal and muscular blood supply, we describe the feasibility of using a vascularized and pedicled occipital bone graft to augment instrumented upper cervical spinal fusion. The use of this vascularized bone graft may increase fusion rates in complex spine surgeries.

Vascularized Bone Grafts for Spinal Fusion-Part 1: The Iliac Crest

BACKGROUND

Iliac crest autograft has been the gold standard for harvest of fusion materials in spine surgery. The benefits of a vascularized version of this bone graft-including delivery of stem cells, ability to deliver antibiotics to the fusion bed, and relative ease of harvest-make this technique superior to free bone transfer in the achievement of augmented spinal fusion.

OBJECTIVE

To present a brief summary of similar existing concepts before describing the novel technique of this vascularized posterior iliac crest bone graft.

METHODS

Vascularized posterior iliac crest bone graft can be harvested from the same midline lumbar incision used for thoracolumbar spinal fusion, through lateral dissection around the paraspinals to the iliac crest. Recipient sites in the posterolateral bony spinal gutters may be as rostral as T12 and caudal as the sacrum. The ability to cover multiple lumbar levels can be achieved with desired lengths of the donor iliac crest.

RESULTS

Over 14 vascularized iliac crest bone grafts have been performed to augment lumbar fusion for salvage after pseudoarthrosis. Operative time and bleeding are reduced compared to free flap procedures, and no patients have experienced any complications related to these grafts. Indocyanine green (ICG) angiography has been utilized in a novel way to ensure the vascularity of the bone graft prior to arthrodesis.

CONCLUSION

While long-term follow-up will be required to fully characterize fusion rates and patient morbidity, this innovative surgical option augments spinal fusion in patients with, or at increased risk for, pseudoarthrosis.

Vascularized Rib Bone Grafting: Indications, Techniques, and Clinical Outcomes

Pseudarthrosis is a difficult complication often seen in patients with complex spinal pathology. To supplement existing neurosurgical approaches to cervicothoracic spinal instrumentation and fusion, novel vascularized rib bone grafts can be utilized in patients at high risk for failed spinal fusion. In this article, we discuss the indications, benefits, surgical technique, feasibility, and limitations of using rib vascularized rib bone grafts to augment spinal fusion.

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

Spinal fusion can be challenging to obtain in patients with complex spinal pathology. Medial scapular vascularized bone grafts (S-VBGs) are a novel approach to supplement cervicothoracic arthrodesis in patients at high risk of failed spinal fusion. In this article, we discuss the benefits of using VBGs compared with both nonvascularized bone grafts and free vascularized bone flaps and the surgical technique, feasibility, and limitations specific to the S-VBG.

Vascularized Posterior Iliac Crest Bone Grafting: Indications, Techniques, Clinical Outcomes, and Alternatives

Pseudarthrosis is a feared complication of spinal fusion procedures. Currently, the gold standard in prevention or treatment of pseudarthrosis is placement of nonvascularized iliac crest bone autograft. While rates of fusion are significantly higher in patients with use of nonvascularized bone autografts than with allografts, patients who have previously failed lumbar arthrodesis or those at a high risk for pseudarthrosis may benefit from a more robust, vascularized bone graft with enhanced osteogenicity. In this article, we discuss the use of iliac crest vascularized bone grafts as an adjunct for high-risk patients undergoing lumbosacral spine arthrodesis.

Vascularized Bone Grafts in Spinal Reconstruction: An Overview of Nomenclature and Indications

Several vascularized bone grafts (VBGs) have been introduced for reconstruction and augmenting fusion of the spine. The expanding use of VBGs in the field of spinoplastic reconstruction, however, has highlighted the need to clarify the nomenclature for bony reconstruction as well as establish the position of VBGs on the bony reconstructive algorithm. In the current literature, the terms "flap" and "graft" are often applied inconsistently when describing vascularized bone transfer. Such inconsistency creates barriers in communication between physicians, confusion in interpreting the existing studies, and difficulty in comparing surgical techniques. VBGs are defined as bone segments transferred on their corresponding muscular attachments without a named major feeding vessel. The bone is directly vascularized by the muscle attachments and unnamed periosteal feeding vessels. VBGs are best positioned as a separate entity in the bony reconstruction algorithm between nonvascularized bone grafts (N-VBGs) and bone flaps. VBGs offer numerous advantages as they supply fully vascularized bone to the recipient site without the microsurgical techniques or pedicle dissection required for raising bone flaps. Multiple VBGs have been introduced in recent years to optimize these benefits for spinoplastic reconstruction.

The Advent of Spinoplastics: Easing the Growing Global Disease Burden of Spinal Injury

Epidemiologic studies have demonstrated a growing global disease burden of pathologies affecting the vertebral column. Allograft or implant-based reconstruction and fusion surgeries have been the mainstay of treatment. The efficacy of various surgical methods and the reliability of instrumentation or implants to execute these surgeries continue to be debated in the literature. Advances such as the free-tissue transfer have improved postoperative measures; however, they add high operative risk. The advent of spinoplastics introduces a practical surgical model to augment these spinal surgeries using vascularized bone grafts. As this technique becomes more widespread, it can be utilized to ease the growing disease burden that spinal injury places on both patients and the health care system. Ultimately, it will ameliorate strains on health care resources, reduce health care costs, and improve patient outcomes and quality of life.

Bone Grafts, Bone Substitutes, and Orthobiologics: Applications in Plastic Surgery

As reconstructive needs often extend past the soft tissue alone, a plastic surgeon must also be well versed in the methods of bony reconstruction. Understanding of the basic science of fracture healing and the biochemical mechanisms of the different bone grafts, bone substitutes, and orthobiologics is essential to selecting among the many different options available to the modern plastic surgeon. This review provides a broad overview of these different options and the specific applications for plastic surgeons based on anatomic location.

Vascularized Iliac Bone Graft for Complex Closure During Spinal Deformity Surgery

Spinal pseudarthrosis is failure of bony union across a segment where arthrodesis has been attempted. A variety of treatment approaches have been proposed to promote bony union, including use of vascularized bone graft. We report a successful application of vascularized pedicled iliac crest bone graft (ICBG) to treat recurrent lumbar and sacral pseudarthrosis. The vascularized ICBG offers the advantages of biocompatibility, mechanical stability, and minimal antigenicity. Vascularized bone transfers to the spine undergo fusion without resorption, even in the presence of compressive and rotatory forces. With its ease of access within the operative field and limited donor site morbidity, vascularized ICBG is an ideal orthobiologic that expedites time to bony union.