The use of vascularized fibula flap with allograft in post-oncologic microsurgical bone reconstruction of lower limbs in pediatric patients

BACKGROUND

Post-oncologic surgical reconstruction of lower limbs in pediatrics remains a challenging topic. Microsurgical techniques allow reconstructions of large bony defects. The use of vascularized fibular flap with allograft has proven to be an ideal biologic construct. We aim to assess the success rate of this operation, including flap survival, bony union, weight-bearing ambulation, and complications in a long-term follow-up in our case series compared to the literature.

PATIENTS AND METHODS

Our case-series includes 18 femoral resections (9 osteosarcomas, 8 Ewing sarcoma, and 1 desmoid tumor) and 15 tibial resections (10 osteosarcoma, 4 Ewing sarcoma, and 1 Malignant Fibrous Histiocytoma). We collected patients' demographics, type of tumor, type of resection, defect size, fibula-flap length, method of fixation, anastomosis site, follow-up data, complications, and their management. All survivals were examined by X-ray and CT-scan to evaluate the morphological changes of the vascularized fibula and follow-up. The functional evaluation was performed by the 30-point Musculoskeletal Tumor Society Rating Score (MSTS) for the lower limb (Enneking et al., Clinical Orthopaedics and Related Research 1993(286):241-246).

RESULTS

The mean age of the femur resection patients' group was 11.2 years with a mean defect size of 14 cm and a mean length of the fibular flap of 18 cm; for the tibia the mean age was 12 years with a mean defect size of 14 cm and a mean length of the fibular flap of 16.6 cm. The overall survival of the reconstructions at 5 years follow-up was 17 out 18 cases for the femur and 13 out of 15 cases for the tibia. MSTS score was 28.2 for the femur and 23.7 for the tibia. The average time of union of the fibula was seen after 5 months, while allograft consolidation was observed around 19.7 months. The mean time of follow-up was 144.5 months for the femur and 139.2 months for the tibia. The complication rate observed was 7 out of 18 for the femur and 7 out of 15 for the tibia reconstructions.

CONCLUSIONS

The viability of the fibula is a cornerstone in the success of reconstruction as well as the successful management of complications in intercalary defects after tumor resection in pediatrics to restore good functionality. Our results are in line with those reported in the literature in terms of overall complication rates. The high primary union of allograft, the high MSTS score obtained, and the low rate of severe complications reflect the mechanical role of this reconstructive technique over a long follow-up.

The distal fibular perforating axial flap for lateral malleolus coverage: an anatomical description and surgical technique

PURPOSE

Skin closure disorders in ankle surgery are a recurrent problem not only in traumatology but also in elective surgery. The aim of the study was to describe the anatomical basis of the fasciocutaneous vascularization of the lateral malleolus region to develop a posterior cover flap for the region.

METHODS

We dissected ten fresh frozen specimens after arterial injection of an Indian ink preparation and individualized the perforating arteries. Their positions and diameters were collated. Then, the surgical technique was clinically applied for two different cases by transferring the fasciocutaneous flap posterior to the lateral malleolus to cover a loss of skin substance.

RESULTS

There were in average 5 fibular perforators over the last 100 mm of the fibula. The average diameter of the first two perforating arteries was 0.6 ± 0.12 mm and 0.9 ± 0.25 mm, respectively, and the consistency of the latter makes it possible to produce a skin flap with anterior translation. This is an axial flap. Two patients were operated on using this technique. There was no necrosis of the posterior fibular flap and healing was achieved by the third post-operative week.

CONCLUSION

This study showed the presence of fibular perforating arteries with a high reproducibility of their dissection. This anatomical description served as the basis for the description of a new distal fibular perforating flap.

An Unreported Variation of Origin of Posterior Tibial Artery Encountered During Free Fibula Flap Harvest

ABSTRACT

Variations in the division of popliteal artery and origin of the 3 vascular systems are well documented. Here, we report a case in which the posterior tibial artery originated from the peroneal artery, in lower leg and then followed the normal course. The anomaly was detected intraoperatively precluding the harvest of free fibula flap. The procedure was abandoned and fibula was fixed using plates and screws and a free radial forearm flap was done over 2 mini-plates, which spanned the bone gap. A second bone flap procedure was to be planned in another sitting.The anomalous origin of posterior tibial artery from the peroneal artery in lower leg did not fall into any of the categories described previously by Kim et al (Ann Surg 1989;210:776-81.). In the event such atypical anatomy is encountered, it must be delineated, and the surgical plan adjusted accordingly. Flexibility in surgical approach can prevent vascular catastrophe.

Osteocutaneous proximal fibular flap: an anatomical and computed tomographic angiographic study of skin and bone perforators

INTRODUCTION

Vascularized proximal fibular epiphyseal transfer is a reconstruction method for joints and growing bones. The authors investigated the vascular supply of the proximal fibula, including skin perforators, for suitability in creating an osteocutaneous flap.

METHODS

Twenty fresh cadaveric knees were studied using computed tomographic angiography combined with anatomical dissection. Three-dimensional angiography was used to develop an overview, and multiplanar two-dimension angiography was used for detailed data collection. Anatomical dissection verified by angiography was used to locate skin perforators of the proximal part of the anterior tibial artery.

RESULTS

Proximal fibular bone perforators from the anterior tibial artery were found to arise either from the anterior tibial recurrent artery, the posterior tibial recurrent artery or the circumflex fibular artery in every specimen (100%), whereas perforators from the inferolateral genicular artery met those criteria in 12 of 18 specimens (66.7%). In the proximal half of 20 anterior tibial arteries, 129 skin perforators with a diameter larger than 0.5 mm were found. There were 54 potential septocutaneous skin perforators between the extensor digitorum longus and the peroneus longus muscles (EDL/PL), and 18 between the extensor digitorum longus and the tibialis anterior muscles (TA/EDL). Skin perforators from the inferolateral genicular artery emerging from the posterolateral corner of the knee had a diameter of < 0.5 mm.

CONCLUSION

Based on this cadaveric study, the reverse flow anterior tibial artery pedicle and the EDL/PL or TA/EDL skin perforators can be considered as options for osteocutaneous proximal fibular transfers.

Application of optimized digital surgical guides in mandibular resection and reconstruction with vascularized fibula flaps: Two case reports

RATIONALE

Currently, digital surgical techniques have been widely used in the precise treatment of mandibular resection and reconstruction with fibula flaps. Utilizing these innovative techniques in surgical planning and hardware fabrication before surgery has shown to provide great help. However, it is difficult for even experienced surgeons to place the preformed reconstruction plate in the same position as its preoperative design, causing surgical results to differ from preoperative planning. This study aims to solve these acknowledged challenges by creating newly designed equipment.

PATIENT CONCERNS

Two patients suffering from long-term expansion of the mandible were admitted to our department. Case I was a 39-year-old female patient who was concerned about the disease in the middle of the mandible, Case II was a 45-year-old female patient who was concerned about the disease at the left mandibular angle and ramus region.

DIAGNOSES

Two patients were diagnosed with the mandibular ameloblastoma based on computed tomography (CT) scan and pathological results.

INTERVENTIONS

Personalized 3-dimensional (3D) surgical guides were applied to 2 patients with mandibular ameloblastoma who underwent mandibular resection and reconstruction with vascularized fibula flaps using a specially optimized and designed reconstruction guide plate.

OUTCOMES

We achieved precise mandibular repair with such a guide in full accordance with the preoperative plan and ensured the restoration of patient facial symmetry.

LESSONS

Optimized reconstruction guide template could accurately locate the preformed reconstruction plate. This component had the ability to ensure that the location of the actual reconstruction plates were highly consistent with preoperative designed models.

Widely Divergent Congenital Inferior Tibiofibular Diastasis with Separate Soft-Tissue Cover and Persistent Sciatic Artery: A Previously Unreported Combination: A Case Report

CASE

We report a case of a child with widely divergent congenital inferior tibiofibular diastasis with persistent sciatic artery (PSA). The dysplastic tibia and fibula were widely divergent, and the fibula was displaced proximally and medially with the foot alongside the thigh between the 2 legs, with PSA diagnosed on computed tomography angiogram. The child was treated with fibula-foot complex excision and below-knee prosthesis and was ambulating independently at 1-year follow-up.

CONCLUSIONS

The combination of a major structural anomaly (tibiofibular diastasis with a separate soft-tissue cover) and an unusual vascular malformation (PSA) has not been reported previously and made surgical reconstruction challenging.

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.

Limb salvage for malignant bone tumours of distal tibia with dual ipsilateral vascularized autogenous fibular graft in a trapezoid-shaped array with ankle arthrodesis and preserving subtalar joint

BACKGROUND

The treatment of malignant tumours of the distal tibia is a challenging surgical problem due to the scarce soft tissue coverage and the instability of the ankle joint that often occurs after resection. However, there is no consensus on the ideal treatment for malignant tumours of the distal tibia.

METHODS

We report a new reconstruction for five patients with high-grade osteosarcoma of distal tibia, using dual ipsilateral vascularized autogenous fibular graft in a trapezoid-shaped array and external fixator, with ankle arthrodesis and preserving subtalar joints. The patients were examined clinically and radiographically.

RESULTS

The average follow-up duration was 88 months. The mean wound healing time was 14 days. Bone healing was achieved for all the five patients at an average time of 7 months. There were no complications of mal-union, skin necrosis, post-operative infection, loss of internal fixation, peroneal nerve injury. One patient had a local recurrence, which required amputation 15 months postoperatively. The remaining four patients were able to walk with an average functional score of 81.25% according to MSTS.

CONCLUSIONS

Our study shows that this technique is safe and effective to perform implantation of dual ipsilateral vascularized autogenous fibular graft in a trapezoid-shaped array and preserving subtalar joints in terms of the distal tibial reconstruction for malignant bone tumour of the distal tibia. This reconstruction represents a biological alternative protocol for limb salvage in cases of malignant bone tumour of the distal tibia, with encouraging results and with the advantages of lower complications and accelerating recovery.

LEVEL OF EVIDENCE

Level IV.

[Vascularised Fibula and Tendon Transfer in the Comprehensive Treatment of Forearm Fracture with Gas Gangrene Complication]

Vascularized bone grafting was for the first time described in the 1970s. It has become a crucial component in the reconstruction of long bone defects and non-unions in a poorly vascularised environment. Although the vascularized bone is well described for the lower extremity and mandibular reconstructions, it started to be used for the upper extremity bone defects only recently. This publication presents a case of a young man with an open fracture of both the forearm bones. The treatment of the injury has been complicated with anaerobic gas gangrene of the forearm. This resulted in a non-union, radius shortening and necrosis of both the thumb extensors and flexors muscles. Once the acute infection was managed, the patient received a two-step treatment provided jointly by orthopaedic and plastic surgeons at the University Hospital in Bratislava. At the first stage auto transplantation of the vascularized fibula into the defect of radius was performed, with radial artery and radial veins being the recipient vessels. One year later, a tendon transfer was made in order to reconstruct the extension and flexion of the thumb. Donor tendons were the following: extensor indicis proprius and flexor digitorum superficialis for ring finger. The result of the reconstruction is the full incorporation of the fibular transplant (6 months after the primary operation) and the excellent range of motion of the hand and wrist. Thanks to the tendon transfer the function of the thumb, including the opposition, was achieved two months after the secondary surgery. Key words: defect of radius, tendon transfer, anaerobic infection, gas necrosis, microsurgery.

Microsurgical reconstruction with vascularized fibula and massive bone allograft for bone tumors

INTRODUCTION

Combining massive bone allograft and vascularized fibula in intercalary reconstruction following resection of bone tumors represents a complex reconstructive procedure that requires specialists in microvascular surgery as well as orthopedic surgery. The purpose of our study was to examine the outcomes using this surgical technique in patients with bone tumors in terms of oncologic results, complications related to surgery, Musculoskeletal Tumor Society (MSTS) scores and duration of surgery.

MATERIALS AND METHODS

We analyzed 81 patients with femoral or tibial sarcomas who underwent intercalary resection and microsurgical reconstruction with massive bone allograft and vascularized fibula. There were 56 boys and 25 girls with a mean age of 13.4 years at the time of surgery. The patients' medical records were reviewed for clinical and functional outcomes as well as postoperative complications. The study group was comprised of 33 patients who underwent reconstruction of the femur with massive bone allograft and free vascularized fibula and 48 patients who underwent reconstruction of the tibia with massive bone allograft and free or pedicle vascularized fibula. The mean length of resection was 15.9 cm (8-31 cm). The functional evaluation of the patients was done at the end of the follow-up using MSTS score for the lower limb. All patients had at least a 2-year follow-up.

RESULTS

The overall limb salvage rate was 94%, although many patients required re-operation after the procedure. Complications occurred in 24 patients, 18 of which underwent additional surgical procedures. They included fractures of the massive bone allograft-vascularized fibula construct with or without implant failure (19) and deep infection (5). After surgical or conservative treatment, all the fractures successfully healed. The overall MSTS functional score was good to excellent in 91% of patients.

CONCLUSIONS

The combination of massive bone allograft and vascularized fibula seems to be a reasonable option for reconstruction of diaphyseal defects following intercalary resection of bone tumors. Although there was a high rate of complications and therefore re-operations, the biology of vascularized fibula was able to save the reconstruction in most of the cases that had complications.

Non-vascularised fibular bone graft after vascular crisis: compensation for the failure of vascularised fibular free flaps

After reconstruction of a segmental mandibular defect with a fibular free flap, a vascular crisis can be detected clinically and a "no-flow" phenomenon found during re-exploration. Traditional methods used to solve this include removal of the failed flap and delayed mandibular reconstruction, or restoration of the defect with a functional reconstruction plate or contralateral fibular free flap. Our aim therefore was to investigate under what circumstances it is feasible to use a non-vascularised fibular bone graft (NVFB) as a free bone graft after the failure of a vascularised fibular free flap. From 1 January 2010-31 December 2014, 10 patients who had NVFB after failure of a fibular free flap were included in the study. All patients were treated at the Peking University School and Hospital of Stomatology. NVFB were preserved successfully without infection in all 10 cases, and follow-up imaging showed that it had incorporated well with the residual mandible, the basic function and facial aesthetics of which were maintained. In conclusion we have identified that by precise selection of patients, detailed preoperative planning, and meticulous postoperative care, NVFB can be used as a "rescue" technique after failure of a fibular free flap, and can successfully restore the segmental mandibular defect and facial contour.

Application of vascularized fibular graft for reconstruction and stabilization of multilevel cervical tuberculosis: A case report

Multilevel cervical reconstruction and fusion after cervical tuberculosis has always been a challenge. The current implantation materials for cervical fusion, including titanium mesh, cage, and plate are limited by its inferior biological mechanical characteristics and the properties of the metallic material. This has led to the increased risk of recurrent infection after surgery. In addition, the unique nature of tuberculosis infection results in the low rate of cervical fusion and high risk of recurrence. This case report presents 1 patient who suffered from long segmental cervical tuberculosis and had reconstruction surgery using a vascularized fibula graft. The patient had successful graft incorporation 3 months postsurgery and was followed-up for 30 months. In this review, we detail the advantages of using vascularized fibular grafts and compare it with other types of grafts.

Free Vascularized Fibula for the Treatment of Traumatic Bone Defects and Nonunion of the Forearm Bones

Eighteen infected nonunions and segmental defects of both the radius and ulna which had failed to resolve with conventional treatment were treated with a free vascularized fibular graft to restore radial, but not ulnar, continuity. In three patients there was destruction of the wrist joint and in two destruction of the elbow. The time from injury to referral ranged from 4 weeks to 3 months. The ipsilateral fibula was used as an osseous or osseocutaneous free flap to reconstruct the radius. All fractures united with good soft-tissue healing and resolution of infection. One patient required additional cancellous bone grafting. The mean period required for radiographic bone union was 4 months. Reconstruction of only the radius provided a stable forearm with a reasonable range of forearm rotation.

[EFFECTIVENESS OF MODIFIED Urbaniak OPERATION TO TREAT AVASCULAR NECROSIS OF THE FEMORAL HEAD]

OBJECTIVE

To investigate the effectiveness of the modified Urbaniak operation to treat avascularnecrosis of the femoral head (ANFH).

METHODS

A retrospective analysis was made on the clinical data of 38 patients (41hips) with ANFH treated between February 2010 and October 2012 with the modified Urbaniak operation (to add lateralfemoral incision based on femoral greater trochanter incision, to preserve the original fibula flap drilling, decompressionand filling through trochanteric outer cortex, and to select the descending branch of lateral circumflex femoral artery asthe supply vessel). Of 38 cases, 25 were male (28 hips), 13 were female (13 hips), aged 16-52 years (mean, 34 years); therewere 19 cases (21 hips) of alcoholic ANFH, 9 cases (9 hips) of traumatic ANFH, 5 cases (6 hips) of hormone ANFH, and5 cases (5 hips) of idiopathic ANFH. The disease duration ranged from 10 months to 6 years (mean, 3.7 years). According to Ficat staging criteria, 24 hips were rated as stages II and 17 hips as stage III. The preoperative Harris hip scores were80.63 ± 5.02 and 77.06 ± 6.77 in patients at stage II and III respectively. The related complications were recorded afteroperation. According to the findings of postoperative X-ray films, 4 grades were improvement, stabilization, deterioration,and failure; improvement or stabilization was determined to radiological success. According to the Harris score toevaluate the function of hips, more than 80 was determined to clinical success.

RESULTS

Healing by first intention wasachieved in all patients after operation. Three cases had numbness and hypoaesthesia of the lateral femoral skin, 1 case had abnormal sensation of the dorsal foot, which had no effect on daily life. Thirty-eight cases (41 hips) were followed up 1 year to 3 years and 3 months (mean, 2 years and 3 months). There was no complication such as hip joint stiffness, hip or groin persistent pain, hip joint infection, or ankle instability. At last follow-up, the X-ray films showed improvement in 23 hips (56.1%), stabilization in 17 hips (41.5%), and deterioration in 1 hip (2.4%); 40 hips obtained the radiological success. According to the Harris score, the results were excellent in 17 hips, good in 20 hips, fair in 3 hips, and poor in 1 hip with an excellent and good rate of 90.2%; 37 hips achieved the clinical success. The Harris scores were 89.92 ± 4.12 and 86.53 ± 5.70 in patients at stage II and III respectively at last follow-up, showing significant differences when compared with preoperative ones (t = 7.011, P = 0.000; t = 4.412, P = 0.000).

CONCLUSION

The modified Urbaniak operation has the advantages of more convenient operation, less complications, higher safety, and better hip functional recovery. It is effective method to treat ANFH.

Minimally invasive harvesting of nonvascularized fibular graft in children

Using a nonvascularized fibular graft is part of the therapeutic arsenal for filling bone loss defects. It is conventionally performed by open surgery. The authors propose a minimally invasive technique for harvesting a free fibular graft. The fibula was removed subperiosteally by two or three small incisions in five patients with a mean age of nine years and nine months. The mean surgical time was 21 min and 40.5% of the length of the fibula was harvested. At the donor site, we found no removal-related complications, regeneration of the fibula was observed in 80% of cases, and the cosmetic result was considered excellent by all patients with a mean 4.3 years follow-up. This minimally invasive technique is simple and fast, with very low morbidity in our experience.

ONE-STAGE (PRIMARY) RECONSTRUCTIONS OF RESECTION MANDIBULAR DEFECTS BY MEANS OF AUTOGENE VASCULARISED ILIAC AND FIBULAR TRANSPLANT

Mandibular resections are most often performed in cases of tumour ablations. Contemporary oral and maxillofacial surgery acknowledges primary one-stage reconstructions of defects through microvscularised transplants. They have intact circulation due to the primarily performed vascular anastomoses. For recovery of the shape and the function of the mandible most frequently used transplants are derived from the iliac crest and fibula. Goal and objectives. We share our experience in the one-stage recovery of mandibular defects simultaneously with the resection, by means of autogene vascularised iliac and fibular transplants. Material and method. 8 patients aged from 24 to 61 (female - 1, male - 7) with tumours engaging the mandible (5 - benign and 2 - malignant) were treated surgically and followed up. We carried those out using extraoral approach in 7 cases, and intraoral aproach - in 1. The resulting post resection mandibular defects in 3 of the patients were reconstructed by means of one-stage autogene bone vascularised iliac transplants. In 5 patients the defects were recovered primarily through vascularised fibular autotransplants. The surgical techniques and protocols, to assess the outcome and characterize of the methods are presented.

RESULTS

We tracked down the postoperative results of the mandibular reconstructions for a period of 1 to 3 years. Support for the lips and tongue was achieved providing for satisfactory speech and feeding. Anatomical remodeling was observed. The conditions for the production of dental implants were improved. In the case, when we used intraoral approach the facial aesthetics was fully restored, as for the rest it was satisfactory.

CONCLUSIONS

Vascularised autogene iliac and fibular bone transplants are extremely appropriate for reconstructions of significant and complicated mandibular and other defects in the maxillofacial area. Their survival is independent from the recipient area, and secured through the vessel anastomoses. With sound surgical technique, success rate of the method is to a large extent guaranteed.

Vascularized bone graft for oncological reconstruction of the extremities: review of the biological advantages

Vascularized bone graft (VBG) is a form of vascularized bone marrow transplant in which the bone marrow is surgically grafted with its microenvironment intact. Due to the preservation of cellular viability, VBG have significant advantages over non-vascularized bone grafts. Free vascularized fibula grafts have superior material properties and tolerate infection. Bone healing can be accomplished in a shorter period, even in an irradiated bed. In addition to these properties, VBG has other biological advantages that are not always familiar to oncological surgeons. Hypertrophic change can be divided into reactive and adaptive hypertrophy. Early hypertrophy is associated with donor-derived cells, whereas later remodeling is associated with recipient-derived cells. VBG has significant advantages in enhancing neo-revascularization of necrotic bone. We reviewed VBG from a novel viewpoint that stems from our basic research.

Free vascularized fibular grafting for patients receiving postoperative corticosteroids

Free vascularized fibular grafting (FVFG) is an effective method to treat corticosteroid-induced osteonecrosis of the femoral head (ONFH). Some patients continued to receive maintenance doses of corticosteroids to treat the primary disease postoperatively. This study was performed to evaluate outcomes of FVFG for corticosteroid-induced ONFH in patients who continued to receive corticosteroids postoperatively. The authors retrospectively reviewed the records of 44 patients (78 hips) who had received corticosteroid treatment for their primary disease after FVFG. They were followed up for at least 2 years (mean, 5.6 years). Demographic details, Harris Hip scores, the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), and radiographic data were collected and analyzed. The mean Harris Hip score for all hips was 70.9±9.9 points before surgery and increased to 84±12.1 points at the latest follow-up. There were also significant increases (P<.05) in physical component summary score and mental component summary score. According to the latest radiographic evaluation, 49 hips (62.8%) appeared improved, 10 hips (12.8%) appeared unchanged, and only 19 hips (24.4%) appeared worse. Seven hips (9%) underwent total hip arthroplasty during the follow-up period. Therefore, the results showed that FVFG was a viable method of treating corticosteroid-induced ONFH in patients who receive maintenance doses of corticosteroids postoperatively.

Vascularized fibular transfer in longstanding and infected large bone defects

The reconstruction of large bone defects in the infectious environment is still a big challenge for limb salvage because of disturbance in bacterial flora, bacterial resistance and limitation of blood supply at scarred tissue. This retrospective study was to evaluate long-term outcomes in patients who were performed vascularized fibular transfers for treatment of large bone defects in the infectious environment. The review included 26 patients with an average age of 27 years old. Bone defects were located at the arm in 1 patient, the forearm in 2 patients, the thigh in 6 patients and the leg in 17 patients. The cause of the bone defects included high-energy trauma in 14 cases, chronic osteomyelitis in 7 cases, infected non-union in 5 cases. All patients had had several previous operative procedures. The average length of fibular vascularized graft was 16.6 cm (range, 10-22 cm), and the average size of the associated fasciocutaneous component in 16 patients was 3.6 x 8.5 cm. Three patients had partial necrosis of skin paddle. Three patients, who were stabilized by screw and external fixator, had an infection at the distal part of the fibular graft and pin tracts. 25 fibular grafts (96%) showed complete bone union. This review has showed that the vascularized fibular transfer can be effective for management of large segmental bone defects in the infectious environment.

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.

[Clinical research of resection of mandibular benign tumors and primary reconstruction with autogenous bone graft via an intraoral approach]

OBJECTIVE

To investigate the clinical outcomes of resection of mandibular benign tumors and primary reconstruction with autogenous bone graft via an intraoral approach.

METHODS

Fifteen patients with mandibular benign tumors were treated between January 2009 and September 2012. There were 7 males and 8 females, aged from 18 to 45 years (mean, 30 years). The pathological diagnosis identified 11 cases of ameloblastoma, 3 cases of odontogenic keratocyst, and 1 case of odontogenic myxoma. According to the Urken's CRBS (Condyle, Ramus, Body, Symphysis) classification criteria based on the location of the mandibular defect, there were 3 cases of body type (B type), 3 cases of ramus type (R type), and 9 cases of body and ramus type (BR type). The surgeries were performed via an intraoral approach, except 1 patient with the lesion at the level of sigmoid notch via an auxiliary preauricular incision. To fix the bone grafts to the dissected mandibular defects, reconstructive titanium plates were used, either indirectly according to the computer aided design/computer aided manufacturing mandibular models before surgery (9 patients) or directly according to the exposed mandibles during surgery (6 patients). The patients received benign mandibular tumor resection and primary autogenous bone graft reconstruction with free iliac bones (11 cases) or vascularized fibular flaps (4 cases). The mandibular inferior alveolar nerves were preserved in 6 cases.

RESULTS

Primary healing of incision was obtained in 14 patients, while secondary healing in 1 patient suffering from bone graft infection. All the patients were followed up 1-4 years (mean, 2.5 years). At last follow-up, no patients showed facial nerve damage; occlusion of remaining teeth was similar to preoperative conditions; the chewing function was satisfactory; mouth opening was 30-35 mm (mean, 33 mm); and swallowing and speaking functions were normal. Only slight extraoral scars caused by the auxiliary incision and the transbuccal appliances were observed, and all the patients were satisfied with the facial appearance. Lower lip numbness was relived in patients with preserved inferior alveolar nerves. There was no tumor recurrence during follow-up period.

CONCLUSION

The intraoral approach is a feasible and proper approach for resection of benign mandibular tumors and primary reconstruction with autogenous bone grafts, with the advantages of inconspicuous facial scars, minimum damage to the facial nerve, and expectable aesthetic appearance.

[A preliminary study on repairing defects at medial malleolus in children by vascularized fibular head composite flap]

OBJECTIVE

To investigate the operative method and effectiveness of repairing defects at medial malleolus in children with vascularized fibular head composite flap.

METHODS

Between November 2008 and January 2011, 8 children with bone and soft tissue defects at the medial malleolus were treated. There were 5 boys and 3 girls, aged 2-9 years (mean, 4.6 years). Injuries were caused by machine twisting in 2 cases and by wheel twisting in 6 cases. Soft tissue defect area ranged from 3.5 cm x 3.0 cm to 7.0 cm x 4.5 cm; defect was total in all medial malleolus. The disease duration from injury to admission was 2-8 hours (mean, 4.5 hours). Defects were repaired with vascularized fibular head composite flap carrying the skin around the head of the fibula in 5 cases, and with vascularized fibular head composite flap and skin flap above the medial malleolus in 3 cases having too large defect (> 5 cm x 4 cm). The donor sites were repaired with direct suture in 2 cases and with skin graft in 6 cases.

RESULTS

All 8 fibular head composite flaps and 3 skin flaps above the medial malleolus survived completely. Wounds healed by first intention; the skin grafts at donor sites survived in the other cases except 1 case having local necrosis, with healing of incision by first intention. The patients were followed up 10 months to 3 years (mean, 22 months). The color and elasticity of the flaps were good. All the children had equal leg length. Of 8 cases, 6 had no joint valgus; 2 cases had progressive ankle varus after 1 year of operation. The ankle flexion and extension function returned to normal in 5 cases, and was slightly limited in 3 cases; horizontal side, forward and backward movements had no difference compared with normal side. According to American Orthopaedic Foot and Ankle Society (AOFAS) ankle function evaluation criteria, the results were excellent in 5 cases, and good in 3 cases at 10 months after operation. X-ray film showed that the ankle hole gap development of both sides was similar; no premature closure of the epiphysis or bone bridge formation of the medial malleolus was observed in 6 cases, and bone bridge formed in 2 cases after 1 year of operation.

CONCLUSION

The satisfactory short-term effectiveness can be obtained in repairing children medial malleolus and soft tissue defects by vascularized fibular head composite flap, and the reconstructed medial malleolus can develop with the growth of children. Long-term effectiveness still need more follow-up study.

Free vascularized fibular transfer with langenskiöld procedure for the treatment of congenital pseudarthrosis of the forearm

Congenital pseudarthrosis of the radius or ulna is a rare entity. It is associated with neurofibromatosis, but occurs much less commonly than congenital pseudarthrosis of the tibia. Pseudarthrosis of the forearm can lead to pain, deformity, and limited forearm rotation. Nonsurgical management leads to poor results, as do surgical treatments such as open reduction internal fixation and conventional bone grafting. The transfer of a free vascularized fibula to the forearm pseudarthrosis has been more successful, and it is our preferred method of treatment for children with this condition. Because the transfer is often performed in young children, there is the potential for valgus deformity at the ankle after the fibula is removed. We describe here our technique for the transfer, including the technique for distal tibiofibular fusion (Langenskiöld procedure) after removal of the fibular graft. In addition, we present the results of 5 patients who have undergone this combination of procedures for pseudarthrosis of the forearm at our institution.

[Study on accuracy of virtual surgical planning in free fibula mandibular reconstruction by using SurgiCase software]

OBJECTIVE

To evaluate the directional significance of SurgiCase software in free fibula mandibular reconstruction.

METHODS

Between September 2010 and March 2012, 10 patients with mandibular defect underwent free fibula mandibular reconstruction. There were 7 males and 3 females, with an age range of 19-43 years (mean, 27 years). The extent of lesions was 7 cm x 5 cm to 16 cm x 8 cm. In each case, three-dimensional spiral CT scan of the maxilla, mandible, and fibula was obtained before surgery. The CT data were imported into the SurgiCase software and the virtual surgery planning was performed. After that, the mandibular rapid prototyping was made according to customized design. The reconstruction surgery was then carried out using these preoperative data. During actual surgery, the extent of mandibular defect was from 6 cm x 3 cm to 16 cm x 5 cm; the length of fibula which was used to reconstruct mandible was 6-17 cm; and the area of flap was from 6 cm x 5 cm to 16 cm x 6 cm.

RESULTS

Preoperative data could not be applied because the intraoperative size of tumor was larger than preoperative design in 1 case of mandibular ameloblastoma, and the fibula was shaped according to the actual osteotomy location; operations were performed successfully according to preoperative design in the other 9 patients. The operation time was 5-7 hours (mean, 6 hours). Primary healing of incision was obtained, without early complications. Ten patients were followed up 1 year. At last follow-up, 8 patients were satisfactory with the appearance and 2 patients complained with unsatisfied wide facial pattern. The panoramic radiograghs showed good bone healing. The range of mouth opening was 2.5-3.5 cm.

CONCLUSION

SurgiCase software can provide precise data for free fibula mandibular reconstruction during surgery. It can be applied widely in clinic.

Reconstruction of isolated mandibular bone defects with non-vascularized corticocancellous bone autograft and graft viability

OBJECTIVE

The aim of this study is to discuss the use of non-vascularized bone grafts in mandibular reconstruction and their viability.

METHODS

In this study, 11 patients with mandibular defect treated by surgery using non-vascularized bone grafts between 2011 and 2012 were reviewed. All patients underwent preoperative and postoperative 3-dimensional computerized tomography scan for surgical planning and evaluation of success after surgery. Grafts were used for defects caused by mandible tumors in 2 patients and firearm injuries in 9 patients. Reconstruction was achieved by using various non-vascularized bones, including iliac crest, fibula and scapula. To improve graft supply, periosteum of the grafts was spared and multiple bores were created on the graft during surgery by drilling. At the postoperative period, Dextran 70 and Bencyclane Hydrogen Fumarate was given in order to enhance micro-circulation. On the postoperative day 5, 15 and 30, Tc-99m methylenediphosphonate scintigraph, blood-pool single photon emission computed tomography and it's bone phase were performed in order to assess viability of bone grafts greater than 3cm.

RESULTS

Mean age was 32. 27±13.33 (min=10-max=56). Of the 11 patients, 10 (90. 9%) were men and 1 (9. 1%) was woman. Mandibular defects were at right corpus in 3 patients; at right ramus and angulus in 1 patient; at left corpus in 1 patient; at left ramus and angulus in 1 patient; at left ramus, angulus and corpus in 1 patient; left parasymphysis in 1 patient; at bilateral corpus in 1 patient; at symphysis in 1 patient and at whole segment from right corpus to left one in 1 patient. The following grafts were used: iliac crest grafts in 9 cases, scapula graft in 1 case and fibula graft in 1 case. The smallest graft used was 1×2cm in size, while the greatest, single piece graft was 7cm in size. The greatest multi-piece graft was a fibula graft of 14cm in length. All grafts with a size of 3 and 7cm had been supplied at the end of first month. No bone resorption or donor site morbidity was observed in any patient.

CONCLUSION

Non-vascular bone grafts can be successfully used in isolated bone defects of mandible in case of appropriate graft selection for fitting anatomical region. A single piece iliac crest grafts up to 7cm can be revascularized in long-term.

Vascularized bone grafts for the management of skeletal defects in orthopaedic trauma and reconstructive surgery

Bone loss from trauma, neoplasia, reconstructive surgery and congenital defects remains a major health problem. The long-term clinical goal is to reconstruct bony tissue in an anatomically functional three-dimensional morphology. In the extremities, bone grafts are used for the treatment of non-unions and necrotic lesions, for skeletal structural support and for the reconstruction of defects resulting from trauma, tumor excision, osteomyelitis, congenital pseudarthrosis, or radiation necrosis. In all cases their use is successful provided that the host bed has adequate vascularization. In cases of decreased blood supply, a vascularized bone graft should be applied. The intrinsic blood supply of the vascularized bone grafts leads to higher success rates and to acceleration of the repair process in the reconstruction of defects and necrotic lesions of the skeleton.

A prospective study of preoperative computed tomographic angiographic mapping of free fibula osteocutaneous flaps for head and neck reconstruction

BACKGROUND

In designing an osteocutaneous fibula flap, poor planning, aberrant anatomy, or inadequate perforators may necessitate modification of the flap design, exploration of the contralateral leg, or additional flap harvest. The authors studied the predictive power of computed tomographic angiography in osteocutaneous fibula flap planning and execution.

METHODS

The authors studied a prospective cohort of 40 consecutive patients who underwent preoperative computed tomographic angiography mapping of the peroneal artery and its perforators and subsequent free fibula flap reconstruction of mandibular or maxillary defects. The authors compared their analysis of perforator anatomy, peroneal artery origin, and fibula length with intraoperative clinical findings.

RESULTS

Overall, computed tomographic angiography identified 94.9 percent of the cutaneous perforators found intraoperatively. Clinically, perforators were located an average of 8.7 mm from their predicted locations. The peroneal artery origin from the tibioperoneal trunk averaged 6.0 mm from its predicted location. The average length of the fibula differed from the predicted length by 8.0 mm. Computed tomographic angiography accurately predicted perforators as either septocutaneous or musculocutaneous 93.0 percent of the time. Perforator size was accurately predicted 66.7 percent of the time. Skin islands and osteotomies were modified in 25.0 percent of the cases on the basis of computed tomographic angiography findings. Two patients had hypoplastic posterior tibial arteries, prompting selection of the contralateral leg. There were no total flap or skin paddle losses.

CONCLUSIONS

Computed tomographic angiography accurately predicted the course and location of the peroneal artery and perforators; perforator size was less accurately estimated. Computed tomographic angiography provides valuable information to facilitate osteocutaneous fibula flap harvest.

[Early reconstruction of congenital pseudoarthrosis of the tibia with free vascularized fibular grafts]

Congenital pseudoarthrosis of the tibia (CPT) is an uncommon disease presenting a tibial nonunion since birth and frequently associated to neurofibromatosis type 1. Surgical management by wide excision of the pseudoarthrosis and sustitution of the defect with vascularized bone in an early stage has proven to be the most effective technique in terms of bone consolidation. We present a clinical case of a 22-month-old patient with CPT treated successfully by reconstruction with a free vascularized fibula graft with an excellent functional result.

The effectiveness of skin perfusion pressure measurements during endovascular therapy in determining the endpoint in critical limb ischemia

A 78-year-old man had right foot ulceration. The skin perfusion pressure (SPP) at the dorsum was 12 mmHg. Angiography revealed right iliac artery occlusion and diffuse stenosis of right superficial femoral artery. After stenting of the iliac arteries, the SPP was still 23 mmHg. Hence, we also inserted stents in the right superficial femoral artery. The anterior tibial artery remained stenosed, and the posterior tibial and fibular arteries were occluded. However, as the SPP had increased to 46 mmHg the treatment was discontinued. The ulcers improved. Measurement of SPP during a procedure may be useful in determining the treatment endpoint.

Treatment of osteonecrosis of the femoral head in lymphoma patients by free vascularised fibular grafting

The purpose of this study was to assess the outcomes of treatment of femoral head osteonecrosis using free vascularised fibular grafting in patients with Hodgkin's disease and non-Hodgkin's lymphoma. We retrospectively reviewed seven patients (14 hips) with lymphoma who underwent free vascularised fibular grafting for osteonecrosis of the femoral head, evaluating pre- and postoperative Harris hip scores, visual analog scale (VAS) pain scores, hip range of motion and radiographs. Patients were followed up for a minimum of 1.5 years (mean, 3.3 years). All these patients exhibited good recovery without severe life-threatening complications. The mean Harris hip score improved from 69 to 88, while average VAS pain score decreased from 54 to 18. At the latest follow-up, we found improvement or unchanged radiographs in all three hips with initial Steinberg stage II osteonecrosis and in nine of 11 hips with stage III or IV osteonecrosis. No hips failed treatment and underwent total hip arthroplasty. The clinical data demonstrated that free vascularised fibular grafting can slow or even halt progression of necrosis, and improve the function of the hip and quality of life in lymphoma patients.

[Wrist joint reconstruction with vascularized fibular head graft after resection of distal radius giant cell tumor]

OBJECTIVE

To observe the effectiveness of wrist joint reconstruction with vascularized fibular head graft after resection of distal radius giant cell tumor.

METHODS

Between March 2000 and March 2009, 31 cases of distal radius giant cell tumor were treated with extended resection and vascularized fibular head graft for repairing defects of the distal radius, and reconstructing wrist joint. There were 14 males and 17 females with an average age of 37.2 years (range, 15-42 years). The disease duration ranged from 1 month to 2 years and 3 months with an average of 8 months. The size of tumor was 6.5 cm x 3.5 cm-8.0 cm x 4.5 cm. The range of motion (ROM) of wrist joint was as follows: extension 5-15 degrees (mean, 10.7 degrees), flexion 9-21 degrees (mean, 14.2 degrees), radial inclination 0-10 degrees (mean, 8.6 degrees), and ulnar inclination 0-15 degrees (mean, 7.9 degrees). The ROM of forearm was as follows: pronation 15-50 degrees (mean, 28.7 degrees) and supination 10-25 degrees (mean, 16.5 degrees). The histopathological examination revealed that there were 5 cases of stage I, 17 of stage II, and 9 of stage III.

RESULTS

All patients achieved primary healing of incision and were followed up 1-9 years with an average of 4.5 years. The X-ray films showed that bone healing time was 12-16 weeks with an average of 13 weeks. No tumors recurrence was observed. The ROM of wrist joint was as follows at 1 year after operation: extension 20-50 degrees (mean, 29.0 degrees), flexion 30-50 degrees (mean, 35.0 degrees), radial inclination 10-20 degrees (mean, 16.5 degrees), and ulnar inclination 20-25 degrees (mean, 23.5 degrees). The ROM of forearm was as follows: pronation 40-90 degrees (mean, 68.3 degrees) and supination 30-80 degrees (mean, 59.6 degrees). There were significant differences in the ROM between before operation and after operation (P < 0.05). According to the Krimmer et al wrist score, the results were excellent in 17 cases, good in 12, and fair in 2.

CONCLUSION

Wrist joint reconstruction with vascularized fibular head graft can restore function of wrist joint. The operation is proved to be safe and effective in treating distal radius giant cell tumor.

Vascularized fibula free flap for implant rehabilitation in the case of extreme atrophy

The skeletal reconstruction in cases of extreme atrophy like a class VI Cawood classification can be carried out using free bone flaps. They represent a valid option for preprosthetic rehabilitation of atrophic maxillas. Over the last 5 years, the use of vascularized bone transplants, aimed at implant-prosthetic rehabilitation, has become a practice, which has gradually found the right indications and the range of applications, which are now widely acknowledged. The key to success in the use of free flaps lies in the identification of the correct indications for use, in meticulous programming and the particular motivation that this type of patient has for reacquiring optimum masticatory functions. The final prosthetic implant rehabilitation must be prosthetically guided and an accurate preoperative planning is of fundamental importance for restoring masticatory functions and esthetic harmony to the patient through a fixed prosthesis. The authors present a case of a rehabilitation of an extreme maxillary and mandibular atrophy.

[Reconstruction of tumor-induced bone defects with vascularized fibula graft]

OBJECTIVE

To study the methods and effects of the reconstruction of tumor-induced bone defects with vascularized fibula graft.

METHODS

From Oct. 1996 to Jan. 2005, 89 patients with bone defects were treated with fibula graft using different methods. Among the patients, 48 patients were male and 41 patients were female, ranging in age from 12 to 67 years, with an average of 35 years. Thirty-five patients were treated with inlay bone grafting after excision of focus, 15 patients were treated with single or double-strut fibula graft after tumor resection, 16 patients were treated with fibular head graft for juxta articular tumor resection, and 23 patients were treated with double-strut fibula combined with iliac graft after marginally resection.

RESULTS

Enneking evaluation system was used to evaluate therapeutic effects. Among 35 patients treated with inlay bone graft after excision, 29 patients were followed up, and 26 patients got an excellent result, 1 good and 2 poor. Among 15 patients treated with single or double-strut fibula graft after tumor resection, 12 patients were followed up, and 8 patients got an excellent result, 1 good, 1 poor and 2 bad. Among 16 patients treated with fibular head graft for juxta articular tumor resection, 12 patients were followed up, and 7 patients got an excellent result, 3 good,1 poor and 1 bad. Among 23 patients treated with double-strut fibula combined with iliac graft after marginally resection, 17 patients were followed up, and 11 got an excellent result, 3 good, 1 fair and 2 bad.

CONCLUSION

These treatment methods can greatly enrich the treatment methods for bone tumor, and satisfy the reconstruction after bone tumor excision in different position of the four limbs. These methods are reliable and can be chosen according to disease types.

Free vascularised fibular grafting with OsteoSet®2 demineralised bone matrix versus autograft for large osteonecrotic lesions of the femoral head

The aim of this study was to compare the safety and efficacy of OsteoSet®2 DBM with autologous cancellous bone in free vascularised fibular grafting for the treatment of large osteonecrotic lesions of the femoral head. Twenty-four patients (30 hips) with large osteonecrotic lesions of the femoral head (stage IIC in six hips, stage IIIC in 14, and stage IVC in ten, according to the classification system of Steinberg et al.) underwent free vascularised fibular grafting with OsteoSet®2 DBM. This group was retrospectively matched to a group of 24 patients (30 hips) who underwent free vascularised fibular grafting with autologous cancellous bone during the same time period according to the aetiology, stage, and size of the lesion and the mean preoperative Harris hip score. A prospective case-controlled study was then performed with a mean follow-up duration of 26 months. The results show no statistically significant differences between the two groups in overall clinical outcome or the radiographic assessment. Furthermore, no adverse events related to the use of the OsteoSet®2 DBM were observed. The results demonstrate that OsteoSet®2 DBM combined with autograft bone performs equally as well as that of autologous bone alone. Therefore, OsteoSet®2 DBM can be used as a safe and effective graft extender in free vascularised fibular grafting for large osteonecrotic lesions of the femoral head.

[Antegrade extended peroneal artery perforator flap for knee reconstruction]

OBJECTIVE

To investigate the operative technique and clinical results of repairing the soft tissue defects of knee with antegrade extended peroneal artery perforator flap.

METHODS

From October 2007 to January 2008, 3 patients (2 men and 1 woman) with the soft tissue defects of knee were treated, with the ages of 18, 31 and 42 years, respectively. The first case sustained femur and pelvis fractures and soft tissue defect over his right popliteal fossa, which were treated with open reduction and internal fixation (ORIF) and debridement of knee joint 2 weeks ago. The second case was necrosis of skin 3 weeks after ORIF for fracture of tibial plateau. The third case suffered from open fracture of tibial plateau and soft tissue defect, which were treated with external fixation and debridement 3 weeks ago. The defect sizes were 16 cm x 9 cm, 11 cm x 6 cm and 14 cm x 7 cm. The flap was raised by dividing the peroneal artery and veins distally and elevating them proximally, which covered for the defects of knee. The flaps were designed with the size of 18 cm x 10 cm, 12 cm 7 cm and 15 cm x 8 cm. The pure vascular pedicle of the flap was 10 cm to 17 cm in length, including the peroneal vessels and one or two perforator branches. The donor site is covered by a split thickness skin graft.

RESULTS

All flaps survived after surgery. The donor sites healed by first intention and the skin grafts survived. After following up for 6, 8 and 11 months, the appearance and function of the flaps were all satisfactory. Based on the modified HSS knee performance system, post-operative knee functional outcomes of three patients were excellent.

CONCLUSION

The antegrade extended peroneal artery perforator flap supplied by a pure vascular pedicle can be a good alternative for reconstruction of knee. The flap, with a long and thin pure vascular pedicle, could provide good texture and contour matching the recipient area.

[Compound grafting of vascularized fibular head and flaps to repair complicated lateral malleolus defects]

OBJECTIVE

To investigate the method and effect of compound grafting of vascularized fibular head and flaps to repair complicated lateral malleolus defects.

METHODS

From July 2000 to April 2006, 6 patients with lateral malleolus bone defect underwent the repairing treatment. There were 5 males and 1 female, aged 9-47 years. The causes of injuries was traffic accident in 4 cases and crash in 2 cases. And 5 cases were in the left side and 1 in right side. The bone defect ranged 3.5-8.5 cm in size and the skin defect ranged 14 cm x 4 cm-18 cm x 7 cm in size. The time from injury to surgery ranged from 15 to 30 days. The complicated lateral malleolus defects were repaired by transplanting the fibular head pedicled with the lateral inferior genicular artery 5-10 cm, and the peroneal perforator flaps or latissimus dorsi flaps 16 cm x 5 cm-20 cm x 8 cm. The raw surfaces of donor site were inflated and packaged with intermediate split thickness skin graft.

RESULTS

One flap with 1 cm distal edge dry necrosis healed after change of dressing and others all survived. The free skin grafts survived and the incision healed by the first intention. All the cases were followed up for 4 to 15 months, and all patients achieved the bony healing within 8-16 weeks and the transplanted fibular head grew well. The shape of reconstructed lateral ankles was similar to the normal one and the ankle mortise moved well. The texture of flaps was soft without diagnosis and abrasion. According to Baird-Jackson criterion, the results were excellent in 3 cases, good in 2 cases and fair in 1 case and the excellent and good rate was 83.3%.

CONCLUSION

The fibular head pedicled with the lateral inferior genicular artery has good blood supply and the reconstructed lateral malleolus is similar to the normal. The peroneal perforator flaps and latissimus dorsi flaps have adequate blood supply and big dermatomic area. So this operation is an effective method to repair lateral malleolus defect.

[Reliability of skin paddle in monitoring blood flow after free fibular osteocutaneous composite flap transfer]

OBJECTIVE

To evaluate the reliability of skin paddle in monitoring blood flow after free fibular osteocutaneous composite flap transfer.

METHODS

Seven hundred and fourteen consecutive cases of mandibular or maxillary reconstruction using free fibular flap from May 1999 to September 2007 were reviewed. The cases with postoperative vessel thrombosis were analyzed.

RESULTS

Postoperative vessel thrombosis occurred in 23 cases, 17 were venous and 6 arterial. Among 14 cases of venous thrombosis with color change of skin paddles, only 6 were successfully salvaged, but 3 cases with no color change of skin paddles were all successfully salvaged. For arterial thrombosis, only one flap was successfully salvaged. The postoperative vessel thrombosis rate was 3.2%, and the salvage rate was 43.5%. The overall successful rate of free fibula flap was 98.2%.

CONCLUSIONS

Postoperative vessel thrombosis can not be detected in the early stage if only observing the color change of skin paddle after free fibula flap transfer.

[Free vascularized fibular associated with iliac graft to treat old femoral neck fracture]

OBJECTIVE

To evaluate the clinical outcome of free vascularized fibular associated with iliac graft in treatment of old femoral neck fracture.

METHODS

From January 1994 to January 1997, 76 cases of old femoral neck fracture were treated with free vascularized fibular associated with iliac graft, including 54 males and 22 females, aging from 24 to 48 years with an average of 31.5 years. All of these fractures resulted from injury. There were 20 cases of Garden II, 41 of Garden III and 15 of Garden IV. Based on the location of fracture, there was 26 cases of subcapital, 42 cases of transcervical and 8 cases of basal. Sixty-five cases were treated with internal fixation, 7 cases with skin traction and 4 just with staying in bed. Their Harris score were from 52 to 72 with an average of 65.6. The time from injury to operation was 2-24 months. The size of free vascularized fibular was 6-8 cm and iliac graft was 3.0 cm x 2.0 cm x 1.5 cm.

RESULTS

In 76 cases, 68 were followed up and all fractures healed within 4 to 6 months with an average of 5.2 months. The increased density in femoral head was observed 1 year after operation. After 10 years of operation normal hip function was achieved in 63 cases followed up 10.1-12.4 years with the average as 10.5 years); the Harris score was 87.5 (84 to 94). The structure of femoral head was normal and the grafted fibular and iliac bone healed with the femoral, no elapse or cyst occurred. Five cases had been complied with total hip replacement for femoral head necrosis or other.

CONCLUSION

Free vascularized fibular associated with iliac graft is a good method to treat old femoral neck fracture.

Epiphyseal preservation and an intercalary vascularized fibular graft with hydroxyapatite composites. Reconstruction in metaphyseal osteosarcoma of the proximal tibia: a case report

BACKGROUND DATA AND OBJECTIVES: We present here a case report of a patient with metaphyseal osteosarcoma with a preserved epiphysis and reconstructed by a vascularized fibular graft and hydroxyapatite composites.

METHODS

The case was a 14-year-old boy, who had osteosarcoma in the proximal tibia. After the diagnosis was confirmed by biopsy, the patient immediately received preoperative chemotherapy including high-dose Methotrexate, Cisplatin and Doxrubicin. Imagings after preoperative chemotherapy including MRI and contrasted enhanced CT confirmed no tumor penetration into the physis. Subsequently, we performed transepiphyseal resection of the proximal tibia to reserve the joint surface. The intercalary twin-barreled vascularized fibular graft was placed with hydroxyapatite composites. The patella tendon was reattached to the grafted fibular to biologically reconstruct the knee extensor mechanism. Postoperative chemotherapy was completed with the same regime as preoperative chemotherapy.

OUTCOMES

The bony union was completed at 10 months after the operation. The Enneking's functional evaluation score was 28 out of 30 points (93%). There was no evidence of local recurrence and no metastatic disease during the 42 months follow-up after initial diagnosis.

CONCLUSION

An accurate evaluation of MRI and CT can give a reliable assessment of intraphyseal penetration of metaphyseal osteosarcoma. In case of no involvement of the tumor in the physis, transepiphyseal osteotomy is the optimal procedure to preserve the joint surface and superior function of the joint, especially in the proximal tibia.

Reconstruction of tibia defects by ipsilateral vascularized fibula transposition

INTRODUCTION

Segmental defects of the tibia after open fractures, sepsis and tumor surgery present a challenging problem. Similarly, tumor surgery often involves radical resections and multiple procedures and is frequently accompanied by irradiation or chemotherapy creating an avascular bed. The aim of this study is to report the results and discuss the role of the ipsilateral pedicle vascularized fibula (IPVF) a technique used for reconstruction of tibia defects.

MATERIALS AND METHODS

Reconstruction of large tibia defects 6-22 cm due to tumor resection were performed in 5 patients by ipsilateral vascularized fibula transposition. The mean age of the patients was 35.4 years (19-42) SD 9.31. The mean follow-up was 59.6 months (24-96) SD 29.2. The mean length of the bone defect was 14.6 cm (6-22) SD 6.066 and the mean time for union was 8 months (6-12) SD 2.82. Arteriography was used preoperatively in all patients to evaluate the lower limb vasculature and to select the optimal surgical approach. The osteosynthesis was stabilized by a plate.

RESULTS

There was sound union in all cases. There were only two minor complications one partial paresis of peroneal nerve and one superficial infection. The mean follow-up was 59.6 months (24-96) SD 29.2. No patient presented with any complaints with the procedure and all had good functional results.

CONCLUSIONS

The procedure was technically simple compared to free vascularized fibula and could be performed in hospital with low resources. There are several advantages: (a) achievement of bone defect reconstruction retaining periosteal and endosteal circulation, (b) preservation of a major vessel of the lower leg, (c) avoidance of difficulty and risk of microvascular technique and (d) no donor-morbidity. We routinely recommend preoperative angiography and intraoperatively meticulous dissection to prevent damage to the vascular pedicle.

[Treatment of old femoral neck and nonunion with free vascularized fibular grafting]

OBJECTIVE

To evaluate the clinical result of the treatment of old femoral neck fracture and nonunion with free vascularized fibular grafting.

METHODS

From November 2000 to December 2005, 29 cases with old femoral neck fracture and nonunion had been treated by free vascularized fibular grafting with an average follow-up of 28.5 months.

RESULTS

All the fracture were healed without any severe complications. And the healing time was 4-6 months (5.6 months on average). During the follow-up, the hips of 28 cases got well-function, and the average Harris hip score was 88.2. One case came about with osteonecrosis of femoral head after one year and finally accepted THA after 2 years.

CONCLUSIONS

The free vascularized fibular grafting is a valuable procedure to treat old femoral neck fracture and nonunion.

Reconstruction of large skeletal defects due to osteomyelitis with the vascularized fibular graft in children

BACKGROUND

Reconstruction of large skeletal defects secondary to osteomyelitis is a challenging problem. The purpose of this study was to evaluate the outcome of the use of a vascularized fibular graft to treat such defects in children.

METHODS

Eight patients with a mean age of seven years and a skeletal defect with a mean length of 11.8 cm (range, 6 to 17 cm) were treated with a vascularized fibular graft. A staged protocol was used for the five patients with an active infection at the time of presentation. The first procedure consisted of radical débridement, and at the second stage a free (seven patients) or pedicled (one patient) vascularized fibular graft was used. The mean follow-up time was 5.7 years.

RESULTS

Union of the graft occurred primarily in seven of the eight patients, at a mean of 3.5 months, and after iliac crest bone-grafting in the remaining patient. There was no recurrence of deep infection. Complications developed in two patients. The mean time to full weight-bearing by the seven patients with a lower-extremity reconstruction was 8.4 months, and all patients were pain-free and able to walk without supportive devices.

CONCLUSIONS

A vascularized fibular graft is a viable option for the management of large skeletal defects resulting from osteomyelitis in children.

Preoperative Evaluation of Lower Extremity Arteries for Free Fibula Transfer Using MDCT Angiography

OBJECTIVE

We discuss the preoperative application of computed tomographic (CT) angiography to identify legs suitable for free fibular flaps.

METHODS

The condition of 118 consecutive patients was prospectively evaluated by means of CT angiography for planned free fibula flap reconstructions. We retrospectively investigated whether fibular free flap transfer was performed in candidate patients and whether the presence of postoperative foot ischemia had been followed.

RESULTS

Multidetector row CT angiography demonstrated a normal arterial anatomy in 82 patients, anatomical variants in 30 patients, and peripheral arterial occlusive disease in 6 patients. The radiologists selected 20 legs as major variants that cannot ensure lower extremity viability after flap harvest. Sixty-three patients underwent fibula free flap transfer. The surgeons followed our imaging diagnosis and selected healthy legs as candidates for fibular free transfer in all but 2 patients. No postoperative foot ischemia presented in any patient.

CONCLUSIONS

Computed tomographic angiography is a reliable preoperative imaging technique for the selection of appropriate legs as candidates for fibular free transfer.

[Application of CAD/CAM techniques in mandible large-scale defect and reconstruction with vascularized fibular bone graft]

OBJECTIVE

To exploit computer-aided design and computer-aided manufactured (CAD/CAM) techniques and application in the reconstruction of mandible large-scale defect with vascularized fibular bone graft.

METHODS

Before actually performing surgery, three-dimensional(3D) computed tomography(CT) was performed in 7 patients with mandibular large-scale defects, and 3D CT images were acquired by processing CT data. Then the CT data were transformed into a readable format and transferred to produce facsimile models by means of using rapid prototyping(RP) techniques. When individual mandibular models and enantiomorphous models were produced, evaluation and surgical simulation was performed in model, which included measuring range of mandible lesions, prefabrication of mandibular reconstructive titanium palate, precise position of titanium screws, shaping the free vascularized fibula by mandibular, etc. According to the simulations, the mandible reconstructions were finished in operation.

RESULT

CAD/CAM techniques and application can distinctly display the mandibular lesions and ambient relationships, which is very useful for clinical assessment and surgical planning. Particular advantages were the unlimited trials with the imaging method, and the feeling of reality with the model method. The actual operative time was shortened, and surgery results were satisfactory with few complications.

CONCLUSION

CAD/CAM techniques are very helpful for simulation of mandible large-scale defect with complicated anatomical and reconstructive problems. By preoperative simulation of procedures, surgeons can improve or refine treatment planning using this method and improve postoperative results.