Treatment of tibial defects and nonunions using ipsilateral vascularized fibular transposition

Eight patients had nine ipsilateral vascularized fibular transpositions (IVFTs) in the period 1978-1987. The procedure, which involves no microvascular anastomosis, was done for difficult problems of the tibia including two long-standing posttraumatic nonunions, three allograft nonunions after tumor surgery, and four segmental tibial defects also after tumor surgery. The average duration of problems before surgery was 3.5 years, and the patients averaged 3.1 procedures before IVFT. The patients were followed for an average of 52.4 months. The average time to union was 4.2 months, and in all patients the grafts healed within six months. Late fracture of the graft developed in two patients after fixation removal; one required an additional procedure, and both eventually healed. Ipsilateral vascularized fibular grafting is a useful alternative to conventional, nonvascularized grafts for difficult tibial nonunions and segmental defects. It offers the advantages of a vascularized graft (early healing and hypertrophy), yet avoids the time-consuming microvascular anastomosis and distant donor site morbidity of free fibular grafts.     

Genetic analysis of the cap5 locus of Staphylococcus aureus

BACKGROUND: Fifteen patients with femoral shaft fractures complicated by infected nonunions were treated with a two-stage protocol. METHODS: In the first stage, radical debridement was performed along with antibiotic bead chains local therapy and external skeletal fixation. In the second stage, the debrided nonunion site was repaired with bone grafting and the external skeletal fixator was used until bony union was achieved. The time between the first and second stages of treatment was 2 to 6 weeks. The debrided bone defects ranged from 0.5 to 15 cm. Autogenous iliac cancellous bone grafting was performed in 11 patients, and microvascularized osteoseptocutaneous fibular transfer was performed in 4 patients. RESULTS: Wound healing and bone union were achieved in all 15 cases. The duration of external fixation of these patients ranged from 7 to 15 months, with an average of 9 months. Minor pin-track infection was seen in seven patients. Postoperative infection after the second-stage bone grafting occurred in three patients. These three infections were arrested by limited debridement along with 2 to 4 weeks of parenteral antibiotic therapy. In one case, stress fracture occurred at 11 months after microvascularized fibular transfer; this was managed with another 5 months of external skeletal fixation. With an aggressive physical therapy program, 10 patients achieved nearly full range of knee motion and 5 patients had relevant knee flexion deficits. The follow-up averaged 58 months (range, 40-76 months); no recurrence of osteomyelitis was observed even at 76 months. CONCLUSION: We have found that our two-stage treatment with antibiotic beads local therapy, definitive external skeletal fixation, and staged bone grafting is an acceptable treatment protocol for the management of femoral diaphyseal infected nonunion. It results in rapid recovery from osteomyelitis and a predictable recovery from nonunion.     

Vascularized fibular graft for reconstruction of the wrist after excision of giant cell tumor

Seven patients with a giant-cell tumor involving the distal end of the radius were treated with en bloc resection and reconstruction with a free vascularized fibular graft. Two patients with stage 2 disease of Enneking's surgical staging and grade 2 of Campanacci's radiographic grading system were reconstructed with an articular fibular head graft. Five patients with stage 3 and grade 3 disease underwent wrist arthrodesis using fibular shaft transfer. There was radiographic evidence of bone union at the host-graft junctions in all cases. No local recurrence was seen in any of the patients at the most recent follow-up examinations. There were six good and one excellent functional results. Wrist arthroplasty using a vascularized fibula head graft is the best procedure for a stage 2 or grade 2 giant-cell tumor of the distal end of the radius. In cases of stage 3 or grade 3 disease, wrist arthrodesis using a vascularized fibular shaft graft is indicated.     

Vascularized fibular grafts for the reconstruction of segmental tibial bone defects

Free vascularized fibular grafts were employed in seven patients with large tibial defects following trauma or resection of tumour. All patients were followed for more than 5 years. Tibial union and excellent functional results were achieved in all seven patients. Free vascularized fibular transfer seems to be an effective method of treatment for massive segmental bone defects.     

Proximal femur fractures after free vascularized fibular grafting to the hip

The management of symptomatic femoral head osteonecrosis in young, active patients is troublesome and controversial. At the authors' institution, 707 consecutive free vascularized fibular grafts were performed for femoral head osteonecrosis between October 1979 and October 1995. Patients who underwent this procedure were at increased risk for proximal femur fractures because of the 16 to 21 mm core drilled through the lateral femoral cortex for removal of the avascular bone and placement of the fibular graft. An ongoing prospective database of patients who underwent this procedure was accessed to determine the incidence of and factors associated with postoperative subtrochanteric femur fractures. Eighteen subtrochanteric fractures occurred for an overall incidence of 2.5%. All fractures occurred through the core decompression site in the lateral femoral cortex. The treatment was nonoperative in seven patients and operative in 11. Fourteen of 18 fractures (77%) healed with an average of 4.1 months until radiographically documented union. Four fractures had nonunions develop, three of which later healed with bone grafting and internal fixation, whereas the fourth eventually required conversion to total hip arthroplasty. Twelve fractures in 251 patients occurred when the weightbearing regimen was touchdown weightbearing for the first 6 weeks and five fractures in 456 patients occurred when the weightbearing regimen was changed to nonweightbearing. The results indicate that nonweightbearing in the immediate postoperative period is associated with the lowest fracture rate.     

Survival analysis of hips treated with core decompression or vascularized fibular grafting because of avascular necrosis

Avascular necrosis of the femoral head is a multifaceted process that leads to articular incongruity and subsequent osteoarthrosis of the joint. Clinicians concur that primary treatment should focus on preservation of the natural surface of the joint; however, there has not been a consensus on how best to accomplish this. While a number of therapeutic interventions have been reported, the efficacy has varied markedly and there have been few statistical comparisons. The purpose of the current study was to use statistical analysis to compare the results of two widely used procedures, vascularized fibular grafting (614 hips; 480 patients) and core decompression (ninety-eight hips; seventy-two patients), for the treatment of avascular necrosis. The patients were stratified according to age and the stage of disease, and a survival analysis was performed with total hip arthroplasty as the end point for failure. None of the eleven hips that had Ficat stage-I disease needed a total joint replacement after being treated with either regimen. Analysis of the hips that had stage-II disease revealed rates of survival, at fifty months, of 65 per cent (twenty-eight of forty-three hips) after core decompression and 89 per cent (ninety-nine of 111 hips) after vascularized fibular grafting. For the hips that had Ficat stage-III disease, the rates of survival at fifty months were 21 per cent (ten of forty-seven hips) after core decompression and 81 per cent (405 of 500 hips) after vascularized fibular grafting. Among the hips that had Ficat stage-II or III disease, the rate of eventual total joint arthroplasty after vascularized fibular grafting was significantly lower than that after core decompression (p < 0.0001). The results indicate that the increased morbidity associated with vascularized fibular grafting is justified by the associated delay in or prevention of articular collapse in hips that have stage-II or III disease.     

Predictors of underlying coronary artery disease in cocaine associated myocardial infarction: a meta-analysis of case reports

A preliminary report presenting the results of fibular strut grafting in the severely resorbed mandibular and maxillary region is presented. Thirteen patients were treated due to severe resorption of alveolar and basilar bone of 49 segments of the mandible and the maxilla. Two patients additionally had pathological fractures of the mandible. In 10 cases the strut graft was harvested by means of a new minimally invasive technique. After modelling the fibular bone it was fixed to the recipient site by miniscrews or implants. After a mean follow-up period of 20 months (max. 31, min. 11 months) a retrospective analysis of clinical and radiological findings was carried out. It showed that a mean augmentation of 16 mm was achieved. Compared to other studies the fibular strut graft was resorbed less, and due to the primary stability it could be used for the treatment of fractures of the mandible. No more than natural resorption was observed when the patients received their prostheses fixed to dental implants.     

Mandibular reconstruction using a microvascular method in the transplantation of a fibular flap

The best results in mandibular reconstruction are achieved by transplantation of vascularised bone. This transplant has an own blood supply therefore its surviving is not influenced by the non-sterile environment of the oral cavity and the insufficient blood supply of the operated area (caused by scar or radiation). A new promising method for reconstruction of a wide segmented defect of the mandible is vascularised fibular flap transplantation. Eight consecutive patients treated with fibular flap transplantation in 1993 and 1994 were reviewed. Osteo- and osteo-cutan flaps were used for reconstruction of the composite tissue defects. The authors report on the surgical technique and their first experiences. The authors consider the application of the fibular flap the most successful procedure of all types of reconstruction of segmented mandibular defect.     

Severe progressive deformities after limb lengthening in type-II fibular hemimelia

Until recently the accepted treatment of choice for severe type-II fibular hemimelia has been Syme's or Boyd's amputation. The alternative of distraction lengthening using the Ilizarov technique is now available. We report three patients (four limbs) with type-II fibular hemimelia who were treated by the Ilizarov technique and followed up for two to six years. Severe progressive procurvatum and valgus deformity of the tibia and valgus deformity and lateral subluxation of the ankle were found in all four limbs. Multiple additional soft-tissue and bony surgery was necessary. In view of these problems we feel that reappraisal of the indications for lengthening in type-II fibular hemimelia is necessary.     

Treatment of nonunion of the humerus using the Ilizarov external fixator

Ilizarov's method of monofocal compression was used in 30 humeri with a diaphyseal pseudarthrosis. Twenty-one patients had previous surgery but had loosening of the osteosynthesis material. Nine patients initially were treated with a hanging cast, resulting in interfragmentary distraction. Fourteen nonunions were hypertrophic, and 16 were atrophic, of which six were infected. A complete circular frame was used only in the first nine patients, whereas the remaining 21 patients were treated with the modified semicircular fixator. Union was obtained in all but two patients, with an average consolidation time of 4.5 months (range, 2.5-10 months). No patient required additional bone grafting. Apart from superficial pin tract infection seen in most of the patients, three had a minor temporary sensory neurologic problem. Four patients experienced a second fracture after removal of the fixator that required a second application of an Ilizarov frame. Although similar results with regard to union are reported after plate osteosynthesis, there was no radial nerve palsy or deep infection in this series, indicating that the treatment by the Ilizarov technique is associated with less complications. The authors' findings suggest that the Ilizarov method is a reliable treatment for humeral nonunions, even after multiple previous operations or in the event of infection.     

Treatment of humeral shaft fractures by retrograde locked nailing

From 1992 to 1994, 29 middle and 19 distal humeral shaft fractures (39 acute fractures, six nonunions, and three pathologic fractures) in 48 patients were treated by retrograde locked nailing. The first eight acute fractures were treated with Seidel nails, the other 40 fractures with specially designed humeral locked nails. Nails were inserted from the supracondylar (6) or the olecranon fossa (42) entry portal. With a single operation, all acute fractures and nonunions achieved osseous union without serious complications. The average time to union was 8.2 weeks for acute fractures and 14.2 weeks for nonunions. Recovery of shoulder function was complete. Elbow motion was excellent in all but one nonunion that resulted from a Type IIIB open fracture. Two patients with supracondylar entry had apex to posterior angular malunion. One patient with a distal comminuted fracture had varus malunion. Three patients had an iatrogenic bony split, but healing was unaffected. Patients with pathologic fractures maintained satisfactory arm function postoperatively. Given the few complications and good functional recovery seen in this study, retrograde locked nailing appears to be a good alternative treatment in middle and distal humeral shaft fractures. The olecranon fossa approach, with more linearity to the humerus, is preferred. In the authors' experience, humeral locked nails are inserted more easily and are associated with fewer complications than are Seidel nails.     

The role of fixation of the fibula in open fractures of the tibial shaft with fractures of the ipsilateral fibula: indications and outcomes

To determine the indications for fibular fixation in cases of combined fractures of the tibia and fibula and the effect of fibular fixation on tibial healing, a retrospective study of open fractures of the tibial shaft with concomitant fibula fractures was conducted at a level one trauma center. Apparent indications for fibular fixation included the presence of a syndesmotic injury and location of fracture within the distal third of the fibula. No significant differences were found in the healing rates, incidence of nonunion and malalignment, or in the number of required subsequent procedures between patients who did and did not undergo fibular stabilization. These results suggest that fixation of the fibula in open fractures of the tibia and fibula has no effect on fracture healing or alignment. A randomized, prospective study is needed to properly validate these findings.     

Clinical morphology of pneumoconiosis]

Different methods of primary mandibular reconstruction carried out at the Tata Memorial Cancer Hospital range from the pectoralis major myocutaneous or osteomyocutaneous composite flap, which is the most frequently performed procedure, to a free vascularised composite tissue transfer with microvascular anastomosis, including, iliac crest free vascularised bone grafts or radial artery forearm flap free vascularised radius bone grafts, free vascularised fibular bone grafts and silastic mandibular implants. The clinical results of immediate mandibular reconstruction with a silastic mandibular implant (SMI) in 69 patients is presented. Out of the 69 cases, 2 patients died in the early post-operative period. Twenty (30%) SMI were retained for a period of 1 year to 5 years. Forty seven (70%) SMI were retained for a period of less than 1 year. These implants have been used in a variety of cases, with or without major flap reconstruction, where a skeletal support was indicated, especially after mandibular arch resection. The results of this series indicates the importance of these implants as a short term spacer, even in advanced, fungating lesions of head and neck cancer where the risk of infection, haematoma and salivary leak is very high. Bone replacements were undertaken at a later date in suitable cases. The effects of preoperative chemotherapy and radiotherapy on the retention of these implants has also been studied.     

Iliac crest bone grafting and Herbert screw fixation of nonunions of the scaphoid with avascular proximal poles

Between 1989 and 1991, 137 nonunions of the scaphoid were treated by the senior author, who noted that 26 of these nonunions had an avascular proximal pole (no punctate bleeding from the bone at the time of surgery). All 26 nonunions were treated with iliac crest bone grafting and Herbert screw fixation. Of these 26 patients, 17 were followed for more than 1 year after their surgery (average follow-up period, 31 months). The average time from injury to surgery was 31 months. Of the 17 patients included in this study, 12 were treated with a palmar approach to the nonunion, 5 with a dorsal approach. The 12 nonunions that occurred at either a midwaist or distal location were approached through a palmar modified Russe incision and treated with interpositional corticocancellous iliac crest bone graft in addition to the Herbert bone screw. The five nonunions with a very small proximal fragment were approached through a dorsal incision and treated with cancellous iliac crest bone graft and Herbert screw fixation. All patients were immobilized after operation in a short-arm thumb spica cast for 3 months and were then allowed active range of motion of their wrists. Return to full activity was permitted once preoperative wrist motion was restored. Radiographic union, as defined as bridging trabeculae of bone present in all x-ray films, occurred in nine patients, an incomplete union or persistent fibrous union in seven, and a nonunion in one patient. Using the scaphoid outcome score, an assessment scale based on pain, occupation, wrist motion, strength, and patient satisfaction, functional results were graded as excellent in six patients, good in five patients, fair in four patients, and poor in two patients. The average range of motion of the wrist did not significantly improve after surgery, but the average grip strength of the injured hand increased by 29 lbs. There were no intraoperative complications. However, three patients required further operative procedures including radial styloidectomy, pin removal, and carpal tunnel release. No patient has required either a proximal row carpectomy or wrist arthrodesis. Previously published results of avascular proximal pole scaphoid nonunions suggest that union cannot be obtained and functional results are uniformly poor. In contrast, the functional and x-ray results of our patients are markedly improved over these previous studies--emphasizing the importance of iliac crest bone grafting, rigid internal fixation, and appropriate postoperative immobilization.     

Enhanced Dissolution of Trichloroethene: Effect of Carbohydrate Addition and Fermentation Processes

Remediation of source areas is challenging because lingering contaminants are often present as nonaqueous phase liquid (NAPL) and sorbed mass, and therefore difficult to remove via biodegradation or other commonly used remedial methods. Experimental results indicate that enhanced dissolution of a model NAPL, trichloroethene (TCE), can occur through the addition and/or subsequent fermentation of a dilute molasses solution. Enhanced mass transfer occurs by two mechanisms, depending upon whether the molasses solution is fresh or has fermented. The addition of fresh molasses worked to increase TCE solubility (>200%), thereby increasing mass transfer from the NAPL phase. Mixing TCE NAPL with a fermented molasses solution, however, increased TCE mass flux via the formation of a NAPL/aqueous phase emulsion. In addition, fermented liquid may have also decreased the soil partitioning coefficient (Kd) of TCE, indicating that enhanced transfer of sorbed mass to the aqueous phase could also occur in the presence of fermented molasses. These results provide guidance on how remedial systems may be optimized to increase NAPL and sorbed-mass dissolution and are therefore important, particularly when bioremediation is used to polish residual source zones.     

A probable explanation for mild extra-articular manifestations in Indian patients of rheumatoid arthritis: a preliminary study

The combination of a total lower lip, chin, and anterior mandibular defect following cancer resection is an extremely complex problem that requires a sequence of operations to optimize functional and aesthetic results. One patient is presented in whom the defect was reconstructed with a free fibular flap followed by a series of ancillary procedures using both modern and traditional techniques. At the time of tumor ablation, the through-and-through oromandibular defect was reconstructed with a fibular osteocutaneous flap. The lower lip and gingivolabial sulcus was reconstructed later with a tongue flap. Tissue expansion was subsequently used to replace the fibular skin with expanded submental hair-bearing skin. A polyethylene implant was added later to the fibular bone for chin augmentation. Subsequently the lower lip was supported with a tendinous graft suspended to the anterior masseter bilaterally. Lastly, the vermilion border was elevated by removing a rim of the tongue flap and covering the secondary wound with a full-thickness skin graft. At the end of the reconstructive procedures, lip seal and oral aperture were good with no drooling and excellent speech.     

Ilizarov procedure in pseudarthrosis

The treatment of nonunions has made an important development through the work of Ilizarov describing the principles of compression and distraction by using the ring-fixator. While local compression is sufficient in hypertrophic nonunions, the treatment of choice for atrophic infected nonunions with bony defects is a corticotomy followed by a segmental transport, especially in case of an osseous defect larger than 3 cm. Primary shortening poses a better starting point both for soft-tissue reconstruction and for early docking. External fixation systems are the ring-fixator, the unilateral fixator and hybrid systems combining both fixation methods. The use of a ring-fixator makes a shorter time of osseous consolidation possible when compared to a unilateral system (25,8 d/cm - 35,8 d/cm). Soft-tissue reconstruction before initiation of transport also shortens the time of osseous consolidation compared to later soft-tissue coverage. A docking-region in the metaphyseal area is supported by minimal internal fixation and cancellous bone graft. Segmental transport is complicated by local infection, regenerate failure (4.3% and regenerate fracture (2.9%).     

Giant cell tumor of lumbar vertebra. A case report with 13-year followup

A combined one stage anterior and posterior approach was used to excise a giant cell tumor involving the second lumbar vertebra. The tumor involved the anterior and posterior elements of the vertebra. A wide excision was feasible with immediate stabilization using the Luque instrumentation posteriorly and fibular strut grafts supporting the vertebral bodies anteriorly. The followup period was 13 years. There is no recurrence, and the patient has no symptoms of disease, and the fibular grafts are fully incorporated.     

One-stage lengthening of femoral nonunion augmented with human bone morphogenetic protein

Fifteen patients with posttraumatic shortened atrophic femoral nonunions were treated with one-stage lengthening. The alloimplant was composed of allogeneic antigen extracted autolyzed human bone perfused with partially purified human cortical bone morphogenetic protein associated with noncollagenous protein and used as graft. The composite was lyophilized and sterilized with ethylene oxide. All 15 nonunions were atrophic diaphyseal and were lengthened through intercalary segmental defects bridged with the human bone morphogenetic protein composite alloimplants stabilized to the medial femoral cortex through plate osteosynthesis and lag screw fixation. One lengthened proximal femur had fatigue failure of the plate and was treated successfully by exchange plating. The average increase in length was 2.8 cm (range, 1.5-5 cm) and an average percentage increase in length of 8% (range, 4%-132%) of the residual shortened femur. The human bone morphogenetic protein composite produced an immediate reactive bone formation in the host bone and progressive remodeling of the donor recipient interfaces. There were no infections, allergic reactions, clinical rejection of the human bone morphogenetic protein composite alloimplants, or evidence of malignant disease. One-stage femoral lengthening augmented with human bone morphogenetic protein composite graft bridged the intercalary defect, remodeled the atrophic host bone and restored bone continuity within 1 to 2 years. Human bone morphogenetic protein composite alloimplants are a substitute of autogeneic bone graft and offer an alternative to iliac crest bone without the associated morbidity.     

Remnant-like particle cholesterol levels in patients with dysbetalipoproteinemia or coronary artery disease

Fibula osteocutaneous free tissue transfer to reconstruct the oromandibular complex is a widely recommended technique following oncologic resection. Preoperative determination of adequate perfusion to the donor extremity is necessary to assure lower extremity viability after flap harvest. Vascular variations and/or peripheral arterial occlusive disease (PAOD) may exist whereby sacrifice of peroneal vessels can cause ischemia to the lower leg and foot. Additionally, variability of cutaneous perforators can make the fibula skin paddle viability unpredictable. Color flow Doppler (CFD) is a reliable modality to preoperatively assess the lower extremity in fibula osteocutaneous free tissue transfer patients. Prospective CFD examination of 38 consecutive patients (76 legs) considered for fibula free flap reconstruction was performed. A standard protocol was designed to evaluate the lower extremity vasculature and identify cutaneous perforators with CFD. Findings were studied with respect to flap choice, operative findings, and reconstruction outcomes. Number of cutaneous perforators and their impact on skin paddle design were also recorded. Color flow Doppler's ability to image peroneal vessels as well as determine collateral and distal perfusion were effective. CFD accurately identified bilateral vascular anomalies in one patient (2.6%), and significant arterial disease in three patients (7.9%). Cutaneous perforators were also accurately mapped and confirmed intraoperatively in 31 patients. In several instances, the information provided by the CFD examination altered flap selection, 4/38 patients (10.5%), or skin paddle design, 5/32 patients (15.6%). Color flow Doppler allowed successful fibula transfer in all the free flap candidates with normal exams. It has the advantages of low cost and no morbidity. CFD allows for accurate mapping of fibula cutaneous perforators which facilitates skin paddle design. We recommended the use of preoperative CFD in all patients being considered for fibular free flap surgery.