Long-term follow-up of the vascularized iliac bone graft

We retrospectively studied four patients who were treated with vascularized iliac bone graft for reconstruction of the tibia. The average length of the graft was 9.8 cm. The follow-up period was 11-18 years (average, 14.8 years). Although two of them were osteomyelitis, no recurrence occurred. We also studied four patients who were treated with nonvascularized iliac bone graft for anterior spinal interbody fusion (average, 10.8 years). Cosmetic problem slightly exists because the vascularized iliac bone still showed the original shape, which was prominent from the tibial contour. The vascularized iliac bone marrow showed iso intensity in both T1 and T2 image of the MRI. However, nonvascularized iliac bone graft on the spine showed high intensity in both T1 and T2 imaging. Since the vascularized iliac bone graft does not present fatty degeneration, it shows strong resistance against infection.     

Endosseous implant and autogenous bone graft reconstruction of mandibular discontinuity: a 12-year longitudinal study of 31 patients

Surgical, medical, and prosthodontic records of 61 consecutively treated patients with mandibular discontinuity were reviewed retrospectively. All 61 patients had undergone discontinuity reconstruction with autogenous bone grafts; 31 of 61 had also received endosseous dental implants and a dental osseoprosthesis. Of these 31 implant-reconstructed patients, 23 had free autogenous nonvascularized and 8 had vascularized bone grafts. The surgical-prosthetic protocol consisted primarily of secondary, free autogenous nonvascularized bone graft reconstruction and secondary root-form endosseous implant and fixed prosthesis dental reconstruction. Vascularized bone (8 patients) or soft tissue (4 patients) grafts were utilized selectively for severely compromised patients after extensive oncologic resection, avulsive trauma, or after previous radiation treatment. Endosseous implant survival (95.5% in 31 patients), autogenous bone graft success (98.4% in 61 patients), and dental osseoprosthesis success (100% in 31 patients) were favorable. A high incidence (9.1%) of nonfunctioning (sleeping) implants was recorded for this patient population. The need to remove the titanium mesh tray for various reasons (17.6%) and the need to reconstruct soft tissue in the irradiated patient (12%) were noteworthy.     

Reconstruction of the jaw and oral cavity with free vascularized grafts

59 microvascular graft transfers performed in 50 patients in our department since 1985 have been studied retrospectively. The indications for microvascular reconstruction were sequelae after tumour surgery in 38 patients, gunshot injury in seven, chronic osteomyelitis of the mandible in three, complication after jaw fracture in one patient, and atrophy of the alveolar ridge also in one patient. Transplants from the iliac crest, fibula, radius, radial forearm skin and jejunum were used. Three transplants were lost because of arterial thrombosis, giving a success rate of 94.9%. Complications were registered in 19 cases, the largest group being wound infections. 21 of the 50 patients have been treated with dental implants for total rehabilitation of masticatory function. Transfer of free vascularized bone and soft tissue grafts has greatly improved the functional and cosmetic results obtained in reconstructive surgery of the orofacial region.     

Functional alveolar ridge reconstruction with prefabricated iliac crest free flap and osseointegrated implants after hemimaxillectomy

We achieved functional alveolar ridge reconstruction after hemimaxillectomy using a prefabricated iliac crest flap. The iliac crest was vascularized secondarily by a long rectus abdominis muscle flap with its inferior epigastric vessels intact to obtain an ideal anatomic location between the maxillary defect and microvascular anastomosis site. The iliac crest was tightly resurfaced with a split-thickness skin graft as well. After a bony surgical delay, the prefabricated iliac crest flap was microsurgically transferred to the face. Three osseointegrated implants were placed in the prefabricated iliac crest, and a dental prosthesis was worn with immobilization and stability. Our procedure enabled recovery of a satisfactory facial appearance and excellent masticatory function.     

Reconstruction of the mandible with conventional bone graft: an evaluation

Eighteen patients with bony defects of the mandible had the mandible reconstructed using conventional nonvascularized bone grafts from the iliac crest. After surgery they received radiotherapy for cancer in the oropharynx or oral cavity. This study was carried out over a 10-year period. All patients were followed-up both for their tumour growth and the results of their reconstruction. Four to 10 years after surgery 55.5 per cent were alive and well. Full dental rehabilitation was achieved in 33 percent and 12.5 percent were without dental rehabilitation.     

Mandibular reconstruction with cancellous bone, hydroxylapatite and titanium mesh

Over the past 20 years, titanium mesh combined with autologous iliac crest spongiosa and hydroxylapatite has performed well in the restoration of mandibular discontinuity defects in 79 patients. In 14 irradiated patients with a transplant bed of inferior quality, however, complications and failures occurred more often than in the 65 non irradiated patients. The results of our investigation clearly show that the success of mandibular reconstruction mainly depends on a well vascularized transplant bed.     

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.     

Study of Enterobacter strains belonging to a particular group related to Enterobacter aerogenes (author''s transl)

Utilizing rats as a model, it was demonstrated that both iliac crest bone and porous carbon disks, when used as only grafts, become vascularized as early as 3 days. There is no significant difference between the two. The soft tissues, periosteum, and recipient bone are all capable of supplying vascularization to the graft or implant.     

A historical review of mental health services in Hong Kong (1841 to 1995)

OBJECTIVE: To review the experience of 1 microvascular surgeon during an 11-year period in performing 210 vascularized bone-containing free flaps for oromandibular reconstruction. DESIGN: Retrospective medical records review of patients who underwent primary and secondary oromandibular reconstruction with the use of vascularized bone free flaps. SETTING: Academic medical center. PATIENTS: A total of 201 patients underwent 210 composite free-flap reconstructions of the mandible for various disorders and with a range of bony and soft tissue defects. INTERVENTION: All patients underwent the microvascular transfer of vascularized bone flaps from the ilium, fibula, or scapula. In selected cases, 2 simultaneous free flaps were transferred to achieve an optimal bone and soft tissue reconstruction. Endosteal dental implants were used in 81 patients, with a total of 360 fixtures placed during these 11 years. MAIN OUTCOME MEASURES: The success of microvascular free tissue transfer, dental implant extrusion, and short- and long-term complications at the recipient and donor sites. RESULTS: Of the 210 mandibular reconstructions that were performed, 202 were successful in reestablishing mandibular continuity. Reexploration for vascular-related complications was done in 16 patients, 8 of whom were successfully treated, yielding an overall success rate of 96%. The overall success rate for endosteal dental implants was 92%. The implant success rate was 86% when the bone in which the fixtures were placed was irradiated postoperatively. The success rate was 64% in the 14 fixtures that were placed into previously irradiated bone. CONCLUSIONS: The success of the use of vascularized bone free flaps in restoring continuity to the mandible is clearly demonstrated in this series. There was an acceptable incidence of donor- and recipient-site complications that resulted in minimal long-term morbidity. The careful selection of a donor site(s) for oromandibular reconstruction allows for an optimal restoration of bony and soft tissue defects. Dental implants can be safely used in oromandibular reconstruction with a high level of success. Placing these implants during the initial surgery shortens the duration for achieving dental rehabilitation and enhances the success of the implants when postoperative radiotherapy is administered.     

Giant cell tumor of bone

Giant cell tumor is a locally aggressive tumor with a high recurrence rate if not completely excised. The condition is more common among Asians than whites. During a 10-year period 44 patients, ranging in age from 12 to 51 years, were treated. The most common sites were the proximal femur and the distal radius. The aim of treatment was to excise the tumor completely. Because the tumor usually occurred at the juxtaarticular region of the bone, difficult reconstruction was expected. The authors' method of choice for filling large defects resulting from resection was to use a large vascularized bone graft from the iliac crest to enhance bone to bone corporation. The recurrence rate was low (4.5%), with only 2 recurrences: 1 at the proximal femur and the other at the proximal tibia. The functional results were highly satisfactory, with excellent stability of the joint, although in the case of the distal radius there was some degree of subluxation of the wrist joint. By applying microsurgical technique for the reconstruction, one was able to be more aggressive with excision of this locally aggressive tumor while maintaining excellent functional results. In the case of the knee, as long as 1 tibial condyle was intact, reconstruction of the other condyle using a vascularized iliac crest block maintained the joint integrity perfectly or created a pseudojoint component that was perfectly stable.     

Complications of spongiosa harvesting of the ilial crest. A retrospective analysis of 1,191 cases

We analyzed retrospectively 1191 cases of bone graft harvesting of the iliac crest which had been performed at our hospital between 1982 and 1991. There was an operative revision rate of 2.8%. For further study, we analyzed the clinical reports of all autograft (iliac crest) donors in a representative year (1991) and re-examined all those who still had symptoms. A total of 104 grafts were taken from 97 patients. Of these, 18 developed postoperative complications (19.6%), such as hematoma, which could usually be treated with local procedures such as aspiration. The rate of hematoma tended to be lower in those patients who had received a local coagulant, but this was not significant. Of the patients 55% still had problems 1 year after operation at the time of re-examination, but in most cases they were minor, for example, local irritation or discomfort. Serious problems developed in those patients who had a palpable defect of the iliac crest. We advise using local coagulants to decrease the rate of postoperative complications, although we cannot statistically prove the effect. When large grafts are harvested, the iliac crest should be reconstructed for better long-term results.     

Use of demineralized bone matrix in hindfoot arthrodesis

Fifty-five patients considering a hindfoot fusion performed by the senior author over a 5-year period were given the choice of having the fusion augmented by either iliac crest bone graft or demineralized bone graft in a study of the relative efficacy of these 2 methods of bone grafting. Eleven patients underwent subtalar fusion (average age, 40.1 +/- 14.0 years), and 44 had a triple arthrodesis (average age, 54.6 +/- 19.2 years). The most common indications for surgery were posterior tibial tendon insufficiency and traumatic arthritis. There were no significant differences between groups regarding underlying disease, medications, or associated medical conditions. In isolated subtalar fusions, all 3 patients who received an iliac crest bone graft experienced healing, as did 7 of 8 patients who received demineralized bone graft. The eighth patient had a radiographic non-union without clinical symptoms. Complete healing of triple arthrodeses was achieved in 13 of 15 patients who received an iliac crest bone graft and in 29 of 29 patients receiving a demineralized bone graft. There were no intergroup differences in the time to union, which generally was between 3 and 4 months. Intraoperative blood loss was significantly less with demineralized bone graft (33 +/- 25 ml) than with iliac crest bone graft (206 +/- 192 ml). This study demonstrated that demineralized bone graft aids arthrodesis at least as well as does iliac crest bone graft, without the increased blood loss, cost, and postoperative pain associated with iliac crest bone harvest.     

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.     

Reconstruction of total maxillectomy defects with preservation of the orbital contents

Reconstruction after total maxillectomy with preservation of the orbital contents is technically more challenging than when the maxillectomy is combined with orbital exenteration. Reconstruction of such defects should (1) provide support to the orbital contents, (2) obliterate any communication between the orbit and nasopharynx, (3) reconstruct the palatal surface, and (4) achieve facial symmetry and a good aesthetic result. We report our experience in performing reconstructive surgery on 14 patients who had a total maxillectomy and preservation of the orbital contents using nonvascularized bone grafts for reconstruction of the orbital floor and maxilla, in conjunction with a soft-tissue free flap or pedicled muscle flap. The orbital floor was reconstructed using split ribs in six cases (42.9 percent), split calvaria in six cases (42.9 percent), and iliac crest graft in two cases (14.3 percent). A myocutaneous rectus abdominis free flap was used for soft-tissue reconstruction and resurfacing of the palatal mucosa in twelve patients (85.7 percent), and a temporalis muscle transposition was used in two elderly patients (14.3 percent). One patient died 2 days after surgery. Mean follow-up and aesthetic and functional results were assessed in the remaining 13 patients a minimum of 6 months postoperatively. In 9 of these 13 patients (69.2 percent), postoperative radiotherapy was administered. No reexplorations or free flap failures were observed. One rectus flap developed partial necrosis of the skin island intraorally without affecting the final result. All patients had adequate functional vision. One patient had a mild vertical dystopia; there were no cases of enophthalmos. Ectropion was the most common undesirable result and was present in 10 of 13 cases (76.9 percent). It was graded as mild in four cases (40.0 percent), moderate in four cases (40.0 percent), and severe in the remaining two cases (20.0 percent). Speech was considered normal in six cases (46.2 percent), near normal in six cases (46.2 percent), and intelligible in one case (7.7 percent). Chewing function was considered good (soft to unrestricted diet) in all cases except for one patient who was only able to eat a pureed diet. Aesthetic results after immediate reconstruction were considered good in nine cases (69.2 percent) and fair in four cases (30.8 percent). Primary reconstruction of total maxillectomy defects with orbital content preservation remains a complex problem without a perfect solution. The combination of nonvascularized bone grafts for orbital/maxillary reconstruction with a soft-tissue free flap is a safe, reliable, and effective method of maximizing postoperative functional and aesthetic results.     

Long-term followup of patients with autogenous resection arthrodesis of the knee

Arthrodesis of the knee may be indicated for the reconstruction after resection of tumor around the knee. Since the introduction of this technique, resection arthrodesis using segmental autogenous grafts has been the principal method of reconstruction. From August 1967 to February 1985, 73 patients underwent resection arthrodesis using autogenous grafts. All procedures were performed for malignant or potentially malignant lesions. Ten-year followup was available on 40 patients. The reconstructive procedure was performed using an intramedullary rod and hemicortical femoral or tibial grafts with a single autogenous nonvascularized fibula or with dual nonvascularized fibulae. Despite a high surgical complication rate, the majority of patients achieved successful limb salvage. Independent ambulation was achieved by 86% of the patients. A Musculoskeletal Tumor Society functional evaluation in 32 available patients at a mean of 17 years showed the majority of patients functioning satisfactorily. Long-term followup of these patients shows continued durability of the reconstruction and a persistent high level of function and patient satisfaction. Resection arthrodesis using massive autogenous grafts should continue to be in the armamentarium of the orthopaedic oncologist.     

Prospective evaluation of morbidity associated with iliac crest harvest for alveolar cleft grafting

PURPOSE: This study prospectively evaluated the morbidity associated with iliac crest bone harvest when performed for alveolar cleft grafting. PATIENTS AND METHODS: Twenty-two consecutive patients who underwent an alveolar cleft graft with iliac crest bone harvest were evaluated. The estimated blood loss, length of hip incision, and volume of bone that was harvested were recorded. The duration of time until postoperative ambulation and the length of hospitalization were measured. RESULTS: All patients tolerated the iliac harvest without major complication, and the volume of bone was sufficient in all but one case. Postoperatively, ambulation occurred at an average of 3 hours 18 minutes. Twenty-one patients were discharged the day after surgery; one patient had the surgery performed as an outpatient. CONCLUSIONS: Harvesting cancellous bone from the iliac crest does not result in delayed ambulation or prolonged hospitalization. The morbidity that has been reported to occur with iliac crest bone harvest was not consistent with the results of this study.     

Long-term effects of pentobarbital anesthesia on the atrial natriuretic peptide system in rats

The midline fascial splitting approach is a modified midline approach to the iliac crest for bone graft that takes advantage of the anatomic planes between layers of the dorsal lumbar fascia. Two hundred consecutive grafts were taken by this technique with one superficial infection, two cases of serous hematoma, and three patients with significant postoperative pain at the harvest site, for an overall complication rate of 3%. In comparison, bone grafts were harvested from 200 consecutive patients by the midline subcutaneous approach to the iliac crest with 2 deep infections, 1 cluneal nerve injury, 15 patients with severe and disabling pain at the harvest site, and 12 patients with a serous hematoma, for an overall complication rate of 15%. The midline fascial splitting approach significantly reduced the incidence of postoperative serous hematoma (P < 0.007) as well as the incidence of significant and disabling pain (P < 0.001). In addition, the approach is simple, straightforward, anatomic, and decreases trauma to soft tissues.     

Prion protein structural features indicate possible relations to signal peptidases

We describe the treatment of 2 patients with extensive midfacial defects by using a customized composite flap. Autogenous bone was transferred from the iliac crest, revascularized by the rectus muscle, and then transferred as a complete unit by microvascular technique to provide a vascularized bone graft to this area of difficult reconstruction. The bone was shaped and customized to fit the osseous defect. Although the rectus muscle was relatively bulky at the time of harvest, its hearty blood supply permitted trimming and contouring to fit the gap. This technique was based on the principles proposed previously by other authors regarding the vascularization of a free bone graft and its transfer as a composite flap. This technique requires more research and refinement, however this clinical demonstration shows the feasibility of revascularizing a composite flap and the extent to which this technique can be performed.     

Differential giant cell epulis diagnosis--malignant melanoma of the mouth mucosa]

Between 1990 and 1996, 16 cases of bone defects were treated by vascularised bone grafting by the authors. Free vascularised fibula was used in 10 cases and one free iliac crest graft was used for upper extremity bone defects. Four vascular pedicled first metacarpal bone and one radial styloid bone were used for scaphoid nonunion. Average follow-up was 26 months (6-78 months) and success rate was 94%. We recommend vascularised bone grafts in the upper extremity when there is risk of infection; the defect is greater than five centimeters when the forearm rotation is unlimited. The avascularity of the scaphoid pseudarthrosis must be verified radiologically or through magnetic resonance imaging. This technique should only be used when other reconstructive techniques are unlikely to succeed.     

Overview of quality measurement and improvement

BACKGROUND: Oro-mandibular reconstruction using vascularized bone-containing free-flaps can be accomplished with flap survival rates in the range of 95%. Primary reconstruction offers the best opportunity to achieve the optimal aesthetic and functional results. Patients presenting for secondary oro-mandibular reconstruction have a unique set of problems; these include the presence of soft tissue contracture displacing the mandibular segments in malposition and soft tissue deficiencies, that makes surgical correction more difficult and potentially more hazardous. Vascularized bone-containing free-flaps are indicated in secondary oro-mandibular reconstruction where both hard and soft tissues replacement is needed or when the recipient bed is unfavourable due to previous surgery and/or radiation. METHODS: Authors presents personal experience in ten cases of secondary oro-mandibular reconstruction treated at Maxillofacial Department of Parma from September 1995 to September 1996 with secondary oro-mandibular reconstruction using bone containing free flaps. Two different donor sites were used to harvest bone-containing free flaps: iliac crest in 2 cases and fibula in the others. In 4 cases the flap was only osseous while in the other 6 cases it was osteocutaneous. RESULTS: All flaps were transplanted successfully; in 1 case necrosis of the skin component of the flap was observed. CONCLUSIONS: The introduction of vascularized bone containing free flaps transferred from distant sites by microvascular techniques has changed mandibular reconstruction. Vascularized bone transferred into tissue beds compromised by salivary contamination and previous irradiation and the rational use of the soft tissutal components of the flap permit also the restoration of articulation, deglutition and mastication with quality of life better than non-vascularized alternatives.