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.     

Correction of a dystrophic cervicothoracic spine deformity in Recklinghausen's disease

A case is presented of a 14-year-old boy with neurofibromatosis who had a 92 degrees dystrophic kyphosis (as measured on radiographs between C3 and C7) of the cervical spine. He was treated successfully by posterior stabilization and anterior fusion using a free vascularized fibula graft. This method appears to be an attractive alternative to an avascular fibula graft and avoids the risk of graft resorption (creeping substitution), weakening (fracture), or nonunion during the process of bony consolidation. It provides a stable and longstanding anterior strut, essential in the management of high grades of kyphosis. At 1-year followup the patient has no symptoms, is fully mobile, and shows radiographically complete incorporation of the graft with no loss of correction.     

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.     

Tibio-talo-calcaneal fusion with a free vascularized fibular graft in comminuted open fractures of the talus and the calcaneus

An operation is described in which a free vascularized fibular graft with a peroneal cutaneous flap is used for tibio-talo-calcaneal fusion and simultaneous skin coverage in treatment of comminuted open fractures of the talus and the calcaneus involving large skin loss. Nine months postoperatively, the tibio-talo-calcaneal arthrodesis was successful, with good coverage of the skin defect on the medial aspect of the sole. One year 7 months postoperatively, the patient is free of pain and able to walk with full weightbearing on the foot.     

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.     

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.     

Free transfer of the vascularized fibula in pseudarthrosis and femoral bone loss

The authors report their experience of femoral reconstruction by free fibular graft transfer. Twenty eight patients were operated on between 1977 and 1988. The average follow-up was 7 years and 3 months. The etiology of most of the cases was a post traumatic lesion (70 per cent). Loss of substance was found in 19 cases. 60 per cent of these were septic. The approach was usually posterior and vessels from the sciatic nerve were used. Union was obtained in 89 per cent of the cases. In 65 per cent of the cases union occurred in less than 1 year. In 1 out of 4 cases graft thickening was necessary and achieved by secondary bone grafts. The comparison of this technique with standard treatments evidenced a definite superiority of vascularized bone grafts in cases of septic pseudarthrosis and significant losses of bone.     

Vascularized bone grafts for congenital pseudarthrosis of the tibia

Eight vascularized fibula grafts and two vascularized rib grafts were used for the treatment of 10 Boyd's Type II congenital pseudarthrosis of the tibia. All but one vascularized fibula graft united within 4 months. The two vascularized rib grafts did not unite until receiving a conventional bone graft. Nine spontaneous fractures were seen in four patients; all were subsequently treated successfully with cast or conventional bone graft. Corrective osteotomies were done in two patients. Follow-up averaged 8 years and 5 months (range, 5 years and 1 month to 14 years and 4 months). Average age at end of follow-up was 13 years and 6 months (range, 7 years and 10 months to 20 years and 4 months). After bony union was achieved, shortening of the affected leg averaged 3.8 centimeters, flexion deformity averaged 20 degrees, and valgus deformity averaged 24 degrees. In three patients, whose leg discrepancy averaged 4.9 centimeters, the leg was lengthened at an average patient age of 13 years and 9 months (age range, 11 years and 7 months to 15 years and 2 months). The resulting limb length discrepancy averaged 2.2 centimeters. Vascularized bone grafting is a reliable technique for achieving bony union in congenital pseudarthrosis of the tibia. Residual shortening may be corrected later by limb lengthening.     

Free fibular graft still has a place in the treatment of bone defects

We report on 27 patients illustrating the use of non-vascularized single fibular strut graft, augmented with a corticocancellous bone graft to bridge bone defects. The indications were varied and included infection, fracture with bone loss, non-union, bone tumour, bone cyst and congenital pseudarthrosis. Primary union was achieved in 92 per cent. Stress fracture occurred in 26 per cent and no significant fibular graft hypertrophy occurred. The aim of this paper is to show that the non-vascularized single fibular graft, if augmented with corticocancellous bone graft along its whole length, is a simple procedure that is still valid to bridge bone defects.     

Osteonecrosis of the femoral head. Hip salvaging with implantation of a vascularized fibular graft

The authors tried to save the hip joint by implanting a vascularized fibular graft, augmented with cancellous bone, into the curetted core of the femoral head that was affected by aseptic necrosis. Forty of 66 hips were observed for a minimum of 20 months and for as long as 66 months (average, 32 months). Clinical assessment according to the cause and severity of the disease was done using the Harris Hip Score. Twenty-eight hips (70%) were rated excellent, 7 (17.5%) were good, 2 (5%) were fair, and 3 (7.5%) failed and were replaced with an artificial joint. Clinically satisfactory results, including good and excellent, were obtained in 35 hips (87.5%). Radiographic evaluation showed improved appearance of the femoral head core in all 15 patients (37.5%) operated on at a precollapse stage of the disease. In 20 hips, the deformity of the femoral head was unchanged (50%), 2 (5%) became worse, and 3 (7.5%) failed. The number of hips with improved appearance as shown on radiographs and those in which the process was unchanged equaled the number of hips with satisfactory clinical results. These data show that the procedure can induce new bone formation that fuses with the affected subchondral bone, thus preventing the articular surface from collapse. This suggests that vascularized fibular grafting is an excellent alternative for hip salvaging when treating femoral head osteonecrosis.     

Repair of bone defect of distal end of radius and its functional restoration

The treatment of the bone defect of the distal part of the radius included repair of the bone defect and restoration of the function of the wrist joint. Since 1979, three operative methods were used to treat 13 cases, and they were grafting of the vascularized fibula by anastomrsis fibular vessels, grafting of upper part of fibular with lateral inferior genicular artery and grafting vascularized scapula flap. Follow-up had been carried out from 1 to 10 years. The result was satisfactory. The discussion included the repair of the defect of the middle or distal part of the radius, the operative methods, main attentions and indications. It was considered that it should be based on the length of bone defect while the operative method was considered.     

Interleukin-8 expression by human neutrophils activated by Helicobacter pylori soluble proteins

A retrospective analysis was done in 60 consecutive patients who underwent anterior cervical fusion using vertebral grafts obtained from the fusion site at the Nagoya University and its affiliated hospitals by a single surgeon (MT). Follow-up results and technical advantages are reported. The average follow-up period was 33 months (range 6 to 55 months). Sufficient decompression of the anterior cervical pathology was performed successfully via a wider operative field. The symptoms and neurological score improved significantly without any new deficits in all patients except in one with a three-level fusion who needed re-operation for further decompression. No major graft complications such as graft extrusion or pseudoarthrosis occurred. Graft fracture was noted in five cases. However, good bony fusion was observed in all these cases without any further treatment. Normal cervical lordosis was preserved in most cases except in four, who lost lordotic alignment but did not show kyphosis. Major advantages of this method are a wider operative field, excellent graft fusion rate, and no need for an additional incision to obtain autogenous bone graft. These benefits seem have to contributed to satisfactory surgical results in this series.     

Adrenocortical function in critical illness

We present the results of fresh cadaver hand dissections and dye injection studies to help in raising a vascularized bone graft from the index or middle metacarpals based on the second dorsal metacarpal artery. This vascularized bone graft could be used for treating nonunion of the scaphoid and other carpal bones.     

A comparison of vascularized and nonvascularized bone grafts for reconstruction of mandibular continuity defects

PURPOSE: This study compared vascularized and nonvascularized bone grafts for the reconstruction of segmental defects of the mandible. PATIENTS AND METHODS: The results in 39 patients having vascularized bone grafts (38 fibulas and one iliac crest) and 29 patients having nonvascularized bone grafts (26 iliac crest [22 corticocancellous block grafts, four cancellous bone grafts in a tray] and three rib grafts) for segmental mandibular reconstruction were evaluated in terms of overall success rate, total number of surgeries performed, total blood loss, total number of hospital days, and total number of hours in the operating room. RESULTS: Of 39 vascularized bone grafts, two failed (95% success rate), whereas of 29 nonvascularized bone grafts, seven failed (76% success rate). Failure for the nonvascularized bone grafts was closely correlated to the length of the defect. Nonvascularized bone graft patients underwent an average of one more surgical procedure for total reconstruction than vascularized bone graft patients, including osseointegrated implants. However, vascularized bone graft patients spent a mean of over 14 additional days in the hospital for all of their reconstructive procedures and an additional 3 hours in the operating room as compared with nonvascularized bone graft patients. Blood loss was similar in both groups (1,100 mL). Only 20% to 24% of patients in each treatment group have completed reconstruction to include osseointegrated implants. CONCLUSIONS: The success rate for vascularized bone grafting is high and is the treatment of choice when primary reconstruction is required, when the patient has been previously irradiated, or when simultaneous replacement of soft tissue is required. Vascularized bone grafts are also the treatment of choice for mandibular replacements over 9 cm in length. Nonvascularized bone grafts create a better contour and bone volume for facial esthetics and subsequent implant insertion, and may be the treatment of choice for secondary reconstruction of defects less than 9 cm in length.     

Reoperation for failed prosthetic replacement used for limb salvage

Patients with segmental bone and joint replacement prostheses because of tumors increasingly need revision surgery because of their long term survival. Between 1970 and 1990, 208 custom prosthetic replacements were performed for limb salvage in patients with tumors. Reoperations were required in 52 patients. The mean time to reoperation was 37 months. The reoperation procedures included 35 prosthetic revisions, 11 amputations, four arthrodeses, one vascularized fibular graft, and one open reduction and internal fixation of a fracture with supplemental bone graft. Functional assessment using the new Musculoskeletal Tumor Society scoring system was available for the 36 living patients, and their mean rating was 63% (18.9) at 12 years' mean followup. Of the 35 patients who received a new prosthesis, 12 (33%) patients needed a third operation at mean followup of 68 months. The probability of prosthetic survival in the group of 35 patients needing revision to the same or another prosthesis was 79% at 5 years and 65% at 10 years. The chance and frequency of needing reoperation increased as patients survived longer. Reoperations for tumor recurrence or infection usually resulted in amputation. Reoperation for failed initial segmental bone and joint prosthetic replacement is feasible and effective and can be done without jeopardizing subsequent patient and implant survival or without significantly affecting functional results compared with the values before reoperation.     

The anatomical basis of the vascularized pronator quadratus pedicled bone graft

The vascular supply of the pronator quadratus was studied in 25 cadaveric dissections following coloured latex injections. This showed that the main blood supply of the pronator quadratus came from the anterior interosseous artery. There was, however, a rich anastomosis between the branches of the anterior interosseous artery and those of the radial and ulnar arteries. It was possible to raise a corticocancellous bone graft from the anterior surface of the radial styloid on a pedicle of the lower fibres of the pronator quadratus muscle. This muscle pedicle had a constant branch of the anterior interosseous artery which vascularized the bone graft. Such a vascularized pedicled bone graft may be useful in the treatment of non-union of the scaphoid and Kienb?ck's disease.     

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.     

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.     

Vascular basis for a compound flap of the finger incorporating a bone graft

A defect of soft tissue and bone is closed by a primary arterialized flap. The flap was constructed to include a vascularized bone graft. The vascular anatomy of the hand permitting creation of this flap is reviewed.