Nonvascularized Bone Grafts Research Articles

Bone grafting the scaphoid nonunionA systematic review of 147 publications including 5 246 cases of scaphoid nonunion

In order to elucidate the history of scaphoid nonunion and to evaluate whether or not the problem has been solved, we have reviewed the literature from 1928 to 2003 for union rates, postoperative immobilization periods and complications of the different scaphoid bone grafting procedures. The outcomes of 5 246 scaphoid nonunions were evaluated in three treatment groups. In the first group involving nonvascularized bone grafting without internal fixation, we found a union rate of 80% (95% CI: 78-82) after an average immobilization period of 15 weeks. In the second group involving nonvascularized bone grafting with internal fixation, the figures were 84% (CI: 82-85) and 7 weeks, respectively. In the last group involving vascularized bone grafting with or without internal fixation, the figures were 91% (CI: 87-94) and 10 weeks, respectively. We found no prospective randomized studies comparing different operative treatments of scaphoid nonunion. We conclude that there still is a need for improvement in the treatment of scaphoid nonunion.

Outcome of nonvascularized bone grafting for osteonecrosis of the femoral head.

Osteonecrosis is a disease with a wide-ranging etiology and poorly understood pathogenesis seen commonly in young patients. Various head-preserving procedures have been used for this disease to avert the need for total hip replacement. These include various vascularized and nonvascularized bone grafting procedures. We will describe the use of bone-grafting through a window at the femoral head-neck junction for the treatment of osteonecrosis of the femoral head. Bone morphogenetic protein (BMP)-enriched allograft was used to avoid donor site morbidity. Nineteen patients (21 hips) were followed up for a mean of 48 months (range, 36-55 months) after a bone grafting procedure in which the diseased bone was replaced by a bone graft substitute (combination of demineralized bone matrix, processed allograft bone chips, and a thermoplastic carrier). Eighteen of 21 hips (86%) were clinically successful at latest followup. Two of these patients have minimal radiographic progression (< 2 mm head collapse). This procedure is straightforward technically, led to low morbidity, and did not necessitate procurement of donor site bone graft. This procedure may be effective at avoiding or forestalling the need for total hip arthroplasty in young patients with early to intermediate stages of osteonecrosis of the femoral head.

Biological resurfacing for osteonecrosis of the femoral head: the use of nonvascularized bone grafting with and without ancillary growth factors

In the past year, there have been several reports detailing the successful results of nonvascularized bone grafting as a treatment alternative for osteonecrosis of the femoral head. It is important to understand the indications, the different techniques presently used, and how these will be used in the future. Although there are a number of variations of approaches, these reports employ strict selection criteria for their application. The authors believe that most procedures are straightforward for the treatment of certain patients with osteonecrosis. and results will be improved in the future with the use of ancillary growth and differentiation factors. The following article will detail the current state of knowledge for nonvascularized bone grafting based on original research and review articles published in the past year.

Discussion of “Microtransfer for Nail and Fingertip Injuries”

The foot donor site scars and the scars on the recipient finger have discouraged all but the most driven from having microvascular free flaps of the distal toe moved to the hand. Lille et al [1] reported free nonvascularized composite toenail grafts in 10 patients, with two excellent, three good, two fair, and three poor results. Sellah et al [2] reported 11 good results in 14 patients with a similar technique. Although free vascularized toenail grafts have more consistent improvement they are less resource, time, and expense saving, as both authors point out in 2000. In the 1991 Hand Clinics [3] Morrison described the toe wrap around flap for nail replacement to the finger, which they had described originally in 1980 [4]. Since then, there has been an evolution of methods of nail transfer that reduces scarring. Wei et al [5] (1993) published the largest series of microvascular transfer (152) from toe to finger with a 98% success rate. Koshima et al [6] (1988) described two patients for which they transferred toenails to the hand. Woo and Seul [7] (1998) reported 25 cases of partial toenail transfers. They used a portion of the toenail only, which resulted in a small nail when other than the large toe was used. Shibata et al [8] (1991) reported 10 patients in whom nails were transferred on a long pedicle anastomosed to digital vessels in the distal hand. Significant scars resulted, especially on the foot. Nakayama et al [9] (1990) described using a two-vein pedicle of the perionychium, one anastomosed to a digital artery and the other to a digital vein of the finger in three patients. The results were good, with less foot scars. Endo et al [10] reported the short pedicle vascularized nail flap with scars more distal and less extensive on the finger and toe in 1996. Dautel et al [11] (1998) also used a short vascular pedicle to decrease scarring. The ‘‘Evolution of Nail Transfer’’ by Endo et al [12] (1997) suggests using bone grafts from the iliac crest for bone replacement. What will be the longterm future of free nonvascularized grafts? Will they persist or resorb? Foucher et al [13] (1991) and Koshima et al, in 1992 [14], 1993 [15], and 2000 [16], described use of the pad, distal phalanx, and nail to replace distal amputations and correct hooked nails. The bone supports the tip and nail bed without the problem of resorption of a free nonvascularized bone graft. Hirase et al [17] (1997) reported 60 free innervated finger flaps in the hand and osteo-onychocutaneous flaps from the toe. Hopefully, the next generation of microsurgeons will continue to make fewer and better scars with improved results.

Free vascularized fibular bone grafting in the management of femoral neck nonunion in patients younger than fifty years.

The incidence of nonunion and osteonecrosis after femoral neck fracture has been well documented. In older patients implant arthroplasty is well established as an acceptable treatment of these problems. However, in the younger population alternatives to implant arthroplasty are favored to preserve the femoral head. Surgical treatments for nonunion of the femoral neck include osteotomy, nonvascularized bone grafting, muscle-pedicle bone grafting, and vascularized bone grafting. The purpose of this study is to examine the results of free vascularized fibular grafting as a treatment of nonunion of the femoral neck in patients younger than fifty years. Twenty-two consecutive patients underwent vascularized bone grafting for nonunion of the femoral neck after failed internal fixation between 1984 and 1998. The mean age of the patients was 28.7 years. There were thirteen male and nine female patients. The mean interval between internal fixation and free vascularized fibular grafting was 18.3 months. The average follow-up to date is 84.7 months (range 29 to 195 months). Twenty of twenty-two nonunions healed. Two patients required an additional procedure to facilitate union; one patient had iliac crest bone grafting at four months postoperatively and another underwent muscle-pedicle grafting at six months postoperatively. The average time to union for all patients was 9.9 months (range 3 to 23 months). Progression of osteonecrosis of the femoral head occurred in thirteen patients. However, successful long-term salvage of the femoral head was achieved in twenty of twenty-two patients, with an average Harris hip score of 78.9. Four patients required hardware removal or exchange for intraarticular migration with no long-term clinical sequelae. Rates of complications, such as nonunion and osteonecrosis, after femoral neck fractures in young patients have been reported to be as high as 86 percent. Treatments such as osteotomy, muscle-pedicle bone grafting, nonvascularized bone grafting, and vascularized bone grafting have reported variable results. Based on the results reported in this study, vascularized fibular bone grafting compares favorably with a high union rate (91 percent initially, 100 percent after secondary procedures) and successful long-term salvage of the femoral head in 91 percent of the patients. Free vascularized fibular bone grafting represents a promising solution for this difficult problem.

イヌ下顎における血管柄付再植骨および遊離再植骨へ埋入したインプラント周囲の骨形成過程に関する研究

The objective of this study was to investigate the characteristics of osteogenesis around dental implants in both vascularized and nonvascularized bone grafts. Vascularized bone grafts were nourished by inferior alveolar vessels providing medullary blood flow to the mandibles of adult dogs. Titanium implants were placed into the bone grafts and normal mandibles. The time course of osteogenesis around the implants was observed histologically from 2 to 24 weeks after operation. Specimers stained with Stevenel's blue and Van Gieson-picrofuchsin stains and fluorescently labeled specimens were examined with a confocal laser scanning microscope. Implant-bone contact rates were determined.In vascularized bone grafts, new bone formation was evident all around the implants at 2 weeks postoperatively. New bone became compact with the passage of time. These processes of new bone formation were similar to those of normal mandibles.In cortical bone of vascularized bone grafts, bone resorption was recognized. However, bone remodeling was found at an early stage, suggesting that implants could be placed into vascularized bone grafts immediately after the primary operation.In nonvascularized bone grafts, bone resorption and remodeling occurred from the outside of cortical bone. New bone formation around implants was found at 8 weeks postoperatively. The implant apex was encapsulated by fibrous tissue at 24 weeks postoperatively. The results suggest that simultaneous implantation with free bone grafting requires a long time for bony linkage and that encapsulation of implants by fibrous tissue may occur in nonvascularized bone grafts.

SCAPHOID NONUNION

The wrist surgeon must be conversant with the many methods of treating scaphoid nonunions. Cancellous bone grafting combined with K-wire fixation is a relatively straightforward technique that has been shown in several studies to predictably produce healing of scaphoid nonunions. Although there may be a trend toward early use of vascularized bone grafts for the treatment of scaphoid nonunions, it would seem reasonable to reserve that procedure for cases in which the vascular supply to the scaphoid fragments is compromised, and for which there is little hope that a nonvascularized bone graft will succeed.

Nonvascularized Bone Grafts for Osteonecrosis of the Femoral Head: Current Concepts and Techniques

For the past 30 years, nonvascularized bone grafts have been used in the treatment of osteonecrosis of the femoral head. Originally, various tibial, fibular, or iliac crest grafts were introduced through a core track into the femoral head. These produced less than optimal long-term results. More recently, various grafts have been used through windows made in the femoral neck or head to more directly replace the dead bone and support the collapsing segment. Results of these recent techniques are promising and may be further improved in the future by pharmacologic agents that enhance bone healing.

Revascularized tissue transfer for the repair of complex midfacial defects in oncologic patients

Purpose: This study reviews the author's experience with revascularized tissue transfer for the repair of complex midfacial defects in oncologic patients. Patients and Methods: Fifteen oncologic patients who had received vascularized tissue repair of combined skeletal and soft tissue defects during 1991 to 1999 were reviewed. The mean postoperative interval was 50.2 months. Primary reconstruction was accomplished by vascularized soft tissue repair alone in 1 case, an osteocutaneous scapula graft in 1 case, and by vascularized soft tissue and nonvascularized bone grafts in 3 cases. Secondary reconstruction with nonvascularized bone after vascularized soft tissue transfer was done in 3 cases, and vascularized secondary reconstructions with composite flaps were performed in the remaining 7 cases. Patients were examined for closure of oronasal or oroantral perforations and restoration of midfacial contour. The results were categorized as good, fair, and poor, and were related to the type and timing of the restoration. Results: One flap loss was encountered and one compromised flap was salvaged. Secondary nonvascularized skeletal reconstructions after vascularized soft tissue transfer were susceptible to infectious complications caused by voids, and they did not provide adequate skeletal contour in higher-order defects. Contour restoration was estimated to be good in 9 patients, fair in 3, and poor in 3. Poor results were limited to secondary reconstructions. Conclusion: It is concluded that the skeletal repair of the midface frame should be done primarily, as far as possible. If the orbital frame can be preserved, primary repair by vascularized soft tissue alone may be sufficient, with secondary restoration of the alveolar crest with nonvascularized bone grafts. Complex midfacial defects of types IV and V according to Wells and Luce require multistep procedures to accomplish all goals of midfacial reconstruction. © 2000 American Association of Oral and Maxillofacial Surgeons

A classification system and algorithm for reconstruction of maxillectomy and midfacial defects.

Maxillectomy defects become more complex when critical structures such as the orbit, globe, and cranial base are resected, and reconstruction with distant tissues becomes essential. This study reviews all maxillectomy defects reconstructed immediately using pedicled and free flaps to establish (1) a classification system and (2) an algorithm for reconstruction of these complex problems. Over a 5-year period, 60 flaps were used to reconstruct defects classified as the following: type I, limited maxillectomy (n = 7); type II, subtotal maxillectomy (n = 10); type IIIa, total maxillectomy with preservation of the orbital contents (n = 13); type IIIb, total maxillectomy with orbital exenteration (n = 18); and type IV, orbitomaxillectomy (n = 10). Free flaps (45 rectus abdominis and 10 radial forearm) were used in 55 patients (91.7 percent), and the temporalis muscle was transposed in five elderly patients who were not free-flap candidates. Vascularized (radial forearm osteocutaneous) bone flaps were used in four of the 60 patients (6.7 percent) and nonvascularized bone grafts in 17 (28.3 percent). Simultaneous reconstruction of the oral commissure using an Estandler procedure was performed in 10 patients with maxillectomy and through-and-through soft-tissue defects. Free-flap survival was 100 percent, with reexploration in five of 55 patients (9.1 percent) and partial-flap necrosis in one patient. Seven of the 60 patients (11.7 percent) had systemic complications, and four died within 30 days of hospitalization. Fifty patients had more than 6 months of follow-up with a mean time of 27.7 (+/- 15.6) months. Postoperative radiotherapy was administered in 32 of these patients (64.0 percent). Chewing and speech functions were assessed in 36 patients with type II, IIIa, and IIIb defects. A prosthetic denture was fixed in 15 of 36 patients (41.7 percent). Return to an unrestricted diet was seen in 16 patients (44.4 percent), a soft diet in 17 (47.2 percent), and a liquid diet in three (8.3 percent). Speech was assessed as normal in 14 of 36 patients (38.9 percent), near normal in 15 (41.7 percent), intelligible in six (16.7 percent), and unintelligible in one patient (2.8 percent). Globe and periorbital soft-tissue position was assessed in 14 patients with type I and IIIa defects. There were no cases of enophthalmos, and one patient had a mild vertical dystopia. Ectropion was observed in 10 of 14 patients (71.4 percent). Oral competence was considered good in all 10 patients with excision/reconstruction of the oral commissure; however, two patients (20 percent) developed microstomia after receiving radiotherapy. Aesthetic results were evaluated at least 6 months after reconstruction in 50 patients. They were good to excellent in 29 patients (58 percent) for whom cheek skin and lip were not resected, and poor to fair (42 percent) when the external skin or orbital contents were excised. Secondary procedures were required in 16 of 50 patients (32.0 percent). Free-tissue transfer provides the most effective and reliable form of immediate reconstruction for complex maxillectomy defects. The rectus abdominis and radial forearm flaps in combination with immediate bone grafting or as osteocutaneous flaps reliably provide the best aesthetic and functional results. An algorithm based on the type of maxillary resection can be followed to determine the best approach to reconstruction.

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

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

Long-Term Remodeling of Vascularized and Nonvascularized Onlay Bone Grafts: A Macroscopic and Microscopic Analysis

The present study was performed to compare vascularized and nonvascularized onlay bone grafts to investigate the potential effect of graft-to-recipient bed orientation on long-term bone remodeling and changes in thickness and microarchitectural patterns of remodeling within the bone grafts. In two groups of 10 rabbits each, bone grafts were raised bilaterally from the supraorbital processes and placed subperiosteally on the zygomatic arch. The bone grafts were oriented parallel to the zygomatic arch on one side and perpendicular to the arch on the contralateral side. In the first group, vascularized bone grafts were transferred based on the auricularis anterior muscle, and in the second group nonvascularized bone grafts were transferred. Fluorochrome markers were injected during the last 3 months of animal survival, and animals were killed either 6 or 12 months postoperatively. The nonvascularized augmented zygoma showed no significant change in thickness 6 months after bone graft placement and a significant decrease in thickness 1 year after graft placement (p < 0.01). The vascularized augmented zygoma showed a slight but statistically significant decrease in thickness 6 months after graft placement (p < 0.003), with no significant difference relative to its initial thickness 1 year after graft placement. In animals killed 6 months after bone graft placement, both the rate of remodeling and the bone deposition rate measured during the last 3 months of survival were significantly higher in the vascularized bone grafts compared with their nonvascularized counterparts (p < 0.02). By 1 year postoperatively, there were no significant differences in thickness, mineral apposition rate, or osteon density between bone grafts oriented perpendicular and parallel to the zygomatic arch. These findings indicate that the vascularity of a bone graft has a significant effect on long-term thickness and histomorphometric parameters of bone remodeling, whereas the direction of placement of a subperiosteal graft relative to the recipient bed has minimal effect on these parameters. In vascularized bone grafts, both bone remodeling and deposition are accelerated during the initial period following graft placement. Continued bone deposition renders vascularized grafts better suited for the long-term maintenance of thickness and contour relative to nonvascularized grafts.

Rehabilitation with dental implants of oral cancer patients

The aim of this study was to evaluate the risks and complications of rehabilitation with dental implants after tumour surgery and radiotherapy. After a disease-free survival of 18 months, 29 patients who had undergone oral cancer treatment were rehabilitated with dental implants. The complication rate of implants in irradiated, non-irradiated and grafted bone was analyzed at least 3 years after implant placement. In the healing period, 28.6% of the implants in irradiated bone and 8.4% in non-irradiated bone showed soft tissue complications. Of the implants, 26.7% in the irradiated and 14.7% in the non-irradiated mandibular bone were lost in the first 36 months after placement. Thirty-one point two percent of implants inserted in non-irradiated bone grafts were affected and did not osseointegrate. Of 109 inserted implants, 70 were suitable for prosthetic rehabilitation. There are high complication rates after implant placement in oral cancer patients. Irradiation adversely affects soft tissue healing. Osseointegration is frequently disturbed, especially when implants were placed in non-vascularized bone grafts.

Vascularized bone flaps versus nonvascularized bone grafts for mandibular reconstruction: An outcome analysis of primary bony union and endosseous implant success

Background Functional restoration following resection or traumatic injury to the mandible depends on the reliability of the bony reconstruction to heal primarily and support endosseous implants. Although vascularized bone flaps (VBF) and nonvascularized bone grafts (NVBG) are both widely used to reconstruct the mandible, indications for each remain ill-defined. The purpose of this study was to compare bone graft/flap healing and success of implant placement in patients reconstructed with VBF versus NVBG. Methods Over the past 10 years, 75 consecutive mandibular reconstructions were performed (26 free bone grafts, 49 vascularized bone flaps). Etiology of the defect, history of irradiation, bone defect size, number of operations, graft/flap success, and dental implant success rates were determined and compared. Bone graft/flap success was defined as complete bony union. Implant success was defined as complete osseointegration. Mean follow-up was 3 years. Results Free flaps were used primarily for malignant disease (78%, 38/49). Bone grafts were used primarily for benign disease (88%, 23/26). History of prior irradiation: 11% (3/26) NVBG versus 45% (22/49) VBF. Length of bony defect (mean): 8.1 cm NVBG versus 9.4 cm VBF. Successful bony union, any size defect: 69% (18/26) NVBG versus 96% (47/49) VBF (p < .0005); lateral defects only: 75% (15/20) NVBG versus 100% (17/17) VBF (p < .05). Number of operations to achieve bony union (mean), any size defect: 2.3 NVBG versus 1.1 VBF (p < .001); lateral defects only: 1.9 NVBG versus 1.0 VBF (p < .005). Twenty-two patients (29%) had a total of 104 endosseous implants placed (NVBG: 8 patients, 33 implants; VBF: 14 patients, 71 implants). Immediate implants placed: 0/33 NVBG versus 54% (38/71) VBF. Overall implant success: 82% (27/33) NVBG versus 99% (70/71) VBF (p < .0001). Implant success in VBF patients with a history of RT: 100% (15/15). Conclusions Despite the fact that patients reconstructed with VBFs were older, had larger defects, and were treated primarily for malignant disease and therefore had a higher incidence of irradiation to the affected mandible than in patients treated with NVBGs, the incidence of bony union was higher, requiring fewer operations to achieve union, and the implant success rate was significantly greater than for NVBG patients. Results were similar when considering lateral defects only. Based on these results, VBFs are indicated in most cases of mandibular reconstruction; NVBGs are effective for short bone defects (<5–6 cm), in nonirradiated tissue, and/or in patients determined to be too medically compromised to tolerate the additional operative time required for a free-flap reconstruction. © 1999 John Wiley & Sons, Inc. Head Neck 21: 66–71, 1999.

Experimental study on vascularized island pedicle bone graft: Bony fusion between the graft and the recipient floor

To evaluate the process of bony fusion between the recipient floor and the bone graft, where a muscle sleeve has been interposed, an experimental model for a vascularized island pedicle bone graft was prepared using rats. The proximal two thirds of the tibia pedicled with the popliteal artery and vein was collected to be used as a vascularized bone. This was onlay grafted to the femur of the same limb in such a manner that the muscle sleeve was interposed between the bone graft and the recipient floor. The animals subjected to this procedure were designated as the vascularized island pedicle bone graft group (hereafter called group V, n = 32). In another group, vascular pedicles were interrupted by ligation and the animals were subjected to nonvascularized bone graft (hereafter called group N, n = 32). In the third group, an appropriate amount of bone chips was transplanted throughout the length of the grafted floor; then the animals were subjected to additional vascularized island pedicle bone graft (hereafter called group B, n = 13). In groups V and B, the vascularized bone graft formed new bone at the site where the bone graft faced the recipient floor 6 weeks after surgery. Hypertrophy of the bone graft was noted. Bony fusion at the section where a muscle sleeve had been interposed was recognized only in group B. Chondrocytes were found around the free bone graft, suggesting chondrocyte participation in osteogenesis. In group N, the bone graft had been absorbed and no bony fusion was recognized between the bone graft and recipient floor in any of the samples. These findings imply that it is important to minimize the size of the muscle sleeve attached to the vascularized island pedicle bone graft and add free bone chips around the grafted bone to assure bony fusion between a vascularized bone graft and the recipient floor in clinical practice. © 1999 Wiley-Liss, Inc. MICROSURGERY 19:239–246 1999

Experimental study on vascularized island pedicle bone graft: bony fusion between the graft and the recipient floor.

To evaluate the process of bony fusion between the recipient floor and the bone graft, where a muscle sleeve has been interposed, an experimental model for a vascularized island pedicle bone graft was prepared using rats. The proximal two thirds of the tibia pedicled with the popliteal artery and vein was collected to be used as a vascularized bone. This was onlay grafted to the femur of the same limb in such a manner that the muscle sleeve was interposed between the bone graft and the recipient floor. The animals subjected to this procedure were designated as the vascularized island pedicle bone graft group (hereafter called group V, n = 32). In another group, vascular pedicles were interrupted by ligation and the animals were subjected to nonvascularized bone graft (hereafter called group N, n = 32). In the third group, an appropriate amount of bone chips was transplanted throughout the length of the grafted floor; then the animals were subjected to additional vascularized island pedicle bone graft (hereafter called group B, n = 13). In groups V and B, the vascularized bone graft formed new bone at the site where the bone graft faced the recipient floor 6 weeks after surgery. Hypertrophy of the bone graft was noted. Bony fusion at the section where a muscle sleeve had been interposed was recognized only in group B. Chondrocytes were found around the free bone graft, suggesting chondrocyte participation in osteogenesis. In group N, the bone graft had been absorbed and no bony fusion was recognized between the bone graft and recipient floor in any of the samples. These findings imply that it is important to minimize the size of the muscle sleeve attached to the vascularized island pedicle bone graft and add free bone chips around the grafted bone to assure bony fusion between a vascularized bone graft and the recipient floor in clinical practice.

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.

Callotasis in nonvascularized periosteal bone grafts and the role of periosteum: a new contribution to the concept of distraction osteogenesis.

Bone lengthening by slow, progressive distraction has gained widespread acceptance. In this study we investigated the possibility of distraction osteogenesis in nonvascularized periosteal bone grafts, and assessed callus formation and callotasis by means of radiological and histological examination with the aim of determining the role of the periosteum. The process of distraction osteogenesis in nonvascularized bone grafts was studied histologically and radiologically in 22 growing rabbits. The metatarsal bone grafts taken from the rabbits were divided into two groups. Group 1 contained 15 bone grafts covered with periosteum and group 2 (the control group) contained 7 bone grafts without periosteum. These grafts were subjected to osteotomy and then placed in the lumbar pocket. After 10 days, distraction was started and continued at 0.5 mm per day for 10 days. Thus an elongation of 4 to 6 mm was achieved in both groups. Radiological examination was performed postoperatively and after 10, 15, 20, and 30 days of starting the distraction. Histological examination was performed after 15, 20, and 30 days. Radiologically, progressive calcification and, histologically, both intramembranous and endochondral ossification were detected in group 1. However, in the control group (group 2), bone lengthening failed. Our study demonstrated the possibility of distraction osteogenesis in periosteal bone grafts, and provides information regarding the importance of periosteum as well as its osteogenic capacity.

Reconstruction of a large mandible defect utilizing a full-thickness vascularized calvarial bone graft

Historically, mandibular reconstruction has always been a challenging problem. Various methods have been used including alloplasts such as stainless steel and titanium plates, trays filled with bone fragments, vascularized and non-vascularized bone grafts [1, 2]. Most methods have had variable success until the advent of microsurgical techniques. With the high success rate now obtainable utilizing free tissue transfer, mandible reconstruction has become a procedure with a more predictable outcome and most other reconstructive methods have now been abandoned. In spite of this, clinical situations do arise, such as with the case presented, where for one reason or another, microvascular techniques are either not available, not applicable or have failed. A case of mandibular reconstruction using a vascularized full-thickness calvarial bone graft is presented in which the end result was very satisfactory, both aesthetically and functionally.

Treatment of osteonecrosis of the femoral head with free vascularized fibular transfer.

Thirty-one free vascularized fibular bone grafts were performed for treatment of osteonecrosis of the femoral head in 26 patients. Twenty-four men and 2 women ranged in age from 16 to 48 years (mean, 32 years). Twenty-one patients had unilateral disease. Five patients had bilateral disease and underwent staged bilateral free vascularized fibular grafts 3 months apart. Associated etiological factors included alcohol (9 patients), steroid use (7 patients), and trauma (1 patient). The condition was considered idiopathic in the remaining 9 patients. Radiological staging by Ficat included stage I in 1 hip, stage II in 15 hips, stage III in 14 hips, and stage IV in 1 hip. A skin island flap was used for monitoring purposes to check the patency of blood flow to the grafted fibula. One flap failed by venous occlusion and was left as a nonvascularized bone graft. Thirty hips were followed. Pain was relieved in 28 hips (93.3%) and aggravated in 2 hips (6.7%). On radiographic evaluation, 26 hips (86.7%) demonstrated excellent preservation of the femoral head contour. Progressive collapse of the femoral head (>1-2 mm) occurred in two hips, with 1-mm depression in one hip with stage III disease and 2-mm collapse in one hip with stage IV disease. Follow-up ranged from 12 to 40 months (mean, 21 months). In conclusion, even in this relatively short follow-up period, the free vascularized fibular bone graft is an excellent treatment modality for preserving the femoral head and relieving symptoms in patients with osteonecrosis of the femoral head.