Osteomyocutaneous Flap Research Articles

Lymph Node Inclusion in a Modified Osteomyocutaneous Allograft for Vascularized Composite Allotransplantation: Establishment and Feasibility Assessment in a Pig Model.

Representative translational animal models play a key role in vascularized composite allotransplantation (VCA) research. A composite porcine hindlimb flap, previously described, is a relevant preclinical model. However, its bulkiness and the absence of critical immunologic tissues make it less suitable for investigating the unique immunologic features of VCA. We aimed to further develop this model by reducing its bulkiness and by including donor-draining lymph nodes. We conducted an anatomic study by harvesting 11 porcine osteomyocutaneous flaps (4 conventional and 7 modified techniques), which were characterized by computed tomography. Furthermore, 8 allotransplantations were performed in Swiss landrace pigs. After the procedure, animals were assigned to a model development and control group (N = 4 per group). No immunosuppression was given, and animals were followed up until grade 3 rejection. With the modified technique, the flap weight was significantly reduced with a mean weight of 831 g, corresponding to 1.8% total body weight versus 1710 g in the conventional technique, representing 4.2% of total body weight (P < 0.0001). The muscle/bone ratio was reduced from 8.24 (conventional) to 2.92 (modified), (P = 0.03). Histologically, graft-draining lymph nodes showed typical changes related to rejection and no signs of ischemia after in vivo transplantation. By modifying the surgical technique, the bulkiness of the flap was markedly reduced, without impairing its vascularization and reliably including vascularized graft-draining lymph nodes. Our modified VCA model in the pig presents distinct advantages for surgery as well as immunologic analysis, warranting a large-scale use for experimental reconstructive transplantation studies.

Delayed maxillary reconstruction following mucormycosis: A comprehensive analysis of surgical strategies and outcomes

Study designThis study is a prospective observational study conducted over two years from December 2020 to March 2023 at the Department of Plastic and Reconstructive Surgery. ObjectiveTo evaluate the outcomes of delayed reconstruction in patients with maxillectomy defects post-COVID-19 associated mucormycosis, focusing on safety, morbidity, and aesthetic results. MethodsFifty patients with post-COVID-19 mucormycosis and maxillectomy defects without skin involvement were included. These patients underwent radical debridement and were treated with Amphotericin B followed by Posaconazole therapy until clinical and radiological resolution of the disease. Reconstruction was performed after a minimum of six months post-maxillectomy. Flaps used for reconstruction included the radial forearm free flap (RAFF), anterolateral thigh flap (ALT), and free fibula osteomyocutaneous flap, planned using a 3D-printed model. Follow-up was conducted weekly for the first month and monthly for the next two months, with semiannual visits thereafter. ResultsOf the 50 patients, 42 % were male, and 58 % were female, with a mean age of 43 ± 8.75 years. Most patients (88 %) were diabetic. Maxillectomy defects were categorized as type IIA, IIB, IIIA, IIIB, and IV based on the Cordeiro classification. Four flaps (8 %) required re-exploration, with three salvaged. Complications included marginal flap necrosis (4 %) and oro-nasal fistula (2 %). The average hospital stay was six days, extended to ten days for re-explored cases. Flap dimensions varied with the largest being 62 cm² for the free fibula flap. ConclusionsDelayed reconstruction using free flaps in patients with post-COVID-19 mucormycosis maxillectomy defects without skin involvement is a safe approach with minimal morbidity. This method allows confirmation of disease resolution before major reconstructive surgery, resulting in excellent aesthetic and functional outcomes.

Use of 3D-Printed Implants in Complex Foot and Ankle Reconstruction.

Treatment of traumatic critical-sized bone defects remains a challenge for orthopaedic surgeons. Autograft remains the gold standard to address bone loss, but for larger defects, different strategies must be used. The use of 3D-printed implants to address lower extremity trauma and bone loss is discussed with current techniques including bone transport, Masquelet, osteomyocutaneous flaps, and massive allografts. Considerations and future directions of implant design, augmentation, and optimization of the peri-implant environment to maximize patient outcome are reviewed.

Mimicking Clinical Rejection Patterns in a Rat Osteomyocutaneous Flap Model of Vascularized Composite Allotransplantation

IntroductionGraft loss in vascularized composite allotransplantation (VCA) is more often associated with vasculopathy and chronic rejection (CR) than acute cellular rejection (ACR). We present a rat osteomyocutaneous flap model using titrated tacrolimus administration that mimics the graft rejection patterns in our clinical hand transplant program. Comparison of outcomes in these models support a role for ischemia reperfusion injury (IRI) and microvascular changes in CR of skin and large-vessel vasculopathy. The potential of the surgical models for investigating mechanisms of rejection and vasculopathy in VCA and treatment interventions is presented. Materials and MethodsFour rodent groups were evaluated: syngeneic controls (Group 1), allogeneic transient immunosuppression (Group 2), allogeneic suboptimal immunosuppression (Group 3), and allogeneic standard immunosuppression (Group 4). Animals were monitored for ACR, vasculopathy, and CR of the skin. ResultsTransient immunosuppression resulted in severe ACR within 2 wk of tacrolimus discontinuation. Standard immunosuppression resulted in minimal rejection but subclinical microvascular changes, including capillary thrombosis and luminal narrowing in arterioles in the donor skin. Further reduction in tacrolimus dose led to femoral vasculopathy and CR of the skin. Surprisingly, femoral vasculopathy was also observed in the syngeneic control group. ConclusionsTitration of tacrolimus in the allogeneic VCA model resulted in presentations of rejection and vasculopathy similar to those in patients and suggests vasculopathy starts at the microvascular level. This adjustable experimental model will allow the study of variables and interventions, such as external trauma or complement blockade, that may initiate or mitigate vasculopathy and CR in VCA.

Indications and Outcomes of a Tibial Turn-up Procedure: A Case Series and Review of the Literature

Background: Treatment options for distal femoral bone loss resulting from malignancy, infection, or trauma can be grouped into limb salvage techniques versus amputation. A vascularized osteomyocutaneous flap using the ipsilateral tibia—a tibial turn-up procedure—can be used to restore femoral length for high above-knee amputations in both the primary and revision setting. We report 3 patients treated with this procedure. Purpose: To describe the treatment algorithm and functional outcomes of patients who have undergone a tibial turn-up procedure and to highlight its viability when considering surgical options for the treatment of distal femoral primary bone and soft tissue malignancy and in cases of severe trauma, infection, or implant failure. Patients and Methods: Three patients ages 21 to 56 years old treated with tibial turn-up as a salvage procedure for failed limb sparing techniques were followed for 1.5 to 3.5 years postoperatively. One was treated for recalcitrant chronic distal femur osteomyelitis, 1 for aseptic loosening of distal femoral replacement, and 1 for infected distal femoral replacement. Radiographic and functional outcomes including prosthetic use, ambulatory status, and current activity level were reported. Results: At a minimum 1.5-year follow-up, all 3 patients achieved bony union and were ambulatory with prosthetics without the use of additional gait aids. Conclusions: Tibial turn-up is an effective treatment option in the setting of distal femoral bone loss and/or limb salvage complications, providing good functional outcomes with a single durable surgery.

Functional Chimeric Double-barrel Fibula and Reinnervated Peroneus Brevis Osteomyocutaneous Flap for One-stage Forearm Reconstruction.

Reconstructing a mangled limb is complex and requires expertise in both bone and soft-tissue reconstruction, particularly when there is significant muscle loss. Typically, multistage surgery is necessary, starting with soft-tissue coverage, followed by bone grafting and tendon transfers. Sometimes, microsurgical techniques such as vascularized bone grafts and free functional muscle transfers are necessary, especially when there is a bone defect of over 6 cm; the soft-tissue environment is infected, scarred, or poorly vascularized; or there are extensive musculotendinous injuries. We treated a 34-year-old man who had a crushed left forearm resulting in an 18 × 8 cm open wound, 5-cm radius and 7-cm ulna bone defects, loss of the extensor pollicis longus and brevis muscles, and extensive injuries to the other musculotendinous structures of the forearm. To accomplish a one-stage reconstruction, we used a chimeric fibula osteomyocutaneous flap that included a 20 × 10 cm skin flap, peroneus brevis muscle with its motor nerve, and two segments of fibula. The proximal and distal fibula segments were used for ulnar and radial bone reconstruction, respectively, preserving forearm supination and pronation. The peroneus brevis tendon was sutured to the extensor pollicis longus tendon, and its motor nerve was coaptated with the posterior interosseous nerve to restore thumb extension. The skin flap provided complete coverage of all exposed bone and tendon structures. At the 12-month follow-up, the patient regained full extension of the thumb, and there were no difficulties with forearm supination and pronation or with foot eversion and plantar flexion at the donor leg.

Reconstruction of complex oro-mandibular defects by four different modifications of free fibula osteomyocutaneous flap: A prudent alternative to multiple flaps

Resection of advanced oral squamous cell carcinoma results in complex oro-mandibular defects involving external skin, oral mucosa, and bone. Reconstruction of such defects by a single free fibula flap (FFF) is limited by the lack of soft tissue bulk and adequate skin paddle for both intra- and extra-oral coverage. In this study, the reconstruction of large defects was achieved by four modifications of free fibula osteomyocutaneous flap as an alternative to multiple flaps. In this prospective study, 29 patients with complex oro-mandibular defects were reconstructed by FFF from December 2018 to October 2020. Reconstruction was done with any one of the four FFF modifications involving large proximal skin paddle from lateral leg: Strip de-epithelialization (De-Ep), chimeric bipaddle (Ch-Bp), muscle orally and skin extra-orally (Mo-Se), and double microvascular (Db-Mi). Outcome variables assessed were functional and esthetic results, early/late complications, donor site morbidity, and operative time. An algorithm based on Cordeiro's classification is proposed to assist in the selection of appropriate FFF modification. Among 29 patients, De-Ep was used in 13, Ch-Bp in 8, Mo-Se in 7, and Db-Mi in 1 case. None of the flaps underwent total loss. Two cases required re-exploration. The median operative time was 775min. Wound dehiscence and oro-cutaneous fistula were common early and late complications, respectively. Partial split skin graft loss (SSG) was the most common donor site morbidity. Functional and facial aesthetics were acceptable at the end of follow-up. Specific FFF modifications can be recommended in selected scenarios. It is reliable for single-stage reconstruction with satisfactory esthetic and functional outcomes. When used for reconstruction in first primary tumors, the second donor site is preserved, which can prove valuable in the event of a recurrence or second primary.

Free fibula osteomyocutaneous flap with lateral supramalleolar and soleus muscle flap—a novel chimeric flap combination

Free fibula osteomyocutaneous flap with lateral supramalleolar and soleus muscle flap—a novel chimeric flap combination

Reconstruction of Foot and Ankle Defects Using Free Lateral Arm Flap: A Retrospective Review of Its Versatile Application.

Background Successful reconstruction of the feet and ankles remains challenging due to limited quantities of soft tissue and laxity. The free lateral arm flap (LAF) is an alternative to conventional flaps and has been widely used due to advancements in its flap characteristics. This study is aimed at utilizing the advantages of this flap to validate its increased applications for foot and ankle defects. Methods Twenty patients with various LAF types between May 2011 and May 2020 were enrolled. Clinical data was retrospectively collected, and defect sites were classified according to the subunit principle. We utilized various LAF types, such as LAFs with sensate, extended, osteomyocutaneous, or myocutaneous flaps, as necessary. A two-point discrimination test was performed, and results were statistically compared between flaps. Results Among the diverse etiologies of skin defects, chronic inflammation was the most common cause of defects. Various LAF types, including LAFs with fasciocutaneous, extended fasciocutaneous, musculocutaneous, and osteomyocutaneous flaps, were used. The versatility of free LAF helped successfully cover various defects in all cases. Results of the two-point discrimination test were statistically significant between groups. Conclusions Free LAF is a unique soft tissue free flap that is more versatile than other flaps, allowing flaps to be continuously modified and applied to various foot and ankle defects under different clinical conditions.

Anterolateral thigh osteomyocutaneous flap in head and neck: Lessons learned

Concerns regarding iatrogenic femur fracture may deter adoption of the anterolateral thigh osteomyocutaneous (ALTO) flap as an alternative reconstructive technique for large composite defects of the head and neck. We describe the evolution of our experience with this flap and the lessons learned in femur management. Records from a prospective database (July 2009-January 2020) were reviewed to identify patients with composite osseous free tissue reconstructions. Venous thromboembolic events (VTE), femur fracture, estimated blood loss (EBL), procedure time, blood transfusions, and length of stay (days) were compared for ALTO flaps prior to and after the adoption of intramedullary fixation protocol. ALTO represented 10.5% (n=23) of total osseus (n=219) flaps. For large composite reconstructions with either ALTO flap, double flap (n=2), or subscapular mega flaps (n=14), ALTO flaps were most frequently used (59%, n=23/59). There were no differences in operative time prior to and after implementation of prophylactic fixation [median (range): 5.4 (1.7-19.2) vs. 5.8 (1.7-15.0), p= .574]. Additionally, there were no differences in VTE, femur fracture, EBL, blood transfusion, or length of stay (p> .05) with adoption of prophylactic intramedullary fixation. The ALTO flap represents a useful tool to consider in the armamentarium of reconstructive options for large through and through defects of the head and neck. In our experience, the ALTO flap is a reasonable alternative to subscapular or double flap reconstructions and especially in the setting of unusable fibular flaps or when bone need exceeds that available from the scapula.

Partial Heterotopic Hindlimb Transplantation Model in Rats.

Vascularized composite allotransplantations (VCA) represent the most advanced reconstruction option for patients without autologous surgical possibilities after a complex tissue defect. Face and hand transplantations have changed disfigured patients' lives, giving them a new aesthetic and functional social organ. Despite promising outcomes, VCA is still underperformed due to life-long immunosuppression comorbidities and infectious complications. The rat is an ideal animal model for in vivo studies investigating immunological pathways and graft rejection mechanisms. Rats are also widely used in novel composite tissue graft preservation techniques, including perfusion and cryopreservation studies. Models used for VCA in rats must be reproducible, reliable, and efficient with low postoperative morbidity and mortality. Heterotopic limb transplantation procedures fulfill these criteria and are easier to perform than orthotopic limb transplants. Mastering rodent microsurgical models requires solid experience in microsurgery and animal care. Herein is reported a reliable and reproducible model of partial heterotopic osteomyocutaneous flap transplantation in rats, the postoperative outcomes, and the means of prevention of potential complications.

Clavicle Survival as a Free Bone Graft: A Case Report of Minor Modification Added to Pectoralis Major Flap

Introduction: Reconstruction of the surgically created defects in the head and neck regions is a crucial step in the patients’ treatment plan. Regarding the involved tissues, various flaps and grafts have been introduced in the literature. The pectoralis major myocutaneous flap (PMMF) is one of the most versatile flaps with many variations for providing more advantages. Also, when bone tissue is needed, it can be reconstructed via an osteomyocutaneous flap including rib, sternum, or clavicle. Case Presentation: In this article, a case of oral squamous cell carcinoma with the extension to facial structures and, then, reconstructed with PMMF was presented, in which a medial half of clavicle bone was resected and employed as a free bone graft. Conclusions: Sectioning clavicle not only increases the arc of rotation and mobility of the PMMF but also provides a new source of bone graft in the vicinity. Besides, the survival of the graft and integration with the native bone is noteworthy.

Osteomyocutaneous Free Fibula Flap Prevents Osteoradionecrosis and Osteomyelitis in Head and Neck Cancer Reconstruction.

Osteoradionecrosis (ORN) is one of the most severe complications of free fibula reconstruction after radiotherapy. The gold standard treatment of osteomyelitis involves extensive debridement, antibiotics, and sufficiently vascularized muscle flap coverage for better circulation. Therefore, we hypothesized that free fibula flap with muscle could decrease the risk of ORN. This study consisted of 85 patients who underwent reconstruction with free fibula flap in head and neck cancer by a single reconstructive surgeon at Kaohsiung Veterans General Hospital over a period of 19 years (1998-2016). Patients with postoperative adjuvant radiotherapy were included in the study and were grouped by either free fibula osteocutaneous flap or free fibula osteomyocutaneous flap (with flexor hallucis longus muscle), and the incidence of ORN was compared. Of the 85 patients, 15 were reconstructed with osteocutaneous fibula flap and 70 were with osteomyocutaneous fibula flap. The rate of ORN or osteomyelitis was significantly lower in the muscle group (18.6%, n = 13/70 vs. 46.7%, n = 7/15, p = 0.020, Chi-square test). Vascularized muscle transfer increases perfusion of surrounding tissues and the bone flap, thereby decreasing the incidence of osteomyelitis or osteonecrosis.

Three-way pectoralis major osteo-myo-cutaneous flap in oral cancer: An option revisited

While free flap is the standard of care for bony reconstruction of the mandible, complex oro-mandibular defects after oral cancer ablation require adequate skin and soft-tissue replacement for optimum functional results. We report a case of multifaceted oral cavity resection effectively reconstructed in single stage by the three-way pectoralis major osteomyocutaneous flap. The technical aspects, benefits, deficiencies, and literature review are discussed. In the background of multiple recurrences and comorbidities, this flap is a viable alternative and should be given due reconsideration in oral cancer surgery. This gains more relevance in the context of developing countries.

Reconstruction of Oromandibular Defect After Tumor Resection by Sternomastoid-clavicular Flap.

The study aims to evaluate sternocleidomastoid-clavicular osteo-myocutaneous flap (SCM-OMCF) for reconstruction of mandibular defects after tumor resection. In the period between 2010 and 2018, thirteen patients with primary mandibular tumors underwent mandibular resection and reconstruction with SCM-OMCF. Patients were followed up for 10 to 66 months. Hospital was 13 ± 4 days. All patients started fluid in the 2nd day. The mean time to start oral fluid was 7.5 ± 0.8 day. Four (30.8%) patients suffered from complications (infection and salivary leak in 1 case due to partial flap loss, donor wound dehiscence in 1 case, deep venous thrombosis in 1 case and chest infection in 1 case). None of our cases experienced motor disability. Two cases (15.9%) underwent reoperations. The overall aesthetic outcome was found excellent in 5 cases, satisfactory in 5 cases and fair in 3 cases. The functional outcomes were satisfactory. Tumor recurrences were detected in 2 (15.9%) patients. Two patients died during follow up within 2 years after 1st surgery due to local and distant recurrences. SCM-OMCF is a versatile, safe and simple technique for reconstructing mandibular defects less than 11 cm.

A Novel and Simple Technique of Reconstructing the Central Arch Mandibular Defects-a Solution During the Resource-Constrained Setting of COVID Crisis.

The current COVID 19 pandemic has a major impact on healthcare delivery globally. Oral cancer involving anterior arch of mandible is difficult to reconstruct and ideally, requires free fibular osteomyocutaneous flap. During this time of resource constraint situation, these free flaps are not a great choice, as it increases exposure of both patient and surgical team to the deadly virus. We are describing a novel method of reconstruction after resection of oral cancer involving anterior arch of mandible. In this new technique, we have reconstructed central arch defect by hanging bipaddle pectoralis major myocutaneous flap with orbicularis oris muscle using ethylene terephthalate suture. Operative time, early postoperative complications and early cosmetic and functional outcome were assessed. We have used this novel technique in eight patients of T4a oral cancer involving anterior arch of mandible and skin over chin. Mean operative time was 180 min. One patient had minor flap loss with surgical site infection (Clavien-Dindo grade I). In all patients, we were able to discharge all patients on eighth postoperative day. Cosmetic outcome and functional outcomes were mostly satisfactory. All patients were able to oppose their lips without any oral incompetence and drooling. Tongue mobility was good. There was no incidence of ‘Andy Gump deformity’. This is a feasible option for reconstructing anterior arch defect in resource- and time-limited setting of COVID 19 pandemic. This technique can also be used in comorbid conditions where it is not advisable to do very long surgery.

Jaw reconstruction with vascularized fibular flap: The 11-year experience among 104 patients

BackgroundA vascularized fibular osteomyocutaneous flap with severe vascular crisis often results in serious consequences. This study aims to examine the clinical effect of non-vascularized fibular graft on patients with severe vascular crisis after reconstruction of the defect jaw with vascularized fibular osteomyocutaneous flap.Materials and methodsFrom December 2007 to December 2018, a total of 104 patients with jaw neoplasms that underwent reconstruction with free vascularized fibular flap were retrospectively analyzed; seven of these cases had postoperative vascular crisis during mandibular reconstruction.ResultsOf the seven cases with postoperative vascular crisis, the vascularized fibular flaps in three patients survived completely, thanks to early detection; two cases were completely necrotic and removed in the end, and the remaining two cases had severe vascular crisis after the removal of the soft tissue attached to the fibular flap. The non-vascular fibular grafts were retained regardless of the severe absorption after follow-ups for 25 and 69 months, respectively.ConclusionsIf vascular crisis occurs following jaw reconstruction with a vascularized fibular osteomyocutaneous flap, early re-surgical exploration effectively improves the salvage rate. In addition, when a severe vascular crisis occurs, the vascularized fibular flap can be changed to a non-vascular fibular graft to reconstruct the mandibular defect, thus avoiding the serious consequences resulting from the complete failure of fibular graft.

Reconstruction of Traumatic Defects of the Tibia With Free Fibula Flap and External Fixation.

Traumatic intercalary defects of the tibia may be effectively managed with the free fibula flap. However, any alteration of limb alignment with residual bony angular deformity of the tibia must be also addressed. We describe the use of the free fibula flap in conjunction with external fixation to allow residual deformity correction and patient mobilization ambulation during healing of the free flap. Retrospective medical record review was conducted of patients with segmental tibial defects greater than 7 cm who underwent reconstruction with fibula free flap and simple pin-bar external fixation, followed by conversion to 6-axis computer-assisted multiplanar circular ring external fixation to correct residual bony deformity. Outcomes analyses included free flap complications, return to the operating room, complications associated with the external fixation, bony union, correction of residual deformity, amputation rate, visual analog pain scales, and patient satisfaction. Eight patients (8 tibiae) underwent reconstruction. Mean tibial bone defect was 10.2 cm; all limbs had soft-tissue defects (mean size, 138 cm). Free fibula grafts were harvested as osteocutaneous or osteomyocutaneous flaps (average length, 12 cm). Complications included 1 delayed union and 3 (37.5%) patients readmitted for graft fracture. Ultimately, 100% of patients achieved graft union with satisfactory correction of residual limb deformity. Limb salvage rate was 100%. Management of segmental tibial bone loss utilizing initial simple external fixation and microsurgical reconstruction followed by application of computer-assisted circular external fixator may provide a reliable reconstructive protocol for posttraumatic tibial defects with residual bone malalignment.

Latissimus Dorsi-Rib Osteomyocutaneous Flaps for Composite Cranial Defects: A Case Series and Anatomical Study

PURPOSE: Latissimus dorsi-rib osteomyocutaneous flaps (LDRFs) are versatile in reconstructing compromised composite defects of the cranium. The flap restores the contour of the skull, protects the brain, and improves neurologic status. There are benefits to using autologous rib instead of alloplastic material; however, rib viability and flap success rely on adequate blood supply. Our aim was to present the outcomes of 6 patients treated with LDRF and provide an anatomical basis for this flap. METHODS: Six patients with cranial defects treated with LDRF were evaluated retrospectively. Defect size, etiology, previous reconstructive attempts, outcomes, and complications were assessed. Red latex was injected into the subscapular arterial system of 20 fresh cadaver sides. In the prone position, latissimus dorsi muscle was dissected from the ribs in a mediocaudal to superolateral direction to locate interconnecting vessels between the thoracodorsal and lateral posterior intercostal systems. The number, diameter and length of perforators, and distance from midline were measured. RESULTS: All patients had a history of ≥2 previous failed reconstructions. Defects were secondary to gunshot injury, post-CVA cranioplasty, postablation irradiation, and postfrontal intracranial hemorrhage cranioplasty. Three defects were reconstructed using 2 ribs, whereas the remaining 3 patients received 1 rib. A prolene mesh was used to fill in the donor site defects in 4 patients. Follow-up ranged from 6 to 35 months. All patients had stable reconstructions. Headache resolved in 2 patients after reconstruction, and neurologic status improved in 2 patients. An average of 13.75 perforators could be localized in each cadaveric latissimus dorsi muscle. No perforator was found for the seventh rib. Not all cadaver sides contained perforating vessels for the eighth and 12th ribs. The distance from the midline to the first perforator was not different between the ribs (P = 0.499). Perforator diameter and pedicle length tended to decrease at more inferior rib levels. The 10th rib (4.65 ± 2.01) followed by ninth rib (3.7 ± 1.63) had the highest number of perforators. The eighth and 12th ribs contained the least perforators. The eighth rib had the longest perforators (4.26 ± 1.52 cm). CONCLUSION: The LDRF can successfully address large composite cranial defects, provide support, and enhanced contour with negligible donor-site morbidity. The 10th followed by the ninth rib has the best vascular supply for this flap. If 2 ribs are considered for the flap, the ninth and 11th are recommended. If only 1 rib is necessary for reconstruction, the 10th is ideal.

Definition of Bone Transport from an Orthoplastic Perspective

Reconstruction of traumatic composite bone and soft tissue loss (TCBSTL) employs several approaches among which is the bone transport (BT). In this procedure a healthy bone segment is mobilized by means of an external fixator to bridge a bone gap. Mobilization of the bone segment entails advancement of the overlying soft tissue envelop altogether. Between the year 2000 and 2017 the authors have treated 150 cases of TBSTL using distraction histogenesis and external skeletal fixation in all cases. The procedure was performed in two modes, in the first group the transport was performed gradually by distraction-compression of the osteotomy and bone defect sites respectively. In the second group, the procedure was performed by acute shortening and re-lengthening (ASRL) technique. Skin grafts(STSG)were used in six cases (4%) and iliac crest bone graft(ICBG) in 42 cases (28%). No free vascularized tissue grafts were used in any case. No internal fixation was attempted in any case. A few problems have been met with during gradual bone transport, and were manageable without effect on the treatment course or final outcome. Based on our observations in this series, BT was defined as “Bone transport is an instrumented advancement of a local vascularized osteomyocutaneous flap to bridge bone and soft tissue defect either gradual or acute.” When perceived as an osteomyocutaneous flap, bone transport extends the umbrella of the reconstruction ladder to include cases where other procedures could not be safely employed. Bone transport, either gradual or acute, is a powerful tool in the armamentarium of Orthoplastic limb reconstruction.