Pedicled Vascularized Bone Graft Research Articles

Treatment of AVN-Induced Proximal Pole Scaphoid Nonunion Using a Fifth and Fourth Extensor Compartmental Artery as a Vascularized Pedicle Bone Graft: A Retrospective Case Series

Treatment of AVN-Induced Proximal Pole Scaphoid Nonunion Using a Fifth and Fourth Extensor Compartmental Artery as a Vascularized Pedicle Bone Graft: A Retrospective Case Series

Novel Approach to Difficult Spinal Reconstruction: Bilateral Simultaneous Rib and Iliac Crest Vascularized Bone Graft Spinoplastic Surgery

Summary: Pseudoarthrosis is a severe complication of spinal fusion surgery with occurrence rates as high as 35%–40%. Current options of revision surgery to correct pseudoarthrosis frequently carry high failure rates and risk of developing junctional kyphosis. Pedicled vascularized bone grafts (VBGs) are an innovative approach to boost spinal fusion rates via improving structural integrity and increasing the delivery of blood to the donor site. This versatile technique can be performed at different spinal levels without additional skin incisions and with minimal added operative time. Here we present the first bilateral rib and iliac crest VBG spinoplastic surgery performed to augment spinal fusion in a 68-year-old woman with distal junctional kyphosis and severe positive sagittal balance with low back and neck pain and significant difficulty standing upright. The patient had history of multiple spinal operations with preoperative CT imaging demonstrating loosening and pull out of L3 and fracture of L2 screws. She underwent two-stage surgical treatment involving anterior lumbar interbody fusion L3-S1 followed by removal of hardware, T4 to pelvis fusion with L2-3 prone lateral interbody fusion, and T11-S1 posterior column osteotomies. The surgery was augmented by bilateral rib and iliac crest VBGs performed by plastic surgery. At three-month follow-up the patient demonstrated functional improvement, being able to maintain upright posture and walk; was satisfied with the result of the surgery; and demonstrated no graft-related complications. In conclusion, utilization of pedicled VBGs is a novel, promising approach to augment spinal surgery in high risk patients.

The Outcome of Scaphoid Fracture Nonunion Managed by 1,2 Intercompartmental Supraretinacular Artery (1,2 ICSRA) Vascularized Bone Graft.

Scaphoid fracture is most often missed and mismanaged leading to scaphoid nonunion with or without avascular necrosis. When avascular necrosis of the proximal pole is confirmed with intraoperative evaluation, conventional bone graft is not enough. The treatment modalities are evolving day by day. The current trend is vascular bone grafting, which has shown good outcomes in terms of union and wrist function. Fifty patients with nonunion fracture of the scaphoid were treated with vascularized pedicle bone graft from the dorsum of the distal radius using the 1st and 2nd intercompartmental supraretinacular artery, from 2014 to 2022. Preoperative and postoperative clinical evaluation included pain, range of motion, grip strength, and satisfaction. The average follow-up period was 12 months. Among 18 patients, 14 were clinically improved after a mean follow-up period of eight weeks. Thirteen patients reported the absence of any discomfort, three patients reported slight discomfort after hard work, and two patients reported pain with light work. The wrist range of motion improved significantly, and the hand grip strength also improved. According to the modified Mayo wrist scoring chart, clinical results were rated as excellent in 24 cases, good in 19 cases, and poor in four cases. 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) is superficial to the extensor retinaculum and is a proper pedicle of vascularized bone graft due to the ease of visibility and dissection. The functional results and union rates were satisfactory in our study.

Vascularized versus non-vascularized bone grafting for scaphoid nonunion without avascular necrosis: a randomized clinical trial.

In this clinical trial, patients were randomized to receive a pedicled vascularized bone graft, based on the 1,2-intercompartmental supraretinacular artery, or a non-vascularized iliac crest graft. Fixation was done with K-wires. Union and time to union were assessed using CT scans at regular intervals. Twenty-three patients received a vascularized graft, and 22 received a non-vascularized graft. Thirty-eight patients were available for union assessment and 23 for clinical measurements. There were no significant differences in union incidence, time to union, incidence of complications, patient-reported outcome scores, or wrist mobility and grip strength at final follow-up between the treatment groups. Smokers were 60% less likely to achieve union, independent of graft type. When controlling for smoking, patients receiving a vascularized graft were 72% more likely to achieve union. Given our small sample size, results should be interpreted with caution.Level of evidence: I.

Comparison of clinical outcomes of autologous bone graft versus pronator quadratus pedicled vascularized bone graft in the treatment of scaphoid nonunion.

We aimed to compare the union rate and clinical outcome of autologous bone graft versus pronator quadratus vascularized pedicled muscle flap in treatment of scaphoid nonunion. Forty patients with a diagnosis of scaphoid nonunion who underwent unilateral pseudarthrosis surgery were included in this study. Notably, the scaphoid nonunion was unilateral, and the contralateral wrist was asymptomatic with normal function, per the physical and radiological examinations. Pronator quadratus vascularized pedicled muscle flap was used in 16 patients (group 1), and autologous bone graft was used in 24 patients (group 2). Patients were compared used Scapholunate angles, Natrass carpal height ratio and Mayo wrist score pre and postoperatively. Fifteen of the 16 (93.3%) patients in group 1 and 19 of the 24 (79.2%) patients in group 2 achieved bone union. Four of twelve patients in group 2 with avascular necrosis (AVN) and one of eight in group 1 with AVN were not able to achieve union. The group 2 (34%) had higher nonunion rate than group 1 (12%) in AVN patients. The scapholunat angle was significantly decreased and the Natress ratio was significantly increased postoperatively compared to the preoperative measurement in both group. There was no statistically significant difference in the postoperative measurement. The postoperative Mayo wrist score showed no statistically significant differences between both groups. The pronator quadratus vascularized pedicled muscle flap was superior to non-vascularized bone grafting in the treatment of scaphoid nonunion with AVN. However, management of the patients without avascular necrosis is not requiring the vascularized pedicled muscle flap technique.

Comparison of the functional and radiological outcomes of vascularized and non-vascularized bone graft options in the treatment of scaphoid nonunion.

Objectives This study aims to compare the functional and radiological outcomes of the patients with scaphoid waist nonunion treated with non-vascularized bone graft and vascularized bone graft options.Patients and methods Between January 2016 and February 2020, a total of 24 patients (22 males, 2 females; mean age: 30.6±9.4 years; range, 18 to 66 years) with scaphoid waist nonunion who were treated with vascularized or non-vascularized bone graft were retrospectively analyzed. Of these patients, eight were treated with iliac crest non-vascularized bone graft (IC-NBG), seven with vascularized free medial femoral condyle (MFC) graft, and nine with 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft (1,2-ICSRA-VBG). The grip strength, flexion, extension, radial deviation, ulnar deviation angles were measured and compared to the contralateral hand for functional outcomes. Union rates, the scaphoid height-to-length ratio, the lateral intrascaphoid angle (LISA) were evaluated for radiological outcomes. The Mayo Wrist Score, Visual Analog Scale (VAS) score, and Quick Disability of the Arm, Shoulder and Hand (Q-DASH) Questionnaire score were calculated.Results Union was observed in seven (87.5%) patients after IC-NBG, in six (85.7%) patients after MFC bone graft and nine (100%) patients in the treatment group with 1,2-ICSRA-VBG. There were no statistically significant differences among the IC-NBG, MFC and 1,2-ICSRA-VBG groups in terms of the union rates, the scaphoid height-to-length ratio, VAS score, Q-DASH score, grip strength and flexion, ulnar deviation, radial deviation angles after surgery (p>0.05). However, extension was statistically lower in the MFC group than IC-NBG and 1,2-ICSRA-VBG groups after surgery. The Mayo score was better in the IC-NBG group than MFC and 1,2-ICSRA-VBG, indicating a statistically significant difference (p<0.05).Conclusion Based on our study results, we suggest to use IC-NBG for scaphoid waist nonunion as the primary procedure, as the union rates are comparable with the MFC and 1,2-ICSRA-VBG techniques and it has advantages such as shorter operation time, easier technique, no special experience requirement, and better functional outcomes.

The Effect of Smoking on the Outcomes of Vascularized Bone Graft Surgery in Scaphoid Nonunion through Meta-analysis

Purpose: A vascularized bone graft is an option showing a good result to treat scaphoid nonunion. The analysis of the effects of smoking, which affects vascular and union of fracture, has been limited. We tried to analyze the effect of smoking on the outcomes of vascularized bone graft in scaphoid nonunion through meta-analysis Methods: Two researchers analyzed 923 papers searched for ‘scaphoid AND (vascularized OR vascularised OR flap OR pedicled)’ on MEDLINE and Embase (until November 2020). We selected 31 papers which contain that vascularized bone graft was performed for scaphoid nonunion, and the number or proportion of smokers could be confirmed. Through meta-regression analysis and subgroup analysis, whether the smoker’s rate had an effect on union rate, union period, functional score, imaging evaluation, range of motion, and complications rate was analyzedResults: A significant negative correlation between smoking and bone union rate was confirmed in pedicled vascularized bone grafting, and a significant positive correlation between smoking and bone union duration was confirmed in free vascularized bone grafting. Conclusion: It is necessary to have caution for nonunion when considering pedicled vascularized bone graft in smoking patients with scaphoid nonunion.

Vascularized Bone Grafting in the Treatment of Scaphoid Nonunion: A Clinical and Functional Outcome Study.

Background A malreduction or missed scaphoid fracture may lead to nonunion or avascular necrosis (AVN). The aim of this study was to analyze the radiological and clinical outcome of patients with scaphoid nonunion (SN), who were treated with 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft (1,2-ICSRA-VBG) fixed with K-wires or screws between 2014 and 2018. Methods Radiological assessment included posteroanterior, lateral, oblique, and angled posteroanterior projection. The wrist active joint range of motion was assessed with a universal goniometer, and grip and pinch strength with a dynamometer. The disabilities of the arm, shoulder and hand (DASH) questionnaire was used to evaluate functionality. Statistical analysis was performed using SPSS software (v16.0). Results A total of 68 patients (65 male) with a mean age 29.7 ± 8.5 years were evaluated in the study, and union was achieved in 55 (81%). A total of 45 (66%) patients had scaphoid waist fracture and 48 (71%) had AVN. Fixation was achieved with K-wires in 48 of the patients, and with screw in 20. The mean length of follow-up was 31.6 ± 14.6 (12-72) months. The mean radioulnar range of motion and DASH scores improved significantly after treatment ( p < 0.001, p ≤ 0.001). Conclusions The findings of this study showed that scaphoid unions can be treated successfully with high rates of union using the 1,2-ICSRA-VBG. This surgical technique requires special surgical experience. The functional outcome of patients improved after treatment, although smoking was found to be an important factor affecting functional results.

Pedicled vascularized versus non-vascularized bone grafts in the treatment of scaphoid non-union: a meta-analysis of comparative studies.

Whether pedicled vascularized bone grafts (PVBGs) are beneficial over non-vascularized bone grafts (NVBGs) still remains controversial. The aim of this study was to compare the clinical results of PVBGs and NVBGs for the treatment of scaphoid non-union. We conducted a meta-analysis of the published studies comparing outcomes of these two different surgical techniques for scaphoid non-union. Outcomes of union rate, time to union, functional results and re-operation rate were analysed. Seven studies including four randomized controlled studies and three retrospective comparative studies with 413 participants were identified fitting inclusion criteria. Meta-analysis showed that (i) union rate in PVBG groups was 1.13 times of NVBG groups (P=0.002); (ii) the PVBG groups reached bone union significantly earlier by 1.73 weeks (P < 0.01); (iii) there was no significant difference in functional results, including active range of motion, grip strength, Mayo Wrist Score and excellent and good rate (P > 0.05); and (iv) re-operation rate was similar between the two groups (P=0.65). Although the PVBG technique attains higher union rate and earlier union, this radiological advantage does not bring any functional benefits. In addition, PVBGs are of greater technical difficulty and need more operation requirements. Hence, clinicians should be cautious in electing PVBGs for treating scaphoid non-union.

Vascularized Bone Grafts for Spinal Fusion-Part 2: The Rib.

Pseudoarthrosis, or failure to achieve bony union, is a well-known complication of spinal fusion operations. Rates range from 5% to 40% and are influenced by both patient and technical factors. Patients who do not achieve complete fusion may experience a return or worsening of their preoperative pain. For patients with complicated pathologies, vascularized bone grafts (VBGs) have been shown to provide better outcomes than nonvascularized bone grafts (N-VBGs). To enhance an instrumented spinal fusion by the innovative technique presented herein that utilizes a rotated, pedicled VBG from the left eighth rib under the paraspinous musculature into the midlumbar posterolateral gutter. For posterior approaches, the rib can be easily accessed and rotated into the appropriate strut position. The rib is dissected out, identifying and preserving the neurovascular bundle medially. The rib is then tunneled medially and appropriately positioned as the spinal graft, with the curve providing anatomic kyphosis or lordosis, depending on the surgical location. It is then successfully fixated with plates and spinal screws. In our limited experience to date, vascularized rib grafting procedures augment fusion and reduce operating room time and bleeding compared to free flap procedures. No patients have experienced complications related to these grafts. Pedicled vascularized rib grafts can be utilized to provide the advantages of a vascularized bone flap in complicated pathologies requiring spinal fusion as far as the L2-L3 level, without the morbidity associated with free tissue transfer.

The results of pedicled vascularized bone grafts in the treatment of scaphoid nonunion

Objectives: Scaphoid nonunion still creates a big challenge for hand surgeons due to high failure rates after surgery, particularly in proximal pole fractures. The pedicled vascularized bone graft (VBG) is a valuable option to achieve union and good outcomes. This study aimed to analyze the clinical and radiological results of patients who underwent scaphoid fixation with pedicled VBG due to non-union of a scaphoid fracture. Methods: The patients who were operated due to scaphoid non-union and underwent fixation with pedicled VBG between 2017 and 2018 were reviewed retrospectively. The patients were evaluated both preoperatively and postoperatively. The clinical assessments included; the range of motion, grip strength, Mayo wrist score, and visual analogue scale (VAS) pain score. The presence of bony union was evaluated with direct radiographs. Results: Eight patients were included in the final analysis. Four patients who had waist non-union were reconstructed with volar pedicled VBG, while the other four patients with proximal non-union were reconstructed with dorsal 1,2 ICSRA pedicled VBG. The average age was 28.7 and the average follow-up was 12.3 months. The bony union was achieved in 7 patients at average 3.1 months with gain of both range of motion and grip strength. The average VAS pain score was improved from 6.8 to 2. The average Mayo wrist score was improved from 52.2 to 80.4. Conclusion: The application of pedicled VBGs harvested from the distal radius provides good clinical and radiological outcomes in the treatment of scaphoid non-unions.

Vascularized Rib Grafts to Augment Spinal Fusion: A Novel Approach

BACKGROUND: Pseudoarthrosis is a well-known complication following spinal fusion. Rates range from 5% to 40% and are influenced by both patient factors and technical factors. Patients with pseudoarthrosis may experience a return or worsening of their preoperative pain, which can significantly decrease quality of life. For patients with complex posterior column defects with either anterior or posterior columnar insufficiency, especially those receiving chemotherapy, radiation, predisposed to recurrent pseudarthrosis or infection, vascularized bone grafts (VBGs) have been shown to provide better outcomes than nonvascularized bone grafts (N-VBGs).1–5 The purpose of this study is to present an innovative pedicled rib VBG (R-VBG) that can be utilized to augment instrumented spinal fusion. METHODS: Following hardware placement for spinal fusion, an incision is made over the target rib. The intercostal muscle attachments to the superior border of the R-VBG are released, and the rib with its blood supply intact is bluntly dissected from the underlying pleura and inferior intercostal muscle attachments, protecting the subcostal vessels. Particular care is taken when separating the intercostal nerve from the subcostal vessels to prevent postoperative numbness and radicular pain. At the lateral limit of the dissection, the subcostal vessels were controlled, and the rib is cut distally and proximally. The R-VBG is then tunneled under the paraspinous muscles and placed along the posterolateral gutters of the spinal levels being augmented. The natural curvature of the rib is used to match the patients kyphosis/lordosis. The rib is cut down to size and fixated. RESULTS: To date, 7 R-VBGs have attempted. Of these 6 (86%) have been successfully harvested, all of which (100%) went on to achieve at least probable radiologic evidence of graft site fusion. CONCLUSION: The technique described for rotating a vascularized rib bone graft into the posterolateral space for spinal fusion as far as the L4/L5 joint space is an effective method for augmentation of spinal fusion in patients with complex spinal pathologies. Although additional data needs to be collected before true indications can be elucidated for this procedure, our preliminary prospective results suggest that this approach is relatively low risk, especially compared to free tissue transfer, and it has the benefit of providing well-vascularized, healthy bone to augment the fusion bed. REFERENCES: 1. Eastlack R, Dekutoski M, Bishop A, et al. Vascularized pedicled rib graft: a technique for posterior placement in spinal reconstruction. Spinal Disord Tech. 2007;20:610–615. 2. Bohl M, Mooney M, Catapano J, et al. Pedicled vascularized bone grafts for posterior occipitocervical and cervicothoracic fusion: a cadaveric feasibility study. Oper Neurosurg. 2018;15:318–324. 3. Bradford DS. Anterior vascular pedicle bone grafting for the treatment of kyphosis. Spine. 1980;5:318–323. 4. Bradford DS, Daher YH. Vascularised rib grafts for stabilisation of kyphosis. J Bone Joint Surg. 1986;68B:357–361. 5. Wilden JA, Moran SL, Dekutoski MB, et al. Results of vascularized rib grafts in complex spinal reconstruction. J Bone Joint Surg. 2006;88A:832–839.

Pronator quadratus pedicled bone graft for scaphoid non-unions

Scaphoid fractures frequently present with nonunion and proximal pole necrosis, the treatment of which is bone grafting. Pronator quadratus pedicled vascularized bone graft is an option especially in the setting of proximal pole necrosis. We describe our experience of managing such scaphoid non-unions using pronator quadratus pedicled vascularized bone graft. Six patients were managed using pronator quadratus pedicled vascularized bone graft following scaphoid fracture nonunion with proximal pole necrosis. All patients had good fracture healing and symptom resolution. Mild deficit in wrist extension was noted in all patients. Pronator quadratus pedicled vascularized bone graft is an attractive option for managing scaphoid nonunion. Lying adjacent to the fracture site, bone can be harvested and transferred without making any other incisions. This procedure introduces another source of blood supply to the fracture site and hence improves fracture healing.

How Long Should We Immobilize the Wrist after Vascularized Bone Grafting for the Treatment of Scaphoid Nonunion?

Background: Although vascularized bone grafting can effectively treat scaphoid nonunion, the optimal duration of the immobilization period after bone grafting is unclear. Therefore, we aimed to examine the difference in the union rate and range of motion between short and long immobilization periods and infer the optimal post-immobilization period after pedicled vascularized bone grafting for scaphoid nonunion treatment. Methods: A total of 23 wrists (21 men and 1 woman) with scaphoid nonunion treated using an intercompartmental supraretinacular artery pedicled vascularized bone graft were analyzed. We examined the difference in the union rate and range of motion between patients immobilized for less than 49 days (short immobilization group) and those immobilized for more than 49 days (long immobilization group). The range of motion of the wrist joint was measured before and after surgery. Patient outcomes were also assessed. Results: The overall union rate was 95.6%. A significant difference was found in postoperative extension and flexion between the two groups, but not in terms of the functional outcome. If the intraoperative fixation is solid, intraoperative proximal pole bleeding is confirmed, and the follow-up radiograph shows a normal healing process, we propose immobilization of the wrist for ≤ 7 weeks. Conclusions: The immobilization duration should depend on the solidity of intraoperative fixation and a satisfactory appearance on follow-up radiography: absence of a gap at the graft interface, surrounding lucency, or movement of the implant and displacement of the graft. If there are no signs of graft failure and fixation is solid, immobilization of the wrist for 7 weeks or less is recommended.

Gefäßgestieltes Beckenkammtransplantat zur Behandlung der Femurkopfnekrose

Illustration of anowadays only rarely performed operative procedure for the treatment of osteonecrosis of the femoral head to prevent or at least delay advanced arthrosis and the need for atotal hip replacement. The pedicled vascularized iliac bone graft is raised without the need for special microsurgical techniques and has less vascular complications often seen in free vascularized grafts. Early stages of osteonecrosis of the femoral head stagesII andIII according to the Association Research Circulation Osseous (ARCO) up to the detection of fracture lines (crescent sign) but without mechanical insufficiency. Osteonecrosis of the femoral head with collapse of the femoral head (ARCO stage ≥IIIB) and mechanical insufficiency. Patients who are noncompliant or anot able to take the weight off the operated leg. Patients who had radiotherapy or an operation on ipsilateral inguinal lymph nodes and patients who have vascular anomalies or severe arteriosclerosis. Debridement of the femoral head osteonecrosis and implantation of apedicled vascularized iliac bone graft. Free movement of the hip joint 4weeks after surgery. Outward rotation of the hip joint allowed after 3months and restriction of weight load on the operated leg for at least 3-6months postoperatively depending on the bony consolidation. Vascularized bone grafts for the treatment of femoral head necrosis show better clinical and radiological results than avascular bone grafts. Nevertheless, after 5years follow-up approximately 25% of the operated hips formerly in stageII show further progression of radiological necrosis. In stageIII all hips eventually show progress of femoral head collapse and the need of atotal hip replacement. Concerning the outcome of afree vascularized bone graft (fibula flap) compared to the pedicled vascularized graft from the iliac crest for treatment, the anatomically demanding area and ahigher complication rate should be considered even though the cancellous bone of the iliac crest is biologically ideal. Nowadays afree vascularized fibular graft is the most frequently used bone graft for treatment of femoral head necrosis.

The use of pedicled vascularized bone grafts in the treatment of scaphoid nonunion: clinical results, graft options and indications.

Scaphoid nonunion is a challenging situation for orthopaedic surgeons. Nonunion rate is especially high in proximal pole fractures of the scaphoid due to tenuous retrograde blood supply.The use of pedicled vascularized bone grafts for the treatment of scaphoid nonunion provides both good clinical and radiological outcomes.The preserved vascularity of the graft leads to better bone remodelling, less osteopenia, faster incorporation and better maintenance of bone mass compared to the conventional non-vascularized grafting.Pedicled vascularized bone grafts also allow the correction of the carpal alignment and humpback deformity of the scaphoid.Clinical and radiological results have been satisfactory and promising, making us anticipate that the role of vascularized bone grafting for the treatment of carpal diseases will increase.Cite this article: EFORT Open Rev 2020;5:1-8. DOI: 10.1302/2058-5241.5.190021

Results of the 4-5 ECA vascularized pedicle bone grafting in avascular pseudoarthroses of the scaphoid proximal pole

Objective: The scaphoid bone is the most injured carpal bone and is the cause of severe wrist dysfunction seen in nonunion cases. The probability of avascular necrosis is very high especially in fractures of the proximal pole, due to the retrograde blood flow in the region. In these cases, vascularized pedicle bone grafts, with high rates of union, is a good alternative to the conventional techniques. In this study, we present the results of vascularized bone grafting with grafts harvested from the 4-5 extensor compartment artery (ECA) and fixation with the Herbert screw in patients with avascular pseudoarthroses of the scaphoid proximal pole. Methods: Fifteen patients who presented to our clinic due to nonunion of the scaphoid and who were applied vascularized pedicle bone grafts harvested from the ECA between 2006 and 2015 were included in the study. The mean age of the patients was 30.1 (19-42) and all patients were male. Patients were followed up for an average period of 22.7 (18-56) months. Union in the patients were evaluated with the preoperative and postoperative wrist ranges of motion. VAS (visual analog scale) and, for functional evaluation, the Turkish version of the Quick-DASH scale were used. Results: Union was achieved in all patients after a mean period of 8.2 (6-10) weeks. The most significant improvements after surgery were detected in the VAS and functional Quick-DASH scores. No significant improvement was observed in wrist contractures. Other than the hematoma in one patient, no complication was observed. Conclusion: In cases of nonunion of the scaphoid proximal pole fractures accompanied by avascular necrosis, pedicle grafts from the 4-5 ECA offer high rates of union and improvement in the pain and functional scores of the patients. Level of evidence Level IV, therapeutic study. Keywords : Scaphoid, proximal pole, vascularized pedicle bone graft

Pedicled Vascularized Bone Graft of the Distal Radius for Recalcitrant Nonunion of the Distal Humerus.

To analyze the clinical and radiological outcomes of a series of patients treated with a pedicled vascularized bone graft (VBG) of the distal radius for the treatment of recalcitrant atrophic nonunions of the distal humerus. Retrospective clinical study. University-affiliated teaching hospital. Fifteen patients with supracondylar humeral atrophic nonunions with at least 3 previous failed surgical interventions were included. Debridement of the distal humerus nonunion through a posterior elbow approach with provisional fixation was performed. Then, a pedicled VBG was harvested from the distal radius and tunneled back into the humeral bone defect. Iliac crest was used as needed, both for the nonunion and to stabilize the radius. Finally, definitive fixation with 2 locked plates was performed. Radiological results, complications, elbow range of motion, Mayo elbow performance score, and subjective pain were evaluated. There were 4 male and 11 female patients, with a mean age of 51 (range, 28-73) years. The mean follow-up period was 46 (range, 37-72) months with a minimum of 3 years. Radiological consolidation was achieved in all patients. Elbow range of motion was >100 degrees in 11 patients and between 50 and 100 degrees in 4 patients. Preoperative Mayo scores were poor in all patients. At final follow-up, Mayo scores were excellent in 3, good in 9, and fair in 3 patients. The mean postoperative visual analog scale score was 1.2 (range 0-3). Pedicled VBG of the distal radius was shown to be a reliable and effective alternative for the treatment of recalcitrant atrophic nonunions of the distal humerus, when other methods have failed. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Pedicled Vascularized Bone Graft Versus Induced Membrane Technique for Reconstruction of Forearm Medium-Size Bone Defects

There is no financial information to disclose. Induced membrane technique has proven satisfactory results for reconstruction of infected nonunion. However, more complex techniques such as vascularized bone grafts (VBG) are usually indicated in the presence of prior graft failure or a poor soft tissue bed. The purpose of this study is to compare the clinical and radiological outcomes of a series of patients treated for ulnar nonunion with medium-size bone defects. Patients were treated with either pedicled distal radius VBG (Figure 68-1) or induced membrane technique (IMT). Twelve patients who underwent surgery for reconstruction of infected forearm nonunion with bone defects up to 6 cm (minimum follow-up, 2 years) were selected retrospectively. Seven patients underwent distal radius pedicled VBG (group A) and 5 patients underwent reconstruction with the induced membrane technique (group B) (Figure 68-2). Mean follow-up was 34 months. The time between the original injury and the index procedure was 16 months (range, 11–20). The mean age was 42 years (range, 26–64). Patients were evaluated clinically and radiographically. The number of previous surgeries was recorded. Elbow and wrist range of motion, visual analog scale (VAS) for pain, the Quick-DASH questionnaire, and Mayo Elbow Perfomance Score (MEPS) were assessed. Complications and the need for reoperations were recorded. All nonunion were healed at final follow-up. The average defect size was 5.3 cm (range, 4.2–6). The average number of previous surgeries in the VBG group was 4.2 (range, 3–7) and in the IMT group was 2.8 (range, 2–5). The average time to union was 3.8 months (range 3–6) for group A, and 4.6 (range 4–6) for group B. Active ROM did not differ significantly between groups. Average QuickDASH was 13, and average MEPS was 83. At the 2-year follow-up, there were no significant differences in the VAS pain score (1.3 in group A; 0.9 in group B). There were 2 complications. In the VBG group, one patient required implant removal, and in the IMT group, 1 nonunion required autogenous iliac crest bone graft. Final results were satisfactory for both. No fracture or persistent donor site pain was observed in the VBG group. •In this limited series, both techniques showed favorable results and could be considered surgical alternatives for the treatment of infected ulnar nonunion.•Pedicled VBG showed a shorter time to union compared with induced membrane.Figure 68-2Intraoperative photographs of an ulnar defect reconstructed with a pedicled radius VBG (A) and with iliac crest bone graft, during the second stage of the induced membrane technique (B).View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Pedicled Vascularized Bone Grafts for Posterior Occipitocervical and Cervicothoracic Fusion: A Cadaveric Feasibility Study.

Arthrodesis is critical for achieving favorable outcomes in reconstructive spine surgery. Vascularized bone grafts (VBGs) have been successfully used to augment fusion rates in a variety of skeletal pathologies, and pedicled VBG has numerous advantages over free transfer VBG. Pedicled VBG has not previously been described for the posterior occipitocervicothoracic spine. To identify, describe, and assess potential donor sites for pedicled VBGs from occiput to T12 using a cadaver model and to describe important technical considerations for graft harvest and placement. A multidisciplinary team of plastic surgeons and neurosurgeons hypothesized that it is feasible to rotate a pedicled VBG from the occiput to T12 via a posterior approach. In 6 cadavers, 3 VBG donor sites were identified as anatomically feasible: occiput, scapula, and rib. Split- and full-thickness occipital VBGs were mobilized on a semispinalis pedicle. Occipital VBGs could be mobilized from occiput to T1 and span up to 4 levels. Scapular VBGs were mobilized on a subscapular pedicle and could be mobilized from occiput to T7 and span up to 8 levels. Rib VBGs were mobilized on subcostal pedicles and could be mobilized from C6 to T12. Ribs T2 to T4 and T11 and T12 could cover 2 levels, and ribs T5 to T10 could cover 3 levels. The first rib was anatomically unsuitable as a VBG due to its primarily ventral course. Pedicled VBGs can feasibly be applied to posterior spinal arthrodesis from occiput to T12. Patients at high risk for nonunion may benefit from this strategy.