Reconstruction Of Long Bone Defects Research Articles

Use of Fibular Strut Graft for Reconstruction of Bone Defects

Introduction • Bone recalcitrant nonunion and bone defects usually follow trauma, resection of a malignant tumor of the musculoskeletal system and osteomyelitis. • Instead of amputation, which was used in the past, limb salvage surgeries, including non-vascularized or vascularized autografts and allografts, bone transport and replacement with prostheses are performed. • Among the above methods, nonvascularized autogenous bone graft use is an important treatment strategy that has been performed for over a hundred years. • The fibula is a tubular bone that has a suitable length, geometrical shape and mechanical strength and is considered to be the best donor bone for large bone defects. • Free vascularized fibular grafts achieve higher union rate than non-vascularized fibular grafts in the reconstruction of long bone defects. • In this study, 6 patients with bone defects treated by non-vascularized fibular grafts .We intended to assess the clinical outcomes of graft union, functional outcome.

A combined active shape and mean appearance model for the reconstruction of segmental bone loss.

This study investigates the novel combination of an active shape and mean appearance model to estimate missing bone geometry and density distribution from sparse inputs simulating segmental bone loss of the femoral diaphysis. An active shape Gaussian Process Morphable model was trained on healthy right femurs of South African males to model shape. The density distribution was approximated based on the mean appearance of computed tomography images from the training set. Estimations of diaphyseal resections were obtained by probabilistic fitting of the active shape model to sparse inputs consisting of proximal and distal femoral data on computed tomography images. The resulting shape estimates of the diaphyseal resections were then used to map the mean appearance model to the patients' missing bone geometry, constructing density estimations. In this way, resected bone surfaces were estimated with an average error of 2.24 (0.5)mm. Density distributions were approximated within 87 (0.7)% of the intensity of the original target images before the simulated segmental bone loss. These results fall within the acceptable tolerances required for surgical planning and reconstruction of long bone defects.

Effects of gamma radiation and post-operative cisplatin injection on the incorporation of bone allografts in rats

Background. The reconstruction of long bone defects that occur after resection of tumors is a problem that requires constant study. Bone allografts are often used in this scenario. Unfortunately, while they are prepared, allografts partially lose their strength and osteoinductive properties; their survivability in oncological patients is only 40% after 10 years. This is why the search for superior allograft treatment methods and the study of allograft remodeling and incorporation in oncological patients, whose state has been affected by radiation or chemotherapy, is an area of interest. Purpose – study the structure of bone tissue in the distal metaphysis of a rat’s femur after bone allograft implantation (sterilized using gamma radiation or antibiotic saturation) and post-operative intraperitoneal cisplatin injection. Materials and Methods. Experiments were performed on 20 male white rats aged 5–6 months at the beginning of the experiment and weighed 365.8 ± 6.4g. All rats underwent a surgery that created a defect in the distal metaphysis of the femur which was filled with a bone allograft treated with gamma radiation (Control-1 and Experimental-1 groups) or saturated with an antibiotic (Control-2 and Experimental-2 groups). 14 days after allograft implantation, animals from the control groups received an intraperitoneal injection of 2.0–2.4 ml of 0.9% NaCl, while animals from the experimental groups received 2.5mg/kg of cisplatin. Histological analysis and histomorphometry were completed 30 days after the surgery. Results. 30 days after the operation, the smallest relative area of bone tissue (11.79%) was observed in rats from the Experimental-1 group, with gamma radiation treated allografts and post-operative intraperitoneal cisplatin injections. A somewhat higher value was found in the Experimental-2 group (antibiotic saturation + cisplatin) – 31.64%. In the control groups, (intraperitoneal injection 0.9% NaCl), the relative area of bone tissue was 16.7% (Control-1, gamma radiation treatment) and 58.09% (Control-2, antibiotic saturation). The relative area of fibrous tissue was the largest in the Experimental-1 group – 31.55% and the smallest in the Control-2 group – 12.79%. Conclusions. Allograft remodeling occurs along with the formation of bone and fibrous tissue when allografts are used to fill defects in the distal femoral metaphysis of rats, However, the relative percentages of those tissues depend on the allograft sterilization method and the use of cytostatic agents. The largest relative percentage of bone tissue (58.09%) was obtained using an allograft saturated with antibiotics and without the administration of cisplatin. The smallest (11.79%), on the other hand, occurred in gamma radiation treated allografts with cisplatin injected intraperitoneally after the operation

Wrist Reconstruction after En bloc Resection of Bone Tumors of the Distal Radius.

Wrist reconstruction after en bloc resection of bone tumors of the distal radius has been a great challenge. Although many techniques have been used for the reconstruction of long bone defects following en bloc resection of the distal radius, the optimal reconstruction method remains controversial. This is the first review to systematically describe various reconstruction techniques. We not only discuss the indications, functional outcomes, and complications of these reconstruction techniques but also review the technical refinement strategies for improving the stability of the wrist joint.En bloc resection should be performed for Campanacci grade III giant cell tumors (GCT) as well as malignant tumors of the distal radius. However, wrist reconstruction after en bloc resection of the distal radius represents a great challenge. Although several surgical techniques, either achieving a stable wrist by arthrodesis or reconstructing a flexible wrist by arthroplasty, have been reported, the optimal reconstruction procedure remains controversial. The purpose of this review was to investigate which reconstruction methods might be the best option by analyzing the indications, techniques, limitations, and problems of different reconstruction methods. With the advancement of imaging, surgical techniques and materials, some reconstruction techniques have been further refined. Each of the techniques discussed in this review has its advantages and disadvantages. Wrist arthrodesis seems to be preferred over wrist arthroplasty in terms of grip strength and long‐term complications, while wrist arthroplasty seems to be superior to wrist arthrodesis in terms of wrist motion. All things considered, wrist arthroplasty with a vascularized fibular head autograft might be a good option because of better wrist function, acceptable grip strength, and a relatively lower complication rate. Moreover, wrist arthrodesis is still an option if the fibular head autograft reconstruction fails. Orthopaedic oncologists should familiarize themselves with the characteristics of each technique to select the most appropriate reconstruction method depending on each patient's situation.

An Analysis of Complications and Bone Defect Length With the Use of Induced Membrane Technique in the Upper Limb: A Systematic Review.

Background: The induced membrane technique was originally described as a technique for the reconstruction of long bone defects. The authors performed a systematic review to determine whether the use of the induced membrane technique is effective in large bony defects in the upper extremity. Methods: A qualitative systematic review was conducted using PubMed, EBSCO, and Google Scholar databases to record all studies reporting on complications of the induced membrane technique in the upper extremity. Studies written after 1990 in English language journals met the inclusion criteria. Exclusion criteria were non-English language publications, animal studies, failure to identify the location of the bone defect, failure to identify whether complications were associated with the procedure, and failure to define the length of bone defect. Results: A total of 1422 studies were identified in the original search. Twelve studies satisfied the criteria for inclusion. A total of 70 patients with 83 upper extremity cases were reported: 1 proximal interphalangeal joint, 22 phalanges, 8 metacarpals, 37 forearms, 14 humeri, and 1 clavicle. The mean bone defect size was 4.0 cm (SD, 1.5). The most common complication was infection. We found that complication rates were independent of the location of the bone defect. Complication rates in the upper extremity ranged from 0% to 100%, with a total weighted mean of 10%. Conclusion: The induced membrane technique is an emerging possible treatment of large bone defects in the upper extremity. More research is needed to determine the outcomes of the induced membrane technique in the upper extremity.

A Bioactive Hydrogel and 3D Printed Polycaprolactone System for Bone Tissue Engineering.

In this study, a hybrid system consisting of 3D printed polycaprolactone (PCL) filled with hydrogel was developed as an application for reconstruction of long bone defects, which are innately difficult to repair due to large missing segments of bone. A 3D printed gyroid scaffold of PCL allowed a larger amount of hydrogel to be loaded within the scaffolds as compared to 3D printed mesh and honeycomb scaffolds of similar volumes and strut thicknesses. The hydrogel was a mixture of alginate, gelatin, and nano-hydroxyapatite, infiltrated with human mesenchymal stem cells (hMSC) to enhance the osteoconductivity and biocompatibility of the system. Adhesion and viability of hMSC in the PCL/hydrogel system confirmed its cytocompatibility. Biomineralization tests in simulated body fluid (SBF) showed the nucleation and growth of apatite crystals, which confirmed the bioactivity of the PCL/hydrogel system. Moreover, dissolution studies, in SBF revealed a sustained dissolution of the hydrogel with time. Overall, the present study provides a new approach in bone tissue engineering to repair bone defects with a bioactive hybrid system consisting of a polymeric scaffold, hydrogel, and hMSC.

Staged reconstruction of diaphyseal fractures with segmental defects: Surgical and patient-reported outcomes

IntroductionTwo-stage limb reconstruction is an option for patients with critical size segmental bone defects following acute trauma or non-union. Reconstruction is technically demanding and associated with a high complication rate. Current protocols for limb reconstruction have well-documented challenges, and no study has reported on patient outcomes using a validated questionnaire. In this study, we aimed to examine the clinical and patient-centered outcomes following our surgical protocol for two-stage limb reconstruction following critical size segmental defects. Patients and methodsA single surgeon performed reconstruction of long bone defects using antibiotic impregnated cement spacers and intramedullary cancellous bone autograft. A retrospective chart review was performed. Three reviewers independently measured time to union based on radiographs. The Lower Extremity Functional Scale (LEFS) survey was administered to patients after most recent follow-up. ResultsTen limbs representing nine patients were included. All patients sustained a lower extremity injury, and one patient had bilateral lower extremity injuries. Average clinical follow-up was 18.3 months (range 7–33) from final surgical intervention, and follow-up to questionnaire administration was 28 months (range 24–37). The mean time between stages was 3.1 months. Average time to unrestricted weight-bearing was 7.9 months from Stage 1 (range 3.4–15.9) and 4.5 months from Stage 2 (range 1.1–11.6). Average time to full union was 16.7 months from Stage 1 (range 6.4–28.6) and 13.5 months from Stage 2 (range 1.8–27). Eight patients (nine limbs) participated in the LEFS survey, the average score was 53.1 (range 30–67), equating to 66% of full functionality (range 38%–84%). Complications included 5 infections, 3 non-unions, and one amputation. There was a moderate positive correlation between infection at any time point and non-union (R=0.65, p=0.03). Discussion and conclusionsOutcomes in this small patient cohort were good despite risks of complication. There is an association between infection and non-union. Further studies addressing clinical and functional outcomes will help to guide expectations for future surgeons and patients.

Study of bone-like hydroxyapatite/polyamino acid composite materials for their biological properties and effects on the reconstruction of long bone defects.

PurposeThe purpose of this study was to investigate the effect of bone-like hydroxyapatite/polyamino acid (BHA/PAA) in the osteogenesis and reconstruction of long segmental bone defects.MethodsIn vitro, MG63 cells were cultured with BHA/PAA. The osteoinductive activity of the BHA/PAA material was evaluated using inverted microscopy, scanning electron microscopy, MTT proliferation assay, and the determination of alkaline phosphatase activity and Ca2+ content. In vivo, the radial bone defect was made in 20 New Zealand White rabbits, and then these animal were randomly divided into two groups (n=10), the experimental group (with BHA/PAA) and the control group (without BHA/PAA). Postoperatively, the osteogenesis effect of BHA/PAA was evaluated through X-ray, hematoxylin–eosin staining, observation of the gross bone specimen, immunohistochemistry, and fluorescent confocal scanning microscopy.ResultsIn vitro, BHA/PAA promoted the adhesion, growth, and calcium nodule formation of MG63 cells, and it had good osteogenesis activity. In vivo, with BHA/PAA material degradation and absorption, the new bone gradually formed, and the bone defect gradually recovered in the experimental group. In the control group, a limited bone formation was found at the bone broken ends, and the bone defect was obviously visible.ConclusionIn vitro and in vivo, we confirmed that BHA/PAA was effective in inducing osteogenesis and reconstructing a long segmental bone defect.

Long-term outcome of free fibula osteocutaneous flap and massive allograft in the reconstruction of long bone defect

Reconstruction of massive bone defects in bone tumors with allografts has been shown to have significant complications including infection, delayed or nonunion of allograft, and allograft fracture. Resection compounded with soft tissue defects requires skin coverage. A composite osteocutaneous free fibula offers an optimal solution where the allografts can be augmented mechanically and achieve biological incorporation. Following resection, the cutaneous component of the free osteocutaneous fibula flaps covers the massive soft tissue defect. In this retrospective study, the long-term outcome of 12 patients, who underwent single-stage limb reconstruction with massive allograft and free fibula osteocutaneous flaps instead of free fibula osteal flaps only, was evaluated. This study included 12 consecutive patients who had primary bone tumors and had follow-up for a minimum of 24 months. The mean age at the time of surgery was 19.8 years. A total of eight patients had primary malignant bone tumors (five osteosarcomas, two chondrosarcomas and one synovial sarcoma), and four patients had benign bone tumors (two giant-cell tumors, one aneurysmal bone cyst, and one neurofibromatosis). The mean follow-up for the 12 patients was 63 months (range 24-124 months). Out of the 10 patients, nine underwent lower-limb reconstruction and ambulated with partial weight bearing and full weight bearing at an average of 4.2 months and 8.2 months, respectively. In conclusion, augmentation of a massive allograft with free fibula osteocutaneous flap is an excellent alternative for reducing the long-term complication of massive allograft and concurrently addresses the soft tissue coverage.

Free vascularized fibular graft bridged vascular pedicle by vein transplantation for infective long bone defect reconstruction

Objective To explore the surgical method and curative effect of free vascularized fibular graft bridged vascular pedicle by vein transplantation for infective long bone defect with or without soft tissue defect reconstruction. Methods From June 2008 to January 2014, 17 patients with infective long bone defect were treated, 11 male and 6 female, 1.5 to 55 years old and averaged 31.3 years. 8 cases in femur, 5 cases in tibia, 3 cases in humerus and 1 case in radius. Bone defect were 4 to 19 cm in length with an average of 9.4 cm. 8 cases with soft tissue defect, from 5.0 cm×3.0 cm to 17.0 cm×5.5 cm. Required adequate surgical debridement, and vacuum sealing drainage (VSD) was used. Free vascularized fibular (skin) flap was designed and harvested. Artery and veins close to the health site were dissected, and bridged vascular pedicle of free vascularized fibular flap by autologous vein transplantation with end to end anastomosis. The length free vascularized fibular graft was from 5 to 18 cm, with an average of 9.6 cm. The free fibula flap ranged from 6.5 cm×4.0 cm to 18.0 cm×6.0 cm. Results All the 17 cases of fibular flap survived, no vascular crisis happened. Post-operative wound primary healed in 11 cases, delayed 1 to 2 weeks to heal in 6 cases. Callus was seen in the 6 to 8 weeks later. 15 cases were followed from 9 months to 6 years (averaged 30 months) while 2 cases were lost to follow-up. Bone defect primary healed in 13 cases, and the fibula graft unhealed in 2 cases, but healed again after a second operation. Fibula stress fracture occurred in one case at 7 months after grafting procedures and bone union was achieved 4 months after reapplying an external fixator. Infected bone defect healing time ranged from 4.2 to 9.8 months, averaged 5.9 months. According to the Enneking score, 11 cases were excellent, good in 3 cases, one in fair. Excellent and Good rate was 93.3%. Conclusion Free vascularized fibular (skin) graft with vein bridged vascular pedicle can not only effectively repair infected bone and soft tissue defect, but also improve local blood supply and control infection, shorten the course of treatment, which is an effective treatment of infective long bone defects with or without soft tissue defects. Key words: Fractures, bone; Infection; Wounds and injuries; Fibula; Surgical Flaps; Blood vessels; Transplantation, Autologous

Vascularised fibula graft for tumours

The reconstruction of long bone defects after tumor resection has been a challenge to the reconstructive surgeon. Increased survival of patients with aggressive or malignant tumors of the extremities has made microsurgical reconstruction more relevant in improving their quality of life. In order to avoid amputation, these long defects are often reconstructed with vascularized autogenous fibular grafts. Vascularized fibular grafts have been reported to have a high union rate and good functional outcome. Union rates for vascularized fibular grafts range from 68-100% in individual case series. However, complications are also frequent. The reported complication rates range from 10-60%, with infection and non-union as the most frequent complications. Revision surgery in the form of additional bone grafting is often needed as well as revision of fixation of the graft. The devices used for fibular autograft fixation include plate and screws, intramedullary nails, circular external fixator, and a combination of K-wires and screws with casting. Rigid fixation is necessary to achieve early adjacent joint motion and prevent graft non-union. Aside from bone union, functional assessment is important in the evaluation of patients treated with microsurgical reconstruction using the fibular graft. The most frequently used functional tool was the modified Enneking MSTS score (Musculoskeletal Tumor Society Score). A retrospective review of patients diagnosed with benign aggressive or malignant extremity tumors with post-oncologic long bone extremity defects reconstructed with vascularized fibula grafts was undertaken from 1993 to 2008 to determine clinical outcome, bone union and functional outcome. A total of 25 patients were able to fulfill the inclusion criteria and were included in the review. Of the 25 patients, eight had benign-aggressive tumors while 17 had malignant tumors. Results showed a union rate of 84% (21/25). Revision surgery was done on seven patients (28%) to achieve union, all of them in the upper extremity. Three patients had infections (12%), and only 2 grafts had fractured (8%). The average length of the fibular graft was 18.22 ± 3.5 cm. Final union time for the grafts to unite was 10.4 ± 4.1 months. The average functional score using the Musculoskeletal Tumor Score in 20 patients was 83.4% (SD, 10.4). The average follow-up was 41 (SD, 32) months. On the latest follow-up, of the 14 patients with malignant bone lesions, two died of the disease and one died of other causes, the rest of the patients with malignant lesions are alive with no evidence of disease. In summary, the use of vascularized fibula autografts for long bone defects after tumor resection represents a valid option of reconstruction. Union rates are high and complication rates are manageable. Among the factors investigated, only graft union was significantly associated with the MSTS score. Patients whose graft united tend to have an MSTS score of 13.8 percentage points higher than those patients who had non-unions.

One-Stage Reconstruction of Composite Extremity Defects with a Sural Neurocutaneous Flap and a Vascularized Fibular Graft

The fibula flap has been widely used for reconstruction of composite bone and soft-tissue defects. The skin paddle of the fibula flap has played a critical role in providing a cutaneous component and good monitor for the bone component. In this report, the authors designed a perforator-based sural neurocutaneous flap instead of a peroneal perforator flap to enlarge a skin paddle for wound coverage. A novel chimeric flap was harvested based on the peroneal artery, and consisted of a sural neurocutaneous flap and a fibular graft. The sural neurocutaneous flap was elevated based on a single peroneal perforator and connected with the bone component by means of the peroneal artery. Two patients with complex bone and soft-tissue defects were treated by using this chimeric flap. In case 1, the radius defect was 8 cm in length and the soft-tissue defect measured 23 × 10 cm. In case 2, the distal radius was injured and the defect was 16 cm in length. The area of soft-tissue defect was 23 × 8 cm. In this case, the fibula head was used for wrist reconstruction. The soft-tissue defects in the two cases stretched across the palmar and dorsal surfaces of the forearm. The lengths of the bone components were 10 and 16.5 cm, respectively, and the areas of the skin components were 24 × 12 cm and 25 × 10 cm, respectively. Both chimeric flaps survived completely without complications. The follow-up period was 42 months in case 1 and 16 months in case 2. Complete bone union was observed in both cases, and no remarkable degeneration of the fibular head occurred in case 2. The sural neurocutaneous flap showed good texture match and contour. No serious donor-site complications occurred. The two patients were satisfied with their daily lives relative to the severity of their injuries. The chimeric flap composed of a sural neurocutaneous flap and a fibular graft by means of the peroneal artery is a good candidate for reconstruction of long bone defects associated with extensive soft-tissue defects in the extremities.

A free vascularized tibia-fibular composite graft for the traumatic femoral bony defect of a 6-year-old boy with 10-year follow up: a case report

IntroductionFree vascularized fibular grafts have been widely used for the reconstruction of long bone defects. However, the use of a vascularized tibial graft is precluded by its weight-bearing function and unacceptable donor site morbidity.Case presentationWe present a rare case of using a vascularized tibia-fibular composite graft taken from a 6-year-old Chinese boy’s ipsilateral lower leg to reconstruct a large bony defect of his traumatic femur. Hypertrophy of the tibial graft, good remodeling of the femoral shaft, and atrophy of the unloaded fibular graft were noted at the 10-year follow up. He was able to participate in outdoor activities such as basketball while wearing his prosthesis.ConclusionsThe 10-year follow up demonstrates the feasibility of this salvage procedure for a floating knee injury with neurovascular compromise.

Management of postinfection defects in long bones with a vascularized fibular bone graft

Background Management of chronic osteomyelitis is a difficult task, complicated by problems including combined bone and soft-tissue loss, bacterial colonization, fibrotic local tissue, and local factors detrimental to wound healing. Vascularized bone grafts, by definition, are placed with their vascularity intact and are thus immediately viable. Objective The aim of this study was to review the clinical and radiographic results of a vascularized fibular graft (VFG) in the management of defects in upper and lower limbs with chronic osteomyelitis. Patients and methods Six patients with chronic osteomyelitis (two tibiae, two ulnae, one femur, and one radius) underwent radical debridement, followed by reconstruction using a VFG, and were evaluated for radiographic and clinical success using standard anteroposterior and lateral radiographs. Four men and two women were included and their average age at surgery was 38.8 years (range 30-50 years). Union, solid hypertrophy, range of motion, grip strength, failure of anastomosis, and recurrence of infection were evaluated at the final follow-up. Results Radiological assessment indicated union in all cases after an average period of 10.6 weeks in upper limb cases and 18 weeks in lower limb cases. Solid hypertrophy and weight bearing were allowed for lower limb cases after an average period of 12 months. No failure of the graft or recurrence of infection was encountered in this study. Conclusion VFG for the reconstruction of long bone defects following radical debridement in cases of chronic osteomyelitis effectively achieves union and eradicates infection.

Different sources of stem cells for skeletal tissue regeneration

The wide variety of bone tissue engineering applications ranges from reconstruction of long bone defects in the femour, articular osteochondral defects to craniofacial reconstruction. Sources of cells in bone tissue engineering include Mesenchymal Stem Cells (MSCs). The most important supply of cells for bone repair seems to be bone itself. Bone and bone marrow (BM) could be therefore considered the main local source of skeletal stem cells/progenitors. More recently, periosteal progenitor cells (PCs), mesenchymal stem cells derived from amniotic fluid (AF-MSCs) and from skin (S-MSCs) have been suggested for bone tissue-engineering applications. In the present research the ability of stem cells isolated from bone marrow (BM-MSCs) and subchondral bone (B-MSCs), PCs, AF-MSCs and S-MSCs to differentiate in osteocytes and chondrocyte were evaluated. Before differentiation, cell phenotype was assessed in agreement with the International Society for Cellular Therapy guidelines.Cell differentiation towards osteoblastic and chondroblastic phenotypes was performed in the appropriate medium and evaluated with alkaline phosphatase and von Kossa stainings for osteoblasts and Alcian Blue staining for chondroblasts As expected, BM-MSCs and B-MSCs differentiate either in osteoblasts or in chondroblasts. Osteoblastic differentiation was observed also in AF-MSCs, S-MSCs and PCs. Our results suggest that differently-derived adult stem cells could represent an interesting aid to produced engineered tissue for a rapid clinical use. Moreover, the use of different stem cell sources may identify explicit tissue engineering approaches: for instance, the use of bone derived progenitors cells (i.e. B-MSCs and PCs), whose harvesting is more invasive, may be restricted to strategies forecasting their recruitment in the lesion site, while S-MSC (most abundant) may be utilized in those tissue engineering applications in which a large cell amount is needed.

Bone transport over an intramedullary nail for reconstruction of long bone defects in tibia

Although long bone defects may be treated by callus distraction, frequent complications arise from the long duration of external fixation. To reduce such complications, bone transport over an intramedullary nail (BTON) has been done for tibial bone defect. In 12 patients (mean age, 46.1 years) of chronic osteomyelitis or bone defect, segmental transport was done using external fixator over an intramedullary nail. Prior to the index procedure, all patients had had serial debridements and five required myocutaneous or free flaps for covering of soft tissue defects. Using Mekhail's criteria, functional results were evaluated. The mean transported amount was 5.9 (range, 3.5-12) cm. The mean external fixation index was 26 days/cm, and healing index was 62.6 days/cm. The primary union of distraction and docking site was achieved in all, except for one failure in union at the docking site, which required another bone graft. Except for one patient with associated ankle injury, all had excellent or good functions. There was one recurrence of osteomyelitis and one procurvatum of the proximal tibia of 10 degrees . BTON may be a successful method in tibial reconstruction and allows patients to return to daily life earlier with relatively few complications.

Reconstruction osseuse des os longs après exérèse carcinologique par l’utilisation de greffons fibulaires vascularisés chez l’enfant et l’adolescent: À propos d’une série de 13 cas à 50 mois de recul moyen

Purpose of the study The vascularized fibular graft is a widely used technique for the reconstruction of long bone defects after tumor resection. Complications are not uncommon despite the presence of a good vascular supply. We report our experience with long bone reconstructions in children and adolescents after resection of primary malignant bone tumors. Material and methods This retrospective analysis included thirteen patients aged 4-17 years (mean age 12 years). Preoperatively, the pathological diagnosis was Ewing tumor (n = 7), osteogenic sarcoma (n = 5), neuroepithelioma (n = 1). All patients except one were given chemotherapy preoperatively and postoperatively and four received adjuvant radiotherapy. Tumor resection created a gap (n = 8) or involved resection-arthrodesis (n = 5, three knees, one ankle, one elbow). All reconstructions used a vascularized fibular flap with a complementary corticocancellous autograft for seven. Results Complete carcinological resection was achieved in all cases. Mean follow-up was 50 months (range 12-144 months). There were no cases of local recurrence. Three patients presented lung metastasis; two patients died. Eleven of the twelve patients who underwent tumor resection involving the lower limb were able to walk with full weight bearing at 13.9 months (range 841 months), half of them without any supportive device. The MSTS score was 21/30 (range 7-29). Both ends healed for eleven of thirteen grafts. Outcome was good in four cases at 7.7 months (range 6-11), fair in seven (with 1-5 complementary procedures) at 14.8 months (range 10-45) and poor in two (nonunion at last follow-up). Among the fibular grafts which healed, primary healing of the distal end was noted in all cases, but not for the proximal end. Significant transplant hypertrophy was noted in 62% of patients, measured at mean 77.1% (range 25-128%). Complications were: skin necrosis (n = 2), nonunion (n = 4, three aseptic and one septic), disassembly (n = 3 with two transplant fractures), and spontaneous fracture which healed (n = 5, all but one treated orthopedically). There were four donor site complications: retraction of the hallux flexor (n = 3), regressive paresia of the common fibular nerve (n = 1). Discussion The rate of healing in this series was similar to earlier reports. Healing was always achieved for the distal focus but not for the proximal focus which receives its blood supply from a branch of the anterior tibial artery which is not harvested. The defective blood supply can thus hinder bone healing. It is necessary to spare the proximal quarter of the fibula or harvest a bipediculated graft. The rate of graft hypertrophy was also similar, as was the rate of complications. The MSTS score was lower due to the poor results obtained with resection-arthrodesis of the knee joint. Graft fractures and aseptic nonunion are the most common complications but septic complications are more serious and can threaten graft survival. Complications at the donor site are exceptional. Conclusion Long bone reconstruction using an autologous vascularized fibular graft is a reliable technique providing satisfactory functional results. Complications can be prevented by making solid fixation and using a corticocancellous graft creating a favorable osteoinducing environment. A massive allograft is another solution providing good immediate mechanical stability.

Cylindrical Titanium Mesh Cage for the Reconstruction of Long Bone Defects

Cylindrical Titanium Mesh Cage for the Reconstruction of Long Bone Defects

Free vascularized bone grafts in surgery of the upper extremity

Free vascularized fibular grafts were employed in five patients with segmental bone defects following trauma or resection of tumors of the upper extremity with excellent results in three patients and satisfactory results in two. No donor site morbidity was experienced. A comparison with rib and iliac crest grafts indicates that the fibula is more suitable for reconstruction of long bone defects. The advantages of this technique are stability without sacrificing viability and a shorter immobilization period with more rapid incorporation and hypertrophy of the graft. The disadvantages are prolonged operating time, difficulty in assessing patency of anastamoses in the immediate postoperative period, and sacrifice of a major vessel in the lower extremity.