Bone Transfer Research Articles

Mandibular reconstruction with microsurgical bone flap and dental implants.

Functional reconstruction of the mandible following resection or traumatic injury depends on the bony reconstruction and support dental implants. Microsurgical bone flaps allow the transfer of bone and soft tissue with a rich vascular supply and provide a firm basis for placement of dental implants in mandible reconstruction. Endosseous dental implants may improve functional restoration by ensuring the stable dentition essential for normal mastication and speech. In this review article, donor sites of microsurgical bone flaps, criteria for placement of dental implants, timing for dental implantation, bone resorption, role of radiotherapy and hyperbaric oxygen, and success rate of dental implants are discussed.

Management of posttraumatic segmental bone defects.

Because of difficulty in managing posttraumatic segmental bone defects and the resultant poor outcomes, amputation historically was the preferred treatment. Massive cancellous bone autograft has been the principal alternative to amputation. Primary shortening or use of the adjacent fibula as a graft also has been used to attempt limb salvage. Of more recent methods of management, bone transport with distraction osteogenesis has been suggested as the leading option for defects of 2 to 10 cm, but problems include delayed union at the docking site and prolonged treatment time. Free vascularized bone transfer has been suggested as the leading option for defects of 5 to 12 cm, but hypertrophy of the graft is unreliable and late fracture, common. Bone graft substitutes continue to be developed, but they have not yet reached clinical efficacy for posttraumatic segmental bone defects. Although each of the new techniques has shown some limited success, complications remain common.

Long term results of reconstruction plates in lateral mandibular defects: Revision of nine cases

Objective: Although microsurgical bone transplant is still the gold standard, mandibular reconstruction plates (MRP) were for several years considered a fast and safe way to restore mandibular continuity without using a bone graft. New plate designs with locking screws have been recently introduced, and these may overcome some of the complications related to previous designs. We review the results of mandibular reconstruction plates in our institution from 1991 to 1995. Methods: The records of nine cancer patients who underwent lateral mandibular resections (with preservation of both condyle and symphysis) followed by reconstruction with a mandibular reconstruction plate, were retrospectively reviewed. Patients were treated between 1991 and 1995 with regular Synthes and Leibinger plates (without locking screws). Immediately after tumour resection, the bone defect was reconstructed with an MRP without bone grafting. Three cases required soft tissue coverage: two flaps and one buccal fat pad flap. Results: There was immediate orocervical fistula in six cases, one of which required surgical closure; and late complications were common. One patient died due to distant metastasis 13 months after surgery without symptoms related to the plate. The remaining eight patients had their plates removed at between 9 and 52 months after reconstruction, due to screw loosening (four cases), plate exposure (one case), or both (three cases). Conclusion: Lateral mandibular reconstruction with non-locking screws and regular profile plates is no longer recommended. New plates with improved designs are currently available. Their low profile and locking screws are the usual characteristics of these new plates. More clinical experience is necessary before plate reconstruction can be recommended over microvascular bone transfer.

Vascularized bone transfers in the wrist and hand

More and more vascularised bone transfer (VBT) sites, free or pedicled, in the wrist and hand have been described since the 1980s. In the distal forearm, two main VBT: the fibula and the iliac crest, are used for large bone loss (> 6 cm) or for radio-carpal reconstruction. We report our experience of radio-carpal reconstruction using the distal-radio-ulnar joint transfer. At the carpal level, VBT are essentially used for "difficult" scaphoid pseudarthrosis: osteonecrosis, sclerotic bone or failures of conventional grafts and for lunate necrosis. Two pedicled VBT are frequently used for the scaphoid, a graft harvested from the antero-medial part of the distal radius (Kuhlmann) or a graft harvested from the postero-lateral part of the distal radius (Zaidemberg). For the trapezo-metacarpal joint, two new articular pedicle transfers can be used in some cases of trapezo-metacarpal arthritis. At the hand level, VBT are used for distal bone loss, "en bout de chaîne". Bone vascularisation is indispensable to preserve sub-chondral bone and avoid articular destruction. In children VBT are necessary to preserve the growth cartilage.

Microsurgical reconstruction of the scaphoid and lunate bones with small, free vascularized iliac crest bone grafts

The primary surgical goal in repairing a scaphoid nonunion, particularly one associated with avascular fragments, or reconstructing the lunate is to prevent progressive carpal collapse. In patients with persistent nonunion of the scaphoid and progressive aseptic necrosis of the lunate bone, reconstruction can be managed with a small microvascular iliac crest bone transfer. This retrospective study reports on the anatomical fundamentals, the operative procedure (particularly the harvesting of the bone flap and microsurgery), the assessment of the viability of the bone graft and the postoperative results in 80 out of a total of 210 patients on whom the surgery had been performed. From 1985 until 1998, 210 carpal bone reconstructions (134 scaphoid bones and 76 lunate bones) were performed using small, free vascularized iliac crest bone grafts. Of these, 80 patients were preoperatively evaluated and postoperatively followed up clinically and by means of conventional radiography and magnetic resonance imaging (MRI). The total rate of viability and bony union was 91.2%. This means a bone flap loss-rate and, consequently, a progressive arthrosis/necrosis/persistent nonunion of 8.8%. The patients who had vital reconstructed carpal bones did not report pain, but motion and grip strength were decreased as compared with the uninvolved side. This procedure offers stability and vascularity to treat avascular scaphoid nonunion and has proved beneficial in achieving union in avascular scaphoid pseudoarthrosis and lunate necrosis. It can be considered to be the definitive alternative technique. The high rate of union and the absence of progressive carpal arthrosis are the best evidence for the vascularity of the bone graft.

The osseofasciocutaneous flap: a new method to transfer fibula along with a sufficient amount of skin

We describe a new technique of bone transfer, using a deep fascial blood supply to transfer bone together with a large area of skin. The viability of this flap and further confirmation by isotope scanning have established that the bone transfer is vascularised. This provides a simple solution to the complex problem of leg trauma with massive skin and bone loss.

Bone grafting to the jaws with special reference to reconstructive preprosthetic surgery. A historical review.

The first report on the transfer of fresh bone was in 1668 when van Meekeren described how a Russian surgeon had repaired a soldier's skull defect by implanting dog bone with good results. Discovery of the anesthetics, nitrous oxide and ether, in addition to the introduction of antisepsis opened up new surgical possibilities and made bone grafting a possible clinical procedure. Around the turn of the last century, papers began to appear on the restoration of continuity defects of the mandibula. In the future it will be possible to acquire a living graft in the exact size desired based on a 3D reconstruction of a CT scan of the defect.

Bimaxillary osteodistraction for the treatment of facial asymmetry in adults

Nine patients with hemifacial microsomia or facial asymmetry were treated between April 1998 and November 1999. The ages of the patients ranged from 21 years to 45 years (mean: 24.6 years); six were female and three were male. The follow-up period ranged from 6 months to 24 months (mean: 15.3 months). The operative procedure was based on Ortiz Monasterio's simultaneous mandibular and maxillary distraction technique. This technique frees only the pterygo-maxillary junction of the affected side, thereby leaving the nasal septum and the pterygo-maxillary junction of the unaffected side intact. It also uses an external corticotomy on the mandible. In contrast, we modified Ortiz Monasterio's method by using a complete LeFort I osteotomy with both a complete separation of the pterygo-maxillary junction and a mandibular osteotomy to avoid any resistance during distraction. In one patient with scleroderma and severe atrophy of the mandible and soft tissue on the right side of the face, a free scapular osteocutaneous flap was used; 1 month later we performed simultaneous distraction of the maxilla and transfer of the scapula bone to the mandible. In one patient with hypoplasia of the zygoma, zygoma expansion was also performed simultaneously. Bidirectional distraction was performed in one patient and intraoral devices were applied in three patients. After a latent period of 5 days, distraction was performed at a rate of 1 mm per day. After a consolidation period of 6-8 weeks, the intermaxillary fixation and distraction devices were removed. Preoperatively, the deviation of the occlusal plane ranged from 8degrees to 13 degrees (mean: 10.5 degrees); the distraction distance ranged from 7 mm to 17 mm (mean: 13 mm). In two patients there was radiologic evidence of relapse 6 months after distraction, but no significant change in facial appearance was observed. Seven patients maintained a stable preoperative occlusal relationship and the preoperative lateral open bite was improved postoperatively in two patients. The postoperative occlusal plane was between 0 degrees and 1 degree in every case.

Surgical Correction of the Face with the Square Jaw and Weak Chin: Angle-to-Chin Bone Transfer

Discussion by S. Anthony Wolfe, M.D. Received for publication February 22, 2001. S. Anthony Wolfe, M.D. 1444 N.W. 14th Avenue Miami, Fla. 33125

Surgical correction of the face with the square jaw and weak chin: angle-to-chin bone transfer.

A square-jawed face with a prominent mandibular angle gives a strong, masculine impression. In women, this is an aesthetic problem that is often due to a protruding hyperostotic bone at the angle of the mandible, which can be successfully treated with a mandibular angle osteotomy and bony contouring through an intraoral approach. When square jaws are combined with a weak or deficient chin, the facial balance becomes worse, accentuating the vertical and horizontal lower facial disproportion. To correct these combined problems at the same time, the protruding mandibular angle was resected by a curvilinear or tangential osteotomy, and the bone from the mandibular angle osteotomy was used as an interpositional bone graft to augment a vertically or horizontally deficient chin after a horizontal osteotomy of the chin. From 1991 to 1998, 33 consecutive patients with a prominent mandibular angle and short chin underwent this operation. The square appearance of the lower face was converted to a more graceful, ovoid, and thinner contour. The mean amount of horizontal and vertical chin movement was 4.3 mm and 7.0 mm, respectively. The aesthetic results, as determined by both patient and surgeon, were satisfactory in 30 of 33 cases during the follow-up period of 6 month to 6 years, with minimal complications. The advantages of this technique include reduction of wide bigonial distance and smoothening of square lower facial contour; vertical and horizontal elongation of the chin and the lower face, which enables visual compensation for sagittal weakness of the lower face; improvement of overall facial balance with a single operative session; no additional bone graft donor-site and morbidity. (Plast. Reconstr. Surg. 108: 225, 2001.)

Upper Extremity Microsurgery

After studying this article, the participant should be able to: 1. Understand the indications for free flap coverage of the upper extremity. 2. Know the advantages and disadvantages of the flaps discussed. 3. Have a basic understanding of the anatomy of the flaps discussed. 4. Have a variety of options for free tissue transfer.The application of microsurgical tissue transfer to reconstruction of the upper extremity allows repair of significant bone and soft-tissue defects. Through the years the approach has changed from one of simply getting the wound covered to primary reconstruction to preserve or regain function. A wide variety of free flaps offers the potential to reconstruct nearly any defect of the arm and hand. Vascularized bone transfer can be utilized to repair large bony defects, while innervated free muscle transfer can replace missing muscle function. The total array of flaps and their indications is beyond the scope of a single discussion, but this article focuses on a few flaps that have found application for coverage and functional restoration in the hand and upper extremity.

Tumor surgery

Surgery is still the primary therapeutic approach in treatment of tumors in the head and neck area, dating back to the early nineteenth century. More than 150 years ago, hemimaxillectomies and mandibular resections as well as hemiglossectomies were already performed by leading surgeons. The block principle we are now following dates back to Crile, who also established the principle of cervical lymph node dissection. Ablative oncologic surgery has always been closely linked with plastic and reconstructive surgery, rendering radical surgical interventions possible without disfiguring patients. The development of facial reconstructive surgery proceeded in stages, in the first instance as secondary reconstruction using tube pedicled flaps. The change to the concept of primary reconstruction occurred via arterialized skin flaps and myocutaneous flaps to the widely accepted and performed free tissue transfer. Free bone grafting, inaugurated earlier and still representing the majority of bone grafting, has been supplemented for certain reconstructive purposes by free vascularized bone transfer from various donor sites. Although the five-year-survival rate of carcinoma of the oral cavity has remained unchanged in the past 30 years, distinctive improvements in tumor surgery can be recorded. This is primarily based on improved diagnostics such as modern imaging techniques and the refinement of surgical techniques. The DOSAK has worked out distinctive guidelines for effective ablative oncologic surgery. Surgical approaches offering wide exposure and carrying low morbidity play a decisive role in radical resections. For this reason, midfacial degloving offers an essential improvement for the resection of midface tumors, especially from an aesthetic point of view. Tumors situated deep behind the viscerocranium at the skull base can be clearly exposed either through a lateral approach following a temporary osteotomy of the mandibular ramus or a transmandibular, transmaxillar, or transfacial approach with minimal morbidity. Concerning the concept of neck dissection, radical techniques are more and more abandoned in favor of a more conservative procedure. Actual inquiries concerning present surgical procedures as to the surgical strategy in "N(o)-neck" or marginal and segmental resection in mandibular adherent carcinomas demand scientific clarification.

Strategic considerations on the configuration of free flaps and their vascular pedicles combined with Ilizarov distraction in the lower extremity.

For the injury of the lower leg associated with both bone and soft-tissue defect, the combined free flap and the Ilizarov distraction method were described as a useful treatment modality. During the procedure of distraction, however, revisions were frequently needed to change the pin position or to change the flap configuration. In case of flap ischemia, distraction should be delayed or abandoned. Then, a vascularized bone transfer might be necessary. To avoid these complications and achieve safe distraction, the configuration of the flap with its vascular pedicle should be carefully planned in terms of the future bony lengthening procedures and the concomitant soft-tissue changes of the lower leg. According to the response of local tissue to the distraction process, the lower limb can be divided into four compartments (active mobile, passive mobile, receptive, and restrictive). The configuration of the transferred free flap with its vascular pedicle can be classified into five types. To minimize the undue forces to the vascular pedicle and reduce the possibility of vascular compromise, the transferred free flap should have the configuration that its vascular pedicle lies in the territory of the mobile compartment. In performing free-tissue transfer combined with the Ilizarov method in the lower extremity, the configuration of the flap with its vascular pedicle should be carefully planned, and the characteristics of lower leg tissue should be kept in mind during the distraction.

LENGTHENING IN FREE VASCULARIZED FIBULAR GRAFT

A free vascularized fibular bone transfer was successfully performed in a 1-year-old child to reconstruct the loss of the right humeral shaft following neonatal osteomyelitis. Subsequent growth of the child resulted in gross arm length discrepancy, with associated functional deficits. Callostatic distraction-lengthening of the vascularized fibular graft was carried out to compensate for this limb length discrepancy by using an Ilizarov external fixator. Lengthening of 6 cm over a 3-month period, representing a 75% increase in the original length of the transplanted fibula, was achieved. Active bone regeneration, good corticalization and endosteal medullary cavity formation was observed in the lengthened fibula. The combined modalities of vascularized bone transfer and Ilizarov callostatic distraction-lengthening offer a solution for reconstruction for large segmental bone loss associated with growth arrest of the epiphyseal plates in children.

Versatility of vascularized fibula and soft tissue graft in the reconstruction of the mandibulofacial region

The anatomical region “laterodorsal calf” with the fibula, the flexor muscles and the overlying skin served by the peroneal vessels, is a suitable donor region particularly for combined microsurgical transfer of bone and soft tissue. In a five and a half year period, 59 reconstructions, 39 (66%) with and 20 (34%) without soft tissue transfer, were performed. The versatility and the functional and esthetic results after osseous, osteocutaneous, osteomuscular and osteomyocutaneous tissue transfer are presented.

Oromandibular reconstruction using a third free flap in sequence in recurrent carcinoma

Successful results of a second microsurgical reconstructive attempt have been reported previously in recurrent oral carcinoma. However, the feasibility of a third free flap following a third excision has remained to be determined. Six oral carcinoma patients with multiple recurrences, surgical excisions and free flap reconstructions on three separate occasions are presented. Resections had a curative intent in all cases in the first and second ablations and in four of the six cases in the third one. Five radial forearm flaps and one double free flap were used for the first reconstruction. During the second reconstruction two radial forearm, two fibula osteoseptocutaneous, one double free flap and one rectus femoris flap were used to reconstruct the larger defects resulting from excision of the recurrent tumours. However, no vascularised bone transfers were performed following the third excision and soft tissue free flap plus plate option was used for segmental mandibular defects. There was one partial flap loss among 21 free flaps performed. Three patients died within an average of 8 months following the third reconstruction while the others remained alive, surviving an average of 6 months. In conclusion, a third free tissue transfer for reconstruction in multiply recurrent oral carcinoma was found to be feasible, safe and effective. The use of free flaps contributed to the prevention of complications in these difficult cases and enabled the patients to spend the remaining days of their lives outside hospital.

The Angular Branch of the Thoracodorsal Artery and Its Blood Supply to the Inferior Angle of the Scapula: An Anatomical Study

An anatomical study of the thoracodorsal arterial system was performed; it focused on the angular branch. The aim of the study was to document the anatomical variations of this pedicle and to delineate the area of supply to the inferior angle of the scapula with a view to free bone transfer. A total of 81 cadaver dissections were performed; they revealed the constant presence of the thoracodorsal artery and four vascular patterns of origin of the angular branch. Selective India ink perfusion studies performed on 11 sides in six fresh cadavers demonstrated a reliable supply to the inferior angle of the scapula to the extent of 6 cm of the vertebral margin and 3 cm of the lateral margin of the scapula. Histologic analysis of sections of this region of the scapula confirmed the presence of ink within the periosteal, cortical, and medullary vascular channels, implying the viability of this area of bone if transferred based on the angular branch.

Bone repair techniques, bone graft, and bone graft substitutes.

This paper reviews the techniques and materials (bone graft and bone graft substitutes) that currently are used to treat nonunions and bone defects. The techniques reviewed are intramedullary nailing, plating, distraction osteogenesis, and electric stimulation. Bone graft and bone graft substitutes reviewed are as follows: vascularized bone transfers; autogenous bone graft; autogenous bone marrow; dimineralized bone matrix; growth factors; calcium sulphate; calcium phosphates; and allograft. The goal of management of fractures, nonunions, and segmental bony defects, is the return of function as quickly and completely as possible. Techniques and management strategies constantly are evolving to accomplish this goal. This paper reviews the history, indications, and limitations of bone repair techniques, methods of bone grafting, and materials available as bone graft substitutes.

Norian SRS Cement Augmentation in Hip Fracture Treatment

Bone quality, initial fracture displacement, severity of fracture comminution, accuracy of fracture reduction, and the placement of the internal fixation device are important factors that affect fixation stability. New high strength cements that are susceptible to remodeling and replacement for fracture fixation may lead to improved clinical outcome in the treatment of hip fractures. Norian SRS is an injectable, fast setting cement that cures in vivo to form an osteoconductive carbonated apatite of high compressive strength (55 MPa) with chemical and physical characteristics similar to the mineral phase of bone. It can be used as a space filling internal fixation device to facilitate the geometric reconstruction, load transfer, and healing of bone with defects and/or fractures in regions of cancellous bone. Furthermore, this cement can improve the mechanical holding strength of conventional fixation devices. Use of this material potentially could improve fracture stability, retain anatomy during fracture healing and improve hip function, thus achieving better clinical outcomes. In vivo animal studies have shown the material's biocompatibility, and cadaveric studies have shown the biomechanical advantage of its use in hip fractures. Initial clinical experience (in 52 femoral neck fractures and 39 intertrochanteric fractures) showed the potential clinical use of this innovative cement in the treatment of hip fractures.

高齢者に対するマイクロサージャリーによる機能再建術の検討

As the number of elderly in our population increases, the number presenting for microsurgical reconstruction is also likely to increase. This study was undertaken to further define the risks of the elderly population with regard to microsurgical reconstruction.Since September 1995, 9 patients older than 60 years underwent reconstructive microsurgery in our hospital. The procedures consisted of 5 digital and palmar replantation in 4 patients, pedicled flap transfer in 3 patients, pedicled vascularized iliac bone transfer in 1 patient and popliteal vascular anastmosis in 1 patient.As a result, 1 replantation failure and cardiac failure leading to death in 1 patient were observed. Three psychologic disturbances and 1 case of Crohn's disease were seen after surgery.Reconstructive microsurgery in the elderly is a feasible procedure, however it is important for the reconstructive surgeon to be familiar with the medical problems inherent in the elderly.