Bone Transfer Research Articles

Neurogenic Thoracic Outlet Syndrome caused by Subacute Clavicle Osteomyelitis

Neurogenic Thoracic Outlet Syndrome caused by Subacute Clavicle Osteomyelitis A rare case of neurogenic thoracic outlet syndrome caused by subacute osteomyelitis (SOM) of clavicle is presented. It was treated by clavicle resection, I rib resection and scalenectomy followed by reconstruction of the clavicle by 6th rib vascularised bone transfer based on serratus anterior muscle as a rotational flap.

Reconstruction of Major Traumatic Segmental Bone Defects of the Tibia with Vascularized Bone Transfers

Segmental bone defects of the tibia after high-energy trauma are limb-threatening conditions. Multiple treatment options have been proposed, including nonvascularized bone grafts, vascularized bone transfers, and callus distraction. A series of 41 patients with major segmental defects of the tibia treated with vascularized bone reconstruction is presented. Forty-one acute or nonacute segmental bone defects of the tibia, 4 cm or more in length, were included in the series. In acute defects (nine cases), a single-stage or two-stage reconstruction with vascularized bone transfer was performed. In nonacute segmental infected bone defects (32 cases), single-stage reconstruction with vascularized bone transfer (seven cases) or two-stage reconstruction with vascularized bone transfer (25 cases) was performed. Reconstruction was performed with fibular flaps in 38 cases (36 contralateral free and two ipsilateral pedicled flaps) and iliac flaps in three cases. Bone fixation was performed with screws and external fixation, with early conversion to locking plate internal fixation. Two fibular flaps needed urgent revision for venous congestion. One fibular flap was lost. Infection after vascularized bone transfer occurred in two delayed reconstructions. Bone healing occurred in all cases. Stress fractures occurred in three fibular flaps. Time to bone union was 5 to 9 months, and time to full weight bearing was 9 to 14 months. The use of vascularized bone transfer in the treatment of major segmental tibial defects was successful in the present series. The management of bone fixation and infection in these cases is discussed.

Salvage of a Lower Extremity by Microsurgical Transfer of Tibial Bone From the Contralateral Extremity Traumatically Amputated at the Ankle Level

The authors present a case of free vascularized transfer of the tibial bone as an osteomyocutaneous flap based on the posterior tibial vessels. A 42-year-old man presented with severe crush injury to bilateral legs. The left tibial bone and soft tissue defect required reconstruction with an osteomyocutaneous free flap. Since the contralateral leg was traumatically amputated at the level of the ankle, a decision was made to harvest a free tibial osteomyocutaneous flap with below-knee-amputation completed. The transfer was achieved successfully with complete survival of the flap and bony union. This report describes the technical and healing aspects of such a unique transfer which may rarely be indicated.

Stable vertical distraction osteogenesis of highly atrophic mandibles after ablative tumour surgery of the oral cavity – a salvage pathway for mandibular reconstruction prior to oral rehabilitation with dental implants

Mandibular reconstruction is still a challenge for surgeons. Distraction osteogenesis (DO) might contribute in certain instances to solve this problem. A principal advantage of DO is the expansion of the surrounding soft tissues that accompanies the bony regeneration. In addition there is no donor site morbidity when compared with reconstruction by autologous bone grafting. However its application may be limited by the thinness of the mandible and the attendant fracture risk. This article describes a technique that combines stable internal fixation with vertical distraction of the alveolar ridge in six patients with critical mandibular thickness after ablative surgery for cancer of the oral cavity. Prior to implant insertion for further prosthodontic restoration stable vertical mandibular distraction produced an additional 11-20mm. Improvement of the surrounding soft tissues, especially intraorally was achieved and dental implants were inserted after bony consolidation. This method can be a useful salvage technique for the augmentation of the atrophic mandible in patients who are not able or willing to undergo the risks and disadvantages of established methods such as free autologous bone transfer or microsurgical techniques.

Osteochondral lesions of the talus

Osteochondral lesions of the talus are becoming common problems in orthopaedics, with increasingly significant short-term and long-term morbidity, for which early diagnosis is critical. Trauma is the most common cause; however, the role of ischemic necrosis, hereditary contributions and hormonal factors are still unknown. Technological advancements in CT, MRI and arthroscopy have allowed us to better diagnose and manage this injury. Nonoperative treatment is limited to small, stable lesions (Berndt and Harty stage I-II). Larger lesions (stage III-IV) can be treated effectively by marrow stimulating techniques such as subchondral drilling, especially for older patients. In younger patients with larger lesions, osteochondral autograft procedures (mosaicplasty and osteochondral autograft bone transfer system) and autologous chondrocyte implantation are available and have promising results.

Die vaskularisierte Knochentransplantation

Vascularized pedicled bone grafts are known since the beginning of the last century. Microvascular bone grafts (free vascularized bone transfer) are known since the beginning of the seventies. In many experimental and clinical studies vascularized bone grafts were compared to their non-vascularized analogues. Because of their own non-interrupted blood supply and thus nearly normal vitality vascularized bone grafts show more rapid fracture healing, more pronounced adaptation to the new mechanical loadings (e. g. graft hypertrophy), higher survival and consolidation rate in poor or bad recipient bed conditions (infection, bad vascularization) and some neovascularization potential on the surrounding tissue. Because of those properties, it became possible to successfully treat a large segmental bone defect by only few operations. As the treatment of complicated combined soft tissue/bone defects led to high complication rate up to 40 to 60% the indications of this method were altered.

Postoperative monitoring of free vascularized bone grafts in reconstruction of bone defects

Vascularized bone transfer is increasingly recognized as a very useful and versatile technique for reconstructing large bone defects. It is especially indicated in patients with challenging conditions, such as nonunions, postoncologic resections, severe trauma, and congenital defects. With increasing experience of reconstructive surgeons, improved microsurgical techniques, and more enhanced flaps, the failure rate of free flaps has been reduced in the last decades. Especially, the early-postoperative period is decisive in the outcome of surgery. Several techniques have been described for monitoring the postoperative viability of microsurgical free vascularized graft, and their sensitivity and reliability continues to be the object of animal experiments and clinical trials. The qualities of an optimal monitoring device should be objective, continuous, noninvasive, safe, reproducible, easily managed, and interpretable for the nursing staff, inexpensive, and a clear indicator of changes in arterial and venous circulation. Presently, no one neither fulfills all of the criteria completely nor is uniformly accepted. In this article, relative advantages and disadvantages of these various postoperative monitoring techniques are discussed.

Vascularized bone transfer for severe injury around the ankle

Severe injuries around the ankle are very difficult to treat. Although technically demanding, vascularized bone transfer has the potential to span bone defects, eradicate infection, and provide soft tissue coverage all in one stage. The fibula is the best choice for transfer as it produces the best results and the least donor site morbidity. Complications are reasonably common as in all complex reconstructive surgery, but in the properly selected patient this approach offers the best chance for salvage of a functional limb. The purpose of this review is to evaluate some of the various options available for managing severe injuries around the ankle with particular focus on vascularized bone grafts, particularly the vascularized fibular bone graft. Selection criteria, surgical timing, potential donor sites, as well as outcomes and possible complications are presented regarding the available options for vascularized bone grafts in managing severe ankle injuries.

The use of vascularized fibular grafts for the reconstruction of spinal and sacral defects

Large segmental defects of the spine may result from tumor resection as well as infection. The surrounding soft tissue in these situations is often compromised due to radiation exposure or infection. In these situations, in which conventional bone grafting has often failed, we have found vascularized fibular grafts an effective method of achieving bony union. The purpose of this study was to review the results of vascularized bone grafting for complex spinal reconstruction using free fibular transfer. We performed a retrospective chart review of all patients who underwent multisegmental spinal reconstruction and pelvic reconstruction using posterior instrumentation and free fibula vascularized bone transfer. Twelve patients underwent 14 free fibula transfers (7 anterior and 5 posteriorly placed) for reconstruction of lumbosacral spinal defects. Preoperative diagnoses included tumor, osteomyelitis, and nonunion. Average number of vertebral body resections was four and posterior instrumentation was used for all arthrodeses. Average duration of follow up was 45 months. Two flaps failed (14%), one resulting in nonunion and the other required salvage with an external hemipelvectomy. All remaining flaps healed at a mean time of 4.5 months (range, 3-10 months). Free fibula transfer for complex spinal reconstruction is a reliable means of obtaining bony union for complex lumbar or sacral resections where traditional bone grafting techniques may not be technically feasible.

Das freie mikrovaskuläre Femurtransplantat zur Behandlung der avaskulären Kahnbeinnekrose

Successful treatment of scaphoid non-union with avascular necrosis of the proximal poles and humpback deformity with carpal collapse is one of the main problems in reconstructive hand surgery. Vascularised bone transfer is one of the most successful techniques for treating these problems. 15 patients with avascular necrosis and non-union of the scaphoid were treated by a microvascular reanastomosed corticocancellous transplant from the distal medial femur. In all patients the success of the microvascular bone transfer was examined by MRI and conventional radiographs immediately, 6 weeks, 3, 6 and 12 months postoperatively. The transplant vitality, signs of reunion and carpal configuration were registered. Furthermore, the Mayo wrist score was employed for clinical evaluation. All transplants remained vital during the follow-up period of one year. Pseudoarthrosis was treated successfully in every case. In 14 cases there was a significant increase of the Mayo wrist score and in one case there was no difference before and after surgery. The microvascular transfer of corticocancellous femur resulted in a high rate of complete healing of scaphoid pseudoarthrosis and correction of the carpal relation.

Double-Barrel Free Fibula Flap for Treatment of Infected Nonunion of Both Forearm Bones

Free vascularized bone transfer is a viable treatment option for extensive bony defects greater than 6 to 8 cm involving scarred, poorly vascularized, or infected recipient beds, such as in chronically infected nonunion of the radius and ulna treated with a double-barrel free fibula flap. Both patients reported here experienced bony union with significant resolution of their symptoms. Although range of motion improved following an aggressive physical therapy regimen, pronation was adversely affected. Chronic infected nonunions or nonunions from radionecrosis involving large segmental defects of both forearm bones are a truly unique challenge and must be treated aggressively to ensure any useful long term function of the injured limb.

Repair of severe lower leg injury at middle and advanced stages

Objective To investigate the methods and therapeutic effects of repairing severe injury to the lower leg at middle and advanced stages. Methods Altogether 45 patients suffering from complications after severe leg injury were investigated. The infections were controlled with vacuum sealing drainage; soft tissue defects, bone defects and nonunion of fracture were treated with microsurgery; large tibial defects were repaired with bone transfer; functions of knee and ankle joints were improved with arthrolysis and arthroplasty. Results Forty-one patients were followed up for 12 to 64 (average, 38) months. All the transplanted flaps survived. Fractures healed in 39 cases, but pathological fractures occurred in 2 cases complicated with chronic osteomyelitis. The function of lower leg was rated as excellent in 20 cases, fine in 15 and poor in 6.with the excellent-to-good rate being 85.4%. Conclusion The severe lower leg injury at the middle and advanced stages can be repaired with a combination of vacuum sealing drainage, micmsurgery, bone transfer, arthrolysis and arthroplasty which can improve the function of the affected limb and decrease the rate of mutilation. Key words: Leg; Trauma; Mierosurgery; Repair

New Horizons in Vascularized Bone Grafts

In 1905, Huntington documented the pedicled transfer of a vascularized fibular bone for the treatment of a segmental tibial defect.[1] Since Huntington's original report, the realm of vascularized bone grafting has grown substantially, particularly with advances in microvascular technique. Vascularized bone grafts provide many benefits over conventional bone grafting including the potential for primary osteogenesis and bone graft hypertrophy while providing enhanced resistance to infection. Newer techniques have added the ability to transfer viable growth plates as well articular cartilage, creating further reconstructive options for the surgeon.

Review: Prevention and Management of Complications of the Ilizarov Treatment Method

Serious orthopaedic conditions such as nonunions and pilon, calcaneal, and Lisfranc fractures, as well as leg lengthening, correction of angular deformities, resection of osteomyelitis, and bone transfer, can be treated successfully with the Ilizarov system. However, complications such as contractures, loss of range of motion, neurologic deficits, articular damage, contractures, and pin track infections can occur. This article describes the costs of limb salvage with the Ilizarov system compared with amputation as well as possible complications and their prevention; it also provides a treatment protocol.

Survival and function in patients with tumours of the head and neck operated on and reconstructed with free flaps

From 1983 to 2003, 131 patients were operated on in the head and neck region with 139 free flaps. They were operated on using a team approach of ear, nose, and throat surgeons and plastic surgeons, and sometimes maxillofacial surgeons. The tumours were squamous cell carcinoma (SCC) 104 (80%), salivary gland cancer 13 (10%), sarcoma 5 (4%), basal cell carcinoma 4 (3%), and others 4 (3%). The staging of the primary intraoral SCC tumours (n=79) was 42% in stage II, 28% in stage III, and 30% in stage IV. The survival of patients with primary oral SCC was compared with a previously treated previous series that gave an increase in tumour-related five-year survival from 48% to 58%. Most flaps were radial forearm flaps (73%). Fifteen percent were vascularised bone transfers. A questionnaire was sent to patients who had had oral/oropharyngeal tumours to measure function and satisfaction, to which 47/49 responded. The results including ability to chew and swallow; speech was good, with a median score of 0.78 (range 1-0).

Salvage of a Below-the-Knee Amputation Level Following a Type-IIIB Open Tibial Fracture

Open tibial fractures present with a wide spectrum of soft-tissue injuries and associated bone loss. Reconstruction of a functional limb is often a complex process that may require soft-tissue reconstruction techniques, including free tissue transfer and its associated risks, to manage the soft-tissue injury. In addition, bone loss, if appreciable, may require massive bone-grafting, bone transport, or free vascularized bone transfer to obtain a durable union. In these cases, successful limb salvage is never guaranteed and an extended period of time may be required to achieve a functional extremity1. Amputation, in these cases, may result in an equally successful functional outcome2. When possible, a below-the-knee amputation is the preferred amputation level because it has recognized functional benefits and is associated with decreased energy requirements for the amputee during activity3. Durable soft-tissue coverage and maintenance of appropriate length of the residual limb are paramount in maintaining an optimal outcome4. Unfortunately, the often high-energy mechanism of injury results in an extensive zone of injury. In some instances, the attainment of adequate bone and soft-tissue coverage may require the use of the same techniques that are utilized for limb salvage, which may result in suboptimal coverage and length to afford functional use of a prosthesis. Faced with these reconstruction dilemmas, amputation at a higher level is often the surgical choice. We report the case of a patient with an open Gustilo-Anderson type-IIIB tibial fracture with extensive soft-tissue loss and an associated bone loss of approximately 17 cm. The patient, not desiring limb salvage with free tissue transfer or bone transport and not wishing to undergo an above-the-knee amputation, elected to undergo a below-the-knee amputation with complex local and osseous soft-tissue reconstruction. An optimal-length residual limb with durable soft-tissue coverage was obtained through the creation of …

3D CT-based contouring of free fibula bone graft for mandibular reconstruction

An anatomically correct mandibular reconstruction after ablative tumour surgery continues to be a challenge even after the advent of microsurgical bone transfer. Complex microvascular reconstruction of the large defects requires accurate preoperative planning. Otherwise, the inappropriate post-operative position of the reconstructed bone would produce gross aesthetic, functional and psychosocial deficits. The precise shaping and positioning of the graft is vital in recreating the aesthetic symmetry of the face.

Navigated implantation after microsurgical bone transfer using intraoperatively acquired cone-beam computed tomography data sets

The use of a combination of intraoperative cone-beam computed tomography (CBCT) and a navigation system via a spinal software platform for the navigated implantation of oral implants after microsurgical bone transfer is described. Intraoperative data sets were generated using Arcadis Orbic 3D (Siemens, Medical Solutions, Erlangen, Germany) and immediately transferred to the VectorVision 2 navigation system (BrainLAB, Feldkirchen, Germany) via the NaviLink interface. In two patients who underwent microsurgical bone transfer for midfacial reconstruction, implants were placed using intraoperatively acquired CBCT data sets for planning and navigated insertion. In both cases, successful realization of the planned implant sites was achieved by the guidance of the drill, leading to rehabilitation of both patients. CBCT data generated by mobile systems are sufficient for the planning of implant position, and can be used for navigated insertion using tools originally developed for spinal surgery.

New Approaches in the Treatment of Critical‐Size Segmental Defects in Long Bones

AbstractSummary: The treatment of large segmental diaphyseal bone deficiencies presents a formidable challenge. The standard treatment modalities such as cancellous bone grafting, cortical allografts, vascularized bone transfer, or distraction osteogenesis exhibit extremely high complication rates, and can culminate in limb amputation or major functional deficits. Recent efforts to develop new treatment modalities for segmental bone loss have resulted in designing new biodegradable polymeric and metallic mesh implants that can incorporate novel osteogenic, osteoinductive, and/or osteoconductive bone healing augmentation materials. These biologic implant composites are capable of further enhancing the efficacy of the treatment applied. This paper briefly reviews the limitations of the currently applied standard treatment modalities for segmental critical size bone defects, provides insight into the specific treatment challenges, and presents the animal and initial clinical results of new alterative treatment approaches that involve the application of cylindrical mesh implants consisting of biodegradable polylactide membranes or titanium cages as a means of potentiating the efficacy of bone graft.

Reconstruction of bony mandibular and maxillary defects with one single transfer of a free fibula osteocutaneous flap

One-stage bone reconstruction of both the maxilla and the mandible with a single bone transfer is unusual in microsurgery. The authors report and describe the surgical technique of an original one-stage bone reconstruction of the maxilla and the mandible in a defect caused by a gunshot injury. The reconstruction was performed with a free fibular osteocutaneous flap. A concomitant maxillo-mandibular defect is uncommon. Gunshot injuries and tumours are the two main causes of this defect. The reconstruction of maxillary and mandibular defects can be a surgical challenge. The reconstruction was performed in one stage with the free transfer of a fibular osteocutaneous flap.