Vascularized Bone Graft Research Articles

Three-Dimensional Planning for Vascularized Bone Grafts: Implementation and Surgical Application for Complex Bone Reconstruction in the Hand and Forearm

Background/Objectives: Vascularized bone grafts have been successfully established for complex bone defects. The integration of three-dimensional (3D) simulation and printing technology may aid in more precise surgical planning and intraoperative bone shaping. The purpose of the present study was to describe the implementation and surgical application of this innovative technology for bone reconstruction. Methods: This prospective pilot study was conducted between June 2019 and June 2024. For this evaluation, patients who received vascularized bone reconstruction assisted with 3D technology were included. For reconstruction, the free medial femoral condyle (MFC) flap was used as the vascularized bone graft. Patient-specific 3D-printed templates, based on individual 3D simulations according to defect characteristics, were used for surgical planning, including flap elevation, shaping and inset. Results: A total of six patients (five male) with an average age of 39 years (range 19–62 years) and a mean follow-up time of 15 months (range 5–24 months) were analysed. The indications were as follows: avascular necrosis of the carpal bones, a metacarpal defect after tumor resection and pseudoarthrosis after a fractured ulna. Three patients received an osteochondral and three patients received a cortico-cancellous MFC flap. Conclusions: Our evaluation of clinical application revealed enhanced preoperative planning as well as intraoperative performance. Although the implementation for this technology is challenging, the new insights gained in planning and surgical guidance have led us to incorporate this technology into our standard routine.

Cancellous bone harvesting from the distal radius for reconstruction of bone defects in the hand

Extraction of cancellous bone from the distal radius for reconstructive procedures on the hand. All reconstructive procedures on the hand for which acorticocancellous and/or vascularized bone graft or alarge amount of cancellous bone is not required. Acute distal radius fracture, osteosynthesis material embedded in the distal radius, e.g., after palmar plate osteosynthesis of adistal radius fracture, tumor in the distal radius. Removal of cancellous bone from the distal radius radially from the dorsal radial tuberosity via asmall bone window at the base of the second extensor tendon compartment. Wound dressing on the distal radius, elevation of the arm above heart level until swelling has subsided, first dressing change on postoperative day1 or 2,depending on the primary procedure on the hand, dressing until wound healing is complete, removal of the skin sutures around postoperative day14. In 2023, cancellous bone was harvested from the distal radius of 17patients for reconstructive procedures on the hand (6mediocarpal partial arthrodeses, 3acute fractures, 5delayed bone healings, 1pseudarthrosis, 2bone tumors). In all cases, the available amount of radius cancellous bone was sufficient, resulting in satisfactory healing. All patients complained of short-term, slight discomfort at the donor site for the first few days after surgery, which resolved completely. There were no complications at the donor site on the distal radius.

Spino-Plastic Surgery: Addressing Spinal Tumors with New Techniques.

Background/Objectives: Spino-plastic surgery describes a specialized, multidisciplinary approach to addressing various spinal pathologies. The field is the innovative product of a multidisciplinary collaboration between plastic and reconstructive, orthopedic, and neurosurgery. Over the last few decades, this collaboration has borne promising surgical techniques and treatment plans geared toward restoring form, function, and aesthetics in patients with a variety of spinal conditions, including failed fusions, pseudoarthrosis, and the need for oncologic reconstruction. This paper explores the application of spino-plastic surgery in the context of post-sarcoma resection reconstructions, focusing on the efficacy in addressing the unique challenges posed by extensive tissue loss and structural deformities. Methods: Our study reviews a series of cases wherein spino-plastic techniques were utilized in patients with sarcomas of the spine and adjacent structures. We also discuss the technical considerations, including preoperative planning, intraoperative challenges, and overall patient care, that are crucial for the success of spino-plastic procedures. Results: The outcomes demonstrate significant improvements in patient mobility, pain reduction, and overall quality of life. Most notably, spino-plastic surgical techniques help facilitate the restoration of functional anatomy by leveraging vascularized bone grafts and muscle flaps, thereby enhancing long-term stability and reducing the risk of complications such as nonunion or infection. Conclusions: Spino-plastic collaboration represents a pivotal advancement in oncologic treatment, spinal care, and reconstructive surgery, offering new hope for patients undergoing post-sarcoma reconstruction. Further research and refinement of the techniques will only expand their application and improve outcomes for a broader range of patients in the future.

Evaluation of the results of reconstruction of large bony defects of humerus using vascularized bone grafts.

Vascularized bone grafts (VBGs) are currently the main surgical option for the restoration of humeral bone defects particularly when defects are larger than 6cm. Because it offers a strong, rapid blood supply, VBGs easily integrate into the recipient sites and undergo active resorption and remodeling into healthy bone through primary bone healing. Additionally, they support the recipient site's immune system in preventing and reducing infection.The Aim was to assess the outcomes of utilizing vascularized bone grafts to reconstruct large humeral bony defects (greater than 6cm). This study comprised twenty patients with major humeral bony defects treated by vascularized bone grafts. Under general anesthesia, the procedure was carried out with the patient in the supine position for free fibula harvesting or in the lateral or prone position for pedicled scapular graft harvesting. The union rate was 90% and the mean healing time was 7.78±3.04 months. Complications were present in 40% of cases, with non-union being the most common, followed by infection and wound dehiscence. The study suggests that the reconstruction of large bony defects of humerus using vascularized bone grafts is effective, with a predictable healing time and a manageable complication rate.

Successful Secondary Reconstruction and Dental Rehabilitation for a Maxillary Bone Defect with Discontinuity after Partial Maxillectomy: A case report.

Secondary reconstruction of the maxillary defect with discontinuity after partial maxillectomy is extremely challenging due to extensive, severe adhesions between the maxillary sinus membrane and oral mucosa, resulting in no space for the grafted bone and a lack of soft tissue to cover the graft. This case reports a 23-year-old female patient who underwent secondary reconstruction for a bone defect caused by a partial maxillectomy to remove an ameloblastoma that had invaded the maxillary sinus. We incised the existing soft tissue ridge at the bone defect and extensive adhesions below the maxillary sinus to create space for the grafted bone and to form an adequate buccal flap. To ensure the grafted bone's stability and to support the surrounding soft tissues, a cortical bone from the iliac crest was placed beneath the sinus membrane, with cancellous bone grafted underneath, and a titanium mesh was applied at the alveolar region. This approach allowed robust bone regeneration at the graft site, demonstrating dense, well-integrated new bone formation that facilitated successful implant treatment with good primary stability for two implants. This surgical approach, when indicated, can be less invasive than vascularized bone grafts.

Treatment Options for Coronal Plane Fractures of the Lunate in Kienböck Disease.

The treatment for Kienböck disease varies widely based on the status of the lunate. To date, there is no consensus regarding the optimal treatment for patients with coronal plane fractures of the lunate, or Lichtman Stage IIIC. Therefore, the purpose of this study was to assess whether coronal plane fractures of the lunate in Kienböck disease healed after surgical intervention, and to determine the outcomes after surgical fixation of the lunate compared with treatment with salvage procedures. A retrospective review of 36 patients with Lichtman IIIC Kienböck disease was conducted. Patients were classified into lunate reconstruction (vascularized bone graft [VBG] or non-VBG) or salvage procedures (proximal row carpectomy [PRC] or limited fusion). Preoperative and postoperative visual analog scale (VAS) pain, range of motion, grip strength, and Mayo Wrist Score (MWS) were analyzed. Radiographs and computed tomographic scans were reviewed for Lichtman stage, fracture location, union, modified carpal height ratio, Stahl index, and radioscaphoid angle. Thirteen patients underwent lunate reconstruction, 13 underwent limited fusion, and 10 underwent PRC. The overall union rate was 45% after lunate reconstruction, with average time to union of 7 months. There were no differences in union rates between VBG and non-VBG. All 3 groups experienced improvement in their postoperative grip strength and MWS. There were no statistically significant differences in preoperative to postoperative changes in clinical outcome measures between the 3 cohorts; however, when we compared lunate reconstruction with all patients who underwent salvage procedures (limited carpal fusion and PRC), we noted the latter had improved functional outcomes (P = .019). Four patients (31%) in the reconstruction cohort and 2 patients (8%) in the limited carpal fusion group required reoperation at latest follow-up. Union rate of coronal plane fractures in Kienböck disease remains variable. While the proportion of patients requiring reoperation was higher in the reconstruction group, all groups of patients experienced improvement in their clinical outcomes, without a significant difference between cohorts.

Factors Influencing the Success of Non Vascularized Iliac Bone Graft for Mandibular Reconstruction: A Retrospective Study of 26 Cases

Objective: This study aimed to identify the prognostic factors influencing the success of nonvascularized iliac bone grafts for mandibular reconstruction. Methods: This was a retrospective cohort study conducted at a single center, involving 26 patients who underwent segmental mandibulectomy followed by nonvascularized iliac bone grafts between 2012 and 2022 at the Oral and Maxillofacial Surgery Unit, Buddhachinaraj Phitsanulok Hospital. Data were collected by reviewing electronic medical records and radiographic images. Patients who had received vascularized bone grafts or had a history of head and neck irradiation therapy were excluded from the study. The patients were classified into two groups: successful and failed. Success was defined as clinical and radiographic evidence of bone continuity, a graft resorption rate not exceeding 30% of the initial height, and no evidence of chronic infection for at least 6 months. Results: Successful bone grafting was achieved in 19 patients (73.1%). Multivariable risk difference regression analysis identified that the factors influencing graft incorporation were jaw immobilization using reconstruction plates with maxillomandibular fixation for at least 21 days (RD 63.0; 95% CI 33.1, 93.0; p<0.001) and long segmental block graft design (51.3%; 95% CI 16.9, 85.7; p<0.003). A clinically significant factor, although statistically insignificant, was the duration of plate stabilization, which should ideally range from 172 to 232 days prior to plate removal. The sample size constituted a limitation of this study. Conclusions: Nonvascularized bone grafting remains a viable option for reconstructing mandibular segmental defects. The factors influencing graft stability can help improve clinical outcomes.

MRI for Scaphoid Nonunion: Utilization Rates, Factors Associated with Utilization, and Subsequent Vascularized Bone Graft Use

The use of magnetic resonance imaging (MRI) for evaluation of scaphoid nonunion may be an example of low-value imaging for the treatment of scaphoid nonunion. The purpose of this study was to investigate variation in MRI use for scaphoid nonunion, the association of MRI with a vascularized bone graft (VBG) and to develop consensus on MRI use for scaphoid nonunion. We identified patients >18 years of age who underwent scaphoid nonunion surgery between 2010 and 2019 using a claims database. Patients who had, and did not have, an MRI within 90 days prior to their diagnosis of scaphoid nonunion were included and a multivariable analysis was performed to evaluate variation in MRI and VBG use. Subsequently, a literature review was performed, and a preliminary consensus statement was developed pertaining to the routine use of MRI for scaphoid nonunion. A consortium of nine hand surgeons evaluated the importance, feasibility, usability, and scientific acceptability of the statement through a modified RAND Coroporation/University of California, Los Angeles Delphi. Panelists evaluated the statement in two voting rounds with an intervening face-to-face discussion. We identified 1,324 eligible patients with surgical repair of a scaphoid nonunion. Two hundred and sixty-three (19.9%) underwent an MRI within 90 days prior to surgery. Differences in age, insurance type, and comorbidity burden existed between patients who received MRI and those who did not. The MRI cohort was more likely to receive VBG (10.6%) compared to those without an MRI (4.7%). Panelists agreed on the voting domains of the consensus statement and therefore the statement, "There is no benefit of routine MRI/MRA in the treatment of scaphoid nonunion with or without presumed avascular necrosis," was considered valid. MRI use within 90 days of surgical repair of scaphoid nonunion varies, is associated with greater rates of VBG use, and may represent low-value imaging given the lack of sufficient evidence on this topic. As MRI use for scaphoid nonunion varies and may represent low-value imaging, a validated consensus statement may help guide the evaluation of patients with scaphoid nonunion.

Early Postoperative Weight Bearing Following the Reconstruction of Traumatic Complex Tibial Bone Defects by Vascularized Free Fibula and Ilizarov External Fixator: A Case Series.

Post-traumatic tibial bone defects represent a significant challenge to orthopedic surgeons. Various reconstructive methods are available based on associated local soft tissue injury and defect size. Free vascularized fibular graft represents a major successful technique; combined with a rigid Ilizarov external fixator, it allows safe, immediate postoperative weight bearing. In this article, we describe a series of six patients managed according to the previously presented plan, achieving satisfactory results. A series of six patients, all males with an average age of 33.3 years, underwent reconstruction for post-traumatic complex tibial bony defects using contralateral free vascularized fibular grafts and Ilizarov external fixation. Initially, all patients underwent multiple sessions of debridement and a simple pin-to-bar external fixator. The bony defect averaged 15 cm, and the average harvested length of the fibula used for reconstruction was 22.1 cm. All patients started immediate total weight bearing postoperatively, with a mean time of 17 days after bony union Ilizarov was replaced with minimally invasive plate osteosynthesis (MIPO) in all patients, and continued full weight bearing (FWB). During the follow-up period, averaging 19.3 months, all patients achieved bony union with a mean time of 3.75 months. Patients spent an average of 6.4 months in the Ilizarov frame before it was replaced with MIPO; graft hypertrophy occurred in all patients, averaging 52.6%. The combined use of a vascularized fibular bone graft and an Ilizarov frame proves to be a successful and safe approach for immediate postoperative FWB. This yields comparable outcomes in terms of union and function.

Bone Graft and Fixation Options in the Surgical Management of Scaphoid Nonunion.

Scaphoid nonunions are a complex challenge that are frequently encountered by hand surgeons. Because of the tenuous blood supply of the scaphoid and secondary deformities that occur as a result of delayed or unsuccessful treatment, the treatment of scaphoid nonunions frequently requires the use of internal fixation and supplemental bone graft. There are multiple bone graft sources and techniques that can be employed based on the patient, the viability of the proximal pole fragment, and the presence of a deformity. Without osteonecrosis or disruption of the scaphoid blood supply, nonvascularized autologous grafts can be used from the distal radius, proximal ulna, or iliac crest. In cases where there is concern for an insufficient blood supply, vascularized bone graft sources can be employed, including pedicled local grafts and free flap grafts. When there is a nonviable and fragmented proximal pole, using osteochondral autografts has become increasingly used to reconstruct the scaphoid. Bone graft substitutes can additionally be used to supplement the fixation construct. This review focuses on the indications and role of bone grafts in scaphoid nonunions to help augment internal fixation, promote healing, and restore carpal alignment.

Distally based sural flaps for soft tissue defects following traumatic osteomyelitis of lower leg and foot.

This retrospective study aimed to determine the incidence and risk factors for osteomyelitis recurrence and present our experiences in treating traumatic osteomyelitis in the lower leg and foot. We retrospectively reviewed data from 174 patients with distally based sural flaps for treating traumatic osteomyelitis with soft tissue defects in the lower leg and foot from November 2003 to February 2021. Possible risk factors for osteomyelitis recurrence were compared between the osteomyelitis control and recurrence groups. A total of 162 (93.1%) flaps survived uneventfully, while 12 (6.9%) flaps developed partial necrosis. Five patients had a bone defect with an average length of 5cm. The free vascularized bone grafts were performed in two patients, and bone transportations were performed in three patients. All patients were followed up with an average period of 72.8 months. There were 152 patients (87.4%) in control group and 22 patients (12.6%) in recurrence group. The recurrence rates of osteomyelitis were significantly higher when the patient's age was 40 years or more and the duration was 10 weeks or more (P < 0.05). Cierny-Mader (C-M) classification type IV osteomyelitis was also significantly associated with osteomyelitis recurrence (p = 0.049). This flap combined with appropriate osteomyelitis treatment was an effective method to treat traumatic osteomyelitis of lower leg and foot with a soft tissue defect. Both patient age ≥ 40 years old and C-M type IV osteomyelitis were nonnegligible risk factors for osteomyelitis recurrence.

Axial split step osteotomy of free iliac crest flaps for mandible reconstruction: Preliminary results.

Vascularized bone grafting (VBG) is preferred for mandibular reconstruction post-tumor ablation. Although various bone-free flaps are used, their application is compromised by limitations including insufficient bone volume and poor shape. Here, we report mandibular reconstruction using axial split-step osteotomy with an iliac crest-free flap. Over December 2018-November 2020, 12 patients underwent mandibular reconstruction via axial split osteotomy using a free iliac-crest flap. The preoperative iliac-crest length was 5.7-9.5 mm (median, 7.5 cm); the mean post-axial split-osteotomy iliac-crest length increased to 9.59 mm (range, 6.34-15.15 mm). All patients presented with initial healing 2 weeks postoperation; good bone healing was achieved in all grafted flaps by the third month of follow-up. We propose a new axial split-step osteotomy technique using free iliac-crest flaps for mandibular reconstruction. We demonstrated this novel technique's reliability for safe and effective bone lengthening and establishing a reliable occlusal relationship.

Treatment of Kienböck's Disease Using Fourth and Fifth Extensor Compartmental Artery Vascularized Bone Grafts.

This study evaluated the radiological and clinical outcomes of bone grafts using fourth and fifth extensor compartmental arteries (4+5 ECAs) for the treatment of Kienböck's disease. In total, 21 patients (12 men and 9 women; mean age, 41 years; range, 19-59 years) were followed for a mean of 33 months. Radiological images were analyzed for the Lichtman stage, carpal height ratio, radioscaphoid angle, and Stahl's index. Clinical evaluation included range of motion, visual analog scale (VAS) score, grip strength, modified Mayo wrist score (MMWS), Lichtman outcome score, and Disabilities of the Arm, Shoulder and Hand (DASH) score. At the time of surgery, 6, 14, and 1 patients had Lichtman stages II, IIIA, and IIIB, respectively. At the final follow-up visit, grip strength had improved from 65.4% to 79.7%, wrist extension had improved from 43° to 57°, and flexion had improved from 42° to 50°. There were no significant changes in the carpal height ratio, Stahl's index, or radioscaphoid angle. The mean VAS score was 1.7, and the mean DASH score was 6.9. The mean MMWS was 87.9, with excellent and good outcomes in 6 and 11 patients, respectively. Satisfactory Lichtman outcome scores were observed in 81%. Body mass index had a strong correlation and age had a weak correlation with MMWS (coefficient=-0.534, P=.013, and coefficient=-0.393, P=.078, respectively). The 4+5 ECA bone graft is effective for the treatment of Kienböck's disease in young patients with low body mass index. [Orthopedics. 2024;47(6)e292-e296.].

Can Any Proximal Pole Scaphoid Fracture Nonunion be Treated with Arthroscopic Bone Grafting? A Series of Case Reports of Successes in Challenging and Unique Cases

AbstractDue to the unique morphology and tenuous vascularity, proximal pole fractures of the scaphoid are prone to nonunion if neglected. The vascular anatomy and the understanding that the blood flow to the proximal pole is retrograde in nature, has supported the concept of disruption of blood flow to the proximal pole with the possibility of avascular necrosis in a nonunited proximal pole. Historically, surgical management at this stage has favored the use of a vascularized bone graft over a nonvascularized bone graft to achieve union and good outcomes. However, the current literature seems to deviate from the long-standing understanding of proximal pole nonunion and its relationship to avascular necrosis. Not only does it state that avascular necrosis is extremely rare, but it also advocates arthroscopic bone grafting of proximal pole nonunions using morselized nonvascularized bone graft which has been proven to be a highly successful operation. Here, in our paper, we present a short series of some unique but surgically challenging cases of proximal pole nonunion and our successful management by bone grafting and fixing them arthroscopically. Our experience and invariably the experience of many may indicate that arthroscopic bone grafting and fixation may be the correct choice of surgery for proximal pole nonunion of the scaphoid bone.

The Impact of Pronator Quadratus Origin Release on the Clinical Outcomes of Scaphoid Nonunion Patients Treated with Pronator Quadratus Pedicled Bone Grafts.

Background/Objectives: A pronator quadratus pedicled bone graft (PQPBG) is a distal radius volar vascularized bone graft used not only for avascular necrosis of the lunate but also for scaphoid nonunion. Despite its potency and its possession of a muscular shield, this vascularized graft has a disadvantage in that the potential shortness of the muscular leash may limit the distal transfer of the bone graft. Releasing of the pronator quadratus (PQ) ulnar origin was used to enhance the distal mobility of the graft. We aimed to investigate the effect of a PQ release on the surgical outcomes of scaphoid nonunions that were operated on with the PQPBG technique. Methods: Patients with scaphoid nonunion that were treated with PQPBG from 2009 to 2020 were reviewed. Patient demographic characteristics, surgical notes, physical examinations, and radiological evaluation data were collected. Wrist range of motion, grip strength, modified Mayo wrist score, and Quick-DASH score were used to evaluate the outcomes. The included patients were divided into two groups based on the origin release status of their PQ, i.e., with and without release. Results: This study included 37 patients, 17 of whom underwent a PQ release and 20 of whom did not. The failure rates for the two groups were one and four patients, respectively, and there was no significant difference between them (p = 0.11). The postoperative mean wrist extension in the patients with a PQ release was significantly greater than that in the patients without a release (43.5 ± 6.8 vs. 36.5 ± 7.7, p = 0.0038). Although wrist flexion, ulnar deviation, radial deviation, mean outcome assessment scores, and grip strength were greater in the patients with a PQ release than in those without, no statistically significant intergroup differences were observed (p > 0.05). Conclusions: The PQPBG technique is a viable option for achieving bony union in patients with scaphoid nonunion, but it results in the postoperative restriction of wrist extension. PQ release during a graft transfer may have a favorable effect on both bone union and clinical outcomes.

Temporoparietal Fascial Flap Combined With Vascularized Outer Table Calvarial Bone Graft and Entire Temporalis Muscle: A Stable Pedicled Flap for Orbital Floor Reconstruction After Total Maxillectomy.

Orbital reconstruction after total maxillectomy is essential to maintain ocular function and facial contour. Free flap transfer with simultaneous orbital bone reconstruction is a straightforward approach; however, it is challenging in medically unstable patients with multimorbidity. The authors developed an easily harvested temporoparietal fascial flap combined with vascularized outer table calvarial bone and entire temporalis muscle. The authors applied this technique in an 81-year-old patient with multiple comorbidities who required orbital floor reconstruction following total maxillectomy. Intraoperative indocyanine green fluorescence imaging confirmed excellent perfusion of the temporoparietal fascia, entire temporalis muscle, and calvarial bone. Although the patient developed postoperative local wound infection, the vascularized bone graft resisted infection and preserved the orbital structure without bone exposure. Our technique is minimally invasive and results in a well-vascularized flap for orbital reconstruction after total maxillectomy involving the orbital bone, and particularly beneficial in patients with multimorbidity or at high risk of local infection.

Vascularized bone grafts in spinal reconstruction: An updated comprehensive review

In the past two decades, plastic surgeons have advanced to the forefront of spinal surgery, joining orthopedic and neurosurgeons in the multidisciplinary field of spino-plastics. As the global disease burden grows with an increased incidence of spinal pathologies, vascularized bone grafts (VBGs) define the current frontier of spino-plastic surgery. Vascularized bone grafting involves lifting segments of bone with the muscular attachments but without the inclusion of a named vessel. When compared to traditional nonvascular bone grafts and allografts, VBGs have come forward as a favored technique for complex spinal reconstruction due to the unique opportunity to capitalize on the relationship between the tendons and Sharpey's fibers which maintain blood flow to both the bone and muscular segments. This technique ensures robust autologous tissue rearrangement and also takes advantage of the osteoinductive properties of the bone segments, promoting adequate structural support and the perfusion necessary for efficient direct healing and fusion in intricate spine reconstructions. Another one of the many favorable qualities of VBGs is the diversity of sources available to surgeons. The review explores the role of VBGs in enhancing spinal fusion rates and minimizing morbidity compared to traditional approaches. Additionally, a detailed examination of six common VBG sources-the iliac crest, ribs, medial scapula, occiput, spinous processes, and clavicle is included, highlighting each graft's specific techniques and emphasizing the range of options available to spino-plastic surgeons.

Revolutionizing Adult Micrognathia Treatment: Should Free Fibular Flap Become an Option?

The management of micrognathia in adults necessitates intricate surgical procedures. A vascularized bone graft, notably the free fibular flap (FFF), offers a novel viable solution for repairing significant defects. However, the limited utilization of FFF in adult micrognathia contributes to gaps in understanding its outcomes. A retrospective case series of 2 patients aged 28 and 65, with severe micrognathia due to neglected trauma and osteoradionecrosis, underwent refracture and reconstruction with FFF. Intraoperatively, no significant complications occurred. The FFF were molded to fit the gaps of refractured mandible sites, with similar surgical approaches for both patients. Upon 3 months' follow up, their quality of life (QoL), structural changes, and sensation alterations were assessed and showed promising results. The sensory impairment caused did not hinder the quality of life. Thus, the free fibular flap demonstrates promising outcomes as the initial treatment for adult micrognathia, yielding minimal morbidities and significant functional and anatomic improvements.

The study of the number and localization of the nutrient foramen on the clavicle and its relationship with other clavicle parameters.

Nutrient foramen (NF) is a hole on the long bones that allows the passage of the nutrient artery. The vasculature of the bone is very important for fracture healing and vascularized bone grafting. Therefore, information about the location and number of NFs is important for surgical and clinical practice. The clavicle is the most commonly fractured bone. The aim of this study was to analyze the relationship between the location and number of NFs on the clavicle and other clavicle parameters. This study was performed on 86 dry clavicles of contemporary adult individuals without age and gender records. Some clavicle parameters and NF parameters were measured and the relationship between them was analyzed. Measurements were performed using a digital caliper. Most of the clavicles had a single NF. There was a positive correlation between DFant/DFpost (distance between NF and anterior border/distance between NF and posterior border) and vertical thickness of sternal end (VTs), vertical thickness of thinnest point (VTt) and clavicular thinnest point index (CIt) in all cases (p < 0.05). Sagittal thickness of acromial end (STa), vertical thickness of clavicle (VTc), sagittal thickness of clavicle (STc) and sagittal thickness of thinnest point (STt) were associated with NF counts. The most common localization of NFs was type 2. The NFs were mostly located in the inferior position. Relationships between the number and morphometric characteristics of NFs and some clavicle parameters were determined. It was suggested that the knowledge of the number and morphometric characteristics of NFs is important for the protection of the nutrient artery in orthopedic surgery applications.

Use of Pectoralis Major Myocutaneous Flap for Marginal Mandibulectomy Defects of Oral Cavity Cancers - A 5 Year Institutional Experience.

Segmental resections of the mandible may cause severe functional and aesthetic problems due to continuity loss. The morbidity after mandibular resection can be minimized after microvascular transfer of vascularized bone grafts. Although free flaps have become the gold standard in the past decades for reconstruction of oral cavity defects, regional flaps can also be a reliable option in certain cases, especially for those belonging to the lower socioeconomic corridor and or with coexisting chronic comorbidities which will not allow lengthier procedures. (Milenović A, Virag M, Uglešić V, Aljinović-Ratković N (2006) The pectoralis major flap in head and neck reconstruction: first 500 patients. J Cranio-Maxillofacial Surg 34(6):340-343); (Sabri A (2003) Oropharyngeal reconstruction: current state of the art. Current opinion in otolaryngology & head and neck surgery. 11(4):251-254); (Porcuna DV, Vintró XL, Vilas ML, Olmo AP, Ayala JM, Agustí MQ (2008) Pectoralis major flaps. Evolution of their use in the age of microvascularized flaps. Acta Otorrinolaringologica (English Edition) 59(6):263-268) There are a very few reports of early oral cancers being reconstructed by PMMC flap. In this article, however, we have exclusively reviewed 247 cases of early oral cancer requiring marginal mandibulectomy and their reconstruction with PMMC flap thus justifying the name, the "workhorse flap" even in early oral cancers. This is a retrospective analysis of 5-year patient data collected from our institutional data register of 247 patients undergoing marginal mandibulectomy and reconstruction with PMMC flap between April 2017 to June 2022. No flap loss was reported. No cases were re-explored either for hematoma or for congestion. All patients recovered uneventfully. Although, in this era, free flaps dominate in the soft tissue reconstruction and PMMC is used only in certain advanced oral cancers, our study proves that it can be used safely in effectively in early oral cancer patients as well. Being a quicker procedure, PMMC flap reconstruction should be considered as a valid alternative in early oral cancers requiring marginal mandibulectomy, to overcome the increasing oral malignancy patient load belonging to low socioeconomic regions. To the best of our knowledge, this is the largest data ever published.