Vascularized Bone Transfer Research Articles

Sarcome d’Ewing mandibulaire chez l’enfant : reconstruction par membrane induite

Ewing's sarcoma (ES) is a malignant bone neoplasm that develops during the first two decades of life, and affects male more than female patients (sex ratio 1.6/1). ES head and neck bone localization is extremely uncommon (2 to 4%). We report a rapid induced membrane reconstruction without primary bone autograft. A 7-year-old boy presented with a 50mm mandibular ES centered on the horizontal branch of the right mandible. This patient was treated by a combination of neo-adjuvant chemotherapy, surgery, and adjuvant radio-chemotherapy, according to the Euro-Ewing 99 protocol. The right horizontal mandibular branch was resected, following induction chemotherapy. A macroplate and a cement spacer were used for the reconstruction, while expecting anatomopathological results. Seventeen days later, we removed the spacer because of scar disunion. The radiographic controls revealed a spontaneous osteogenesis along the macroplate despite the early cement spacer removal. This spontaneously bone growth allowed avoiding a free vascularized bone transfer for the reconstruction. The tissue regeneration potential of this young boy and the cement spacer induced membrane could explain this spontaneous osteogenesis phenomenon. Induced membrane can be added to the therapeutic options for pediatric oncologic mandibular bone loss. It avoids using of a free vascularized bone transfer.

Vascularized bone transfer for the treatment of advanced-stage juvenile lunatomalacia

We present the first two cases of juvenile patients, with advanced-stage lunatomalacia (Lichtman stage IIIB) in the literature, who were successfully treated with vascularized bone transfers. A corticoperiosteal metacarpal II bone graft was used in both patients, accompanied by an external monorail fixateur that was mounted for 6 weeks to achieve temporary wrist distraction. At 1-year follow-up, the patients had no residual pain, full wrist range of motion, and proper radiologic remodeling of the collapsed lunate. Surgically diminished compression forces at wrist level, temporary gain of joint width, as well as high juvenile potential for remodeling might have enhanced lunate revascularization.

Statistical Analysis of Surgical Site Infection After Head and Neck Reconstructive Surgery

Surgical site infections (SSIs) occur at a rate exceeding 40 % after head and neck reconstruction and are due in part to the clean-contaminated surgical field, in which cutaneous fields interact with oral or pharyngeal fields. The aim of this study was to clarify the most important risk factors for SSI and to identify effective strategies for preventing SSI. In 2011 and 2012, 197 patients who underwent head and neck reconstructive surgery were studied at National Cancer Center Hospital East, Japan. The SSI rate, risk factors for SSI, and biological aspects of SSI were evaluated prospectively. A total of 42 patients (21.3 %) had SSIs, and 62 bacterial species were identified at infection sites. Significant risk factors for SSI identified with multivariate analysis were hypoalbuminemia [P = 0.002, odds ratio (OR) = 3.37], reconstruction with vascularized bone transfer (P = 0.006, OR = 3.99), and a poor American Society of Anesthesiologists Physical Status score (P = 0.041, OR = 3.00). Most bacteria identified were species that persist around cutaneous and pharyngeal fields, but multidrug-resistant bacteria were rare. The SSI rate at our hospital is lower than rates in previous studies. To minimize SSI, intervention to improve the patient's perisurgical nutritional status and a more appropriate mandible reconstructive strategy should be considered.

The induced membrane technique for treatment of large segmental or cavitary bone defects: How to maximize the success

Large bone defects are a challenging situation for surgeons, either in acute management, either in case of a nonunion or a septic nonunion. Different treatment proposals have been made since a long time using autologous cancellous bone graft, open-air cancellous Papineau grafting, free vascularized bone transfer, bone transport or allograft (1,2,3). Since 2000, the induced membrane technique, so-called the Masquelet technique, has been described for treatment of such very difficult cases that we can express as treatment of critical sized bone defects (4,5). In the following, we’ll try to give as much details as possible for a positive result when using the induced membrane technique. Clinical based algorithm will be emphasized.

Therapeutic Use of Vascularized Bone Transfer for Bone Reconstruction

Reconstruction of bone is often required for large bone defects and also in cases of impaired bone regeneration. Vascularized bone transfer has been widely used for reconstruction, especially for segmental mandibular defects, and for reconstruction of long bones of the upper limb and lower limb after trauma or after significant bone resection for tumour. It has also been used in cases of scaphoid non-union, cases of congenital pseudarthrosis of the tibia or forearm and chronic osteomyelitis. In this review, the clinical indications, types of graft and outcomes of the procedure are discussed further.

Free Non-Vascularized Fibular Graft for Treatment of Pediatric Traumatic Radial Bone Loss: A Case Report

Various methods, such as vascularized bone transfers, Illizarov bone transport, allogenic bone grafts, bone graft substitutes, are available in treating traumatic bone loss. Free non-vascularised fibular graft is an autografting method that only requires minimal facilities or expertise. However, this method is not popularized due to its avascular property and there is not many reports regarding its use in treating a large traumatic bone loss. We reported a case in our center to demonstrate its possibility of successfully treating the traumatic radial bone loss in pediatric patient. Patient had good recovery with the regain of good range of movement of forearm and there is no harvest site morbidity after two years of follow up. Free non-vascularized fibular graft, pediatric radial bone loss.

Applications of the Medial Femoral Condyle Free Flap for Foot and Ankle Reconstruction

Avascular necrosis (AVN) or persistent nonunion occurs in situations of poor vascular supply. Some specific situations that plague the foot and ankle surgeon are talus nonunion, talus AVN, navicular AVN, and failed ankle arthrodesis with bone loss. The medial femoral condyle (MFC) flap has emerged as a popular source of vascularized corticocancelous bone. We present a series of cases demonstrating the versatility of the MFC flap in complex foot and ankle pathology. A retrospective review was completed of all MFC flaps used in the foot and ankle over the past 5 years. Five patients were identified (average age 48). Surgical indications included talar AVN and ankle arthritis, talar nonunion, and navicular AVN. All patients had undergone conventional bone grafting techniques, which failed, prior to being treated with a MFC free flap; this series of patients did not possess significant medical comorbidities. Fixation techniques included compression screw fixation, plate osteosynthesis, or fine wire external fixation. The average follow-up was 20 months (range 8 to 40 months). There was a 100% flap success rate with no returns to the operating room for thrombosis. The volume of the bone flaps was 5.6 cm(3) (range 1 cm(3) to 12 cm(3)). The average follow-up time was 20 months (range 8 to 40 months). All cases resulted in union, and full weight bearing status was achieved at a mean of 23.8 weeks (range 10 to 52 weeks) postoperatively. Vascularized bone transfer in the form of the MFC free flap was a valuable method for foot and ankle reconstruction. The MFC flap provided an alternative for those defects that were smaller then 3 cm in length. In our experience, for small bone defects requiring vascularized bone, the MFC flap is currently the ideal donor location supplanting the iliac crest. Level IV, retrospective case series.

Pedicle and Free Vascularized Bone Transfers to the Foot and Ankle

Pedicle and Free Vascularized Bone Transfers to the Foot and Ankle

The Superolateral Thigh Flap

There are few references to the reconstructive possibilities of the ascending branch of the lateral circumflex femoral artery other than the tensor fasciae latae muscle flap and the so-called muscle pedicle bone grafting technique. An anatomical study was performed to evaluate the ascending branch of the lateral circumflex femoral artery and its contribution, through direct branches, to the iliac crest and skin. In nine of 20 dissections, a small branch of the ascending branch of the lateral circumflex femoral artery was found to reach the iliac crest in the space defined by the rectus femoris, gluteal muscles, and tensor fasciae latae. After emergence of the tensor fasciae latae pedicle, the ascending branch coursed through an anatomical triangular space before entering the trochanteric skin as a direct terminal branch and running for a considerable distance in a posteroinferior direction in the subcutaneous fat. This pretrochanteric triangle was defined by the tensor fasciae latae, the trochanteric insertions of the vastus lateralis and gluteus medius muscles, and the greater trochanter. The superolateral skin of the thigh can be transferred based on terminal branches of the ascending branch of the lateral circumflex femoral artery. Although inconstant, a small branch of the ascending branch reaches the iliac crest and might support vascularized bone transfer, although more studies are needed to define its role in composite tissue transplantation. This ascending branch might be a good alternative in pedicle or microvascular skin/fat transfer, breast reconstruction, tendocutaneous reconstructions, or composite tissue transplantation. Diagnostic, II.

The Microvascular Corticocancellous Femur Flap for Reconstruction of the Anterior Maxilla in Adult Cleft Lip, Palate, and Alveolus Patients

Free nonvascularized alveolar bone grafting in severe defects of the cleft region often results in poor implant bed conditions. Here an alternative augmentation technique using a new technique of vascularized bone transfer is described. In five patients with clefts of the lip, palate, and alveolus (four unilateral, one bilateral) there was a severe defect of the anterior maxillary alveolar ridge after tooth loss. The patients previously had augmentative surgery one to three times without success. The defect was covered using a microvascular corticocancellous transplant from the medial distal femur. The defects to be corrected measured 2.5 to 4.0 cm long, 1.0 to 1.5 cm wide, and 1 to 1.5 cm high. The microvascular pedicle of the femur bone flap was 3 to 7 cm long. The descending genicular artery was anastomosed to the facial or labial superior artery and the accompanying veins accordingly. In every case, the anastomoses were performed via an intraoral transmucosal approach. There were no serious complications and no flap loss. In all patients the defect was covered by a flap of the correct size and design. All patients were treated with dental implants (13 total) 6 months after successful reconstruction of the ridge. The implants were loaded 4 to 6 months after placement with fixed superstructures. There were good peri-implant conditions and no implant loss. The microvascular osteoperiosteal femur flap can be used successfully in individual reconstruction of segmental defects of the alveolar ridge in adult cleft patients.

Pre-operative planning for mandibular reconstruction - A full digital planning workflow resulting in a patient specific reconstruction

ObjectivesReconstruction of large mandiblular defects following ablative oncologic surgery could be done by using vascularized bone transfer or, more often, primarily with simultaneous or delayed bone grafting, using load bearing reconstruction plates. Bending of these reconstruction plates is typically directed along the outer contour of the original mandible. Simultaneously or in a second operation vascularized or non-vascularized bone is fixed to the reconstruction plate. However, the prosthodontic-driven backward planning to ease bony reconstruction of the mandible in terms of dental rehabilitation using implant-retained overdentures might be an eligible solution. The purpose of this work was to develop, establish and clinically evaluate a novel 3D planning procedure for mandibular reconstruction.Materials and methodsThree patients with tumors involving the mandible, which included squamous cell carcinoma in the floor of the mouth and keratocystic odontogenic tumor, were treated surgically by hemimandibulectomy.ResultsIn primary alloplastic mandible reconstruction, shape and size of the reconstruction plate could be predefined and prebent prior to surgery.Clinical relevanceThis study provides modern treatment strategies for mandibular reconstruction.

Femurrekonstruktion mit kombiniertem autologem Fibulatransfer und Humerus-Allograft

Wide resection far into the femoral metaphysis may be required to treat malignant bone tumors in the pediatric and adolescent patient population. Biological reconstruction using a free, vascularized fibular graft is a well-established surgical technique. A short remaining femoral medullary canal and a relatively small fibula diameter can make fixation of the vascularized bone transfer difficult. Stable fixation and short fusion times, however, can be achieved with the use of an additional humeral allograft and plate osteosynthesis.

The free vascularized fibular graft for bridging large skeletal defects of the upper extremity

Large skeletal defects of the upper extremity pose a serious clinical problem with potentially deleterious effects on both function and viability of the limb. Recent advances in the microsurgical techniques involved in free vascularized bone transfers for complex limb injuries have dramatically improved limb salvage and musculoskeletal reconstruction. This study evaluates the clinical and radiographic results of 18 patients who underwent reconstruction of large defects of the long bones of the upper extremity with free vascularized fibular bone grafts. Mean patient age was 27 years (7-43 years) and mean follow-up was 4 years (1-10 years). The results confirm the value of vascularized fibular grafts for bridging large bone defects in the upper extremity.

Recent updates of surgical techniques and applications of free vascularized fibular graft in extremity and trunk reconstruction

Successful free vascularized bone transfers have revolutionized the limb salvage and musculoskeletal reconstruction. The free vascularized fibula remains the mainstay in bone reconstruction combines the benefits of blood supply, biological potential, and callus formation with its unique biomechanical characteristics offering a supreme candidate for various dissolvable issues. Especially in conditions where there was lack of other applicable method and the free vascularized fibular graft was introduced as the only alternative. Extensive traumatic bone loss, tumor resection, femoral head osteonecrosis and congenital defects have been managed with exceptional results beyond expectations. The present manuscript updates several issues in application of free vascularized fibular graft in extremity and trunk reconstruction. It also highlights tips and pearls of surgical technique in some crucial steps of harvesting the vascularized fibular graft in order to offer a vascularized bone with safety and low donor site morbidity.

Reconstruction of Massive Bone Losses of the Elbow with Vascularized Bone Transfers

Reconstruction of Massive Bone Losses of the Elbow with Vascularized Bone Transfers

Use of non-vascularized autologous fibula strut graft in the treatment of segmental bone loss

Fractures resulting in segmental bone loss challenge the orthopedic surgeon. Orthopedic surgeons in developed countries have the option of choosing vascularized bone transfers, bone transport, allogenic bone grafts, bone graft substitutes and several other means to treat such conditions. In developing countries where such facilities or expertise may not be readily available, the surgeon has to rely on other techniques of treatment. Non-vascularized fibula strut graft and cancellous bone grafting provides a reliable means of treating such conditions in developing countries. Over a period of six years all patients with segmental bone loss either from trauma or oncologic resection were included in the study. Data concerning the type of wound, size of gap and skin loss at tumor or fracture were obtained from clinical examination and radiographs. Ten patients satisfied the inclusion criteria for the study. The average length of the fibula strut is 7 cm, the longest being 15 cm and the shortest 3 cm long. The average defect length was 6.5 cm. Five patients had Gustillo III B open tibial fractures. One patient had recurrent giant cell tumor of the distal radius and another had a polyostotic bone cyst of the femur, which was later confirmed to be osteosarcoma. Another had non-union of distal tibial fracture with shortening. One other patient had gunshot injury to the femur and was initially managed by skeletal traction. The tenth patient had a comminuted femoral fracture. All trauma patients had measurement of missing segment, tissue envelope assessment, neurological examination, and debridement under general anesthesia with fracture stabilization with external fixators or casts. Graft incorporation was 80% in all treated patients. Autologous free, non-vascularized fibula and cancellous graft is a useful addition to the armamentarium of orthopedic surgeon in developing countries attempting to manage segmental bone loss, whether created by trauma or excision of tumors.

La technique de la membrane induite pour les pertes de substance osseuse de la main et du poignet

The induced membrane technique of bone reconstruction initially proposed for long bone defects can be extended to the hand and wrist defects. The two stages procedure is particularly useful in infected lesions or when the viability of the segment is not initially acquired. It avoids to have recurs to vascularised bone transfers which are not reliable in septic conditions and not easily performed in emergency. The induced membrane technique offers great capacities of bone reconstruction whatever the sizes of the defect.

La scintigraphie osseuse dans l’évaluation de la vascularisation osseuse au niveau de la main et du poignet

Diphosphonate bone scintigraphy is used since the 1970s for studying bone pathology; it is increasingly common because of increased physical activity of the population. The disphosphonate uptake in bone requires the preservation of bone vascularity and reflects osteoblastic activity; it allows studying the viability of bone. Using data from the literature and our experience, we tried to take stock of its main uses in routine emphasizing the study of vascular and describe its use in fractures of the scaphoid and in the study of vascularised bone transfers. If the value of scintigraphy is well known, the use made by means of pinhole collimator and the market entry of new and more sensitive detectors with better resolution could allow the side of the imaging anatomy of improving the study of the vascularisation of small bone transfers which are increasingly used, particularly at wrist and hand.

Transfert libre microvascularisé de fibula dans la reconstruction de l’extrémité inférieure du radius

Free vascularized bone transfers are indicated to reconstruct large bone loss, either after traumatism or bone tumor resection. Free vascularized fibular transplant is particularly well designed for reconstruction of large defect of the distal radius. Anatomy is constant and harvesting is versatile and reliable. It may be used as bony transplant alone, osteocutaneous or osteocutaneomuscular. The length of the fibula harvested can be up to 25 cm. In children bone reconstruction, the proximal physis of the fibula can be transferred to allow secondary bone growth but there is a need for double anastomosis of the anteriotibial and the fibular bundles. Donor site sequelae are minimal.

Transfert osseux vascularisé d’épiphyse scapulaire

The vascularized bone transfer of the scapular apophysis was described for the first time by Gilbert and Téot (1982) [1]. The growing pattern of this specific apophysis has large capacity and the plasticity during remodeling is unique. Primarily used for mandibular reconstruction, the scapular crest is also suitable for humeral or femoral reconstruction as well as for carpal stabilization in radial hand malformation, which is considered to be the main clinical indication. The radial hand malformation is characterized by an insufficient ulnar carpal stabilization which leads to luxation and radial deviation of the carpus. Using the vasularized scapular transfer in volar apposition to the ulnar, it enables enlarging the contact surface area with the carpus, thus stabilizing the wrist. Due to the preserved epiphyseal vascularization, good remodeling and integration of the scapular crest is achieved until consolidation takes place.