Metal trabecular bone reconstruction system better improves clinical efficacy and biomechanical repair of osteonecrosis of the femoral head than free vascularized fibular graft: A case–control study

In this study, we aim to compare and analyze the biomechanical repair and clinical efficacy of osteonecrosis of the femoral head (ONFH) with the use of metal trabecular bone reconstruction system and free vascularized fibular graft. The study enrolled 66 adult patients from medical records of nontraumatic ARCO 2A–3B stage ONFH. A simple ONFH model without surgical treatment was established in 13 cases, 29 cases were treated with metal trabecular bone reconstruction system, and 24 cases were treated with free vascularized fibular graft. Computer-recognized and extracted femur outlines were imported, and three-dimensional reconstructions were performed. The stress concentration and stress peak value were analyzed, and the Harris score, visual analog scale pain score, and operation status of the above patients were compared. Finally, quality of life assessment was performed using SF-36 scale. Metal trabecular bone reconstruction system provided less operation time, blood loss, and the total length of postoperative hospital stay than free vascularized fibular graft. Metal trabecular bone reconstruction system promoted bone reconstruction, increased bone mineral density and Harris score. The total clinical effective rate of young patients (20–40 years) was higher than that of older patients (41–60 years). Metal trabecular bone reconstruction system provided higher physical component summary, mental component summary, and role/social component summary than free vascularized fibular graft. This study demonstrates that both metal trabecular bone reconstruction system and free vascularized fibular graft can prevent or delay the progression of ONFH, while metal trabecular bone reconstruction system is a better choice because of better short-term clinical efficacy.     

Vascularized fibular graft after excision of giant-cell tumor of the distal radius: wrist arthroplasty versus partial wrist arthrodesis

Several reconstructive procedures have been described for the complete defect of the distal radius that is created after a wide excision of a giant-cell tumor of bone, including hemiarthroplasty using the vascularized fibular head and partial wrist arthrodesis between a vascularized fibula and the scapholunate portion of the proximal carpal row. The objectives of this study are to compare clinical and radiographic results between the partial wrist arthrodesis and the wrist arthroplasty, and to discuss which procedure is superior. Four patients with giant-cell tumors involving the distal end of the radius were treated with en bloc resection and reconstruction with a free vascularized fibular graft. The wrists in two patients were reconstructed with an articular fibular head graft and the remaining two patients underwent partial wrist arthrodesis using a fibular shaft transfer. There was radiographic evidence of bone union at the host-graft junctions in all cases. In the newly reconstructed wrist joint, there was palmar subluxation of the carpal bones and degenerative changes in both patients. Local recurrence was seen in one patient. According to the functional results described by Enneking et al., the mean functional score was 67 percent. The functional scores including wrist/forearm range of motion in the cases with partial wrist arthrodesis were superior to those with wrist arthroplasty. A partial wrist arthrodesis using a vascularized fibular shaft graft appears a more useful and reliable procedure for reconstruction of the wrist after excision of the giant-cell tumor of the distal end of the radius than a wrist arthroplasty using the vascularized fibular head, although our study includes only a small number of patients.     

Prefabrication of bone by use of a vascularized periosteal flap and bone morphogenetic protein.

The purpose of this pilot study was to prefabricate a vascularized bone graft by using a vascularized periosteal flap containing osteoprogenitor cells, a structural matrix, and recombinant human bone morphogenetic protein-2 (rhBMP-2). In a rat model, a periosteal flap vascularized by the saphenous artery and vein was dissected off the medial surface of the tibia. This flap consisted of three layers-periosteum, muscle, and fascia-and was tubed on itself to form a watertight chamber that was then transferred on its vascular pedicle to the groin. A total of 78 vascularized periosteal chambers were constructed in 39 animals and divided into 10 groups. In group 1, the periosteal chamber was left empty. Groups 2, 3, and 4 consisted of the periosteal flap and rhBMP-2, but in group 3, the proximal vascular pedicle was ligated, and in group 4, the flap was harvested without the periosteal layer and turned inside out. Groups 5 through 10 consisted of the vascularized periosteal flap containing several different structural matrices (calcium alginate spheres, polylactic acid, or demineralized bone matrix) with or without rhBMP-2. Animals were killed at 2, 4, or 8 weeks in each group. The presence and density of any new bone formation was evaluated both radiologically and histologically. Significant bone formation was seen only in those periosteal flaps containing rhBMP-2 and either the calcium alginate or polylactic acid matrix. New bone formation increased both radiologically and histologically from 2 weeks to 8 weeks only in the periosteal flaps containing the polylactic acid matrix and rhBMP-2. This preliminary study therefore suggests that four factors-blood supply, osteoprogenitor cells in the periosteal layer, a biodegradable matrix, and rhBMP-2-are required for optimal prefabrication of a vascularized bone graft.     

Periosteal and endosteal blood supply of the human fibula and its clinical importance]

The angioarchitecture of the human fibula was investigated by anatomical dissection. The main artery of the periosteal and endosteal blood supply is the arteria fibularis. The proximal part of the facies lateralis is additionally nourished by a well-built branch of the arteria tibialis anterior. The periosteal branches of the arteria fibularis are most voluminous on the dorsal side in the middle of the fibula. Small plates take care of these branches. For an additional revascularization the well-built branch of the arteria tibialis anterior is proposed. The best anatomical region for a vascularized fibular transfer is at an average of 20% up to 75% of the fibular length.     

The free vascularized anterior rib graft

The free vascularized anterior rib graft, one of the earliest free osseous transfers to the head and neck, has not gained widespread acceptance, perhaps due to early reservations concerning the adequacy of the periosteal circulation. The authors present further laboratory evidence, with clinical cases, attesting to the adequacy of the periosteal circulation alone. Our surgical technique varies from other reports in that a substantially greater length of the internal mammary vessels is harvested and includes the dual periosteal supply by means of the supracostal and intercostal vessels, both branches of the internal mammary vessels. This modification is based on anatomic and angiographic findings. The incorporation of both branches enhances the margin of safety in raising this free bone graft.     

Peroneal flap for reconstruction in the extremity: preliminary report

The peroneal flap has many advantages, such as thin subcutaneous tissue, availability of a large-diameter artery and vein for anastomosis, a long pedicle, and freely designed size and shape. This technique is introduced because it has many outstanding features that allow it to be used to meet a variety of specific needs, such as a free peroneal flap, a peroneal island flap, a free vascularized fibular graft with skin, and a monitoring flap in free vascularized fibular grafts. We have found the peroneal flap to be especially useful.     

Vascularized periosteum associated with cancellous bone graft: an experimental study

The association of a vascularized periosteal flap with a cancellous bone graft was studied on a group of 20 Wistar rats. Ten rats were sacrificed at 6 weeks and seven at 12 weeks (three died prematurely). The behavior of the cancellous bone graft buried in striated muscle and the osteogenic capacity of a simple vascularized periosteal flap also were observed on the same animals. Results of the study are as follows: In 14 of 17 animals, a vascularized periosteal flap wrapped around a cancellous bone graft resulted in new cortical bone formation with little resorption of the initial cancellous graft. A vascularized musculoperiosteal flap has produced a small amount of new compact bone only in 4 of 17 animals. A cancellous bone graft buried into well-vascularized muscle tissue was resorbed (15 cases) or necrotic (2 cases) at 12 weeks. In conclusion, the association of a vascularized periosteal flap and cancellous bone is a better means to produce compact bone than a vascularized periosteal flap alone or an isolated cancellous bone graft.     

Bipedicled vascularized fibula flap for proximal humerus defect in a child

Vascularized bone transfer is becoming the most important option in the many cases in which durable, long-standing bone reconstruction is needed. The transfer of the vascularized epiphyseal plate, although controversial, is advantageous in cases where future growth is needed (i.e., congenital anomalies and tumor resections in children). The use of the free fibular head flap, based on epiphyseal blood supply augmentation, was reported using the anterior tibial artery, or part of it, as the nutritional vessel. By using both the peroneal artery and the specific branch to the fibular head as a bipedicled free flap, we ensured both long-bone fibula reconstruction and augmented blood supply to the head. We report a case of subtotal resection of the humerus due to osteosarcoma in a child that was reconstructed by this method. A preoperative study was conducted on fresh cadavers to identify the specific pedicle of the fibular head. The biceps femoris tendon was used to better stabilize the shoulder joint. The child recovered well and showed good progress in rehabilitation. On follow-up 1 year postoperatively, the shoulder joint remained limited, but showed no signs of substantial remodeling on x-ray. Good elbow and wrist-hand functions were noted. The child developed a single lung metastasis that was also removed. The question remains if the theoretical advantages in bone remodeling, shoulder stability, and bone growth are worth the extra time of surgery or the possible added donor and recipient site complications.     

Folded free vascularized fibula transfer

A technique of improved free vascularized fibula grafting for bone defects up to 15 cm in length is presented with three illustrative cases. By dividing a harvested free fibula graft at its midpoint without dividing its vascular pedicle, two vascularized bone lengths are produced that require only one set of anastomoses. This folded fibula provides twice the cross-sectional area of a single fibula transfer and allows biomechanically improved graft placement. This technique has been successfully used in long bone defects of the upper and lower limbs.     

Free flap from the flexor aspect of the wrist for resurfacing defects of the hand and fingers

The distal portion of the flexor aspect of the forearm has been used as the donor site of full-thickness skin grafts, venous skin grafts, and Chinese forearm flaps. This article describes the use of a free flap harvested from the flexor aspect of the wrist and based on the superficial palmar branch of the radial artery to repair skin defects of the hand and fingers. The advantages of this flap are as follows: (1) the operative field is the same; (2) the radial artery is preserved; (3) it is thin, pliable, and hairless and thus can supply a gliding surface for tendons beneath it; (4) when it involves a palmaris longus tendon and/or the palmar cutaneous branch of the median nerve, it can be used as a vascularized tendon or nerve graft; and (5) in view of the flow-through type of the pedicle of the flap, the digital artery can be reconstructed simultaneously. However, it should be noted that a hypesthesia in the proximal central carpal area remains when the palmar cutaneous branch of the median nerve is harvested as a vascularized nerve graft. The scar of the donor site should be left in the distal wrist crease. If it is not lying in the distal wrist crease, it may suggest that the patient has tried to commit suicide.     

Vascularized bone allografts: in vitro assessment of cell-mediated and humoral responses

The immunologic consequences of transplantation of vascularized bone allografts have not been previously characterized. In this study, knee allografts, both vascularized and nonvascularized, were transplanted from Lewis rats to Brown Norway rats across a strong histocompatibility barrier. A total of 66 transplants and 8 control animals were evaluated. The vascularized knee grafts consisted of 1 cm of proximal tibia and distal femur with a minimal muscular cuff isolated on the femoral vessels, and these were transplanted to a heterotopic, subcutaneous position on the abdominal wall of the recipient rat. Nonvascularized allografts (identical but without anastomoses) were transplanted for comparison. The cell-mediated response was measured by lymphocytotoxicity assay, and the humoral response was measured by cytotoxic antibody assay, both employing 51Cr-labeled target cells. The timing and intensity of the immune response differed according to the type of graft. The vascularized bone allografts generated significant cell-mediated and humoral responses as early as 5 days posttransplant. A significant humoral response in nonvascularized bone allografts was not apparent until day 14, while cell-mediated response in these grafts was variable. These findings were correlated with the histologic appearance of the grafted tissue. Cyclosporine, which was administered to one group of vascularized bone allografts, resulted in the suppression of both types of immune responses. The histologic appearance of this group resembled that of isografts transplanted as controls. The clinical application of vascularized bone allografts may offer significant advantages over nonvascularized allografts in the reconstruction of massive bone defects. Complications such as nonunion, fracture, and collapse of articular segments seen in nonvascularized allograft transplantation may be avoided by preservation of the blood supply to the graft. Characterization of the immune response to vascularized bone allografts may subsequently allow the manipulation of the host and/or graft tissue and promote graft incorporation.     

The "reduced" latissimus dorsi musculocutaneous flap

This report introduces a new device among latissimus dorsi flaps: the "reduced" latissimus dorsi musculocutaneous flap. This flap consists of a proximal musculocutaneous unit and a distal, thin fasciocutaneous unit (the "reduced" portion). The former unit carries a reliable blood supply from the thoracodorsal artery and is able to cover deeper recipient defects, while the latter provides a well-contoured reconstruction of the defect. If needed, an extended portion and/or a thin cutaneous flap can be carried along with the flap according to the defect. In our clinic, we have so far used four pedicled and one free reduced latissimus dorsi musculocutaneous flap in the repair of a variety of defects. All flaps survived, and satisfactory contour of the recipient site was achieved in each case. These clinical experiences clarify that a reduced portion 10 cm in length can be safely carried, and it is suggested that survival of this flap does not depend on its width-to-length ratio.     

A combined rectus abdominis musculocutaneous flap and vascularized iliac bone graft with double vascular pedicles

Although a free vascularized iliac bone graft has been successfully used for the reconstruction of large bone defects, there is a serious problem of how to repair in one stage patients having a large bone defect with a very wide skin defect. A free combined rectus abdominis musculocutaneous flap and vascularized iliac bone graft with double vascular pedicles seems to be one of the most suitable methods for patients having large defects of both bone and skin. Based on our patient, the main advantage of this flap is the extreme width of the skin territory. The pedicle vessels are large and long, and the donor scar can be made in an unexposed area. This flap should be considered for use in one-stage reconstructions of large defects of both bone and skin in the leg region.     

Experimental study and clinical use of the fasciosteal flap

Thirty-seven domestic rabbits, 4 dogs, and 2 freshly amputated human limbs were divided into three groups as three different models of fasciosteal flaps that were taken from the distal radii or the tibiae. Through the methods of histology, fluorochrome bone labeling, and perfusing stain, it was confirmed that viability of the bone graft can be maintained by blood flow by means of the fascial route. This technique was used for treating eight patients with nonunion of such different fractured sites as the scaphoid, the talus, and so forth or with osteomyelitic tibial defects or both skin and tibial defects. With 8 to 15 months of follow-up, the osteomyelitis cleared uneventfully and the fracture healed. Patients recovered their normal function. We think that there are at least three routes for the blood supply from deep fascia to bone: direct blood supply, blood supply by means of bone membrane, and blood supply by means of the intermuscular septum. We feel that the fasciosteal flap is an ideal random-pattern vascularized bone graft.     

Fibular osteoseptocutaneous flap: anatomic study and clinical application

The vascularized fibular graft has been expanded to an osteoseptocutaneous flap by including a cutaneous flap on the lateral aspect of the lower leg. The cutaneous flap can serve not only for postoperative monitoring of the grafted fibula, but also as extra skin coverage to replace substantial skin defects or prevent tight closure of the wound. From anatomic studies of 20 cadaver legs and 15 clinical cases, it has been possible to demonstrate adequate circulation to the skin of the lateral aspect of the lower leg from the septocutaneous branches of the peroneal artery alone. This finding has allowed the development of a new concept and technique to elevate the fibula as an osteoseptocutaneous flap for reconstruction which provides the following advantages: Elevation of the fibular osteoseptocutaneous unit is easy and fast. The cutaneous flap of the fibular osteoseptocutaneous unit can slide almost freely while attached to the paper-thin posterior crural septum without being tethered by a bulky muscle cuff, facilitating the setting of the fibular osteocutaneous flap when the bone and skin are widely separated. Intraoperatively, in a situation in which it is necessary to change from originally selected recipient vessels to ones more suitable, the thin posterior crural septum can be folded around the fibula allowing more flexibility in choice of recipient vessels. The fibular osteoseptocutaneous flap meets the criteria outlined for composite tissue reconstruction of defects of the extremities.(ABSTRACT TRUNCATED AT 250 WORDS)     

Transarticular bony defects after trauma and sepsis: arthrodesis using vascularized fibular transfer

Ten male patients with previously infected bony defects involving both sides of an articulation underwent arthrodesis using a vascularized fibular transfer. The average age of these patients was 38 years (range, 20 to 60 years). The size of the bony defect averaged 9 cm (range, 3 to 21 cm). The ankle was involved in five patients, the knee in two patients, the wrist in two patients, and the elbow in one patient. Nine cases represented septic pseudarthroses (eight after trauma and one after attempted ankle arthrodesis). One patient had a defect across the wrist after debridement of a chronic infection. The patients were followed for an average of 71 months (range, 26 to 144 months). Nine patients healed after the index vascularized fibular transfer, and one patient (ankle arthrodesis) required a second cancellous bone-grafting procedure for delayed union at the junction of the fibula with the talus. Four of seven patients with lower limb involvement had residual leg length discrepancies averaging 5 cm (range, 3 to 8 cm), and one had a persistent 20-degree internal rotation deformity. Two of the patients with upper limb involvement had stiff digits. Five of the nine previously employed patients returned to their former occupation (including heavy labor in four cases). Complications included two wound separations, one case of instability of the donor ankle after removal of a large fibular graft (related in part to a prior injury), and one fracture at the junction of the fibular graft with the local bone 10 months after the index procedure, which united after plate fixation and application of autogenous cancellous bone graft. Arthrodesis using a transfer of vascularized fibular bone represents a viable option for limb salvage in the face of an infected transarticular bony defect.     

The vascularized pig fibula bone flap model: effect of segmental osteotomies and internal fixation on blood flow

The free fibular flap is the flap of choice for reconstruction of complex mandibular defects, although two or more osteotomies may be required to recreate the normal mandibular contour. The effect of these surgical manipulations on the fibula has not been adequately investigated. This study was designed to study the effect of multiple segmental osteotomies and internal fixation techniques on blood flow in the vascularized pig fibula bone flap model. The hindlimbs of 15 Yorkshire pigs were randomized into 1 of 5 groups (n = 6 fibulae per group) consisting of: (1) a nonoperated, in situ fibula; (2) an elevated fibula flap; (3) an elevated fibula flap with two segmental osteotomies; (4) an elevated fibula with two segmental closing osteotomies rigidly fixed with 2-mm miniplates; (5) an elevated fibula with two segmental closing osteotomies rigidly fixed with 2-mm lag screws. Total and gradient blood flow was measured in the bone and soft-tissue components of these flaps using the 15-microm radioactive microsphere technique. The creation of two segmental osteotomies in the vascularized pig fibula bone flap model resulted in a significant decrease (p<0.05) in the gradient blood flow in the segment of bone distal to the second osteotomy. Application of miniplates or lag screws across closing osteotomies resulted in a significant decrease (p<0.05) in total and gradient blood flow to the bone component of the fibulae, as compared with the elevated and osteotomized fibulae groups. An increase in blood flow suggesting a hyperemic response was noted in the bone and soft tissue in the elevated and osteotomized flap groups as compared with the in situ, nonoperated controls. This study established the validity of the pig fibula as a suitable model for investigating the pathophysiology of blood flow changes in the face of standard surgical maneuvers necessary for the restoration of mandibular form and function. The results demonstrated that the creation of multiple segmental osteotomies and the application of internal fixation significantly decreases (p<0.05) blood flow to the distal portion of the flap. The effects of segmental osteotomies and internal fixation on healing and growth of the pig fibula bone flap model are investigated in a separate study.     

The free thoracoumbilical flap for resurfacing large soft-tissue defects of the lower extremity

Both cadavers and living patients were studied regarding a method to resolve large skin defects with bone exposure in the leg, with long-distance thrombosis of the anterior tibial vessels or posterior tibial vessels resulting from traumatic lesions. Forty-six casting mold specimens of cadaveric legs were investigated. There were rich communication branches among the anterior tibial artery, posterior tibial artery, and fibular artery in the foot and ankle, which complemented each other well. Twenty-six patients with large skin defects with bone exposure in the proximal or middle segment of the leg were admitted to the authors' hospital. Among those patients, 19 demonstrated long-distance thrombosis of the anterior tibial vessels or posterior tibial vessels resulting from traumatic lesions. During treatment, a thoracoumbilical flap based on the inferior epigastric vessels was anastomosed to the distal stump of the anterior tibial vessels or the posterior tibial vessels, with reversed flow. All defects were successfully repaired, with good color and texture matches of the flaps. This method can be used for patients with normal anterior tibial vessels or posterior tibial vessels, normal distal stumps of the injured blood vessels, and good reversed flow. The method has the advantages of dissecting blood vessels in the recipient area during the débridement, not affecting the blood circulation of the injured leg, not sacrificing blood vessels of the opposite leg, and not fixing the patient in a forced posture. The muscles are less bulky in the distal one-third of the leg, and the blood vessels are shallow and can be dissected and anastomosed easily. When the flap is used for reconstruction in the proximal two-thirds of the leg, the blood vessel pedicle of the free flap is at a straight angle, without kinking.     

Revascularized periosteal grafts--a new method to produce functional new bone without bone grafting

Rib periosteum was transplanted to the groins of 9 dogs. In half of the periosteal grafts, no microvascular anastomoses were done (free grafts); at 6 weeks after grafting they had become resorbed. The other periosteal grafts were revascularized by microvascular anastomoses of the intercostal vessels to local muscular vessels; at 6 weeks those with confirmed vascular patency had all formed substantial amounts of new bone. Five cm, full-thickness defects were created in the tibias of 10 dogs. The control animals (without grafting) did not heal in two months. However, the experimental dogs, with vascularized periosteal grafts in the defects regenerated their tibias with healthy new bone by 6 weeks--and were walking on them then.     

Free vascularized thin corticoperiosteal graft

This paper describes a new thin corticoperiosteal graft harvested from the medial condylar and supracondylar areas of the femur. It is based on the articular branch of the descending genicular artery and vein and consists of periosteum with a thin (0.5 to 1.0 mm) layer of outer cortical bone. By retaining the cortex, the cambium layer is preserved, and this is thought to have a better osteogenic capacity than vascularized periosteal grafts. This graft was used to treat six patients with fracture nonunion of the upper extremity in which conventional treatment had failed. Uneventful bony union was achieved in all patients within 10 weeks.