Early experience in a high complexity Hospital with the vascularized fibular graft in segmental bone defects of the upper limb.
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Published:
Jul 28, 2017
Main Article Content
Abstract
IntroductionReconstruction of bone defects greater than 6 cm in the upper limb is a difficult problem. Some of the surgical procedures described to treat them are: the use of allogeneic bone graft, the Masquelet technique and the vascularized fibular graft (VFG).The VFG has become the most popularized method to treat this bone defects, because of their biological advantages. The aim of this study was to evaluate the rate of bony union and the time to accomplish this union and the complications associated with this technique in a continuous series of patients. Material and methodsA review in our database was performed to identify all patients who underwent reconstruction with VFG for a period of five years. All patients who were treated for defects larger than 6 cm on upper limbs were included. Reconstructions on lower limbs or associated for augmentation stability in shoulder arthrodesis were excluded. Preoperative, intraoperative, and immediate and long-term postoterative variables were analyzed. ResultsDuring the assessment period, 18 patients underwent reconstructive surgery with VFG. Six patients (4 males / 2 females) met the inclusion criteria. The average age was 47 years old (range 16 to 66 years). On average, patients had three previous surgeries (range 1 to 4). The time between the initial trauma and reconstructive surgery ranged from 2 to 21 years (mean 7 years). The causes of the defect were post-traumatic (nonunion) sequel in five patients and oncological disease in a patient with a Giant Cells Tumor. The bone segments involved were the humerus (three patients), radius (two), and ulna (one). The average bone defect was 10 cm (range 6 to 15 cm). An osteocutaneous fibular graft was performed in five cases, and in one case without associated skin flap. In all cases, we used locked fixation plates. The average follow-up was 17 months (range 5 to 40 months). Bone healing was achieved in all cases. Bone healing was on average 16 weeks (range 8 to 22 weeks). Two patients had postoperative complications. One of them had an exposure of hardware. The other one suffered loosening of the internal fixation. None of the patients had complications or functional sequelae in the donor site.ConclusionThe VFG is a valid option in reconstructive surgery of segmental bone defects larger than 6 cm in the upper limb. It has a high consolidation rate, even in cases with multiple previous surgeries or long evolution time. The technical details prevent complications in the donor site.
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Estefan, M. M., Diaz Dilernia, F., Gallucci, G. L., De Carli, P., & Boretto, J. G. (2017). Early experience in a high complexity Hospital with the vascularized fibular graft in segmental bone defects of the upper limb. Revista De La Asociación Argentina De Ortopedia Y Traumatología, 82(3), 170-181. https://doi.org/10.15417/598
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Clinical Research
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References
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7. Heitmann C, Erdmann D, Levin L. Treatment of segmental defects of the humerus with an osteoseptocutaneous fibular transplant. J Bone Joint Surg Am 2002;84:2216–2223.
8. Wood MB. Upper extremity reconstruction by vascularized bone transfers: results and complications. J Hand Surg [Am]. 1987;12:422-7.
9. Guo Q, Xu Z, Wen S, Liu Q, Liu S, Wang J et al. Value of a skin island flap as a postoperative predictor of vascularized fibular graft viability in extensive diaphyseal bone defect reconstruction. Orthop Traumatol Surg Res. 2012; 98(5):582.
10. Gilbert A. Free vascularized bone grafts. Intern Surg 1991;66:27–31.
11. Jupiter JB, Gerhard HJ, Guerrero JA, Nunley J, Levin LS. Treatment segmental defects of the radius with use of the vascu vascularized osteoseptocutaneous fibular autogenous graft. J Bone Joint Surg [Am] 1997;79:542_550.
12. Vail TP, Urbaniak JR. Donor-site morbidity with use of vascularized autogenous fibular grafts. J Bone Joint Surg Am. 1996 Feb;78(2):204-11.
13. Gaskill TR, Urbaniak JR, Aldridge JM 3rd. Free vascularized fibular transfer for femoral head osteonecrosis: donor and graft site morbidity. J Bone Joint Surg Am. 2009 Aug;91(8):1861-7.
14. Soucacos PN, Dailiana Z, Beris AE, Johnson EO. Vascularized bone grafts for the management of nonunion. Injury 2006;37:S41–50.
15. Soucacos PN, Johnson EO, Babis G. An update on recent advances in bone regeneration. Injury 2008;39:S1–4.
16. Soucacos PN. The free vascularized fibular graft for bridging large skeletal defects of the upper extremity. Microsurgery 31:190–197, 2011.
18. Enneking WF, Eady JL, Burchardt H. Autogenous cortical bone graft in the reconstruction of segmental defects. J Bone Joint Surg. 1980;62-A(7):1039–58.
19. Obert L. Induced membrane technique (masquelet technique) to treat bone defects at upper limb prospective multicentre evaluation.Bone Joint J Dec 2014, 96-B (SUPP 19) 47.
20. Villa A, Paley D, Catagni MA, Bell D, Cattaneo R. Lengthening of the forearm by the Ilizarov tecnique. Clin Orthop 1990;250:125137.
21. Emara KM. Ilizarov technique in management of non united fracture of both bones of the orearm. J Orthop Traumatol 2002;3:177180.
22. Adani R. Reconstruction of large postraumatic skeletal defects of the forearm by vascularized free fibular graft. Microsurgery 24:423–429, 2004.
23. de Boer HH, Wood MB. Bone changes in the vascularised fibular graft. JBone Joint Surg Br. 989;71:374-8.
24. Del Piñal F, Innocenti M. Evolving concepts in the management of the bone gap in the upper limb. Long and small defects. J Plast Reconstr Aesthet Surg 2007;60:776–792
25. de Boer HH, Wood MB, Hermans J. Reconstruction of large skeletal defects by vascularized fibula transfer: factors that influenced the outcome of union in 62 cases. Int Orthop. 1990;14:121–8.
26. Gebert C, Hillmann A, Schwappach A, Hoffmann C, Hardes J, Kleinheinz J, Gosheger G. Free vascularized fibular grafting for reconstruction after tumor resection in the upper extremity. J Surg Oncol 2006;94:114.
27. Noaman H. Management of upper limb bone defects using free vascularized osteoseptocutaneous fibular bone graft. Ann Plast Surg. 2013; 71(5):503-509.
2. Taylor G, Miller G, Ham F. The free vascularized bone graft: A clinical extension of microvascular techniques. Plast Reconstr Surg 1975;55:533.
3. Masquelet AC. The Concept of Induced Membrane for Reconstruction of Long Bone Defects. Orthop Clin N Am 41 (2010) 27–37.
4. Hollenbeck S, Levin LS. The current role of the vascularized-fibular osteocutaneous graft in the treatment of segmental defects of the upper extremity. Microsurgery 31:183–189, 2011.
5. Chen Z, Yan W. The study and clinical application of the osteocutaneous flap of fibula. Microsurgery 1983;4:11–16.
6. Mattar R, Azze RJ, Castro Ferreira M, Starck R, Canedo AC. Vascularized fibular graft for management of severe osteomyelitis of the upper extremity. Microsurgery 1994;15:22_27.
6. Heitmann C, Erdmann D, Levin L. Treatment of segmental defects of the humerus with an osteoseptocutaneous fibular transplant. J Bone Joint Surg Am 2002;84:2216–2223.
7. Heitmann C, Erdmann D, Levin L. Treatment of segmental defects of the humerus with an osteoseptocutaneous fibular transplant. J Bone Joint Surg Am 2002;84:2216–2223.
8. Wood MB. Upper extremity reconstruction by vascularized bone transfers: results and complications. J Hand Surg [Am]. 1987;12:422-7.
9. Guo Q, Xu Z, Wen S, Liu Q, Liu S, Wang J et al. Value of a skin island flap as a postoperative predictor of vascularized fibular graft viability in extensive diaphyseal bone defect reconstruction. Orthop Traumatol Surg Res. 2012; 98(5):582.
10. Gilbert A. Free vascularized bone grafts. Intern Surg 1991;66:27–31.
11. Jupiter JB, Gerhard HJ, Guerrero JA, Nunley J, Levin LS. Treatment segmental defects of the radius with use of the vascu vascularized osteoseptocutaneous fibular autogenous graft. J Bone Joint Surg [Am] 1997;79:542_550.
12. Vail TP, Urbaniak JR. Donor-site morbidity with use of vascularized autogenous fibular grafts. J Bone Joint Surg Am. 1996 Feb;78(2):204-11.
13. Gaskill TR, Urbaniak JR, Aldridge JM 3rd. Free vascularized fibular transfer for femoral head osteonecrosis: donor and graft site morbidity. J Bone Joint Surg Am. 2009 Aug;91(8):1861-7.
14. Soucacos PN, Dailiana Z, Beris AE, Johnson EO. Vascularized bone grafts for the management of nonunion. Injury 2006;37:S41–50.
15. Soucacos PN, Johnson EO, Babis G. An update on recent advances in bone regeneration. Injury 2008;39:S1–4.
16. Soucacos PN. The free vascularized fibular graft for bridging large skeletal defects of the upper extremity. Microsurgery 31:190–197, 2011.
18. Enneking WF, Eady JL, Burchardt H. Autogenous cortical bone graft in the reconstruction of segmental defects. J Bone Joint Surg. 1980;62-A(7):1039–58.
19. Obert L. Induced membrane technique (masquelet technique) to treat bone defects at upper limb prospective multicentre evaluation.Bone Joint J Dec 2014, 96-B (SUPP 19) 47.
20. Villa A, Paley D, Catagni MA, Bell D, Cattaneo R. Lengthening of the forearm by the Ilizarov tecnique. Clin Orthop 1990;250:125137.
21. Emara KM. Ilizarov technique in management of non united fracture of both bones of the orearm. J Orthop Traumatol 2002;3:177180.
22. Adani R. Reconstruction of large postraumatic skeletal defects of the forearm by vascularized free fibular graft. Microsurgery 24:423–429, 2004.
23. de Boer HH, Wood MB. Bone changes in the vascularised fibular graft. JBone Joint Surg Br. 989;71:374-8.
24. Del Piñal F, Innocenti M. Evolving concepts in the management of the bone gap in the upper limb. Long and small defects. J Plast Reconstr Aesthet Surg 2007;60:776–792
25. de Boer HH, Wood MB, Hermans J. Reconstruction of large skeletal defects by vascularized fibula transfer: factors that influenced the outcome of union in 62 cases. Int Orthop. 1990;14:121–8.
26. Gebert C, Hillmann A, Schwappach A, Hoffmann C, Hardes J, Kleinheinz J, Gosheger G. Free vascularized fibular grafting for reconstruction after tumor resection in the upper extremity. J Surg Oncol 2006;94:114.
27. Noaman H. Management of upper limb bone defects using free vascularized osteoseptocutaneous fibular bone graft. Ann Plast Surg. 2013; 71(5):503-509.