Vascularized bone grafts for post-traumatic defects in the upper extremity

Abstract

Vascularized bone grafts (VBGs) are widely employed to reconstruct upper extremity bone defects. Conventional bone grafting is generally used to treat defects smaller than 5–6 cm, when tissue vascularization is adequate and there is no infection risk. Vascularized fibular grafts (VFGs) are mainly used in the humerus, radius or ulna in cases of persistent non-union where traditional bone grafting has failed or for bone defects larger than 6 cm. Furthermore, VFGs are considered to be the standard treatment for large bone defects located in the radius, ulna and humerus and enable the reconstruction of soft-tissue loss, as VFGs can be harvested as osteocutaneous flaps. VBGs enable one-stage surgical reconstruction and are highly infection-resistant because of their autonomous vascularization. A vascularized medial femoral condyle (VFMC) free flap can be used to treat small defects and non-unions in the upper extremity. Relative contraindications to these procedures are diabetes, immunosuppression, chronic infections, alcohol, tobacco, drug abuse and obesity. The aim of our study was to illustrate the use of VFGs to treat large post-traumatic bone defects and osteomyelitis located in the upper extremity. Moreover, the use of VFMC autografts is presented.

Free Fibula Flap for Extremity Oncologic Defects: Factors Influencing Union and Functional Outcomes

“…Although the fibula flap's clinical use for limb salvage procedures has been demonstrated in several case series, outcomes have not been fully elucidated. 2,[5][6][7][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] Despite the high complication rate associated with oncologic limb salvage, the eventual outcome is largely favorable and predictable: our study found a bony union rate of 91.7% at a mean time of 15.7 months, with no amputations and only five patients requiring conversion to a modular endoprosthesis. All patients were able to bear weight with their reconstruction, with full weightbearing achieved at a mean of 16 months.…”

Free Vascularized Fibular Flap with Bilateral Bipolar Latissimus Transfer for Upper Extremity Reconstruction

“…15,16 Vascularized bone grafts are indicated in cases like ours where the bone defect is too large for local osteogenesis (>5-to 6cm bone defect), cases of nonunion, poor local vascularization, or in avascular necrosis [17][18][19][20][21] . Use of the medial femoral condyle VBG has also been reported for humeral bone reconstruction 19 ; however, FVFF was favorable for our patient because of its long pedicle, need for 14 cm of length, strong cortical structure, and ability to harvest a composite osteocutaneous flap for additional soft-tissue coverage. The FVFF at the recipient site has been shown to appropriately hypertrophy with increased weightbearing-an additional functional benefit 22,23 .…”

“…The Capanna technique attempted to mitigate this by combining allograft with an FVFF to properly fix and provide nutrients to the allograft. 15,16 Vascularized bone grafts are indicated in cases like ours where the bone defect is too large for local osteogenesis (>5-to 6cm bone defect), cases of nonunion, poor local vascularization, or in avascular necrosis [17][18][19][20][21] . Use of the medial femoral condyle VBG has also been reported for humeral bone reconstruction 19 ; however, FVFF was favorable for our patient because of its long pedicle, need for 14 cm of length, strong cortical structure, and ability to harvest a composite osteocutaneous flap for additional soft-tissue coverage.…”

Vascularized Bone Graft Reconstruction for Upper Extremity Defects: A Review

“…2 9 23 24 25 Given vascularized reconstruction provides an immediate, robust blood supply, VBGs readily incorporate into the recipient sites and are actively resorbed and remodeled into healthy bone via primary bone healing. 23 25 Furthermore, they contribute immunologically to the recipient site to fight and lower the risk of infection. They can also be raised as osteocutaneous flaps for additional soft tissue coverage when needed.…”

“…VBGs are considered the gold standard for reconstruction when defects are more than 5 to 6 cm, have poor local vascularization, and/or when previous bone grafting has failed, as in the cases of recalcitrant nonunion. 2 9 23 24 25 Given vascularized reconstruction provides an immediate, robust blood supply, VBGs readily incorporate into the recipient sites and are actively resorbed and remodeled into healthy bone via primary bone healing. 23 25 Furthermore, they contribute immunologically to the recipient site to fight and lower the risk of infection.…”