MICROVASCULARIZED FIBULAR BONE GRAFT IN POST TRAUMATIC RECONSTRUCTIVE SURGERY OF THE UPPER LIMB

Abstract

Background: The reconstructive surgery of the upper limb is able to avoid an amputation and a severe functional impairment. Nevertheless the therapeutic challenge is difficult because of the diversity of the injuries and the complex function of the upper limb.

Aim: The aim of this study is to assess the results of vascularised fibular bone graft in the immediate and secondary post traumatic reconstructive surgery of the upper limb.

Material and method: Between 1985 and 2006, 16 vascularised fibular bone grafts were performed for 15 post traumatic reconstructions of the upper limb. In this study there were 7 females and 8 males, with an average age of 42 years (20–79). The fibular bone grafting was performed in 9 cases in the immediate post traumatic reconstructive surgery. In 7 cases the fibular bone graft was performed after a first failed surgery, as salvage reconstructive surgery. The transfer was composed of bone and skin in 2 cases, of bone and muscle in 6 cases and of only bone in 8 cases.

Results: The percentage of bone union was 80%. Eight fibular bone graft healed spontaneously, 2 after a additional iliac crest bone grafting. The average duration of bone healing was 6,5 months, from 4 to 12 months. The functional result was good for 10 patients allowing them to go back to their initial activities.

Discussion: In severe bone and soft tissues destruction of the upper limb, a complete reconstruction in one operative session may be performed in order to reduce the time of bone healing and rehabilitation. The micro-vascularized fibular bone grafting may be an excellent therapeutic option. The other techniques as amputation or conventional bone grafting techniques are usually proposed when the vital status of the patient is not compatible with a to extended surgery.

The fibular bone grafting appeared as a very reliable technique with a small morbidity on the donor site. Malunions are frequently described in the literature. It might be partially due to the difficulty in having a stable internal fixation. It has to be as less aggressive a possible on the fibular bone graft vascularisation but has also to offer a good stability. The internal fixation used in these cases was not perfectly adapted for this bifocal fixation of the fibular bone graft on the upper limb. A better device should be developed, with an endomedullary fixation and an axial compression effect.

Conclusion: We recommend this technique in severe trauma cases of the upper limb as salvage procedure at an early stage when is compatible with the initial general status of the patient.