To determine union rate in complicated nonunions of the scaphoid treated with a vascularised bone graft. Vascularised bone grafting for scaphoid nonunions (1–2 ICSRA, Zaidemberg technique) has shown initial enthusiasm. Its usefulness has been challenged in cases where the proximal pole of the scaphoid is avascular. Complicated nonunions where the proximal pole is highly likely to be avascular occur in revision surgery and proximal pole nonunions. Fourteen patients were retrospectively followed up. Eight had nonunion following previous scaphoid surgery (two previous ORIF, two previous nonvascular grafting, and four with two previous surgeries). Six patients had no previous surgery for a proximal pole nonunion of 12.5 months’ duration. All patients were male with an average age of twenty-four. Delay from fracture to vascularised bone grafting was twenty months. Graft harvesting was done according to the Zaidemberg technique by two orthopaedic surgeons. CT-scan was used to confirm union in all patients except two who were lost of the follow-up. Twelve patients were followed up by an independent surgeon at a postoperative minimal period of four months. Functional status was assessed with the DASH questionnaire and follow x-rays were performed to determine the presence of degenerative changes. Union was confirmed by CT-scan in eleven of twelve followed patients (92%) at an average time of six months following vascularised graft. Radio-scaphoid osteoarthritis was seen in the one patient that didn’t achieve union. This series suggests that the Zaidemberg graft is useful and may be proposed in situations of revision surgery and proximal pole non-unions. We achieved a high union rate in these complicated nonunions even though there was high likelihood that the proximal pole was avascular. This study stresses the importance of protective immobilization until documented union by CT-scan in this difficult subset of patients

The Authors report their experience in the treatment of scaphoid non-union recurring to the vascularised bone graft technique as described by Zeidemberg. The patients have been treated between the 1999 and 2004. The authors report 22 cases (21 males and 1 female) with an average age of 31 years (from 17 to 42). 10 cases the involved wrist was the right one and in the other 12 cases was the left one.

18 patients presented an avascular necrosis of the proximal fragment of the scaphoid, recognised by the MNR. Two patients have been previously treated by the traditional bone graft technique as described by Matti-Russe, using a cannulated screw for the stabilization of the graft. 16 patients have been controlled at the follow-up (mean 23 months, from 3 to 65). The authors, looking at the good results obtained at the follow-up, feel that this technique might be a very useful one in the treatment of the established scaphoid non-union, mainly in presence of an avascular necrosis of the proximal third of the scaphoid. This technique might also be useful in the treatment of the failure of the classic bone graft technique.

Background Scaphoid non-union remains a difficult problem to treat effectively. Screw fixation and standard bone grafting techniques are good options with union reported in approximately 90% of cases. Studies of the vascular supply to the distal radius have revealed a consistent vascular bone graft source from the dorsal radius. This allows for a pedicled vascularised bone graft to be fashioned, further enhancing the local blood supply to the fracture site.

Methods 14 male patients with a mean age of 30 years (21 to 51 years) and a mean duration of injury of 57 months (15 – 348 months) underwent vascularised bone grafting of established non–union of the scaphoid. The graft was vascularised with a pedicle based on the 1, 2 intercompartmental supraretinacular branch of the radial artery. In addition the long standing deformity resulting from the non-union was corrected by a tri-cortical iliac crest bone graft. (The results were assessed with regard to evidence of union at the fracture site and resolution of pain with return of function). Some of the cases had previous operations with conventional bone graft and failed.

Results Fracture healing was demonstrated radiologically in 9 of 14 cases (64%). 12 of 14 cases (86 %) showed resolution of pain and improvement in function.

Conclusion This technique shows promising results for treating established non-union of the scaphoid, even after long intervals between initial injury and the grafting procedure.

Introduction: We report on our experience of using a vascularised bone graft harvested from the volar face of the radius in the treatment of Kienböck’s disease, with an average follow up of 79 months and a minimum of 5 years.

Materials: We treated 22 patients with Kienböck’s disease. There were 8 women and 14 men whose average age was 31.4 years old (range 18–63 years). Pain was always present and incapacitating in 19 cases. All patients underwent pre-operative tomodensitometry and an MRI, based on LICHTMAN’s classification there were 8 stage II, 10 stage IIIA and 4 stage IIIB.

Methods: The volar carpal artery of the carpus originates from the radial artery and vascularises medial part of the radial epiphysis. Using the same anterior surgical approach it was possible to harvest the pedicled bone graft from this artery and to place it into the lunate for revascularisation. Shortening of the radius was carried out in all cases, as was immobilisation until union of the radius.

Results: Our average follow up is 79 months (range 60–138 months). Pain disappeared completely in 20 cases, and was moderate and tolerable in 2 cases. The average active range of motion was higher than 71°. The average period for return to work was 3.5 months. Post-operative MRI at an average of more than 8 months showed 16 complete revascularisations of the lunate, 5 stabilizations of lesions and one failure which necessitated secondary palliative treatment. There were 4 delayed unions of the radius and one Südeck’s dystrophy. There was a clear correlation between the stage of Kienböck’s disease and the final outcome of surgery.

Discussion: The use of a vascularised bone graft harvested from the anterior face of the radius for the revascularisation of the lunate associated with shortening of the radius has given encouraging results. A longer-term study is necessary.

Following a laboratory rat study where iliac crest was removed, the femoral vessels were placed as a pedicle through the centre of the graft which was wrapped in silastic sheeting and transplanted to the subcutaneous abdominal wall, which showed in all cases bone revascularisation and viability within three weeks. A human study followed in two patients with chronic complex scaphoid non unions where iliac crest was placed in the anterior interosseous pedicle in the proximal forearm. The pedicle was ligated proximally. Four months later, the graft was dissected on its pedicle distally to the scaphoid. In both cases, the scaphoid united and in both cases the bone was viable at biopsy. Rather than this tedious two stage procedure, Russe and Fisk grafts are routinely pedicled with the superficial radial vessels flowing retrograde at scaphoid bone grafting.

At the same time of our rat study, Zaidemberg published his dorso-radial radius vascularised pedicled bone graft on the “irrigating artery”. The details were scant as they were at the oral presentation three years later. The irrigating artery was subsequently beautifully demonstrated in Zancolli’s Atlas of Hand Surgery and this and other dorsal pedicled bone grafts of the radius have been well described by Bishop and colleagues at the Mayo Clinic. The technique of 1-2 SRA (Zaidemberg) pedicled bone grafting is described in detail together with the indications for prefabrication and vascularised pedicled bone grafting and the necessary pre operative imaging information to plan and select the correct procedure.

Autologous bone grafting is a standard procedure for the clinical repair of skeletal defects, and good results have been obtained. Autologous vascularized bone grafting is currently the procedure of choice because of high osteogenic potential and resistance against reabsorption. Disadvantages of this procedure include limited availability of donor sites, clinical difficulty in handling, and a failure rate exceeding 10%. Allografts are often used for massive bone loss, but since only the marginal portion is newly vascularized after the implantation non healing fractures are often reported, along with a graft reabsorption. To overcome these problems, some studies in literature tried to conjugate bone graft and vascular supply, with encouraging results. On the other side, several studies in literature reported the ability of bone marrow derived cells to promote neo-vascularization. In fact, bone marrow contains not only hematopoietic stem cells (HSCs) and MSCs as a source for regenerating tissues but also accessory cells that support angiogenesis and vasculogenesis by producing several growth factors. In this scenario a new procedure was developed, consisting in an allogenic bone graft transplantation in a critical size defect in rabbit radius, plus a deviation at its inside of the median artery and vein with a supplement of autologous bone marrow concentrate on a collagen scaffold.

Twenty-four New Zealand male white rabbits (2500–3000 g) were divided into 2 groups, each consisting of 12 animals. Surgeries were performed as follow:

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Group 1 (#12): allogenic bone graft (left radius) / allogenic bone graft + vascular pedicle + autologous bone marrow concentrate (right radius)

For each group, 3 experimental time: 8, 4 and 2 weeks (4 animals for each time).

The bone used as graft was previously collected from an uncorrelated study. An in vitro evaluation of bone marrow concentrate was performed in all cases, and at the time of sacrifice histological and histomorphometrical assessment were performed with immunohistochemical assays for VEGF, CD31 e CD146 to highlight the presence of vessels and endothelial cells. Micro-CT Analysis with quantitative bone evaluation was performed in all cases.

The bone marrow concentrate showed a marked capability to differentiate into osteogenic, chondrogenic and agipogenic lineages. No complications such as infection or intolerance to the procedure were reported. The bone grafts showed only a partial integration, mainly at the extremities in the group with vascular and bone marrow concentrate supplement, with a good and healthy residual bone. immunohistochemistry showed an interesting higher VEGF expression in the same group. Micro CT analysis showed a higher remodeling activities in the groups treated with vascular supplement, with an area of integration at the extremities increasing with the extension of the sacrifice time.

The present study suggests that the vascular and marrow cells supplement may positively influence the neoangiogenesis and the neovascularization of the homologous bone graft. A longer time of follow up and improvement of the surgical technique are required to validate the procedure.

Purpose: We report our experience with vascularised bone grafts harvested from the anterior aspect of the radius for the treatment of Kienböck disease. We reviewed our patients at minimum three years, average 67 months.

Material and methods: We treated 22 patients with Kienböck disease, eight women and fourteen men, mean age 31.4 years (18–63). Pain was present in all cases and was disabling in nineteen. After systematic computed tomography and magnetic resonance imagine (MRI), the Büchler classification was stage II=8, stage IIA=10 and stage IIIB=4. The transverse anterior artery of the carpus arises from the radial artery and supplies blood to the medial part of the radial epiphysis. The pediculated bone graft fed by this artery can be harvested via the same anterior approach as used to position it in the semilunate for revascularisation. Radial shortening was performed in all cases. The patients were immobilised until the radius healed.

Results: Mean follow-up was 67 months (36–104). Pain resolved completely in all twenty patients. Two patients nevertheless reported moderate pain occasionally. Mean active motion was greater than 71°. Mean time to resumption of former activities was 3.5 months. Postoperative MRI, performed at mean 8 months, demonstrated complete revascularisation of the semilunate in six cases, stable lesions in five, and one failure requiring secondary palliation. There were four cases of late healing of the radial osteotomy and one reflex dystrophy. There was a direct correlation between Kienböck disease stage and final outcome.

Conclusion: Use of a vascularised graft harvested from the anterior aspect of the radius for revascularisation of the semilunate associated with radial shortening has provided encouraging results. Long-term follow-up is needed to verify these results.

Vascularised bone grafts have been most commonly applied in reconstructions of the lower extremities. However, the indications for vascularised bone grafts in the upper extremities have now been expanded, as this technique is becoming more widely appreciated. Between 1993 and 2000, 12 patients who had segmental bone defects following trauma of the forearm received vascularised fibular grafts, among them six men and six women. The average age was 39 years (range 16–65 years). The reconstructed sites were the radius in eight patients and the ulna in four. The length of the bone defect ranged from 6 to 13 cm. In four cases the fibular graft was raised as a vascular osteoseptocutaneous fibular graft. For fixation of the grafted fibula, plates were used in ten cases, screws and Kirschner wires in two. In these two cases an external skeletal fixator was used for immobilisation of the extremity. The follow-up period ranged from 93 to 10 months. In 11 patients grafting was successful. There were no instances of fractures of the grafted bone; however, non-union occurred at the proximal site in one case and only one patient required an additional bone graft. No patient showed evidence of resorption of the graft or symptoms related to the donor leg. No recurrence of local infection was encountered in the patients with previous osteomyelitis. The mean period to obtain radiographic bone union was 4.8 months (range 2.5–8 months). With the use of fibular grafts a segment of diaphyseal bone can be transferred that is structurally similar to the radius and ulna and that is of sufficient length for the reconstruction of most skeletal defects in the forearm. A vascularised fibular graft is indicated in patients with intractable non-unions, where conventional bone grafting has failed or for large bone defects (in excess of 6 cm) in the radius or ulna

Fibula autograft reconstruction, both vascularised (v) and non-vascularised (nv), has been established as a standard method in limb salvage surgery of bone and soft tissue tumours of the extremities. This study retrospectively analyses the results of fibula autograft procedures in general and in relation to vascular reconstruction or simple bone grafting. Since the implementation of the Vienna Tumour Registry in 1969, 26 vascularised and 27 non-vascularised fibula transfers have been performed at our institution in 53 patients, 26 males and 27 females with an average age of 21 years (range 4 to 62 years). Indications included osteosarcoma in 18, Ewing’s Sarcoma in 15, adamantinoma in 5, leiomyosarcoma in 3 and others in 12. Thirty patients were operated for reconstruction of the tibia (8v/22 nv), 7 for the femur (6v/1nv), 7 for defects of the forearm (4v/3nv), 5 for metarsal defects (all v), 3 for the humerus (1v/2nv) and one patient was treated for a pelvic defect (nv). Average follow-up was 63 months (range 2 to 259 months). 43 patients showed successful primary bony union of the autograft. In 12 cases pseudarthrosis indicated further surgical revision, 9 of these patients were primarily reconstructed by use of a nv autograft. 4 patients, 2 with v and 2 with nv reconstruction, suffered a fracture of the transplant and were operated for secondary osteosynthesis. 10 patients with v bone graft developed wound healing disturbances which led to surgery, 2 patients with nv grafts suffered such complications. In 2 patients recurrent infection of a nv and a v fibula transfer led to the implantation of a modular tumour prostheses or amputation, retrospectively. Function of all patients with primary bone healing was rated satisfactory. The use of fibula autograft in limb-salvage surgery under oncological conditions allows biological reconstruction with good functional outcome, especially when primary bone healing is achieved. Vascularised bone grafting seems to have a better outcome in terms of primary bone healing than simple fibula bone grafting, and thus represents a feasible choice in the reconstruction of bone defects from tumour resection