Resection of a primary sarcoma of the diaphysis of a long bone creates a large defect. The biological options for reconstruction include the use of a vascularised and non-vascularised fibular autograft. The purpose of the present study was to compare these methods of reconstruction. Between 1985 and 2007, 53 patients (26 male and 27 female) underwent biological reconstruction of a diaphyseal defect after resection of a primary sarcoma. Their mean age was 20.7 years (3.6 to 62.4). Of these, 26 (49 %) had a vascularised and 27 (51 %) a non-vascularised fibular autograft. Either method could have been used for any patient in the study. The mean follow-up was 52 months (12 to 259). Oncological, surgical and functional outcome were evaluated. Kaplan–Meier analysis was performed for graft survival with major complication as the end point. At final follow-up, eight patients had died of disease. Primary union was achieved in 40 patients (75%); 22 (42%) with a vascularised fibular autograft and 18 (34%) a non-vascularised (p = 0.167). A total of 32 patients (60%) required revision surgery. Kaplan–Meier analysis revealed a mean survival without complication of 36 months (0.06 to 107.3, . sd. 9) for the vascularised group and 88 months (0.33 to 163.9, . sd. 16) for the non-vascularised group (p = 0.035). . Both groups seem to be reliable biological methods of reconstructing a diaphyseal bone defect. Vascularised autografts require more revisions mainly due to problems with wound healing in distal sites of tumour, such as the foot. Cite this article: Bone Joint J 2014;96-B:1258–63

Various kinds of bone have been used as a donor for vascularised bone grafts (VGF) to the upper extremities; among them the fibula has been widely used because of its structural characteristics and low donor site morbidity. Vascularised fibular graft is indicated in patients with large bone defects, bone tumour resection, established or infected non-union, congenital pseudarthrosis, avascular necrosis or bone defects surrounded by scarred, infected and poorly vascularised soft tissue or failure of conventional techniques. Between 1994 and 2003 nine patients were treated with vascularised fibular graft (VFG) and five for reconstruction of upper extremities defects, following trauma of the forearm with failure of conventional treatments. Four were male and one were female; the mean age was 32 years; the reconstructed sites were four radius and one ulna. The mean lengths of the bone defect was 9 cm. All patients were evaluated pre-operatively with angiography and/or magnetic resonance imaging. Two patients had a concomitant arthrodesis of the wrist. The bone graft was stabilised with plates (AO/LCP), screws, K-wires and the forearm was immobilised in plaster or with external fixation for several months. Cancellous iliac bone graft was packed about the proximal and distal junctions. In two recent cases autologous platelet gel was added at the sites of fixation. Bone healing was assessed clinically by the absence of pain and mobility on stress, and radiologically. Patients’ satisfaction and function results were assessed by the DASH questionnaire. After an average duration of follow-up of 48 months (from December 1996 to December 2003), all but one of the patients had radiographic evidence of osseous union of both bone junctions. All wounds healed primarily and no patient had problems related to the donor leg. Three patients had returned to their pre-injury occupation. Vascularised fibula transfer is a valuable technique for the reconstruction of extensive long-bone defects in the upper extremities. The fibula allows a transfer of a bone that is structurally similar to the radius and is of sufficient length for the reconstruction of most skeletal defects in the forearm. In these serious forearm injuries, rapidity of fracture healing is not the primary issue, but rather control of infection and bone stability. The only disadvantage of VFG is that it is more costly; because more technical expertise is required for the microvascular work and the operating time is extended. The reliability and the value of vascularised fibula transfer will increase, with further experience, careful patient selection and appropriate pre and post-operative technical details

The results and complications of 104 vascularised fibular grafts in 102 patients are presented. Bony union was ultimately achieved in 97 patients, with primary union in 84 (84%). The mean time to union was 15.5 weeks (8 to 40). In 13 patients, primary union was achieved at one end of the fibula and secondary union at the other end. In these patients, the mean time to union was 31.1 weeks (24 to 40). Five patients failed to achieve union, with a resultant pseudarthrosis (3 patients) or amputation (2 patients). There were various complications. Immediate thrombosis occurred in 14 cases. In two of 23 patients with osteomyelitis, infection recurred at two and six months after surgery, respectively. Both patients had active osteomyelitis less than one month before the operation. Bony infection occurred in a patient with a synovial sarcoma of the forearm one year after surgery. In 15 patients, 19 fractures of the fibular graft occurred after bony union, all except one within one year after union. In patients in whom an external fixator had been used, fracture occurred soon after its removal. Union was difficult to achieve in cases of congenital pseudarthrosis of the tibia. Appropriate alignment of the fibular graft is an important factor in preventing stress fracture. The vascularised fibula should be protected during the first year after union. Postoperative complications at the donor site included transient palsy of the superficial peroneal nerve in three patients, contracture of flexor hallucis longus in two and valgus deformity of the ankle in three. Vascularised fibular grafts are useful in the reconstruction of massive bony defects. We believe that meticulous preoperative planning, including choosing which vessels to select in the recipient and the type of fixation devices to use, and care in the introduction of the vascularised fibula, can improve the results and prevent complications

We describe our experience with vascularised bone grafting for the treatment of fibrous dysplasia of the upper limb in eight patients, five men and three women, aged between 17 and 36 years. The site was in the humerus in six and the radius in two. Persistent pain, progression of the lesion and pathological fracture with delayed union were the indications for surgical intervention. We used a vascularised fibular graft after curettage of the lesion. Function and radiological progress were serially monitored. Early radiological union of the graft occurred at periods ranging from 8 to 14 weeks. The mean period for reconstitution of the diameter of the bone was 14 months (12 to 18) predominantly through inductive formation of bone around the vascularised graft, which was a prominent feature in all patients. There were no recurrences and none of the grafts sustained a fracture or failed to unite. After operation function was excellent in three patients and good in five. Vascularised bone grafts provide a safe and reliable means of ensuring good continuity of bone with little risk of recurrence and failure

In our practice sequestration of the shafts of long bones in children because of acute osteomyelitis continues to be a problem. Conventional procedures for bone grafting are likely to fail. Vascularised grafts with microvascular anastomosis are technically demanding with a high rate of failure. Transfer of the rib on its vascular pedicle to achieve anterior fusion in the thoracic spine is now well established and the length of the pedicle available is adequate to allow grafting of a diaphyseal defect in the humerus. We describe the successful use of this procedure in two patients

Five children with congenital pseudarthrosis of the tibia treated by free vascularised fibular grafts were followed up until skeletal maturity. The ipsilateral fibula was used in four cases, the contralateral fibula in one. All our cases achieved bone union, but leg length discrepancy, atrophy of the foot and ankle stiffness were frequent complications, due perhaps to the many previous operations. Vascularised fibular grafting might achieve better results if it were done as the primary procedure

Vascularised soft tissue transfer may be helpful in the salvage of severe sepsis involving avascular tissues hosting joint replacements or other metal work. Transferred tissue covers the exposed implants and delivers intravenous antibiotics. Twenty-one cases for the knee, elbow and shoulder are presented. Gastrocnemius flaps were used for seven knee replacements and 10 knee fractures. Antegrade radial artery flaps were used for two elbow replacements. Pectoralis major or minor flaps were used for two shoulder replacements. All procedures were performed by an orthopaedic surgeon with supplementary plastics training. Synchronous bony surgery included revision arthroplasty in seven cases, conversion to fusion in one case and preservation of existing hardware in the remainder. Sepsis was eliminated in the longterm in 9 of 10 knee fracture fixation cases, 5 out of 7 knee replacements and both elbow replacements. Both shoulder replacements remained septic despite multiple repeat procedures. Complications included necrosis of two gastrocnemius flaps, one from pre-existing partial compartment syndrome and one when combined with fusion of the knee. One other knee replacement developed further sepsis three years post procedure. No limb required amputation. These procedures are well within the remit of orthopaedic surgeons, the non reliance on plastics surgeons allowed prompt treatment combined with bony procedures. Results were good for the knee and elbow but disappointing for the shoulder—this, probably related to the natural mobility of the joint

Purpose: Therapeutic options for shaft reconstruction are allografts, shaft prosthesis, and autografts, which may be vascularised or not. The purpose of this work was to assess mid-term results and complications after upper limb reconstructions using a vascularised fibula in children and adolescents undergoing surgery for tumour resection. Material and methods: A vascularised fibular graft was used for reconstruction in ten patients who underwent surgery for resection of upper limb tumours between 1994 and 2000. The patients were seven boys and three girls, aged seven to seventeen years. the vascularised fibula was used for reconstruction after tumour resection in the same operation for eight patients and to salvage a proximal humeral prosthesis in two patients. The eight single-procedure reconstructions concerned four resections of the humeral shaft and four resections of the radius. Tumour histology was: classical osteosarcoma (n=7), low-grade osteosarcoma (n=1), Ewing tumour (n= 1) and aggressive enchondroma (n=1). Six patients were on chemotherapy at the time of the fibular transfer. Graft lengths varied from nine to 21 cm (mean 14 cm). Plate fixation was used in most cases. All patients wore a cast for six to twelve weeks after surgery. Results: Results were analysed retrospectively after 3.9 years follow-up (range 1 – 7 years). Mean time to bone healing was three months (range 1.5 – 5 months). Five of the six humeral shaft reconstructions fractured due to trauma, requiring revision surgery in four cases. All patients who were reoperated achieved bone healing rapidly. One radius had to be revised to add supplementary bone. The mean functional score (MSTS) was 25.5/30 (range 21 – 30). One patient died from lung metastasis and the others exhibited complete tumour remission. Discussion: Vascularised fibula reconstruction of the upper limb provides good radiological results, particularly for the radius. For the humerus, the results are better for younger children because the bone can grow in thickness. Certain mechanical complications may occur if normal sports activities are resumed too early. Functional outcome after these shaft reconstructions is nearly normal

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

Purpose: To describe our experience with vascularised fibulas used in sarcoma limb salvage surgery using standardized patient outcome measures. Methods: All vascularised fibulas and osteochondral allografts performed in the Capital District Health authority were assessed. A complete chart review and current functional assessment of the patients using the Toronto Extremity Salvage score (TESS) and the Musculosketal Tumour Society (MSTS) score were performed. Results: Nineteen patients with 19 tumors were recorded. The tumors range from 11 osteosarcomas, 4 Ewing’s sarcoma, 3 Malignant Fibrous Histiocytoma’s and 1 Chondrosarcoma. Average age was 23. The patient demographics are 75% male, 42% smokers, 86% femoral lesions and 13 % presented with pathological fracture. There were 9 hip fusions, 3 knee fusions, 6 intercalary grafts and one osteochondral graft. There was 21 % mortality with 21% lung mets, 20% local recurrence, 15.7% rates of amputation or infection or and non union. Allograft fracture rates of 10% were noted. Two patients underwent numerous operations (18) due to non-compliance. Rate of surgical failures defined as patients requiring re-operation after 2 years is 21%. Of 19 patients 10 are working, 4 are unable and 4 are deceased and 1 lost to follow up. Average follow up is 9.8 years (range of 4–18). Our functional results include TESS averaging 57.5 with a range of 30–105 and MSTS scores of average of 16.8 with a range of 3–28 and a percent score average of 55.8. The average score on the subjective assessment question was 4 equaling a response of accept it and would do it again. The Halifax outcome and functional data corresponds well with that in the literature. Conclusions: The biological repair of a combination of large Allografts with Vascularised Fibula’s is an excellent long term solution for construct survival with unrestricted patient activity

Purpose: Reconstruction using a revascularised fibula has advantages in terms of remodelling the transplant to the stress forces and of better resistance against infections. Osteosynthesis offers mechanical advantages (stabilisaton facilitating primary and stress fracture healing) but with the risk of preventing hypertrophy of the fibula which is not exposed to the stress forces. Material and methods: Our series of 25 vascularised fibular transfers (maximum follow-up 15 years) concerned post-trauma tissue loss (11 cases) and tumour resections (14 cases). For this study of remodelling, we retained only oncological reconstructions because in the event of trauma sequelae, many factors can interfer (infection, preservation of the homolateral fibula with tibial tissue loss). None of the patients were lost to follow-up and remodelling was assessed at two years or more. Results: There was one failure requiring leg amputation (infected nonunion of the distal tibia on a radiated osteo-sarcoma). All the other fibulae healed. Three metaphyseal resections of the distal femur were assembled with a lateral plate using the fibula as a medial strut under compression. This type of assembly favours remodelling and excellent results were obtained in three cases. Five arthrodeses of the knee were performed using a fibula with a femorotibial nail. Healing was slow and the fibula thickened little, particularly when it was simply apposed on the tutor (three cases) rather than encased under compression (two cases). For five proximal humeri, use of a thin plate in three cases (forearm plate) was sufficient to allow healing without inhibiting remodelling. Discussion: For the lower limb, good remodelling is obtained with an assembly allowing compression of the fibula placed medially to the shaft alignment. For metaphyseal loss, we advise a lateral plate with a fibular strut medially. For arthrodesis, a nail is probably more prudent. The position of the lateral tutor decreases the stress on the fibula and is recommended less than the medial strut position. For the humerus, synthesis is required but may be minimal to allow optimal remodelling. Conclusion: Vascularised fibula transfer is a reliable technique which can be recommended for major resections (mean 160 mm) in active subjects. Axial compression forces applied to the graft and use of light osteosynthesis appear to favour healing and remodelling

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

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

Autografts produced by recycling of tumor-bearing bone have been used for bridging intercalary bone defects but they are known to act as massive allografts after recycling procedures due to devitalisation. Recycled bone is superior to massive allografts since it allows anatomical reconstruction. Vascularised fibular grafts are inserted into recycled bone segments to provide biological support and to promote healing. Twelve patients with a mean age of 13.3 years (6–31), who had undergone curative resection of malignant bone tumor followed by biological reconstruction comprised of recycled bone combined with vascularised fibula, were followed up for a mean period of 16.8 (6–46). The tumor was located in distal femur in 7 patients, proximal femur in 2, proximal tibia in 2 and mid-diaphyseal tibia in 1. Cryopreservation with liquid nitrogen was employed for all patients. Contralateral single strut vascularised fibular grafts were used in all except one patient for whom bilateral fibula grafts were harvested to span a longer defect. Plates were used for fixation in 11 patients, and intramedullary nailing in one case. Mean length of bony defect was 16.1 cm (9.0–25.0). Mean fibular graft length was 17.5 cm (10.0–23.0 cm). Complete union and full weight bearing was achieved in 6 patients, and mean time to detect the commencement of union was 6 months (4–8). Incomplete union was detected in 4 patients and no union in 2. Five patients were complicated by implant failure, 1 with deep infection and 1 with drop foot. In order to fill large defects after resection of bone tumors, recyled bone combined with vascularised fibular graft is an effective reconstructive tool. Union rate of this technique is quite satisfactory with good functional results

The management of osteonecrosis of the femoral head ranges from symptomatic therapy to total hip replacement. Conservative treatment is effective only in small, early-stage lesions. Free vascularised fibular grafting has provided more consistently successful results than any other joint-preserving method. It supports the collapsing subchondral plate by primary callus formation, reduces intra-osseous pressure, removes and replaces the necrotic segment, and adds viable cortical bone graft plus fresh cancellous graft, which has osseoinductive and osseoconductive potential. Factors predisposing to success are the aetiology, stage and size of the lesion. Furthermore, it is a hip-salvaging procedure in early pre-collapse stages, and a time-buying one when the femoral head has collapsed.

Aim

Segmental bone defects following osteomyelitis in pediatric age group may require specifically designed surgical options. Clinical and radiographic elements dictate the option. Different elements play a role on the surgeon's choice. Among them, the size of the defect, the size and the quality of the bone stock available, the status of the skin envelope, the involvement of the adjacent joint. When conditions occur, vascularized fibula flap may represent a solution in managing defects of the long bones even during the early years of life.

Infected non-union after severe open fracture or unsuitable fracture operation is frequently associated with bone defect and its treatment has been controversial. We have used microsurgical vascularised composite graft for these problematic cases. Fifty one patients aged 17∼70 year old (43.6 years old in average), including 41 men and 10 women. Follow-up has been more than 6 months. The vascularised composite graft included a free fibular osteocutaneous flap in 41 cases, a vascular pedicled fibular osteocutaneous flap in 2 cases, a free iliac osteocutaneous flap in 5 cases, a vascularised cutaneous flap in 2 cases and other in one case. All infected non-unions were united without trouble and co-existing infection was successfully eradicated. This method also enables the patients rapid bone union and subsequent early functional recovery. This success was attributed to greater transport of oxygen and good antibiotic perfusion in presence of good blood supply. We conclude that microsurgical vascularised composite graft for infected non-union is an extremely useful method with early bone union and subsidence of infection.

From 1979 to 1990 we treated 20 patients with large bone defects or established nonunion of the femur by vascularised fibular grafts. There were 18 men and two women with an average age at operation of 36.6 years (16 to 69). Ten patients had infected nonunion, three had post-traumatic nonunion or a bone defect without infection, four had a defect after tumour resection, and three had other lesions. The mean length of the fibular grafts was 18.1 cm. Postoperative circulatory disturbances needed revision surgery in five patients, including three with circulatory problems in the monitoring flap, but not at their anastomoses. The outcome was successful in 19 of the 20 patients with bone union at means of 6.1 months at the proximal site and 6.6 months at the distal site. Three patients had fractures of the fibular grafts but all these united in two to three months after cast immobilisation.

The results of vascularised rib graft transfers are analysed in 25 patients followed up for more than two years (average 34 months). Radiographs showed early and rapid incorporation of the grafts in 4 to 16 weeks (average 8.5 weeks); external immobilisation averaged 11 weeks (range 5 to 24 weeks). The technique seems a useful alternative to allografts or homografts employing an avascular rib or fibula since it promotes rapid healing without needing microsurgical techniques.

Aims

The aims of this study were to analyse the long-term outcome of vascularised fibular graft (VFG) reconstruction after tumour resection and to evaluate the usefulness of the method.

Introduction and Objectives: Muscular neurotisation is one of the reconstructive techniques used in peripheral nerve surgery. A funded study was designed to evaluate function and maturation of the motor endplate in reconstructions done using free and vascularized nerve grafts.

Materials and Methods: An experiment was designed with 3 groups of female Wistar rats: a control group which underwent heterotopic neurotization of the superior gastrocnemius through the peroneal nerve. Group A consisted of 25 animals (free nerve graft, FNG) which underwent neurotisation of the gastrocnemius using an autologous EPS nerve graft. Group B consisted of 25 animals (vascularised nerve grafts, VNG) which underwent neurotisation of the gastrocnemius using vascularized peroneal nerve grafts. Animals were sacrificed and studied in groups of 5 individuals at 4, 8, 12, 16, and 20 weeks. Results were obtained using electromyographic and nervous conduction studies measuring graft conduction latency, motor action potential, and wave duration. Statistical analysis was done using Student’s t-test, Wilcoxon, Kruskal–Wallis, and Mann-Whitney U tests.

Results: Latency: There was no difference in latency between VNG and FNG groups except during the first and last month, although latencies tended to shorten and approach normal values. There was no difference in the control group. Amplitude: The FNG group never showed a normal amplitude, while the VNG group did only in the fifth month. No difference was noted between the control and VNG group in the first month. Potential duration: This parameter normalised in the VNG group in the fifth month but never normalised in the FNG group. In fact, during the fifth month there was no difference between the VNG and control groups, and by the second month, it was different from the FNG group.

Discussion and Conclusions: 1) There was no significant difference between FNG and VNG neurotisation in conduction latency as measured by nerve fiber conduction speed or motor unit excitement. 2) There was no significant difference in conduction amplitude between FNG and VNG as measured by the number of excited motor units. 3) There was a statistically significant difference in motor action potential duration between the FNG and VNG groups, with a shorter duration in the VNG group as measured by synchrony and maturation of motor unit conduction.

Purpose

Scaphoid non-unions can result in debilitating wrist problems. This study compared treatment of scaphoid non-unions using either a non vascularised (NVBG) or a vascularised bone graft (VBG).

Aims: Osteomyelitis after open injuries or internal fixation of forearm fractures is uncommon. Established chronic infections do not respond fully to antibiotic suppression or limited debridement. We describe a two-stage treatment of segmental chronic osteomyelitis where wide excision of the affected area was followed by spanning external fixation and supplementary local and systemic antibiotic delivery. The bony defect was subsequently filled by vascularised fibula transfer, held by internal or external fixation.

Methods: Eleven male patients (mean age 41 years) with post-traumatic segmental chronic osteomyelitis were reviewed. There were 6 radii and 5 ulnas; the mean post-debridement defect was 7.7cm (range 5–11cm). The first stage involved wide excision and metalwork removal, followed by application of a spanning external fixator to restore distal radio-ulnar congruency. Gradual distraction was needed in some cases with long standing subluxation. ‘Dead-space’ management used gentamicin beads or gentamicin-loaded calcium sulphate, supplemented with systemic antibiotics according to tissue culture results.

A second stage reconstruction was performed after 4–6 weeks, using a free vascularised fibular graft, fixed using internal and/or external fixation.

Results: The mean follow-up period was 42.4 months. There was no recurrence of infection and union occurred at both graft-host junctions in all patients. The mean period to radiographic bone union was 4.4 months (range 4–6 months).

Patients gained an average of 46° forearm rotation (range 0–105°) with wrist or elbow motion significantly improved in 3 patients. At last review, all patients had a pain-free stable forearm with unhindered hand functions of grasp, hook and pinch. SF-36 assessment showed varied results, although mean values for the physical components of the survey were lower than general population values, while mental/emotional scores were as good.

Conclusions: Staged reconstruction, as described, is a suitable treatment strategy for this challenging problem and produces a good functional outcome.

Free, vascularised fibular grafting is well described in limb salvage surgery. The mechanical properties of the fibula make it ideal for replacement of bony defects after tumour resection and it can be sacrificed with minimal morbidity. We review the outcome of a consecutive series of 24 patients.

Between 1993 and 2002 we performed free vascularised fibular grafts in 24 patients as part of a limb salvage procedure following tumour excision. Pre-operatively patients were staged using the Musculoskeletal Tumour Society (MSTS) system. Post-operatively patients were followed up with radiographs and clinical examination. From the radiographs graft hypertrophy and time to bony union was documented. Functional outcome was assessed using the MSTS scoring system. Complications were recorded.

There were 15 women and 9 men with a mean age of 26 years (6–52). Mean follow up was 51 months (12–106). There were 19 malignant tumours, all stage 2b, and 5 giant cell tumours. The mean length of graft was 12.5 cm. (4.5–25). 16 grafts were used in the upper limb and 8 in the lower limb. Arthrodesis was performed in 8 cases and intercalary reconstruction in 16 cases. Fixation of grafts was achieved with a plate and screws in 21, a blade plate in 2 and an IM nail in 1. In 6 cases the resected tumour bone was reinserted as autograft after extracorporeal irradiation. In all but one patient the tumour margins were clear. Primary bony union was achieved in 22 patients (92%) at a mean of 35 weeks (12–78). Graft hypertrophy was seen in 7/29 cases (24%). Complications included 2 wound breakdowns, 3 stress fractures, 1 muscle contracture, 1 malunion and 1 painful plate. Overall 8 patients (33%) required second operation. 2 patients died of recurrent disease and one has metastases. The mean MSTS functional score was 87% (80–93).

Free vascularised fibula grafts offer a reliable method of reconstruction after excision of bone tumours. The complication rate appears high and some patients require a revision procedure. However, the problems are relatively easy to correct, bony union is achieved in the majority and functional outcome is good.

Introduction Free, vascularised fibular grafting is well described in limb salvage surgery. The mechanical properties of the fibula make it ideal for replacement of bony defects after tumour resection and it can be sacrificed with minimal morbidity. We review the outcome of a consecutive series of 24 patients.

Methods Between 1993 and 2002 we performed free vascularised fibular grafts in 24 patients as part of a limb salvage procedure following tumour excision. Pre-operatively patients were staged using the Musculoskeletal Tumour Society (MSTS) system. Post-operatively patients were followed-up with radiographs and clinical examination. From the radiographs graft hypertrophy and time to bony union was documented. Functional outcome was assessed using the MSTS scoring system. Complications were recorded. There were 15 women and nine men with a mean age of 26 years (6 to 52). Mean follow-up was 51 months (12 to 106). There were 19 malignant tumours, all stage 2b, and five giant cell tumours. The mean length of graft was 12.5 cm (4.5 to25). Sixteen grafts were used in the upper limb and eight in the lower limb. Arthrodesis was performed in eight cases and intercalary reconstruction in 16 cases. Fixation of grafts was achieved with a plate and screws in 21, a blade plate in two and an IM nail in one. In six cases the resected tumour bone was reinserted as autograft after extracorporeal irradiation.

Results In all but one patient the tumour margins were clear. Primary bony union was achieved in 22 patients (92%) at a mean of 35 weeks (12 to 78). Graft hypertrophy was seen in 7/29 cases (24%). Complications included two wound breakdowns, three stress fractures, one muscle contracture, one malunion and one painful plate. Overall eight patients (33%) required second operation. Two patients died of recurrent disease and one has metastases. The mean MSTS functional score was 87% (80 to 93).

Conclusions Free vascularised fibula grafts offer a reliable method of reconstruction after excision of bone tumours. The complication rate appears high and some patients require a revision procedure. However, the problems are relatively easy to correct, bony union is achieved in the majority and functional outcome is good.

A vascularised fibular strut graft was used for anterior spinal fusion in 16 patients with spinal kyphosis. The procedure was abandoned in three because of difficulty in establishing a vascular anastomosis and in one because the grafted fibula dislodged two days after operation. One patient died after five days. Of the 11 remaining patients, there were seven males and four females. Their ages at the time of operation averaged 30.9 years (12 to 71). The number of vertebrae fused averaged 6.7 (5 to 9) and the length of fibula grafted averaged 10.9 cm (6.5 to 18).

Average follow-up was 54 months (27 to 84). Bone union occurred at both ends of the grafted fibula in all 11 patients, with an average time to union of 5.5 months (3 to 8). We did not see a fracture of the grafted fibula. Two patients had postoperative complications; the graft dislodged in one and laryngeal oedema occurred two days after operation in the other.

A vascularised fibular strut graft provides a biomechanically stable and long-standing support in spinal fusion because the weak phase of creeping substitution does not take place in the graft.

We assessed the usefulness of vascularized bone transfer for treatment of aggressive musculoskeletal tumours. Classification by reconstruction method with vascularized bone transfer of our 33 patients was made into five types: 1) intercalary type in 6 cases, 2) arthrodesis type in 5 cases, 3) arthroplasty type using fibular head in 8 cases, 4) hybrid type with recycling autograft as heat treated bone or irradiated bone in 4 cases, and 5) inlay type after curettage of benign tumour chiefly for femoral head and/or neck in 10 cases.

From October 1975 to December 1999, 33 patients composed of 18 males and 15 females with age ranging from 9 to 69 years (average of 30 years) received vascularized bone transfer. There were 28 cases of bone tumour and 5 cases of soft tissue tumour. In 31 cases we grafted the fibula of 8 to 20 cm in size and in 2 cases the ileum of 8 cm in size. Postoperative follow-up period ranged from 10 months to 15 years with average of 65 months.

Primary union was achieved in 31 cases postoperatively between 1.5 month and 4 months with average of 3 months. As complication, we observed fracture of the graft in 4 cases and local recurrence in 3 cases. Postoperative functional evaluation ranged from 33.3% to 96.7% with average of 76.7%. As for oncological therapeutic results, continuous disease free cases accounted for 27, case of no evidence of disease for 1, case alive with disease for 1, and cases of death of disease for 4.

Intercalary transfer of vascularized bone is best indicated for defect of long bone. Arthrodesis was performed in only one knee joint where reconstruction with prosthesis is usually indicated. In arthroplasty type, remodeling of fibular head was observed. In hybrid type, rapid bone union and low complication rate can be expected when compared to recycling autograft alone. In inlay type, femoral head necrosis even after wide curettage can be prevented.

Purpose: We report the long-term outcome after treatment of scaphoid nonunion using a graft harvested on the anterior aspect of the radius and vascularised with the anterior carpus artery.

Material and methods: We treated 72 patients, 11 women and 61 men. Mean age was 31.4 years (15–61) and mean delay from initial fracture of the scaphiod to treatment of nonunion was 22 months (4–120 months). Twenty-seven patients had had prior tratments (11 Mati-Russe, 16 screw fixations). Alnot classification was 40 grade 2A, 28 grade 2B and 4 grade 3A. the patients were generally treated as out-patients under locoregional anaesthesia. A single approach was needed. After reduction and fixation of the scaphoid, the graft was harvested from the anterior aspect of the radius and inserted in the bone gap, usually fixed with a temporary pin. A palmar brace was maintained until bone healing.

Results: Bone healing was achieved in 66 patients (91.6%). Mean delay to healing was 9.8 weeks (6–24). Pain relief was achieved in all patients; 59 were completely pain free. Mean flexion improved from 45° to 56° and mean extension from 54° to 65°. Muscle force improved from 50% to 90% of the healthy side. There were three cases of reflex dystrophy, two cases of styloid radial osteoarthritis and three cases of postoperative stiffness requiring secondary arthrolysis. Functional outcome was excellent in 46 patients, good in 13, fair in 9 and poor in 4.

Discussion: The vascularised graft advocated by Judet as early as 1964 has proven its efficacy for repeated nonunions of the scaphoid. In our series, there was a direct correlation between the grade of the nonunion and the final outcome, the best results being obtain for grade 2A.

Conclusion: Use of a bone graft vascularised with the anterior carpus artery only requires on approach, and provides a high rate of bone healing. We recommend this method for first line treatment of nonunion of the scaphoid.

Purpose: Transfer of the vascularised fibula causes an imbalance in the lower limb due to the small calibre of the bone compared with the recipient bone (femur, tibia). “Femorisation” or “tibialisation” is slow, requiring prolonged protection with an orthesis. The doubled fibula or “shotgun” technique which maintains fibular periosteal vascularisation may overcome this inconvenience.

Material and methods: We report a series of eight free vascular shotgun fibular transfers at a mean four years follow-up (1–11). The recipient site was the lower limb in all patients who had undergone multiple operations, seven for chronic osteitis and one for chondrosarcome (five femoral supracondylar grafts, one knee arthrodesis, two metaphyseal tibial grafts). A cortico-cancellous autologous graft was associated during the same operation for six patients; Osteo-synthesis was achieved in seven cases with an external fixator and in one case with locked centromedullary nailing.

Results: The bone scintigraphy obtained in all cases at the third postoperative day showed intense uptake in the graft in six cases. We had seven cases of osteitis with no case of recurrent sepsis. Mean delay to bone healing assessed radiographically was 5.2 months. Hypertrophy of the fibula was noted at last follow-up in four cases. The external fixator was removed on the average at 6.8 months (5–9). Weight bearing was allowed in all cases with an adjustable protective orthesis. There was one fracture of the graft in a patient with a knee arthordesis which was treated with a corticocancellous autologous bone graft.

Conclusion: This series demonstrates the interest of doubling the free fibular transplant compared with other bone transfers to the lower limbs, improving the balance of the bone calibre and resistance. For patients with loss of supracondylar femoral bone, we describe a widened posterior access allowing the preparation of the recipient site with a single installation for the graft harvesting and fibular transfer.

We have reviewed 30 patients at a mean of 36 months after free vascularised fibular transfer to reconstruct massive skeletal defects after resection of primary bone tumours. There were 23 malignant and 7 benign neoplasms, half in the lower limb and half in the upper. Arthrodesis was performed in 15 and intercalary bone replacement in 15. The mean fibular graft length was 189 mm.

Union was achieved in 27 (90%) at an average of 7.6 months, and the 3-year survival was 89%. There was a high complication rate (50%), but most resolved without greatly influencing the final outcome. There was local recurrence in two (6.7%), but 16 of the 24 assessed patients (67%) had satisfactory functional results. This is a reasonably effective means of reconstruction for limb salvage after resection of tumours.

We did a retrospective comparative analysis of twenty five patients treated with Ilizarov bone transport [IBT] and twenty one patients treated with vascularised fibular graft [VFG] from 1994 to 2003 in one institution, for post traumatic tibial bone defects of more than six centimetres.

The aim of the study was to find out if there were any differences in achieving radiological end points, bone and functional score and return to work (final outcome), hospital stay and operating time (logistic factors) and complication rates. The mean defect size in the IBT group was 11.9 centimetres and in the VFG group 14.6 centimetres.

Twenty one and sixteen patients in the IBT and VFG group respectively achieved the radiological end point that is union of the defect and graft hypertrophy [p 0.5]. Nineteen patients in the IBT group and fifteen in the VFG group returned to productive work [p 0.72]. Bone and functional results were analyzed by Paley's evaluation system and there were no significant differences in the two groups of patients [bone result p 0.97 and functional result p 0.1]. The logistic factors were significantly less of IBT group [p < 0.05]. Two patients in the IBT group and one patient in the VFG group had amputation and one patient in VFG group died. Three cases in the VFG group had flap loss. Stress fracture of the graft occurred in eight patients in the VFG group [p 0.0007].

The final outcome was same in both groups. Hospital stay, operating time and refractures were significantly less in IBT group.

Surgical treatment of infected bones with vascularised bone grafts is well established as an efficient strategy since several years. Nevertheless orthopaedic and trauma surgeons seem to apply vascularised bone grafts as the last treatment option only.

Two strategies exist for treatment of chronically infected bones with vascularised bone grafts. First: Complete resection of the infected, often non-united part of the bones and reconstruction with large vascularised bone grafts, mostly fibular grafts. Second: Augmentation of the kept and intact parts of the bones with vascularised bone grafts. Two small series of patients are presented to illustrate both techniques and to show the results and outcome.

Resection of big parts of the tibia and reconstruction with mostly ipsilateral fibular grafts – single barrel in children and double barrel in adults – led to uneventful healing in all cases. Augmentation of radius, femur and calcaneus with vascularised grafts from the iliac crest or the scapula was followed by primary healing, too. All patients were disburdened from infection up to now and regained full extremity function.

The presented vascularized bone grafts did not only salvage the extremities but also could maintain their functionality. The procedure is demanding, but reliable and safe at a low rate of complications. Thus vascularised bone grafts should not only be used as ultimative salvage procedures, but as early as possible whenever standard treatments for osteomyelitis fail.

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.

In order to investigate the efficacy of free vascularised fibular graft (VFG) after bone intercalary tumour resection in tibia, we present our results with a minimum follow-up of 2 years. From 1988 to 2001, 47 patients affected by high-grade tibial sarcoma in 31 cases (66%), and low-grade diesease in 16 cases (34%) were treated in our department. Average age was 19 years (range 5–60 years), with a male/female ratio of 1.35. The average length of tibial resection was 15 cm, while the average length of the fibular graft was 19 cm. In 11 cases (21%) VFG was assembled alone, while in 36 cases (79%) a massive bone allograft was associated to the fibula. Three patients developed a deep infection, treated by amputation in two cases and by graft removal and an Ilizarov device in one case. Minor complications occurred in 28 cases (55%) (stress fractures, wound slough, osteosynthesis breakage), all healed by minor surgery or conservative treatment. At an average follow-up of 108 months (range 24 to 185 months), four patients had died of disease and three were lost to follow-up. Regarding the overall results, the combined group of fibula plus massive allograft showed to be more effective than the group of fibula alone in terms of early weight bearing (6 versus 12 months), while VFG showed intrinsic efficacy in achieving early bony fusion at the osteotomy lines and hypertrophy of the graft in both groups. Furthermore, using the combined assembly the articular surface could be spared in all the trans-epiphyseal resections, while VFG alone appeared to be electively indicated for infected or irradiated fields.

In conclusion, despite the demanding surgical technique, VFG appears to be a long-lasting and definitive biological reconstruction procedure after intercalary tibial resection.

The reconstruction of a skeletal defect after resection of a bone tumour represents a challenge for the orthopaedic surgeon. Age, site of the lesion and extension of the disease often limit the choice of surgical technique for a conservative procedure, but several options are available, mainly modular, composite or custom prostheses, massive bone allografts with or without autologous vascularised fibular grafts (AVF), and arthrodeses.

An interesting reconstructive technique uses the AVF graft, with microsurgical technique, alone or associated with a massive allograft. The association of a fibular transplant with an allograft increases the mechanical strength of the reconstruction, also promoting more rapid integration. The fibula is a cortical bone and it may provide mechanical strength in the reconstruction of a large segmental bony defect if employed as a viable biological rod.

In the present paper the authors discuss their experience with 17 patients treated at the Oncological Orthopaedic Unit of the G.Pini Orthopaedic Institute, for bone tumour resection and reconstruction using AVF graft, almost always combined with a bone allograft.

No treatments were performed as augmentation in osteoarticular massive allografts. Subjects’ ages ranged from 7 to 66 years (mean 25.2 years). Most of the patients were referred for a diagnosis of malignancy (15 of 17 cases) and in only two patients were the tumours not aggressive. In 11 patients the AVF was transplanted immediately after tumour resection, while in the others it was used after problems of previous reconstruction.

The authors report two cases of deep infection and four mechanical fractures (all healed after a period of cast immobilisation with or without bone bridging). All the AVF survived and healed with a good functional result for the patients except for two recurrences that required an amputation.

A vascularised bone-graft procedure from the base of the second metacarpal was performed in 14 patients with nonunion of the scaphoid. There were 11 men and three women with a mean age of 22 years. In eight patients, who had dorsiflexed intercalated segment instability (DISI), an open wedge was formed at the site of nonunion, and the vascular pedicle was grafted from the volar side. In the six patients without DISI, transplantation was carried out through the same dorsal skin incision.

Complete bony union was obtained in all patients after a mean post-operative period of 10.2 weeks, and DISI was corrected in all affected patients. According to Cooney’s clinical scoring system, the results were excellent in five, good in six, and fair in three patients. Because of its technical simplicity and the limited dissection needed, the procedure should be considered for the primary surgical treatment of patients with nonunion of the scaphoid.

Aim: To review the effectiveness of ipsilateral þbular transfer with its vascular pedicle mobilised in bridging defects in the tibial shaft. Method & Results: This operation was performed in 8 patients with segmental tibial defect following injury. We reviewed these cases with a minimal follow up of 2.5 years. All the tibial defects were the result of severe open fractures (Gustilo Grade III) and either bone loss or infected non-union, and ranged in size from 1 to 12 cm. The patients had an average of seven procedures and a delay of 33 months before þbular transfer. The procedure was successful in achieving fracture union in all cases, with an average time to union of 15 months (range, 5–33 months). Shortening of up to 3 cm and some residual ankle stiffness was found but all patients were ambulating bearing full weight and six had returned to their previous occupation by their þnal follow up. Only one patient had signiþcant pain affecting function. Conclusion: This is a successful and relatively simple method of reconstructing segmental tibial defects with relatively avascular beds, and avoids the problems of tibial transport and of microvascular anastomoses.

Vascularized bone grafts (VFG) have brought great benefits in the field of reconstruction of the lower extremity. However, complications such as fracture of the grafted fibula and delayed union are sometimes seen. Not only to prevent these complications but also for stability after fracture of the grafted fibula, the Ilizarov external fixator is a very useful option. We report here the clinical results of cases treated by VFG combined with Ilizarov external fixator for reconstruction of the lower extremity.

We have performed 53 vascularized fibula transfers to reconstruct lower extremities. An Ilizarov external fixator was used for the initial immobilization in 7 (2 femur, 5 tibia) and for delayed union or fracture of the grafted fibula in 2 cases of congenital pseudoarthrosis of the tibia.

All patients achieved good bone reconstruction. All are able to walk without a brace except for one congenital case. The average period to achieve bony fusion was 13 months in femur cases, 6 months in adult tibia cases and 2 months in congenital cases. The average periods to walk without a brace were 14 months, 8 months and 10 months respectively. However, it took 9 months and 28 months to achieve bony union in the cases with delayed union or fracture of the grafted fibula.

In the reconstruction of the lower extremities using VFG, the determining factor in method selection is whether sufficient mechanical support is available. An Ilizarov external fixator for immobilization permits the patient to walk as soon as possible. Dynamization from this semi-rigid external fixator causes bone hypertrophy and improved incorporation of the graft.

It has long been recognised that the periosteal membrane has osteogenic capability and experimental studies have concluded that periosteum transplanted to a distant site could also be osteogenic. This ability of periosteum to generate new bone at distant sites may have clinical application. In the laboratory setting however periosteal flaps in animals have demonstrated variable results. Little clinical work using the technique of periosteal transfer has been reported, with only individual case reports in the literature.

A clinical review of a series of three fracture patients in whom vascularised periosteal transfer has been used is presented. Cases involved a primary bony defect at the fracture site (first metatarsal), established non-union (tibia) or post-traumatic AVN (talar dome). The technique is described and clinical follow-up of the patients is presented.

In each instance evidence of lasting new bone formation was demonstrated clinically and radiologically.

The efficacy of this technique in forming new bone is demonstrated. The technique may have utility alongside other techniques in cases where new bone is required.

Gap defects in the tibial shaft can arise as a consequence of auto-sequestrectomy in chronic osteomyelitis. Whilst bone transport techniques can be utilised to treat defects, the skills and equipment necessary for such procedures are seldom available in the developing world. An alternative, and more freely available method of reconstruction is to use ipsilateral vascularised fibular transfer.

Approach to the fibula is postero-lateral. Muscle attachments to the lateral and antero-medial surfaces of the bone are released but care is taken to maintain the posterior proximal vascular pedicle, arising from the peroneal artery and to keep the periosteum intact. The fibula is then osteotomised proximally and distally and then transposed, by translation and rotation into a pre-prepared graft bed spanning the tibial defect. Some form of fixation and stabilisation may then be required and cancellous bone graft applied.

Over the past 12 months 5 cases of ipsilateral vas-cularised fibular transfer have been performed. Mean age of the patients was 6.4. In three cases stabilisation was by a trans-calcaneal, intramedullary K-wire. In the remainder interfragmentary screws were used at the proximal and distal ends of the graft, supplemented by external fixation. Cancellous bone grafting was only performed in those cases also undergoing external fixation.

In all cases the graft united satisfactorily at both the proximal and distal ends. No further procedures were necessary to effect this union. Particularly in the younger patients compensatory hypertrophy of the fibula, in response to the increased weight-bearing demand, was both marked and rapid. All five cases have completed treatment and need no mobility aids when walking.

In conclusion we feel that the ipsilateral vascular-ised fibular graft is a useful method for treating tibial gap defects of osteomyelitic origin. Few specialised resources are required and thus it is a suitable technique for the developing world.

Purpose: Giant cell tumour (GCT) of the distal radius is associated with high local recurrence rates unless the tumour is aggressively resected, which often leaves a significant skeletal defect. The purpose of this study is to compare the functional outcomes of two commonly used reconstructive techniques, vascularised free fibular transfer (VFF) and non-vascularised structural iliac crest transfer (NIC).

Method: Patients treated for giant cell tumour of the distal radius in either Vancouver or at Mount Sinai Hospital, Toronto were identified in the prospectively collected databases maintained in each centre. Twenty-seven patients were identified, 14 of whom underwent VFF transfer as their primary procedure. The two groups were comparable for age, sex and tumour grade. Functional outcomes were assessed with TESS, MSTS, DASH and the Ankle Osteoarthritis Scale.

Results: Fourteen patients were included in the VFF group, 13 of which were performed as the primary index procedure, one followed prior cementation. Thirteen patients underwent NIC, one followed prior cementation. Two local recurrences occurred in the VFF group and one in NIC group, all treated with local excision. In the VFF group three patients underwent further surgery for cosmesis, hardware removal and tendon release respectively. One is scheduled for future surgery for tendon release. In the NIC group two patients suffered infections requiring debridement, one of which ultimately went on to require free fibular transfer. This patient’s results were included in the NIC group as this was the index procedure. Functional scores showed no differences between the two groups on any of the parameters studied for the upper limb (Mann-Whitney test). The Ankle osteoarthritis scale had a median score of 9% for the six patients on which it was available.

Conclusion: Both VFF and NIC are effective surgical techniques that result in a well-functioning wrist arthrodesis. VFF may be more useful where there is a significant skin defect from previous interventions. We were unable to demonstrate any difference in functional scores between VFF and NIC.

For decades the treatment of chronic post-traumatic osteomyelitis associated with bone exposure has been one of the most serious problems in the field of orthopaedic surgery. “Sterilisation” of the osteomyelitic site, that is radical débridement of all infected tissue, is the basic requirement of the treatment; in the past, the remaining defect of the débrided area was closed with skin grafts, which were removed in a further stage when the infection had cleared; then the defect was filled with muscle flap and bone graft of various types. Both soft tissue and osseous reconstruction took a relatively long period of time, requiring several-stage treatment. Over the years, introduction of microsurgery led to free muscle flaps and skin graft in one reconstruction setting in the 1970s and thin fascio-cutaneous flap reconstruction in the 1980s, allowing a shorter period of hospitalisation and an improvement in patients’ lifestyle.

We performed a retrospective study of 22 patients treated for chronic osteomyelitis (middle or distal 1/3 of the leg, n=10; tarsus, n=6; forearm, n=6) by means of free vascularised bone graft or composite grafts between 1992 and 2003. In most of them a two-stage treatment was performed (resection and sterilisation in the first stage and bone transfer in the second one); in others a one-stage treatment was performed.

In 78.5% of cases the infection was cured without requiring secondary procedures; revision of the flap was carried out in 12.3% of cases. In only one case leg amputation under the knee was necessary.

In spite of advanced treatment protocols, persisting infection and residual functional deficit is not rare. Over the years the approach has changed. The application of microsurgical tissue transfers for reconstruction of the extremities allows repair of significant bone and soft-tissue defects. A wide variety of free flaps offers the potential to reconstruct nearly any defect of the limbs. The total array of flaps and their indications is beyond the scope of a single discussion, but this paper focuses on a few flaps that have found application for coverage and functional restoration of the limbs.

Microsurgical transfers allow more radical débridement of the area affected by osteomyelitis with low peri-operative morbidity, reducing the number of procedures required to obtain bony union and subsequently effect a quick “return to work”. In management of chronic, post-traumatic osteomyelitis with soft-tissue loss, we prefer a well-vascularised muscle flap rather than a fascio-cutaneous flap (its important vascular supply helps reduce bacterial contamination).

We developed a 3D vascularized bone remodeling model embedding human osteoblast and osteoclast precursors and endothelial cells in a mineralized matrix. All the cells included in the model exerted their function, resulting in a vascularized system undergoing mineralized matrix remodeling.

Bone remodeling is a dynamic process relying on the balance between the activity of osteoblasts and osteoclasts which are responsible for bone formation and resorption, respectively. This process is also characterized by a tight coupling between osteogenesis and angiogenesis, indicating the existence of a complex cross-talk between endothelial cells and bone cells. We have recently developed microscale in vitro hydrogel-based models, namely the 3D MiniTissue models, to obtain bone-mimicking microenvironments including a 3D microvascular network formed by endothelial cell self-assembly [1–2]. Here, we generated a vascularized 3D MiniTissue bone remodeling model through the coculture of primary human cells in a 3D collagen/fibrin (Col/Fib) matrix enriched with CaP nanoparticles (CaPn) to mimic bone mineralized matrix.

Human umbilical vein endothelial cells (HUVECs), bone marrow mesenchymal stem cells (BMSCs), osteoblast (OBs) and osteoclast (OCs) precursors were cocultured in plain and CaPn-enriched Col/Fib according to the following experimental conditions: a) HUVECs-BMSCs; b) OBs-OCs; c) HUVECs-BMSCs-OBs-OCs. Undifferentiated BMSCs were used to support HUVECs in microvascular network formation. BMSCs and peripheral blood mononuclear cells were respectively pre-differentiated into OB and OC precursors through 7 days of culture in osteogenic or osteoclastogenic medium. Needle-shaped CaPn (Ø ∼20 nm, length ∼80 nm) were added to a collagen/fibrinogen solution. Cells were resuspended in a thrombin solution and then mixed with plain or CaPn-enriched collagen/fibrinogen. The cell-laden mix was injected in U-shaped PMMA masks and let to polymerize to generate constructs of 2×2×5 mm³. Samples were cultured for 10 days. Microvascular network formation was evaluated by confocal microscopy. OB differentiation was analyzed by quantification of Alkaline Phosphatase (ALP) and cell-mediated mineralization. OC differentiation was assessed by Tartrate-Resistant Acid Phosphatase (TRAP) and cell-mediated phosphate release quantification.

HUVECs developed a robust 3D microvascular network and BMSCs differentiated into mural cells supporting vasculogenesis. The presence of CaPn enhanced OB and OC differentiation, as demonstrated by the significantly higher ALP and TRAP levels and by the superior cell-mediated mineralization and phosphate release measured in CaPn-enriched than in plain Col/Fib. The coculture of OBs and OCs with HUVECs and BMSCs further enhanced ALP and TRAP levels, indicating that the presence of HUVECs and BMSCs positively contributed to OB and OC differentiation. Remarkably, higher values of ALP and TRAP activity were measured in the tetraculture in CaPn-enriched Col/Fib compared to plain Col/Fib, indicating that also in the tetraculture the mineralized matrix stimulated OB and OC differentiation.

The 3D MiniTissue bone remodeling model developed in this study is a promising platform to investigate bone cell and endothelial cell cross-talk. This system allows to minimize the use of cells and reagents and is characterized by a superior ease of use compared to other microscale systems, such as microfluidic models. Finally, it represents a suitable platform to test drugs for bone diseases and can be easily personalized with patient-derived cells further increasing its relevance as drug screening platform.

We are presenting the outcome of a young adult with extensive epithelioid hemangioendothelioma of the femur treated with wide excision and vascularised fibular graft.

An 18-year-old builder was referred with an aggressive primary bone tumor of the right femur. Initial staging showed no evidence of distant disease but tumor confined to a 26.5cm diaphyseal segment of the femoral shaft. The patient’s pre-operative Oxford knee score was 28 and the AKSS scores were 74 (observational) and 65 (functional). True cut open biopsy confirmed low grade angiosarcoma. The patient underwent a wide excision of the lesion through a lateral approach leaving a generous cuff of bone and muscle tissue around the tumor. Clear resection margins were assessed intraoperatively. Histologically, the tumor was found to be epithelioid hemangioendothelioma. The 29.5cm defect was filled with a vascularised bone graft of the ipsilateral fibula. The graft was secured with a 22-hole DCS bridging plate and screws at both ends. Intraoperative knee range of motion was from 0 to 125 degrees without recurvatum and graft movement.

The patient had an unremarkable recovery. At the latest follow-up, one year after his operation, the patient had made an excellent functional recovery with non-symptomatic full weight bearing and had also returned to his work as a builder. He demonstrated a knee range of motion of 0 to 115 with a slight genu varum. The patient’s post-operative Oxford knee score was 40 and the AKSS scores were 70 (observational) and 90 (functional). Radiographs showed excellent union at the distal aspect of the graft and a healing stress fracture of the fibula graft at the proximal aspect.

Vascularized fibular graft with plating is a safe reconstruction limb salvage option for defects of long bones after tumor resection.

The aetiology, pathogenesis and clinical staging of osteonecrosis of the femoral head have been the subject of considerable discussion. The same is true regarding the treatment of such conditions, which could be non-operative (shockwaves, no traction, PEMFs) or operative (conservative methods or prosthetic substitution), depending on the age of the patient and the degree of compromise of the femoral head.

During the period between 1972 and 2003 at the CTO Hospital of Turin, Italy, 54 patients underwent surgery. We used core decompression (forage biopsy) in 39 cases and in the other 15 cases free vascularised fibular grafting (microsurgical techniques). All the patients were at the initial stages of the condition (Steinberg I–IIIa), stages in which subchondral collapse had not yet occurred. Follow up average 125.6 months.

The results were estimated according to the Harris Hip Score, which allows for a score in relation to pain upon motional, functional and clinical deformity.

In light of our data, we can confirm that the advantage of the result is secondary to the appropriate use of surgical techniques in relation to the clinical staging of the pathology. We have, in fact, established a treatment protocol that calls for core decompression at stage 0 – IA and free vascularised fibular grafting at the more advanced stages that go from IB to IIIA.

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: Reconstruction after resection of malignant bone tumours remains a major challenge. Free vascularised fibular grafts may be a useful alternative in this indication.

Material: Thirty children (nine girls, twenty-one boys) were treated between 1993 and 2000. Mean age was eleven years. Tumour histology was: osteogenic osteo-sarcoma (n=20), Ewing tumour (n=5), justacortical osteosarcoma (n=3), synovialosarcoma (n=1), and chondrosarcoma (n=1). Tumours were located in the femur (n=17), the tibia (n=6), the humerus (n=5), the radius (n=1), and the distal fibular (n=1). The length of resection varied from 100 mm to 260 mm (mean 160 mm). Internal fixation was used in 27 cases and external fixation in three. The adjacent epiphysis was preserved in 22 cases and initial arthrodesis was performed in eight.

Method: Patients were followed clinically and radiographically. A bone scintigram was obtained in all patients at least once during the postoperative period. Radiological assessment was based on the hypertrophy index of the graft using the method described by DeBoer and Wood. Functional outcome was assessed using the Enneking criteria.

Results: Mean follow-up was 51 months (range 2 – 9 years). Early amputation was required in two patients due to local ocological complications. One patient died at eight months follow-up due to lung metastasis. Among the remaining 27 patients, primary bone healing was achieved in 22. The five other patients exhibited clear signs of non-vascularisation. Successful healing was achieved in four of these patients after a complementary autologous graft. All cases of stress fracture healed after simple immobilisation.

The twenty-two patients who achieved primary bone healing developed a hypertrophic graft (mean 61%, range 22 – 190%). Graft hypertrophy was not observed in the five cases requiring a secondary graft after the scintigram demonstrated lack of vascularisation. Hypertrophy of the vascularised fibular graft was more marked for lower limb reconstructions than for upper limb reconstructions..

Functional outcome was satisfactory in all cases. On the 30-point Enneking scale as modified, our patients achieved a mean 26 points (range 19 – 30).

Discussion: Outcome was directly related to patency of the vascular anastomoses. Bone scintigraphy, performed one month after reconstruction surgery, was an important element for assessing prognosis. In case of unsuccessful vascularisation, a complementary cortico-cancellous graft should be used. Early weight-bearing is advisable using adequate protective devices. Dynamic osteosynthesis systems should be helpful in improving graft hypertrophy.

Retrospective comparative analysis of twenty five patients treated with Ilizarov bone transport [IBT] and twenty one patients treated with vascularised fibular graft [VFG] from 1994 to 2003 in one institution, for post traumatic tibial bone defects of more than six centimeters. The aim of the study was to find out if there were any differences in achieving radiological end points, bone and functional score and return to work (final outcome), hospital stay and operating time (logistic factors) and complication rates. The mean defect size in the IBT group was 11.9 centimeters and in the VFG group 14.6 centimeters.

Twenty one and sixteen patients in the IBT and VFG group respectively achieved the radiological end point that is union of the defect and graft hypertrophy [p 0.5]. Nineteen patients in the IBT group and fifteen in the VFG group returned to productive work [p 0.72]. Bone and functional results were analyzed by Paley’s evaluation system and there were no significant differences in the two groups of patients [bone result p 0.97 and functional result p 0.1]. The logistic factors were significantly less of IBT group [p < 0.05]. Two patients in the IBT group and one patient in the VFG group had amputation and one patient in VFG group died. Three cases in the VFG group had flap loss. Stress fracture of the graft occurred in eight patients in the VFG group [p 0.0007].

The final outcome was same in both groups. Hospital stay, operating time and refractures were significantly less in IBT group.

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.

In oncological resections there is a higher risk of infection around the foot and ankle. An infection here can be difficult to treat and easily lead to an amputation due to the limited amount of soft tissue coverage of the region. In three patients an infection developed after resection of a bone tumour in the foot and ankle.

In the first case, female 34 years, an epitheloid hemangioepithelioma was excised from the anterior part of the calcaneus, cuboid and lateral os cuneiform. An iliac crest graft was initially used to fill the defect, but got infected. The antibiotic loaded bone cement spacer cured the infection and filled the dead space but was painful. A free vascularised fibula with skin-flap was used successfully to fill the defect and take away the pain. At three-year follow-up there is no pain and full weight bearing, with a nice hypertrophy of the graft. In the second case, a 14-year old girl, there was an Aneu-rismal Bone Cyst (ABC) of the distal tibia with a deep infection after ethibloc injection. The vacuum assisted closure cleaned the wound but a defect resulted. It was successfully filled with an ipsilateral free vascularised fibula with skin-flap. Follow-up shows full function and nice hypertrophy at 24 months. In the third case, male 65 years, a chondrosarcoma grade one (after biopsy) in the cuboid was curetted out. It proved grade two in the definitive histology and furthermore it got infected. The cuboid was excised and a cement spacer was placed. The soft tissues were insufficient to close it properly. A free vascularised fibula with skin-flap was used. The vascularity of the graft was insufficient and the skin-flap did not survive. A vacuum assisted closure was done. He can bear weight and has no pain. The fibula graft is shows some hypertrophy and a fistula persists for 18 months now.

We conclude that vascularised free fibula with skinflap can successfully prevent amputation in case of infection in oncological resection of foot and ankle. The fibula reconstructs the bone defect and the skin-flap the soft tissue defect.