Michael B. Wood

Vascularized bone transfer.

We evaluated the results of reconstruction of a skeletal defect with use of a vascularized bone graft from the iliac crest or fibula in 160 patients who had been managed consecutively between 1979 and 1989. The indications for the procedure were a skeletal defect including non-union, resulting from resection of a tumor; traumatic bone loss; osteomyelitis; or a congenital anomaly. The average duration of follow-up was forty-two months (range, twelve to 112 months). For the entire series, the rate of union after the primary procedure was 61 per cent and the over-all rate at the latest follow-up examination (including the patients who had a secondary procedure) was 81 per cent. In a subgroup of seventy-six patients who had union after the primary procedure and did not have additional treatment, the average interval until union was six months and the average interval until full activity was sixteen months. The results were more favorable for the patients who had had reconstruction for resection of a tumor (of sixty-nine patients, fifty-six had union), for a congenital anomaly (of six patients, five had union), or for a non-union without infection (of twenty-five patients, twenty-three had union). The results were less satisfactory for patients who had had the reconstruction for bone loss due to osteomyelitis (of sixty patients, forty-six had union). Our data suggest that vascularized bone transfer for the reconstruction of large skeletal defects is a valuable procedure in appropriately selected patients.

Bone changes in the vascularised fibular graft

We report a retrospective review of 62 consecutive patients who had a vascularised fibular transfer to reconstruct a large skeletal defect. We were particularly interested in the bone dynamics of the vascularised graft, since fractures occurred in 25% of the cases at an average time of eight months after surgery. Hypertrophy was more common when the limb was mechanically loaded; it was enhanced where the graft was not bypassed by internal fixation. The length of the graft and the use of additional bone graft material had no influence on the incidence of stress fracture or on hypertrophy. We conclude that a vascularised graft should be protected against fatigue fracture during the first year, and that a gradual increase in mechanical loading will enhance remodelling and hypertrophy.

Scaphoid nonunion: Role of anterior interpositional bone grafts

Twenty-one cases of unstable fractures of the scaphoid were treated by open reduction, length restoration by interpositional anterior wedge grafting, and fixation with a Herbert screw to obtain union and restore carpal stability. There was primary union in 15 (71%) of 21 patients. Two failed cases were treated with a second anterior wedge graft and Herbert screw fixation; overall rate of union was 81%. Nonunions were related to improper screw placement, failure of compression at the nonunion, bone-graft resorption, or persistent avascular necrosis. In the united scaphoids, carpal instability was corrected, with improvement in the scapholunate angle (65 degrees to 54 degrees) and capitolunate angulations (35 degrees to 15 degrees). Scaphoid malalignment associated with nonunion was improved on biplanar tomographic measurement of the scaphoid angles.

Anatomy of the sural nerve complex

The anatomy of the sural nerve complex in 20 cadaveric limbs was determined by dissection. The nerve usually consists of four named components: the medial sural cutaneous nerve, the lateral sural cutaneous nerve, the peroneal communicating branch, and the sural nerve. In most instances (80%), the sural nerve is formed in the distal portion of the leg by the union of the medial sural cutaneous nerve and the peroneal communicating branch. In 20% of cases, the peroneal communicating branch is absent. In such cases, the sural nerve is derived from the medial sural cutaneous nerve alone. The lateral sural cutaneous nerve is laterally situated and usually divides into medial and lateral branches. In a few cases, its medial division may contribute to the sural nerve through the peroneal communicating branch. The peroneal communicating branch can be of substantial caliber and may be useful as a source of nerve graft without complete sacrifice of the sural nerve. We describe a technique of isolation of the peroneal communicating branch for use as a nerve graft.

FREE VASCULARISED FIBULAR GRAFTING FOR RECONSTRUCTION AFTER TUMOUR RESECTION

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.

Revascularized periosteal grafts--a new method to produce functional new bone without bone grafting.

In the replacement of bone lost from trauma, tumor, or infection, and also for the correction of certain congenital abnormalities, conventional bone grafting is not always successful. The survival of these grafts, as such or as materials for new bone, is often unpredictable, and they may become resorbed.1,2 Recently, the microvascular transfer of living bone has been performed—but there are strict limitations on thé size and configuration of such free vascularized grafts.3, 4 We will discuss an alternative to bone grafting—vascularized periosteal grafts— by means of which new bone may be intentionally formed.

Arthrodesis of the ankle with a free vascularized autogenous bone graft: Reconstruction of segmental loss of bone secondary to osteomyelitis, tumor, or trauma

Reconstruction after massive loss of bone about the ankle is difficult because of the limited amount of surrounding soft tissue and because of technical factors pertaining to adequate internal or external fixation. Conventional techniques are often unsuccessful because of the frequency of associated deep infection and of previous operative procedures. In this report, we describe eleven patients with a large defect of the distal aspect of the tibia who were managed at our institution with arthrodesis of the ankle with free vascularized bone graft. The defect was related to a tumor resection; an acute open fracture with bone and soft-tissue loss caused by a shotgun injury; or osteomyelitis, either alone or in combination with septic arthritis, with chronic non-union following a fracture of the ankle. A free fibular graft was used in osseous defects that were larger than four centimeters, and a free iliac-crest graft was used in smaller defects. Osteocutaneous or osteomuscular flaps were constructed to cover accompanying soft-tissue defects when necessary. A successful fusion was obtained in nine of the eleven patients. The results in the remaining two were regarded as clinical failures, and a below-the-knee amputation was performed. One amputation was done because of recurrent infection and the other, because of failure of the fracture to unite after four years.

Instability patterns of the wrist.

Carpal instabilities are generally the result of a hyperextension injury. The deformities are mediated through the internal compressive force supplied by the musculotendinous units and are dependent on the extent of injury as well as the precise structures that are disrupted. The scaphoid inherently tends to palmar flex. It will pull the lunate with it if the lunotriquetral integrity has been interrupted, and conversely the lunate and triquetrum will dorsiflex if the scapholunate integrity is disrupted. If the integrity of the oblique external ligaments, particularly the volar (palmar) radiolunate, is disrupted, the entire carpus has a tendency to translate ulnarly. Carpal instabilities are invariably associated with weakness, limitation of motion, and pain.

Upper extremity reconstruction by vascularized bone transfers: Results and complications

Twenty-one cases of vascularized fibula transfer for upper limb reconstruction are reviewed. Recipient sites included the humerus in 11 patients, radius in five, ulna in three, and clavicle in two. Overall, primary bone union occurred in 15 patients (71.4%), and eventual union was achieved in 17 patients (81%). Two of the patients in whom there was failure to unite are minimally symptomatic, with stable fibrous nonunions. The most favorable results were achieved in cases of forearm bone reconstruction (100% union) and for long-bone reconstruction after tumor resection (83% union).

Staged flexor tendon reconstruction in the fingers and hand.

A two-stage tendon-grafting technique was used to reconstruct 130 fingers in 101 patients between 1973 and 1984. Eighty-nine patients with 117 fingers that had undergone operation were evaluated 6 months or longer after stage II surgery. Sixty-five percent of the patients were in the Boyes salvage group before operation. Overall, 54% had good or excellent results by the total active motion (TAM) as a percentage of total passive motion (TPM) method, although only 19% had final TAM of greater than 180 degrees. Complications included infection in 15%, rupture in 4%, amputation in 4%, and reflex sympathetic dystrophy in 1% of the patients. Sixteen percent of the patients required tenolysis after stage II surgery. Factors associated with a poor result included zone I or II injury and patients who were less than 10 years of age. Factors associated with a better result included zone IV or V injury and all postoperative therapy under the direct supervision of the treating surgeon.