Vascularised fibula graft inlaid in a massive bone allograft: Considerations on the bio-mechanical behaviour of the combined graft in segmental bone reconstructions after sarcoma resection

Ceruso, Massimo; Taddei, Fulvia; Bigazzi, Prospero; Manfrini, Marco

doi:10.1016/j.injury.2008.05.014

Cited by 42 publications

(33 citation statements)

References 17 publications

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“…Regular CT of the surgically treated leg was performed every 6 months for the first 2 years, and once a year thereafter to evaluate the morphologic changes, incorporation, and failure of the vascularized fibula graft. Hypertrophy of the fibula was assessed on radiographs and CT scans with the following patterns: (1) When an allograft was intact, an increase in the diameter of the fibula without cortical thickening was observed; (2) when an allograft had a stress fracture, a substantial increase in the diameter of the medullary and cortical components of the fibula was observed in response to increased load on the fibula; (3) loss of viability of the vascularized fibula graft was the occurrence of progressive thinning or microfractures without subsequent healing [9,25]. Failure of the reconstruction was considered a change of the vascularized fibula and massive bone allograft construct with subsequent graft-implant revision.…”

Section: Followup Routinementioning

confidence: 99%

Is There Benefit to Free Over Pedicled Vascularized Grafts in Augmenting Tibial Intercalary Allograft Constructs?

Manfrini

Bindiganavile

Say

et al. 2017

Clinical Orthopaedics &Amp; Related Research

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Background Intercalary reconstruction of tibial sarcomas with vascularized fibula autografts and massive bone allografts is reliable with predictable long-term results. However, inadequate data exist comparing free and pedicled vascularized fibula autografts in combination with a massive bone allograft in patients undergoing intercalary tibia reconstructions. Questions/Purposes Among patients undergoing largesegment intercalary allografting, we sought to compare supplemental free vascularized fibular autografts with supplemental pedicled vascularized fibular autografts, in terms of (1) oncologic results, (2) complications associated with surgery, (3) Musculoskeletal Tumor Society (MSTS) scores, and (4) surgical time. Methods Between 1994 and 2013, we treated 320 patients, younger than 40 years, with tibial sarcomas. Thirty-five patients (11%) underwent amputations. One hundred ninetyfive patients (61%) were treated with intraarticular resection of the tibia, which constituted 104 tumor endoprostheses, 63 proximal tibia allograft prosthetic composites, 21 osteoarticular allografts, and seven arthrodeses with allografts. Ninety patients (28%) underwent joint-sparing intercalary reconstruction. Forty-one (13%) of these 90 patients were treated with allografts alone, two (1%) with vascularized fibula grafts, and 47 (15%) with intercalary allografts supplemented by autografts (free fibular autografts, 22 patients, 7%; pedicled fibular autografts, 25 patients, 8%). During the study period, we used free vascularized fibular autografts in association with massive bone allograft for a resection longer than 12 cm with a very small periarticular residual segment. The choice for using a pedicled fibula harvested in the ipsilateral leg initially was for patients having only diaphyseal resections and the indication was later extended to intraepiphyseal osteotomies with a small periarticular residual segment. The goals of this study are to present the long-term results in this group of patients and compare their results based on the type of vascularized fibula harvest. There were 33 male and 14 female patients with mean age of 14 ± 6 years. The median followup was 84 months This study was supported by Italian Ministry of Health (Grant Minsal RF-2010-2321501 (range, 7-231 months). No patients were lost to followup before 1 year. Four patients died and were not available for followup after 18 months. The mean tibia resection length was 15 ± 4 cm and mean length of the harvested vascularized fibula was 18 ± 4 cm. Results Overall 5-and 10-year oncologic survival rates in this study were 87% ± 5% and 83% ± 6% respectively. With the numbers available, we observed no difference in survivorship free from death from disease between the study groups (85% ± 8% [95% CI, 174-232 months] of the free vascularized group versus 82% ± 8% [95% CI, 148-206 months] of the pedicled fibula graft group; p = 0.741). At last followup, 40 patients had no evidence of disease and seven had died of disease. Local recurrence was observed in two pa...

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Section: Followup Routinementioning

confidence: 99%

Is There Benefit to Free Over Pedicled Vascularized Grafts in Augmenting Tibial Intercalary Allograft Constructs?

Manfrini

Bindiganavile

Say

et al. 2017

Clinical Orthopaedics &Amp; Related Research

Self Cite

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“…Application of papaverine and dextran-40 can effectively promote the patency rate of anastomosed blood vessels. Stress fracture of a vascularized fibular graft is a complication that had been reported by many authors, even in early hypertrophied bone (Toh et al, 2001;Ceruso et al; Repetitive mechanical loading which exceeds the bone strength was the main cause of this complication. The application of external fixation was required in case of fractures of the grafting fibula after the operation, the commonly used external fixation device were external fixator or splint.…”

Section: Discussionmentioning

confidence: 99%

Vascularized fibular graft combined with vacuum assisted closure in the reconstruction of tibial defects

Liu¹,

Song²,

Xu³

et al. 2015

Afr. J. Trad. Compl. Alt. Med.

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Background: To investigate the application of Flow-through free vascularized fibular graft combined with Vacuum Assisted Closure for the patients suffering from tibial defects caused by chronic osteomyelitis. Methods: We retrospectively analysed 20 cases of patients who accepted this operation in the treatment of tibial defects. Among the tibial defects, six cases resulted from blood stream infection while 14 cases resulted from comminuted fractures. All the patients included in the study were accompanied with 1 to 3 sinuses. The length of the defects ranged from 6cm to 16cm, with an average of 11.3cm. 6 patients were also faced with soft tissues defects combined with tendon or bone exposures, and the defects areas ranged from 11cm×7cm to 19cm×14cm. There were 5 patients suffering from fibular fractures at the same side of the defects. The courses of this disease were 5.5 -15 months, with an average of 9.8 months.Results: The patients included in the study were followed up from 10 months to 4 years, with an average of 1.9 years. Sinuses of 18 patients healed within 4 weeks, giving a primary healing rate of 90%. We undertook debridement of the remaining sinuses and they healed within 2 weeks. All skin flaps grafted to the patients survived, thus the survival rate was 100%. The radiographs indicated that 18 patients had good prognosis and the primary union time of grafting fibula were from 4 to 8 months, with average of 6.3 months. The healing patients achieved an average of 25.6 points based on the Enneking evaluation system which was used to evaluate the function of limbs after the operation, indicating that 85.9% of the limb function recovered. 4 patients required revision surgery for complications resulting from the operation: 1 wound breakdown, 2 bone non-unions, 1 graft fracture. Infection occurred only as a pin-tract infection, and was controlled with oral antibiotics and repeated dressing; there was no deep infection out of control in any of these patients. Conclusion:The flow-through free vascularized fibular graft did not only repair tibial defects, but retained the continuity of trunk vessels. The flowthrough fibular graft combined with Vacuum Assisted Closure (VAC) controlled the infection, shortened the course of treatment, and effectively restored limb function when applied to the treatment of tibial defects.

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“…On last follow-up, the functional scores were acceptable (76%, 93%) and hypertrophied fibula seemed to have increasing bony mass up to a remodelling level, which can be considered as the outcome of its reactive hypertrophy. 13,31) Compared to other reconstructive options, the use of allograft and VFBG showed superior outcome especially in skeletal immaturity as in LLD. 22,23) Although rate of complication occurrence in allograft transplantation is high, published results for allografts show success rates of 66% to 84%.…”

Section: )mentioning

confidence: 99%

“…Many authors described the advantages of combined grafts (vascularized fibular bone graft + massive bone allograft) in reconstruction following segmental skeletal resection for bone sarcoma. 22,23,31) The use of the free vascularized fibular graft as a salvage method for complications of allograft reconstruction of the long bones has been reported. 32,33) The rationale for a combined graft is to combine the advantages provided by the mechanical endurance of a massive allograft to the biological properties of the vascularized fibula graft.…”

Section: )mentioning

confidence: 99%

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How to Overcome Complications of Allograft Transplantation?

Cho

Choi

Kwon

et al. 2011

J Korean Bone Joint Tumor Soc

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IntroductionAllograft reconstruction is one of the functional reconstructive options, as a biologic reconstructive alternative to the bone defect in limb salvage surgery.1-3) However, allograft transplantation after malignant bone tumor and aggressive benign bone tumor have shown a high rate of complications.2) Mankin et al reported the complications of allograft in 870 massive frozen cadevaric allografts over a long term.2) During the first 3 years complications including fracture (19%), nonunion (17%) and infection (11%) before achieving stability with their grafts.2) Many other authors reported similar results concerning complication after allograft reconstruction. 3-9)The most common causes of graft failure are limited incorpora- that the use of autologous bone marrow mononuclear cell has a role in the re-building of large segmental defects. Original Article 11)The purpose of this study was to evaluate the complications of reconstruction after a bone tumor resection for the period of eventfree survival, and allograft survival as well as to elucidate how to prevent and overcome these complications based on our experiences and the literatures that have been reviewed. 대한골관절종양학회지：제17권 제2호 2011Purpose: We evaluated the complications of allograft reconstruction after a bone tumor resection, and reviewed literatures to overcome such complications. Materials and Methods:We retrospectively reviewed clinical records and radiographs of fifteen patients in whom reconstruction with allograft after bone tumor resection.Results: Eight patients were men and seven were women with a mean age of 27.1 years (1-56 years) and a mean follow-up period of 89.5 months (33-165 months). All postoperative complications related to the allograft were recorded. Twenty patients (80.0%) obtained a radiologic bony union at a mean of 8.35 months (4-12 months). The mean Musculoskeletal Tumor Society score was 73.5% (46.6-93.0%). Nine patients (60.0%) experienced one event and 3 (20.0%) patients experienced multiple events during the follow-up period. Recorded events were infection (3), fracture (2), nonunion (2), limb length discrepancy (2) and varus deformity (2). The mean event free survival period was 60.8 months (6-144 months). The mean allograft survival period was 80.2 months and the 5 year survival rate of the allografts was 83.0%. Conclusion:In order to overcome complications, the combination of an allograft and vascularized fibular graft is highly recommended. In the near future, the tissue engineering technique, the application of the stem cell and PRP, could reduce the complication of allograft such as resorption and nonunion.

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Vascularised fibula graft inlaid in a massive bone allograft: Considerations on the bio-mechanical behaviour of the combined graft in segmental bone reconstructions after sarcoma resection

Cited by 42 publications

References 17 publications

Is There Benefit to Free Over Pedicled Vascularized Grafts in Augmenting Tibial Intercalary Allograft Constructs?

Is There Benefit to Free Over Pedicled Vascularized Grafts in Augmenting Tibial Intercalary Allograft Constructs?

Vascularized fibular graft combined with vacuum assisted closure in the reconstruction of tibial defects

How to Overcome Complications of Allograft Transplantation?

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