Ventral cervical fusion at multiple levels using free vascularized double-islanded fibula – a technical report and review of the relevant literature

Abstract

IntroductionVarious methods of spinal stabilization, ranging from multiple wire fixation to complex reconstruction with vascularized bone struts, are described in the literature [21]. The choice of method depends on the specific indications posed by the clinical and morpho-physiological situation. Like any surgical method, each spinal fusion technique has its own pitfalls. Graft resorption, collapse, sequestration and pseudarthrosis formation are some of the common complications in using non-vascularized autogenous and allogenous bone grafts, especially in the old and in patients with compromised healing [7,13]. Screw loosening and plate or rod migration are some problems associated with stabilization using implants [7,8]. It has been suggested that vascularized bone flaps do not undergo resorption, and maintain twice the bone density of non-vascularized grafts [28]. The mechanical stability of vascularized bone used in spinal surgery, both initially and in Abstract Reconstruction of the cervical spine using free vascularized bone flaps has been described in the literature. The reports involve either one level or, when multiple levels, they describe en bloc resection and reconstruction. Stabilization of different levels with a preserved intermediate segment with a single vascularized flap has not been described. We report on the case of a 55-yearold man, who had been operated several times using conventional techniques for cervical myelopathy and instability, who presented to us with severe neck pain. Diagnostic procedures showed pseudarthrosis of C3/4 and stress-overload of the C3/4 and C5/6 segments. The C4/5 fusion was adequately rigid, but avascular. We performed anterior cervical fusion at the C3/4 and C5/6 levels with a vascularized fibula flap modified as a double island. The rigidly fused C4/5 block was preserved and vascularized with the periosteum bridging the two fibular islands. The method and technique are described in detail. Fusion was adequate. Donor site morbidity was minimal and temporary. The patient is symptom free to date (25 months). The suggested method provides the possibility of vertebral fusion at different levels using a single vascularized flap. The indications for this procedure are (1) repeated failure of conventional methods, (2) established poor bone healing and bone non-union with avascular grafts and (3) a well-fused or preserved intermediate segment. The relevant literature is reviewed.

Use of the Microvascular Free Fibula Transfer as a Salvage Reconstruction for Failed Anterior Spine Surgery due to Chronic Osteomyelitis

“…25 Although we found no prospective studies with relevant patient numbers in the literature, these conventional methods are reported to be "satisfactory" 25 or "highly effective." 26 Vascularized fibular grafting to the spine has been reported for a variety of pathologies 10,14,17,19,20,29,30 but not for osteomyelitis.…”

Nonunion of the Clavicle: A Rare Indication for Vascularized Free Fibula Transfer

“…Various modifications of the fibular flap have been described, such as the double "barrel," "twin barrel," "folded," "double-strut" fibula, 8,26,30,31 the "bipedicled vascularized" fibula, 32 and the osteocutaneous fibula, 3,33-35 also know as the osteoseptocutaneous fibula. 11,12 Segmental bone defects suitable for reconstruction using the free vascularized fibula flap include the upper and lower extremities, [15][16][17][18][19][20][21][22][23][24]36 the cranium, specifically, the midface including the maxilla, 8,14,37,38 and the mandible.…”

“…9 -13 Additional indications are mentioned in the literature. [25][26][27][28][29] Because of its superior blood supply, vascularized bone transfer seems to provide certain advantages over the nonvascularized bone transfer for reconstruction of large segmental bone defects. 39 A more than 90 percent union rate can be expected in the reconstruction of large skeletal defects resulting from tumor resection, traumatic bone loss, or nonunion.…”

“…[15][16][17][18][19][20][21][22][23][24] Additional indications have been reported. [25][26][27][28][29] Persistent clavicle nonunion is a rare indication for vascularized free fibula transfer. We report two clinical cases of refractory clavicle nonunions reconstructed with a fibula osteoseptocutaneous free flap.…”

The Free Vascularized Fibular Epiphyseal Transfer: Long-Term Results of Wrist Reconstruction in Young Patients

“…Donor site morbidity of fibular grafts is reported to be moderate, especially when grafts are harvested without nerves or without extended skin islands. 9,13,17,23,27,28 In children, donor site morbidity comprises talocalcanean joint instability due to bone length discrepancy of the lower leg. Nevertheless, as we experienced, donor site morbidity and especially ankle stability can be restored when fixation of the distal fibula to the tibia is performed with a screw.…”