I am proud now to bring this exacting and intricate surgical technique to. Free vascularized fibular graft as a salvage procedure for large clavicular defect. The fibulas anatomy lends itself to this procedure, where the bone is long and straight, and its vascular supply is radially directed. For decades, osseous vascularised flaps has been used for mandibular reconstruction with the vascularised fibula flap vff remaining the commonly used osseous free flap. When the fibula is to be harvested without accompanying. The use of free vascularized fibular grafts for reconstruction of segmental bone defects arik zaretski ravit yankoarzi yehuda kollender eyal gur jacob bickels background wide resection of long bone tumors can create a large intercalary bone defect requiring reconstruction.
Mar 23, 2012 vascularized free fibula flap and computerguided implant surgery the safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Free vascularized fibula grafts in limbsalvage surgery. This booklet provides a wealth of information about fvfg, a microsurgical procedure pioneered in the 1970s by dr. Wouldnt it be interesting to have an occasional zebra in a horse race. Hip avascular necrosis san antonio hand to shoulder. The hip pain is gone and have only what i call surgical pain. Fracture of the grafted fibula, one of the most common complications after this operation, can easily be treated with cast immobilization or internal fixation with conventional cancellous bone. Vascularized fibula flaps for mandibular reconstruction. The fibula has long been recognized as an attractive choice for vascularized bone grafting procedures. This has been reported to occur on average 18 months after surgery. Dec 31, 20 our unit has previously published results of salvage of the upper limb using vascularised fibula flaps.
Pertinent pearls on using fibular autograft with ex fix for. Mattar junior j, azze rj, ferreira mc, starck r, canedo ac. The fibula is extremely well suited as a graft and is considered to be a longbone flap. This paper deals with bilateral vascularized fibular grafts bvfg as a method for reconstruction of metadiaphyseal defects of the femur and tibia in young patients suffering from malignant bone tumors of the lower limb. Complications of vascularized fibula graft for reconstruction. Free vascularized fibular grafting yields extremely good results, particularly in precollapse. Large bone defect, free vascularized fibular graft fvfg, ilizarov external fixator, compressiondistraction. We used the induced membrane technique combined nonvascularized fibula graft with massive bone allograft for the treatment of bone defects resulting from sequestrectomy of chronic osteomyelitis in 2yearold boy. Modified surgical techniques of free vascularized fibular.
Vascularized fibular graft as a surgical option for. Free vascularized fibular graft with vein transplantation bridged vascular pedicle can effectively repair the infected bone, improve blood supply to the bone defect site, and help. Assessment of vascularized fibular graft one year after reconstruction of the wrist after excision of a giantcell tumour 7 november 2016 journal of hand surgery, vol. Free vascularized fibular graft for distal tibial and ankle arthrodesis. In a 10year period, 30 patients underwent reconstruction of a large skeletal defect with a vascularized fibular graft. Nevertheless, there are few reports in the literature dealing with this procedure and surgical technique remains unclear. Oct 28, 2011 after talkign with my local os, he thinks i may be a candidate for a free vascularized fibular bone graft. Free vascularized fibula graft for avascular necrosis. Today was my first day where i didnt take the percocet every 46 hours. It is long and straight, has good bone mass, a tricortical profile and can be up to 3 cm x 40 cm in size.
One of the report showed their graft incorporation was 80% in all treated patients with average defect length of 6. I am scouring the internet for more information, but havent found many people posting their experience with it. Its dimensions allow it to anatomically match forearm defects, and it can be fitted into the medullary canals of the larger long bones humerus, femur and tibia. We have studied the efficacy, both clinically and in the laboratory, of the free vascularized fibular graft fvfg for the treatment of onfh. The aim of this study was to determine long term follow up of the patients who had femoral head osteonecrosis and had been treated with free vascularized fibular grafting. A study was undertaken to determine the growth potential and radiographic appearance of a free vascularized fibular graft as it responds to the mechanical and physiologic features of its new environment. T1 free vascularized fibular graft salvage of complications of longbone allograft after tumor reconstruction. Nonunion at the hostgraft junction is difficult to treat since the graft is in an avascular state. Free vascularized fibular graft salvage of complications of longbone allograft after tumor reconstruction jeffrey b.
Treatment of osteonecrosis of the femoral head with free. Free vascularized fibular grafts have been widely used for the reconstruction of long bone defects. Free vascularised fibular graft in multioperated patients. Over 15 years later the arthritis has of course progressed some, and i find my. Jul 22, 2016 the use of free vascularized fibular grafts for reconstruction of segmental bone defects arik zaretski ravit yankoarzi yehuda kollender eyal gur jacob bickels background wide resection of long bone tumors can create a large intercalary bone defect requiring reconstruction.
It is believed that the key role of this microsurgical technique is to provide adequate revascularization to the new subchondral bone while at the same. Explain the goals, benefits, and risks of free vascularized fibular grafting. This report aimed to present the clinical results of the use of a modified surgical technique of fvfg for treatment of onfh. Free vascularized fibular graft for tibial pseudarthrosis. A free vascularized tibiafibular composite graft for the. In the practice of orthopedics, bone grafting is a common procedure used to. We present a rare case of using a vascularized tibiafibular composite graft taken from a 6yearold chinese boys ipsilateral lower leg to reconstruct a large. Four of the patients received both chemother reconstruction of skeletal defects can be made with autogenic or allogenic avascular bone grafts.
Mobility of the ankle at the donor site was evaluated using the kofoed ankle score system. Traditional free vascularized fibular graft vfg with minimal internal fixation. The role and benefits of free vascularized fibular grafts in avascular necrosis of the hip clinical practice today cme coprovided by learning objectives upon completion, participants should be able to. Microsurgical vascularized fibular grafts for avascular. Improved technique has led to complication rates, including donorsite morbidity, statistically similar to that of nonvascular fibular grafts. Penn orthopaedic surgeons are performing free vascularized fibular grafts fvfg to treat patients with avascular necrosis of the hip. Free vascularized fibular grafting for the treatment of postcollapse. I had a fvfg back in 2001, in lieu of hip replacement, from steroid induced avascular necrosis. Patients with postcollapse, predegenerative osteonecrosis of the femoral head appear to benefit from free vascularized fibular grafting, with good overall survival of the joint, and significant. Biology of the vascularized fibular graft springerlink. However, the use of a vascularized tibial graft is precluded by its weightbearing function and unacceptable donor site morbidity. Reasons for this resonate with its adequate bone and pedicle length to its receptive dental implant placement quality 4 7. The free vascularized fibular graft fvfg was first described in 1975 as a solution for large bone defects in orthopedic trauma. Free vascularised fibular bone grafts fvfgs have proven to be extremely effective in managing larger defects longer than 6 cm where other conventional grafts have failed.
Indications for free vascularized fibular grafting for the. Pedicled vascularized fibular graft with ilizarov external. Fvfgs also have a role in the treatment of avascular necrosis avn of the femoral head, failed spinal fusions and complex arthrodeses. Pre and postoperative imaging of vascularized fibular. Avn is a condition in which blood flow to the bone is restricted, causing that portion of the bone to. Salvage arthrodesis of the knee with a vascularized fibular graft.
Vascularized fibular graft for management of severeosteomyelitis of the upper extremity. The free vascularized fibular grafting fvfg has been shown to support the subchondral architecture as well as restore local circulation for the necrotic femoral head in treatment of onfh. Large bony defects in the middle or distal third of the tibia resulting from surgical resection of malignant bone tumors present a difficult reconstructive challenge. However, literature documenting distal tibial and proximal ankle reconstruction using this technique is lacking. The present study aimed to determine the indications for free vascularized fibular grafting for the treatment of osteonecrosis of the femoral head. Free vascularized fibula graft for avascular necrosis avascular necrosis avn or osteonecrosis of the femoral head onfh is a commoncause of hip pain and. Etiologies were alcohol abuse in 31 hips, steroid use in 27, idiopathic in 7 and trauma in 6. In our study, we conclude that vascularized free fibula flap is a versatile option for reconstruction of large mandibular defects with its good quality and quantity of bone and ease of manipulation to restore the original anatomy of the mandible and permit implant based prosthetic rehabilitation. The contralateral leg was chosen for the harvest site of the fibular free flap. Tumors of the proximal tibia, in children, can affect the growth plate and pose a challenge to further reconstruction of the bone defects resulting from tumor resection. We expose here a technique and results of free vascularized fibular graft for two patients with large clavicular defects. From 1981 to 2015, 10 patients were treated using nonvascularized fibular graft or free vascularized fibular graft. Modified capannas technique vascularized free fibula combined with allograft as a singlestage procedure in posttraumatic longsegment. After induction chemotherapy, wide excision and reconstruction using free vascularized fibular graft followed with interpositional elbow arthroplasty technique was done.
This reconstructional technique was used in 11 patients undergoing metadiaphyseal resection of lower limb malignant bone tumors. Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting. Penn orthopaedics free vascularized fibular graft surgery 12 showering may be resumed when there has been no drainage for at least 48 hours or at seven days postsurgery. The aim of this study was to evaluate the results and complications of free vascularized fibular grafting fvfg for the reconstruction of bone defects in gustilo type 3 open tibia fractures. The incision is approximately 1015 cm in length and is directed convex anterior. The bone defects reconstructed were proximal femoral diaphysis. Vascularized grafts were more likely to require surgical revision for wound breakdown, nonunion, graft fracture, or mechanical problems hazard ratio hr, 5. The fibular graft is harvested at the same time as the hip preparation.
Lower limb reconstruction with tibia allograft after. Free fibula graft to the hip for i avascular necrosis ree fibula grafting to the hip is contem plated as treatment for avascular necro sis avn of the femoral head. The biological reconstruction was realised with a bilateral free fibular graft and lateral plate fixation for a defect of 16,5 cm figure 3a. Proof corrected by the author available online since jeudi 2 aout 2012 free vascularised fibular graft in multioperated patients for an aseptic nonunion of the humerus with segmental defect. Approximately 10,000 to 20,000 new patients are affected by osteonecrosis of the femoral head onfh each year in the united states. Free nonvascularized fibular graft for treatment of. Patients with postcollapse, predegenerative osteonecrosis of the femoral head appear to benefit from free vascularized fibular grafting, with good overall survival of the joint, and significant improvement in the harris hip score. Use of vascularised free fibula in limb reconstruction for. The role and benefits of free vascularized fibular grafts in. Case report, clinical report by case reports in orthopedics. Since its appearance, the fvfg emerged as the firstline option for a number of reconstructions, including intercalary defects of the upper and lower extremities, craniofacial defects, as well as pelvis and spine applications. We report a technique with little interference to the surrounding soft tissues to harvest more than onethird of whole length fibula.
But nonvascularized fibular graft used only, were considered such as an inappropriate filling up bone defect 8. We feel that the free vascularized fibular graft more closely addresses these objectives as compared with any other biologicpreserving procedure currently available. The patient is placed in the supine position with a bump under the ipsilateral hip to lessen the need for excessive internal rotation of the lower leg. Bone defect reconstruction in a 2 years old boy with non. Nine grafts were harvested one patient had the femoral shaft reconstructed by two grafts and with the exception of one graft used as a double barrelled pedicle vascularized graft for reconstruction of an ipsilateral 6 cm tibial shaft bone defect figure 1, all grafts were free vascularized grafts. Of these options, free vascularized fibular graft fvfg is the treatment of choice for its structural and vascular support within the femoral head. Vascularized fibular grafting for osteonecrosis of the femoral head. Feb 22, 2014 bony defects caused by trauma, tumors, infection or congenital anomalies can present a significant surgical challenge. In these cases, we offer an approach that we pioneered free vascularized fibular graft which allows younger patients to delay or possibly eliminate the need for hip replacement in the future. Vascularized fibular grafting for osteonecrosis of the. Twelve patientseight males and four females with mean. Free vascularized fibular graft salvage of complications. Free vascularized fibular bone graft joint replacement. Free fibula graft association of surgical technologists.
Autologous bone grafting for large segmental bone defects 68 cm, soft. Avascular necrosis of the hip frequently occurs in people between the ages of 20 to 35, ages at which hip replacement may not be the best option. In large defects the healing time is considerable and graft complications, i. The lower extremity is exsanguinated with an esmarch bandage and a thigh tourniquet is inflated to 350 mmhg. Proximal tibial reconstruction with auto transplantation. Nov 30, 2015 traditional free vascularized fibular graft vfg with minimal internal fixation.
Vascularized fibula grafts for reconstruction of bone. Complication rates for vascularized fibular graft are between 7% and 35%, as reported in the literature,30,35 36 37 whereas the rate for nonvascularized fibular grafts vary between 4%. The outcomes were bony union time, graft hypertrophy and complications based on radiograph and functional outcomes according to the musculoskeletal tumor society msts score. C two screws arrows are fixed at proximal and distal graft sites and an external fixator is applied. Mandibular reconstruction using the free vascularized fibula. Health, general bone cysts care and treatment development and progression bones cysts orthopedic surgery methods patient outcomes. The hip is approached through a curvilinear incision over the lateral aspect of the affected hip. The original technique described by urbaniak and aldridge et al was used in all cases. The conventional technique of free nonvascularized fibular grafting is attended with some amount of morbidity and a long scar. Lower limb reconstruction with tibia allograft after resection of giant aneurysmal bone cyst. With the use of a canine model in which onfh was induced with cryotherapy, we implanted into the canine femoral head core either nonvascularized bone grafts, pedicled muscular flaps, or vascularized bone. Introductionintroduction contemporary oral and maxillofacialcontemporary oral and maxillofacial surgeons need bone grafting techniques tosurgeons need bone grafting techniques to satisfy patient needs in trauma, pathology,satisfy patient needs in trauma, pathology, reconstructive. The vessels in the fibula graft are then microsurgically anastamosed to donor vessels at the hip. A line is marked on the skin connecting the fibular head with the lateral.
The use of a vascularized fibular graft that is rotated on its peroneal artery pedicle is technically demanding. Free vascularized fibular grafting improves vascularity compared with core decompression in femoral head. Since then ive had arthritis in the joint that has not been too bad, along with some weakness. The necrotic area is debrided and cancellous graft placed in the periphery of the. Refinements of the surgical technique that expand graft size and graft mobility are described. Hence, a biological approach for harvesting long free non vascularized fibular graft with least interference of surrounding soft tissue maintaining periosteal sleeve hence biological by minimal invasive technique was attempted and critically evaluated in respect to recovery of satisfactory functions and development of complications compared. I am on a 50% weight restriction for another 4 weeks but my cheating tells me it is going to be no problem walking on it normally. Technique of vascularized fibular grafting for femoral head osteonecrosis. Vascularized fibular grafting for the treatment of congenital. Vascularized fibula graft for humeral reconstruction. Three cases treated by cree vascularized iliac crest graft.
Vascularized fibula grafts for reconstruction of bone defects. Extracapsular free vascularized fibular grafting is the treatment of choice for avn of all grades in the young patient at our institution. According to the ficat classification, at the time of surgery, 17 hips were in grade 2 and 9 hips were in grade 3. Thank you for your interest in free vascularized fibular graft fvfg surgery at penn orthopaedics. Free vascularized fibula grafting for reconstruction of the. We evaluated the results of limbsparing surgery and reconstruction of bone defects with vascularized fibula grafts in 8 consecutive patients mean age at operation. Vascularized free fibula flap and computerguided implant surgery. Onlay vascularized fibular grafting as a salvage procedure. The necrotic area is debrided and cancellous graft placed in the periphery of the defect. Recent updates of surgical techniques and applications of free. Vascularized free fibular transfer combined with autografting for the management of fracture nonunions associated with radiation therapy. The mean length of bone defects in the group of ilizarov technique was 6.
Free vascularized fibular graft as a salvage procedure for. Free vascularized fibular grafting improves vascularity. Free nonvascularized fibular graft for treatment of pediatric traumatic radial bone loss 39 the reported union rate for traumatic large bone defect in nonvascularised fibula grafting is almost 90% 1,2. Washing over the incision should be performed gently, with warm sudsy water. Fibular grafting is a common procedure in orthopedic practice. Friedrich, steven lawrence moran, allen thorp bishop, christina m. Reconstruction methods do not always compensate the potential for bone growth in this segment. Free vascularized osteocutaneous fibular graft is a good treatment modality for the reconstruction of extensive bone and soft tissue defect in the leg. Of these options, free vascularized fibular graft fvfg is the treatment of choice for its. Vascularized fibula graft is a good option for large humeral defects resulting from trauma, tumor resection, or infection and for smaller defects where enhanced blood supply is necessary for healing. Alternatively, the lateral decubitus position can be used, with the harvest leg placed up and the patient held in position with a beanbag. Listing a study does not mean it has been evaluated by the u. One disadvantage of the free fibula graft is the height discrepancy between the native mandible and the transplanted fibula, especially at the. Recent updates of surgical techniques and applications of free vascularized fibular graft in extremity and trunk reconstruction.
The role and benefits of free vascularized fibular grafts. Seventyone hips 60 patients were clinically followed for a minimum of 3 years. Free vascularised fibular grafts in orthopaedics request pdf. Practical procedures in orthopedic surgery pp 7982 cite as. Such defects were traditionally reconstructed with prosthetic implants, allografts, and allograft prosthetic composites. We aimed to investigate the clinical and radiographic results of an onlay free vascularized fibular grafting vfg as a salvage procedure for nonunion management after biologic reconstruction of the femur following bone tumor resection. In cases of resection of the radial articular surface, three reconstructive options are possible. A infected nonunion of tibia with soft tissue defect in 56yearold man. The conventional technique of harvesting fibular graft by long incision results in increased morbidity and a long scar, 1 3 weakness of extensor hallucis longus and ankle instability particularly when the required graft is long and extended into distal third. A free vascularized fibular graft fvfg is a graft containing tissue andor bone of the fibular region with its vascular pedicle that is attached to a recipient site for reconstruction of bone defects. Free vascularized osteocutaneous fibular graft to the tibia. We present a new surgical technique of bone reconstruction, based on the transposition of the ipsilateral fibula with its growth. Free vascularized fibula transfer is an established method for reconstruction of the wrist following tumor resection.
Vascularized free fibula flap for reconstruction of. Tantalum rod implantation and vascularized iliac grafting. The donor site morbidity of the free vascularized fibula graft is consistently acceptable among different studies, and is mostly avoidable with careful planning and appropriate technique 48,49,50. Free vascularized fibular grafting for the treatment of postcollapse osteonecrosis of the femoral head. Surgical technique wheeless textbook of orthopaedics.
Background the use of free vascularized fibular graft fvfg for proximal and midshaft tibial reconstruction is well documented in the literature. To reduce operation time, the preparation of hip and harvesting of fibular graft were performed concurrently by 2 teams. Free vascularized fibular graft salvage of complications of. Vascularized fibular grafting for the treatment of congenital pseudarthrosis of the tibia. In the practice of orthopedics, bone grafting is a common procedure used to enhance. Free vascularized fibular grafting for hip avn can restore your dying hip. Although many jointpreserving procedures are available to treat onfh, free vascularized fibular grafts fvfg can be an appropriate strategy for select patients to relieve pain, preserve or restore the femoral head, and delay the need for total hip arthroplasty. Cureus free vascularized fibular graft transfer in the. Penn orthopaedics free vascularized fibular graft surgery 8 about free vascular fibular grafting at penn penn medicine is among the few medical centers nationwide to offer free vascularized fibular grafting free vascularized fibular grafting fvfg is a microsurgical procedure that replaces dead bone with viable, structurally sound, vascularized. We present four illustrative case histories of patients with a pedicled fibular graft for a salvage arthrodesis of the knee.
The iliac graft pedicled with the ascending branch of the lateral femoral circumflex vessels can provide blood supply to the femoral head, like a free vascularized fibular graft. One of the option for surgical treatment for distal humerus osteosarcoma is limb. Various methods of reconstruction are available, such as allografts, vascularized fibular graft either free or pedicled, or endoprothesis replacement for distal defects. An elective microsurgical procedure, free vascularized fibular grafting is an option for hip joint preservation. Free vascularized fibular grafting for the treatment of. Free vascularized fibular graft mayo clinic connect.
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