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Conventional autografts versus vascularized fibula in humerus diaphyseal reconstruction for bone tumors
FREE COMPOSITE
TISSUE TRANSFERS
(cont.) AND VASCULAR
FREE COMPOSITE TISSUE TRANSFERS AND VASCULAR DISORDERS
DISORDERS
(cont.)
Experience with lateral arm flap in hand and forearm defects N. Cerkeg, M. Topalan, M. Erer, H. Agir Istanbul University, Istanbul Medical Hand Surgery, Istanbul, Turkey
School, Department
of
The lateral arm flap is currently one of the most frequently used free tissues. Easy dissection, constant anatomy and a long pedicle are the major advantages of this hap. 21 patients who had an upper extremity reconstruction with the lateral arm free flap are reviewed. The aetiology of the defects was electrical burn in 12 patients, thermal burn in 3 patients and trauma in 6 patients. The flap was transferred for distal forearm defects in 15 cases and for distal and volar soft tissue defects of hand in 6 cases.In 19 casesout of 2 1, the flaps were harvested from the ipsilateral limb. In 8 casesthe transfers were performed under axillary block anesthesia. All transfers were successfuland 4 casesrequired secondary thinning of flaps. In this presentation, indications and results with lateral arm flap will be discussed.
3
in skeletal microsurgical reconstruction. When it is used to reconstruct bone defects created by oncological resections involving the epiphysis of a growing child, the graft should include the fibular head in order to preserve the growth potential of the transplanted bone. Different techniques have been described to harvest a fibular autograft mantaining the blood supply to the proximal growth plate. According to Taylor’s anatomical findings the anterior tibia1 artery is supposed to be a reliable pedicle in order to vascularize both the fibular head and the proximal two-thirds of the shaft. Four children underwent surgery in the last 2 years; the resected bones have been the proximal humerus in three cases and the distal radius in one case. Two patients were affected by Ewing’s sarcoma and two by osteo-sarcoma. The follow-up ranges between 8 and 26 months. Function and growth rate of the transplanted bones are reported. No major complications at the donor site were observed. Pre- and postoperative chemotherapy was received by all patients.
Conventional autografts versus vascularized fibula humerus diaphyseal reconstruction for bone tumors One-stage repair of both skin and tendon digital defects using the arterialized venous flap with palmaris longus tendon G. Inoue Nagoya University School of Medicine, Nagoya, Japan
The combined loss of skin and tendon of the fingers is not uncommon and is a challenging problem. In the past, these injuries have been managed with a regional or distant flap, with tendon grafting done as a secondary procedure. This technique involves a multiple procedure usually requiring considerable time. The arterialized venous flap is now a routine procedure in our clinic to resurface skin defects of the hand and we considered that, if a palmaris longus tendon were taken as a composite unit, this might provide a potential donor graft. We have undertaken 6 arterialized venous flaps with a palmaris longus tendon, each having a minimum follow-up period of 6 months. Recipient sites were the dorsum of the PIP joint of the digit in 3, the dorsum of the DIP joint in 2 and the palmar aspect at the middle phalangeal level in 1. 4 flaps survived completely and 2 flaps survived with marginal necrosis. 2 patients involving loss of extensor slip and skin at the PIP joint had almost full range of motion of the PIP joint but the remaining 4 patients failed to achieve functional motion at the involved joint.
VFT in upper limb skeletal reconstruction cularized growth plate M. Innocenti, M. Ceruso, R. Angeloni, Capanna, M. Manfrini, Centro Traumatologico
with vas-
G. Lauri,
R.
Ortopedico, Fiuenze, Italy
VFT is probably the most popular and effective procedure
M. Ceruso, R. Capanna”, M. Innocenti, G. Lauri
M. Manfrini”,
in
R. Angeloni,
Centro Traumatologico Outopedico, Firenze, *Istituto pedico Rizzoli, Bologna, Italy
Orto-
The upper extremity is affected by bone and soft tissue neoplasms one-third as often as the lower extremity. Most tumors in the humerus occur in the proximal periarticular region while diaphyseal tumors are especially rare: very few reports in fact are available in the literature comparing the different techniques applicable in this location. The authors report their experience over 15 years in intercalary reconstructions of the humerus after bone sarcoma resection comparing vascularized fibula autograft and conventional autografts. Between 1978 and 1992 thirteen patients with diaphyseal malignant bone tumors of the humerus were treated by resection and intercalary reconstruction by means of autografts (8 patients) or vascularized fibular grafts (5 patients). Both groups presented a satisfactory outcome (92% good or excellent functional results) with no evidence of donor site morbidity. We have compared the indications and results and have found that a diaphyseal humeral defect shorter than 12 ems may be effectively treated by autogenous bone graft: this is usually achieved by a combination of tibia1 cortical struts, fibular nonvascularized grafts and iliac crest grafts. These invariably demand rigid fixation by long plates which may be required to be placed quite proximally in the humeral epiphysis and thus interfere with shoulder function. A vascularized fibular graft to bridge bony defects in the humeral shaft has been preferred in the following situations: a) if a very long diaphyseal resection is required for tumor excision or the resection needs to be extended either proximally or distally leaving small periarticular fragments. In these cases a VFG is preferred because its time to union is much shorter than a conventional graft and, therefore, the osteotomy can be internally fixed with a minimal amount of osteosynthesis.
THE JOURNAL
4
b) presumed inadequate quality of the receiving bed because of pre- and postoperative chemotherapy or a surgical field previously irradiated. c) presenceof infection or presumed infection: a vascularized graft is ideal in this setting becausethe preserved blood supply provides the humoral mechanisms for defence against infection.
Radial artery occlusion-a
SURGERY
VOL. 19B SUPPLEMENT
I
same non-invasive vascular studies. The risk factors studied are smoking, medication and concomitant medical problems. The morphological characteristics of the PVRs and DBIs were compared as well as the incidence of ulnar/radial artery dominance. The “odds ratio” was calculated for each of the factors studied.
response to transplantation-related Microcirculatory trauma. A model for composite tissue transfers
clinical entity?
A. Gupta, F. Stockmans, J. M. Kleinert Christine M. Kleinert Institute for Hand and Micro Louisville, KY, USA
OF HAND
G. D. Lister, M. Siemionow, T. Andreasen Surgery,
In contrast to ulnar artery occlusion (UAO), radial artery occlusion (RAO) is rarely described in the literature. Only three cases have been reported of which 2 describe a spontaneous radial artery thrombosis and 1 report describes a radial artery occlusion by a ganglion cyst. In a retrospective chart review study of the non-invasive vascular laboratory, 99 patients were identified with radial and/or ulnar artery occlusion. In all cases, the diagnosis was based on bilateral non-invasive vascular studies including pulse and pressure recordings, Doppler evaluation of the blood’flow in the hand, pulse volume recordings in upper, proximal and distal forearm and all digits, differential wrist occlusion test (Allen’s test) and temperature mapping of the hand. In 6 patients the diagnosis was confirmed by subclavian angiograms. 21 patients presented with unilateral RAO and 4 patients had combined, unilateral radial and ulnar artery occlusion. When these patients were divided into different subgroups according to etiology, 6 were post-traumatic, 3 patients presented with vasculitis, 6 patients suffered from renal disease and were on chronic dialysis, 2 patients presented with concomitant congenital vascular anomalies and 7 patients presented with a spontaneous occlusion of the radial artery. The average age of the patients was 42.5 years with a 1.17:1 male to female ratio. 4 patients initially presented in the clinic with a mass,over the radial artery, 11 with trophic changes, 21 with pain and Raynaud type complaints. Surgical intervention was undertaken in 6 cases. An interpositional vein graft was done in 3 cases,resection of an external compressing mass in 2 cases and digital sympathectomy in one case. The indication for surgery was ischaemic pain combined with trophic changes. The group with idiopathic radial artery occlusion was of particular interest and was studied seperately as a case control study where each case was matched with 6 controls for age and sex. All controls were normal volunteers and underwent the
University of Utah, Division qf Plastic & Reconstructive Surgery, Utah, USA
The rat cremaster muscle flap model for direct in vivo microcirculatory studies was combined with a rat hind limb amputation/replantation model to evaluate changes related to transplantation trauma. 48 inbred Sprague Dawley rats were studied in two experimental groups. Group I (control)
The cremaster muscle was dissectedas an island tube flap transposed into the hind limb, and anchored at ankle level. No amputation was performed. Group II: composite-limb-cremaster
graft
The limb, with the inserted cremaster muscle flap, was amputated at mid-thigh level and transplanted to the recipient animal. In both groups, at follow-up periods of 1 hour, 24,48, and 72 hours, the cremaster flap was withdrawn from the limb and prepared for microcirculatory studies. The following parameters were measured: vesseldiameters, RBC velocities, capillary density, and leukocytes in the postcapillary venules. Results
Arteriolar and venular diameters as well as RBC velocity values were comparable in both groups. The composite isografts, however, presented 50% more leukocytes sticking to the lumen of the postcapillary venules (p < 0.05) immediately following transplantation. In addition, a significant decrease(15%) in the number of perfused capillaries was observed in the composite grafts throughout 72 hours. In this study on composite tissue transplantation, trauma alone compromised the microcirculatory integrity of the tissue and proved to act as an independent factor. This should be considered during allotransplantations, where the addition of a rejection factor can further compromise graft survival.
TISSUE TRANSFERS
(cont.) AND VASCULAR
FREE COMPOSITE TISSUE TRANSFERS AND VASCULAR DISORDERS
DISORDERS
(cont.)
Experience with lateral arm flap in hand and forearm defects N. Cerkeg, M. Topalan, M. Erer, H. Agir Istanbul University, Istanbul Medical Hand Surgery, Istanbul, Turkey
School, Department
of
The lateral arm flap is currently one of the most frequently used free tissues. Easy dissection, constant anatomy and a long pedicle are the major advantages of this hap. 21 patients who had an upper extremity reconstruction with the lateral arm free flap are reviewed. The aetiology of the defects was electrical burn in 12 patients, thermal burn in 3 patients and trauma in 6 patients. The flap was transferred for distal forearm defects in 15 cases and for distal and volar soft tissue defects of hand in 6 cases.In 19 casesout of 2 1, the flaps were harvested from the ipsilateral limb. In 8 casesthe transfers were performed under axillary block anesthesia. All transfers were successfuland 4 casesrequired secondary thinning of flaps. In this presentation, indications and results with lateral arm flap will be discussed.
3
in skeletal microsurgical reconstruction. When it is used to reconstruct bone defects created by oncological resections involving the epiphysis of a growing child, the graft should include the fibular head in order to preserve the growth potential of the transplanted bone. Different techniques have been described to harvest a fibular autograft mantaining the blood supply to the proximal growth plate. According to Taylor’s anatomical findings the anterior tibia1 artery is supposed to be a reliable pedicle in order to vascularize both the fibular head and the proximal two-thirds of the shaft. Four children underwent surgery in the last 2 years; the resected bones have been the proximal humerus in three cases and the distal radius in one case. Two patients were affected by Ewing’s sarcoma and two by osteo-sarcoma. The follow-up ranges between 8 and 26 months. Function and growth rate of the transplanted bones are reported. No major complications at the donor site were observed. Pre- and postoperative chemotherapy was received by all patients.
Conventional autografts versus vascularized fibula humerus diaphyseal reconstruction for bone tumors One-stage repair of both skin and tendon digital defects using the arterialized venous flap with palmaris longus tendon G. Inoue Nagoya University School of Medicine, Nagoya, Japan
The combined loss of skin and tendon of the fingers is not uncommon and is a challenging problem. In the past, these injuries have been managed with a regional or distant flap, with tendon grafting done as a secondary procedure. This technique involves a multiple procedure usually requiring considerable time. The arterialized venous flap is now a routine procedure in our clinic to resurface skin defects of the hand and we considered that, if a palmaris longus tendon were taken as a composite unit, this might provide a potential donor graft. We have undertaken 6 arterialized venous flaps with a palmaris longus tendon, each having a minimum follow-up period of 6 months. Recipient sites were the dorsum of the PIP joint of the digit in 3, the dorsum of the DIP joint in 2 and the palmar aspect at the middle phalangeal level in 1. 4 flaps survived completely and 2 flaps survived with marginal necrosis. 2 patients involving loss of extensor slip and skin at the PIP joint had almost full range of motion of the PIP joint but the remaining 4 patients failed to achieve functional motion at the involved joint.
VFT in upper limb skeletal reconstruction cularized growth plate M. Innocenti, M. Ceruso, R. Angeloni, Capanna, M. Manfrini, Centro Traumatologico
with vas-
G. Lauri,
R.
Ortopedico, Fiuenze, Italy
VFT is probably the most popular and effective procedure
M. Ceruso, R. Capanna”, M. Innocenti, G. Lauri
M. Manfrini”,
in
R. Angeloni,
Centro Traumatologico Outopedico, Firenze, *Istituto pedico Rizzoli, Bologna, Italy
Orto-
The upper extremity is affected by bone and soft tissue neoplasms one-third as often as the lower extremity. Most tumors in the humerus occur in the proximal periarticular region while diaphyseal tumors are especially rare: very few reports in fact are available in the literature comparing the different techniques applicable in this location. The authors report their experience over 15 years in intercalary reconstructions of the humerus after bone sarcoma resection comparing vascularized fibula autograft and conventional autografts. Between 1978 and 1992 thirteen patients with diaphyseal malignant bone tumors of the humerus were treated by resection and intercalary reconstruction by means of autografts (8 patients) or vascularized fibular grafts (5 patients). Both groups presented a satisfactory outcome (92% good or excellent functional results) with no evidence of donor site morbidity. We have compared the indications and results and have found that a diaphyseal humeral defect shorter than 12 ems may be effectively treated by autogenous bone graft: this is usually achieved by a combination of tibia1 cortical struts, fibular nonvascularized grafts and iliac crest grafts. These invariably demand rigid fixation by long plates which may be required to be placed quite proximally in the humeral epiphysis and thus interfere with shoulder function. A vascularized fibular graft to bridge bony defects in the humeral shaft has been preferred in the following situations: a) if a very long diaphyseal resection is required for tumor excision or the resection needs to be extended either proximally or distally leaving small periarticular fragments. In these cases a VFG is preferred because its time to union is much shorter than a conventional graft and, therefore, the osteotomy can be internally fixed with a minimal amount of osteosynthesis.
THE JOURNAL
4
b) presumed inadequate quality of the receiving bed because of pre- and postoperative chemotherapy or a surgical field previously irradiated. c) presenceof infection or presumed infection: a vascularized graft is ideal in this setting becausethe preserved blood supply provides the humoral mechanisms for defence against infection.
Radial artery occlusion-a
SURGERY
VOL. 19B SUPPLEMENT
I
same non-invasive vascular studies. The risk factors studied are smoking, medication and concomitant medical problems. The morphological characteristics of the PVRs and DBIs were compared as well as the incidence of ulnar/radial artery dominance. The “odds ratio” was calculated for each of the factors studied.
response to transplantation-related Microcirculatory trauma. A model for composite tissue transfers
clinical entity?
A. Gupta, F. Stockmans, J. M. Kleinert Christine M. Kleinert Institute for Hand and Micro Louisville, KY, USA
OF HAND
G. D. Lister, M. Siemionow, T. Andreasen Surgery,
In contrast to ulnar artery occlusion (UAO), radial artery occlusion (RAO) is rarely described in the literature. Only three cases have been reported of which 2 describe a spontaneous radial artery thrombosis and 1 report describes a radial artery occlusion by a ganglion cyst. In a retrospective chart review study of the non-invasive vascular laboratory, 99 patients were identified with radial and/or ulnar artery occlusion. In all cases, the diagnosis was based on bilateral non-invasive vascular studies including pulse and pressure recordings, Doppler evaluation of the blood’flow in the hand, pulse volume recordings in upper, proximal and distal forearm and all digits, differential wrist occlusion test (Allen’s test) and temperature mapping of the hand. In 6 patients the diagnosis was confirmed by subclavian angiograms. 21 patients presented with unilateral RAO and 4 patients had combined, unilateral radial and ulnar artery occlusion. When these patients were divided into different subgroups according to etiology, 6 were post-traumatic, 3 patients presented with vasculitis, 6 patients suffered from renal disease and were on chronic dialysis, 2 patients presented with concomitant congenital vascular anomalies and 7 patients presented with a spontaneous occlusion of the radial artery. The average age of the patients was 42.5 years with a 1.17:1 male to female ratio. 4 patients initially presented in the clinic with a mass,over the radial artery, 11 with trophic changes, 21 with pain and Raynaud type complaints. Surgical intervention was undertaken in 6 cases. An interpositional vein graft was done in 3 cases,resection of an external compressing mass in 2 cases and digital sympathectomy in one case. The indication for surgery was ischaemic pain combined with trophic changes. The group with idiopathic radial artery occlusion was of particular interest and was studied seperately as a case control study where each case was matched with 6 controls for age and sex. All controls were normal volunteers and underwent the
University of Utah, Division qf Plastic & Reconstructive Surgery, Utah, USA
The rat cremaster muscle flap model for direct in vivo microcirculatory studies was combined with a rat hind limb amputation/replantation model to evaluate changes related to transplantation trauma. 48 inbred Sprague Dawley rats were studied in two experimental groups. Group I (control)
The cremaster muscle was dissectedas an island tube flap transposed into the hind limb, and anchored at ankle level. No amputation was performed. Group II: composite-limb-cremaster
graft
The limb, with the inserted cremaster muscle flap, was amputated at mid-thigh level and transplanted to the recipient animal. In both groups, at follow-up periods of 1 hour, 24,48, and 72 hours, the cremaster flap was withdrawn from the limb and prepared for microcirculatory studies. The following parameters were measured: vesseldiameters, RBC velocities, capillary density, and leukocytes in the postcapillary venules. Results
Arteriolar and venular diameters as well as RBC velocity values were comparable in both groups. The composite isografts, however, presented 50% more leukocytes sticking to the lumen of the postcapillary venules (p < 0.05) immediately following transplantation. In addition, a significant decrease(15%) in the number of perfused capillaries was observed in the composite grafts throughout 72 hours. In this study on composite tissue transplantation, trauma alone compromised the microcirculatory integrity of the tissue and proved to act as an independent factor. This should be considered during allotransplantations, where the addition of a rejection factor can further compromise graft survival.