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,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,Free vascularized bular grafting combined with a locking plate for massivebone defects in the lower limbs,You-Shui Gao, Chang-Qing Zhang,Department of Orthopedic Surgery, Shanghai Sixth Peoples Hospital, Shanghai, China,Background,Massive femoral and tibial defects due to severe trauma, osteomyelitis and resection of malignancies present challenging problems for orthopedic surgeons.,As an alternative, distraction osteogenesis using the Ilizarov technique has proved of great significance in manipulation of massive bone defects. However, complications following the sophisticated technique are not negligible,treatment duration is long, and much inconvenience is caused by the complex external fixators,.,Free vascularized fibular grafting (FVFG) could be a good option for the restoration of massive bone defects in lower limbs.,However, post-op complications could be reach 54% following FVFG, and graft fracture is significant with traditional stabilization.,Then, how to promote the functionality of transplanted fibula?,how to prevent secondary complications?,Arai K, et al. PRS 2002.,A locking plate, which has been well described in the published literature, achieves advances in angular stability, integrity of screws and plate, and elastic stabilization.,The locking plate systems possess improved mechanical properties and include newly designed screws to anchor the plate system firmly in the bone while exerting compression.,Dynaminization of the bone-plate construct,Hypertrophy of the transplanted fibula,Patients and Methods,Eighteen patients with a massive bone defect in a lower limb reconstructed by FVFG combined with a locking plate were retrospectively enrolled in the current study.,The degree of fibular hypertrophy was calculated based on the measurements from anteroposterior imaging at regular intervals of 3 months, 6 months, 1, 2 and 3 years postoperatively.,Patients,Gender,Age,Site(L/R),Femur/Tibia,Length of defect,Previous op times,Infection,Time to union,1,F,21,L,T,12 cm,twice,Yes,3,2,M,37,L,T,8 cm,twice,No,3,3,M,37,R,T,8 cm,twice,No,3,4,M,42,L,F,7 cm,once,Yes,6,5,M,40,R,F,13 cm,twice,Yes,3,6,M,19,L,T,9 cm,once,No,3,7,F,18,L,T,8 cm,once,No,3,8,M,16,R,T,12 cm,once,Yes,6,9,F,40,R,T,14 cm,twice,Yes,6,10,M,30,R,T,12 cm,twice,Yes,3,11,M,31,R,F,8 cm,twice,No,6,12,M,49,L,T,7 cm,once,No,3,13,M,27,L,F,7 cm,once,No,3,14,F,56,L,F,10 cm,once,No,3,15,M,33,L,F,8 cm,once,No,3,16,M,28,R,T,6 cm,twice,No,3,17,F,54,R,F,8 cm,twice,No,6,18,M,40,L,T,9 cm,once,No,3,Repeated measures analysis of variance was employed to evaluate and compare correlative factors including gender (male vs. female), age distribution ( 30 years), site (femur vs. tibia) and length of bone defect (610 cm vs. 10 cm), previous number of operations (once vs. twice), and concomitant infection (detected vs. non-detected).,There were five time-points over the postoperative follow-up period, at three and six months and one, two, and three years.,Results,Multivariate,Number of cases,P,value,Gender,Male,13,0.715,Female,5,Age,6,Times of pre-op,once,9,0.997, twice,9,Infection,Yes,6,0.331,No,12,Multivariate and statistical results,FH = 55%,FH = 85%,FH = 116%,Discussion,The fibula undergoes mechanical, geometric priority and minor morbidity at the donor site. Moreover, vessels accompanying the fibula are relatively invariable, factors which combine to make the fibula a favorite donor autograft for massive bone defects in reconstructive surgery.,FVFG could be a useful option in the salvaging procedure to reconstruct limbs with massive defects as one tool in a powerful armamentarium.,Several authors have reported their experience in the management of massive bone defects with ipsilateral transposition of the fibula (ITF), which is also called the Huntington procedure.,We retained the ipsilateral fibula,in situ,for its mechanical support, which was better for earlier weight-bearing exercise which acts as a biomechanical stimulus for fibular hypertrophy.,Moreover, an intact fibula could act as a marker to discriminate any discrepancy and maintain accurate alignment of the affected tibia.,De Boer noticed that graft hypertrophy was more common in the mechanically-loaded lower extremity in comparison with upper extremities, and hypertrophy was enhanced significantly in patients in whom the graft was not bypassed by internal fixation, which could induce stress shielding.,El-Gammal,et al.,investigated the effect of several factors on the degree of hypertrophy, and found no significant differences between patients with regard to age, graft length, reconstruction site, fixation method (interlocking nails,vs.,bridge plates,vs.,external fixators), or chemotherapy administration.,De Boer HH, et al. JBJS Br 1989; 71: 374-378.,El-Gammal TA, et al. Microsurgery 2002; 22:367-370.,Recent experimental and clinical studies have demonstrated the superiority of locking plates in the care of tibial fractures, and the biomechanical conditions provided by such stabilization equipment probably act as an important influencer.,Internal fixators, which are a more logical and diplomatic choice for osteosynthesis due to their biomechanical superiority, are better for fibular tibialization.,Moss DP, et al. Bull NYU Hosp Joint Dis 2007; 65: 294-299.,Pearls,A thorough debridement of the infected defect was critical for prevention of infection recurrence, and vital replacement by FVFG was another important factor for final elimination of the lesion and reconstruction of a massive defect.,The rationale has to be followed when a locking plate system is used.,The transplanted fibula is LIVE following vascular anastomosis.,A well-designed plan of functional exercise is critically important.,Conclusion,Free vascularized fibular grafting could be a good choice for the reconstruction of massive bone defects when combined with a locking plate. Factors including gender, age distribution, site and length of bone defects, number of previous operations, and infection do not impact the progress of fibular hypertrophy, which implies that intrinsic factors might play an important role in restoration.,We found that the variables discussed in the current study did not affect the progress of fibular hypertrophy, which implies that,intrinsic factors,might contribute to the results of hypertrophy.,Although those concerning the degree of hypertrophy were non-significant, as mentioned above, a longer follow-up period and a larger number of patients is required in the future for a better understanding of peculiar hypertrophy, enabling a more reasonable and logical decision preoperatively.,The biological effect of,in vivo,mechanics has to be investigated.,Thank you!,
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