Ovid: Chapman’s Orthopaedic Surgery

Editors: Chapman, Michael W.
Title: Chapman’s Orthopaedic Surgery, 3rd Edition
> Table of Contents > SECTION III – THE HAND > Microvascular Surgery > CHAPTER 36 – VASCULARIZED BONE GRAFTS

Kimberly K. Mezera
Andrew J. Weiland
K. K. Mezera:
Hand, Wrist, Elbow, Shoulder, and Microvascular Surgery, Department of
Orthopaedic Surgery, Southwestern Medical School, Dallas, Texas 75235.
A. J. Weiland: Hospital for Special Surgery, New York, New York 10021.
Since first reported in the mid-1970s, the use of
vascularized bone grafts has continued to be refined. Offering rapid
bony union, increased stiffness and strength, less resorption, and more
rapid hypertrophy than conventional bone grafts, they have distinct
advantages in selected cases. They do, however, require specialized
microsurgical skills and careful preoperative planning. With sources
including the fibula, iliac crest, rib, radial styloid, and indications
ranging from nonunion, tumor reconstruction, congenital pseudarthrosis,
and radial club hand (52) to traumatic and infectious defects, the opportunities that can be afforded by vascularized bone grafts are vast and varied.
Strauch, Bloomberg, and Lewin performed some of the
first experiments on free tissue transposition in dogs in 1971 when
they isolated a rib on the internal mammary pedicle and transposed it
to the jaw (48). This was followed, again in the canine, with a free vascularized rib graft in 1973 by McCullough and Fredrickson (37).
With the advent of microvascular techniques and development of
microsurgical instruments, anastomosis of vessels as small as 1 mm was
successfully accomplished by Buncke in 1965 in a rhesus monkey (11).
Improvement on these techniques opened the door for the transfer of
composite tissue. The first free skin flap was reported by Daniel and
Taylor in 1973, involving the transfer of an iliofemoral island flap
based on the superficial circumflex iliac artery to the right lower
extremity (15). This was followed by a report
in 1975 of the first free bone graft by Taylor et al., who transferred
a fibula to a tibial defect (53). Buncke et al. (10) successfully transferred the first osteocutaneous flap utilizing a rib to the tibia in 1977 to treat a tibial


pseudarthrosis, and this was followed shortly by Taylor’s report of the
first such graft using groin skin and iliac bone in 1978 (56).

The basic goals of treatment are:
  • To provide restoration of skeletal continuity
  • To achieve union rapidly, thus avoiding the slow process of creeping substitution as required for conventional grafts
  • To provide viable soft tissue coverage early
  • To restore and maintain the anatomy of the limb
  • To restore limb function including motion and strength
The surgeon should always strive to avoid complications
and perform the procedures with the least morbidity and operative time
necessary. For three-quarters of a century, conventional
corticocancellous bone grafting, which has been shown to involve
necrosis of the graft followed by a long process of revascularization,
osteogenesis, and remodeling, has been the sole option in treatment of
segmental bone defects. The living bone graft circumvents this
prolonged process. With these goals in mind, the next step is the
assessment of the patient and his or her expectations, the underlying
pathology, and what is available to use as graft tissue. All of these
points have to be considered in individualizing the treatment plan for
each patient. Once this is determined, the surgical team can move to
the next step in planning a vascularized bone graft.
Several issues regarding patient selection are crucial
to planning a vascularized bone graft. Patient age and underlying
medical condition play an important role in determining which patients
are candidates. Although there is no age limit for vascularized bone
grafts, elderly patients with underlying medical problems may present
an unacceptably high surgical risk. Carefully weigh the risks of a long
surgical procedure and requirement for prolonged limb protection
against patient expectations. Those patients with evidence of
peripheral vascular disease may also present risks that predispose to
failure. Patients with multiple previous attempts at treatment may have
altered local anatomy and limited availability for tissue coverage.
Patients who smoke have been shown to have delayed bone healing. Those
with hypercoagulable conditions or clotting abnormalities may also
require special consideration.
In patients with a history of trauma, irradiation, or
infection, the condition of the recipient vessels in the defect must be
carefully considered, as they may be at increased risk for failure of
the graft because of poor arterial inflow and venous outflow. These
procedures are often long and tedious, and the extensive dissection and
long operative time required may exacerbate a previously quiescent
infection and may increase the risk of graft failure.
Several factors must be considered when choosing a bone
for vascularized transfer. First, the donor bone must be of sufficient
size to fill the defect. Free vascularized grafts offer advantages over
conventional grafts in cases of defects greater than 6 to 8 cm. Lesser
defects may not require as extensive a procedure, and a pedicled
vascular graft may suit such a case well. Free vascularized iliac crest
grafts are useful for defects no longer than 10 cm because of both the
curvature and the structural characteristics of the bone. The nutrient
vessels must be of adequate size for successful microvascular
anastomoses. Arteriograms may aid in determining the availability and
status of vessels. Last, donor site morbidity must be minimized.
Current applications for vascularized bone grafts
continue to expand. Well established are the uses of such grafts in
patients with large defects secondary to trauma or after resection of
locally aggressive or malignant bone tumors. Refractory nonunions,
resection for osteomyelitis, and congenital pseudarthrosis of the tibia
or forearm are other situations in which living grafts can be most
useful. More recently, the use of vascularized bone grafts in the
treatment of avascular necrosis of the femoral head has been reported
with some mixed results. Avascular necrosis of the scaphoid (Priser’s
disease) and of the lunate (Kienbock’s disease) has also been treated
with vascularized bone grafts in hopes of arresting the underlying
disease process.
Trauma is the most common cause of segmental bone loss
in both upper and lower extremities. Perhaps the most frequent
indication for vascularized bone grafts is the posttraumatic and often
massive bone loss associated with severe trauma. Autogenous cancellous
bone graft methods are not well suited for large defects of bone
greater than 6 to 8 cm, as resorption of the graft may occur, and it
does not provide structural support. In addition, scarring


relative avascularity of the recipient bed may not be conducive to
graft incorporation. Defects in the tibia are most common; however,
defects of the femur, ankle, and radius have also been treated with
vascular bone grafts. An important concern in this setting is the
condition of the recipient site, as often the bed has significant
scarring. The arterial inflow to the area may be tenuous as well
because of the “zone of injury,” which may extend a significant
distance from the apparent bony defect. The fibular graft is most often
utilized, as it nicely fits the longitudinal defect and is of
sufficient length for most reconstructive settings. The rib graft was
the first reported graft used clinically, but its usefulness in
orthopaedics is somewhat limited because of its curved and malleable
nature. It also has the potential for higher donor site morbidity if
careful harvesting technique is not followed. The iliac crest is also
useful; however, again the curvature of the bone often limits its
application for defects less than 10 cm, and donor site morbidity is
not insignificant.

Much has been written about the use of vascularized bone
grafts in the setting of tumor resection and reconstruction. Patients
with locally aggressive or malignant tumors of bone often require en bloc resections that leave a large defect requiring reconstruction. Weiland et al. (61,62)
have reported on a large series in which they used free fibula graft
for the reconstruction of defects after massive tumor resections.
Case Study 1
A 20-year-old college athlete presented with pain,
swelling, and increased deformity of his wrist and forearm over several
months’ duration (Fig. 36.1).
Figure 36.1. A: Radiographs of a 20-year-old man demonstrate a lytic lesion in the distal radius that has thinned and expanded the cortex. B: Intraoperative photograph demonstrating a 7-cm en bloc resection of the distal radius from a dorsal approach. C: This 4-month postoperative radiograph demonstrates sound union proximally and distally.
A locally aggressive fibromyxoma was treated by en bloc resection and vascularized fibular grafting.
Case Study 2
A 10-year-old girl presented with pain in her right hip of several months’ duration (Fig. 36.2).
A low-grade chondrosarcoma was treated by wide local excision, leaving
a defect measuring 14 cm in the proximal femur. The defect was
reconstructed using a vascularized fibula doweled into the recipient
femur and external fixation to stabilize the graft. The graft healed
uneventfully, but the patient later required a valgus intertrochanteric
osteotomy to correct a resultant varus deformity of the proximal femur.
Figure 36.2. A: Radiographs of a 10-year-old girl demonstrate a lucency and periosteal reaction in the right proximal femur. B: An MRI of the femur further delineates the lesion in the proximal shaft. C:
Postoperative radiograph revealing the fibular graft and the external
fixator in place. Note the doweling of the graft into the femur. D:
Anteroposterior and lateral radiographs 3 years postoperatively reveal
incorporation and hypertrophy of the graft but a varus deformity of the
femoral neck. E: A 50° intertrochanteric valgus corrective osteotomy performed to improve neck shaft angle.
A frequent problem faced by the orthopaedic surgeon,
osteomyelitis can pose management and treatment problems for many
reasons. The resection of soft tissue and bone is often too massive to
obtain adequate debridement of the infected area. Often the patient has
undergone multiple procedures including several irrigations and
debridements. As many as 18 procedures were reported in a recent study (5)
to have preceded presentation for the definitive grafting procedure.
This leaves a significantly scarred and relatively avascular soft
tissue bed to work with. The integrity of the surrounding vessels could
also be potentially compromised, leading to high risk of graft failure.
Furthermore, the potential of recurrence of the infection leading to
almost certain graft failure is a foremost concern.
Case Study 3
A 32-year-old patient sustained a bumper-type injury
that resulted in a comminuted open fracture of the proximal tibia
complicated by osteomyelitis (Fig. 36.3).
Following debridement and application of an external fixator, the
patient was left with a 13-cm bone defect, with interval healing after
a vascular latissimus dorsi flap. A vascularized fibular graft was
performed. The patient subsequently fractured at the proximal juncture
site, however, and later required an open reduction, internal fixation,
and plating before complete healing occurred.
Figure 36.3. A: Radiograph of a patient who sustained a bumper-type injury that resulted in a comminuted open fracture of the proximal tibia. B: Radiographic appearance following radical debridement demonstrates a 13-cm bone defect. C: Clinical appearance of leg following free soft-tissue transfer and coverage. D: A 6-month postoperative radiograph demonstrates sound union of vascularized fibular graft proximally and distally. E:
Radiograph of patient 3 months following a repeated internal fixation
performed because of a stress fracture of the proximal juncture site.
Refractory nonunions can occur in many locations, but
the well-known sites are the tibia and scaphoid. The tibia is often
subjected to open injuries, and the blood supply to the area can be
easily interrupted. The anatomy of the blood supply to the scaphoid
lends itself to compromise, especially with proximal pole fractures.
These situations may not often require the massive size grafts as seen
in the previously discussed conditions; however, they still require a
nutrient blood supply in which osteocytes and osteoblasts can survive,
thus facilitating healing of the bone without the usual replacement of
the graft with creeping substitution. In the case of scaphoid
nonunions, a local pedicled vascularized bone graft will often be
adequate to treat a nonunion. Zaidemberg et al. (72)
described a vascularized graft to the scaphoid based on the radial
styloid that offers promising results. Several other authors have
reported on vascularized metacarpal bone grafts based on the branches
of the radial and ulnar arteries.
Congenital pseudarthrosis remains one of the most
challenging problems facing the orthopaedic surgeon today. Conventional
bone-grafting methods have failed to successfully treat these patients.
Chen, Weiland, Hagan, and Bunke have all reported promising results
using vascularized free fibular grafts in the treatment of this
difficult problem. Congenial pseudarthrosis of the forearm is uncommon.
Sellers (45) reported only 23 cases after a
review of the literature. Conventional treatment has been fraught with
poor results and recurrent nonunion. Allieu (1) and





Sellers (45) both report improved results with the use of free vascularized graft for this condition.

Case Study 4
An 11-year-old boy with von Recklinghausen’s disease
presented with a congenital pseudarthrosis of the right tibia and
fibula that had defied several previous attempts at bone grafting and
immobilization (Fig. 36.4). An extraperiosteal
dissection and excision of the pseudarthrosis of the tibia and fibula
were performed, resulting in an 8-cm tibial defect. A buttress plate
was used to secure the graft to the tibia proximally and distally. Six
months postoperatively there was good incorporation of the fibula graft
proximally as well as distally. The patient subsequently required a
contralateral epiphysiodesis to equalize a leg length discrepancy and
an osteotomy of the tibia to correct valgus bowing.
Figure 36.4. A: Anteroposterior radiograph of an 11-year-old boy with von Recklinghausen’s disease and congenital pseudarthrosis of the tibia. B:
Lateral radiograph demonstrating a proximally as well as distally bowed
tibia along with marked osteoporosis of the distal tibia and foot. C: Intraoperative photograph of resected specimen, including tibial and fibular pseudarthrosis. D:
Intraoperative photograph demonstrating bony defect. Vessel loops are
noted around the anterior neurovascular bundle as well as the saphenous
vein. E: Intraoperative photograph
demonstrating buttress plate. The vascular pedicle can be seen
transversing the proximal portion of the plate into the graft. F:
Radiograph of leg 6 months postoperatively, demonstrating sound union
of the vascularized graft. However, tibial bowing was noted.
Several recent reports on the treatment of avascular
necrosis of the femoral head have been published. This difficult
problem often presents in the younger patient as a result of trauma,
steroid use, or alcohol use or may be idiopathic. This group of
patients is often too young for hip arthroplasty but is severely
debilitated secondary to pain and stiffness. A vascularized bone graft
may offer them a chance to retain their native hip as long as possible
while restoring some of their quality of life. Both iliac crest and
fibula have been reported in the literature as possible sites of donor
bone graft. Results have been mixed, with some authors reporting good
results and others saying that the results are no better than with
simple core decompression. Scaphoid and lunate AVN have also been
treated with vascularized bone grafts with promising results.
The surgeon should first be well trained and well versed
in microvascular techniques and be able to perform multiple types of
microvascular anastomoses that may be required in scarred or otherwise
traumatized tissue. Assess the patient, the defect, and the possible
donor sites as described elsewhere in this chapter well before the
procedure. Obtain preoperative arteriograms of both the donor and
recipient site to evaluate any vascular abnormalities that could
preclude a successful graft transfer. Be aware that a normal
arteriogram may not provide a true assessment of the arterial inflow.
Scarred blood vessels or those easily prone to spasm may appear normal
on an arteriogram. The surgeon will often be required to make
intraoperative judgments of vascular viability and should be able to



vessel damage that would interfere with successful microvascular anastomoses.

Studies have shown that the peroneal artery, which is
intimately related to the undersurface of the bone, is the predominant
blood supply to the fibula, supplying a nutrient artery and segmental
musculoperiosteal vessels (53). Commonly an
arteriogram of a normal leg exhibits a proximal anterior tibial artery
takeoff followed by a bifurcation of posterior tibial and peroneal
arteries. Occasionally, a separate peroneal artery does not exist,
which may preclude use of the fibula as a donor.
  • Although not essential, a two-team
    approach can save considerable operative time. The surgical technique
    for the donor fibula is rather constant, with the patient supine and
    the hip and the knee flexed.
  • Use a lateral approach to the fibula, extending from the neck of the fibula in a distal direction.
  • Identify the interval between the peroneus longus and the soleus muscles (Fig. 36.5). Incise the deep fascia the entire length of the incision.
    Figure 36.5. Cross section of the middle third of the lower extremity, outlining the lateral approach for harvest of the fibula (dotted line). T.A., tibialis anterior; D.P.N., deep peroneal nerve; A.T.V., anterior tibialis vessels; E.D.L., extensor digitorum longus; P.T., peroneus tertius, S.P.N., superficial peroneal nerve; P.B., peroneus brevis; P.L., peroneus longus; P.C.S., posterior crural septum; F.H.L., flexor hallucis longus; P.V., peroneal vessels; G.A., gastrocnemius aponeurosis; P., plantaris; I.S., intermuscular septum; P.T.V., posterior tibial vessels, P.T.N., posterior tibial nerve; F.D.L., flexor digitorium longus; I.M., interosseous membrane. (From Weiland AJ. Vascularized Bone Transfers. In Murray JA, ed. AAOS Instructional Course Lectures, Vol. 33. St. Louis: CV Mosby, 1984:448.)
  • Expose the lateral border of the fibula.
    Approach the fibula in a proximal-to-distal direction and elevate, with
    extraperiosteal dissection, the peroneus longus and brevis off the
    anterior border of the fibula.
  • Divide the anterior crural septum along
    the length of the graft and identify and protect the deep peroneal
    nerve and anterior tibial artery and vein as the extensor group of
    muscles is dissected from the interosseous membrane.
  • Divide the posterior crural septum the
    entire length of the graft and reflect the soleus as well as flexor
    hallucis muscles off the posterior border of the fibula. Preserve the
    nerve to the flexor hallucis longus while performing this dissection.
    Continue this dissection until the peroneal vessels are encountered.
  • The nutrient artery is found in the
    middle half of the fibula, usually just proximal to the midpoint. The
    periosteal vessels pass circumferentially around the fibula. Preserve
    them with extraperiosteal dissection. The venous drainage is via paired
    venae comitantes of the peroneal artery and closely parallels it.
  • Measure the length of the fibular graft
    needed and mark it, taking care to preserve at least the distal 6 cm of
    fibula to maintain stability of the ankle mortise. In children less
    than 10 years of age, we perform a synostosis between the fibula and
    tibia to prevent proximal migration of the distal fibula, which can
    cause valgus ankle deformity.
  • Perform the proximal and distal
    osteotomies with a Gigli or power saw, taking care to place a bone
    retractor between the peroneal vessels and the fibula. Retract the bone
    graft posteriorly and laterally and divide the interosseous membrane
    along the entire length of the bone graft.
  • Retract the graft anteriorly. Dissect the
    tibialis posterior muscle off the posterior aspect of the middle third
    of the fibula. At this point, the fibula graft will be isolated on the
    peroneal neurovascular bundle (Fig. 36.6).
    Dissect the pedicle proximally until the bifurcation of the posterior
    tibial artery and peroneal artery is identified. Before dividing the
    pedicle, deflate the tourniquet and allow circulation to the fibula for
    10 to 15 min.
    Figure 36.6.
    The osteotomized fibula after the interosseous membrane has been
    divided. The vascular pedicle of the peroneal artery and vein is
    clearly visible in the proximal extent of the wound.
  • The structure most at risk proximally is the peroneal nerve and its branches, which must be protected at all times.
  • The technique for preparing the recipient
    site varies depending on the clinical condition being treated. In
    posttraumatic cases, focus initial attention at identification


    protection of neurovascular structures. Failure to isolate a healthy
    level of recipient vessels is the most common cause for failure of free
    tissue transfer. The zone of injury often far exceeds the limits of the
    bone defect in posttraumatic and infected cases.

  • Resect necrotic or nonviable bone ends.
  • Rigidly fix the fibular graft into the
    defect. A variety of techniques may be used, including doweling of the
    end of the fibula inside the tibia, end-to-end apposition, or
    bayonet-type fixation. Regardless of the position of the fibular graft,
    rigid fixation is needed with external and/or internal fixation. Do not
    use medullary fixation through the vascularized fibular graft to avoid
    disrupting its blood supply. In most instances, pack cancellous bone
    graft in and around the juncture points of the recipient and donor bone
    to promote more rapid union.
  • Perform the microvascular anastomoses.
    Usually one artery and one vein are anastomosed. Whenever possible,
    perform end-to-side arterial anastomosis so as not to compromise distal
    circulation to the extremity. End-to-end vein anastomosis is standard
    practice. The caliber of the recipient vein must be equal to or larger
    than that of the peroneal vein so that venous hypertension does not
    occur. Some authors recommend two venous anastomoses to assure adequate
    venous drainage. The recipient vein may be from either the superficial
    venous system or venae comitantes, as long as it is of sufficient
    caliber and scar-free.
  • The fibular graft, because it is devoid
    of larger amounts of soft tissue or muscle, seems particularly tolerant
    of ischemia lasting up to 6 h. Do not rush attempts at achieving secure
    bony fixation to limit ischemia time, as secure fixation is of utmost
  • Adequate circulation is assessed by a
    patent and functioning anastomosis as well as by bleeding at the edges
    of the muscle cuff on the fibular graft. Before wound closure,
    ascertain that the vascular pedicle is not redundant, twisted, or
    kinked. It is preferable to resect and tailor a functioning anastomosis
    that is looped or kinked because of the potential danger of thrombosis.
  • Although there is no universal agreement
    on the use of anticoagulants, some surgeons find it helpful to give
    intraoperative heparin before removing the vascular clamps from large
    lower extremity vessels.
  • Pack cancellous bone chips harvested from
    the iliac crest about the proximal and distal juncture sites, insert
    deep drains, and close the skin.
  • Close the donor site defect in two
    layers, the subcutaneous layer and the skin. Do not close the fascia,
    as this may lead to a compartment syndrome. Postoperatively, continue
    low-dose aspirin therapy and instruct patients not to smoke.
At present, there are no 100% reliable techniques for
monitoring the vascularity to the bone graft in a noninvasive fashion.
Overlying skin islands may be taken with the fibula; however, the
presence or absence of the cutaneous circulation may not accurately
reflect the osseous circulation. Bone scans have been used in the
laboratory and clinically but are useful only for the first week after
surgery and are impractical as a sequential monitoring system. If a
scintiscan performed within the first week is negative, patent
microvascular anastomosis is unlikely (65).
Immobilize and protect the grafted bone segment from
weight bearing for at least 2.5 months or until incorporation and
callus around the juncture sites are seen. In the adult, lower
extremity graft incorporation usually occurs in 4 to 6 months, but it
may be wise to protect the graft site with an orthosis throughout the
first year.
Even experienced microsurgeons, if a novice at
vascularized fibular grafting, should perform cadaveric dissections
before surgery to refamiliarize themselves with the relationships of
neurovascular structures to the interosseous membranes. With attention
to meticulous technique, a very low incidence of donor-site morbidity
can be expected.


First described by Taylor as based on the superficial
circumflex iliac artery (SCIA), this graft has undergone changes. In an
elegant study combining cadaver dissection, angiography, and clinical
trial, Taylor showed that the most reliable pedicle for the
osteocutaneous iliac crest graft is the deep circumflex iliac artery,
as it supplies a greater portion of the bone as well as an elliptical
area of skin over the iliac crest and the iliacus, transversus, and
internal oblique muscles as compared to the superficial system (54).
In planning this graft, the incisions, orientation of the bone, and the
choice of donor side should be carefully planned in advance. Use the
ipsilateral crest in the tibia if the recipient artery is to be the
anterior tibial; however, use the contralateral crest for the recipient
posterior tibial artery.
The iliac crest graft, based on the deep circumflex
iliac artery (DCIA), can be harvested with or without a skin flap. If a
skin graft is taken, place the incision in the long axis along the
upper border of the anterior part of the iliac crest. The upper limit
of area of skin that can be harvested is not known currently. Areas
averaging 18 × 7.7 cm have been taken and closed primarily (55).
Skin medial to the anterior superior iliac spine (ASIS) relies more on
its blood supply from the anastomoses between the DCIA and the SCIA,
and this means there may be temporary sluggish flow to this skin, but
expect viability.
  • Place the patient supine on the table
    with a small bump under the donor hip to help elevate the crest and aid
    in harvesting. If skin is to be harvested with the graft, mark the area
    on the skin.
  • Make an incision from the femoral artery
    to a point about 10 cm posterior to the anterior superior iliac spine.
    A transinguinal approach to the vascular pedicle is preferred.
  • Expose the external oblique muscle and
    incise it in line with its fibers, approximately 3 cm superior to the
    iliac crest. This edge of the muscle includes perforator branches of
    the DCIA. Then curve the incision toward the ASIS and parallel to the
    inguinal ligament to enter the inguinal canal. Next, identify the
    spermatic cord or round ligament and retract upward and medially. The
    external iliac artery can be palpated through the transversalis fascia.
  • Incise the fascia and identify the DCIA
    and vein. They are most easily identified where they converge toward
    each other about 1 to 2 cm lateral to the external iliac artery. Trace
    the DCIA vessels laterally, dividing the transversalis fascia, internal
    oblique, and transversus abdominis from the inguinal ligament. As the
    ASIS is approached, it may become easier to identify the ascending
    branch lateral to the ASIS and then trace it medially to its origin
    from the SCIA by incising the internal oblique muscle 3 cm above and
    behind the ASIS.
  • To isolate the bone, incise the
    transversus muscle parallel to the iliac crest, leaving a minimal rim
    of muscle on the bone. Incise the transversalis fascia, retract the
    extraperitoneal fat, and expose the line between the transversalis and
    the iliacus fascia. Incise the iliacus 1 cm medial to this line, thus
    exposing the periosteum of the iliac fossa. Bluntly dissect the iliacus
    muscle away from the remainder of the bone.
  • Incise the lower skin border and cut the
    attachment of the tensor fasciae latae and glutei muscles sharply from
    the bone. Divide the inguinal ligament and the origin of the sartorius
    muscle just medial to the ASIS.
  • Osteotomize the bone as measured to
    isolate the flap on its vascular pedicle. Allow the flap to sit for 20
    min to assure viability before sectioning the pedicle.
  • The lateral cutaneous nerve of the thigh
    will be encountered in close relation to the DCIA. The nerve may have
    to be sectioned to remove the graft, but attempt to preserve it.
  • At the lateral margin of the iliac crest,
    use an oscillating saw to cut through the crest, creating a graft 2.5
    cm in depth (wide). Then continue the cut medially with the
    osteocutaneous flap finally isolated on its vascular pedicle,
    consisting of the deep circumflex iliac artery and vein.
  • Using sutures widely placed at the edges
    of the graft, carefully preserve the attachment of the overlying skin
    and subcutaneous tissue to the iliac crest to avoid accidental shearing
    of the small nutrient vessels supplying the skin.
  • Because of the curvature of the ilium,
    grafts longer then 10 cm usually cannot be obtained. A portion of the
    iliacus must be retained on the inner table in order to preserve the
    nutrient blood supply to the bone. Close the donor site primarily.
    Harvest cancellous graft for use at the junction sites before closing
    the donor site. The hip may be flexed about 30° by flexing the table to
    facilitate closure of the defect.
  • To avoid abdominal herniation, suture the
    iliacus fascia and muscle to the transversalis fascia and muscle. Next,
    suture the internal and external oblique muscles to the glutei, the
    fascia lata, and its muscle. Repair the inguinal canal and reattach the
    inguinal ligament laterally.
  • Internally fix the graft into the
    recipient site; there is healthy bone on either end of the defect.
    Plates can often easily be used to fix the graft but should not lie on
    top of the nutrient artery. Fixation into the graft itself should be
    limited and avoid the nutrient artery and pedicle. Two plates can be
    used at either end or T-plates if a metaphysis is involved. Use no more
    than two screws in the graft. The use of Kirschner wires and screws
    alone has been reported (51) but is often associated with loss of position at the junction site.
  • P.1220

  • If adequate bone stock is not available for internal fixation, use external fixation (19,27,31).
    Almost any external fixator can be used, and the choice is dependent on
    the anatomic site, bone quality, and functional demands. Ilizarov-type
    frames offer multiplanar control and variation as to configuration,
    whereas the others offer ease of application. It has been used in many
    defects involving transfer of free vascularized grafts including the
    humerus, forearm, hand, femur, tibia, and foot for defects ranging from
    trauma and tumor to infection and congenital deformities (19).
  • Regardless of the frame used, it must not
    block access to the microvascular anastomoses. The pins or wires can be
    carefully passed through the graft, always protecting the nutrient
    artery and pedicle. Pack cancellous graft around the junction sites and
    close the wound over drains.
  • Healing of the graft can be expected in 8 to 12 weeks, roughly the same as healing rate for fractures at the same site.
Östrup, Fredrickson, and Tam showed by injection studies
that the posterior intercostal vessels give rise to the principal
nutrient vessel of the ribs, whereas the anterior intercostal arteries
supply mainly the periosteum of the rib. The graft, therefore, is based
on the posterior vessels (10). The graft can survive on the anterior pedicle, but the bone may show some necrosis.
  • Measure the pattern of the defect and
    trace out the pattern on the chest. Make a posterior transverse
    incision between two ribs (10).
  • Identify the intercostal vessels
    posteriorly at the beginning of the dissection and develop the flap
    margins of the underlying rib in an anterior direction.
  • Expose the rib and cut a segment sized to
    the bony defect. Dissect the vessels back to the pedicle and carefully
    ligate them. Then transpose the graft to the defect and secure it.
    Close the donor defect primarily over drains.
Complete survival of the rib as free living bone occurs
only when the intramedullary blood supply is maintained via the
nutrient artery, which is a branch of the posterior intercostal artery.
Thus, the rib must be isolated on its nutrient artery. This requires a
complicated posterior dissection within 3 cm of the costovertebral
joint rather than a simple lateral segmental excision. This location
will often obligate ligation of the adjacent dorsal branch of the
intercostal artery, which risks transection of the artery of
Adamkiewicz. This vessel arises between T-7 and L-1 and is the
principal supply to the thoracolumbar segment of the spinal cord. Loss
of this can result in permanent paraplegia. Preoperative angiography is
recommended; however, the sixth rib should be selected when
arteriography is not possible.
Nonunion and avascular necrosis of the scaphoid continue
to be difficult to treat. Conventional methods of treatment including
bone grafting and internal fixation have resulted in reports of
successful union in 90% of patients (14,22,36,44,47,72).
The period of immobilization is long, however, and the 10% of cases
that are refractory despite conventional procedures present especially
difficult treatment dilemmas. The vascularized bone graft offers the
advantages of decreased times of immobilization and a high union rate
for these refractory nonunions (12,32,33,72).
Zaidemberg has most recently described a technique using a vascularized
graft from the distal dorsoradial aspect of the radius based on a
consistent retrograde branch from the radial artery that has shown good
results and is technically straightforward (72).
  • Perform a dorsal approach to the wrist by
    making an oblique incision on the radiodorsal aspect of the wrist. Take
    care to avoid injury to the dorsal sensory branch of the radial nerve.
  • Divide the extensor retinaculum. Retract
    the first dorsal compartment containing the extensor pollicis brevis
    and abductor pollicis longus tendons palmarly. Reflect the extensor
    carpi radialis longus and finger extensor tendons ulnarly. The
    longitudinal course of the vessel is easily identified overlying the
    distal radius. Design a vascularized bone graft centering this
    perfusing periosteal blood vessel in the bone to be harvested.
  • Visualize the nonunion of the scaphoid
    and freshen the sclerotic bone ends. Reduce the fracture. If adequate
    reduction of the scaphoid fracture cannot be achieved, then a combined
    palmar approach may be necessary to reduce the scaphoid fracture before
    bone grafting.
  • Fashion a trough 15 to 20 mm in length running parallel to the long axis of the scaphoid.
  • Harvest a bone graft corresponding in
    size to the cavity created in the scaphoid from the distal radius
    underlying the vascular pedicle. The bone graft is then easily
    transposed to the recipient scaphoid site. Secure the bone graft with
    Kirschner wires.
  • If additional cancellous bone graft is
    needed, it can be harvested through the same distal radius site. A
    monitoring island of skin can be raised with the bone for postoperative
    documentation of vascularity if desired, as the periosteal vessel does
    continue into the skin overlying the bone.
  • Close and apply a long arm cast with
    thumb spica for 1 month, followed by a short arm cast with thumb spica
    for 2 weeks. At 6 weeks, use radiographs to assess union. When stable
    bony union is certain, begin range-of-motion exercises.


Microvascular surgery has the same complications as
other surgery, such as infection, wound problems, and others. Use good
surgical technique to minimize these.
Loss of function of the flexor hallucis longus (FHL) can
occur when a fibula is harvested as a result of dissection of its
origin off of the fibula, damage to its nerve, or postoperative
scarring. Avoid loss of FHL function and peroneal nerve palsy by
identifying and protecting these structures when necessary and avoiding
unnecessary dissection into the muscles surrounding the fibula. When
the fibula is harvested, a major vessel to the leg is sacrificed, but
this rarely leads to any problems.
In harvesting the iliac crest, the lateral femoral
cutaneous nerve to the thigh may need to be sacrificed. Advise patients
about this ahead of time. Iliac grafts may be bulky. Minimize bulk by
placing the grafts in the defect in the coronal plane. Secondary
debulking may be necessary.
Vascularized bone grafts have expanded treatment options
for multiple clinical situations where obtaining bone union has
traditionally been difficult. However, the ability to perform such a
procedure and the practical nature of doing this are two different
situations. It is our opinion that the vascularized fibular graft is
most useful for defects of the tibial and for avascular necrosis of the
femoral head. The use of iliac crest grafts is somewhat more limited
because of the more curved nature of the bone and the morbidity of the
donor site. It should be considered if the fibular graft is not an
option for a patient because of trauma or previous harvesting. Rib
grafts have very limited use in orthopaedic surgery and are used only
as a last resort to the other graft sites. Their curved nature makes
them very amenable to use in the mandible. The dorsal/radial graft is
useful for nonunions of the scaphoid, but we would recommend its use
only for selected proximal pole nonunions and only after failed open
reduction, internal fixation, and standard bone grafting, as it is more
involved and requires greater dissection on the dorsal aspect of the
Each reference is categorized according to the following
scheme: *, classic article; #, review article; !, basic research
article; and +, clinical results/outcome study.
+ 1. Allieu
Y, Gomis R, Yoshimura M, et al. Congenital Pseudarthrosis of the
Forearm. Two Cases Treated by Free Vascularized Fibular Graft. J Hand Surg 1981;6:475.
+ 2. Berggren
A, Weiland AJ, Dorfman HD. Free Vascularized Bone Grafts: Factors
Affecting Their Survival and Ability to Heal to Recipient Bone Defects.
Plast Reconstruct Surg 1982;69:19.
+ 3. Berggren
A, Weiland AJ, Östrup LT, Dorfman H. Microvascular Free Bone Transfer
with Revascularization of the Medullary and Periosteal Circulation or
the Periosteal Circulation Alone. J Bone Joint Surg 1982;64A:73.
+ 4. Berggren
A, Weiland AJ, Östrup LT. Bone Scintigraphy in Evaluating the Viability
of Composite Bone Grafts Revascularized by Microvascular Anastomosis,
Conventional Autogenous Bone Grafts and Free Nonrevascularized
Periosteal Grafts. J Bone Joint Surg 1982;64A:799.
+ 5. Bishop AT, Wood MB, Sheetz KK. Arthrodesis of the Ankle with a Free Vascularized Autogenous Bone Graft. J Bone Joint Surg 1995;77A:1867.
+ 6. Bohay DR, Manoli A II. Clawtoe Deformity Following Vascularized Fibula Graft. Foot Ankle Int 1995;16:607.
* 7. Boyd HB. The Treatment of Difficult and Unusual Non-unions. J Bone Joint Surg 1943;25:535.
+ 8. Brookes M, Elkin AC, Harrison RG, Heald CB. A New Concept of Capillary Circulation in Bone Cortex. Some Clinical Applications. Lancet 1961;1:1078.
# 9. Brookes M. The Blood Supply of Bone. London: Butterworths, 1971.
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! 11. Buncke HJ, Schulz WP. Experimental Digital Amputation and Reimplantation. Plast Reconstruct Surg 1965;36:62.
+ 12. Chacha PB. Vascularised Pedicular Bone Grafts. Int Orthop 1984;8:117.
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IG, Golubev VG, Goncharenko IV, et al. Transfer of Free Vascularized
Bone and Skin-Bone Autografts: Experiences in the Application of
External Fixation Apparatus. J Reconstruct Microsurg 1990;6:1.


* 20. Harmon PH. A Simplified Surgical Approach to the Posterior Tibia for Bone Grafting and Fibular Transference. J Bone Joint Surg 1945;27:496.
+ 21. Hasegawa
Y, Iwata H, Torii S, et al. Vascularized Pedicle Bone-grafting for
Nontraumatic Avascular Necrosis of the Femoral Head: A 5 to 11 Year
Follow-up. Arch Orthop Trauma Surg 1997;116:251.
+ 22. Herbert TJ, Fisher WE. Management of the Fractured Scaphoid Using a New Bone Screw. J Bone Joint Surg 1984;66B:114.
+ 23. Hertel R, Pisan M, Jakob RP. Use of the Ipsilateral Vascularised Fibula for Tibial Reconstruction. J Bone Joint Surg 1995;77B:914.
+ 24. Hirayama T, Suematsu N, Inoue K, et al. Free Vascularised Bone Grafts in Reconstruction of the Upper Extremity. J Hand Surg 1985;10B:169.
+ 25. Hou SM, Hang YS, Liu TK. Ununited Femoral Neck Fractures by Open Reduction and Vascularized Iliac Bone Graft. Clin Orthop 1993;294:176.
! 26. Hurlbut PT, Van Heest AE, Lee KH. A Cadaveric Anatomic Study of Radial Artery Pedicle Grafts to the Scaphoid and Lunate. J Hand Surg 1997;22A:408.
+ 27. Ilizarov
GA. The Tension-Stress Effect on the Genesis and Growth of Tissues.
Part I. The Influence of Stability of Fixation and Soft Tissue
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! 29. Iwata
H, Torii S, Hasegawa Y, et al. Section III: Basic Science and
Pathology: Indications and Results of Vascularized Pedicle Iliac Bone
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JB, Gerhard HJ, Guerrero J, et al. Treatment of Segmental Defects of
the Radius with Use of the Vascularized Osteoseptocutaneous Fibular
Autogenous Graft. J Bone Joint Surg 1997;79A:542.
+ 31. Jupiter JB, Kour AK. Reconstruction of the Humerus by Soft Tissue Distraction and Vascularized Fibula Transfer. J Hand Surg 1991;16A:940.
+ 32. Kawai H, Yamamoto K. Pronator Quadratus Pedicled Bone Graft for Old Scaphoid Fractures. J Bone Joint Surg 1988;70B:829.
+ 33. Kuhlmann
JN, Mimoun M, Boabighi A, Baux S. Vascularized Bone Graft Pedicled on
the Volar Carpal Artery for Non-union of the Scaphoid. J Hand Surg 1987;12B:203.
+ 34. Leung PC. Femoral Head Reconstruction and Revascularization: Treatment for Ischemic Necrosis. Clin Orthop 1996;323:139.
+ 35. Low CK, Pho RWH, Kour AK, et al. Infection of Vascularized Fibular Grafts. Clin Orthop 1996;323:163.
+ 36. Manske PR, McCarthy JA, Strecker WB. Use of the Herbert Bone Screw for Scaphoid Nonunions. Orthopedics 1988;11:1653.
+ 37. McCullough DW, Fredrickson JM. Neovascularized Rib Grafts to Reconstruct Mandibular Defects. Can J Otolaryngol 1973;2:96.
# 38. Moore JR, Weiland AJ. Vascularized Bone Grafts. In Chapman MW, ed. Operative Orthopaedics, 2nd ed. Philadelphia: JB Lippincott, 1993:1079.
+ 39. Ozaki
T, Hillmann A, Wuisman P, Winkelmann W. Reconstruction of Tibia by
Ipsilateral Vascularized Fibula and Allograft: 12 Cases with Malignant
Bone Tumors. Acta Orthop Scand 1997;68:298.
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+ 41. Parrish FF. Treatment of Bone Tumors by Total Excision and Replacement with Massive Autologous and Homologous Grafts. J Bone Joint Surg 1966;48A:968.
+ 42. Pho RWH. Malignant Giant-cell Tumor of the Distal End of the Radius Treated by a Free Vascularized Fibular Transplant. J Bone Joint Surg 1981;63A:877.
+ 43. Riordan DC. Congenital Absence of the Radius. J Bone Joint Surg 1955;37A:1129.
+ 44. Schneider LH, Aulicino P. Nonunion of the Carpal Scaphoid: the Russe Procedure. J Trauma 1982;22:315.
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+ 47. Stark
HH, Rickard TA, Zemel NP, Ashworth CR. Treatment of Ununited Fractures
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