Abstract
Background
Vascularized bone grafts (VBGs) are currently the main surgical option for the restoration of humeral bone defects particularly when defects are larger than 6 cm. Because it offers a strong, rapid blood supply, VBGs easily integrate into the recipient sites and undergo active resorption and remodeling into healthy bone through primary bone healing. Additionally, they support the recipient site's immune system in preventing and reducing infection.
The Aim was to assess the outcomes of utilizing vascularized bone grafts to reconstruct large humeral bony defects (greater than 6 cm).
Patients and methods
This study comprised twenty patients with major humeral bony defects treated by vascularized bone grafts. Under general anesthesia, the procedure was carried out with the patient in the supine position for free fibula harvesting or in the lateral or prone position for pedicled scapular graft harvesting.
Results
The union rate was 90 % and the mean healing time was 7.78 ± 3.04 months. Complications were present in 40 % of cases, with non-union being the most common, followed by infection and wound dehiscence.
Conclusion
The study suggests that the reconstruction of large bony defects of humerus using vascularized bone grafts is effective, with a predictable healing time and a manageable complication rate.
Keywords: Vascularized fibula, Reconstruction, Non union, Humerus
1. Introduction
Large skeletal defects are difficult and challenging issue in orthopedic reconstructive surgery and they cause considerable morbidity and functional impairment for the patient. It is accepted that in a healthy tissue bed with adequate vascularity, a defect of up to 6 cm can be managed by a non-vascularized bone graft. In the upper limb, shortening alone is acceptable for defects not exceeding 3 cm.1
Skeletal defects can be classified according to their etiology as primary or secondary. Primary bone defects are associated with high energy trauma, resulting from open fractures with extensive soft-tissue damage and bone loss. Secondary defects result from excision of pathologic tissue that may be congenital as congenital pseudarthrosis or acquired as aseptic and septic nonunions, osteomyelitis and bone tumors.2,3
There are several options for reconstruction of large bone defects which include biological reconstruction as vascularized bone graft, allograft or a combination, induced membrane (Masquelet technique), and distraction lengthening (Ilizarov technique) and non biological reconstruction as endoprosthetic replacement.4, 5, 6
The biological advantages of vascularized bone grafting over conventional grafts include more rapid and predictable union, less graft resorption, lower rate of infection, fewer fatigue fractures, graft hypertrophy, and the ability to respond to biomechanical loads similar to living bone. These advantages result from the different manner in which vascularized bone grafts incorporate into the recipient bed, while non-vascularized bone grafts heal via "creeping substitution”.7,8
Vascularized bone graft options include Free Vascularized Fibular Graft (FVFG), free vascularized iliac crest, vascularized lateral border of scapula (pedicled or free) and vascularized ribs (pedicled or free). Among these flaps, FVFG and scapular flap are most suitable because they are straight.9,10
The fibula is the ideal bone for microvascular reconstruction of extensive segmental long bone defects. It has a high density of cortical bone, is straight and tubular, and has a triangular cross section, which make it highly resistant to torsional and angular stresses. In the adult, a length of up to 22–26 cm of the fibula can be harvested for vascularized straight graft. The fibula can be transferred as a free bone, or with an accompanying fasciocutaneous and/or muscular flap based on the same pedicle, which permits concomitant reconstruction of any associated soft tissue defect in a single procedure. Finally, in the pediatric population, the proximal epiphysis and physeal plate can be incorporated into the transfer to provide for potential longitudinal growth.11, 12, 13, 14, 15, 16, 17
The scapular crest bone graft was described in 1982 by Gilbert and Teot. The vascularization of this flap is supplied by circumflex scapular vessels. Deraemaecker described another blood supply for the angle and the lateral border of the scapula in 1988 named the angular branch. Harvesting procedure is easy to perform for a surgeon who is familiar with sub-scapular flaps. However, this flap has some limitations: the length of the bone is smaller than with free flaps, local trauma may have destroyed the blood supply and anatomical variations are possible.10,18,19
2. Aim of the study
The study's objective was to assess the outcomes of utilizing vascularized bone grafts to reconstruct large humeral bony defects (greater than 6 cm).
3. Patients and methods
3.1. Patients
This study comprised twenty patients from our institution who require restoration of major humeral bony deformities utilizing vascularized bone grafts. Patients with aggressive benign or malignant bone tumors of the humerus bone without involvement of the vascular bundles, large sequestra excision after trauma, or humerus bone defects larger than 6 cm were included. Patients who had prior vascular repairs or vascular injuries that may compromise limb survival or hinder microvascular anastomosis were not included. Every patient participating in the trial was asked to sign an informed consent.
3.2. Methods
Every patient had a preoperative examination that included a thorough review of their medical history, a clinical assessment, regular laboratory testing, and the appropriate medical imaging. (Fig. 1).
Fig. 1.
Pre-operative plain radiographs showing loosening of screws.
Under general anesthesia, the procedure was carried out with the patient is in the supine position for free fibula harvesting or in the lateral or prone position for pedicled scapular graft. The location and size of the defect determined the type of vascularized graft that was utilized; for proximal humeral defects and defects up to 12 cm in size, a pedicled scapular graft was employed; for larger and more distal defects, FVFG was used (Fig. 2).
Fig. 2.
A: cement spacer after excision of osteomyelitic segment. B: isolation of radial nerve.
The recipient site was prepared by preparation of the free bone ends of the humerus and, in the case of FVFG, the brachial vessels and their branches, particularly the profunda brachii vessels were dissected and isolated (Fig. 3). The peroneal vessels served as the basis for the free fibular graft harvesting technique and the circumflex scapular vessels served as the starting point for the scapular graft harvesting technique. The graft was inserted primarily as an inlay graft in the intramedullary canal and was secured according to the recommended fixation techniques.
Fig. 3.
Anastomosis of FVFG with recipient vessels (The profunda brachii vessels).
Postoperatively, a temperature chart, radiography, and prophylactic wide spectrum antibiotics such as third generation cephalosporins were done. The patients were followed up clinically and radiologically. (Fig. 4, Fig. 5).
Fig. 4.
A,B: follow up plain x-ray showing healing of FVFG. C: clinical photo showing survival of skin paddle.
Fig. 5.
A,B&C: Shoulder and elbow range of motion at the end of follow up.
4. Results
4.1. Demographic characteristics of the patients
Among 20 patients participated in the study, 16 patients were less than 40 years, 14 patients were males and 6 patients were females. Manual workers constituted the higher percentage (7 patients), followed by students (5 patients), and housewives (5 patients) (Table 1, Table 2).
Table 1.
Distribution of the studied cases according to age (n = 20).
| Age (years) | No. | % |
|---|---|---|
| <20 | 5 | 25.0 |
| 20–30 | 4 | 20.0 |
| >30 | 11 | 55.0 |
| Min. – Max. | 6.0–68.0 | |
| Mean ± SD. | 34.45 ± 18.51 | |
| Median (IQR) | 33.50 (26.0–49.50) | |
IQR: Inter quartile range SD: Standard deviation.
Table 2.
Distribution of the studied cases according to sex (n = 20).
| Sex | No. | % |
|---|---|---|
| Male | 14 | 70.0 |
| Female | 6 | 30.0 |
4.2. Clinical characteristics of the patients
An equal distribution of the patients was observed in the side affected, while regarding the pathology, the majority of causes were trauma (14 patients), while the remaining (6 patients) were tumors (Table 3, Table 4).
Table 3.
Distribution of the studied cases according to side affected (n = 20).
| Side affected | No. | % |
|---|---|---|
| Right | 10 | 50.0 |
| Left | 10 | 50.0 |
Table 4.
Distribution of the studied cases according to pathology \ trauma (n = 20).
| Pathology \ trauma | No. | % |
|---|---|---|
| ABC | 1 | 5.0 |
| Atrophic NU | 1 | 5.0 |
| Ewing sarcoma | 3 | 15.0 |
| Infected NU | 6 | 30.0 |
| Osteosarcoma | 2 | 10.0 |
| Traumatic bone loss | 7 | 35.0 |
Free vascularized fibular grafts (FVFG) was the graft selected in 18 patients of the cases, epiphyseal transfer in one patient, and pedicled scapula in one patient. According to fixation method, intramedullary (IM) method was used in 16 patients with bridging plates in 8 patients and non-bridging plates in 8 patients. The arterial anastomsis mainly was to profunda brachii branch of brachial artery (n = 14) in 70 % of cases (Table 5, Table 6).
Table 5.
Distribution of the studied cases according to graft selection (n = 20).
| Graft selection | No. | % |
|---|---|---|
| FVFG | 18 | 90.0 |
| Epiphyseal transfer | 1 | 5.0 |
| Pedicled scapula | 1 | 5.0 |
Table 6.
Distribution of the studied cases according to arterial anastomosis (n = 20).
| Arterial anastomosis | No. | % |
|---|---|---|
| No | 1 | 5.0 |
| Yes | 19 | 95.0 |
| End to side brachial | 1 | 5.0 |
| Reversed flow radial | 1 | 5.0 |
| Muscular branch | 3 | 15.0 |
| Profunda brachii | 14 | 70.0 |
4.3. Outcomes of the surgical procedure
Regarding healing and healing time, healing occurred in 90 % of cases with a mean healing time of 7.78 ± 3.04 months. There were no statistically significant correlations between healing time and age, time since initial trauma to index surgery, and defect size. Also, there was no statistically significant association between healing time and the used fixation method either bridging plate or non-bridging plate.
4.4. Complications of the surgery
Complications occurred in 40 % of cases with 15 % non-union, and 20 % infection with wound dehiscence.
4.5. Surgical and clinical characteristics associations with secondary intervention
Secondary intervention was significantly higher in case that time since initial trauma to index surgery was lower than or equal 12 months (p = 0.042). While there was no significant association between secondary intervention and fixation method or associated injuries.
5. Discussion
Extensive bone loss involving the humerus can be managed with various surgical techniques. There are two main groups of indications for vascularized bone grafts (VBGs). The first indication is for bone defects larger than 6–8 cm, which are typically seen in patients who have undergone oncological resection or who have had post-infectious or post-traumatic bone injury. The second indication relates to skeletal defects resulting from a biological failure of bony healing, such as congenital pseudoarthroses, osteonecrosis, or recalcitrant non-union of fracture.20
Non-VBGs have multiple features that stimulate bone healing. The efficacy of materials used for grafts is determined based on their osteogenicity, osteoinductivity, and osteoconductivity. It is also critical to take into account the mechanical strength and vascular supply to the bone graft material. Autologous bone grafts show very good histocompatibility, osteoconductivity, osteoinductivity and osteogenicity; therefore, they enable bone incorporation into the adjacent host site through the process of “creeping substitution,” for which reason autologous bone grafting is considered to be the standard of care. The bone graft material is progressively revascularized and finally reabsorbed, allowing new living bone to form; this new bone is then incorporated and remodeled in the host skeleton.21,22
VBGs use cortical or cortico-cancellous bone grafts, harvested with their vascular supply, and are therefore immediately viable. The vascularized free graft (VFG) was first described 49 years ago and this technique is now commonly used in clinical practice. VBGs are incorporated via primary bone healing into the bone recipient site with no need for creeping substitution. This process enables preservation of the structural integrity and mechanical strength of the graft, yielding immediate stability and greater strength. VBG is more efficient than conventional cortico-cancellous grafts due to several advantages. Specifically, the living bone graft enables straightforward and rapid fracture healing by serving as a source of osteogenic cells, promoting vascularization, eliminating infection and enhancing intrinsic stability at the non-union site. VBGs can be harvested from the fibula, iliac crest, distal radius, ribs, scapula, medial femoral condyle, the phalanx of the toe and metacarpal bones.14,15,23,24
Reconstructing upper limb bony defect may include a variety of methods and donor locations. Nonetheless, because it's vital to guarantee that the recipient bone's diameter matches the donor sites. VFGs' unique characteristics make them ideal for great bone regeneration in this anatomical area. After the fibula is placed at the recipient location, it might undergo remodeling to support the increased functional load. This remodeling is seen on radiography as humeral hypertrophy.12,24, 25, 26, 27, 28
We found that the healing occurred in 90 % of cases with a mean healing time of 7.78 ± 3.04 months and this was higher than the typical healing period described in the literature which was 6 months. The following actions should be taken in order to shorten the time to union: using an only bridging plate to decrease the risk of stress fractures caused by weak points between plates, especially in the case of humerus reconstruction; preserving a periosteal flap to overlap the connection between the fibula and host bone, utilizing uni-cortical screws to fix the VFG to the plate.24,29,30
Lefebvre et al. published a study in 2023 reporting their experience with vascularized fibula graft for segmental defects of the humerus in 10 patients with septic humerus nonunion treated with staged reconstruction using a FVFG, with a mean follow-up of 32.3 months. After the two-stage reconstruction using a FVFG, radiographic union was achieved in 6/10 patients, with a mean time to union of 19.9 weeks. The remaining 4 patients required an additional operation for graft augmentation and/or implant revision. After that, union was noted in 3/4 patients, 21 weeks postoperatively. Mean patient visual analog scale pain scores improved from 5.8 preoperatively to 0.9 at final follow-up (P = 0.02). Postoperatively, mean elbow flexion was 110 ± 20° and extension 15 ± 7.5°.31
Also, in study of Matthew R. Claxton et al., published in 2020 about using FVFG in upper limb reconstruction, mainly involving the humerus (n = 17, 61 %) and most of pathologies were malignant tumor (n = 23, 82 %). The limb salvage rate was 93 % (n = 26), with primary union occurring in 71 % (n = 20) of patients. After bone grafting the overall union was 96 % (n = 27) at a mean 13 ± 11 months. They concluded that FVFG effectively provided a functional reconstruction following tumor resection. Although, one in four patients needed additional bone grafting, the overall union rate is high.32
5.1. Limitations of the study
With a small sample size, the study may lack the statistical power necessary to detect significant associations or differences. Also, there was no control group, it's difficult to determine if the results are due to the treatment or other factors.
6. Conclusion
The study suggests that the reconstruction of large bony defects of humerus using vascularized bone grafts is effective, with a predictable healing time and a manageable complication rate. However, the timing of the surgery post-trauma appears to be a critical factor in the need for secondary interventions. The fixation method and other clinical characteristics did not significantly affect the outcomes.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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