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J Reconstr Microsurg 2009; 25(2): 117-124
DOI: 10.1055/s-0028-1090624
© Thieme Medical Publishers

Treatment of Chronic Nonunions of the Humerus with Free Vascularized Fibula Transfer: A Report of Thirteen Cases

A. Bobby Chhabra1 , 2 , S. Raymond Golish1 , 2 , Michael E. Pannunzio3 , Thomas E. Butler4  Jr. , Luis E. Bolano5 , William C. Pederson6
  • 1Department of Orthopaedics, University of Virginia, Charlottesville, Virginia
  • 2University of Virginia Hand Center, Charlottesville, Virginia
  • 3Reconstructive Hand Surgeons of Indiana, Carmel, Indiana
  • 4Southwest Shoulder and Elbow Surgery, Tucson, Arizona
  • 5Scott Orthopaedic Center, Huntigton, West Virginia, San Antonio, Texas
  • 6Hand Center of San Antonio, San Antonio, Texas
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Publication History

Publication Date:
16 October 2008 (online)

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ABSTRACT

Chronic nonunions of the humerus remain a challenging problem. We reviewed 13 cases of chronic nonunion of the humerus resulting from trauma or osteomyelitis treated with vascularized fibula transfer after failure of conventional treatment. Patient averages were 35 years of age, follow-up of 19 months, and 4.2 prior operations. Healing was obtained in 12 of 13 (92%) patients with an average healing time of 18 weeks and graft length of 12.5 cm. In total, 11 of 12 (91%) patients who united had good to excellent range of motion of their shoulder and elbow. There were eight complications in 7 of 13 patients (54%). Two patients developed fractures of the graft, and three had superficial infections at the harvest site requiring operative debridement. Two patients had median neurapraxia that resolved by 4 months. Two patients complained of intermittent pain at the donor site. No significant correlations were found between time to heal and other covariates.

KEYWORDS

Humerus - nonunion - vascularized bone graft

REFERENCES

  • 1 Ackerman G, Jupiter J B. Non-union of fractures of the distal end of the humerus.  J Bone Joint Surg Am. 1988;  70(1) 75-83
    PubMedSearch in Google Scholar
  • 2 Brighton C T. The treatment of non-unions with electricity.  J Bone Joint Surg Am. 1981;  63(5) 847-851
    PubMedSearch in Google Scholar
  • 3 Cattaneo R, Villa A, Catagni M A, Bell D. Lengthening of the humerus using the Ilizarov technique: description of the method and report of 43 cases.  Clin Orthop Relat Res. 1990;  250 117-124
    PubMedSearch in Google Scholar
  • 4 Esterhai Jr J L, Brighton C T, Heppenstall R B, Thrower A. Nonunion of the humerus: clinical, roentgenographic, scintigraphic, and response characteristics to treatment with constant direct current stimulation of osteogenesis.  Clin Orthop Relat Res. 1986;  211 228-234
    PubMedSearch in Google Scholar
  • 5 Foster R J, Dixon Jr G L, Bach A W, Appleyard R W, Green T M. Internal fixation of fractures and non-unions of the humeral shaft: indications and results in a multi-center study.  J Bone Joint Surg Am. 1985;  67(6) 857-864
    PubMedSearch in Google Scholar
  • 6 Loomer R, Kokan P. Non-union in fractures of the humeral shaft.  Injury. 1976;  7(4) 274-278
    PubMedSearch in Google Scholar
  • 7 Rosen H. Compression treatment of long bone pseudarthroses.  Clin Orthop Relat Res. 1979;  138 154-166
    PubMedSearch in Google Scholar
  • 8 Duffy G P, Wood M B, Rock M G, Sim F H. Vascularized free fibular transfer combined with autografting for the management of fracture nonunions associated with radiation therapy.  J Bone Joint Surg Am. 2000;  82(4) 544-554
    CrossrefPubMedSearch in Google Scholar
  • 9 Gerwin M, Weiland A J. Vascularized bone grafts to the upper extremity: indications and technique.  Hand Clin. 1992;  8(3) 509-523
    PubMedSearch in Google Scholar
  • 10 Hirayama T, Suematsu N, Inoue K, Baitoh C, Takemitsu Y. Free vascularised bone grafts in reconstruction of the upper extremity.  J Hand Surg [Br]. 1985;  10(2) 169-175
    CrossrefPubMedSearch in Google Scholar
  • 11 Osterman A L, Bora F W. Free vascularized bone grafting for large-gap nonunion of long bones.  Orthop Clin North Am. 1984;  15(1) 131-142
    PubMedSearch in Google Scholar
  • 12 Sowa D T, Weiland A J. Clinical applications of vascularized bone autografts.  Orthop Clin North Am. 1987;  18(2) 257-273
    PubMedSearch in Google Scholar
  • 13 Takami H, Takahashi S, Ando M, Masuda A. Vascularized fibular grafts for the reconstruction of segmental tibial bone defects.  Arch Orthop Trauma Surg. 1997;  116(6–7) 404-407
    CrossrefPubMedSearch in Google Scholar
  • 14 Tu Y K, Yen C Y, Yeh W L, Wang I C, Wang K C, Ueng W N. Reconstruction of posttraumatic long bone defect with free vascularized bone graft: good outcome in 48 patients with 6 years' follow-up.  Acta Orthop Scand. 2001;  72(4) 359-364
    CrossrefPubMedSearch in Google Scholar
  • 15 Urbaniak J R, Coogan P G, Gunneson E B, Nunley J A. Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting: a long-term follow-up study of one hundred and three hips.  J Bone Joint Surg Am. 1995;  77(5) 681-694
    CrossrefPubMedSearch in Google Scholar
  • 16 Wei F C, El-Gammal T A, Lin C H, Ueng W N. Free fibula osteoseptocutaneous graft for reconstruction of segmental femoral shaft defects.  J Trauma. 1997;  43(5) 784-792
    CrossrefPubMedSearch in Google Scholar
  • 17 Weiland A J, Kleinert H E, Kutz J E, Daniel R K. Free vascularized bone grafts in surgery of the upper extremity.  J Hand Surg [Am]. 1979;  4(2) 129-144
    PubMedSearch in Google Scholar
  • 18 Wood M B, Cooney W P. Vascularized bone segment transfers for management of chronic osteomyelitis.  Orthop Clin North Am. 1984;  15(3) 461-472
    PubMedSearch in Google Scholar
  • 19 Wood M B. Free vascularized bone transfers for nonunions, segmental gaps, and following tumor resection.  Orthopedics. 1986;  9(6) 810-816
    PubMedSearch in Google Scholar
  • 20 Wood M B. Upper extremity reconstruction by vascularized bone transfers: results and complications.  J Hand Surg [Am]. 1987;  12(3) 422-427
    PubMedSearch in Google Scholar
  • 21 Yajima H, Tamai S, Ono H, Kizaki K. Vascularized bone grafts to the upper extremities.  Plast Reconstr Surg. 1998;  101(3) 727-735
    CrossrefPubMedSearch in Google Scholar
  • 22 Yajima H, Tamai S, Ono H, Kizaki K, Yamauchi T. Free vascularized fibula grafts in surgery of the upper limb.  J Reconstr Microsurg. 1999;  15(7) 515-521
    Search in Google Scholar
  • 23 Weiland A J, Moore J R, Daniel R K. Vascularized bone autografts. Experience with 41 cases.  Clin Orthop Relat Res. 1983;  174 87-95
    PubMedSearch in Google Scholar
  • 24 Taylor G I, Miller G D, Ham F J. The free vascularized bone graft: a clinical extension of microvascular techniques.  Plast Reconstr Surg. 1975;  55(5) 533-544
    Search in Google Scholar
  • 25 Heitmann C, Erdmann D, Levin L S. Treatment of segmental defects of the humerus with an osteoseptocutaneous fibular transplant.  J Bone Joint Surg Am. 2002;  84(12) 2216-2223
    CrossrefPubMedSearch in Google Scholar
  • 26 Brown K L. Limb reconstruction with vascularized fibular grafts after bone tumor resection.  Clin Orthop Relat Res. 1991;  262 64-73
    PubMedSearch in Google Scholar
  • 27 Jupiter J B. Complex non-union of the humeral diaphysis: treatment with a medial approach, an anterior plate, and a vascularized fibular graft.  J Bone Joint Surg Am. 1990;  72(5) 701-707
    PubMedSearch in Google Scholar
  • 28 Jupiter J B, Kour A K. Reconstruction of the humerus by soft tissue distraction and vascularized fibula transfer.  J Hand Surg Am. 1991;  16(5) 940-943
    PubMedSearch in Google Scholar
  • 29 Coghlan B A, Townsend P L. The morbidity of the free vascularised fibula flap.  Br J Plast Surg. 1993;  46(6) 466-469
    CrossrefPubMedSearch in Google Scholar
  • 30 Gore D R, Gardner G M, Sepic S B, Mollinger L A, Murray M P. Function following partial fibulectomy.  Clin Orthop Relat Res. 1987;  220 206-210
    PubMedSearch in Google Scholar
  • 31 Tang C L, Mahoney J L, McKee M D, Richards R R, Waddell J P, Louie B. Donor site morbidity following vascularized fibular grafting.  Microsurgery. 1998;  18(6) 383-386
    CrossrefPubMedSearch in Google Scholar
  • 32 Yoshimura M, Shimamura K, Iwai Y, Yamauchi S, Ueno T. Free vascularized fibular transplant. A new method for monitoring circulation of the grafted fibula.  J Bone Joint Surg Am. 1983;  65(9) 1295-1301
    PubMedSearch in Google Scholar
  • 33 Doi K, Tominaga S, Shibata T. Bone grafts with microvascular anastomoses of vascular pedicles: an experimental study in dogs.  J Bone Joint Surg Am. 1977;  59(6) 809-815
    CrossrefPubMedSearch in Google Scholar
  • 34 Springfield D S. Massive autogenous bone grafts.  Orthop Clin North Am. 1987;  18(2) 249-256
    PubMedSearch in Google Scholar
  • 35 Ceruso M, Falcone C, Innocenti M, Delcroix L, Capanna R, Manfrini M. Skeletal reconstruction with a free vascularized fibula graft associated to bone allograft after resection of malignant bone tumor of limbs.  Handchir Mikrochir Plast Chir. 2001;  33(4) 277-282
    Thieme ConnectPubMedSearch in Google Scholar
  • 36 de Boer H H, Wood M B. Bone changes in the vascularised fibular graft.  J Bone Joint Surg Br. 1989;  71(3) 374-378
    PubMedSearch in Google Scholar
  • 37 Dell P C, Burchardt H, Glowczewskie Jr F P. A roentgenographic, biomechanical, and histological evaluation of vascularized and non-vascularized segmental fibular canine autografts.  J Bone Joint Surg Am. 1985;  67(1) 105-112
    CrossrefPubMedSearch in Google Scholar
  • 38 Enneking W F, Burchardt H, Puhl J J, Piotrowski G. Physical and biological aspects of repair in dog cortical-bone transplants.  J Bone Joint Surg Am. 1975;  57(2) 237-252
    PubMedSearch in Google Scholar
  • 39 Brunelli G, Guizzi P A, Battiston B, Vigasio A. A comparison of vascularized and nonvascularized bone transfer in rabbits: a roentgenographic, scintigraphic, and histologic evaluation.  J Reconstr Microsurg. 1987;  3(4) 301-307
    PubMedSearch in Google Scholar
  • 40 Goldberg V M, Shaffer J W, Field G, Davy D T. Biology of vascularized bone grafts.  Orthop Clin North Am. 1987;  18(2) 197-205
    PubMedSearch in Google Scholar
  • 41 Pirela-Cruz M A, DeCoster T A. Vascularized bone grafts.  Orthopedics. 1994;  17(5) 407-412
    PubMedSearch in Google Scholar
  • 42 Shaffer J W, Field G A, Goldberg V M, Davy D T. Fate of vascularized and nonvascularized autografts.  Clin Orthop Relat Res. 1985;  197 32-43
    CrossrefPubMedSearch in Google Scholar
  • 43 Lazar E, Rosenthal D I, Jupiter J. Free vascularized fibular grafts: radiographic evidence of remodeling and hypertrophy.  AJR Am J Roentgenol. 1993;  161(3) 613-615
    CrossrefPubMedSearch in Google Scholar
  • 44 Gazdag A R, Lane J M, Glaser D, Forster R A. Alternatives to autogenous bone graft: efficacy and indications.  J Am Acad Orthop Surg. 1995;  3(1) 1-8
    PubMedSearch in Google Scholar
  • 45 Muramatsu K, Doi K, Ihara K, Shigetomi M, Kawai S. Recalcitrant posttraumatic nonunion of the humerus: 23 patients reconstructed with vascularized bone graft.  Acta Orthop Scand. 2003;  74(1) 95-97
    CrossrefPubMedSearch in Google Scholar
  • 46 Judet H, Gilbert A, Mathoulin C et al.. Reconstruction of loss of bony substance in limbs by free vascularized fibula transplant.  Chirurgie. 1991;  117(5–6) 469-476
    PubMedSearch in Google Scholar
  • 47 Wright T W, Miller G J, Vander Griend R A, Wheeler D, Dell P C. Reconstruction of the humerus with an intramedullary fibular graft: a clinical and biomechanical study.  J Bone Joint Surg Br. 1993;  75(5) 804-807
    PubMedSearch in Google Scholar
  • 48 Barnea Y, Amir A, Shlomo D et al.. Free fibula flap elbow-joint hemiarthroplasty reconstruction for chronic osteomyelitis of the distal humerus.  J Reconstr Microsurg. 2006;  22(3) 167-171
    Thieme ConnectPubMedSearch in Google Scholar
  • 49 Hriscu M, Mojallal A, Breton P, Bouletreau P, Carret J P. Limb salvage in proximal humerus malignant tumors: the place of free vascularized fibular graft.  J Reconstr Microsurg. 2006;  22(6) 415-421
    Thieme ConnectPubMedSearch in Google Scholar
  • 50 Pollock R, Stalley P, Lee K, Pennington D. Free vascularized fibula grafts in limb-salvage surgery.  J Reconstr Microsurg. 2005;  21(2) 79-84
    Thieme ConnectPubMedSearch in Google Scholar
  • 51 Rose P S, Shin A Y, Bishop A T, Moran S L, Sim F H. Vascularized free fibula transfer for oncologic reconstruction of the humerus.  Clin Orthop Relat Res. 2005;  438 80-84
    PubMedSearch in Google Scholar
  • 52 Jones N F. The need for preoperative leg angiography in fibula free flaps.  J Reconstr Microsurg. 1994;  10(5) 287-289
    PubMedSearch in Google Scholar
  • 53 Rosson G D, Singh N K. Devascularizing complications of free fibula harvest: peronea arteria magna.  J Reconstr Microsurg. 2005;  21(8) 533-538
    Thieme ConnectPubMedSearch in Google Scholar
  • 54 Arai K, Toh S, Tsubo K, Nishikawa S, Narita S, Miura H. Complications of vascularized fibula graft for reconstruction of long bones.  Plast Reconstr Surg. 2002;  109(7) 2301-2306
    CrossrefPubMedSearch in Google Scholar

A. Bobby ChhabraM.D. 

Department of Orthopaedic Surgery, University of Virginia Health System

Box 800159, Charlottesville, VA 22908

Email: ac2h@virginia.edu