Upper Extremity Diaphyseal Osseous Gap Reconstruction with Free Vascularized Bone Flaps: A Scoping Review

Abstract

Background Reconstruction of upper extremity osseous diaphyseal defects often requires complex reconstructions. In this study, we characterized and summarized the available literature on free vascularized bone flap (VBF) reconstruction for upper extremity diaphyseal defects.

Methods A scoping review using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews was conducted. A literature search of major electronic databases was conducted to identify journal articles relating to the management of VBF reconstruction of upper limb long bone defects. Articles with patient-level data were included. Descriptive statistics were performed using Python.

Results Overall, 364 patients were included in this study. The most common indications for VBFs included atrophic nonunion (125, 34.3%), postoncologic resection (125, 34.3%), septic nonunion (56, 15.4%), and trauma (36, 9.9%). Mean defect size was 8.53 ± 5.14 cm. A total of 67 (18.4%) cases had defects < 6 cm, and 166 cases (45.6%) had defects > 6 cm. The fibula was the most utilized VBF (272, 74.73%), followed by the medial femoral condyle flap (69, 18.96%). Overall, primary union rate was 87.1%. Subsequent flap fracture rate was 3.3%. There were only two (0.6%) VBF losses reported in the included cases, and donor-site complications were similarly rare (17, 4.7%).

Conclusion VBF reconstruction is often utilized for postoncologic defects and recalcitrant nonunions. The fibula is the most utilized VBF, but the medial femoral condyle flap is used frequently for smaller defects. VBF reconstruction demonstrates high union rates and low flap fracture rate across indications.

Keywords

upper extremity - osseous defects - fibula - vascularized bone - microsurgery

• References

• 1 DeCoster TA, Gehlert RJ, Mikola EA, Pirela-Cruz MA. Management of posttraumatic segmental bone defects. J Am Acad Orthop Surg 2004; 12 (01) 28-38
• 2 Dahl MT, Morrison S. Segmental bone defects and the history of bone transport. J Orthop Trauma 2021; 35 (Suppl. 04) S1-S7
• 3 Weiland AJ. Current concepts review: vascularized free bone transplants. J Bone Joint Surg Am 1981; 63 (01) 166-169
• 4 Kusnezov N, Dunn JC, Stewart J, Mitchell JS, Pirela-Cruz M. Acute limb shortening for major near and complete upper extremity amputations with associated neurovascular injury: a review of the literature. Orthop Surg 2015; 7 (04) 306-316
• 5 Klifto CS, Gandi SD, Sapienza A. Bone graft options in upper-extremity surgery. J Hand Surg Am 2018; 43 (08) 755-761.e2
• 6 Vail TP, Urbaniak JR. Donor-site morbidity with use of vascularized autogenous fibular grafts. J Bone Joint Surg Am 1996; 78 (02) 204-211
• 7 Pirela-Cruz MA, DeCoster TA. Vascularized bone grafts. Orthopedics 2013; 17 (05) 407-412
• 8 Avraham T, Franco P, Brecht LE. et al. Functional outcomes of virtually planned free fibula flap reconstruction of the mandible. Plast Reconstr Surg 2014; 134 (04) 628e-634e
• 9 Ackerman DB, Rose PS, Moran SL, Dekutoski MB, Bishop AT, Shin AY. The results of vascularized-free fibular grafts in complex spinal reconstruction. J Spinal Disord Tech 2011; 24 (03) 170-176
• 10 Jones Jr DB, Rhee PC, Bishop AT, Shin AY. Free vascularized medial femoral condyle autograft for challenging upper extremity nonunions. Hand Clin 2012; 28 (04) 493-501
• 11 Chen CM, Disa JJ, Lee HY. et al. Reconstruction of extremity long bone defects after sarcoma resection with vascularized fibula flaps: a 10-year review. Plast Reconstr Surg 2007; 119 (03) 915-924 , discussion 925–926
• 12 Awad ME, Altman A, Elrefai R, Shipman P, Looney S, Elsalanty M. The use of vascularized fibula flap in mandibular reconstruction; a comprehensive systematic review and meta-analysis of the observational studies. J Craniomaxillofac Surg 2019; 47 (04) 629-641
• 13 Hollenbeck ST, Komatsu I, Woo S. et al. The current role of the vascularized-fibular osteocutaneous graft in the treatment of segmental defects of the upper extremity. Microsurgery 2011; 31 (03) 183-189
• 14 Ferreira N, Saini AK, Birkholtz FF, Laubscher M. Management of segmental bone defects of the upper limb: a scoping review with data synthesis to inform decision making. Eur J Orthop Surg Traumatol 2021; 31 (05) 911-922
• 15 Tricco AC, Lillie E, Zarin W. et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med 2018; 169 (07) 467-473
• 16 Peters MDJ, Godfrey C, McInerney P, Munn Z, Tricco AC, Khalil H. Chapter 11: Scoping reviews. In: Aromataris E, Munn Z. (eds). JBI Manual for Evidence Synthesis. JBI; 2020.
• 17 Harris CR, Millman KJ, van der Walt SJ. et al. Array programming with NumPy. Nature 2020; 585 (7825) 357-362
• 18 Virtanen P, Gommers R, Oliphant TE. et al; SciPy 1.0 Contributors. SciPy 1.0: fundamental algorithms for scientific computing in Python. Nat Methods 2020; 17 (03) 261-272
• 19 Ring D, Allende C, Jafarnia K, Allende BT, Jupiter JB. Ununited diaphyseal forearm fractures with segmental defects: plate fixation and autogenous cancellous bone-grafting. J Bone Joint Surg Am 2004; 86 (11) 2440-2445
• 20 Luo TD, Nunez Jr FA, Lomer AA, Nunez Sr FA. Management of recalcitrant osteomyelitis and segmental bone loss of the forearm with the Masquelet technique. J Hand Surg Eur Vol 2017; 42 (06) 640-642
• 21 Borzunov DY, Kolchin SN, Malkova TA. Role of the Ilizarov non-free bone plasty in the management of long bone defects and nonunion: problems solved and unsolved. World J Orthop 2020; 11 (06) 304-318
• 22 Shaffer JW, Field GA, Goldberg VM, Davy DT. Fate of vascularized and nonvascularized autografts. Clin Orthop Relat Res 1985; (197) 32-43
• 23 Shaffer JW, Davy DT, Field GA, Bensusan JS. Temporal analysis of vascularized and nonvascularized rib grafts in canine spine surgery. Spine 1989; 14 (07) 727-732
• 24 Dell PC, Burchardt H, Glowczewskie Jr FP. A roentgenographic, biomechanical, and histological evaluation of vascularized and non-vascularized segmental fibular canine autografts. J Bone Joint Surg Am 1985; 67 (01) 105-112
• 25 Foster RD, Anthony JP, Sharma A, Pogrel MA. Vascularized bone flaps versus nonvascularized bone grafts for mandibular reconstruction: an outcome analysis of primary bony union and endosseous implant success. Head Neck 1999; 21 (01) 66-71
• 26 Aibinder WR, Wagner ER, Bishop AT, Shin AY. Bone grafting for scaphoid nonunions: is free vascularized bone grafting superior for scaphoid nonunion?. Hand (N Y) 2019; 14 (02) 217-222
• 27 Ribak S, Medina CEG, Mattar Jr R, Ulson HJR, Ulson HJ, Etchebehere M. Treatment of scaphoid nonunion with vascularised and nonvascularised dorsal bone grafting from the distal radius. Int Orthop 2010; 34 (05) 683-688
• 28 Fuchs B, Steinmann SP, Bishop AT. Free vascularized corticoperiosteal bone graft for the treatment of persistent nonunion of the clavicle. J Shoulder Elbow Surg 2005; 14 (03) 264-268
• 29 Dell PC, Sheppard JE. Vascularized bone grafts in the treatment of infected forearm nonunions. J Hand Surg Am 1984; 9 (05) 653-658
• 30 Beredjiklian PK, Hotchkiss RN, Athanasian EA, Ramsey ML, Katz MA. Recalcitrant nonunion of the distal humerus: treatment with free vascularized bone grafting. Clin Orthop Relat Res 2005; (435) 134-139
• 31 Malizos KN, Zalavras CG, Soucacos PN, Beris AE, Urbaniak JR. Free vascularized fibular grafts for reconstruction of skeletal defects. J Am Acad Orthop Surg 2004; 12 (05) 360-369
• 32 Richard MJ, DiPrinzio EV, Lorenzana DJ, Whitlock KG, Hein RE, Urbaniak JR. Outcomes of free vascularized fibular graft for post-traumatic osteonecrosis of the femoral head. Injury 2021; 52 (12) 3653-3659
• 33 Berend KR, Gunneson EE, Urbaniak JR. Free vascularized fibular grafting for the treatment of postcollapse osteonecrosis of the femoral head. J Bone Joint Surg Am 2003; 85 (06) 987-993
• 34 Garvey PB, Chang EI, Selber JC. et al. A prospective study of preoperative computed tomographic angiographic mapping of free fibula osteocutaneous flaps for head and neck reconstruction. Plast Reconstr Surg 2012; 130 (04) 541e-549e
• 35 Guidi M, Guzzini M, Civitenga C. et al. Multifactorial analysis of treatment of long-bone nonunion with vascularized and nonvascularized bone grafts. J Hand Microsurg 2022; 15 (02) 106-115
• 36 Higgins JP, Bürger HK. Osteochondral flaps from the distal femur: expanding applications, harvest sites, and indications. J Reconstr Microsurg 2014; 30 (07) 483-490
• 37 Kaiser D, Levin LS. Medial femoral condyle free flap for persistent osseous nonunion of the first metatarsophalangeal joint: a preliminary report of a new surgical indication for the medial femoral condyle free flap. Foot Ankle Orthop 2023; 8 (03) 24 730114231191135
• 38 Karunaratne YG, Romeo PB. Vascularized reconstruction of recalcitrant clavicular nonunion with the medial femoral condyle free flap: a systematic review of the literature. J Hand Microsurg 2024; 16 (01) 100016
• 39 DeKeyser GJ, Bailey TL, Higgins TF, Tyser AR. Treatment of recalcitrant femoral shaft nonunion with medial femoral condyle pedicled autograft: technical trick. J Orthop Trauma 2022; 36 (02) e80-e80
• 40 Guzzini M, Ciclamini D, Arioli L. et al. Correlation between risk factors and healing times in long bone nonunions treated with corticoperiosteal flap from the medial femoral condyle. J Reconstr Microsurg 2023; 39 (07) 502-507