[Iliac crest bone graft with vascular pedicle for treatment of fibrous ankylosis of the ankle].

THE PROBLEM: 63-year-old man with a painful fibrous ankylosis of the left ankle in spite of two surgical attempts at arthrodesis. The subtalar joint had been fused 3 years previously during a reconstruction of the posterior tibial tendon. The severe, activity-related pain was partially due to a reflex sympathetic dystrophy. Wearing of orthopedic shoes did not relieve the symptoms; a below-knee amputation had been considered. THE SOLUTION: Tibiotalar arthrodesis in functional position with a free pedicled iliac bone graft. SURGICAL TECHNIQUE: Microsurgical harvesting of a pedicled iliac bone graft. Debridement of the fibrous ankylosis and transplantation of the bone graft into an anterior tibiotalar groove. RESULT: Bony fusion within 3 months. Pain-free weight bearing. The favorable outcome persisted after 1 year.

Titanium plate reconstruction of the osseous defect after harvest of a composite free flap using the deep circumflex iliac artery.

Hernia formation following harvest of bicortical iliac crest bone occurs infrequently as a late complication and may lead to chronic pain at the donor site and rarely to obstruction and strangulation of bowel. We describe the use of a custom-made titanium plate used to reconstruct the iliac donor site following harvest of a DCIA composite free flap. A pre-operative 3D CT and stereolithography model of the ilium are used to fabricate a titanium plate of the desired shape and size. This plate is used to reconstruct the donor site defect at the time of primary surgery. This technique may reduce late complications following DCIA composite free flap harvest.

Successful management of atrophic nonunion of a severely osteoporotic femoral shaft in a child.

We present a case illustrating the successful use of a conventional intramedullary rod and vascularized iliac crest graft in atrophic nonunion combined with severe osteoporosis of the femoral shaft in a child, in whom classical osteosynthesis failed after two operations. The conventional intramedullary rod offered excellent purchase in the severely porotic, partially destroyed bone. Combined with a vascularized iliac crest grafted laterally, mechanical support and an osteoinductive stimulus were provided. The atrophic nonunion healed completely after this revision surgery.

[Free vascularized iliac bone graft for the treatment of scaphoid nonunion with avascular proximal fragment]. / Die Rekonstruktion der Kahnbeinpseudarthrose mit avaskulärem proximalen Fragment mit freiem mikrovaskulär gestielten Beckenkammtransplantat.

OBJECTIVE: The goal of the procedure is osseous healing of the scaphoid in an anatomic position and replacement of necrotic bone at the site of the scaphoid nonunion by a vascularized iliac bone graft. INDICATIONS: Scaphoid nonunion with necrotic fragment in SNAC (scaphoid nonunion advanced collapse) < 1. Nonunion following previous surgery. CONTRAINDICATIONS: Pattern of advanced carpal collapse (SNAC > 1). Malformation, disease or previous injury of the vascular system. Poor compliance. Reduced general health. SURGICAL TECHNIQUE: Principles of the surgical technique according to Pechlaner et al.: harvesting of a corticocancellous bone graft from the anterior iliac crest with a nutrient vascular bundle from the deep circumflex iliac artery, debridement of the necrotic scaphoid, press-fit fixation of the tailored graft, pin fixation, and microvascular anastomosis to the radial artery. POSTOPERATIVE MANAGEMENT: Fixation in an upper-arm cast for 4 weeks, followed by lower-arm cast fixation including the thumb to the interphalangeal joint until week 12. Physiotherapy. Wrist splinting in patients enforced to heavy manual load. RESULTS: The described procedure has been practiced at the own institution since 1985 and evaluated in different studies. Using a free vascularized iliac bone graft, union could be achieved in 85% of patients with avascular scaphoid nonunion and in 80% with avascular proximal pole nonunion. The nonunion can be bridged in 93% following failed previous scaphoid screw fixation.

Use of vascularized pedicle iliac bone graft combined with transtrochanteric rotational osteotomy in the treatment of avascular necrosis of the femoral head.

INTRODUCTION: A vascularized pedicle iliac bone graft combined with transtrochanteric anterior rotational osteotomy was performed in patients with extensive necrosis in whom the necrotic area occupied more than two-thirds of the weight-bearing zone of the femoral head. The purpose of this procedure is to supply vascularity and mechanical strength to the avascular femoral head. MATERIALS AND METHODS: Seventeen hips in 14 patients (8 male, 6 female) whose average age at surgery was 37.9 (range 21-51) years underwent this procedure between June 1992 and December 2002. These hips (stage 2 in 3 hips, stage 3A in 13 hips, and stage 3B in 1 hip) were examined for changes according to the Japanese Orthopedic Association (JOA ) score and the presence or absence of progression of the clinical stage at least 1 year after surgery. RESULTS: The mean JOA score improved from 67.8 points preoperatively to 78.1 points by 18-133 (mean 50.7) months postoperatively. There was no disease progression to a more advanced stage in 12 of 17 hips (71%) postoperatively. CONCLUSION: A vascularized pedicle iliac bone graft combined with transtrochanteric anterior rotational osteotomy to treat avascular necrosis of the femoral head is considered promising for joint preservation.

Femoral head reconstruction and revascularization. Treatment for ischemic necrosis.

There is no solution to ischemic necrosis of the femoral head, a condition that leads to collapse, rapid degenerative changes, and subluxation of the hip joint. Core decompression, osteotomy, and various means of femoral head reconstruction have been tried, but the results have been mixed. When ischemic necrosis has led to cartilage indentation and marked collapse, any means of reconstructing the femoral head could be too late. However, if the collapse is not severe, the logical treatment may be the removal of the dead bone and restoration of the bony contents with chip grafts and a vascularized bone strut. A new method of treatment using a vascular pedicled iliac crest strut graft has been used for 13 years. Followup assessments 4 to 12 years later have shown good results with the early involvements, whereas the late collapsed cases showed good control of pain but unsatisfactory maintenance of femoral head integrity. Thus, the technique is recommended for restoring and maintaining femoral head integrity for Stage 3 and early Stage 4 of the disease.

Use of vascularized pedicle iliac bone graft in the treatment of avascular necrosis of the femoral head.

A vascularized pedicle iliac bone graft was performed in patients with extensive necrosis in whom the necrotic area occupied more than two-thirds of the femoral head. The purpose of this procedure is to supply vascularity and mechanical strength to the avascular femoral head. Our series consisted of 18 hips. The patients' age at surgery ranged from 21 to 55 years. Fourteen hips were identified as stage II and 4 hips as stage III. Iliac bone graft alone was performed in 4 stage II joints. Transtrochanteric anterior rotational osteotomy of the femoral head was done additionally in 10 stage II joints and 4 stage III joints. In the group who underwent iliac bone graft alone, the mean Japanese Orthopedic Association (JOA) score improved from 58.5 to 63.8 (mean follow-up 52 months). In the group who underwent combination procedure with osteotomy, the mean JOA score improved from 71.7 to 85.0 (mean follow-up 43 months). Stage progression was noted in 3 of 4 joints in the group who underwent iliac bone graft alone. In the group who underwent the combined procedure, stage progression was noted in 2 of 10 joints at more than 1 year after operation. A vascularized pedicle iliac bone graft to treat avascular necrosis of the femoral head is considered promising for joint preservation.