Vitamin K deficiency-induced hemorrhagic shock after thoracentesis: a case report.

BACKGROUND: Vitamin K deficiency results in serious coagulation dysfunction, but hemorrhagic shock is rare. Herein, we describe a case of vitamin K deficiency and abnormality in the path of the intercostal artery, the combination of which led to hemorrhagic shock. CASE PRESENTATION: An 83-year-old woman was hospitalized for suspected gallstones. She developed septic shock after 4 days of hospitalization. We considered cholecystitis or cholangitis and performed abdominal ultrasonography, which revealed gallbladder enlargement, biliary sludge, and hyperplasia of the bile duct wall. Antibiotic treatment with sulbactam/ampicillin (SBT/ABPC) was initiated on day four, and percutaneous transhepatic gallbladder drainage (PTGBD) was performed on day five. The treatment was successful, but the patient developed bilateral pleural effusion because of hypoalbuminemia. We performed drainage for bilateral pleural effusion on days 13 and 17. The patient developed hypotension on day 18; blood tests showed anemia and severe coagulation dysfunction but a normal platelet count. We suspected vitamin K deficiency-induced coagulation dysfunction because of previous antibiotic treatment and restricted diet, and it led to hemorrhagic shock. Massive right hemothorax was observed by computed tomography, and urgent interventional radiology was performed. We observed no injury to the intercostal artery truncus but confirmed an abnormality in the course of the intercostal artery; therefore, we inferred that the cause of hemothorax in this case was injury to a small vessel, not truncus because of the abnormality. Because of the likelihood of rebleeding, we performed coil embolization from the seventh to the ninth intercostal artery. Because we confirmed vitamin K deficiency-induced coagulation dysfunction, we referred to the concentration of protein induced by vitamin K absence/antagonist-II (PIVKA-II), and it was found to increase by 23,000. CONCLUSIONS: A combination of vitamin K deficiency and abnormality in the course of the intercostal artery led to hemorrhagic shock. When using certain antibiotics and restricting diet, it is important to measure coagulation function, even if the platelet count is normal. Further, when thoracentesis is performed, abnormalities in the course of the intercostal artery should be identified. Thoracentesis with ultrasound may prevent hemothorax.

Reconstruction of ulnar defect with vascularized rib graft: A case report.

This case report describes the reconstruction of a segmental ulnar defect using a vascularized rib graft. A 27-year-old man was injured during military service by an improvised explosive device, resulting in bilateral through-the-knee amputations, left hand deformity, and a segmental left ulnar defect. After unsuccessful ulnar reconstruction with nonvascularized autologous bone and allograft bone substitutes, he presented to our institution. We removed the residual allograft fragments from the ulnar defect, harvested a vascularized left sixth rib with the intercostal artery and vein, secured the construct with internal hardware, and performed microanastomoses of the intercostal artery and vein to the posterior interosseous artery and vein. Postoperatively, he had a hematoma at the vascularized graft recipient site caused by anticoagulation therapy for his chronic deep vein thrombosis. Despite this, the rib graft successfully incorporated on the basis of radiographic and clinical examinations at 27 months. He had no pain and good function of the arm. The results of this case suggest that a vascularized rib graft for forearm reconstruction may be a viable option with minimal donor site morbidity. © 2015 Wiley Periodicals, Inc. Microsurgery 37:160-164, 2017.

Lateral Intercostal Artery Perforator Flap in Breast Reconstruction: A Simplified Pedicle Permits an Expanded Role.

BACKGROUND: The lateral intercostal artery perforator (LICAP) flap is a versatile second-tier option in breast reconstruction. The flap is rotated from redundant lateral chest fold on an easily dissected skin bridge pedicle without microsurgery in an outpatient setting. This series illustrates safety and effectiveness of the LICAP flap for prosthesis coverage when a muscle flap is not available or desired. In some cases, it even provides adequate soft tissue to reconstruct the breast mound without an implant. METHODS: Lateral intercostal artery perforator flaps performed for breast reconstruction at an ambulatory surgery center were reviewed. RESULTS: A total of 39 flaps were performed on an outpatient basis for a variety of breast reconstruction indications. One immediate reconstruction with bilateral LICAP flaps was performed after mastectomy. All remaining flaps were for delayed breast reconstruction. Mean operative time for each flap was 65 minutes, and concomitant procedures were performed in 25 of 27 patients. Follow-up was 5 to 96 months. There was 1 major complication (2.5%) and 5 minor (12.8%) complications. CONCLUSIONS: This series demonstrates unique advantages of the LICAP flap for a variety of breast reconstruction problems, including outpatient setting, no muscle sacrifice, flap reliability, and low donor site morbidity. These results confirm previous reports in post bariatric augmentation that the LICAP flap reliably supplies a large skin/adipose flap from the redundant tissue of the lateral chest fold with minimal morbidity even after radiation. The LICAP flap warrants closer consideration in breast reconstruction.

Posterior trunk reconstruction with the dorsal intercostal artery perforator based flap: Clinical experience on 20 consecutive oncological cases.

BACKGROUND: Few studies in the recent literature have investigated the reliability of dorsal intercostal artery perforator (DICAP) flap in posterior trunk reconstruction. The purpose of this report is to describe our clinical experience with the use of DICAP flaps in a cohort of oncological patients. PATIENTS AND METHODS: Twenty patients underwent posterior trunk reconstruction with DICAP based flaps. Patients age ranged from 45 to 76 years. All defects resulted from skin cancer ablation. Defect sizes ranged from 4 × 4 to 6 × 8 cm. The flaps were mobilized in V-Y or propeller fashion. The flaps were islanded on 1 (12 cases), 2 (6 cases), or 3 (2 cases) perforators. Donor sites were always closed primarily. RESULTS: Eleven V-Y advancement flaps were performed; one of these was converted to a perforator-plus peninsular flap design, which retained an additional source of blood supply from the opposite skin bridge. Nine flaps were mobilized in propeller fashion. Flap dimensions ranged from 4 × 6 to 6 × 14 cm. Mean operative time was 70 min. One V-Y flap complicated with marginal necrosis that healed with no need for reintervention. All the other flaps survived uneventfully. No other complications were observed at recipient and donor sites. Follow-up ranged from 3 months to 2 years. All the patients were satisfied with the surgical outcome. CONCLUSIONS: DICAP based flaps proved to be a reliable option to resurface posterior trunk defects following oncological resection, allowing to achieve like-with-like reconstruction with excellent contour and minimal donor-site morbidity. © 2015 Wiley Periodicals, Inc. Microsurgery 36:546-551, 2016.

Intercostal aneurysm causing spinal cord compression in an NF1 patient.

PURPOSE: The authors illustrate a case where an intercostal aneurysm was observed in a patient with type 1 neurofibromatosis. METHODS: A 32-year-old man with NF1 presented with thoracic back pain. The patient's symptoms progressed to include myelopathic symptoms, including difficulty urinating, numbness in the lower extremities, and increased weakness. Imaging revealed what appeared to be a neurofibroma at the T4-T5 level and a plan to resect the mass was formulated. Upon initial limited hemilaminotomy, significant arterial blood was encountered. The patient was then taken to the interventional suite and angiography was performed, revealing a left T4 intercostal aneurysm. The aneurysm was coil-embolized with no residual filling. RESULTS: By 6 months post-surgery, the patient had regained full strength and sensation in his lower extremities and no longer had difficulty urinating. There has been no recurrence of symptoms 3 years postoperatively. CONCLUSIONS: Intercostal artery lesions must be considered as a possible diagnosis in NF1.

[Prophylaxis and treatment of postoperative complications of abdominoplasty].

Results of abdominoplasty conduction in 206 patients were analyzed. Early postoperative complications are studied and methods of their prophylaxis are elaborated. Minimization of the local complications rate was achieved due to estimation of the anterior abdominal wall state, its angioarchitectonics, the apparatus control of PO2 in cutaneous-subcutaneous flap, rational combination of dermolipectomy and liposuction, prophylaxis of microcirculation disorders. In detailed analysis of remote, first of all, esthetic results of the anterior abdominal wall plasty we have concluded about necessity of the state estimation of surrounding anatomic structures. While planning and conduction of the anterior abdominal wall plasty it is mandatory to take into account the pubis subcutaneous layer width, as well as lateral regions of abdominal wall, pelvis and costal arcs, the form and localization of costal arcs, especially of XII rib and a vertebral column form. Such approach have secured the operation esthetic level raising, reduction of local complications rate, permitted more trustworthy to prognosticate the outcome.

Treatment of left tenth rib haemangioma vascularised by a costal artery giving the artery of Adamkiewicz.

Haemangioma of the ribs is considered an extremely rare benign tumour. Here, we present a case of a young male with left tenth rib haemangioma vascularised by a costal artery giving the artery of Adamkiewicz presented as chronic cough. This was successfully treated through preoperative embolisation and surgical resection. A preoperative angiogram was performed to identify the origin of the artery of Adamkiewicz. The final diagnosis was confirmed histopathologically. There were no complications in the postoperative course and no recurrence during 12 months of follow-up.

Clinical utility of preoperative evaluation of bronchial arteries by three-dimensional computed tomographic angiography for esophageal cancer surgery.

An identification of bronchial arteries (BAs) is critical in esophageal cancer surgery to avoid tracheobronchial ischemia and unexpected massive bleeding during surgical procedure particularly in thoracoscopic video-assisted esophagectomy. We describe the efficacy of three-dimensional computed tomographic angiography (3D-CTA) of BAs for preoperative evaluation in esophageal cancer surgery. Sixty-four patients with esophageal cancer who preoperatively underwent multidetector computed tomography examination were included in this study. We evaluated the number, origin, and intraoperative preservation rate of BAs, and we compared the number of thoracic paratracheal lymph nodes harvested between two groups comprising patients who either underwent preoperative 3D-CTA of BAs (3D-CTA group) or did not (non-3D-CTA group). The right and left BAs were preoperatively identified in 62 patients (97%) and 55 patients (86%), respectively, using 3D-CTA. In 34 patients (53%), the right BA originated as a common trunk with the right intercostal artery. In 48 patients (75%), the left BA originated from the descending aorta as a single or double branch. Some anomalies such as the right BA originated from the left subclavian artery were observed. In all patients, either the right or the left BA was preserved. The number of harvested lymph nodes in left side of paratrachea was significantly increased in 3D-CTA group, than those in non-3D-CTA group. 3D-CTA clearly revealed BA anatomy, contributing to BA preservation and safe and precise lymphadenectomy in esophageal cancer surgery. 3D-CTA of BAs is useful for preoperative evaluation in esophageal cancer surgery.

Thoracic ultrasound demonstrates variable location of the intercostal artery.

BACKGROUND: Ultrasound (US) guidance is advocated to reduce complications from thoracocentesis or intercostal catheter (ICC) insertion. Although imaging of the intercostal artery (ICA) with Doppler US has been reported, current thoracic guidelines do not advocate this, and bleeding from a lacerated ICA continues to be a rare but serious complication of thoracocentesis or ICC insertion. OBJECTIVES: It was the aim of this study to describe a method to visualise the ICA at routine US-guided thoracocentesis and map its course across the posterior chest wall. METHOD: The ICA was imaged in 22 patients undergoing US-guided thoracocentesis, at 4 positions across the back to the axilla. Its location, relative to the overlying rib, was calculated as the fraction of the intercostal space (ICS) below the inferior border of that rib. RESULTS: An ICA was identified in 74 of 88 positions examined. The ICA migrated from a central 'vulnerable' location within the ICS near the spine (0.28, range 0.21-0.38; p < 0.001) towards the overlying rib (0.08, range 0.05-0.11; p < 0.001) in the axilla. CONCLUSIONS: The ICA can be visualised with US and is more exposed centrally within the ICS in more posterior positions; however, there is a marked variation between individuals, such that the ICA may lie exposed in the ICS even as far lateral as the axilla. Future studies need to identify which patients are at risk for a 'low-lying' ICA to further define the role of US imaging of the ICA during thoracocentesis or ICC insertion.

Vascularized Bone Flap Options for Complex Thoracic Spinal Reconstruction.

BACKGROUND: Osseous reconstruction following total spondylectomy/vertebrectomy in the thoracic spine is indicated to restore spinal stability. To assist with bony reconstruction, vascularized bone flaps including free vascularized fibula flaps and pedicled rib flaps can be used. However, there are limited data comparing various techniques. The authors aimed to evaluate the outcomes of free vascularized fibula flaps and pedicled rib flaps used for thoracic spinal reconstruction. METHODS: The authors reviewed 44 vascularized bone flaps [10 anterior pedicled rib flaps, 25 posterior pedicled rib flaps, and nine vascularized fibula flaps] for corpectomy defects spanning T1 to L1 between January of 1999 and June of 2018. Mean age and follow-up were 46 ±17 years and 74 ± 52 months, respectively. RESULTS: The union rate was 93 percent, with a similar mean time to union among the three groups: free vascularized fibula flaps, 9 ± 4 months; anterior pedicled rib flaps, 9 ± 6 months; and posterior pedicled rib flaps, 9 ± 5 months (p = 0.95). Surgical-site complications were found in 27 vascularized bone flaps (61 percent), and reoperations and revisions were performed in 14 (32 percent) and 10 (23 percent) vascularized bone flaps, respectively. No differences were identified among anterior pedicled rib flaps, posterior pedicled rib flaps, and vascularized fibula flaps with regard to complication, reoperation, and revision rates. CONCLUSIONS: Free vascularized fibula flaps and pedicled rib flaps provide durable reconstruction for thoracic spinal defects. Union, time to union, revision, and reoperation rates were similar among anterior and posterior pedicled rib flaps and vascularized fibula flaps. Given the variability in indication and defect types among the flap cohorts, the authors' results should be interpreted carefully as an insight into the outcomes of different vascularized bone flaps for the unique cases of thoracic spinal reconstruction rather than to compare the different flaps used. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Utilization of a partial rib-sparing procedure in microvascular breast reconstruction for preserving intercostal nerve and nipple reconstruction.

BACKGROUND: In microvascular breast reconstruction, internal mammary vessel (IMV) exposure has been performed. The preservation of intercostal nerve (ICN) is effective for preserving sensibility and decreasing postoperative pain. In nipple reconstruction, cartilage grafting is performed to provide additional support and projection. We considered that ICN preservation and costal cartilage banking could be performed simultaneously. This method was described as the "partial rib-sparing procedure." The purpose of this study was to introduce this procedure. METHODS: Surgical technique of this procedure was as follows. The second intercostal space was used. The width of the trimmed cartilage was kept within the superior half of the third costal cartilage. Soft tissue within 5 mm of the inferior border of the second rib edge was preserved to save the second ICN. The length of IMVs in the partial rib-sparing procedure and that in the total rib-sparing procedure was compared. RESULTS: The number of patients in the partial rib-sparing and total rib-sparing groups was 137 procedures and 57 procedures, respectively. The length of IMVs was significantly longer in the partial rib-sparing procedure (median 20.5 mm vs. 17.6 mm, P < 0.001). In the partial rib-sparing group, no patient complained of prolonged local pain, and chest wall contour abnormalities were absent in all cases. CONCLUSIONS: The partial rib-sparing procedure is superior, especially for patients with narrow intercostal spaces and/or patients who decide to undergo nipple reconstruction with costal cartilage. This procedure could be performed to preserve the soft tissues around the ICN and decrease the postoperative pain.

Spatial gradients of blood vessels and hematopoietic stem and progenitor cells within the marrow cavities of the human skeleton.

This report evaluates the spatial profile of blood vessel fragments (BVFs) and CD34(+) and CD117(+) hematopoietic stem and progenitor cells (HSPCs) in human cancellous bone. Bone specimens were sectioned, immunostained (anti-CD34 and anti-CD117), and digitally imaged. Immunoreactive cells and vessels were then optically and morphometrically identified and labeled on the corresponding digital image. The distance of each BVF, or CD34(+) or CD117(+) HSPC to the nearest trabecular surface was measured and binned in 50-microm increments. The relative concentration of HSPCs and BVFs within cancellous marrow was observed to diminish with increasing distance in the marrow space. On average, 50% of the CD34(+) HSPC population, 60% of the CD117(+) HSPC population, and 72% of the BVFs were found within 100 microm of the bone surfaces. HSPCs were also found to exist in close proximity to BVFs, which supports the notion of a shared HSPC and vessel spatial niche.

Predictors of axillary vein location for vascular access during pacemaker and defibrillator lead implantation.

BACKGROUND: The axillary vein is a commonly used extrathoracic access site for cardiac rhythm device lead implantation. We sought to describe variation in axillary vein location and identify predictors of a more cranial or caudal radiographic location to facilitate blind venous cannulation. METHODS: This was a single-center, retrospective study of patients undergoing lead implantation between 2006 and 2010. The cranial-caudal location of the axillary vein lateral and medial to the rib cage border was determined by reviewing peripheral contrast venograms. Multivariate linear regression was performed. RESULTS: Of 155 patients, the majority were men (62%) and White (53%). The most frequent position of the lateral and medial axillary vein was over the third rib (40%) and top of the third rib (15%), respectively. In multivariate analysis, whites had a more caudal location of both the lateral (0.56 rib spaces lower, 95% confidence interval [CI] 0.22-0.91, P = 0.002) and medial axillary vein (0.50 rib spaces lower, 95% CI 0.85-0.91, P = 0.019). Other independent predictors included an approximate 3-4% higher rib space location for every digit increase in body mass index (BMI) (P = 0.049 for the lateral location and P = 0.016 for the medial location) and an approximate half rib space higher location for males (P = 0.015 for the lateral location and P = 0.013 for the medial location). CONCLUSIONS: The most common radiographic position of the axillary vein was over the third rib. Whites have a more caudal axillary vein location while men and patients with higher BMI have a more cranial position of the axillary vein.

New surgical technique: Simultaneous use of contiguous intercostal spaces during total rib preservation exposure of the internal mammary vessels in microvascular breast reconstruction.

INTRODUCTION: Microvascular free tissue transfer is the gold standard for autologous breast reconstruction. For many surgeons, the internal mammary vessels (IMV) are the preferred recipient vessels. The merits of the rib preservation technique have been previously discussed. There are, however, instances in which greater access than afforded by one intercostal space (ICS) may be required, for example, multiple or redo anastomoses or inadvertent recipient vessel damage. We therefore have refined this technique further to allow exposure of two ICSs without sacrifice of the intervening rib cartilage. METHOD: We identified all patients who had simultaneous contiguous ICSs dissected whilst preserving the intervening costal cartilage for microvascular anastomoses for breast free flaps. The indications, surgical technique, and its refinements are described. RESULTS: Simultaneous exposure of the IMVs in both the second and third ICSs whilst preserving the intervening costal cartilage for microvascular anastomoses was successfully performed in 15 patients with no flap failures. Indications included bipedicled DIEP flaps (9), bipedicled DIEA/SIEA flap (1), stacked DIEP flaps (4), and salvage (1). One flap was successfully re-explored for venous congestion. There were no intraoperative complications. CONCLUSION: We have demonstrated that simultaneous contiguous ICS exposure of the internal mammary recipient vessels with total rib preservation is technically feasible, has no adverse patient sequelae, and has the benefit of allowing multiple anterograde and retrograde microvascular anastomoses (even in patients with narrow ICSs). This technique preserves the intervening rib and is of particular utility in bipedicled flaps when multiple "extra-flap" anastomoses may be required.

The ideal intercostal space for internal mammary vessel exposure during total rib-sparing microvascular breast reconstruction: A critical evaluation.

BACKGROUND: Total rib-preserving free flap breast reconstruction (RP-FFBR) using internal mammary vessel (IMV) recipients usually involves vessel exposure in the second or third intercostal spaces (ICS). Although the third one is more commonly used, no direct comparisons between the two have hitherto been performed. OBJECTIVES: To compare the in-vivo topography and vascular anatomy of second and third ICSs in patients undergoing FFBR using the rib-preservation technique of IMV exposure. METHODS: An analysis of prospectively collected data on intercostal space distance (ISD), number and arrangement of IMVs, location of venous confluence, and vessel exposure time was conducted on a single surgeon's consecutive RP-FFBRs. RESULTS: A total of 296 RP-FFBRs were performed in 246 consecutive patients. The second, third, or both second and third spaces were utilized in 282, 28, and 22 cases, respectively. The ISDs were 20.6 mm ±â€¯3.52 for the second ICS and 14.0 mm ± 4.35 for the third ICS (p<0.0001, CI = 5.17-7.97, t-test). The second versus third ICS vein content was as follows: single 81.4% vs. 74%, dual 18.6% vs. 26%, and confluence 3.7% vs. 13%. The second ICS single vein was medial to the artery in 92.6%. The third ICS single vein was medial to the artery in 88.2% Vessel exposure times for second (47.2 mins ±â€¯26.7) and third (46.5 mins ±â€¯31.4) spaces were similar (p = 0.93). The overall intraoperative anastomotic revision rate was 9.1%, and the postoperative flap re-exploration rate was 4.0%, with 99.7% overall flap success. DISCUSSION AND CONCLUSION: Preferential use of the second ICS is supported by its more predictable vascular anatomy, a broader space for performing the microanastomoses and a higher frequency of a single postconfluence (and thus larger) vein facilitating the microsurgery.

Subcostal artery bleeding after percutaneous nephrolithotomy: a case report and literature review.

Postoperative bleeding is a dangerous complication after percutaneous nephrolithotomy (PCNL). Pseudoaneurysm, arteriovenous fistula, and arterial laceration are the three most common causes of post-PCNL bleeding. Subcostal artery bleeding is a rare cause. We herein present a clinical case involving a 43-year-old man who presented with right renal complex calculi and was managed by PCNL in the prone position using an inferior calyceal puncture approach. Intermittent extreme bleeding occurred 1 day postoperatively, and immediate renal angiography was performed. However, we found no sign of a pseudoaneurysm, arteriovenous fistula, or arterial laceration. Another well-trained and experienced doctor also found no pseudoaneurysm, arteriovenous fistula, or arterial laceration. After adjusting the catheter position, subcostal artery bleeding finally appeared and was successfully controlled by coils. This finding indicates that subcostal artery damage is one cause of post-PCNL bleeding. We suggest that clinicians should carefully and patiently perform angiography and/or embolization to avoid misdiagnosis and mistreatment.

Lateral Costal Artery: Clinical Importance of an Accessory Thoracic Artery.

The lateral costal artery has sometimes been identified as the culprit for the "steal phenomenon" after coronary artery bypass grafting, besides being occasionally used for myocardial revascularization. Its branches make anastomoses with the internal thoracic artery through lateral intercostal arteries. We aim to report, on three cases, the clinical significance of a well-developed lateral costal artery after coronary artery bypass grafting. Two out of three patients who underwent coronary artery bypass graft surgery in our center between June 2010 and August 2017, applied to us with stable angina pectoris, while the third one was diagnosed with acute coronary syndrome after applying to the emergency department. In coronary cineangiography, in all three cases, a well-developed accessory vessel arising from the proximal 2.5 cm segment of the left internal thoracic artery coursed as far as the 6th rib was detected, and it was confirmed to be the lateral costal artery. A stable angina pectoris in two of the patients was thought to be the result of steal phenomenon caused by the well-developed lateral costal artery. In the two cases with stable angina pectoris the lateral costal artery was obliterated via coil embolization. In the other case with the proximal left anterior descending artery stenosis, before percutaneous coronary intervention, the lateral costal artery was obliterated via coil embolization and the occluded subclavian artery was stented. Routine visualization in cineangiography and satisfactory surgical exploration of the left internal thoracic artery could be very helpful to identify any possible accessory branch of the left internal thoracic artery like the lateral costal artery.

Results of vascularized rib grafts in complex spinal reconstruction. Surgical technique.

BACKGROUND: The application of vascularized rib grafts in spine surgery has been limited to the treatment of kyphosis with anterior placement of the rib graft to facilitate anterior spine arthrodesis. The outcomes following use of vascularized rib grafts in complex spinal reconstruction have not been adequately evaluated. The purpose of this study was to determine the results, including the time to osseous union and complications, following anterior or posterior placement of pedicled vascularized rib grafts for complex spinal reconstruction. METHODS: The medical records and images of all patients in whom a vascularized rib graft had been used for a multisegmental spine reconstruction at a single institution between 1994 and 2004 were retrospectively reviewed. Eighteen patients (mean age, 45.3 years) who had been followed for an average of 31.8 months were identified. Details regarding indications, the levels that were spanned, the graft length, the time to union, and complications were evaluated. RESULTS: The preoperative diagnoses included metastatic or primary tumor (thirteen patients) and progressive kyphosis secondary to chronic osteomyelitis (two), injury (one), congenital anomalies (one), or implant failure (one). On the average, 4.4 levels were fused and 1.9 vertebral bodies were excised. All eighteen arthrodeses included various forms of allograft and/or autograft material, and instrumentation was used, in addition to the vascularized rib graft, in twelve patients. The mean rib length was 16.1 cm, and a rib between the fifth and eleventh ribs, inclusive, was used, depending on the location of the spinal reconstruction. The average time to union was 6.8 months, and all rib grafts united. There were no complications specific to the rib-harvesting procedure. CONCLUSIONS: The use of a vascularized rib graft in complex spinal reconstruction adds little time to the overall procedure, is associated with low morbidity, and appears to offer substantial benefits to the patient.

The role of vascularized bone grafts in spine surgery.

The use of vascularized bone grafts in complex spine reconstruction is particularly attractive in situations that involve large segmental bone defects, failed previous attempts at arthrodesis, poor soft tissue beds secondary to infection or radiation exposure necrosis or failed arthrodesis in neuromuscular disease processes. This article details the indications and rationale for vascularized bone grafting as well as the results of vascularized bone grafting of the spine.