Vascularized bone transfers

Our experience with microvascular transfer of autogenous fibular grafts and osteocutaneous groin flaps has been favorable. These technically demanding operative procedures have been employed in patients with severely traumatized extremities and those individuals with locally aggressive or low-grade malignant bone tumors who were not considered candidates for traditional methods of bone grafting. In many patients amputation would have been the only alternative. The treatment of congenital pseudarthrosis of the tibia remains one of the most challenging problems confronting the orthopaedic surgeon today. Although various techniques of bone grafting have been advocated in addition to the use of pulsating electromagnetic coils, a significant number of failures have occurred. Early experience with the technique of free vascularized fibular transfer in the treatment of these patients has been encouraging. A significant problem associated with free vascularized fibular grafts concerns the immediate postoperative monitoring of circulation to the graft. Unlike osteocutaneous groin flaps, in which the skin serves as a model for arterial inflow and venous outflow, the fibular graft is subcutaneous and not visible for direct monitoring. Bone scans have been used in the postoperative period (24 to 72 hours) and affords the surgeon reasonable assurance that circulation of the graft is intact. However, if circulation is not intact, a revision of anastomoses at this stage is not feasible. More effective methods of monitoring patency of anastomoses need to be developed. Thermocouples and laser Doppler flowmeters are being experimented with in several institutions. Microsurgery is not a discipline but rather a technique. It is a tool that can be used by any well-trained orthopaedic surgeon. With more experience clinically and in the laboratory the applicability of vascularized autogenous bone grafts in the treatment of musculoskeletal defects will become more clearly defined.