Indications for Vascularized Rib in Long-Bone Reconstruction and Long-Term Results

The advantages of using vascularized bone grafts in treating bone defects in emergency or for sequelar problems are well-known. The most frequently used bone with the best results currently is the vascularized peroneum, as an independent unit or as part of an osteomuscular/osteomusculocutaneous flap. The authors presented some indications, advantages and disadvantages in using another vascularized bone—the rib, as part of an osteomuscular/osteomusculocutaneous flap—and some acceptable or very good results obtained after long-term follow-up.

The authors used vascularized bone flaps for bone defects in 65 cases. In 45 of these, they used the vascularized rib as part of a composite flap including latissimus dorsi muscle (5 cases), serratus anterior and latissimus dorsi musucle (7 cases), and serratus anterior (33 cases). They used the rib in emergency free flaps for treating complex traumas with soft tissue and bone defects, but also for patients suffering from pseudarthrosis, septic pseudarthrosis, bone tumors, etc. In the majority of cases, they preferred the vascularized rib together with serratus anterior or latissimus dorsi muscle or rib + serratus anterior + latissimus dorsi for vascular reasons. The length of harvested vascularized bone segment was 5–10 cm. The rib was grafted onto both the upper and lower limbs.

Immediate evolution was uneventful in 93% of cases; in the remaining cases, there were some problems – arterial (3%) or venous (4%) thrombosis; 3% of these were solved by secondary surgery and revision of the anastomosis. The follow-up was 4–48 months. Lower-limb amputations were performed in 2 cases with severe trauma and postoperative vascular complications. There was only one case of grafted bone fracture in the lower limb. In the infected cases, local sepsis was eradicated, followed by fast consolidation of the fracture. The bone fragment was rapidly and perfectly integrated. Functional rehabilitation was started early and with good results. Disadvantages referred only to donor-site morbidity.

The rib + S-A flap is extremely useful for treatment of small or medium sized complex tissue defects. The use of the vascularized rib graft (because of its spongious structure) reduces consolidation time, and even with thin bone, it can produce effective hypertrophy. As part of an osteomuscular flap, it is a vascularized bone that can be of help in septic cases.