Subscribe to RSS
DOI: 10.1055/s-0028-1090624
Treatment of Chronic Nonunions of the Humerus with Free Vascularized Fibula Transfer: A Report of Thirteen Cases
Publication History
Publication Date:
16 October 2008 (online)
![](https://www.thieme-connect.de/media/jrm/200902/lookinside/thumbnails/10.1055-s-0028-1090624-1.jpg)
ABSTRACT
Chronic nonunions of the humerus remain a challenging problem. We reviewed 13 cases of chronic nonunion of the humerus resulting from trauma or osteomyelitis treated with vascularized fibula transfer after failure of conventional treatment. Patient averages were 35 years of age, follow-up of 19 months, and 4.2 prior operations. Healing was obtained in 12 of 13 (92%) patients with an average healing time of 18 weeks and graft length of 12.5 cm. In total, 11 of 12 (91%) patients who united had good to excellent range of motion of their shoulder and elbow. There were eight complications in 7 of 13 patients (54%). Two patients developed fractures of the graft, and three had superficial infections at the harvest site requiring operative debridement. Two patients had median neurapraxia that resolved by 4 months. Two patients complained of intermittent pain at the donor site. No significant correlations were found between time to heal and other covariates.
KEYWORDS
Humerus - nonunion - vascularized bone graft
REFERENCES
- 1 Ackerman G, Jupiter J B. Non-union of fractures of the distal end of the humerus. J Bone Joint Surg Am. 1988; 70(1) 75-83
- 2 Brighton C T. The treatment of non-unions with electricity. J Bone Joint Surg Am. 1981; 63(5) 847-851
- 3 Cattaneo R, Villa A, Catagni M A, Bell D. Lengthening of the humerus using the Ilizarov technique: description of the method and report of 43 cases. Clin Orthop Relat Res. 1990; 250 117-124
- 4 Esterhai Jr J L, Brighton C T, Heppenstall R B, Thrower A. Nonunion of the humerus: clinical, roentgenographic, scintigraphic, and response characteristics to treatment with constant direct current stimulation of osteogenesis. Clin Orthop Relat Res. 1986; 211 228-234
- 5 Foster R J, Dixon Jr G L, Bach A W, Appleyard R W, Green T M. Internal fixation of fractures and non-unions of the humeral shaft: indications and results in a multi-center study. J Bone Joint Surg Am. 1985; 67(6) 857-864
- 6 Loomer R, Kokan P. Non-union in fractures of the humeral shaft. Injury. 1976; 7(4) 274-278
- 7 Rosen H. Compression treatment of long bone pseudarthroses. Clin Orthop Relat Res. 1979; 138 154-166
- 8 Duffy G P, Wood M B, Rock M G, Sim F H. Vascularized free fibular transfer combined with autografting for the management of fracture nonunions associated with radiation therapy. J Bone Joint Surg Am. 2000; 82(4) 544-554
- 9 Gerwin M, Weiland A J. Vascularized bone grafts to the upper extremity: indications and technique. Hand Clin. 1992; 8(3) 509-523
- 10 Hirayama T, Suematsu N, Inoue K, Baitoh C, Takemitsu Y. Free vascularised bone grafts in reconstruction of the upper extremity. J Hand Surg [Br]. 1985; 10(2) 169-175
- 11 Osterman A L, Bora F W. Free vascularized bone grafting for large-gap nonunion of long bones. Orthop Clin North Am. 1984; 15(1) 131-142
- 12 Sowa D T, Weiland A J. Clinical applications of vascularized bone autografts. Orthop Clin North Am. 1987; 18(2) 257-273
- 13 Takami H, Takahashi S, Ando M, Masuda A. Vascularized fibular grafts for the reconstruction of segmental tibial bone defects. Arch Orthop Trauma Surg. 1997; 116(6–7) 404-407
- 14 Tu Y K, Yen C Y, Yeh W L, Wang I C, Wang K C, Ueng W N. Reconstruction of posttraumatic long bone defect with free vascularized bone graft: good outcome in 48 patients with 6 years' follow-up. Acta Orthop Scand. 2001; 72(4) 359-364
- 15 Urbaniak J R, Coogan P G, Gunneson E B, Nunley J A. Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting: a long-term follow-up study of one hundred and three hips. J Bone Joint Surg Am. 1995; 77(5) 681-694
- 16 Wei F C, El-Gammal T A, Lin C H, Ueng W N. Free fibula osteoseptocutaneous graft for reconstruction of segmental femoral shaft defects. J Trauma. 1997; 43(5) 784-792
- 17 Weiland A J, Kleinert H E, Kutz J E, Daniel R K. Free vascularized bone grafts in surgery of the upper extremity. J Hand Surg [Am]. 1979; 4(2) 129-144
- 18 Wood M B, Cooney W P. Vascularized bone segment transfers for management of chronic osteomyelitis. Orthop Clin North Am. 1984; 15(3) 461-472
- 19 Wood M B. Free vascularized bone transfers for nonunions, segmental gaps, and following tumor resection. Orthopedics. 1986; 9(6) 810-816
- 20 Wood M B. Upper extremity reconstruction by vascularized bone transfers: results and complications. J Hand Surg [Am]. 1987; 12(3) 422-427
- 21 Yajima H, Tamai S, Ono H, Kizaki K. Vascularized bone grafts to the upper extremities. Plast Reconstr Surg. 1998; 101(3) 727-735
- 22 Yajima H, Tamai S, Ono H, Kizaki K, Yamauchi T. Free vascularized fibula grafts in surgery of the upper limb. J Reconstr Microsurg. 1999; 15(7) 515-521
- 23 Weiland A J, Moore J R, Daniel R K. Vascularized bone autografts. Experience with 41 cases. Clin Orthop Relat Res. 1983; 174 87-95
- 24 Taylor G I, Miller G D, Ham F J. The free vascularized bone graft: a clinical extension of microvascular techniques. Plast Reconstr Surg. 1975; 55(5) 533-544
- 25 Heitmann C, Erdmann D, Levin L S. Treatment of segmental defects of the humerus with an osteoseptocutaneous fibular transplant. J Bone Joint Surg Am. 2002; 84(12) 2216-2223
- 26 Brown K L. Limb reconstruction with vascularized fibular grafts after bone tumor resection. Clin Orthop Relat Res. 1991; 262 64-73
- 27 Jupiter J B. Complex non-union of the humeral diaphysis: treatment with a medial approach, an anterior plate, and a vascularized fibular graft. J Bone Joint Surg Am. 1990; 72(5) 701-707
- 28 Jupiter J B, Kour A K. Reconstruction of the humerus by soft tissue distraction and vascularized fibula transfer. J Hand Surg Am. 1991; 16(5) 940-943
- 29 Coghlan B A, Townsend P L. The morbidity of the free vascularised fibula flap. Br J Plast Surg. 1993; 46(6) 466-469
- 30 Gore D R, Gardner G M, Sepic S B, Mollinger L A, Murray M P. Function following partial fibulectomy. Clin Orthop Relat Res. 1987; 220 206-210
- 31 Tang C L, Mahoney J L, McKee M D, Richards R R, Waddell J P, Louie B. Donor site morbidity following vascularized fibular grafting. Microsurgery. 1998; 18(6) 383-386
- 32 Yoshimura M, Shimamura K, Iwai Y, Yamauchi S, Ueno T. Free vascularized fibular transplant. A new method for monitoring circulation of the grafted fibula. J Bone Joint Surg Am. 1983; 65(9) 1295-1301
- 33 Doi K, Tominaga S, Shibata T. Bone grafts with microvascular anastomoses of vascular pedicles: an experimental study in dogs. J Bone Joint Surg Am. 1977; 59(6) 809-815
- 34 Springfield D S. Massive autogenous bone grafts. Orthop Clin North Am. 1987; 18(2) 249-256
- 35 Ceruso M, Falcone C, Innocenti M, Delcroix L, Capanna R, Manfrini M. Skeletal reconstruction with a free vascularized fibula graft associated to bone allograft after resection of malignant bone tumor of limbs. Handchir Mikrochir Plast Chir. 2001; 33(4) 277-282
- 36 de Boer H H, Wood M B. Bone changes in the vascularised fibular graft. J Bone Joint Surg Br. 1989; 71(3) 374-378
- 37 Dell P C, Burchardt H, Glowczewskie Jr F P. A roentgenographic, biomechanical, and histological evaluation of vascularized and non-vascularized segmental fibular canine autografts. J Bone Joint Surg Am. 1985; 67(1) 105-112
- 38 Enneking W F, Burchardt H, Puhl J J, Piotrowski G. Physical and biological aspects of repair in dog cortical-bone transplants. J Bone Joint Surg Am. 1975; 57(2) 237-252
- 39 Brunelli G, Guizzi P A, Battiston B, Vigasio A. A comparison of vascularized and nonvascularized bone transfer in rabbits: a roentgenographic, scintigraphic, and histologic evaluation. J Reconstr Microsurg. 1987; 3(4) 301-307
- 40 Goldberg V M, Shaffer J W, Field G, Davy D T. Biology of vascularized bone grafts. Orthop Clin North Am. 1987; 18(2) 197-205
- 41 Pirela-Cruz M A, DeCoster T A. Vascularized bone grafts. Orthopedics. 1994; 17(5) 407-412
- 42 Shaffer J W, Field G A, Goldberg V M, Davy D T. Fate of vascularized and nonvascularized autografts. Clin Orthop Relat Res. 1985; 197 32-43
- 43 Lazar E, Rosenthal D I, Jupiter J. Free vascularized fibular grafts: radiographic evidence of remodeling and hypertrophy. AJR Am J Roentgenol. 1993; 161(3) 613-615
- 44 Gazdag A R, Lane J M, Glaser D, Forster R A. Alternatives to autogenous bone graft: efficacy and indications. J Am Acad Orthop Surg. 1995; 3(1) 1-8
- 45 Muramatsu K, Doi K, Ihara K, Shigetomi M, Kawai S. Recalcitrant posttraumatic nonunion of the humerus: 23 patients reconstructed with vascularized bone graft. Acta Orthop Scand. 2003; 74(1) 95-97
- 46 Judet H, Gilbert A, Mathoulin C et al.. Reconstruction of loss of bony substance in limbs by free vascularized fibula transplant. Chirurgie. 1991; 117(5–6) 469-476
- 47 Wright T W, Miller G J, Vander Griend R A, Wheeler D, Dell P C. Reconstruction of the humerus with an intramedullary fibular graft: a clinical and biomechanical study. J Bone Joint Surg Br. 1993; 75(5) 804-807
- 48 Barnea Y, Amir A, Shlomo D et al.. Free fibula flap elbow-joint hemiarthroplasty reconstruction for chronic osteomyelitis of the distal humerus. J Reconstr Microsurg. 2006; 22(3) 167-171
- 49 Hriscu M, Mojallal A, Breton P, Bouletreau P, Carret J P. Limb salvage in proximal humerus malignant tumors: the place of free vascularized fibular graft. J Reconstr Microsurg. 2006; 22(6) 415-421
- 50 Pollock R, Stalley P, Lee K, Pennington D. Free vascularized fibula grafts in limb-salvage surgery. J Reconstr Microsurg. 2005; 21(2) 79-84
- 51 Rose P S, Shin A Y, Bishop A T, Moran S L, Sim F H. Vascularized free fibula transfer for oncologic reconstruction of the humerus. Clin Orthop Relat Res. 2005; 438 80-84
- 52 Jones N F. The need for preoperative leg angiography in fibula free flaps. J Reconstr Microsurg. 1994; 10(5) 287-289
- 53 Rosson G D, Singh N K. Devascularizing complications of free fibula harvest: peronea arteria magna. J Reconstr Microsurg. 2005; 21(8) 533-538
- 54 Arai K, Toh S, Tsubo K, Nishikawa S, Narita S, Miura H. Complications of vascularized fibula graft for reconstruction of long bones. Plast Reconstr Surg. 2002; 109(7) 2301-2306
A. Bobby ChhabraM.D.
Department of Orthopaedic Surgery, University of Virginia Health System
Box 800159, Charlottesville, VA 22908
Email: ac2h@virginia.edu