Vascularized Bone Grafts about the Wrist and Forearm: Indications and Techniques

Introduction Nonunion treatment should be done by debridement, bone grafting, and stable fixation. Vascularized bone transfer is a treatment option for extensive bony defects involving scarred, poorly vascularized tissues, infected recipient beds, or persistent nonunions.

Our experience with vascularized bone grafts about wrist and forearm and indications on posttraumatic nonunions and bone defects of the upper extremity will be presented.

Results Small bone defects (< 2 cm) or full contact without gap after debridement: corticoperiosteal flaps from medial femoral condyle (MFC), with cancellous bone from the depth of the condyle. Indicated for phalanges, metacarpals, and epiphyseal-metaphyseal areas (distal radius).¹ Medium defects (3–5 cm): structural tricortical grafts from iliac crest (with cancellous bone impacted) and vascularized flap from MFC (corticoperiostical or only periosteal flap).^1,3 Useful in large diaphyseal bone defects. According to our experience, rigid and stable osteosynthesis is key to the success of the procedure and allows early rehabilitation and recovery. No differences were found between corticoperiosteal versus periosteal flap.⁴ Large bone defects (> 5 cm): vascularised fibula graft. Indicated for diaphyseal reconstruction of large bones caused by tumors, congenital disorders of forearm, and postraumatic defects.² Chronic, infected nonunions or nonunions from radionecrosis involving large segmental defects of both forearm bones were treated using a double-barrel free fibula flap.⁵

Conclusion With these guidelines, we have obtained a high rate of primary consolidation (75 to 100%) in upper limb defects with over 15 years of experience.^2–4

References

References

1 del Piñal F, Innocenti M. Evolving concepts in the management of the bone gap in the upper limb. Long and small defects. J Plast Reconstr Aesthet Surg 2007;60(7):776–792

2 González del Pino J, Bartolomé del Valle E, Graña GL, Villanova JF. Free vascularized fibular grafts have a high union rate in atrophic nonunions. Clin Orthop Relat Res 2004;(419):38–45

3 Rodríguez-Vegas JM, Delgado-Serrano PJ. Corticoperiosteal flap in the treatment of nonunions and small bone gaps: technical details and expanding possibilities. J Plast Reconstr Aesthet Surg 2011;64(4):515–527

4 Vegas MR, Delgado P, Roger I, Carosini R. Vascularized periosteal transfer from the medial femoral condyle: is it compulsory to include the cortical bone? J Trauma Acute Care Surg 2012;72(4):1040–1045

5 Saint-Cyr M, Farkas J, Gupta A. Double-barrel free fibula flap for treatment of infected nonunion of both forearm bones. J Reconstr Microsurg 2008;24(8):583–587