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Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al. | ||
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| The free vascularized bone graft, introduced in 1974,1 has become firmly established as a reliable technique for reconstructing a large bone gap, especially if an associated soft- tissue defect is present. Large series have been reported worldwide with success rates above 90%. Survival of the osteocytes within the graft has been proven by many workers, using tetracycline labeling, early bone scans, bone biopsy, and postoperative angiography. These bone grafts have been shown to unite at a rapid rate, independent of the status of the recipient site.2 They have been shown to survive in an irradiated area and sometimes in the presence of infection. Hypertrophy and remodeling of bone occur according to Wolff's law; and if a stress fracture is sustained, rapid formation of callus at the fracture site is the norm.
To date, we have performed 106 such bone transfers, selecting the fibula in 36 cases and the iliac crest in 70. Our philosophy has always been to devise an operation to suit the patient's needs. Interestingly, when we first conceived the idea of a vascularized bone graft in 1973, the iliac crest was the first bone investigated for this purpose. The deep circumflex iliac artery (DCIA), along with the other three vessels that supply the iliac crest, were dissected in fresh cadavers and were considered an ideal pedicle for vascularized bone transfer. The bone was too curved, however, and appeared too short to repair the defect in our first patient's tibia, which measured 12.5 cm. The rib was also examined, but appeared to be frail. Finally, we settled on the fibula, which proved ideal for this purpose and was successfully transferred in June, 1974.1 |
Then, in 1975, we re-evaluated the iliac crest for possible combined skin and bone transfer for two patients with large areas of skin loss and relatively short bone defects. After multiple fresh cadaver dissection and injection studies, the superficial circumflex iliac artery was chosen as the stem because of its large contribution to the groin skin and to the blood supply to the iliac crest, which was considered sufficient for our purpose. The DCIA was again dissected, but its supply to the skin seemed tenuous; however, at that time, we had not injected this artery with dye. In 1977, when confronted again with the clinical problem of a huge defect in the hemipelvis of a young woman, we reappraised the DCIA for the third time. On this occasion, we injected the artery with dye in fresh cadavers and, to our surprise, found that this vessel supplied a significant area of groin skin as well as the majority of the ilium.4,5 |
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