A skeletal defect represents loss of osseous tissue, which alters to a variable degree the anatomy and architecture, the biomechanical properties and the functional ability of load transfer of the affected bone. A skeletal defect is considered critical when it is of such dimensions that it cannot be spontaneously restored by the intrinsic healing process and necessitates surgical intervention and augmentation of the healing process.
Skeletal defects can be classified according to their etiology as primary or secondary. Primary bone defects result from high-energy trauma, which can produce an open fracture with extensive soft tissue damage, osseous comminution and even extrication of bone fragments. Secondary defects result from excision of pathological tissue. Pathologic processes involving the skeleton may be congenital, as in congenital pseudarthrosis of the tibia, or acquired, as in aseptic and septic nonunions, osteomyelitis and bone tumors.
Large skeletal defects constitute a difficult challenge for the surgeon and a source of significant morbidity, functional impairment, and economic, psychological and social distress for the patient.
Detailed evaluation of each case will disclose the elements on which the treatment plan will be based. It should include assessment not only of defect parameters, such as location and dimensions, but also of the soft tissue envelope condition, the limb length and alignment, the adjacent joint range of motion, the presence of associated injuries and the patient's functional requirements and general health condition.
In many cases where most of these parameters are not favorable the surgeon is confronted with a critical decision, that is to salvage or to amputate the limb. Although this dilemma appears frequently in clinical practice, the complexity of the situation due to the interplay of multiple patient and local extremity factors (age, hemody-namic status, skeletal, soft tissue, vascular and nerve injury) may pose difficulty in reaching a decision.
Reconstruction of skeletal defects has been attempted with a variety of treatment methods. Since the first report by Job Van Meeckeren in the 17th century of bridging a human skull defect with a canine graft, the surgeon's armamentarium has considerably expanded to include several biologic techniques (bone grafts, bone
Reconstructive Microsurgery, edited by Konstantinos Malizos. ©2003 Landes Bioscience.
substitutes, growth factors and distraction osteogenesis), as well as endoprostheses implantation.
Vascularized bone grafting was first attempted in 1905 by Huntington, who transposed the ipsilateral fibula as a pedicle graft for reconstruction of a tibial defect. However, it was not until 1975, that free transfer of a vascularized fibular graft using microvascular techniques became possible and was reported by Taylor et al.
Vascularized bone grafts from other donor sites have been utilized, mostly from the iliac crest and the rib, but also from the scapula, humerus, radius, tibia and second metatarsal. However, the free vascularized fibular graft (FVFG) is the one that has found the most widespread application in the management of large skeletal defects and will be reviewed in detail.
The free vascularized iliac crest bone graft is an other alternative also utilized in a number of applications where its morphological characteristics fit better.
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