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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5213_Библиотеки_им_академика_М_И_Перельмана.pdf
92
F. Holc et al.
a
b
c
d
Fig. 6.6 Case 6.1, postoperative X-rays show consolidation progress from the initial postoperative period to 6weeks,
12weeks, and 1year postoperatively
Fig. 6.7 Case 6.1, clinical assessment 1year postoperatively showed excellent range of motion and a QuickDASH
score of 0
a
b
6 Transfer ofVascularized Bone inFracture-Related Infection
Fig. 6.8 Case 6.2,
initial postoperative
X-rays following open
reduction and internal
xation of the tibia and
bula fracture
93
Fig. 6.9 Case 6.2, (a) The patient presented with ankle
edema and multiple stulas. (b) Anteroposterior and lateral radiographs of the ankle. The cement spacer was
placed on the anterior aspect of the tibia. The articular
surface of the talus shows radiolucencies
94
F. Holc et al.
a
Fig. 6.10 Case 6.2, (a) Contralateral bula ap har-
vest. (b) Ankle arthrodesis with a cemented nail. (c)
The osteocutaneous bula ap ready for transfer. (d)
a
b
b
c
After wound closure, the skin paddle is left on the anterior aspect of the ankle to monitor the ap
postoperatively
d
Fig. 6.11 Case 6.2, (a) One-year postoperative X-rays showing bone union. (b) Clinical result after 1 postoperative
year. The patient was free of pain during walking or standing
6 Transfer ofVascularized Bone inFracture-Related Infection
95
a
b
c
d
Fig. 6.12 Case 6.3, (a, b) Anteroposterior and lateral
X-rays show nonunion at the distal third of the radial
shaft. There was a radial shortening of 12 mm,
increased volar angulation of 23°, deviation in the cor-
onal plane of 20°, and dislocation of the distal radioulnar joint. (c, d) X-rays of the healthy opposite upper
limb were used as a reference for the patient’s normal
anatomy
96
F. Holc et al.
a
b
c
d
Fig. 6.13 Case 6.3, (a, b) Postoperative X-rays after sur-
gical debridement and placement of an antibiotic-loaded
cement spacer in the 6cm bone defect of the radius. The
spacer was xed with an intramedullary pin to maintain
radial alignment. (c, d) After antibiotic treatment, the sec-
ond stage of the induced membrane technique was performed, and the radius was xed with a 3.5mm locking
compression bridge plate. Due to persistent dislocation of
the distal radioulnar joint, a 7mm ulnar shortening was
performed and plated
6 Transfer ofVascularized Bone inFracture-Related Infection
97
a
b
c
d
Fig. 6.14 Case 6.3, (a, b) Four months after the last sur-
gery, X-rays show signs of bone union at the ulna but
delayed healing at the radius. (c, d) At 16months postop-
eratively, the X-ray shows a nonunion of the radius with
resorption of the bone graft
98
F. Holc et al.
a
c
Fig. 6.15 Case 6.3, (a) After debridement of the non-
union site, a 2cm bone defect (yellow asterisk) ensued.
(b) Medial femoral condyle ap harvest. Through a
medial approach, dissection was performed until the
medial femoral condyle was reached. The descending
geniculate artery was repaired using a vessel loop. The
b
d
division of the artery, located beyond the vessel loop,
gives rise to the articular branch, which supplies blood to
the ap. (c) Once the ap was placed into the defect, it
was press-xed. (d) The extent of pedicle dissection of
this ap depends on the length necessary for adequate
placement at the recipient site (up to 10cm)
6 Transfer ofVascularized Bone inFracture-Related Infection
99
a
g
h
b
c
d
e
Fig. 6.16 Case 6.3. (a–f) Clinical images at 2 years of follow-up showing adequate range of motion. (g, h)
Anteroposterior and lateral X-rays showing bone union with complete integration of the medial femoral condyle ap
Conclusions
f
compared to the rest of the techniques to treat
infected critical bone defects.
Bone aps allow reconstructive treatment even in
the most complex scenarios. This is mostly due to
their intrinsic blood supply, which allows ap
survival regardless of the local conditions, and is
responsible for bone aps’ improved bone healing and resistance to infection, as well as retention of their biomechanical properties
(hypertrophy, minimal resorption). The result is
that bone aps have the lowest complication rate
and lowest number of surgical revisions when
The main disadvantages of bone aps are the
associated lengthy protected weight-bearing in
lower limb FRIs, donor-site morbidity, longer
surgical times (the patient must be t enough to
undergo this safely), and a higher technical
demand.
The patients with FRI most beneted from
bone ap surgery are those with poor vascularity
of the FRI site (e.g., multiple previous unsuccessful attempts with other techniques), I4-type soft
100
F. Holc et al.
tissues of the FRI classication, and/or large segmental bone defects.
Large defects are usually reconstructed with a
bula ap, the workhorse for bone reconstruction
in FRI.Donor-site morbidity is not rare but generally minor. To avoid stress fractures, limiting
weight-bearing and adequate bone xation are
essential.
Small defects (< 5cm) can be reconstructed
with a MFC or distal radius ap. Donor-site morbidity is low if the size of these aps is kept under
5cm.
The iliac crest, scapula, and rib aps are usually reserved for situations in which the bula (or
MFC and distal radius) ap is unavailable.
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