Functional outcome in patient with giant cell tumour distal radius after reconstruction by en-bloc resection and non-vascularized fibular bone graft: a case report

Giant cell tumor (GCT) is a relatively common benign primary bone tumor, commonly seen in end of long bones. Treatment goals for GCT of the distal radius are complete excision of the tumor and preservation of wrist function. Usually it can be treated by en-bloc resection and reconstruction using autogenous non vascularized ipsilateral proximal fibular graft. Authors present a case of twenty two years old female complaining of pain and lump in left wrist since two years ago. The pain worsened since 1 month before consultation, but did not radiate elsewhere. Pain was aggravated by movement and decreased with rest. Physical examination revealed a 3 cm mass with tenderness over left wrist. With clinical suspicion of benign bone tumor on left wrist, further evaluation was needed. Plain radiograph revealed an expansile, lytic lesion and soap bubble appearance on her left distal radius like a GCT. Open biopsy result revealed similar morphology with GCT. Reconstruction by en-bloc surgical excision, followed with non-vascularized fibular bone graft fixed with dynamic compression plate (DCP) and wrist ligament reconstruction and fixation of the head of the fibula with carpal bones and distal end of the ulna using K-wires along with palmaris longus tendon were performed. En-bloc resection of giant cell tumors of the lower end radius is a widely accepted method. Reconstruction with non-vascularized fibular graft, internal fixation with DCP with trans fixation of the fibular head and wrist ligament reconstruction minimizes the problem and gives satisfactory functional results.

Comparison outcome in management of femoral neck fracture using multiple cancellous screws with and without fibular graft

Multiple cancellous cannulated screw is preferred method in fresh cases of fracture neck of femur in young patients. Fibular strut graft is sometimes used along with multiple cancellous cannulated screws to enhance union and early restoration of function. We conducted a retrospective study to patients aged between 20-50 years old with femoral neck fracture treated with multiple cancellous screws either with or without fibular graft between the period of January 2016 to January 2018. We obtained total of six patients (five males and one female) with femoral neck fracture treated with multiple cancellous screws either with or without fibular graft. All fractures were garden type II-IV fresh femoral neck fractures. The functional outcome based on Harris hip score was excellent for all patients. The mean time of full weight bearing was 16±8 weeks in both multiple cancellous screws without fibular group and multiple cancellous screws with fibular group. The mean time of union was also 16±8 weeks in both groups. There is no complication such as non-union, avascular necrosis of femoral head and/or broken fibular graft in both the groups occurrences. Fixation with cancellous screws and fibular strut grafts for femoral neck fractures is cost effective and technically less demanding and associated with good outcomes. There is no added advantage of non-vascularized fibular grafting with multiple hip screw fixation in fresh femoral neck fractures in young adults over multiple hip screw fixation alone.

Long-term effectiveness of vascularized fibula flap in radiocarpal joint reconstruction following excision of Campanacci grade Ⅲ giant cell tumor / 中国修复重建外科杂志

Objective: To evaluate the long-term effectiveness of vascularized fibula flap in radiocarpal joint reconstruction following excision of Campanacci grade Ⅲ giant cell tumor (GCT) of distal radius. Methods: Between December 2010 and December 2014, 10 patients with Campanacci grade Ⅲ GCT of distal radius were treated with en bloc excision and inradiocarpal joint reconstruction using vascularized fibula flap. They were 6 males and 4 females, with an average age of 39.9 years (range, 22-65 years). The disease duration was 1.5-6.0 months (mean, 2.6 months). The length of distal radius defect was 6.0-12.5 cm (mean, 8.4 cm) after en bloc excision of GCT. Vascularized fibula flap with inferior lateral genicular vessels were performed in 6 patients and with inferior lateral genicular vessels and peroneal vessels in 4 cases. Results: All incisions healed by first intention. All patients were followed up 4.4-8.3 years (mean, 6.0 years). There was no tumor recurrence during follow-up. At last follow-up, the mean ranges of motion of wrist joint were 55.0° (range, 25-85°) in extension, 26.5° (range, 15-40°) in flexion, 12.0° (range, 5-25°) in radial deviation, 19.6° (range, 10-30°) in ulnar deviation, 50.5° (range, 5-90°) in pronation, and 66.5° (range, 20-90°) in supination. The mean grip strength of effected wrist was 75% (range, 60%-85%) of the healthy wrist. The mean Musculoskeletal Tumor Society (MSTS) score was 82.7% (range, 75%-90%). X-ray films showed that the fibula flap healed at 12-16 weeks after operation (mean, 14.1 weeks) and there were 9 cases of radiological complications. Conclusion: For Campanacci grade Ⅲ GCT of distal radius, application of the vascularized fibula flap in radiocarpal joint reconstruction after en bloc excision of GCT can obtain good wrist function.

Locking plate in the treatment of proximal humeral fractures involving humeral calcar: Effective support, complications and functional recovery / 中国组织工程研究

BACKGROUND: Saving the humeral head is a challenge when the proximal humerus is fracture in orthopedic trauma, and how to obtain medial column support is a hot topic in recent years. OBJECTIVE: To summarize the general concept, clinical significance and function, the common injury mechanism of humeral calcar, and the progress using locking plate so as to improve the clinicians' understanding for the humeral calcar and to reduce the occurrence of surgical complications. METHODS: From 2004 to 2019, Wanfang, CNKI, VIP, PubMed, Web of Science, and Springer Link about the treatment and research progress of proximal medial wall of the humerus were searched by the first author. The key words were "proximal humeral fracture, Philos, intermedial screw, calcar screw, fibular allograft, middle support" in English, and "proximal humeral fracture, humeral spur, medial column, plate, fibular allograft" in Chinese. The references were retrieved by hand. Finally, 51 studies were used for review according to the inclusion and exclusion criteria. RESULTS AND CONCLUSION: (1) The range of the humeral calcar region is still unclear. There is no uniform classification standard for fractures involving the humeral calcar region. X-ray films show that calcar fracture patterns are often inconsistent with the actual fracture situation, which is often a complex fracture. Lack of understanding and paying litter attention to the humeral calcar region is the main reason of iatrogenic injury and the failure to get a good repair. (2) Treatment using the locking plate is still the preferred method for proximal humerus fracture. Meanwhile, it is a feasible method that using the screw, the allogeneic iliac bone graft, the bone cement or the medial plate to reconstruct the medial column if there is a "repairable medial wall". Getting anatomical reduction of the internal wall and effective support of the medial column during operation can help to reduce postoperative complications. However, the use of the medial buttress plate requires further research to verify. It is critical important to repair the rotator cuff for the medial column support. (3) The range of the humeral calcar region needs to be unified. Understanding the humerus calcar is essential for the treatment of proximal humeral fracture. Only by mastering the fracture mode of the humerus calcar and choosing the most appropriate surgical procedure before surgery, meanwhile, achieving anatomical reduction of the medial wall and the effective support of the medial column during operation can reduce the postoperative complications of the fracture. Repairing of the rotator cuff carefully during operation is indispensable for patients to obtain better shoulder function.

Free vascularized fibular graft in patient with skeletal defect after neurofibroma surgical excision of forearm

The free vascularized fibular graft has been successfully applied as a reconstruction option in patient with large secondary skeletal defects result from excision of pathologic tissue after neurofibroma surgical excision. It provides a strong cortical strut for reconstruction of defects, so that the free vascularized fibular graft is ideal for ulna reconstruction. A 22-year-old male with lump in his right forearm for 3 months previously which become bigger and more painful. There was also sings of ulnar nerve disfunction. From the CPC result, we diagnosed forearm neurofibroma. We performed wide excision and reconstruction using free vascularized fibular graft. On the last follow up, the active and passive ranges of motion (ROM) of 4th and 5th metacarpal was measured with the help of a goniometer. The ulnar neurological state was tested by manual testing and graded on the Medical research council (MRC) scale. Four weeks after surgery, the operation wound at the right forearm and right lower leg was good and no infection signs. The graft viability was good with compromised vascularity. The post-operative passive and active ROM of the 4th and 5th metacarpal able did full extend. The post-operative sensoris level of the ulnar area improved from pre-operative sensoris level.Post-operative follow-up, in the early period (up to 6 weeks) we monitor the graft viability. Our case reported good result in the operation wound, the graft viability, the passive and active ROM of the 4th and 5th metacarpal and the sensoris level of the ulnar area.

Operative management of chondrosarcoma in pelvic region: case series

Chondrosarcoma is the second most frequent malignant bone tumour after osteosarcoma. It most often occurs in the pelvis. Treatment of pelvic chondrosarcoma is a difficult problem for the musculoskeletal oncologist. We report 3 patient with chondrosarcoma in pelvic region that undergoing internal hemipelvectomy. First patient, male 28 y.o. with chondrosarcoma in left iliac wing 11.2cm x 10.8cm x 9.2cm. Second, woman, 47 y.o with chondrosarcoma in right superior and inferior pubic rami 13.7cm x 11.5cm x 14.2cm with soft tissue mass around extended to medial part of proximal thigh. Already done A wide excision of the tumor was performed and we use non-vascularized fibular graft (NVFG) to fill the defect. Last patient, pregnant woman 22 y.o. (16weeks gestational age) with chondrosarcoma in right pubic rami 9.8cm x 11.4cm x 13cm. We already done internal hemipelvectomy without terminating the fetus. The second and third patient confirmed with the histopathology result with chondrosarcoma grade II, and the first patient with chondrosarcoma grade I. After 3month post operatively, all of the patients have no pain, no urinary tract complain. The first patient can ambulatory full weight bearing with no crutches or walker. Second patient ambulatory partial weight bearing with crutches. The last patient ambulatory with wheel chair during the pregnancy. Since chondrosarcomas are unresponsive to chemotherapy or radiotherapy, surgical resection was the only therapeutic solution for these patients. It also reinforce the need of a correct diagnose and collaboration between specialities in the treatment of oncological patients.

Inducción de membrana y trasposición de peroné ipsolateral no vascularizado en neoformación ósea postraumática. Reporte de caso / Membrane induction and transposition of non-vascularized ipsilateral fibula in posttraumatic bone neoformation. Case report

Resumen: Objetivo: Demostrar los resultados en la neoformación ósea de tibia utilizando la técnica de inducción de membrana más la transposición de peroné ipsolateral no vascularizado. Caso clínico: Masculino de 25 años, antecedente de sufrir impacto por arma de fuego en pierna izquierda dos años antes, presentó un diagnóstico inicial de fractura expuesta Gustilo IIIB AO 42C3 IO4NV1MT2 con pérdida ósea de 7 cm de diáfisis tibial. Durante su evolución se realizaron múltiples aseos quirúrgicos y colocación de injertos cutáneos con resultados no favorables, por lo que se emplea la técnica de membrana inducida más colocación de peroné ipsolateral no vascularizado, teniendo una evolución a los cuatro meses posterior a su última intervención con deambulación dependiente de bastón. Conclusión: La técnica de inducción de membrana con transposición de peroné ipsolateral no vascularizado podría ser una alternativa adecuada para el manejo de pérdidas óseas en los pacientes.

Abstract: Objective: To demonstrate the outcome of tibial bone neo formation, using induced-membrane technique and non-vascularized ipsolateral fibular graft transposition. Case report: A 25 years old male with a 2 years ago firearm injury in left leg, presenting an initial diagnosis of open fracture Gustilo IIIB AO 42C3 IO4NV1MT2 with a 7cm tibial diaphyseal bone defect. During his hospital evolution multiple interventions were made including surgical debridement and skin grafts placement, with unfavorable results. Therefore, we decided to use the induced-membrane technique and non-vascularized ipsolateral fibular graft transposition, resulting in a cane dependent ambulation, in 4 months evolution after last intervention. Conclusion: Induced-membrane technique and non-vascularized ipsolateral fibular graft transposition could be a successful alternative for the management of patients with severe bone loss.

Un-United Fracture Neck Femur Results of Treatment with Close Reduction, Cancellous Screw Fixation & Fibular Strut Graft

Background: Ununited, femur neck fractures are a common problem in the developing countries like India where medical facilities are already deficient and ignorance, illiteracy and poverty further delay the patients in seeking proper treatment. The struggle to find the best treatment continues as relentlessly as it did half a century ago. The study was undertaken to evaluate the results of close reduction, cancellous screw fixation and fibular graft in ununited fractures of femoral neck in young adults with regards to achievement of fracture union, effect of this procedure on pre-existing AVN and establishment of relatively easy new surgical technique. Materials & Methods: This study was conducted in Government hospital, Pali, Rajasthan. It includes 25 cases treated by close reduction, cancellous screw fixation and fibular strut graft who have non-united fracture. The patients are systemically interrogated for personal details, mode of injury, time elapsed after injury, complaints, any other associated injury, any previous treatment taken and other systemic illness. Grading of fracture (Garden’s classification) resorption of neck and avascular necrosis changes are based on roentgen graphic findings. Results: Our study showed that the mean age of patients was 35.19 years and maximum patients were seen in 21-40 years of age (72%), male to female ratio was 2.57:1. Average union time in our series was 19 weeks. In present series good to excellent results found in 96% of cases; in only one case (4%) result was poor that was because of failure of procedure. Conclusion: We concluded that the cancellous screws fixed in closed reduced fracture and supplemented with fibular strut graft is one of the good methods as far as union and functional results are concerned in ununited fractures of femoral neck.

Free Vascularized Fibular Graft for Femoral Head Collapse Combined with Ununited Pathologic Intertrochanteric Fracture / 대한정형외과학회잡지

Surgery for pathologic hip fracture poses significant challenges regarding the fixation of fracture and management of the original tumor lesion. An extensive destruction of the femoral neck and intertrochanteric region by benign or malignant lesions complicated by a pathological fracture generally necessitates total hip arthroplasty; however, in adolescents and young adults, preservation of the hip is preferable. We present a 14-year-old female patient, who sustained a pathological intertrochanteric fracture through a pre-existing aneurysmal bone cyst. Several operative interventions with internal fixation and bone graft were unsuccessful, and combined nonunion and progression of osteolysis around the compression hip screw eventually caused femoral head collapse, mimicking osteonecrosis. Hip preservation and resolution of the original tumor were achieved by free vascularized fibular graft.

Un-united Fractures of Femoral Neck Treatment Modalities in Young Adults: A Hospital Based Study in Udaipur

Background: Neglected, femur neck fractures are a common problem seen in the developing countries like India where medical facilities are still in developing stage especially in rural area, where illiteracy and poverty is predominant. The study was undertaken to evaluate the results of close reduction, cancellous srew fixation and fibular graft in ununited fractures of femoral neck in young adults with regards to achievement of fracture union, effect of this procedure on pre-existing AVN and establishment of relatively easy new surgical technique. Material & Methods: This study was conducted in Department of Orthopaedics, Pacific Medical College and Hospital, Udaipur, Rajasthan. This prospective study included 20 cases during 3 months study period (March 2016 and May 2016) treated by close reduction, cancellous screw fixation and fibular strut graft who have non- united fracture. The patients are systemically interrogated for personal details, mode of injury, time elapsed after injury, complaints, any other associated injury, any previous treatment taken and other systemic illness. Grading of fracture (Garden’s classification) resorption of neck and avascular necrosis changes are based on roentgen graphic findings. Results: Our study showed that the mean age of patients was 38.78 years and maximum patients were seen in 21-35 and 36-50 years of age (72%). Average union time in our series was 20 weeks. In present series good to excellent results found in 92% of cases; in only one case (8%) results was poor that was because of failure of procedure. Conclusion: We concluded that the cancellous screws fixed in closed reduced fracture and supplemented with fibular strut graft is one of the excellent method as far as union and functional results are concerned in ununited fractures of femoral neck.

Experiencia inicial en un centro de alta complejidad con el injerto vascularizado de peroné en defectos óseos segmentarios del miembro superior / Early experience in a high complexity hospital with the vascularized fibular graft in segmentalbone defects of the upper limb

Introducción: Los defectos óseos >6 cm en los huesos largos plantean un problema difícil de solucionar en la reconstrucción del miembro superior. El peroné vascularizado se ha convertido en el principal método de reconstrucción por sus ventajas biológicas. El objetivo de este estudio fue evaluar la tasa y el tiempo de consolidación ósea, y las complicaciones asociadas en una serie continua de pacientes. Materiales y Métodos: Se realizó una revisión durante un período de 5 años. Se incluyeron los pacientes que fueron tratados por defectos >6 cm en el miembro superior. Se analizaron variables preoperatorias, intraoperatorias y posoperatorias inmediatas y alejadas. Resultados: Durante el período de evaluación, 6 pacientes (4 hombres/2 mujeres) cumplían con los criterios de inclusión. La edad promedio fue de 47 años. El tiempo transcurrido entre el trauma inicial y la cirugía reconstructiva varió de 2 a 21 años. El defecto óseo promedio fue de 10 cm. El tiempo de seguimiento promedio fue de 17 meses. Se logró la consolidación ósea en todos los casos, como promedio, en 16 semanas. Dos pacientes sufrieron complicaciones posoperatorias. Ninguno presentó complicaciones o secuelas funcionales en la zona dadora. Conclusiones: El injerto óseo vascularizado de peroné es una opción válida para el tratamiento quirúrgico reconstructivo de defectos óseos segmentarios >6 cm en el miembro superior, con una tasa alta de consolidación, aun en casos con múltiples cirugías previas o con una lesión de larga evolución. Los detalles técnicos previenen las complicaciones en la zona dadora.

Introduction: Reconstruction of bone defects >6 cm in the upper limb poses a problem. The vascularized fibular graft has become the most popularized method to treat these bone defects, because of their biological advantages. The aim of this study was to evaluate the rate of bone union, time to accomplish this union and complications associated with this technique in a continuous series of patients. Methods: A review was performed during a period of five years. All patients who were treated for defects >6 cm on upper limbs were included. Preoperative, intraoperative, and immediate and long-term postoperative variables were analyzed. Results: During the assessment period, 6 patients (4 males/2 females) met the inclusion criteria. The average age was 47 years. Time between the initial trauma and reconstructive surgery ranged from 2 to 21 years. The average bone defect was 10 cm. The average follow-up was 17 months. Bone healing was achieved in all cases at a mean of 16 weeks. Two patients had postoperative complications. None of the patients had complications or functional sequelae in the donor site. Conclusions: The vascularized fibular graft is a valid option in reconstructive surgery of segmental bone defects >6 cm in the upper limb. It achieves a high consolidation rate, even in cases with multiple previous surgeries or a long-standing lesion. The technical details prevent complications in the donor site.

A study on management of high grade spondylolisthesis

Background: Spondylolisthesis is defined as a displacement of one vertebra over the next lower vertebra in the sagittal plane. High-grade spondylolisthesis (HGS) is defined as greater than 50% slippage of a spinal vertebral body relative to an adjacent vertebral body as per Meyerding classification, and most common location being L5/S1 followed by L4/L5. The treatment of symptomatic high grade lumbo sacral spondylolisthesis has its own technical difficulties for surgical stabilization and fusion unlike low grade listhesis. We used single transvertebral fibular graft and implant stabilization to the vertebra one level above the pathological vertebra via posterior approach to treat the high grade spondylolisthesis of lumbo sacral spine. Materials and methods: Prospective study done from January 2012 to January 2016 for the management of High grade spondylolisthesis (Grade 3 and Grade 4), patient aged between 15-60 years. Total 15 patients were included in the study. High grade listhesis patients who were not willing for surgery were excluded from the study. All the patients were operated posteriorly with pedicle screw and rod stabilization with trans vertebral single fibular graft with posterolateral fusion was done under fluoroscopic guidance Results: Preoperative and post-operative status was analyzed in reference to the clinical symptoms and radiological evaluation. All the patients showed improvement following surgery without any implant failure. Conclusion: This procedure is technically simple, safe and effective method to treat high grade listhesis with no additional peri operative or postoperative complications.

Comparison of Fixation Techniques in Young Patients with Fracture Neck of Femur: Multiple Hip Screws with Fibular Graft or Multiple Hip Screws Alone.

Background: Fracture neck of femur occurs infrequently in young patients compared to geriatric age groups. The occurrence in the younger age group is associated with high-energy trauma and more complications. The study was conducted to compare the results of two fixation techniques in management of fracture neck of femur in young age group patients. Methods: A total of 60 patients included in this prospective randomized trial were divided into two groups. Group I includes patients managed by multiple hip screws with fibular graft and group II includes patients managed by multiple hip screws alone. Assessment of fixation was done on basis of Harris Hip score at 6 week and 3 monthly intervals. Results: According to Garden's classification, a total of 40 (66.67%) cases were of type III, out of which 24 patients were in group I and 16 were in group II. The rest 20 (33.33%) patients were of type IV with 6 cases ingroup I and 14 cases in group II. In our study, functional outcome was calculated according to Harris hip score. In Group I we got 21 patients (70%) with excellent result, 7 patients (23.33%) with good result and 2 patients were failure cases. In Group II 17 patients (56.67%) got excellent outcome, 9 patients (30%) good outcome and 4 were failure cases.Conclusion: The study showed that there was no significant difference in any of the procedures and either of the technique could be employed depending on user experience and skills.

Chronic Tibial Osteomyelitis in Children. A Case Review at Hospital Tengku Ampuan Afzan, Kuantan

Osteomyelitis in children has various clinical manifestations causing diagnostic and therapeutic difficulties. Inappropriate treatment of acute osteomyelitis may lead to chronic, serious and complicated condition. Chronic osteomyelitis continues to be a major cause of morbidity and disability in children living in developing countries. We present three cases of tibial osteomyelitis that have different presentations and sequalae. Our intention is to alert our colleagues, particularly primary physicians, regarding the variety of presentation and the important of early diagnosis and treatment to reduce the risk of morbidity following osteomyelitis.

Repair of infectious bone defect in femur with free vascularized fibular graft / 中华显微外科杂志

Objective To investigate the clinical application and effect of repair infectious bone defect in femur with free vascularized fibular graft.Methods From April,2008 to April,2013,9 patients that had infectious bone defect in femur underwent repaired with free vascularized fibular graft.The bacterier cultivation of sinus tract excretion in preoperation and focal zone in operation had proved the infection.The length of bone defect were7.5 cm on average.The bone defect was repaired with free vascularized fibular graft on one stage in 6 cases and two stages in 3 cases after the cure of infection.Six patients underwent folded and 3 patients underwent single vascularised fibula graft transfer.The skin island flaps were used as a postoperative predictor of vascularized fibula graft viability in 6 cases.The transfer fibulars were fixed with plate in 6 cases,external fixor in 3 cases.Time to union was recorded through evaluation of plain radiographs.The Enneking score system was applied to evaluate the lower extremity function.Results The vascularized fibular survived and bony fusion was achieved in all patients.All cases were followed up 24.5 months(12-39 months).The average length of the transfer fibula was 14.5 ± 3.2 cm.The average time for bone union at allograft-host junction was 5.5 ± 1.2 months.Of the 9 cases,the mean scores was 24 (their scores ranged from 20 to 27) at final follow-up.The functions of supplied regions were not found malfunctional,no recurrence of infection occurred.There were no stress fracture in inlay fibula.Conclusion Free vascularized fibular graft will benefit to control the infection in femur,have high bone union rate,and is an optimal choice.

Updated Surgical Techniques and Expanded Indications of Free Vascularized Fibular Graft

Free or pedicled vascularized fibular grafts (VFG) are useful for the reconstruction of large skeletal defects, particularly in cases of scarred or avascular beds, or in patients with combined bone and soft tissue defects. Compared to non-VFG, VEG, which contains living osteocytes and osteoblasts, maintains its own viability and serves as good osteoconductive and osteoinductive graft. Due to its many structural and biological advantages, the free fibular osteo- or osteocutaneous graft is considered the most suitable autograft for the reconstruction of long bone defects in the injured extremity. The traditional indication of VFG is the long bone and soft tissue defect, which cannot be reconstructed using a conventional operative method. Recently, the indications have been widely expanded not only for defects of midtibia, humerus, forearm, distal femur, and proximal tibia, but also for the arthrodesis of shoulder and knee joints. Because of its potential to allow further bone growth, free fibular epiphyseal transfer can be used for the hip or for distal radius defects caused by the radical resection of a tumor. The basic anatomy and surgical techniques for harvesting the VFG are well known; however, the condition of the recipient site is different in each case. Therefore, careful preoperative surgical planning should be customized in every patient. In this review, recently expanded surgical indications of VFG and surgical tips based on the author's experiences in the issues of fixation method, one or two staged reconstruction, size mismatching, overcoming the stress fracture, and arthrodesis of shoulder and knee joint using VFG are discussed with the review of literature.

Virtual surgical design in accurate mandibular reconstruction with vascularized fibular graft / 中华显微外科杂志

Objective To introduce the application and assess the outcome of ProPlan CMF software in virtual surgery of mandibular resection and reconstruction with vascularized fibular graft.Methods Nineteen patients were performed mandibular resection,and immediate reconstruction with free fibular graft by application of ProPlan CMF software between March 1,2013 and January 31,2014,including 7 cases of osteoradionecrosis,6 cases of adamantoblastoma,4 cases of carcinoma of gingiva,2 cases of intra-osseous carcinoma of mandible.There were 12 males and 7 females,with an age range of 21-73 years (median,54 years).In each case,three-dimensional spiral CT scan of mandible and fibula was obtained before operation.The CT data were imported into the ProPlan CMF software and the virtual surgical planning was performed.After that,the mandibular rapid prototyping and surgical guide plates were made according to customized design.The segmental resection of mandible,titanium plate bending,fibular molding,insetting and fixing were then carried out by using these surgical guide plates.Results Operations were undertaken successfully according to preoperative design in all nineteen patients and negative margin was detected by intraoperative frozen section.The fibula was cut,shaped and fixed accurately.The operations took 4.5-7.0 hours (mean,5.5 hours).Primary healing of incision was obtained without complications except fistula in 2 cases of osteoradionecrosis,which were resolved with local wound care after 4 weeks.19 patients were followed up between 3 months to 1 year and all patients were alive with disease free.All patients were satisfactory with their maxillofacial appearance,occlusion and function.The ranges of mouth opening was 2.0-4.0 cm.The postoperative panoramic radiographs or CT scan showed perfect situation and contour of fibular graft.Healing of the donor site occurred without significant complications.All patients started early postoperative ambulation,and walked normally after 2 or 3 months.Conclusion The application of ProPlan CMF software in virtual surgical design and guide plates creation can simplify the operation,and improve the accuracy of mandibular resection and reconstruction,especially the spatial relationship of the mandible and the fibula graft.It is worth promotion widely in clinical practice.

Clinical analysis of vascularized fibular graft for the repairment of maxillofacial defects / 中国医师进修杂志

[Objective]To explore the application value of vascularized fibular graft in the repairment of maxillofacial defects.[Methods] Forty-five patients with maxillofacial defects caused by various reasons were enrolled and treated by vascularized fibular graft.The related disease history,survival situation of blood vessels and tissue flaps of all the patients were recorded.[Results]All the patients were followed up for 3-6 months after surgery.All the patients could eat by mouth and without no obvious obstacle.There was no facial asymmetry,healthy side bite jaws deflection and so on.The maxillofacial appearance and functions almost returned back to normal.Oral panoramic radiography showed that the osseous healing of transplanted fibular and mandibular was good,and there was no bone nonunion,osteonecrosis,titanium plate rejection or fracture happened.Three-dimensional CT scàn revealed that the recovery of mandibular appearance was good.There was 1 case with leg wound drainage and 1 case with cervical wound effusion,which were all healed after the second phase by dressing change and necessary treatment.The rest of the patients were all healed at the first phase.There was no free tissue flap necrosis and calf obvious dysfunction.[Conclusions] Using vascularized fibular graft for the repairment of maxillofacial defects,the maxillofacial appearance and functions of patients almost return to normal after surgery.The surgery can satisfy the requirements of patients on postoperative oral and maxillofacial appearance and function with lower incidence of complications and hig her survival rate of free tissue flap.Therefore,it is worthy of clinical application.

Staged Surgery for Severe Soft Tissue and Bone Loss of the Knee

A 20 year old female student was involved in a motor vehicle accident. She sustained a severe friction injury to the left knee that resulted in considerable soft tissue and bone loss. There was also damage to the knee extensor mechanism, tibialis anterior muscle, femoral trochlea, the anterior half of the tibial plateau extending distally to the proximal tibia and skin. However, there was no crushing of the limb or resultant neurovascular deficit but cancellous bone and the remainder of the joint were exp

Nonunion of Humeral Intercondylar Comminuted Fracture Treated with Fibular Graft: A Case Report

Nonunion of comminuted distal humeral fracture is troublesome problem to orthopedic surgeon. We report a case of 59 years old woman, who suffered nonunion of comminuted distal humeral fracture previously treated by open reduction and internal fixation with plate and screws concomitantly autoiliac bone graft. We reconstructed humeral condyle with fibular inlay graft inside cortical shell of intercondylar bone fragment and obtained excellent result in radiological and functional outcome.