gms | German Medical Science

Surgical treatment of malignant tumors or trauma and chronic osteomyelitis sometimes requires to replace big parts of the bony skeleton, a rare demand especially in the upper extremity.

Reconstruction of the upper extremity by use of vascularized bone grafts was perfomed in 10 patients (3 female, 7 male) aging from 14 to 56a (mean age 33 years). Complex fracture was followed by pseudarthrosis of the humerus (2). Trauma (gun shot and blunt laceration) to the forearm followed by chronical osteomyelitis caused bone defects of the radius (2) and radius and ulna (1). Septicaemia of a shoulder (1) and an elbow (1) prosthesis caused not only loss of shoulder and elbow joint but loss of more than one third of the humerus and osteomyelitis. Giant cell tumors necessitated replacement of the distal radius in 2 patients and in one patient an osteosarcoma of the third metacarpal had to be treated by radical resection. A radical debridement was performed in all infected cases. The humerus fractures were reconstructed with single barrel vascularized diaphyseal fibular grafts. Missing joints were reconstructed by double barrel, ulna and radius with single strut vascularized diaphyseal fibular grafts, a big vascularized skin island for soft tissue reconstruction at the recipient side was incorporated in three flaps, plating in the two nonifected cases was performed in the other cases external fixation was used to stabilize the skeleton. After resection of the giant cell tumors and debridement of the distal radius in a gun shot case, the distal part of the radius was reconstructed by vascularized epiphyseal fibular grafts. The third metacarpal was reconstructed by free vascularized second metacarpal bone graft (toe-transfer).

In all patients the vascularized bone grafts healed without complications. Skin islands had to be partially or fully replaced by local (1) or free flaps (LDM 1). Osteomyelitis was cured successfully in all these patients up to now, bony consolidation was achieved in all patients, with minor reintervention in two cases. In one case of radiocarpal joint reconstruction a dome osteotomia of the fibula/radius was carried out as a secondary procedure to treat the chronic radiopalmar subluxation of the joint.

The vascularized bone transfer did not only salvage the extremities but also could maintain functionality of the upper extremities and hands in all of our cases. Vascularized bone grafts at the upper extremity were not only suitable to replace diaphyseal parts of bones but also to reconstruct epiphyseal parts and joints and were reliable in treating chronic osteomyelitis.