Wood, Michael B.

We have reviewed 30 patients at a mean of 36 months after free vascularised fibular transfer to reconstruct massive skeletal defects after resection of primary bone tumours. There were 23 malignant and 7 benign neoplasms, half in the lower limb and half in the upper. Arthrodesis was performed in 15 and intercalary bone replacement in 15. The mean fibular graft length was 189 mm. Union was achieved in 27 (90%) at an average of 7.6 months, and the 3-year survival was 89%. There was a high complication rate (50%), but most resolved without greatly influencing the final outcome. There was local recurrence in two (6.7%), but 16 of the 24 assessed patients (67%) had satisfactory functional results. This is a reasonably effective means of reconstruction for limb salvage after resection of tumours.

During a 4-year period, one of the authors (M.B.W.) performed 16 nerve reconstructions by interfascicular grafting in the lower extremities of 13 patients. Three patients were excluded from the study: one was lost to follow-up and two had less than 1-year follow-up. At an average follow-up of 30 months, the results of 13 procedures in 10 patients were evaluated. Results were good after five procedures, fair after five, and poor after three. Superior results were evident with shorter graft lengths and after nerve transection injuries.

Free skin flap transfer for foot salvage and reconstruction was done in 10 patients whose follow-up exceeded 1 year. Nine of the 10 had successful results, and generally all achieved the desired reconstructive goal in one stage, with a minimum of hospitalization and disability time. In using a free skin flap transfer in weightbearing locations, the need for cutaneous innervation of the flap should be considered, but such innervation is not necessary for success.

The methods and materials for ACL reconstruction are important issues for the practicing orthopaedic sur geon. In this study a model was developed to study the biological and biomechanical characteristics of a patel lar tendon autograft used for ACL reconstruction. Spe cifically it was hypothesized that since vascularity of these grafts reflects their "healthiness," strength and vascularity should be inversely related in the early pe riod after implantation. Using an over the top technique, a patellar tendon graft was placed in three groups of dogs and studied at 37, 57, and 120 days. Vascularity of the grafts was measured using technetium-tagged red blood cells, and percent water by weight was determined by dessication. Tensile testing to failure was performed using an MTS machine. The grafts became more vascular, more hydrated, less stiff, and less strong (by 4 weeks) than controls. By 16 weeks the vascular response was subsiding but the grafts remained only 40% as strong as controls. Percent water increased significantly over controls for all time periods. Decrease in strength correlated poorly with vascularity but correlated well with increase in percent water. These findings suggest that the change in strength of an intraarticular ACL replacement relates more to a basic rearrangement of its collagen-ground substance relationships, and that vascularity may re flect the inflammatory response bringing about these changes. The model developed in this study serves as a basis for further studies, and the findings reveal important information about the behavior of ACL graft ing materials.

A new technique for wrist fusion using vascularized bone graft is described. A distally based, pedicled segment of the distal ulna, nourished by the ulnar artery or the distally based palmar-ulnar branch of the anterior interosseus artery was used in three patients to restore carpal height after infection ( n = 2) or tumour resection ( n = 1). The forearm is converted to a situation similar to a wide ulnar resection. All three wrist fusions healed uneventfully. This new technique is suitable in cases where a vascularized bone graft is required, but microsurgical techniques are not appropriate or are rejected by the patient.