Reconstruction of Bony Defects in the Upper Extremity by Vascularized Bone Transfer

The authors presented their experience of free bone transfer in the upper extremity, approaching the topic of different donor sites available and the indications for the selections made according to the location and extent of the defects. Whenever a bony defect exceeds 6 cm or the recipient bed is sclerotic (post traumatic, post infectious, or post radiation therapy), the use of a conventional bone graft is hazardous.

For reconstruction of the humerus (11 cases) the choice of the transfer depended on its location and extent. If the upper third can be adequately reconstructed by an osteoperiosteal or osteocutaneous pedicled flap, including the free edge of the scapula and a parascapular skin flap, the defect should not exceed 12 cm. Free fibula is indicated for more extensive defects (one case). If the middle third is involved, a free iliac bone transfer immobilized by a metal plate is a satisfactory solution, but the defect should not exceed 8 cm (one case). For other cases, a free fibula osteocutaneous or composite fibula and soleus was mandatory (one case). If the lower third ( metaphyseal and epiphyseal part) of the humerus presents an extensive defect to be reconstructed for saving satisfactory function of the elbow, a free iliac osteoctaneous or osteoperisteal transfer is an excellent choice (eight cases).

For reconstruction of the radius or ulna, this is more often achieved by a free fibula transfer including the upper epiphyseal plate in children (one case).Whenever a compound defect involves the bone and a muscle component, a reinnervated soleus and fibula transfer has been described in the literature with a satisfactory functional result (one case). For metacarpal or phalangeal defects (12 cases), there are several options depending on the location of the defect and the number of fingers involved. For loss of several metacarpal bones, a free composite parascapular transfer adequately fits the defect with satisfactory aesthetic result (one case).

For single metacarpal defects, a lateral arm flap (one case), or an ipsilateral or contralateral osteocutaneous Chinese flap (two cases) are satisfactory solutions.

But for phalangeal defects, a new donor site from the authors' department is the anterior interosseous flap. This flap is harvested from the posterior aspect of the forearm and is based on perforator branches of the anterior interosseous artery. The flap can be osteoperiosteal or osteocutaneous, probably the smallest vascularized bone transfer ever described (eight cases).

No complications have been observed, and cosmetic sequelae at the donor site have been minimized.

Whenever a bony defect exceeds 6 cm in the upper extremity, the recipient bed is sclerotic, or there is a compound defect (skin, bone, tendon), a reconstruction by a free transfer is the best choice.