Introduction
It is frequently impossible for large bone abnormalities brought on by musculoskeletal tumors, infections, or trauma to heal naturally. The difficulty for surgeons is preventing amputation while delivering the greatest functional results. The most popular surgical techniques for treating major bone defects are allografts, vascularized fibular or iliac grafts, hybrid grafts, extracorporeal devitalized autografts, distraction osteogenesis, induced-membrane method, and segmental prosthesis. Autologous grafts are the most widely utilized method for replacing missing bone because of their superior osteogenesis, osteoinduction, osteoconduction, histocompatibility qualities, and decreased risk of immunological rejection. However, there is still disagreement on the optimum surgical method, and no decision has been made.
What Is The Bone Reconstruction Surgery?
Even with proper treatment and surgical stabilization, large bone defects brought on by musculoskeletal tumors, infections, or trauma constitute a tissue deficit that cannot recover independently. Surgical care aims to restore the lesion while preventing amputation and delivering satisfactory functional results. When the entire diaphysis is replaced, substantial intercalary replacement may be necessary. Alternatively, joint components may be replaced with prosthetic components if necessary. Because of less morbidity of the surrounding joints, intercalary reconstructions outperformed previous limb salvage techniques regarding functional results. Large bone defects can be repaired using autograft, allograft, and non-biological materials.
The characteristics of osteogenesis, osteoinduction, osteoconduction, and histocompatibility, which result in a low risk of immunological rejection, autografts like vascularized fibular graft or vascularized iliac bone graft are regarded as the gold standard for reconstruction of post-traumatic bone defects with non-union or malunion. The restricted supply of bone grafts, infection, extended wound drainage, and reoperation of the donor site are all drawbacks. After removing the bone tumor, the bone segment is used again as an autograft. The bone segment should be prepared for this approach by pasteurization, autoclaving, gamma irradiation, or cryotherapy, which will reduce the osteogenicity and osteoinductivity of the transplant.
What Are The Different Types Of Bone Reconstruction Options?
-
Biologically-Based Reconstruction:
Bone material that is viable or non-viable can be used to control biological reconstructions. Viable bone material was regarded as the gold standard for reconstructing post-traumatic bone defects resulting from non-union or malunion due to its properties of osteogenesis, osteoinduction, osteoconduction, and histocompatibility, as well as its low risk of immunological rejection and high rate of bone neoformation. Reconstruction methods that use viable bone include the induced-membrane approach, the vascularized fibular graft, the vascularized iliac bone graft, and bone lengthening with external fixation. After removing a bone tumor, repair is done using allograft, a biological rebuilding approach utilizing non-viable bone. The benefits of both previously discussed procedures are integrated into the repair using an allograft and a vascularized fibula.
-
Vascularized Fibular Graft:
Vascularized fibular grafts are frequently utilized to repair larger than six centimeters of bone defects following trauma, infection, and tumor removal, frequently in conjunction with soft tissue deficiencies. Single vascularized fibular graft, double-barrel method, and combined vascularized fibula and allograft repair are the three vascularized fibular graft solutions that have been created. Fibular grafts up to 25 to 26 cm can be extracted from adult patients. The proximal fibula and the lateral malleolus should be avoided to maintain stability in the knee and ankle joints, safeguard the common peroneal nerve, and maintain weight-bearing capability. A traditional single vascularized fibular graft with a smaller cross-section may be susceptible to stress fractures if utilized in the lower limbs.
-
Hybrid Graft Or Combined Vascularized And Allograft Repair:
This approach, which was first introduced by Capanna et al. in the early 1990s, combines the benefits offered by the mechanical strength of allografts with the benefits of the biological features of the autograft. The vascularized fibula helps the host and allograft integrate and can consolidate quickly, whereas the allograft primarily offers bone support and early stability. This hybrid transplant may be put together using either the intramedullary or the only approach. The vascularized fibula is inserted within the allograft using the intramedullary method. In order to do this, the allograft's anterolateral cortex is opened, and the length of the medullary canal that can fit the fibula is reamed.
-
Iliac Crest Bone Transplant:
Another often-used method to repair bone deficiencies brought on by infections, tumor removal, and fractures is iliac crest bone grafting. The benefits of autografts, including osteogenesis, osteoinduction, osteoconduction, and histocompatibility, are all present in the iliac crest bone graft. Either the anterior or posterior iliac crest can be used to harvest the bone transplant. To avoid iliac crest stress fracture, the anterior iliac crest is removed from the body around four to five centimeters posterior to the anterior superior iliac spine. Several methods have been devised to harvest the anterior iliac crest, including the tricortical, segmental bicortical, iliac crest-splitting, trephine, and acetabular reamer.
-
Distraction Osteogenesis For Reconstruction:
First described by Ilizarov in the 1950s, Distraction osteogenesis has been used to treat bone malformations, congenital musculoskeletal diseases, bone abnormalities caused by trauma, infections, and cancer surgery. Since distraction osteogenesis was thought to promote tumor recurrence, it was rarely used in previous decades. In actuality, only complete tumor removal allows for distraction osteogenesis. Segmental transfer, shortening-distraction with an external fixation, and shortening-distraction with an intramedullary nail to decrease the length of use of the external fixation are three alternative techniques for bone rebuilding following tumor removal that have been documented.
-
Induced-Membrane Method With A Spacer Made Of Bone Cement:
After infection, tumor removal, and fractures, the induced-membrane approach, also known as the Masquelet procedure, is used to mend bone defects. Two steps are needed to complete this method. Debridement is the initial step, and then a polymethylmethacrylate spacer is inserted into the bone defect. A modest foreign-body inflammatory reaction brought on by polymethylmethacrylate leads to a thick pseudo-synovial membrane that serves as a newly created periosteum. This pseudomembrane has several growth factors and is extensively vascularized. After 6 to 8 weeks, the second step begins: opening the membrane, removing the spacer, and replacing it with a bone transplant. The spacer is a local antibiotic carrier that also lowers dead space, making it particularly useful for treating infected bone deformities.
-
Reconstructions Using Extracorporeal Devitalized Autografts:
Recycling the tumor-bearing bone section to restore bone deficiencies after cancer surgery provides an option to the allograft. Irradiation, pasteurization, and cryotherapy are only a few of the procedures that have been devised to get cancer cells out of the resected bone fragment and make it reimplantable. The fact that the processed autograft has the exact form of the bone lesion is a crucial benefit. For reconstructions at anatomically complex tumor sites, this is very suitable.
Conclusion
Large bone abnormalities continue to be difficult to treat. There still needs to be an agreement on the preferred approach. There are many methods for treating bone abnormalities, however, it is difficult to draw firm conclusions due to a lack of quantitative data and insufficiently reliable information. Quantitative information on the rates of complications and reoperation must be provided by more research.
