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 FIG. 16-16. Vein grafts were used to lengthen the peroneal artery and vein before the fibular transplant was placed.
 FIG. 16-17. Interosseous wiring was used for fixation.
 FIG. 16-18. Solid healing and remodeling of the osteosynthesis site with pronation and supination restored were evident on x ray 1 year after the transplant procedure. At this time, a stress fracture occurred through the middle of the graft while the patient was carrying out unrestricted activities. Stress fractures have occurred in 30 to 40% of fibular transplants, but in most cases have gone on to spontaneous healing with immobilization alone.
CASE 3
A 23-year-old man caught his arm in a grain auger, causing a multilevel bone, nerve, and vessel injury.
 FIG. 16-19. Appearance of arm before surgery.
 FIG. 16-20. (new slide) X ray of the forearm bones showing a two-level fracture with six segments.
 FIG. 16-21. The extremity was salvaged with temporary intra-arterial silastic stems to preserve circulation during the prolonged intramedullary stabilization of the bone fragments. Interpositional vein grafts were then inserted into the radial and ulnar arteries. Venous drainage was through a posterior skin bridge and the traumatized muscle.
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 FIG. 16-22. Loose wound closure was accomplished with meshed skin grafts.
 FIG. 16-23. Swelling gradually subsided, but vascular necrosis necessitated removal of the central radial bone segment. X ray before debridement.
 FIG. 16-24. X ray after removal of necrotic radial segment. The patient now needs a vascularized bone graft, cover, and a median nerve graft.
 FIG. 16-25. Intraoperative view shows vascularized fibular segment notched and screwed into the radial defect, segmental sural nerve grafts into the median nerve defect, and a simultaneous latissimus muscle transplant to cover the entire repair (folded proximally). The thoracodorsal nerve (arrows at medial epicondyle) was repaired to a branch of the anterior interosseous nerve.
 FIG. 16-26. Postoperative x ray shows fibular graft with screws and double plates across the ulnar two fracture sites.
 FIG. 16-27. A. Early function, extension. B. Early function, flexion. C. Early function, grip.
CASE 4
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