Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 16:
Fibular Free Flaps
  This patient had a recurrent tumor of the spinal cord that had been removed on two previous occasions but recurred. The approach had been interthoracic with removal of portions of the vertebral bodies causing subluxation of the thoracic vertebrae at the T-2, T-3 level with compression of the cord. The patient was asymptomatic in bed, but as soon she was upright, pressure on the cord produced paraplegia.

FIG. 16-28. A tomogram in the lateral view depicts the subluxation of the vertebral bodies.

FIG. 16-29. A model shows the operative plan in which the avascularized fibula was to be wired across the posterior aspect of the vertebral bodies and spinous prostheses to prevent anterior subluxation.

FIG. 16-30. CT scan slices going from above downward show the progressive loss of the vertebral bodies at the level of subluxation. T2 level.

FIG. 16-31. T3 level.

FIG. 16-32. The vascularized fibular graft has been mobilized completely on the peroneal vessels, which are traced back to their junction with the posterior tibial vessels. Unfortunately, this is a relatively short vascular pedicle and interpositional vein grafts will be needed in the arterial and venous side.

  FIG. 16-33. The fibula bone graft is wired in place at successive levels above and below the level of subluxation.

FIG. 16-34. An x ray at 4 months shows the consolidating fibular graft, which has not become sclerotic and therefore is presumed to be vascularized. Technetium scans were not helpful at this level because of the overlying structures. Rods have also been wired across the level of subluxation to provide an internal temporary splint. Such metal supports become loose or break in time if bone consolidation does not take place.

FIG. 16-35. The scar is shown on the right posterior thorax used for exposure. The original plan was to anastomose the vascular pedicle of the fibula extended with vein grafts to the occipital or transverse cervical vessels. These could not be located. The descending branch of the scapular circumflex vessel was isolated on the medial border of the scapula as a recipient vessel.

FIG. 16-36. The patient now stands and walks without assistance, more than 1 year after transplant. Unfortunately, the tumor recurred 5 years later.


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