From the Departments of Plastic Surgery and Neurosurgery, University of Texas M. D. Anderson Cancer Center.
Plast Reconstr Surg. 2020 Jan;145(1):219-229. doi: 10.1097/PRS.0000000000006382.
Nonvascular bone grafts larger than 4 cm have a 50 percent nonunion rate in spine surgery. Vascular bone flaps are one potential solution; however, their utility in spine surgery has not been fully elucidated. The authors hypothesized that the addition of a free fibula flap after oncologic vertebrectomy would safely potentiate bone union.
The authors performed a retrospective analysis, including all patients who underwent oncologic vertebrectomy for a primary bone tumor at their institution from 2002 to 2017. Patients were divided into two groups: those who underwent spinal reconstruction with nonvascularized bone graft and an alloplastic cage (control) and those whose reconstruction was augmented with a free fibula flap.
Forty patients were included (free fibula flap, n = 16; control, n = 24). Adjuvant therapies and medical comorbidities were similar between the two groups. Chordoma was the most common abnormality in both groups. The median number of vertebrae resected in the free fibula flap group was two, compared to one in the cage group (p = 0.08). Despite the smaller mean resection size, there were significantly more nonunions (41.7 percent versus 6.3 percent; p = 0.02), instrumentation complications (33.3 percent versus 6.3 percent; p = 0.04), and neurologic complications (25 percent versus 0 percent; p = 0.03) in the control group. Multivariate logistic regression revealed a control reconstruction significantly predictive of nonunion (OR, 57.04; 95 percent CI, 1.17 to 2773; p = 0.04). Free fibula flap patients demonstrated evidence of bony union at a mean of 4.8 months versus 22.4 months in the control group (p < 0.001).
Free fibula flap surgery in spinal reconstruction after oncologic vertebrectomy is safe and effective. Free fibula flap surgery is independently protective against nonunion and is associated with more rapid union compared with the control.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
大于 4cm 的非血管化骨移植物在脊柱手术中存在 50%的不愈合率。血管化骨瓣是一种潜在的解决方案；然而，它们在脊柱手术中的应用尚未得到充分阐明。作者假设，在骨肿瘤切除术后增加游离腓骨瓣可以安全地促进骨愈合。
作者进行了回顾性分析，纳入了 2002 年至 2017 年期间在该机构接受骨肿瘤脊柱切除术的所有患者。患者分为两组：一组接受非血管化骨移植物和人工关节融合器（对照组）的脊柱重建，另一组接受游离腓骨瓣重建。
共纳入 40 例患者（游离腓骨瓣组 16 例，对照组 24 例）。两组的辅助治疗和合并症相似。两组均以脊索瘤最为常见。游离腓骨瓣组切除的平均椎体数为 2 个，而对照组为 1 个（p = 0.08）。尽管切除的平均椎体数量较小，但对照组的非融合率（41.7%比 6.3%；p = 0.02）、器械并发症（33.3%比 6.3%；p = 0.04）和神经并发症（25%比 0%；p = 0.03）显著更高。多变量逻辑回归显示，对照组的重建显著预测非融合（OR，57.04；95%CI，1.17 至 2773；p = 0.04）。游离腓骨瓣组患者在平均 4.8 个月时出现骨性愈合，而对照组则为 22.4 个月（p < 0.001）。
在骨肿瘤切除术后的脊柱重建中，游离腓骨瓣手术是安全有效的。游离腓骨瓣手术独立于对照组，可预防非融合，并与更快的融合相关。
临床问题/证据水平：治疗性，III 级。
