The current status of free vascularized bone grafts.

In the last decade, free vascularized bone transfer has become an established technique, with success rates above 90 per cent reported in most series. These operations have special application for those situations in which the bone defect is large, the recipient bed is poorly vascularized, and there is an associated soft tissue deficiency. The donor sites now include the fibula, iliac crest, rib, metatarsal, radius, and scapula. Because this is a rapidly expanding field of surgical endeavor, much of the work is unpublished and information in some instances has been obtained necessarily from recent clinical meetings and by personal communication with surgeons. Our experience of 41 bone transfers, using the fibula and the iliac crest as the donor grafts, over a 9-year period has been presented. In general, the fibula is recommended for the reconstruction of a long bone. In the lower extremity it should be placed within the medullary cavity of the recipient bone ends so as to be sited in the line of the weight-bearing stress. The iliac osteocutaneous graft is ideal for reconstructing the mandible and other curved bones but can be used also for shorter defects of the tibia. With appropriate osteotomies the curvature of this bone can be increased or straightened to satisfy the requirements of the recipient site. Stress fracture of a long graft is not uncommon in the lower extremity, especially in adults. Nevertheless, this is followed usually by rapid formation of callus at the fracture site and hypertrophy of the bone. The use of angiography, replica bone models, and trial operations on cadavers is recommended in planning. Operative refinements include a simpler dissection of the fibula with a thinner sleeve of muscle; shaping the iliac bone graft while it is still attached at the donor site; and the suture of vein grafts to the bone graft on a side table when the pedicle is too short. Finally, it must be remembered that these are still relatively sophisticated procedures that place demands on personnel and hospital routine. They do not replace conventional bone grafting techniques but offer an alternative solution for difficult situations (Fig. 19). John Hunter stated, "A surgeon must approach the victim of his operation with a sacred dread and reluctance." Although a century has passed this is still a sage message.