Vascularized periosteum plays a pivotal role in fracture healing and bone regeneration through the provision of osteoblastic cells and bone morphogenic proteins. The ability to induce local bone formation would prove beneficial in addressing a wide range of reconstructive problems. The possibility of enhancing local osteoinduction and reducing resorption of non-vascularized bone grafts utilizing periosteum containing free flaps has been investigated in the clinical setting.

Materials and Methods: Periosteum containing free flaps have been utilized in treating bony defects in the craniofacial skeleton and lower extremity. The first patient is a 50 year old male with an alveolar arch and palate defect after a self induced GSW. The midface defect was reconstructed utilizing a radial forearm, fascial-periosteal free flap and non-vascularized bone graft. The bone was contoured to fit the spacially complex defect with the assistance of a sterolithographic model. The reconstruction was evaluated with serial radiographs, CT scans, a bone biopsy (8th postoperative week) and a bone scan performed during the 4th postoperative month. The second patient is a 21 year old male with a Gastillo Grade IIIb fracture of the distal tibia with a 7 cm segmental bone loss. Reconstruction was performed utilizing a latissimus dorsi- serratus anterior free muscle flap that included vascularized rib periosteum. Bony healing was monitored with serial radiographs.

Results: A twenty month follow up is available for the patient who underwent midface reconstruction. Radiographs demonstrate good bony preservation and histological evaluation of a bone graft performed during the 8th postoperative week identified viable osteoblasts and normal bony architecture. Active uptake of radioactive tracer was also present in a bone scan performed during the 4th postoperative month. The 7 cm tibial bone gap in the second patient was filled with visible callus by the 8th postoperative week despite the patient’s reluctance to weight bear. Fracture healing was achieved utilizing Ilizarov bone transport without secondary bone graft at the time of docking.

Conclusion: Preliminary clinical experience suggests that the osteoinductive capabilities of periosteum containing free flaps may be beneficial in supporting non-vascularized bone grafts and augmenting the reconstruction of large bone gaps in the traumatized lower extremity.