The use of free fibula-flexor hallucis longus osteomuscular flap for calcaneal reconstruction after partial calcanectomy for the chronic osteomyelitis: A case report

A Systematic Review of the Complications Associated with Free Fibular Flaps in Adult and Pediatric Spinal Reconstruction

BACKGROUND

 Free fibular flaps have been suggested as a modality of reconstruction for complex spinal deformities. However, there is limited data that describes associated postoperative outcomes. The purpose of this systematic review was to characterize outcomes after spinal reconstruction using the free fibular flap for both adults and children.

METHODS

 Thirty-nine articles among four databases were identified as having met inclusion criteria. Patient demographics, indications for spinal reconstruction as well as location and anastomosis, history of chemotherapy and radiation therapy, and postoperative outcomes including complications were identified. Major complications were defined as complications requiring reoperation, while minor complications were those that did not require reoperation. Systemic complications were defined as complications affecting sites or organ systems beyond the local donor and recipient sites. Statistical analysis was performed using Fischer's exact, chi-squared, and t-tests.

RESULTS

 We identified 218 adult patients (mean age 47.7 years, 56.4% male) and 27 pediatric patients (mean age 12.7 years, 55.6% male). While there was no significant difference in the rates of bony union between the two groups (adults: 90.8%, children: 90%, p > 0.9), adults had significantly higher rates of major (27% vs. 7.4%, p = 0.026), minor (26.1% vs. 7.4%, p = 0.032), and systemic (14.2% vs. 0%, p = 0.047) complications.

CONCLUSION

 Free fibular flaps are effective for spinal reconstruction for both adults and children, as evidenced by the high rates of bony union. However, adults exhibited significantly higher complication rates. Further research is required to better understand the patient and clinical risk factors associated with increased rate of complications.

Clinical characteristics, treatment and efficacy of calcaneal osteomyelitis: a systematic review with synthesis analysis of 1118 reported cases

BACKGROUND

Calcaneal osteomyelitis (CO) still poses great challenges to orthopedic surgeons due to the unique anatomic and functional features of the calcaneus. This study summarized the current data regarding clinical characteristics, treatment and efficacy of CO, based on an analysis of literature-reported cases.

MATERIALS AND METHODS

The authors searched the PubMed, Embase, and Cochrane Library databases to find English and Chinese studies reporting on CO patients published between 2000 and 2021, with available data for synthesis analysis. The quality of the included studies was evaluated by the National Institutes of Health (NIH) assessment scale. Effective data were extracted and pooled for analysis.

RESULTS

Altogether 198 studies involving 1118 patients were included, with a male-to-female ratio of 2.3 (724 males and 310 females). The median age at CO diagnosis was 46 years, with a median symptom duration of 3 months. Injury-related infections (524 cases) and diabetic foot infections (336 cases) were the two most common causes, with ulcers (468 cases) and wound sinus or exudation (209 cases) being the predominant symptoms. The overall positive culture rate was 80.2%, with polymicrobial infections accounting for 18.1%. Staphylococcus aureus was the most frequently detected pathogen (42.7%), with fungal-related infections isolated in 17 cases. Although most patients received surgical interventions (96.9%), the recurrence rate was 20.1%. The incidence of infection relapse following partial calcanectomy, total calcanectomy, debridement with implantation of local antibiotics, and debridement with or without flap or skin coverage were 31.7%, 45.0%, 16.8%, and 15.1%, respectively. The overall incidence of limb amputation was 12.4%, with all-cause and CO-related mortalities of 2.8% and 0.2%, separately.

CONCLUSIONS

CO shared similar characteristics with extremity chronic osteomyelitis, primarily affecting young males, with trauma and diabetic foot as the leading causes and Staphylococcus aureus as the most frequently detected pathogen. Despite surgery being the primary treatment modality, clinical outcomes remained unsatisfactory, marked by high rates of infection recurrence and limb amputation.

The Concept of Treatment for Surgical Infection in the Hindfoot

Background

Chronic osteomyelitis of the calcaneus (OC) and open infected calcaneal fractures, especially when complicated by infected soft tissue defects, present significant surgical challenges. Accepted recommendations for the surgical treatment of this pathology are yet to be established.

Methods

Drawing from our experience and the consensus among experts, we have developed a concept for selecting optimal, well-known surgical approaches based on the specific pathologic presentation. This concept distinguishes 4 main forms of hindfoot infection: infected wounds, open infected fractures, OC, and their mixed forms. Patients with conditions that could confound the treatment outcomes, such as diabetes mellitus and neurotrophic diseases, were excluded from this analysis. We present a retrospective analysis of the treatment outcomes for 44 patients (4 women and 40 men) treated between 2009 and 2022 using some refined surgical techniques. Treatment success was evaluated based on the absence of disease recurrence within a 2-year follow-up, the avoidance of below-knee amputations, and the restoration of weightbearing function.

Results

The treatment results were considered through the prism of our proposed concept and according to the Cierny-Mader classification. There were 4 instances of disease recurrence, necessitating 6 additional surgeries, 2 of which (4.5% of the patient cohort) resulted in amputations. In the remaining cases, we were able to restore weightbearing function and eliminate the infection through reconstructive surgeries, employing skin grafts when necessary.

Conclusion

Surgical infections of the hindfoot area remain a significant challenge. The strategic concept we propose for surgical decision making, tailored to the specific pathology, represents a potential advancement in addressing this challenge. This framework could provide valuable guidance for orthopaedic surgeons in their clinical decision-making process.

Level of Evidence

Level IV, case series.

Treatment for Calcaneal Osteomyelitis with Pseudoarthrosis with a Vascularized Fibula Bone Graft and Autologous Cancellous Bone Graft: A Case Report

Calcaneal osteomyelitis with pseudarthrosis after calcaneal fracture is rare, and its treatment is challenging. We describe the use of a free fibular osteocutaneous flap to treat a 52-year-old man who presented with calcaneal osteomyelitis and pseudarthrosis after an operation for a closed comminuted fracture. The patient was previously treated with multiple surgeries and antibiotics for 8 months, but he was not cured. We performed radical osteomyelitis bone debridement and reconstruction with a free fibular osteocutaneous flap and autotrabecular bone grafting from the iliac crest. The skin flap survived, and rehabilitation was initiated early. At 2 years postoperatively, his pain and ambulatory function had markedly improved, and he could walk without problems in daily life. Free fibular osteocutaneous flap and autogenous cancellous bone grafting are considered practical options for the treatment of calcaneal osteomyelitis with pseudarthrosis.

Calcaneal reconstruction using a femoral head allograft and biologic adjuncts: A case report

We present a case of calcaneal reconstruction after both an improvised explosive device injury and subsequent salvage procedures left the patient with a large calcaneal defect and damaged hindfoot soft tissue. A subtalar arthrodesis was performed with a femoral head allograft, where it was fused to the remaining calcaneus and superiorly through the talus, to successfully reconstruct this defect. Demineralized bone matrix, bone morphogenetic protein, and concentrated bone marrow aspirate were also added as adjuncts to promote bone remodeling. At final follow-up, the patient denied pain, was fully weight-bearing, and had resumed an active lifestyle. Level of Evidence: Level V, Case Report.

Fibula Musculo-Osteocutaneous Flap with Full Thickness of Flexor Hallucis Longus Muscle

BACKGROUND

Fibula flap has been a gold standard method for reconstruction of the mandible. It has been used for reconstruction of maxilla as well as long bones, effectively. Fibula flap in selected cases has been used as a pedicled flap. The flexor hallucis longus muscle has been used to obliterate the dead space during the reconstruction. With a wide range of indications, the use of flexor hallucis muscle has studied for the reconstruction.

METHODS

In a retrospective case record analysis study, 38 subjects were enrolled, included 32 patients with reconstruction of mandible, 1 patient with reconstruction of maxilla, 4 patients with 3 free flaps and 1 pedicled flap with reconstruction of the tibia.

RESULTS

The success rate was 89%, with 4 flap failures. The muscle was used for reconstruction of the tongue, floor of the mouth, antrum, and to cover the fibula graft.

CONCLUSION

Flexor hallucis longus muscle harvested with the flap could decrease the operative time, ease the harvest, and fill the dead space during reconstruction.