Use of the ipsilateral vascularised fibula for tibial reconstruction

Vascularized fibular grafts for the treatment of long bone defects: pros and cons. A systematic review and meta-analysis

PURPOSE

To quantify union rate, complication rate, reintervention rate, as well as functional outcome after vascularized fibular bone grafts (VFGs) for the treatment of long-bone defects.

METHODS

A comprehensive search was performed in the PubMed, Web of Science, and Cochrane databases up to August 18, 2020. Randomized controlled trials, comparative studies, and case series describing the various techniques available involving VFGs for the reconstruction of segmental long-bone defects were included. A meta-analysis was performed on union results, complications, and reinterventions. Assessment of risk of bias and quality of evidence was performed with the Downs and Black's "Checklist for Measuring Quality".

RESULTS

After full-text assessment, 110 articles on 2226 patients were included. Among the retrieved studies, 4 were classified as poor, 83 as fair, and 23 as good. Overall, good functional results were documented and a union rate of 80.1% (CI 74.1-86.2%) was found, with a 39.4% (CI 34.4-44.4%) complication rate, the most common being fractures, non-unions and delayed unions, infections, and thrombosis. Donor site morbidity represented 10.7% of the total complications. A 24.6% reintervention rate was documented (CI 21.0-28.1%), and 2.8% of the patients underwent amputation.

CONCLUSIONS

This systematic review and meta-analysis documented good long-term outcomes both in the upper and lower limb. However, VFG is a complex and demanding technique; this complexity means an average high number of complications, especially fractures, non-unions, and vascular problems. Both potential and limitations of VFG should be considered when choosing the most suitable approach for the treatment of long-bone defects.

Union, complication, reintervention and failure rates of surgical techniques for large diaphyseal defects: a systematic review and meta-analysis

To understand the potential and limitations of the different available surgical techniques used to treat large, long-bone diaphyseal defects by focusing on union, complication, re-intervention, and failure rates, summarizing the pros and cons of each technique. A literature search was performed on PubMed, Web of Science, and Cochrane databases up to March 16th, 2022; Inclusion criteria were clinical studies written in English, of any level of evidence, with more than five patients, describing the treatment of diaphyseal bone defects. The primary outcome was the analysis of results in terms of primary union, complication, reintervention, and failure rate of the four major groups of techniques: bone allograft and autograft, bone transport, vascularized and non-vascularized fibular graft, and endoprosthesis. The statistical analysis was carried out according to Neyeloff et al., and the Mantel–Haenszel method was used to provide pooled rates across the studies. The influence of the various techniques on union rates, complication rates, and reintervention rates was assessed by a z test on the pooled rates with their corresponding 95% CIs. Assessment of risk of bias and quality of evidence was based on Downs and Black’s “Checklist for Measuring Quality” and Rob 2.0 tool. Certainty of yielded evidence was evaluated with the GRADE system. Seventy-four articles were included on 1781 patients treated for the reconstruction of diaphyseal bone defects, 1496 cases in the inferior limb, and 285 in the upper limb, with trauma being the main cause of bone defect. The meta-analysis identified different outcomes in terms of results and risks. Primary union, complications, and reinterventions were 75%, 26% and 23% for bone allografts and autografts, 91%, 62% and 19% for the bone transport group, and 78%, 38% and 23% for fibular grafts; mean time to union was between 7.8 and 8.9 months in all these groups. Results varied according to the different aetiologies, endoprosthesis was the best solution for tumour, although with a 22% failure rate, while trauma presented a more composite outcome, with fibular grafts providing a faster time to union (6.9 months), while cancellous and cortical-cancellous grafts caused less complications, reinterventions, and failures. The literature about this topic has overall limited quality. However, important conclusions can be made: Many options are available to treat critical-size defects of the diaphysis, but no one appears to be an optimal solution in terms of a safe, satisfactory, and long-lasting outcome. Regardless of the bone defect cause, bone transport techniques showed a better primary union rate, but bone allograft and autograft had fewer complication, reintervention, and failure rates than the other techniques. The specific lesion aetiology represents a critical aspect influencing potential and limitations and therefore the choice of the most suitable technique to address the challenging large diaphyseal defects.

Pedicled fibular transfer for biologic knee extensor tendon reinsertion following proximal tibial resection in pediatric osteosarcoma: Long-term outcomes

INTRODUCTION

Proximal tibial sarcoma resections result in a reconstructive challenge, necessitating joint and extensor mechanism reconstruction. The gait and functional outcomes for children reconstructed with a combination of megaprosthesis and pedicled fibular flap for extensor mechanism reconstruction, are presented.

METHODS

Four patients, aged 11-18 years old, were available for comprehensive analysis. The proximal tibial osteosarcoma was resected, and the reconstructive technique involved a megaprosthesis for the knee joint, used in combination with a pedicled fibula flap as a biologic structure for reinsertion of the knee extensor mechanism. Outcomes were measured with three-dimensional gait analysis and patient questionnaires.

RESULTS

Minor postoperative wound issues occurred in some patients, requiring debridement with skin grafting. One patient fractured their transferred fibula, requiring fixation. The follow up period ranged from 1.7 to 24 years postoperatively. The longevity and quality of reconstructions were strong, measured by both objective and patient-reported outcomes. All patients reported independent walking >500 m in the Functional Mobility Scale and rated their walking as a nine or 10 (out of 10) on the Functional Assessment Questionnaire. Knee society scoring revealed overall satisfaction rate of 75-80%. No patients required gait aids. The gait profile analysis revealed effective gait patterns, with patterns deviating 5.4-7° from "typical gait." Deviations >6.5° are considered abnormal.

CONCLUSION

The long-term results of combining a megaprosthesis with a pedicled fibula flap for extensor reinsertion, revealed a high level of independent function. The patients performed well, without the need for aids, and gait study evidence of minimal gait deviations.

Reconstruction of firearm and blast injuries in Syrian war refugees

BACKGROUND

War injuries differ from other injuries owing to the large tissue defects they cause and their high risk of contamination. As fragments scattered by high-energy firearms and explosives cause serious composite tissue damage, repair of such injuries is difficult and requires a long treatment period. We discuss the treatment methods used for injured Syrian War refugees admitted to our clinic and present the most effective repair methods for war-related tissue defects for each region of the body.

METHODS

A total of 61 patients treated between June 2012 and April 2015 were retrospectively evaluated in terms of age, gender, duration of hospitalisation, injury site and repair method employed. The patients were grouped by region injured (head/neck, extremities and trunk).

RESULTS

The female-to-male ratio of the patients was 16/45, and their mean age was 25.2 (range, 3-51) years. Twenty-two patients were under the age of 18. The mean duration of hospitalisation was 28.5 days. A total of 130 operations were performed on the patients, including debridement and revisions. Repairs were conducted with free flaps in 17 patients (6 on the head/neck region, 11 on extremities) and with pedicle flaps in 28 patients (11 on the head/neck region, 12 on extremities, 5 on the trunk). Two patients experienced flap loss without other complications, and other patients experienced complications including bleeding, infection, flap detachment, hematoma and seroma.

CONCLUSIONS

War injuries cause tissue damage of a composite and extensive nature. Most affect the extremities, followed by the head/neck and trunk regions. They are primarily sustained by the young population, not usually easy to treat, and require long hospitalisation periods. A variety of methods may be preferred to treat these injuries.

Limb salvage for malignant bone tumours of distal tibia with dual ipsilateral vascularized autogenous fibular graft in a trapezoid-shaped array with ankle arthrodesis and preserving subtalar joint

BACKGROUND

The treatment of malignant tumours of the distal tibia is a challenging surgical problem due to the scarce soft tissue coverage and the instability of the ankle joint that often occurs after resection. However, there is no consensus on the ideal treatment for malignant tumours of the distal tibia.

METHODS

We report a new reconstruction for five patients with high-grade osteosarcoma of distal tibia, using dual ipsilateral vascularized autogenous fibular graft in a trapezoid-shaped array and external fixator, with ankle arthrodesis and preserving subtalar joints. The patients were examined clinically and radiographically.

RESULTS

The average follow-up duration was 88 months. The mean wound healing time was 14 days. Bone healing was achieved for all the five patients at an average time of 7 months. There were no complications of mal-union, skin necrosis, post-operative infection, loss of internal fixation, peroneal nerve injury. One patient had a local recurrence, which required amputation 15 months postoperatively. The remaining four patients were able to walk with an average functional score of 81.25% according to MSTS.

CONCLUSIONS

Our study shows that this technique is safe and effective to perform implantation of dual ipsilateral vascularized autogenous fibular graft in a trapezoid-shaped array and preserving subtalar joints in terms of the distal tibial reconstruction for malignant bone tumour of the distal tibia. This reconstruction represents a biological alternative protocol for limb salvage in cases of malignant bone tumour of the distal tibia, with encouraging results and with the advantages of lower complications and accelerating recovery.

LEVEL OF EVIDENCE

Level IV.

Vascularized fibular medialization for reconstruction of the tibial defects following tumour excision

PURPOSE

The purpose of this study was to evaluate the functional and oncologic results of fibular medialization when used alone as a single-stage reconstructive technique after wide excision of malignant tumours of the proximal, middle, or distal tibia.

METHODS

Between December 2010 and May 2015, 14 patients (six males and eight females) with primary malignant tumours of the tibia (eight proximal, four diaphyseal, two distal) were treated by wide excision. The mean age of the patients at the time of surgery was 23.2 years (11-38). The fibula was mobilized medially with its vascular pedicle to fill the defect and was fixed by a long plate and screws bypassing the graft. The average size of the defects reconstructed was 19.5 cm (18-22). Patients were evaluated functionally using the Musculoskeletal Tumour Society (MSTS) scoring system.

RESULTS

The mean follow-up period was 31.3 months (range, 17-54). The average time for complete union was 7.6 months (range, 6-9). At final follow-up all patients had fully united grafts; 11 walked without aids. Chest metastases developed in one patient, superficial wound infection in two patients and leg length discrepancy in four patients; one case had LLD of more than 3 cm. The mean MSTS score was 23/30 points (76.5%). The minimum score was 40% (12/30) and the maximum was 90% (27/30).

CONCLUSIONS

Ipsilateral pedicled vascularized fibular centralisation or medialization is a durable reconstruction for tibial defects after wide excision of bone tumours with an acceptable functional outcome. Stable osteosynthesis is the key to union.

Free non-vascularized fibular graft for treatment of large bone defect around the elbow in pediatric patients

BACKGROUND

Large bone defect is a challenging problem in orthopedics practice. Several methods are available for bridging of these bone defects, including cancellous bone graft, free vascularized fibula graft, and bone transport with external ring fixator. The aim of this study was to describe our experience in nine pediatric cases of free non-vascularized autogenous fibular strut bone graft in which large bone defect and bone loss of >7 cm was caused by open fracture and infective nonunion around the elbow joint.

OBJECTIVE

To describe our experience in nine pediatric cases of free non-vascularized autogenous fibular strut bone graft in which large bone defect and bone loss of >7 cm was caused by open fracture and infective nonunion around the elbow joint.

METHOD

This retrospective review was conducted in patients with large bone defect with bony gap >7 cm. Time to union, range of motion, complications, Mayo Elbow Performance Score, and Foot and Ankle Disability Index (FADI) were recorded.

RESULT

The large bone defects included in this study were managed by free non-vascularized fibular strut bone grafts (FNVFG) that were harvested subperiosteally. Nine patients with a mean age of 11 years (range: 6-17) underwent this procedure. Nine grafts (100%) united at both ends within an average of 9 weeks (range: 8-14). Mean length of defect was 9.3 cm (range: 8-13 cm). Mean postoperative Mayo Elbow Performance Score was significantly higher than the mean preoperative score (98.33 vs. 64.44, respectively; p < 0.001). Three fibulae were observed for hypertrophy. Mean Foot and Ankle Disability Index score was 100 both preoperatively and postoperatively in all patients.

CONCLUSION

Free non-vascularized fibular graft is a simple procedure and a reliable method for bridging large bone defect or loss caused by open fracture and/or infection around the elbow in pediatric patients.

Management of post-traumatic bone defects of the tibia using vascularised fibular graft combined with Ilizarov external fixator

INTRODUCTION

Post-traumatic bone defects of the tibia present a difficult reconstructive challenge. Various methods of reconstruction are available, such as allografts, vascularised fibular graft (either free or pedicled) and bone transport technique.

PATIENTS AND METHODS

Fourteen patients with an average age of 34.1 years at operation (range, 12-65) with post-traumatic bony defects of the tibia were selected for reconstruction with vascularised fibular graft combined with Ilizarov external fixation. There were 12 male and two female. The size of the bony gap was 10.4 cm (range, 7-13) and the average length of the fibula used was 16.4 cm (range, 14-21).

RESULTS

The mean follow up period was 20.4 months (range, 10-37). All patients had bony union at both proximal and distal ends of the fibula primarily except one patient that required secondary iliac bone graft at the distal end of the fibula to obtain union. The average time for bone healing was 3.9 months (range, 3-9). The average time spent in Ilizarov frame was 5.9 months (range, 5-11). Unprotected full weight-bearing was achieved within an average of 7.3 months (range, 6-12).

CONCLUSION

Vascularised fibular bone graft combined with an Ilizarov frame is a successful approach to safely and effectively reconstruct bone defects of the tibia. It has the advantages of vascularised fibular bone grafts together with the biomechanical advantages of Ilizarov frame that allows weight bearing to start almost immediately after surgery. This leads to a good outcome regarding the union and function.

Natural tibialization of fibula in non-union tibia: Two cases

BACKGROUND

Non-union of tibia is known to be a common complication after fracture both bones of leg treated conservatively. During the course of natural healing, fibula usually unites early as it had more soft tissue attachment and vascular supply. Due to early union of fibula and absence of axial force across the tibia, it undergoes non-union.

CASE CHARACTERISTICS

Two cases, a 32-year-old male and 65-year-old female treated conservatively for fracture both bones of leg long years back, presented to us with mild calf pain on and off. On radiological examination, there was non-union of tibia along with compensatory fibular hypertrophy to the extent that fibula became main weight bearing bone.

OUTCOME

In both the cases, we observed gross fibular hypertrophy in presence of non-union of tibia.

CONCLUSION

In conservatively treated cases of fracture, both bones of leg, non-union of tibia may coexist with compensatory hypertrophy of fibula to the extent that, it becomes main weight bearing bone of the leg. We are presenting here two cases of natural tibialization of fibula along with nonunion tibia. Our article supports the theory of Wolff's law.

Management of high-energy tibial pilon fractures

Tibial pilon fractures result from high-energy trauma unlike usual ankle fractures. Their management provides numerous challenges to the orthopaedic surgeon including obtaining anatomic reduction of articular surface and the management of associated soft tissue injuries. This article aims to review major advances and principles that guide our practice today. We also discuss a treatment algorithm based on a staged approach to the fracture: initial spanning external fixation followed by definitive fixation.

Pedicled vascularised fibular grafting in a flow-through manner for reconstruction of infected non-union of the tibia with preservation of the peroneal artery: a case report

We report on an 82-year-old man with an infected non-union of the right tibia in which the peroneal artery was the sole artery supplying the lower leg, owing to peripheral arterial disease. He underwent tibial reconstruction using the pedicled vascularised fibular graft in a flow-through manner (without ligation of either the proximal or distal ends of the peroneal artery) and achieved successful bony union.

Critical-sized defect in the tibia: is it critical? Results from the SPRINT trial

OBJECTIVES

The purpose of this study was to determine whether the SPRINT definition of a "critical-sized defect" (fracture gap at least 1 cm in length and involving over 50% of the cortical diameter) was accurate, to discern which factors predict reoperation in patients with these defects, and to compare the patient-based outcomes of these patients with patients without a critical defect.

DESIGN

Therapeutic Cohort Study.

SETTING

Level 1 and level 2 trauma centers.

PATIENTS

Thirty-seven patients in the SPRINT trial with a critical-sized defect participated. We evaluated these patients for planned and unplanned secondary intervention to gain union. Additionally, we evaluated which other factors predicted the need for reoperation. Finally, the 37 patients with a critical defect were compared with the larger cohort of patients without a defect with respect to demographics, mechanism of injury, fracture characteristics, and patient-based outcome.

INTERVENTION

Revision surgery for tibial nonunion.

RESULTS

Of the 37 patients with a large fracture gap, 7 patients had a planned secondary procedure. Of the remaining 30 patients in whom the attending surgeon adopted a "watch and wait" strategy, 14 patients (47%) never required additional surgery to gain union. Additional surgery to gain union was less likely in patients treated with a reamed nail (P = 0.04) and in female patients (P = 0.04). Patients with a critical-sized defect were more likely to have a high-energy mechanism of injury (P = 0.001), AO-OTA fracture type 42 B or C (P < 0.001), and location involving the middle third of the tibia (P = 0.02). The 12-month SF-36 physical component summary score in patients with a critical-sized defect was 38.2 ± 10.5 (mean ± SD) compared with 43.3 ± 10.7 in those without a critical defect (P = 0.02, difference = 5.2, 95% confidence interval = 0.8-9.6).

CONCLUSIONS

Tibial diaphyseal defects of >1 cm and >50% cortical circumference healed without additional surgery in 47% of cases. This definition of a critical-sized defect is not "critical." However, as compared with the overall cohort of tibial fractures, patients with these bone defects had a higher rate of reoperation and worse patient-based outcomes. Further investigation is required to determine which factors predict union in this challenging fracture to avoid unnecessary secondary surgery.

LEVEL OF EVIDENCE

Prognostic level I. See instructions for authors for a complete description of levels of evidence.

Ankle fusion with centralisation of the fibula after distal tibia bone tumour resection

Background

Management of distal tibial tumours with limb salvage surgery poses a challenge for the orthopaedic surgeon. This study was done to evaluate the results of fibular centralisation as a technique to reconstruct defects that occurred after resection at this site.

Materials and methods

Nine patients with a mean age of 23.2 years (range 17–34) with diagnosis of osteosarcoma in four patients, Ewing’s sarcoma in two, giant cell tumour in two and chondrosarcoma in one patient underwent surgical treatment for tumour in the distal tibia. All patients had wide resection of the tumour and ankle arthrodesis with centralisation of the fibula. Patients were assessed clinico-radiologically for bone union, infection and complications. The final functional outcome was estimated according to Musculoskeletal Tumor Society (MSTS) scores.

Results

The mean age at the time of surgery was 23.2 years (17–34). There were five females and four males. The mean follow-up was 37 months (range 28–54 months). One of the patients with osteosarcoma had a recurrence a year after limb salvage surgery, underwent above-knee amputation, and died 18 months later due to metastasis. One patient developed leg length discrepancy. The mean MSTS score was 22.75 (range 17–27).

Conclusion

Fibular centralisation is a durable reconstruction tool for defects of the distal tibial metaphysis with an acceptable functional outcome. It is an inexpensive and simple procedure, with a low rate of late complications, and reproducible results.

Level of evidence

IV Retrospective case series.

Acute emergency tibialization of the fibula: reconstruction of a massive tibial defect in a type IIIC open fracture

Gustilo type IIIC open fractures of the tibia are high-energy injuries necessitating long treatment periods and usually multiple surgical procedures and eventually resulting in high morbidity rates and even amputations. We present here a case involving a type IIIC open tibial fracture with massive loss of the entire tibial diaphysis, which we treated by performing acute tibialization of the fibula after revascularization of the posterior tibial artery in a single-stage emergency operation.

Reconstruction of a tibial defect with a previously fractured fibula including the fractured segment as a free osteoseptocutaneous flap

INTRODUCTION

Reconstruction of major bone defects using free fibular transfer provides a good biological option in unsound situations. Most authors recommend selection of the recipient blood vessels outside the zone of injury to achieve successful free fibular transfer. Occasionally, in polytraumatized patients, the surgeon has to use a previously fractured fibula as a graft, with increased risk of inclusion of the injury zone that may lead to failure.

METHODS

We report a rare case of successful reconstruction of a large tibial defect using a previously fractured fibula as a free osteoseptocutaneous flap. The innovative point in our case is the inclusion of the fracture site within the utilized segment, which to our knowledge has never been reported.

CONCLUSIONS

As long as the microsurgical principles are adhered to, the effect of the zone of injury on the graft viability should not be overwhelming.

Pedicled vascularized fibular graft with Ilizarov external fixator for reconstructing a large bone defect of the tibia after tumor resection

BACKGROUND

Large bony defects in the middle or distal third of the tibia resulting from surgical resection of malignant bone tumors present a difficult reconstructive challenge. Various methods of reconstruction are available, such as allografts, vascularized fibular graft (either free or pedicled), or endoprothesis replacement for distal defects.

MATERIALS AND METHODS

Twelve patients--eight males and four females with mean age of 18 years at operation (range 14-25 years)--with malignant bone tumors of the tibial shaft were selected as candidates for wide resection of the tumor and reconstruction of the bony defect by ipsilateral vascularized fibular graft based on the peroneal vessels. Preoperative staging studies, including plain radiography, local MRI, isotopic bone scan, and chest CT, were done for every patient before biopsy. Ilizarov external fixation was then applied in all cases. The average length of the bony gap bridged was 14.5 cm (13-16.5 cm) and the mean length of the harvested graft was 16.3 cm (15-18 cm). The average operation time was 7.5 h (5.5-9.5 h).

RESULTS

The mean follow-up period was 38 months (range 32-52 months). Bony union at the proximal and distal ends of the fibula occurred in nine patients (75 %) and at a mean time of 5.5 months (range 4.5-8 months). Graft hypertrophy occurred in all patients. The mean percentage of hypertrophy was 95 % (range 80-160 %). The mean MSTS functional score was 84 % (range 80-92 %). A leg length discrepancy of 2 cm was reported in two patients and was managed using a shoe lift.

CONCLUSION

Reconstruction of bony defects of the middle or distal tibia after bone tumor resection using pedicled vascularized fibula is a useful limb salvage procedure. The procedure can be performed relatively quickly and inexpensively and has a low rate of late complications. It leads to a good outcome regarding the union, hypertrophy, and function.

Inter-tibiofibular graft for traumatic segmental bone defect of the tibia

INTRODUCTION

The present study sought to assess the interest of inter-tibiofibular graft (ITFG), alternatively called posterolateral bone graft, in traumatic segmental tibial bone defect.

MATERIAL AND METHODS

Twenty-eight ITFGs were performed in 125 tibial reconstructions for traumatic bone defect. Patient's records were reviewed retrospectively in a multicenter study. Tibial reconstruction with and without ITFG was compared for bone healing and patient's return to full weight-bearing status.

RESULTS

There were no failures of bone healing in the ITFG group, versus 14 (14%) in the non-ITFG group. Graft-to-consolidation delays were shorter with first-line ITFG, at a mean 10 months (range, 3-20 months) versus 16.5 months (range, 3-63 months) in the non-ITFG group (P<0.05). Weight-bearing was likewise more quickly resumed, with full weight-bearing at a mean 9 months (range, 3-19 months) versus 15 months (range, 1-34 moths) respectively (P<0.05). Return to work was also quicker, at a mean 15 months (range, 4-28 months) versus 27 months (range, 8-56 months) respectively (P<0.05).

DISCUSSION

This study confirmed the interest of ITFG in tibial bone defect reconstruction. ITFG may singly be used for small defects less than 4 cm, or in conjunction with another tibial reconstruction technique; ITFG in the present series achieved consolidation in all cases and significantly shortened the times to return to full weight-bearing status and to work.

LEVEL OF EVIDENCE

III: retrospective case-control study.

Treatment of a fibular autograft non-union with a resulting deformity by stabilization, progressive correction and callotasis using an Ilizarov fixator: a case study

Bone tumours present a challenge to reconstructive surgery when the tumour breaches the physeal and periphyseal region of the growing bone. Though a host of options are available, these are not without complications. We report one such case of osteosarcoma of the tibia treated initially with wide resection of the tumour and intercalary fibular strut grafting using plate and screws. The operation was complicated by a non-union at the proximal tibio-fibular autograft junction. This leads to a multiplanar deformity with severe procurvatum at the proximal tibio-fibular graft junction, which was successfully treated by callotasis using an Ilizarov fixator. Appropriate consent was obtained from the patient and parents to publish this case report.

Managing bone defects

The management of bone defects caused by trauma and nonunion continues to represent a substantial clinical challenge in the management of orthopaedic trauma patients. A variety of treatment options have been described and reported in the literature. The relative rarity of these injuries means that high level, comparative evidence to guide their management is sparse. As such, treatment decisions must be based on knowledge of the available evidence, contemporary fracture management principles, and consideration of patient and surgeon factors. This article reviews the available evidence for the different treatment options available for the management of bone defects.

Reconstruction of composite tibial defect with free flaps and ipsilateral vascularized fibular transposition

Composite defects of the tibia following open fractures are among the most challenging of clinical problems. The aim of this study is to report the results of treatment using a free flap procedure followed by ipsilateral vascularized fibular transposition (IVFT) for reconstruction of composite tibial defects. Ten patients underwent a free flap procedure followed by IVFT and plating. The mean size of the flaps was 12.1 × 6 cm(2). The mean length of bone defect was 5.35 cm. IVFT were performed 4.3 months following the free flap. Patients were followed for an average of 3.4 years. All flaps survived. The average time to union of the proximal and distal ends was 5.2 and 6.7 months, respectively. There were neither stress fractures of the transferred fibula nor recurrent infections. One patient demonstrated a medial angulation of 8° in the reconstructed tibia but experienced no difficulties in activities of daily living. At the last follow-up time point, all patients were able to walk without an assist device and were satisfied with the preservation of the injured lower extremity. Free flap procedures followed by IVFT for the treatment of composite tibial defects may reduce complications at the recipient site and infections, such as osteomyelitis. The plating technique combined with IVFT allowed bone union without additional operations or stress fractures in our series. We suggest that staged free flap and IVFT is useful for the treatment of composite segmental tibial defects.

Transfer of ipsilateral fibula on vascular pedicle for treatment of congenital pseudarthrosis of the tibia

BACKGROUND

Although the use of free vascularized fibula grafts has frequently been reported in the treatment of congenital pseudarthrosis of the tibia, the use of ipsilateral fibula graft on a vascular pedicle is uncommon. We reviewed the long-term results of this procedure in 11 patients.

METHODS

The records of 11 patients who underwent transfer of the ipsilateral fibula on a vascular pedicle between 2.1 and 10.8 years of age were retrospectively reviewed. Average follow-up was 11 years after the index procedure. Seven patients had reached skeletal maturity. Clinical records and radiographs were reviewed to determine patient demographics, surgical parameters, union rate, refracture rate, residual deformity, and functional outcome.

RESULTS

Eight patients (73%) achieved union at an average of 20.1 months. Additional bone grafting procedures were required in 4 patients with distal nonunions. There were 3 refractures (38%). Four patients eventually underwent amputation, and 1 patient had a persistent nonunion at final follow-up. Residual deformity included tibial valgus and procurvatum deformities, limb length discrepancy, and ankle valgus. Use of the ipsilateral fibula did not seem to increase the risk of ankle valgus. Functional outcomes were good in all but one patient.

CONCLUSIONS

Use of the ipsilateral fibula as a pedicle graft provides reasonable results in healing congenital pseudarthrosis of the tibia. Patients should be monitored for the sequelae of this condition, including nonunion, refracture, shortening, and angular deformity, and treated accordingly.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Treatment of congenital pseudarthrosis of the fibula by periosteal flap

Pseudarthroses of the fibula are frequently associated with a pseudarthrosis of the tibia, but they can be isolated. To treat them it is usually necessary to have ankle alignment at skeletal maturity. We report six cases of fibular pseudarthrosis treated with periosteal flap, all having Recklinghausen's neurofibromatosis type 1. The mean age at the time of treatment was 4 years. Four children were diagnosed with isolated congenital pseudarthrosis of the fibula, with a simple curvature of the tibia, and two children had an associated pseudarthrosis of the tibia that was treated earlier. Treatment of the pseudarthrosis of the fibula was indicated to prevent a fracture of a curved tibia or to prevent ankle valgus. The technique of periosteal flap was different: in one case, the periosteum was taken from the fibular diaphysis as a free pedicled flap; in two cases, the flap was taken with its proximal pedicle; and in three cases, the flap was taken from the fibular diaphysis with its distal pedicle and returned to the pseudarthrosis. We analyzed the different operative techniques used for each patient, the complications and the functional result to follow-up. We did not use any osteosynthesis in two cases; a centro-medullary wire and a screwed plate were used in two cases. The pseudarthrosis healed in four cases in a mean period of 10 months. Healing was faster in the cases treated with distal pedicled returned periosteal flaps, a relatively simple technique not requiring vascular sutures. The distal pedicled returned periosteal flap permits good mobility of the periosteum and gives the best healing times. This treatment is indicated for young children to prevent a fracture and a pseudarthrosis of a dysplastic or congenital curvature of the tibia, or after treatment of congenital pseudarthrosis of the leg after healing of the tibia to prevent ankle instability and severe ankle valgus formation.

Fibular centralisation for the reconstruction of defects of the tibial diaphysis and distal metaphysis after excision of bone tumours

We evaluated the results of fibular centralisation as a stand alone technique to reconstruct defects that occurred after resection of tumours involving the tibial diaphysis and distal metaphysis. Between January 2003 and December 2006, 15 patients underwent excision of tumours of the tibial diaphysis or distal metaphysis and reconstruction by fibular centralisation. Their mean age was 17 years (7 to 40). Two patients were excluded; one died from the complications of chemotherapy and a second needed a below-knee amputation for a recurrent giant-cell tumour. A total of 13 patients were reviewed after a mean follow-up of 29 months (16 to 48). Only 16 of 26 host graft junctions united primarily. Ten junctions in ten patients needed one or more further procedure before union was achieved. At final follow-up 12 of the 13 patients had fully united grafts; 11 walked without aids. The mean time to union at the junctions that united was 12 months (3 to 36). The mean Musculoskeletal Tumor Society Score was 24.7 (16 to 30). Fibular centralisation is a durable reconstruction for defects of the tibial diaphysis and distal metaphysis with an acceptable functional outcome. Stable osteosynthesis is the key to successful union. Additional bone grafting is recommended for patients who need postoperative radiotherapy.

Ipsilateral fibular transport using Ilizarov-Taylor spatial frame for a limb salvage reconstruction: a case report

Segmental bone defects of the tibia present a challenging problem, particularly when they are associated with soft tissue injuries or instability. Various techniques have been reported to treat bone loss in the tibia. This case report describes a patient with massive segmental bone loss associated with a soft tissue injury, which required a flap for coverage. The injury was treated with an ipsilateral fibular transport utilizing an Ilizarov/Taylor spatial frame. At one and a half year follow-up, the patient was able to walk without any support at home and wore a protective shell for outdoor activities. The outcome of this case study indicates that ipsilateral fibular transport using the Ilizarov method is a valuable technique for limb salvage reconstruction.

Reconstruction of tibia defects by ipsilateral vascularized fibula transposition

INTRODUCTION

Segmental defects of the tibia after open fractures, sepsis and tumor surgery present a challenging problem. Similarly, tumor surgery often involves radical resections and multiple procedures and is frequently accompanied by irradiation or chemotherapy creating an avascular bed. The aim of this study is to report the results and discuss the role of the ipsilateral pedicle vascularized fibula (IPVF) a technique used for reconstruction of tibia defects.

MATERIALS AND METHODS

Reconstruction of large tibia defects 6-22 cm due to tumor resection were performed in 5 patients by ipsilateral vascularized fibula transposition. The mean age of the patients was 35.4 years (19-42) SD 9.31. The mean follow-up was 59.6 months (24-96) SD 29.2. The mean length of the bone defect was 14.6 cm (6-22) SD 6.066 and the mean time for union was 8 months (6-12) SD 2.82. Arteriography was used preoperatively in all patients to evaluate the lower limb vasculature and to select the optimal surgical approach. The osteosynthesis was stabilized by a plate.

RESULTS

There was sound union in all cases. There were only two minor complications one partial paresis of peroneal nerve and one superficial infection. The mean follow-up was 59.6 months (24-96) SD 29.2. No patient presented with any complaints with the procedure and all had good functional results.

CONCLUSIONS

The procedure was technically simple compared to free vascularized fibula and could be performed in hospital with low resources. There are several advantages: (a) achievement of bone defect reconstruction retaining periosteal and endosteal circulation, (b) preservation of a major vessel of the lower leg, (c) avoidance of difficulty and risk of microvascular technique and (d) no donor-morbidity. We routinely recommend preoperative angiography and intraoperatively meticulous dissection to prevent damage to the vascular pedicle.

A simple treatment for a 15-cm tibia bone defect: a case report of an ipsilateral vascularized fibula transfer

Segmental defects of the tibia present a challenging problem. This report demonstrates the use of an ipsilateral vascularized fibula transfer (IVFT) in a patient with a 15 cm tibial bone defect following tumor resection. Bone union was achieved within 6 months, and 8 years after the surgery the patient has full knee flexion and extension and is still employed in the same vocation as he was prior to surgery. With current interest in reconstructive techniques such as vascularized fibular grafts, segmental allografts, and bone transportation, the technique of ipsilateral vascularized fibula transfer has become neglected. The purpose of this case report is to highlight its use and draw attention to its advantages and disadvantages.

Method of quadriceps attachment following upper tibial resection

Limb salvage procedures for osteosarcomas of the upper tibia present combined problems of knee-joint and tibial reconstruction. Many methods of overcoming this have been described. We describe a new technique of prosthetic knee-joint and upper-tibial reconstruction, combined with a vascularized fibular bone flap for reattachment of the quadriceps muscle and tendon unit, resulting in superior long-term function.

Management of posttraumatic segmental bone defects

Because of difficulty in managing posttraumatic segmental bone defects and the resultant poor outcomes, amputation historically was the preferred treatment. Massive cancellous bone autograft has been the principal alternative to amputation. Primary shortening or use of the adjacent fibula as a graft also has been used to attempt limb salvage. Of more recent methods of management, bone transport with distraction osteogenesis has been suggested as the leading option for defects of 2 to 10 cm, but problems include delayed union at the docking site and prolonged treatment time. Free vascularized bone transfer has been suggested as the leading option for defects of 5 to 12 cm, but hypertrophy of the graft is unreliable and late fracture, common. Bone graft substitutes continue to be developed, but they have not yet reached clinical efficacy for posttraumatic segmental bone defects. Although each of the new techniques has shown some limited success, complications remain common.

Ipsilateral fibular transposition in tibial nonunion using Huntington procedure: a 12-year follow-up study

Eleven patients (10 men and 1 woman) with a mean age of 32 years (range: 16-61 years) and a mean follow-up of 12 years (range: 2-21 years) were studied retrospectively after ipsilateral fibular transposition. The cause of tibial nonunion was a motor vehicle collision (MVC) in eight patients, a fall from a window in one, an adamantinoma in one, and osteomyelitis in one. There was one type I and eight type IIIb open fractures according to the Gustilo classification, and the nonunion was infected in seven patients. Healing of the tibial defect was obtained in eight patients, after a mean interval of 10.5 months. In the patient with the adamantinoma, resection of the tumour left a 22 cm defect in the tibia. Two patients required amputation for acute local infection. Seven of the eight patients in whom tibial union was achieved were able to walk with no aids. The authors conclude that transposition of the ipsilateral fibula is a valuable component of the therapeutic armamentarium and a salvage procedure for patients with multi-operated, infected or uninfected, tibial nonunion.

One-stage treatment of chronic osteomyelitis of the proximal tibia using a pedicled vascularised double-barrel fibular flap together with a muscle flap

Although segmental bone loss together with a soft-tissue defect after debridement of a chronic osteomyelitic lesion of the tibia represents a challenging problem for the reconstructive surgeon, bone management has not usually been carried out at the time of soft-tissue coverage. In a one-stage procedure, we treated a patient who had suffered from chronic osteomyelitis of the tibia for 12 years, using a pedicled vascularised double-barrel fibular flap together with a pedicled medial gastrocnemius muscle flap, immediately after radical debridement of the osteomyelitic lesion. Bony union was obtained at 4 months. Full unprotected weight-bearing for normal walking was achieved 10 months after fibular transfer. Follow-up at 2 years showed no recurrence of the osteomyelitis.

Percutaneous bone grafting in the treatment of the delayed union and non-union of tibial fractures

The classic method of open bone grafting in the treatment of un-united tibial fractures has been associated with some complications. A novel, minimally invasive, percutaneous technique of bone grafting is described. Forty-one consecutive patients with delayed union or non-union of a tibial fracture was treated with percutaneous bone grafting from 1993 to 1999. The mean age of the patients was 41 (15-86) years. Twenty-seven patients had grade I-III open fractures. The fractures had initially been treated in a cast (n=26), external fixator (n=14) or intramedullary nail (n=1). Two patients had an earlier unsuccessful Phemister-Charnley-type bone-grafting procedure for delayed union. The mean interval from injury to percutaneous bone grafting was 21 (13-66) weeks. Thirty-seven of the 41 un-united fractures healed in 13 (10-48) weeks after the percutaneous bone grafting. The mean hospital stay was 1 day. No infections, bleeding or neural complications existed. Percutaneous bone grafting appeared to be as effective as open techniques, and possessed considerable advantages. It is safe, time saving and economical, it involves minimal trauma at the fracture site and it avoids major donor site problems.

Concomitant ipsilateral pedicled fibular transfer and free muscle flap for compound tibial defect reconstruction

Three patients with compound injuries of the lower extremities were treated with pedicle fibular grafts and a free muscle flap concomitantly. There were 1 female and 2 male patients, all of whom sustained high-energy trauma in a motor vehicle accident. The bone defect of the tibia ranged from 8 to 12 cm. The size of the soft-tissue defect ranged from 24 x 15 cm to 28 x 15 cm. All patients underwent preoperative angiography to ensure the patency of the peroneal artery and to avoid its use by risking viability of the leg. All patients were treated with an antegrade-flow pedicle fibular graft. The fibular graft was inserted as a single strut in 2 patients and as a double-barrel strut in 1 patient. The pedicle of the free muscle flap was anastomosed to the distal runoff of the fibular bone flap. All free muscle flap transfers succeeded without complication. Bone scans performed on postoperative day 7 showed viability of transferred bone. The average time to radiological union was 9 months, and the average time to full weight bearing was 12 months. Screw loosening occurred in 2 patients and osteomyelitis was noted in another patient who was treated successfully with sequestrectomy and antibiotics. Indications for this technique are a large segmental bone defect with a huge soft-tissue defect, and patency of the peroneal artery and at least one other major artery. This method provides the advantages of one-stage reconstruction, avoidance of contralateral donor site morbidity, easy control of infection, and chance for early weight bearing. When selected carefully, this technique can be considered when one wants to avoid a two-stage, two free flap transfer.

Split free flap and monofixator distraction osteogenesis for leg reconstruction

The use of a split muscle flap widens the indications of unilateral external fixation in the treatment of type IIIB open tibial fractures with large bone defects. The same frame can be used for early stabilization and for secondary distraction lengthening procedures. The use of a split flap allows an easy, safe, and painless pin migration. The combination of these techniques represents a very safe solution, especially for patients in poor general and vascular condition.

The cylindrical titanium mesh cage for treatment of a long bone segmental defect: description of a new technique and report of two cases

This report describes a new technique for treatment of a segmental defect in long bones that uses a cylindrical titanium mesh cage, in combination with cancellous bone allograft and demineralized bone matrix putty (Grafton), stabilized with a statically locked intramedullary nail. Two clinical cases of tibia defects treated with this technique are presented. At the one-year follow-up, radiographically both cases demonstrated excellent limb alignment, stability, and bony healing. Immediate full weight-bearing was initiated in each case, and early limb functional recovery was achieved. Preliminary data suggest that this technique may be a reasonable alternative to currently used methods for management of select long bone segmental defects.

Ipsilateral island fibula transfer for segmental tibial defects: antegrade and retrograde fashion

Five patients with segmental tibial defects whose contralateral fibula could not be used as a donor were treated with ipsilateral island fibular transfer in an antegrade or retrograde fashion. Antegrade-flow pedicled flaps based on the peroneal vessel as in the conventional free flap were used for the proximal or middle one-third tibial defects, whereas retrograde-flow pedicled flaps based on the communicating branch between the peroneal and posterior tibial vessels were used for the middle or distal one-third of the tibia. All patients had one of the following problems: a previously failed free flap, below-knee amputation of the opposite leg because of open tibia fracture, refusal to use the contralateral sound leg, or poor general condition to endure a lengthy operation. Four of the patients also had an associated fibular fracture on the same leg, which was ultimately used as one of the osteotomy sites. The follow-up period was from 31 to 48 months. Time to bony union ranged from 4 to 7 months. Time to full weight bearing was from 5 to 9 months after operation. All of the transferred fibulas showed hypertrophy after weight bearing. Nonunion occurred in two cases, which were treated with a long leg cast and cancellous bone graft, respectively. The limb was shorter by an average of 0.5 cm in three cases, longer by 1.1 cm in one case, and in the last case, it was uncheckable because the opposite limb was previously amputated. Limited arc of rotation was not a problem. Other disabling complications were not seen. We believe that these methods can be a valuable alternative to the contralateral free fibula flap in certain cases.

Tibial reconstruction by ipsilateral vascularized fibular transfer

Between 1979 and 1991 ipsilateral vascularized fibular transposition was performed on eight patients with segmental tibial defects following injury. We report these cases with a minimum follow-up of 2.5 years. All the tibial defects were the result of severe open fractures (Gustilo Grade III) and either bone loss or infected non-union, and ranged in size from 1 to 12 cm. The patients had an average of seven procedures and a delay of 33 months before fibular transfer. The procedure was successful in achieving fracture union in all cases, with an average time to union of 15 months (range, 5-33 months). Shortening of up to 3 cm and some residual ankle stiffness was found, but all patients were ambulating bearing full weight and six had returned to their previous occupation by their final follow-up. Only one patient had significant pain affecting function. This is a successful and relatively simple technique compared to microvascular and bone transport procedures for reconstructing segmental tibial defects with relatively avascular graft beds.