Free non-vascularized fibular strut bone graft for treatment of post-traumatic lower extremity large bone loss

Non-vascularized Fibular Autograft and Locking Plate: A Solution to the Resistant Nonunion of a Tibial Metaphyseal Fracture

The union of tibial fractures often raises concerns. In one such case, a 62-year-old female patient presented in our Emergency Room (ER) with a comminuted tibial metaphyseal fracture resulting from a traffic accident. The patient underwent three surgical procedures in the following two years. The first intervention was open reduction internal fixation (ORIF) with a plate and screws. The second intervention, which took place three months after the first surgery, addressed the union delay through implant removal and closed reduction and internal fixation (CRIF) with an antegrade intramedullary tibial nail. The third intervention addressed the implant failure and oligotrophic nonunion through the removal of the broken tibial nail and ORIF using a proximal tibia locking plate and screws, augmented with fibular shaft and reamed iliac crest autografts. We conducted frequent follow-ups with the patient and performed multiple X-rays to confirm and monitor the fracture union. At the last follow-up, two years after the last surgical intervention, imagistic investigations showed that the patient presented with fracture union, she could support her full body weight on the operated leg, and was able to walk and carry out normal daily activities. As such, we concluded that the surgical method chosen (ORIF with proximal tibia locking plate and screws, augmented with a fibula shaft strut and reamed iliac crest autograft) was a viable option to treat an aseptic oligotrophic nonunion in a high-energy comminuted tibia fracture.

A retrospective cohort study of autogenous iliac strut bone grafting in large bone defects of the lower extremity

Autogenous iliac bone graft (AIBG) is the treatment of choice for managing bone defects, and favorable results have been reported for bone defects < 5 cm in length. In large bone defects ≥ 5 cm, it is difficult to obtain good results with simple bone grafting, and other management options have drawbacks, such as long immobilization periods and high complication rates. We hypothesized that AIBG in the strut form might show favorable results in large bone defects with minimal complications. This study aimed to investigate the outcomes of strut-type AIBG and evaluate its effectiveness compared to cancellous AIBG. This retrospective study included 50 patients who underwent AIBG for bone defects at a single institution between March 2011 and April 2020. We performed corticocancellous AIBG in a strut form to manage bone defects ≥ 5 cm in the lower extremities. The strut bone was harvested along the iliac crest and grafted slightly longer than the bone defect to apply a sufficient compressive force. Demographic information and radiographic and clinical results of patients who underwent strut AIBG (Group S) were analyzed. The outcomes of union, time to union, complications, and reoperation were compared with those of patients who underwent cancellous AIBG (Group C). The study population comprised 37 men (74%) and 13 women (26%), with a mean age of 50.0 (range: 19-78). The average follow-up period was 25.6 months (12-104 months). Group S included 16 patients with a mean bone defect length of 6.8 ± 1.2 cm. In Group S, union was achieved in all patients, with an average time to union of 6.7 months. Complications occurred in four cases, all related to wound problems. Group C comprised d 34 patients with a mean defect length of 2.8 ± 1.1 cm. Complications occurred in five patients in Group C, including four soft tissue problems and one implant failure. When comparing the outcomes of Groups S and C, no significant differences were observed. AIBG is an effective and safe technique for managing bone defects. Strut AIBG can be used effectively for bone defects ≥ 5 cm in the lower extremities.

Distal Radius Reconstruction Using Proximal Non-vascularized Fibula Graft in a Patient During the Syrian Conflict: A Case Study of Treatment Outcomes

In conflict zones like Syria, accessing specialized medical care presents significant challenges. Here, we present the case of a 22-year-old female with a giant cell tumor in her distal forearm, exacerbated by limited access to healthcare due to the Syrian conflict. Despite these obstacles, we successfully performed en bloc resection and reconstructed the defect with a proximal non-vascularized fibular graft, restoring arm function. This case underscores the critical importance of adapting to adverse circumstances to deliver essential medical interventions in conflict-affected regions.

Nonvascularized fibular graft with locking screw fixation for metaphyseal bone loss of distal femur: biomechanical assessment validated by a clinical case series

BACKGROUND

The optimal modality to surgically treat significant bone loss of distal femur remains inconclusive. The objectives of the present study were to assess the mechanical performance of nonvascularized fibular graft (NVFG) with locking screw fixation in distal femur fixation construct by finite element analysis and to retrospectively describe the outcomes of the present technique in clinical cases.

METHODS

Four constructs which the fractured femur was stabilized by LCP-DF alone, dual plating, LCP-DF combined with NVFG, and LCP-DF combined with NVFG (LCP-DF-NVFG-S) with locking screw were assessed the biomechanical performance under physiological loads. For the clinical case series, 12 patients with open intercondylar fracture with metaphyseal bone loss of distal femur were operated by LCP-DF-NVFG-S. The collected data included fracture consolidation, length of NVFG, perioperative complications and objective clinical results.

RESULTS

LCP-DF-NVFG-S demonstrated lower implant equivalent von Mises stress (EQV) stress and better fracture stability than other constructs. A locking screw presented its essence in maintaining the NVFG in the required position and subsequently enhancing the fracture stability. In regard to the clinical series, all fractures were consolidated with an average duration of 27.8 weeks (range 20-32). An average NVFG length was 7.8 cm (range 6-12). No perioperative complication was demonstrated. By the Knee Society score, 1 was considered to be excellent, 9 to be good and 2 to be poor.

CONCLUSION

Based on the results of mechanical assessment and case series, LCP-DF-NVFG-S can be an effective technique in the management of metaphyseal bone loss of distal femur.

Induced membrane technique combined with a retrograde intramedullary nail for the treatment of infected bone defects of the ankle

In this study, we treated infected ankle bone defects with the induced membrane two-stage technique. The ankle was fused with a retrograde intramedullary nail in the second stage, and the aim of this study was to observe the clinical effect. We retrospectively enrolled patients with infected bone defects of the ankle admitted to our hospital between July 2016 and July 2018. In the first stage, the ankle was temporarily stabilized with a locking plate, and antibiotic bone cement was used to fill the defects after debridement. In the second stage, the plate and cement were removed, the ankle was stabilized with a retrograde nail, and tibiotalar-calcaneal fusion was performed. Then, autologous bone was used to rebuild the defects. The infection control rate, fusion success rate and complications were observed. Fifteen patients were enrolled in the study with an average follow-up of 30 months. Among them, there were 11 males and 4 females. The average bone defect length after debridement was 5.3 cm (2.1-8.7 cm). Finally, 13 patients (86.6%) achieved bone union without recurrence of infection, and 2 patients experienced recurrence after bone grafting. The average ankle-hindfoot function score (AOFAS) increased from 29.75 ± 4.37 to 81.06 ± 4.72 at the last follow-up. The induced membrane technique combined with a retrograde intramedullary nail for the treatment of infected bone defects of the ankle after thorough debridement is an effective treatment method.

Modified Masquelet technique in children

Masquelet technique is one of the modalities for the treatment of long bone defect. Using cancellous bone graft to fill the bone defect is always a concern in children due to the small size of their iliac crest and open growth plate. We reported a case of 13-year-old male who presented with gap non-union of middle third of tibia. We applied a modified Masquelet technique by using only the cortical fibular graft instead of cancellous bone to fill the space surrounded by induced membrane. Fibula was used as a nonvascularized strut graft and matched stick graft to achieve complete union. We concluded that nonvascularized fibula grafting is an easy and effective option to fill the bone defect in children in the second stage of Masquelet technique.

Calcaneal Reconstruction With Free Deep Circumflex Iliac Artery Osseocutaneous Flap Following Aggressive Benign Bone Tumor Resection

BACKGROUND

Advances in limb-salvage techniques have made total calcanectomy and primary reconstruction possible in managing calcaneal aggressive benign tumors and selected cases of intraosseous malignant tumors. However, there is still no consensus on the operative approach, oncologic margin, and the best reconstruction method to date. These 2 cases describe our experience in calcaneal reconstruction with the free deep circumflex iliac artery (DCIA) osseocutaneous flap in benign aggressive calcaneal tumors.

METHODS

We reported 2 consecutive male and female patients, with an average age of 25 years (age 19 and 31, respectively), who underwent total calcanectomy and primary calcaneal reconstruction with the free DCIA osseocutaneous flaps for calcaneal chondroblastoma and giant cell tumor. A marginal resection of the entire calcaneus through the subtalar and calcaneocuboid joints (intra-articular approach) was performed in the first case and a wide local resection leaving 1 cm normal calcaneal bone margin anterosuperiorly (intraosseous approach) was performed in the second case.

RESULTS

The follow-up period averaged 48 months. Negative oncologic margins were achieved in both cases. The first case was complicated with venous thrombosis; however, the graft remained viable after emergency reexploration. Normal foot function was restored with good solid osseous union and bony hypertrophy observed. Both patients achieved good short-term functional and aesthetic outcomes with no donor site pain or disability. No local recurrence was reported either.

CONCLUSION

Primary calcaneal reconstruction with the free DCIA osseocutaneous flap can lead to good short-term functional and aesthetic outcomes.

LEVEL OF EVIDENCE

Level IV, case series.

Use of Nonvascularized Autologous Fibular Strut Graft in the Treatment of Major Bone Defect after Periprosthetic Knee Fracture

We present the case of a patient who suffered a comminuted supracondylar periprosthetic femur fracture. The patient was an 86-year-old lady who suffered a minor fall at home and presented at our hospital with a right comminuted distal femur fracture around a total knee arthroplasty. The patient was submitted to a cruciate-sacrificing total knee replacement 6 years before at the same institution. Despite severe metaphyseal fragmentation and short distal fragment, the prosthesis was stable; thus, open fracture reduction and stabilization with internal fixation were performed. The surgical technique included the use of a nonvascularized autologous fibular strut graft as an augmentation technique in conjunction with double plating fixation. Clinically, patient presented a painless aligned knee 12 months after femur fixation, although she was not able to return to an independent level of activity. No pain involving the donor graft site was reported at the time of the most recent follow-up examination. This case study demonstrates the use of free nonvascularized autogenous fibular strut bone graft as an option to bridge major bone defects. This proved to be a relatively simple, not expensive procedure that can be done percutaneously and does not need high-quality training.

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.

A solution to the vessel shortage during free vascularized fibular grafting for reconstructing infected bone defects of the femur: Bridging with vein transplantation

PURPOSE

The present study aimed to evaluate the feasibility and clinical efficacy of bridging vein transplantation to deal with the vessel shortage during free vascularized fibular grafting for reconstructing infected bone defects of the femur.

METHODS

Twelve patients (aged 15-58 years) with infected bone defects of the femur (between 6.0 and 18.0cm) were recruited in this study. Vacuum sealing drainage were applied after extensive debridement of the infected bone defects and irrigated with 0.9% sodium chloride solution for 1-2 weeks. After the drainage was clear and the focal infections were controlled, the free vascularized fibula was harvested for reconstructing the femoral bone defects. The vascularized fibula was grafted and fixated appropriately at the recipient site. The autogenous great saphenous vein was harvested, one end was anastomosed and bridged the vascular pedicles of the fibular grafts, and the other end anastomosed the artery and/or the vein in the recipient healthy site.

RESULTS

Mean length of vein transplantation with vascularized fibular graft was 10.2 cm (range 7-15cm). All patients had good radiological healing without recorded nonunion or malunion. No patient developed deep infection or implant failure. Primary bone healing was achieved in 10 patients; however, 2 grafted fibular formed pseudarthrosis with the recipient femoral and then healed after a secondary surgery. One patient suffered from graft stress fracture after bone healing and healed after external fixation. After the mean follow-up of 30 months (9-72 months), according to the Enneking scoring system, clinical outcomes were excellent in 7 patients, good in 4 and fair in one. The functional recovery rate of the lesion limb was 89.4%.

CONCLUSIONS

Free vascularized fibular graft with vein transplantation bridged vascular pedicle can effectively repair the infected bone, improve blood supply to the bone defect site, and help control infection. It is a feasible and effective treatment for infected bone defects of the femur with poor soft tissue conditions, or blood supply vessel shortage.

Reconstruction of the distal radius with non-vascularised fibular graft after resection of giant cell tumour of bone

PURPOSE

To evaluate outcomes of wide resection and reconstruction of the distal radius with non-vascularised autogenous fibular grafts for giant cell tumour (GCT) of bone.

METHODS

Medical records of 7 men and 5 women aged 22 to 47 (mean, 31) years who underwent wide resection of the distal radius and reconstruction with non-vascularised autogenous fibular grafts for GCT of bone were reviewed. The mean length of the resected radius was 9 (range, 7-11) cm. The ipsilateral proximal fibula with a small portion of attached ligament was harvested. The articular surface of the graft was fixed to the scapholunate articular surface by Kirschner wires, and the ligament of the fibular head was sutured to the carpal ligaments. The graft was fixed to the proximal radius with a small dynamic compression plate. Iliac cancellous bone graft was added. Pain, instability, and functional status were assessed. Wrist joint movements were measured using a goniometer. The grip strength was measured. The operated and contralateral sides were compared.

RESULTS

The mean follow-up was 24 (range, 20-27) months. All patients achieved radiological union after a mean of 16 (range, 14-20) weeks. The mean active range of movement in the operated wrists was 32º dorsiflexion, 38º palmar flexion, 15º radial deviations, 12º ulnar deviations, 50º supination, and 60º pronation. Compared with the contralateral wrists, the operated wrists regained 60% of the function, with satisfactory grip strength, and normal finger and thumb movements and hand sensation. No patient had recurrence after 2 years. Two patients had minor dorsal subluxation, which was resolved with a wrist brace. Three patients had superficial infection, which was resolved with intravenous antibiotics and dressings. Two patients had peroneal nerve palsy, which recovered completely in 12 weeks.

CONCLUSION

Non-vascularised fibular grafts for reconstruction of the distal radius after resection of a GCT of bone achieved good cosmetic and functional outcomes.