Role of vascularized bone grafts in lower extremity osteomyelitis

Free Vacularized Fibula Flap for Septic Bone Defects of the Lower Limb

Free fibula flap (FFF) is one of the reconstructive techniques to treat bone defects, although in septic conditions there are some limitations that have made it less popular. We present our experience with FFF for the reconstruction of lower limb infectious bone defects. From September 2015 to January 2020, 10 patients underwent reconstruction with FFF without rigid internal fixation of septic bone defects of the lower extremities. Demographic, clinical, and operative data were retrospectively collected. All the flaps survived and consolidated. The only major complication was a stress fracture of a fibula that required osteosynthesis. Median time to consolidation and full weight-bearing was 2.5 and 9.8 months, respectively. Bipedal gating was achieved in all the patients, 7 of them without walking aids. Despite it has some limitations and technical difficulties, in our experience FFF is an effective and reliable option in the reconstruction of septic bone defects of the lower limb.

Debridement-Reconstruction-Docking Management System Versus Ilizarov Technique for Lower-Extremity Osteomyelitis

BACKGROUND

Osteomyelitis causes marked disability and is one of the most challenging diseases for orthopaedists to treat because of the considerable rate of infection recurrence. In this study, we proposed and assessed the debridement-reconstruction-docking (DRD) system for the treatment of lower-extremity osteomyelitis. This procedure comprises 3 surgical stages and 2 preoperative assessments; namely, pre-debridement assessment, debridement, pre-reconstruction assessment, reconstruction, and docking-site management. We evaluated the use of the DRD system compared with the Ilizarov technique, which is defined as a 1-stage debridement, osteotomy, and bone transport.

METHODS

This retrospective cohort included 289 patients who underwent either DRD or the Ilizarov technique for the treatment of lower-extremity osteomyelitis at a single institution between January 2013 and February 2021 and who met the eligibility criteria. The primary outcome was the rate of infection recurrence. Secondary outcomes included the external fixator index (EFI), refracture rate, and the Paley classification for osseous and functional results. An inverse-probability-weighted regression adjustment model was utilized to estimate the effect of the DRD system and Ilizarov technique on the treatment of lower-extremity osteomyelitis.

RESULTS

A total of 131 and 158 patients underwent DRD or the Ilizarov technique, respectively. The inverse-probability-weighted regression adjustment model suggested that DRD was associated with a significant reduction in infection recurrence (risk ratio [RR], 0.26; 95% confidence interval [CI], 0.13 to 0.50; p < 0.001) and EFI (-6.9 days/cm, 95% CI; -8.3 to -5.5; p < 0.001). Patients in the DRD group had better Paley functional results than those in the Ilizarov group (ridit score, 0.55 versus 0.45; p < 0.001). There was no significant difference between the 2 groups in the rate of refracture (RR, 0.87; 95% CI, 0.42 to 1.79; p = 0.71) and Paley osseous results (ridit score, 0.51 versus 0.49; p = 0.39).

CONCLUSIONS

In this balanced retrospective cohort of patients with lower-extremity osteomyelitis, the use of the DRD system was associated with a reduced rate of infection recurrence, a lower EFI, and better Paley functional results compared with the use of the Ilizarov technique.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Osteocutaneous superficial circumflex iliac perforator flap for the lower extremity bone and soft tissue reconstruction with perforator-to-perforator anastomosis after radical debridement of tibia osteomyelitis: A case report

Reconstruction of soft tissue and bone defects in tibia chronic osteomyelitis is challenging and often managed by free flap with bone graft. However, the use of osteocutaneous free flap combined with perforator-to-perforator anastomosis has not been reported. We report the case of a 62-year-old man presenting with soft tissue and bone defects with right tibial chronic osteomyelitis, which was successfully treated with an osteocutaneous superficial circumflex iliac perforator (SCIP) flap with perforator-to-perforator anastomosis. After radical debridement and excision of the sequestrum, a 17 × 10-cm skin defect and a 4 × 3-cm bone defect remained. An osteocutaneous SCIP flap, containing a 16 × 9-cm skin paddle and 4 × 2-cm iliac bone, was transferred and anastomosed to the posterior tibial perforator in an end-to-end fashion. An artificial dermis was placed to cover the soft tissue. At 1 week postoperatively, the artificial dermis was partially infected, which required small debridement. Full weight-bearing was permitted 5 weeks postoperatively, and the patient walked independently. No evidence of recurrence of osteomyelitis or skin ulcers was observed at 15 months postoperatively. Therefore, osteocutaneous SCIP flap with perforator-to-perforator anastomosis may be a potential alternative treatment for soft tissue and bone defects after radical debridement of tibia osteomyelitis.

Supine harvest of vascularised scapular bone grafts-Anatomical study and clinical application

BACKGROUND

We report our findings from an anatomical study on harvest of a vascularized scapular bone graft from a supine position. A clinical case is presented to illustrate the operative approach.

METHODS

Twenty cadaveric hemibody specimens were dissected in the supine position. Outcomes of interest included the characterization of anatomical variants and measurements of pedicle length. Specific measurements included distance from the origin of the subscapular artery (at the axillary artery) to the branch point of the angular artery from the thoracodorsal artery or serratus branch and the length of the angular branch proper.

RESULTS

There are five reported anatomic variations regarding the origin of the angular branch of the thoracodorsal artery. In our cadaveric cohort only four known types were seen, and an entirely new variant was encountered. Six cadaveric dissections exhibited a type 3 configuration, six were type 1, four were type 2, three were type 4, and one was a previously unreported variant we termed a type 6, with multiple angular artery branches originating from the posterior branch of the thoracodorsal. The mean distance between the origin of the subscapular artery and the takeoff of the angular branch was 6.3 ± 2.0 cm. The mean length of the angular branch was 3.7 ± 1.4 cm.

CONCLUSIONS

Supine positioning for harvest of a vascularized bone graft obviates the need for an intraoperative position change and allows reconstruction of bone defects in the hand and upper extremity within a single surgical field.

Ipsilateral vascularised fibula with external locking plate for treatment of massive tibial bone defects

INTRODUCTION

Management of massive tibial bone defects remains challenging for orthopaedic doctors. This study aimed to ascertain the viability and reliability of utilising an ipsilateral vascularised fibula with an external locking plate for the difficult situation.

MATERIALS AND METHODS

Between January 2012 and December 2017, eight patients (7 men) with a mean age of 32.3 (19-54) years who presented with massive tibial bone defects were treated using the described technique. The mean length of the bone defect was 12.4 (8-20) cm. The patients were assessed for clinical and radiographic results, hypertrophy of the fibular graft with DeBoer and Wood's method, and SF-36 functional score.

RESULTS

The mean follow-up period was 40.3 (26-60) months. The average time for union was 5.6 (3-8) months. At the final follow-up, all patients had fully united grafts and walked without restriction. The mean graft hypertrophy index was 98.2 %. The SF-36 score was > 75 % in five patients, and 50-75 % in three. Three patients had a leg length discrepancy of > 1.5 cm. Two patients with equinus foot were treated using tibiotalocalcaneal fusion. Three patients had pin-tract infections. Four screws were broken in two cases.

CONCLUSION

Ipsilateral vascularised fibular transfer combined with an external locking plate as a definitive external fixator provides a simple and comfortable treatment, and appropriate mechanical loading and vascularisation of the graft site to achieve hypertrophy of the fibular graft. Hence, our technique can serve as a valuable alternative for the treatment of massive tibial bone defects.

Management of critical-sized bone defects in the treatment of fracture-related infection: a systematic review and pooled analysis

PURPOSE

This systematic review determined the reported treatment strategies, their individual success rates, and other outcome parameters in the management of critical-sized bone defects in fracture-related infection (FRI) patients between 1990 and 2018.

METHODS

A systematic literature search on treatment and outcome of critical-sized bone defects in FRI was performed. Treatment strategies identified were, autologous cancellous grafts, autologous cancellous grafts combined with local antibiotics, the induced membrane technique, vascularized grafts, Ilizarov bone transport, and bone transport combined with local antibiotics. Outcomes were bone healing and infection eradication after primary surgical protocol and recurrence of FRI and amputations at the end of study period.

RESULTS

Fifty studies were included, describing 1530 patients, the tibia was affected in 82%. Mean age was 40 years (range 6-80), with predominantly male subjects (79%). Mean duration of infection was 17 months (range 1-624) and mean follow-up 51 months (range 6-126). After initial protocolized treatment, FRI was cured in 83% (95% CI 79-87) of all cases, increasing to 94% (95% CI 92-96) at the end of each individual study. Recurrence of infection was seen in 8% (95% CI 6-11) and amputation in 3% (95% CI 2-3). Final outcomes overlapped across treatment strategies.

CONCLUSION

Results should be interpreted with caution due to the retrospective and observational design of most studies, the lack of clear classification systems, incomplete data reports, potential underreporting of adverse outcomes, and heterogeneity in patient series. A consensus on classification, treatment protocols, and outcome is needed to improve reliability of future studies.

The influence of biomechanical stability on bone healing and fracture-related infection: the legacy of Stephan Perren

Bone healing is a complicated process of tissue regeneration that is influenced by multiple biological and biomechanical processes. In a minority of cases, these physiological processes are complicated by issues such as nonunion and/or fracture-related infection (FRI). Based on a select few in vivo experimental animal studies, construct stability is considered an important factor influencing both prevention and treatment of FRI. Stephan Perren played a pivotal role in the evolution of our current understanding of the critical relationship between biomechanics, fracture healing and infection. Furthermore, his concept of strain theory and the process of fracture healing is familiar to several generations of surgeons and has influenced implant development and design for the past 50 years. In this review we describe the role of biomechanical stability on fracture healing, and provide a detailed analysis of the preclinical studies addressing this in the context of FRI. Furthermore, we demonstrate how Perren's concepts of stability are still applied to current surgical techniques to aid in the prevention and treatment of FRI. Finally, we highlight the key knowledge gaps in the underlying basic research literature that need to be addressed as we continue to optimize patient care.

Fracture blisters: pathophysiology and management

Open fractures are considered an orthopaedic emergency due to the severe soft tissue disruption that might potentially lead to devastating complications. On the other hand, closed fractures, and especially those resulting from high-energy mechanisms, are also often accompanied by severe soft tissue trauma. Soft tissue envelope compromise can have a detrimental effect on the final outcome of the patients. Fracture blisters in particular, develop as a sign of significant local tissue trauma and appear in a time period between 6 to 72 hours post-injury. They can delay the definitive fracture treatment for a considerable amount of time and at the same time they also increase the risk for post-operative wound complications. Awareness of fracture blisters pathophysiology and their management options are crucial for orthopaedic surgeons, in order to achieve a favorable clinical outcome. In the herein study we present a concise synopsis of the pathophysiology pathways and management options of fracture blisters.

Treatment options for infected bone defects in the lower extremities: free vascularized fibular graft or Ilizarov bone transport?

Abstract

Objective

The objective was to explore the relative indications of free vascularized fibular graft (FVFG) and Ilizarov bone transport (IBT) in the treatment of infected bone defects of lower extremities via comparative analysis on the clinical characteristics and efficacies.

Methods

The clinical data of 66 cases with post-traumatic infected bone defects of the lower extremities who underwent FVFG (n = 23) or IBT (n = 43) from July 2014 to June 2018 were retrieved and retrospectively analyzed. Clinical characteristics, operation time, and intraoperative blood loss were statistically compared between two groups. Specifically, the clinical efficacies of two methods were statistically evaluated according to the external fixation time/index, recurrence rate of deep infection, incidence of complications, the times of reoperation, and final functional score of the affected extremities.

Results

Gender, age, cause of injury, Gustilo grade of initial injury, proportion of complicated injuries in other parts of the affected extremities, and numbers of femoral/tibial defect cases did not differ significantly between treatment groups, while infection site distribution after debridement (shaft/metaphysis) differed moderately, with metaphysis infection little more frequent in the FVFG group (P = 0.068). Femoral/tibial defect length was longer in the FVFG group (9.96 ± 2.27 vs. 8.74 ± 2.52 cm, P = 0.014). More patients in the FVFG group presented with moderate or complex wounds with soft-tissue defects. FVFG treatment required a longer surgical time (6.60 ± 1.34 vs. 3.12 ± 0.99 h) and resulted in greater intraoperative blood loss (873.91 ± 183.94 vs. 386.08 ± 131.98 ml; both P < 0.05) than the IBT group, while average follow-up time, recurrence rate of postoperative osteomyelitis, degree of bony union, and final functional scores did not differ between treatment groups. However, FVFG required a shorter external fixation time (7.04 ± 1.72 vs. 13.16 ± 2.92 months), yielded a lower external fixation index (0.73 ± 0.28 vs. 1.55 ± 0.28), and resulted in a lower incidence of postoperative complications (0.87 ± 0.76 vs. 2.21±1.78, times/case, P < 0.05). The times of reoperation in the two groups did not differ (0.78 ± 0.60 vs. 0.98 ± 0.99 times/case, P = 0.615).

Conclusion

Both FVFG and IBT are effective methods for repairing and reconstructing infected bone defects of the lower extremities, with unique advantages and limitations. Generally, FVFG is recommended for patients with soft tissue defects, bone defects adjacent to joints, large bone defects (particularly monocortical defects), and those who can tolerate microsurgery.

Management of bone defects due to infected non-union or chronic osteomyelitis with autologous non-vascularized free fibular grafts

OBJECTIVES

Bone defects as a result of infected non-union or chronic osteomyelitis are difficult to manage. The purpose of this study was to present the results of treatment of bone defects of < 6 cm due to a previous infected non-union or chronic osteomyelitis with autologous non-vascularized fibular grafts in a 2-stage surgery.

PATIENTS AND METHODS

The records of patients who were treated with autologous non-vascularized fibular grafts for bone defects of < 6 cm due to a previous infected non-union or chronic osteomyelitis between 2008 and 2013 were retrospectively reviewed. Primary complete bone union was the primary outcome. Time until fracture union, and return to normal daily activities or previous work were recorded. Radiographs were evaluated for graft hypertrophy as well as for stress fracture and other complications.

RESULTS

A total of 27 cases were included. The mean length of the bone defects was 4.4 cm (range 2 - 6 cm). Complete union and healing occurred in 25/27 patients (primary success rate of 92.6%). Non-union was present in two patients with suboptimal soft tissue condition 10 months after surgery, one patient was subsequently treated with a vascularized free fibular graft from the contralateral fibula, and the other patient was treated with distraction osteogenesis, bone union was achieved after the second surgery. Average time to return to normal daily activity after surgery was 7.82 months (6 ~ 11 months). Graft hypertrophy occurred in 15 cases 15/25 (60%) two years post-surgery. There were no other surgical or postoperative complications.

CONCLUSIONS

With careful evaluation of soft-tissue condition surrounding bone defect, management of infected bone defects with autologous non-vascularized fibular grafts technique has a high success rate with few complications.

Investigating clinical characteristics and prognostic factors in patients with chronic osteomyelitis of humerus

Background

Chronic osteomyelitis in the humerus, which has complex neuroanatomy and a good soft tissue envelope, represents a unique clinical challenge. However, there are relatively few related studies in the literature. This article retrospectively reviewed a large case series with the aims of sharing our management experiences and further determining factors associated with the outcomes.

Methods

Twenty-eight consecutive adult patients with a mean age of 36 years were identified by reviewing the osteomyelitis database of our clinic centre. The database was used to prospectively identify all osteomyelitis cases between 2013 and 2017, and all data then was retrospectively analysed.

Results

The mean follow-up period was 35 months (range 24–60). The aetiology was trauma in 43% (12) of the patients and haematogenous in 57% (16) of the patients, and Staphylococcus aureus was a solitary agent in 50% (14) of the patients. Host-type (Cierny’s classification) was IA in 8, IIIB in 11 and IVB in 9 patients. All patients required debridement followed by the placement of a temporary antibiotic-impregnated cement spacer (rod). Seventeen patients received a cement-coated plate for internal fixation after debridement, and 13 patients needed bone grafts when the spacer was staged removed. All patients attained an infection-free bone healing state at the final follow-up. The final average DASH (disabilities of the arm, shoulder and hand) score was 18.14 ± 5.39, while 6 patients (two developed traumatic olecranarthritis, four developed radial nerve injuries) showed the lowest levels of limb function (p = 0.000) and were unemployed. Three patients (type I; significant difference between type I versus type III and type IV patients, p < 0.05) experienced recurrence after debridement and underwent a second revision, which was not related to the bone graft (p = 0.226) or plate fixation (p = 0.050).

Conclusions

Humeral chronic osteomyelitis can be treated with general surgery and anti-infective therapy; medullary (type I) infection presents a challenge, and the antibiotic-coated cement plate provides favourable fixation without increasing recurrence of infections. Clinicians should be aware of potential iatrogenic nerve injuries when treating these patients with complicated cases, and an experienced surgeon may improve the outcome.

L-shaped corticotomy with bone flap sliding in the management of chronic tibial osteomyelitis: surgical technique and clinical results

BACKGROUND

We described the use of the technique of L-shaped corticotomy with bone flap sliding to treat chronic osteomyelitis of the tibia in eight patients and presented the preliminary results.

METHODS

L-shaped corticotomy with bone flap sliding was performed in eight patients between 2007 and 2014. All patients had chronic tibial osteomyelitis involving the anterior tibial cortex with intact and healthy posterior cortex. The size of bone defects following sequestrectomy and radical debridement was 8.1 cm on average. One patient required a latissimus dorsi flap. The mean follow-up period was 34.1 months. The functional and bone results were evaluated at the time of the latest follow-up.

RESULTS

Complete eradication of infection and union of docking sites were achieved in all patients. Functional results were judged excellent in five patients and good in the rest three patients. Bone results were graded as excellent in all cases. The mean external fixation time was 169.9 days and external fixation index was 21.2 days/cm. Pain was the most common complaint that we faced during lengthening. Pin tract infections were observed in four patients, and mild transient stiffness of ankle joint was observed in three patients.

CONCLUSIONS

We have found this technique to be safe and effective, significantly diminishing the external fixation index. The earlier removal of the external fixator may result in increased patient comfort, a reduced complication rate, and a rapid and convenient rehabilitation.

Insights into treatment and outcome of fracture-related infection: a systematic literature review

INTRODUCTION

Standardized guidelines for treatment of fracture-related infection (FRI) are lacking. Worldwide many treatment protocols are used with variable success rates. Awareness on the need of standardized, evidence-based guidelines has increased in recent years. This systematic literature review gives an overview of available diagnostic criteria, classifications, treatment protocols, and related outcome measurements for surgically treated FRI patients.

METHODS

A comprehensive search was performed in all scientific literature since 1990. Studies in English that described surgical patient series for treatment of FRI were included. Data were collected on diagnostic criteria for FRI, classifications used, surgical treatments, follow-up protocols, and overall outcome. A systematic review was performed according to the PRISMA statement. Proportions and weighted means were calculated.

RESULTS

The search yielded 2051 studies. Ninety-three studies were suitable for inclusion, describing 3701 patients (3711 fractures) with complex FRI. The population consisted predominantly of male patients (77%), with the tibia being the most commonly affected bone (64%), and a mean of three previous operations per patient. Forty-three (46%) studies described FRI at one specific location. Only one study (1%) used a standardized definition for infection. A total of nine different classifications were used to guide treatment protocols, of which Cierny and Mader was used most often (36%). Eighteen (19%) studies used a one-stage, 50 (54%) a two-stage, and seven (8%) a three-stage surgical treatment protocol. Ten studies (11%) used mixed protocols. Antibiotic protocols varied widely between studies. A multidisciplinary approach was mentioned in only 12 (13%) studies.

CONCLUSIONS

This extensive literature review shows a lack of standardized guidelines with respect to diagnosis and treatment of FRI, which mimics the situation for prosthetic joint infection identified many years ago. Internationally accepted guidelines are urgently required to improve the quality of care for patients suffering from this significant complication.

Outcomes of cement beads and cement spacers in the treatment of bone defects associated with post-traumatic osteomyelitis

Background

Cement spacers (Masquelet technique) have traditionally been used for the treatment of segmental bone defects. However, no reports have used cement spacers for the treatment of small/partial segmental bone defects associated with osteomyelitis and compared the outcomes with cement beads.

Methods

We retrospectively analysed 40 patients with post-traumatic osteomyelitis of the tibia who underwent treatment, which was performed in two stages. In the first stage, thorough debridement was performed, and bone defects were filled with either antibiotic-impregnated cement beads (bead group, 18 patients) or spacers (spacer group, 22 patients). In the second stage, the cement beads or spacers were removed (for the spacer group, the induced membrane formed by the spacer was preserved) and the bone defects were filled with cancellous autografts.

Results

All patients in the bead group had small/partial segmental bone defects after debridement, while 3 patients in the spacer group had large/segmental bone defects.

The mean volume of bone defects of the spacer group (40.4 cm³) was significantly larger than that of the bead group (32.4 cm³). The infection control rate (88.9%,16/18 vs 90.9%, 20/22), bone healing time (8.5 months vs 7.5 months) and complication rates (22.2%, 4/18 vs 27.2%, 6/22) were comparable between bead group and spacer group.

Conclusion

The results of this study suggest that cement spacers may have an infection control rate comparable to cement beads in the treatment of bone defects associated with post-traumatic osteomyelitis. Furthermore, cement spacers could be used for the reconstruction of small/partial segmental bone defects as well as for large/segmental bone defects, whereas cement beads were not suitable for the reconstruction of large/segmental bone defects.

Three-stage treatment protocol for recalcitrant distal femoral nonunion

INTRODUCTION

In this study, we proposed a three-stage treatment protocol for recalcitrant distal femoral nonunion and aimed to analyze the clinical results.

MATERIALS AND METHODS

We retrospective reviewed 12 consecutive patients with recalcitrant distal femoral nonunion undergoing our three-stage treatment protocol from January 2010 to December 2014 in our institute. The three-stage treatment protocol comprised debridement of the nonunion site, lengthening to eliminate leg length discrepancy, deformity correction, stabilization with a locked plate, filling of the defect with cement spacer for inducing membrane formation, and bone reconstruction using a cancellous bone autograft (Masquelet technique) or free vascularized fibular bone graft. The bone union time, wound complication, lower limbs alignment, amount of lengthening, knee range of motion, and functional outcomes were evaluated.

RESULTS

Osseous union with angular deformity <5° and leg length discrepancy <1 cm were achieved in all the patients. The average amount of lengthening was 5.88 cm (range 3.5-12 cm). Excellent or good outcomes were obtained in 9 patients.

CONCLUSIONS

Although the current study involved only a small number of patients and the intervention comprised three stages, we believe that such a protocol may be a valuable alternative for the treatment of recalcitrant distal femoral nonunion.

Two stage management of Cierny-Mader type IV chronic osteomyelitis of the long bones

INTRODUCTION

Cierny-Mader (C-M) type IV chronic osteomyelitis represents a complex clinical challenge with permeation of extensive bone and soft tissue involvement. Aggressive debridement through viable tissue margin includes en bloc resection improves the odds of eradication of infection, which creates large bone and soft tissue loss in treating this type of osteomyelitis. The potentially large defects increase reconstruction problems with traditional reconstruction technique. The newly staged induced membrane technique presents length-independent, potential as an alternative reconstruction method for segmental bone defects due to type IV chronic osteomyelitis. The purpose of this study was to assess the result and related factors of C-M type IV chronic osteomyelitis treated with staged methods of aggressive debridement and induced membrane technique.

METHODS

From January 2012 to January 2014, 36 consecutive adult patients of C-M type IV chronic osteomyelitis were treated by this staged method in our clinical center with a minimum of 2-years follow-up. The clinical and imaging results were retrospectively analyzed.

RESULTS

Five patients had a second debridement and eight needed a local flap transfer to cover the wound in the first stage. Patients formed a mean of 5.5cm (range: 2-10.9) segmental bone defect; Sixteen patients had autograft and twenty had autograft mixed allograft in the second stage. The mean follow-up time was 29.5 months (range: 24-45). No patients required amputation. Bone union was achieved in all patients. Clinical eradication of osteomyelitis was achieved in 35 (97%) patients, 35 (97%) patients were able to walk independently, and 31patients (86%) returned to work. Patients returned to a mean of 82% (46.3%-100%) lower extremity function. Bone union time was not dependent on the length of bone defect, but associated with the infection site (p=0.005) and age (p=0.005).

CONCLUSIONS

Staged methods of aggressive debridement and induced membrane technique seems to be a simple, reliable and effective for the treatment of C-M type IV chronic osteomyelitis. Advanced age and poor soft tissue envelope may have adverse affects and are relative contraindications. The combined assessment and management of such patients with a plastic surgeon are advocated.

Do stress fractures induce hypertrophy of the grafted fibula? A report of three cases received free vascularized fibular graft treatment for tibial defects

The presence of large segmental defects of the diaphyseal bone is challenging for orthopedic surgeons. Free vascularized fibular grafting (FVFG) is considered to be a reliable reconstructive procedure. Stress fractures are a common complication following this surgery, and hypertrophy is the main physiological change of the grafted fibula. The exact mechanism of hypertrophy is not completely known. To the best of our knowledge, no studies have examined the possible relationship between stress fractures and hypertrophy. We herein report three cases of patients underwent FVFG. Two of them developed stress fractures and significant hypertrophy, while the remaining patient developed neither stress fractures nor significant hypertrophy. This phenomenon indicates that a relationship may exist between stress fractures and hypertrophy of the grafted fibula, specifically, that the presence of a stress fracture may initiate the process of hypertrophy.

Pedicled fibular flap for reconstruction of composite defects in foot

INTRODUCTION

Reconstruction of complex injuries involving bone and soft-tissue in foot remains a tough challenge for surgeons. The free fibular flap is a popular flap for treating these composite defects. However, complications caused by microvascular anastomoses are not uncommon. Herein, we designed a pedicled fibular flap elevated in the ipsilateral leg for reconstruction of multiple defects in foot.

METHODS

From July 2005 to April 2013, four patients with composite defects in foot were treated by pedicled fibular flaps. The defects were located in the first metatarsal bone and medial cuneiform bone in two patients, in the fourth metatarsal bone in one patient, and in the second to fourth metatarsal bones in one patient. The size of soft-tissue defects ranged from 10×7 cm to 15×7 cm, and the length of bone defects ranged from 6 to 8 cm.

RESULTS

The length of fibular grafts ranged from 7 to 8.5 cm, and the size of skin flaps ranged from 11×8 cm to 16×8 cm. All flaps survived completely. Complications occurred in two patients. One suffered moderate venous congestion and the flap survived without intervention. The other one sustained re-infection. Debridement was performed and the wound healed uneventfully. Follow-up ranged from 8 to 32 months. Bone union occurred at an average of 12 weeks, and the skin flaps showed good cosmetic results. No serous donor-site complications occurred.

CONCLUSION

The pedicled fibular flap transfer could avoid anastomosis complications and preserve healthy limb. It is a good option for reconstruction of complex defects in foot.

Single-stage anterior debridement and fibular allograft implantation followed by posterior instrumentation for complicated infectious spondylitis: report of 20 cases and review of the literature

Complicated infectious spondylitis is an infrequent infection with severe spinal destruction, and is indicated for combined anterior and posterior surgeries. Staged debridement and subsequent reconstruction is advocated in the literature. The purpose of this study is to evaluate the feasibility and clinical outcome of patients who underwent single-stage combined anterior debridement and fibular allograft implantation followed by supplemental posterior fixation for complicated infectious spondylitis. We retrospectively reviewed the medical records of 20 patients who underwent single-stage combined anterior and posterior surgeries for complicated infectious spondylitis from January 2005 to December 2010. Complicated infectious spondylitis was defined as at least 1 vertebral osteomyelitis with pathological fracture or severe bony destruction and adjacent discitis, based on imaging studies. The severity of the neurological status was evaluated using the Frankel scale. The clinical outcomes were assessed by careful physical examination and regular serological tests to determine the visual analog scale (VAS) score and Macnab criteria. Correction of the sagittal Cobb angle on radiography was also compared before and after surgery. The Wilcoxon signed-rank test was used to analyze patient surgical prognosis and radiological findings. All patients with complicated infectious spondylitis were successfully treated by single-stage combined anterior and posterior surgeries. No patients experienced neurologic deterioration. The average VAS score was 7.8 before surgery and significantly decreased to 2.1 at discharge. Three patients had excellent outcomes and 17 had good outcomes, based on Macnab criteria. The average length of the allograft for reconstruction was 64.0 mm. Kyphotic deformity improved in all patients, with an average correction angle of 13.4°. There was no implant breakage or allograft dislodgement during at least 36 months of follow-up. Single-stage anterior debridement and fibular allograft implantation followed by posterior pedicle screw instrumentation provide immediate stability, satisfactory alignment, and successful infection control. Fibular allograft implantation seems to be a good alternative for anterior reconstruction; it can proceed to bony incorporation and avoids donor site morbidity.

Management of upper limb bone defects using free vascularized osteoseptocutaneous fibular bone graft

Sixteen patients (11 men and 5 women), who formed the basis of the study, underwent surgery in the Hand and Reconstruction Microsurgical Unit, Orthopedic Department, Sohag Faculty of Medicine, from January 2001 to January 2009.The right side was involved in 7 cases and the left side in 9 cases. Average age was 35.2 years. The causes of bone defects were infected nonunion of both bone forearms in 5 cases, infected nonunion of the middle part of radius in 4 cases, posttraumatic bone loss of distal radius in 4 cases, and tumor of shaft humerus in 3 cases (aneurysmal bone cyst in 1 and osteosarcoma in 2 patients).The principle of treatment was debridement and excision of either infected unhealthy bone or tumor tissues with wide safety margin.The average bone defect was 8 cm (range, 6-14 cm). The defect was bridged by osteoseptocutaneous vascularized fibular bone graft. The donor bone was the right fibula in 7 cases and the left fibula in 10 cases. Two grafts were used in 1 patient because of soft tissue injuries, which included the peroneal vessels during osteotomy. The vascularized fibula was fixed by small dynamic compression plate. The operative time ranged between 7 and 11 hours. Blood transfusion was indicated in all the cases and its average transfusion was 1000 mL. The average follow-up was 84 months. Bone union was ultimately obtained in 15 patients except 1 who had failure of the graft. Arthrodesis of the distal ulna with the wrist joint was done during the follow-up. Arthrodesis of the wrist joint was also performed for 1 patient who had loss of carpal bones, distal radius, and wrist and finger extensors. The average time for union was 3.5 months. The hand function was normal in all cases. Stress fracture and fibular donor-site morbidity did not occur in this series. Neither shoulders nor elbows were affected postoperatively. There was no recurrence for either infection or tumor.

Reconstruction of bone defects after osteomyelitis with nonvascularized fibular graft: a retrospective study in twenty-six children

BACKGROUND

Persistent infection, soft-tissue fibrosis, and damage to periosteum compound the treatment of children with a bone defect following osteomyelitis. We report on a series of twenty-six patients treated with nonvascularized fibular graft and intramedullary fixation.

METHODS

The series included eleven boys and fifteen girls (mean age, 6.8 years; range, three to twelve years) with gap nonunion after osteomyelitis. Initial treatment involved thorough debridement and sequestrectomy. When the infection was quiescent as indicated by inflammatory parameters, nonvascular fibular grafting with intramedullary Kirschner wire fixation (with or without additional external fixation) was performed. The time to union was noted, and a subgroup analysis was performed to correlate the size of the bone defect with the time to union.

RESULTS

The mean duration of follow-up was 3.02 ± 0.74 years (range, 1.3 to 4.2 years), and the mean time to union was 38.76 ± 12.02 weeks (range, fifteen to sixty weeks). There was a weak positive correlation between the time to union and the preoperative bone defect size (Pearson correlation coefficient, 0.699). The mean time to union was 31.7 ± 11.5 weeks for a defect of <4 cm, 36.6 ± 9 weeks for a defect of 4 to 6 cm, and 51 ± 6.7 weeks for a defect of >6 cm. Delayed union was seen at one end of the fibular graft in four (15%) of the patients and was treated with plate fixation. One patient had recurrence of infection. Limb-length discrepancy (range, 2 to 5 cm) was seen in all patients in whom the lower limb was involved and was treated with a shoe lift.

CONCLUSIONS

This series illustrates the potential benefits of staged sequestrectomy and nonvascular fibular grafting for the treatment of gap nonunion following osteomyelitis in children. The procedure is simple, does not require specialized training or equipment, and has a low complication rate.

Treatment algorithms for chronic osteomyelitis

BACKGROUND

Osteomyelitis was described many years ago but is still incompletely understood. Its exogenously acquired form is likely to become more common as the population ages. We discuss biofilm formation as a clinically relevant pathophysiological model and present current recommendations for the treatment of osteomyelitis.

METHODS

We selectively searched the PubMed and Cochrane databases for articles on the treatment of chronic osteomyelitis with local and systemic antibiotics and with surgery. The biofilm hypothesis is discussed in the light of the current literature.

RESULTS

There is still no consensus on either the definition of osteomyelitis or the criteria for its diagnosis. Most of the published studies cannot be compared with one another, and there is a lack of scientific evidence to guide treatment. The therapeutic recommendations are, therefore, based on the findings of individual studies and on current textbooks. There are two approaches to treatment, with either curative or palliative intent; surgery is now the most important treatment modality in both. In addition to surgery, antibiotics must also be given, with the choice of agent determined by the sensitivity spectrum of the pathogen.

CONCLUSION

Surgery combined with anti-infective chemotherapy leads to long-lasting containment of infection in 70% to 90% of cases. Suitable drugs are not yet available for the eradication of biofilm-producing bacteria.

Free vascularised fibular graft for reconstruction of defects of the lower limb after resection of tumour

We describe a retrospective review of 38 cases of reconstruction following resection of the metaphysiodiaphysis of the lower limb for malignant bone tumours using free vascularised fibular grafts. The mean follow-up was for 7.6 years (0.4 to 18.4). The mean Musculoskeletal Tumor Society score was 27.2 (20 to 30). The score was significantly higher when the graft was carried out in a one-stage procedure after resection of the tumour rather than in two stages. Bony union was achieved in 89% of the cases. The overall mean time to union was 1.7 years (0.2 to 10.3). Free vascularised fibular transfer is a major operation with frequent, but preventable, complications which allows salvage of the limb with satisfactory functional results.

Treatment for large skeletal defects by free vascularized fibular graft combined with locking plate

BACKGROUND

Reconstruction of large skeletal defects secondary to osteomyelitis or open fracture is a challenging problem. The purpose of this study was to evaluate the results of using free vascularized fibular graft (FVFG) combined with locking plate in the treatment of large skeletal defects from open fracture and infection.

METHODS

Ten patients with a mean age of 34 years (ranged 13-57 years) and a mean length of 8.7 cm (range 6-17 cm) skeletal defect were treated with FVFG and locking plate. The mean follow-up time was 26 months.

RESULTS

Grafting union occurred in all patients, with a mean healing time of 4.5 months. No recurrence of osteomyelitis and stress fractures was observed. The mean time to full weight-bearing was 10 months, and all patients were pain-free and able to walk without supportive devices.

CONCLUSIONS

FVFG combined with locking plate is a viable option for the management of large skeletal defects from open fracture and infection.

Reconstruction of a phalangeal bone using a vascularised metacarpal bone graft nourished by a dorsal metacarpal artery

We report on a patient with an infected nonunion of the left little-finger phalanges following a gunshot injury. The defect was treated by transplanting a partial fifth metacarpus, vascularised by the fourth dorsal metacarpal vessels. Bone union was obtained 6 months after surgery and no signs of infection were found at the site of the nonunion. Although the range of the interphalangeal joints of the finger was limited, the patient was satisfied because the preserved little finger had a metacarpophalangeal (MP) joint with unrestricted motion.

Treatment for scaphoid fracture and nonunion--the application of 3.0 mm cannulated screws and pedicle vascularised bone grafts

SUMMARY BACKGROUND

Scaphoid fractures are very common in wrist trauma, and scaphoid nonunions with avascular necrosis are frequent complications of a fractured scaphoid. The purpose of these two retrospective studies was to examine the clinical and x-ray results of treatments for acute scaphoid fracture and scaphoid nonunion. The surgical techniques of cannulated screw fixation and pedicled vascularised bone graft are described.

METHODS

From 2001-2004, 80 patients with scaphoid fractures were treated with 3.0 mm cannulated screws and 5.5 mm threaded washers in our hospitals. The average age was 35 years, and the average time from injury to surgery was 16.5 hours. Outcomes were assessed by x-ray and the modified Mayo wrist score system. During the 6-year period of 1998-2004, 72 patients with scaphoid nonunions were treated using pedicled vascularised bone graft (VBG)in our hospitals. The average age was 38.5 years, and the average time from injury to surgery was 9.5 months.

RESULTS

The union rate was 96.25% and satisfactory function rate was 93.75% in acute scaphoid fractures with an average follow-up of 3.5 years. The union rate (90.28%) and satisfactory function rate (81.94%) achieved in scaphoid nonunions were acceptable, with an average follow-up of 5 years.

CONCLUSIONS

Our studies suggested that appropriate application of a cannulated screw and threaded washer was able to produce satisfactory results in scaphoid fracture, and that pedicled vascularised bone graft was effective for treating scaphoid nonunion.

Soft-tissue injury management and flap reconstruction for mangled lower extremities

The treatment for mangled lower extremities poses a clinical challenge for orthopaedic surgeons. The complexities of soft-tissue injury combined with open fractures and osteomyelitis have frequently resulted in amputation of the lower extremity. The current advances in soft-tissue flap reconstruction techniques have significantly improved the results of limb-salvage attempts. Understanding the reconstructive ladders around the zone of injury, debridement, timing and nuances of techniques regarding skin graft, local and distant flaps and microsurgical reconstruction is necessary to complete limb salvage in a timely and appropriate fashion. Various soft-tissue flap applications have been described, including emergent flow-through flap, acute soft-tissue flap, acute combined soft-tissue and bone flap, pedicle gastrocnemius/soleus flap, pedicle sural artery flap, soft-tissue flap for chronic osteomyelitis, composite osseous-myocutaneous flap for chronic osteomyelitis and free functioning muscle flap for functional reconstruction of mangled lower limbs. Clinical experience of 850 flaps reconstructions for mangled lower limbs in both acute and chronic stages has revealed that adequate application of flap technique was able to achieve quite acceptable results. This article provides a comprehensive review of the soft-tissue injury management and flap reconstruction for mangled lower limbs.

Soft-tissue injury in orthopaedic trauma

This paper reviews the current concepts of soft-tissue injury in orthopaedic trauma. Six topics are described in this Injury Supplement, including influencing factors and mechanisms, co-morbidities, biological responses, diagnosis and treatment of closed soft-tissue injury, compartment syndrome and gunshot wounds. Since one of the current AO principles emphasises respect for soft tissue when performing open reduction and internal fixation, this article further discusses the pathophysiology of soft-tissue injury and the specific concerns in treating compartment syndrome and gunshot injury. Understanding the basic and updated principles of soft-tissue management will be beneficial for the clinical practice of orthopaedic trauma surgeons.

Technical refinements of composite thoracodorsal system free flaps for 1-stage lower extremity reconstruction resulting in reduced donor-site morbidity

A multitude of local flaps has been suggested for lower extremity reconstruction. However, the gold standard for defect coverage remains free tissue transfer. In this regard, the scapular vascular axis is a well-established source of expendable skin, fascia, muscle, and bone for use in free flap reconstruction of defects requiring bone and soft tissue in complex 3-dimensional relationships. Composite bone and soft-tissue flaps derived from the subscapular vascular axis include the osteocutaneous scapular flap, the "latissimus/bone flap," and the thoracodorsal artery perforator-scapular osteocutaneous flap.Patient outcome following reconstruction of lower extremity defects with composite free flaps from the thoracodorsal system were analyzed. Here, we demonstrate the execution of technical refinements on free composite flap transfers based on the thoracodorsal vascular axis, thus resulting in a stepwise reduction of donor-site morbidity.

Lumbosacral reconstruction for intractable pyogenic spondylitis using a total leg flap with a vascularized tibia graft

✓This report describes an effective technique of using a total leg flap for treating a 57-year-old male paraplegic patient with intractable sacral pyogenic spondylitis caused by methicillin-resistant Staphylococcus aureus. Spondylitis was accompanied by severe instability of the lumbosacral area, a large lumbosacral ulcer, and a large bone and muscle defect, which made it difficult for the patient to maintain a sitting position. A total leg flap procedure, a modification of the total thigh flap procedure, was performed as a 1-stage salvage surgery. The vascularized tibia and fibula were grafted between the lumbar and sacral vertebrae, and a musculocutaneous flap was used to cover the extensive ulceration in the lumbosacral skin defect. The intractable lesion of the lumbosacral spine, which had not been cured for more than 2 years despite repeated debridement, intravenous antibiotic injections, sugar treatment, pyoktanin treatment, and hyperbaric O2 treatment, subsided and stabilized within 1 year of surgery. The patient returned to activities of daily living using a wheelchair, and was very satisfied with the results. Use of a total leg flap with a vascularized tibia graft is an effective treatment for intractable pyogenic spondylitis accompanied by a large bone defect and large lumbosacral ulcers.