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Vascularized fibular graft in infected tibial bone loss

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Abstract

Background: The treatment options of bone loss with infections include bone transport with external fixators, vascularized bone grafts, non-vascularized autogenous grafts and vascularized allografts. The research hypothesis was that the graft length and intact ipsilateral fibula influenced hypertrophy and stress fracture. We retrospectively studied the graft hypertrophy in 15 patients, in whom vascularized fibular graft was done for post-traumatic tibial defects with infection.

Materials and Methods: 15 male patients with mean age 33.7 years (range 18 – 56 years) of post traumatic tibial bone loss were analysed. The mean bony defect was 14.5 cm (range 6.5 – 20 cm). The mean length of the graft was 16.7 cm (range 11.5 – 21 cm). The osteoseptocutaneous flap (bone flap with attached overlying skin flap) from the contralateral side was used in all patients except one. The graft was fixed to the recipient bone at both ends by one or two AO cortical screws, supplemented by a monolateral external fixator. A standard postoperative protocol was followed in all patients. The hypertrophy percentage of the vascularized fibular graft was calculated by a modification of the formula described by El-Gammal. The followup period averaged 46.5 months (range 24 – 164 months). The Pearson correlation coefficient (r) was worked out, to find the relationship between graft length and hypertrophy. The t-test was performed to find out if there was any significant difference in the graft length of those who had a stress fracture and those who did not and to find out whether there was any significant difference in hypertrophy with and without ipsilateral fibula union. The Chi square test was performed to identify whether there was any association between the stress fracture and the fibula union. Given the small sample size we have not used any statistical analysis to determine the relation between the percentage of the graft hypertrophy and stress fracture.

Results: Graft union occurred in all patients in a mean time of 3.3 months, at both ends. At a minimum followup of 24 months the mean hypertrophy noted was 63.6% (30 – 136%) in the vascularized fibular graft. Ten stress fractures occurred in seven patients. The mean duration of the occurrence of a stress fracture in the graft was 11.1 months (2.5 – 18 months) postoperatively. The highest incidence of stress fractures was when the graft hypertrophy was less than 20%. The incidence of stress fractures reduced significantly after the graft hypertrophy exceeded 20%.

Conclusion: In most cases hypertrophy of the vascularized fibular graft occurs in response to mechanical loading by protected weight bearing, and the amount of hypertrophy is variable. The presence or absence of an intact fibula has no bearing on the hypertrophy or incidence of stress fracture. The length of the fibular graft has no bearing on the hypertrophy or stress fracture.

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References

  1. Taylor GI, Graeme D, Miller H, Ham FJ. The free Vascularized bone graft: A clinical extension of microvascular techniques. Plast Reconst Surg 1975: 55: 533.

    Article  CAS  Google Scholar 

  2. Bishop AT, Wood MB, Sheetz KK. Arthrodesis of the ankle with a free vascularized autogenous bone graft. J Bone Joint Surg Am 1995;77:1867–75.

    Article  CAS  Google Scholar 

  3. Arai K, Toh S, Yasumura M, Okamoto Y, Harata S. One bone forearm formation using vascularized fibula graft for massive bone defect of the forearm with infection: Case report. J Reconstr Microsurg 2001;17:151–3.

    Article  CAS  Google Scholar 

  4. Ring D, Jupiter JB, Toh S. Transarticular bony defects after trauma and sepsis: Arthrodesis using vascularized fibular transfer. Plast Reconstr Surg 1999: 104: 426.

    Article  CAS  Google Scholar 

  5. Dagher F, Roukoz S. Compound tibial fractures with bone loss treated by ilizarov technique. J Bone Joint Surg Br 1991: 73: 316.

    Article  CAS  Google Scholar 

  6. Paley D, Marr DC. Ilizarov bone transport treatment for tibial defects. J Orthop Trauma 2000;14:76–85.

    Article  CAS  Google Scholar 

  7. Catagni MA, Camagni M, Combi A, Ottaviani G. Medial fibula transport with the ilizarov frame to treat massive tibial bone loss. Clin Orthop Relat Res 2006;448:208–16.

    Article  Google Scholar 

  8. Harrison DH. The osteocutaneous free fibular flap. J Bone Joint Surg Br 1986: 68: 804.

    Article  CAS  Google Scholar 

  9. Ikeda K, Yokoyama M, Okada K, Tomita K, Yoshimura M. Long term follow up of the vascularized Iliac Crest Graft. Microsurgery 1998;18:419–23.

    Article  CAS  Google Scholar 

  10. Buncke HJ, Furnas DW, Gordon L, Achauer BM. Free osteocutaneous flap from a rib to the tibia. Plast Reconstr Surg 1977: 59: 799.

    Article  CAS  Google Scholar 

  11. Steinlechner CW, Mkandawire NC. Non vascularized fibular transfer in the management of defects of long bones after sequestrectomy in children. J Bone Joint Surg Br 2005: 87: 1259.

    Article  CAS  Google Scholar 

  12. Green S. Skeletal defects comparison of bone grafting and bone transport for segmental skeletal defects. Clin Orthop. Relat Res 1994: 301: 50.

    Google Scholar 

  13. Hoffman GO, Kirschner MH, Buhren V, Land W. Allogenic vascularized transplantation of human femoral diaphysis under cyclosporin A immunosupression. Transl Int 1995: 8: 418.

    Article  Google Scholar 

  14. Weiland AJ, Moore JR, Daniel RK. Vascularized bone grafts: experience with 41 cases. Clin Orthop Relat Res 1983;174:87–95

    Google Scholar 

  15. Toh S, Tsubo K, Nishikawa S, Narita S, Kanno H, Harata S. Ipsilateral pedicle vascularized fibula grafts for reconstruction of tibial defects and non-unions. Reconstr Microsurg 2001: 17: 487.

    Article  CAS  Google Scholar 

  16. Yokoyamma K, Itoman M, Nakamura K, Tsukamoto T, Saita Y, Aoki S. Free vascualrized fibular graft vs. ilizarov method for post traumatic tibial bone defect. Reconstr Microsurg 2001: 17: 17.

    Article  Google Scholar 

  17. Keating JF, Simpson AH, Robinson CM. The management of fractures with bone loss. J bone Joint Surg Br 2005: 87: 142.

    Article  CAS  Google Scholar 

  18. Chacha PB, Ahmed M, Daruwala JS. Vascular pedicle graft of the ipsilateral fibula for non-union of the tibia with a large defect. J Bone Joint Surg Br 1981: 63: 244.

    Article  Google Scholar 

  19. Chew WY, Low CK, Tan SK. Long-term results of free vascularized fibular graft: A clinical and radiographic evaluation. Clin Orthop Relat Res 1995;311:258–61.

    Google Scholar 

  20. El-Gammal TA, El-Sayed AM, Kotb MM. Hypertrophy after free vascularized fibular transfer to lower limb. Microsurgery 2002: 22: 367.

    Article  Google Scholar 

  21. Lazar E, Rosenthal DI, Jupiter J. Free vascularized fibular grafts: Radiographic evidence of remodeling and hypertrophy. AJR Am J Roentgenol 1993: 161: 613.

    Article  CAS  Google Scholar 

  22. Wada T, Usui M, Nagoya S, Isu K, Yamawaki S, Ishii S. Resection arthrodesis of the Knee with a Vascularized Fibular Graft. J Bone Joint Surg Br 2000;82:489–93.

    Article  CAS  Google Scholar 

  23. de Boer HH, Wood MB. Bone changes in the vascularized fibular graft. J Bone Joint Surg Br 1989;71:374–8.

    Article  Google Scholar 

  24. Bos KE, Besselaar PP, vd Eijken LW, Raaymakers EL. Failure of hypertrophy in re vascularized fibula grafts due to stress protection. Microsurgery 1996;17:366–70.

    Article  CAS  Google Scholar 

  25. Ikeda K, Tomita K, Hashimoto F, Morikawa S. Long-term followup of vascularized bone grafts for the reconstruction of tibial nonunion: Evaluation with computed tomographic scanning. J Trauma 1992;32:693–7

    Article  CAS  Google Scholar 

  26. Yoshimura M, Ikeda K, Hashimoto F, Okada K, Tomita K. Fate of the vascularized fibular graft: Report of two cases with 15 year follow-up. J Trauma Injury Infect Crit Care 1999;47:777–9.

    Article  Google Scholar 

  27. Falder S, Sinclair JS, Rogers CA, Townsend PL. Longterm behaviour of the free vascularized fibula following reconstruction of large bony defects. Br J Plast Surg 2003;56:571–84.

    Article  CAS  Google Scholar 

  28. Hsu RW, Wood MB, Sim FH, Chao EY. Free vascularized fibular grafting for reconstruction after tumor resection. J Bone Joint Surg Br 1997;79:36–42.

    Article  Google Scholar 

  29. Enneking WF, Lady JL, Burchardt H. Autogenous cortical bone grafts in reconstruction of segmental skeletal defects. J Bone Joint Surg Am 1980;62:1039–57.

    Article  CAS  Google Scholar 

  30. Han CS, Wood MB, Bishop AT, Cooney WP. Vascularized bone transfer. J Bone Joint Surg Am 1992;74:1441–9.

    Article  CAS  Google Scholar 

  31. Imran Y, Zulmi W, Halim AS. Skeletal union following long bone reconstruction using vascularized fibula graft. Singapore Med J 2003;44:286–7.

    CAS  PubMed  Google Scholar 

  32. Berggren A, Weiland AJ, Ostrup LT. Bone scintigraphy in evaluating the viability of composite bone grafts revascularized by micro vascular anastomoses, conventional autogenous bone grafts, and free non revascularized periosteal grafts. J Bone Joint Surg Am 1982;64:799–809.

    Article  CAS  Google Scholar 

  33. Woo SL, Kuei SC, Amiel D, Gomez MA, Hayes WC, White FC, et al. The effect of prolonged physical training on the properties of long bone: A study of wolfs law. J Bone Joint Surg Am 1981;63:780–7.

    Article  CAS  Google Scholar 

  34. Goodship AE, Lanyon LE, McFie H. Functional adaptation of bone to increased stress. J Bone Joint Surg Am 1979;61:539–46.

    Article  CAS  Google Scholar 

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Authors and Affiliations

  1. Departments of Orthopedic and Microvascular Surgery, Specialist’s Hospital, North, Kochi, 682 018, India

    C. Cheriyan Kovoor, R. Jayakumar, V. V. George, Vinod Padmanabhan, A. J. Guild & Sabin Viswanath

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  1. C. Cheriyan Kovoor
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  2. R. Jayakumar
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  3. V. V. George
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  4. Vinod Padmanabhan
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  6. Sabin Viswanath
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Correspondence to C. Cheriyan Kovoor.

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Kovoor, C.C., Jayakumar, R., George, V.V. et al. Vascularized fibular graft in infected tibial bone loss. IJOO 45, 330–335 (2011). https://doi.org/10.4103/0019-5413.82337

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