Induced Membrane Technique Combined with a Free Vascularized Fibula Flap for the Management of a Severe Acute Femoral Bone Loss: A Case Report and Literature Review

Abstract

Background Management of segmental bone defects is a challenge for orthopedic surgeons. The most commonly used methods are the free vascularized bone transfer, bone transport, and induced membrane technique. However, none of these methods is fully suitable for some cases. Case Report A 41-year-old woman was presented with a Gustilo IIIA left distal femoral fracture (AO 32-C and 33-C) with bone loss. The length of femoral bone loss was 15 cm (12 cm medially and 18 cm laterally). After thorough debridement, the intercondylar fracture was fixed with K-wires, and an external fixator bridged the knee joint. The bone defect was filled with antibiotic cement spacer. After 2 months, the external fixator was removed; the femur was fixed by internal fixation. The induced membrane was opened and the antibiotic cement removed. A free vascularized fibular graft of 18 cm was transferred and the residual bony defect was filled with morcellized cancellous autologous bone graft. At 6 months postoperatively, the graft appeared completely integrated at X-ray and the patient could walk without brace at 11 months postoperatively. Conclusion The distal femur is a large-caliber bone and is under severe stress during weight bearing. When only the induced membrane technique is used, the autologous bone graft seems not enough for the present case. On the other hand, single free vascularized fibular graft also could not provide sufficient strength to allow weight bearing despite significant hypertrophy. Therefore, the induced membrane technique combined with free vascularized fibular graft used in the present case may be an alternative.