Adherent Scars Research Articles

A one year follow-up on quality of adherent scars after autologous fat grafting processed by a filtration technique

Autologous fat grafting (AFG), mostly in combination with adhesiolysis, has become the workhorse for reconstructing a dysfunctional or absent subcutaneous layer. In a previous study we showed that fat grafts isolated by centrifuging led to more than 20 % improvement in scar pliability. Nevertheless, there is still debate on which technique should be used to process and purify fat grafts. Therefore, a cohort with matured scars was obtained using the same study protocol but with filtration as processing technique. Scar quality was evaluated by the Patient and Observer Scar Assessment Scale (POSAS version 2.0), the Cutometer (pliability) and the DSM II ColorMeter (erythema and melanin). Scar evaluation was performed pre-operatively (baseline) and at 3 and 12 months after AFG. Between 2014 and 2018, 46 patients were included. Mean scar age was 20 ± 17 years and the majority of scars was caused by burns. Compared with baseline, patients showed improvement in scar quality measured by POSAS items at 12 months follow-up. The item score of ‘pliability’ improved the most from 7.4 to 5.8 (p = 0.001). Item scores of ‘pain’, ‘itch’ and ‘color’ also improved significantly. Clinicians also scored ‘pliability’ as most improved, but this was not statistically significant (p = 0.111). Objectively measured pliability and erythema and melanin showed no statistically significant differences at 12 months follow-up. Patient-reported outcomes revealed a significant improvement in scar quality, especially scar pliability, after AFG processed by filtration in patients with adherent scars. However, no scar quality improvement was found when assessed with objective tools.

Outcomes of Autologous Fat Graft Injection(s) in Treating Sequelae of Digital Trauma: A Case Series.

Background: Sequelae of digital trauma, such as painful scars adherent to tendons and bones, pain of neural origin, cold intolerance, skin and pulp atrophy, occur frequently. Autologous fat graft injections is an interesting option to treat these sequelae. The aim of this study is to describe the outcomes of autologous fat graft injections to treat sequelae of digital trauma. Methods: This retrospective study included all adult patients with digital trauma who underwent an autologous fat grafting procedure at our hospital between 2015 and 2019. The procedure was done at least 6 months after the initial trauma. Outcomes were assessed at least 9 months after the injection and included 2-point epicritic discrimination by Weber test (2-PD) and pulp circumference of the affected finger compared with the contralateral finger, a satisfaction questionnaire concerning the improvement of symptoms, aesthetic aspects and pain related to the operation, evaluation of pain by visual analogue scale, quality of life by SF-36 score and quick disabilities of the arm, shoulder and hand questionnaire (QuickDASH) score. We also assessed whether the patients had reintegrated a previously excluded finger. Results: The study included 14 patients. All patients received one session except for one patient who received two sessions. The average 2-PD of the injured finger was 7 mm compared to 3.57mm for the contralateral finger. There was no difference in pulp circumference between the treated and contralateral fingers. The mean satisfaction score for symptom improvement and aesthetic improvement was 3.36/5, and the mean score for procedure-related pain was 2.36/5. The mean VAS of the patients was 2.91/10, the mean SF-36 was 60.42/100 and the mean QuickDASH was 40.09/100. Five of the nine patients who had a previously excluded finger were able to reintegrate it. Conclusions: Autologous fat transfer seems to offer some benefit in patients with adherent scars and pulp atrophy. It has little effect on neuropathic pain. Level of Evidence: Level IV (Therapeutic).

Stromal vascular fraction-enriched fat grafting as treatment of adherent scars: study design of a non-randomized early phase trial

BackgroundIn the last decades, autologous fat grafting has been used to treat adherent dermal scars. The observed regenerative and scar-reducing properties have been mainly ascribed to the tissue-derived stromal vascular fraction (tSVF) in adipose tissue. Adipose tissue’s components augment local angiogenesis and mitosis in resident tissue cells. Moreover, it promotes collagen remodeling. We hypothesize that tSVF potentiates fat grafting-based treatment of adherent scars. Therefore, this study aims to investigate the effect of tSVF-enriched fat grafting on scar pliability over a 12-month period.Methods and designA clinical multicenter non-randomized early phase trial will be conducted in two dedicated Dutch Burn Centers (Red Cross Hospital, Beverwijk, and Martini Hospital, Groningen). After informed consent, 46 patients (≥18 years) with adherent scars caused by burns, necrotic fasciitis, or degloving injury who have an indication for fat grafting will receive a sub-cicatricic tSVF-enriched fat graft. The primary outcome is the change in scar pliability measured by the Cutometer between pre- and 12 months post-grafting. Secondary outcomes are scar pliability (after 3 months), scar erythema, and melanin measured by the DSM II Colormeter; scar quality assessed by the patient and observer scales of the Patient and Observer Scar Assessment Scale (POSAS) 2.0; and histological analysis of scar biopsies (voluntary) and tSVF quality and composition. This study has been approved by the Dutch Central Committee for Clinical Research (CCMO), NL72094.000.20.ConclusionThis study will test the clinical efficacy of tSVF-enriched fat grafting to treat dermal scars while the underlying working mechanism will be probed into too.Trial registrationDutch Trial Register NL 8461. Registered on 16 March 2020

Human oil: From magic and medicine to art

During research for my artistic project involving human fat/oil I discovered a wide range of historic reference of its use. The extraction and use of human oil has not only been present in myths and magical rituals but also practically used for medicinal healing and skincare. Allegedly hunted down by Peruvian Pishtacos, who then sold it to the cosmetic industry, it was also extracted for use in pain relief or healing of adherent scars, as well as an ingredient for use in black magic. Human oil was sought as a lucrative product for centuries until early 1900. The proposal of my project HUMANOIL is a follow-up from my previous work where biofuel was made from my own fat. HUMANOIL will involve rendering human oil, the last oil produced, from my body, sought to offer anointing, white magic or pure skincare – your choice.

Abstract: Efficacy and Outcomes of Fat Grafting Beyond the Breast: A Meta Analysis

INTRODUCTION: As autologous fat transfer (AFT) has become almost ubiquitous in the operating rooms of most aesthetic and reconstructive surgeons, the regenerative nature of grafted adipose tissue is fueling investigations into further applications beyond the usage in the setting of breast reconstruction. Empiric observation has demonstrated that grafted fat may ameliorate adherent scars, aide in the release of contractures, and even accelerate and improve wound healing in radiation damaged skin. As we are only beginning to understand the potential of lipotransfer, it is essential that we properly evaluate our progress. In the setting of its widespread and expanding use, the purpose of our study is to conduct a meta-analysis of “non-breast” fat grafting to elucidate the current measures of success, both from the patient and physician perspective. METHODS: A PubMed/MEDLINE, Web of Science, and Embase search was conducted for all publications from January 1st, 2000 to October 1st, 2017 containing the phrase “autologous fat grafting” and related terms. The initial search yielded a total of 2255. Studies pertaining to AFT other than in the setting of breast reconstruction were individually selected to review. A review of this literature revealed significant heterogeneity of results. Of these studies, only 28 reported quantitative comparative data beyond observational or individual outcomes. No single measure of outcomes could be identified to reliably correlate the results of the various applications, so none were chosen for statistical analysis. RESULTS: A thorough review of the literature demonstrated significant inconsistency in the reporting of measurable outcomes after AFT. Of the publications which presented quantifiable data, similar applications had consistently differing measurements of the same outcome. For example, in the treatment of vocal cord paralysis, one study utilized the Grade, Roughness, Breathiness, Asthenia, Strain (GBRAS) perceptual scale, maximum phonation time (MPT), and Voice Handicap Index (VHI) whereas another described phonation time, jitter, and harmonic-to-noise ratio. In the treatment of neuropathic pain, two studies utilized the Visual Analog Scale (VAS) and Neuropathic Pain Symptom Inventory (NPSI) scales, but a third just simply described the pain or lack thereof. Lastly, in the treatment of scars, one study utilized the Vancouver Scar Scale while another was evaluated using the Patient and Observer Scar Assessment Scale. While these measures are similar in nature, a statistical analysis was impractical unless the raw data could be collected. CONCLUSION: While the aggregate data demonstrates that fat grafting has led to positive outcomes in a multitude of applications beyond breast reconstruction, this meta-analysis serves to underline the growing necessity of a validated measure of outcomes of fat grafting in these disparate settings in order to ensure we continue practicing evidence based medicine.

Sustainable effectiveness of single-treatment autologous fat grafting in adherent scars.

Following severe injury, not just the skin but also the subcutis may be destroyed. Consequently, the developing scar can become adherent to underlying structures. Reconstruction of the subcutis can be achieved by autologous fat grafting. Our aim was to evaluate the long-term scar outcome after single-treatment autologous fat grafting using a comprehensive scar evaluation protocol. Scar assessment was performed preoperatively in 40 patients. A 12-month follow-up assessment was performed in 36 patients, using the Cutometer, the Patient and Observer Scar Assessment Scale, and DSM II ColorMeter. The Cutometer parameters elasticity and maximal extension improved with 28 and 22% (both p < 0.001), respectively. Nearly all scores of the scar assessment scale decreased significantly, which corresponds to improved scar quality. In addition, the mean melanin score was ameliorated over time. Thus, we demonstrated the sustainable effectiveness of single-treatment autologous fat grafting in adherent scars, indicated by improved pliability, and overall scar quality.

Repair of peripheral nerve with vein wrapping.

The post-traumatic neuro-anastomosis must be protected from the surrounding environment. This barrier must be biologically inert, biodegradable, not compressing but protecting the nerve. Formation of painful neuroma is one of the major issues with neuroanastomosis; currently there is no consensus on post-repair neuroma prevention. Aim of this study is to evaluate the efficacy of neuroanastomosis performed with venous sheath to reduce painful neuromas formation, improve the electrical conductivity of the repaired nerve, and reduce the discrepancies of the sectioned nerve stumps. From a trauma population of 320 patients treated in a single centre between January 2008 and December 2011, twenty-six patients were identified as having an injury to at least one of the peripheral nerves of the arm and enrolled in the study. Patients were divided into two groups. In the group A (16 patients) the end-to-end nerve suture was wrapped in a vein sheath and compared with the group B (10 patients) in which a simple end-to-end neurorrhaphy was performed. The venous segment used to cover the nerve micro-suture was harvested from the superficial veins of the forearm. The parameters analyzed were: functional recovery of motor nerves, sensitivity and pain. RESULTS. Average follow-up was 14 months (range: 12-24 months). The group A showed a more rapid motor and sensory recovery and a reduction of the painful symptoms compared to the control group (B). The Authors demonstrated that, in their experience, the venous sheath provides a valid solution to avoid the dispersion of the nerve fibres, to prevent adherent scars and painful neuromas formation. Moreover it can compensate the different size of two nerve stumps, allowing, thereby, a more rapid functional and sensitive recovery without expensive devices.

Intraoperative and delayed wound approximation in closure of skin defects in different areas.

Wound approximation device is an interesting reconstructive option but not well popularised. In this study we present a simple device that can be used for immediate or delayed closure of large dermal wounds in different anatomical areas. Patients with acute and chronic wounds were recruited and underwent immediate intra-operative wound approximation and/or delayed wound approximation, with a home-made wound approximation device. Approximation time in the immediate closure group ranged from 20-140 minutes. Satisfactory scars were obtained in 19 patients (76%) and adherent scars developed in 6 patients. Delayed wound approximation was used successfully in closure of 9 defects. This simple dermal wound approximation device can be used intraoperatively to successfully close large difficult wounds, located on the trunk and thigh, with minimal complications. The device can also be used to approximate delayed wounds located in regions where closure is particularly problematic, like the lower leg, foot, and scalp. Some modifications of the device are needed to improve its safety and efficacy. Wound tension is detrimental to adequate wound healing and tensile strength, another basic principle that should not be overlooked to avoid wound dehiscence. Wound approximation is adding to reconstructive options, not replacing them, and they must always be considered.

Is Adherent Scar Always Nonpliable?

Sir: We read the article by Perry and colleagues1 with great interest and agree that objective assessment of skin scars is crucial for planning their treatment. The article is a review aimed “to explore the current range of noninvasive objective assessment tools available for cutaneous skin scarring” described in the literature since 1937. The authors classify the reviewed tools according to four physical characteristics of skin scar (i.e., color, surface area, height/depth, and pliability) and state that the skin's “elasticity, extensibility, firmness, and tensile strength constitute the collective definition of pliability.” They add that “scars are required to glide and stretch with normal skin to facilitate normal physiologic function” (Fig. 1).Fig. 1.: The Adheremeter. Scar adherence (marked with a black fine-line pen) in original position O at rest (above) and at maximal lateral excursion L1(below) when pulled with maximal force within a comfort range for the patient. The red arrow indicates the pulling direction. In this example, maximal lateral excursion of the adherence (from O to L1) is 3 mm.In reality, gliding and stretching are two different biomechanical properties, and we agree with those who consider and measure separately the adherent condition (capacity to glide) and the scar firmness and inflexibility (capacity to stretch).2 For instance, pathologic scar might be adherent in one point and at the same time globally supple. This occurs, for example, in surgical linear wounds where the pathologic scarring may not affect the entire incision but occurs mainly at a depth. Unfortunately, scar pliability and adherence are sometimes analyzed with the same items3; in fact, the tools considered in the article by Perry et al. are aimed to assess scar stretching but not specifically to measure scar gliding. Recently, we validated in postsurgical scars a cheap and easy-to-use device to objectively measure scar gliding, dubbed the Adheremeter (Fig. 1).4 This device measures adherence of postsurgical scar, defined as the restriction of scar mobility with respect to underlying tissue at the worst adherent point when pulled in four orthogonal directions. To our knowledge, no other instruments have been validated to assess degree of scar adherence, and only one scale has been developed for adherent scars (the Skin Glide Grade scale, which subjectively grades the amount of scar restriction).5 Because there is not currently a consensus on this topic, we think it would be relevant for the readers if Perry and colleagues could express their expert opinion on the following points: (1) the relationship between scar capacity to glide (adherence) and to stretch (pliability), and (2) the best tools with which to assess scar adherence of different type and origin in a clinical setting. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Giorgio Ferriero, M.D. Stefano Vercelli, P.T., M.Sc. Unit of Occupational Rehabilitation and Ergonomics S. Maugeri Foundation Istituto Di Ricovero e Cura a Carattere Scientifico Scientific Institute of Veruno Veruno, Italy Ludovit Salgovic, M.D., C.Sc. Univerzita sv Cyrila a Metoda Trnava, Slovak Republic Francesco Sartorio, P.T. Franco Franchignoni, M.D. Unit of Occupational Rehabilitation and Ergonomics S. Maugeri Foundation Istituto Di Ricovero e Cura a Carattere Scientifico Scientific Institute of Veruno Veruno, Italy

Reply: Is Adherent Scar Always Nonpliable?

Reply: Is Adherent Scar Always Nonpliable?

Surgical Treatment of Depressed Scar: A Simple Technique

Scar formation is a process consequent to the healing of soft tissues after a trauma. However, abnormal or disturbed collagen production can cause anomalies of the cutaneous surface and textural irregularities. In the presence of a depressed scar in deep tissue, we began to use a new simple technique. In the presence of adherent scars, a small incision is performed so that an undermining scissor can enter inside. The entire cicatricial area is undermined on a subcutaneous plane which, by separating the deep scar from the superficial one, completely frees it from the present adhesions so that the existing depression is totally eliminated. In order to avoid the recreation of relapses, stitches formed in a U-shape are made in Nylon or Monocril 2-3/0 are made with a large needle and are placed close together so that a wide aversion is achieved at the margins of the scar and a deep wound closure is obtained by adhering to the undermined tissue. These stitches will then be removed about 2 weeks later.

Treatment of Soft Tissue Contour Defects by a Combination of Surgical Subcision with a Beaver Tympanoplasty Blade and Autologous Fat Grafting

This report describes a technique for treating depressed scars and soft tissue contour deformities. Surgical subcision with a Beaver tympanoplasty blade is undertaken for depressed or adherent scars to release the fibrous attachments beneath the scar before autologous fat grafting. Satisfactory results were observed, with an improvement in surface contour for 16 patients over a 3-year period. The authors recommend the described technique as a safe, minimally invasive, and precise method for subcutaneous dissection of scar tissue before fat injections.

Erfolgreiche Korrektur einer adhärenten Narbe im Bereich des Handrückens mit Matriderm®

Adherent scars on the hand often lead to a major functional impairment and an aesthetic deformity. The rate of recurrence after scar correction is usually very high. A 57-year-old woman with an adherent scar on the back of her hand and major functional impairment was successfully treated with Matriderm. Using Matriderm as an additional layer between the atrophic skin and the tendons adherency of the scar could be prevented. One year after surgery the patient is free of pain. There is normal mobility between the skin and the underlying tissue. Complete wrist flexion and extension could be achieved. To the best of our knowledge this is the first case reported of using Matriderm for the correction of a scar that was caused by the paravasal injection of cytostatic drugs.

Prelaminated free radial forearm flap for a total nasal reconstruction

A prelaminated osteocutaneous radial forearm flap has previously been described for total nasal reconstruction, but achieving good aesthetics at the dorsum and tip tends to be difficult with a flap that can be too bulky. We present a case of total nasal reconstruction in a burns patient where a tight adherent scar at the forehead precluded the use of a forehead flap, ideal for such reconstructions. We successfully used a prelaminated free radial forearm flap, with a non-vascularised bone graft. The existing scarred skin at the dorsum was turned down as pedicled flaps for the lining. We were able to achieve a successful total nasal reconstruction which was aesthetically pleasing and made a tremendous impact on the quality of life of the patient.

Autologous Platelet-Rich Plasma as an Adipocyte In Vivo Delivery System: Case Report

Tissue engineering has emerged as a promising alternative to current clinical treatments for restoration of soft tissue defects. A key element in the process of tissue engineering is an ideal implant that provides structural support and a favorable environment for growing cells. The authors hypothesized that autologous platelet-rich plasma (APRP) could be used as an in vivo adipocyte delivery system to favor cell survival and to stimulate early recruitment of microcapillaries to the site of implantation. Autologous fat was included in APRP and injected as a gel into a subcutaneous pocket created to correct a painful, adherent scar at the shoulder level in a 75-year-old woman. The surgical outcome was evaluated by histologic and immunohistochemical analysis as well as by ecography before and after surgery. The results were satisfactory, showing fat survival 1 year after surgery. The characteristics of this new material should stimulate research into future clinical applications for such cell constructs in plastic and reconstructive surgery.

Pathways to nephron loss starting from glomerular diseases—Insights from animal models

Studies of glomerular diseases in animal models show that progression toward nephron loss starts with extracapillary lesions, whereby podocytes play the central role. If injuries remain bound within the endocapillary compartment, they will undergo recovery or be repaired by scaring. Degenerative, inflammatory and dysregulative mechanisms leading to nephron loss are distinguished. In addition to several other unique features, the dysregulative mechanisms leading to collapsing glomerulopathy are particular in that glomeruli and tubules are affected in parallel. In contrast, in degenerative and inflammatory diseases, tubular injury is secondary to glomerular lesions. In both of the latter groups of diseases, the progression starts in the glomerulus with the loss of the separation between the tuft and Bowman's capsule by forming cell bridges (parietal cells and/or podocytes) between the glomerular and the parietal basement membranes. Cell bridges develop into tuft adhesions to Bowman's capsule, which initiate the formation of crescents, either by misdirected filtration (proteinaceous crescents) or by epithelial cell proliferation (cellular crescents). Crescents may spread over the entire circumference of the glomerulus and, via the glomerulotubular junction, may extend onto the tubule. Two mechanisms concerning the transfer of a glomerular injury onto the tubulointerstitium are discussed: (1) direct encroachment of extracapillary lesions and (2) protein leakage into tubular urine, resulting in injury to the tubule and the interstitium. There is evidence that direct encroachment is the crucial mechanism. Progression of chronic renal disease is underlain by a vicious cycle which passes on the damage from lost and/or damaged nephrons to so far healthy nephrons. Presently, two mechanisms are discussed: (1) the loss of nephrons leads to compensatory mechanisms in the remaining nephrons (glomerular hypertension, hyperfiltration, hypertrophy) which increase their vulnerability to any further challenge (overload hypothesis); and (2) a proteinuric glomerular disease leads, by some way or another, to tubulointerstitial inflammation and fibrosis, accounting for the further deterioration of renal function (fibrosis hypothesis). So far, no convincing evidence has been published that in primary glomerular diseases fibrosis is harmful to healthy nephrons. The potential of glomerular injuries to regenerate or to be repaired by scaring is limited. The only option for extracapillary injuries with tuft adhesion is repair by formation of a segmental adherent scar (i.e., segmental glomerulosclerosis).

Microvascular Omental Transfer for the Treatment of Severe Recurrent Median Neuritis of the Wrist: A Long-Term Follow-Up

The results of reoperation for recurrent carpal tunnel syndrome have been quite disappointing. In addition to a secondary external or internal neurolysis, multiple tissues and procedures have been used to decrease scar adherence of the reoperated median nerve including muscle, fascial or fat flaps, and vein wrapping. However, each technique has certain limitations, especially in the carpal tunnel that has previously undergone multiple operations, with diffuse scar and adherence over an extended length of the median nerve. The purpose of this study was to evaluate the long-term functional and symptomatic outcome following microvascular omental transfer for severe recalcitrant median neuritis. Between 1989 and 1993, 10 extremities in seven patients underwent omental transfer for severe recurrent median neuritis at the wrist. Nine extremities in six women were available for personal evaluation at an average follow-up of 6.6 years (range, 4.5 to 8.75 years). All extremities had undergone a minimum of two previous surgical procedures, and since 1991, all patients also failed local pedicle tissue coverage. Each patient completed a physical examination, a questionnaire, and electrophysiologic studies. At surgery, all median nerves were encased in dense adherent scar, which often extended proximal to the wrist crease. There were seven neural abnormalities in six extremities, three patent median arteries, and one aberrant palmaris longus muscle. The Functional Status Index was 3.1 +/- 0.7 and the Symptom Severity Index was 3.1 +/- 0.9, with a range of 1 (best) to 5. Most symptoms were improved but not completely alleviated. Four of nine extremities exhibited improved two-point discrimination and five of seven improved sensitivity, according to the Semmes-Weinstein monofilament test. Grip strength increased an average of 73 percent in seven of nine extremities and pinch strength increased 101 percent in four of nine extremities. Five of six patients were satisfied with their results and reported improved quality of life. Preoperatively, five of seven patients were working on light duty; postoperatively, three of six patients attempted to return to work, but none were working at final follow-up. Electrophysiologic data did not correlate with the symptomatic or functional outcome. There were four complications; three were related to delayed wound healing, and one morbidly obese patient developed a ventral hernia. Wrapping the median nerve with vascularized omentum is a viable option for the treatment of severe recalcitrant carpal tunnel syndrome. Despite a high satisfaction rate and significant symptomatic improvement, many symptoms will persist, but to a lesser degree.

Progressive neurological deficit in children with spina bifida aperta.

The results of re-operation of 15 patients with spina bifida aperta are reported. The operation was necessary because of neurological deterioration with increasing motor and bladder dysfunction. In all patients a tethered cord syndrome was present (CT-myelography). The myelum was adherent to the scar of the myelomeningocele repair. At operation the myelum is released from the adherent scar and in this way untethered. The early complications were mild except for one patient with decompensation of hydrocephalus. The aim of the operation was to stop further progression. The results of the operation were satisfactory with stabilisation of motor function in four patients and improvement of motor dysfunction in ten patients. Backache or fixation, bladder dysfunction and abnormal foot shape improved in some of the patients. In our experience the operative untethering procedure was useful. Intensive neurological control of operated spina bifida aperta patients is mandatory especially in those patients who can walk.

Treatment of essential blepharospasm. II. A modification of exposure for the muscle stripping technique.

The refinement of a muscle excision technique for the correction of essential blepharospasm has been a major contribution to treatment. In this procedure, incisions are made directly above the eyebrow to excise the brow muscles, often resulting in adherent scars and poor brow position. The bicoronal scalp flap has been used by many other surgical subspecialities for exposure of the frontal bone area, eg, in neurosurgical procedures, sinus surgery, and cosmetic forehead lifts. The use of the coronal flap exposure for excision of the corrugator and procerus muscles has allowed them to be more easily excised and has avoided the problems associated with the direct brow incisions. The Anderson muscle stripping technique, combined with the coronal flap exposure for the brow muscles, provides the best correction for the spasms in patients who have essential blepharospasm. The frequency of complications is low, and patient acceptance is high.

Vascular pedicle graft of the ipsilateral fibula for non-union of the tibia with a large defect. An experimental and clinical study.

Failure of union of the tibia with a large defect is difficult to treat, especially in the presence of sepsis and adherent scars. Conventional methods of fixation and bone grafting are not easily applicable. Experiments on Macaca monkeys showed that a vascularised pedicle graft of the shaft of the ipsilateral fibula could be fixed across a defect in the tibia and remain viable, even if it was isolated from surrounding soft tissues. Transfer of part of the shaft of the ipsilateral fibula on a vascular and muscle pedicle was carried out in 11 patients with large tibial defects and sepsis. There was one failure because of severe infection, but the other 10 patients gained sound union in about four months. The tibia was then protected by a caliper for the 18 months of full reconstitution. The bone infection healed and there was no evidence of avascular necrosis. Although the salvaged limbs were scarred, stiff and ugly, none of the patients suffered from pain, recurrent oedema or persistent infection.