Reconstruction Of Tibial Defects Research Articles

Reconstruction Using an Osteofasciocutaneous Fibula Free Flap for a Distal Tibial Defect in Refractory Chronic Osteomyelitis: A Case Report

The fibular free flap (FFF) is an option used for tibial defect reconstruction in post-traumatic chronic osteomyelitis (PCOM). However, as the tibia is a weight-bearing bone, there exists a risk of compression fracture risk after FFF. This complicates reconstructing distal tibial defects adjacent to the articular cartilage. We report a successful case of reconstruction using FFF for a bone defect adjacent to the distal tibial articular surface in refractory PCOM. The patient was a 73-year-old woman with refractory PCOM in the right distal tibia secondary to a tibial fracture from a traffic accident that occurred 28 years ago. After bone debridement, the tibial bone defect was 8 cm in length, and its distal margin was located 0.5 cm above the articular surface of the tibiotalar joint. Tibial bone and soft tissue defects were reconstructed using a contralateral FFF consisting of an 8-cm fibula bone and a 14×5-cm-sized skin paddle. After 2 months, an Ilizarov apparatus was applied and maintained for 3 months. After 6 months, she started weight-bearing. The follow-up period was 15 months. Imaging studies revealed bone block union. The patient displayed no difficulty in ambulation and had no additional infections or flap necrosis.

40 years of microvascular reconstruction with latissimus dorsi muscle free flap

Introduction: The first use of the latissimus dorsi as a myocutaneous flap was described as early as the end of the 19th century, in the coverage of an extensive defect following radical mastectomy (Tansini 1895). Subsequently, the surgical procedure was forgotten and later re-introduced as a pedicled flap for breast reconstruction (Olivari 1976). Olivari prompted the microsurgical team from Ljubljana to perform a free muscle transfer (Godina 1978). The first emergency free flap transfer in Ljubljana was performed in 1979.Patients and Methods: Latissimus dorsi flap can be used as a muscle or musculocutaneous flap, in a pedicle or a free form. The procedure of reconstructing large tibial defects always proceeded as a two-team procedure simultaneously. For the continuity of the axial blood flow of the tibia, M. Godina developed end-to-side anastomosis.Results: Using latissimus dorsi free flap for reconstruction of tibial defects the first statistics by M. Godina from 134 patients showed a 0.75% flap loss rate and 1.5% infection rate; an average healing time of 6.8 months and a bed rest period estimated at 27 days. In the case of delayed reconstruction, the author reported an infection rate of 17.5%.Conclusions: Due to clinical experience, good results and a new doctrine of the Ljubljana School of microsurgery played a historical role in the reconstruction of the tibia with a muscular microvascular muscle flap.

Vascularized fibular graft combined with vacuum assisted closure in the reconstruction of tibial defects

Vascularized fibular graft combined with vacuum assisted closure in the reconstruction of tibial defects

VASCULARIZED FIBULAR GRAFT COMBINED WITH VACUUM ASSISTED CLOSURE IN THE RECONSTRUCTION OF TIBIAL DEFECTS.

Background: To investigate the application of Flow-through free vascularized fibular graft combined with Vacuum Assisted Closure for the patients
 suffering from tibial defects caused by chronic osteomyelitis.
 Methods: We retrospectively analysed 20 cases of patients who accepted this operation in the treatment of tibial defects. Among the tibial defects,
 six cases resulted from blood stream infection while 14 cases resulted from comminuted fractures. All the patients included in the study were
 accompanied with 1 to 3 sinuses. The length of the defects ranged from 6cm to 16cm, with an average of 11.3cm. 6 patients were also faced with soft
 tissues defects combined with tendon or bone exposures, and the defects areas ranged from 11cm×7cm to 19cm×14cm. There were 5 patients
 suffering from fibular fractures at the same side of the defects. The courses of this disease were 5.5 -15 months, with an average of 9.8 months.
 Results: The patients included in the study were followed up from 10 months to 4 years, with an average of 1.9 years. Sinuses of 18 patients healed
 within 4 weeks, giving a primary healing rate of 90%. We undertook debridement of the remaining sinuses and they healed within 2 weeks. All skin
 flaps grafted to the patients survived, thus the survival rate was 100%. The radiographs indicated that 18 patients had good prognosis and the primary
 union time of grafting fibula were from 4 to 8 months, with average of 6.3 months. The healing patients achieved an average of 25.6 points based on
 the Enneking evaluation system which was used to evaluate the function of limbs after the operation, indicating that 85.9% of the limb function
 recovered. 4 patients required revision surgery for complications resulting from the operation: 1 wound breakdown, 2 bone non-unions, 1 graft
 fracture. Infection occurred only as a pin-tract infection, and was controlled with oral antibiotics and repeated dressing; there was no deep infection
 out of control in any of these patients.
 Conclusion: The flow-through free vascularized fibular graft did not only repair tibial defects, but retained the continuity of trunk vessels. The flowthrough
 fibular graft combined with Vacuum Assisted Closure (VAC) controlled the infection, shortened the course of treatment, and effectively
 restored limb function when applied to the treatment of tibial defects.

The Huntington procedure: still a reasonable option for large tibial defects in paediatric patients.

BackgroundManagement of gap nonunion of tibia is technically difficult, time consuming, physically and psychologically demanding for the patient with unpredictable results. Various techniques have been described in literature for the treatment of gap nonunions, but each one has its own limitations.PurposeThis study reports the outcomes of ipsilateral fibular transposition for reconstruction of tibial defects in paediatric age group.MethodsWe retrospectively reviewed records of 14 patients who underwent surgery for gap nonunion tibia with ipsilateral tibialization of fibula. Fibula is transferred to tibia as pedicle graft in two-staged procedure. Due to retained blood supply to one end of the transplant, the graft easily takes up and hypertrophies upon weight bearing over a period of time.ResultsAverage time of radiographic union was 13.35 weeks. Guarded partial weight bearing was started at an average of 16.5 weeks with gradual progression to full weight bearing. The leg length discrepancy at final follow-up ranged from 0 to 7 cms with an average of 2.60 cms. Hypertrophy of tibialized fibula was observed in all patients, with 8 patients showed grafted fibula reaching the diameter of opposite tibia. On subjective assessment, 9 patients were highly satisfied, 4 patients were satisfied and one patient was dissatisfied with the procedure.ConclusionsHuntington procedure is a simple, cost-effective and easy procedure for large tibial defects in paediatric patients which does not require any specialized team and implants, and can be performed in moderately equipped hospital. Leg length discrepancy may be addressed, after the transferred fibula is well developed.

Allografts with Autogenous Platelet-Rich Plasma for Tibial Defect Reconstruction: A Rabbit Study

To evaluate the effect of autogenous platelet-rich plasma (PRP) for fresh-frozen allografts in tibial defect reconstruction in rabbits. 40 adult New Zealand white rabbits underwent tibial defect reconstruction with autografts (n=12), allografts without PRP (n=12), or allografts with PRP (n=12) and were observed for 12, 16, and 24 weeks (4 for each period). Tibias of the remaining 4 rabbits were used as donor allografts, and the remaining allografts were procured from recipient rabbits. A 1.5- cm cortical segment of the tibia was osteotomised, and then fixed with a 9-hole mini-compression plate and 2 cerclage wires. Allografts were stripped off the periosteum and soft tissues and medullary contents, and then stored in a freezer at -80 ºC. All allografts were deep frozen for at least 4 weeks before transplantation. 7 ml of whole blood was drawn to prepare 1 ml of PRP. The PRP was then mixed with 1.0 ml of human thrombin to form a platelet gel. The PRP gel was then packed into the medullary canal of the allograft and applied on the cortical surface before tibial defect reconstruction. Rabbits were sacrificed at 12, 16, and 24 weeks. The specimens were assessed for bone union at host-graft junctions and for bone resorption, new bone formation, callus encasement, and viable osteocyte counts. There were 4 specimens in each group at each observation period. Osteoid bridging the gap at host-graft junctions was noted in all specimens in the autograft and allograft-with-PRP groups at week 12 and in the allograft-without-PRP group at week 24. Bone union in allografts without PRP was delayed. All indices for biological incorporation (resorption index, new bone formation index, callus encasement index, and viable osteocyte count) were significantly greater in the autograft than allograft-without-PRP groups, except for the resorption index at week 24, whereas the differences were not significant between the autograft and allograft-with-PRP groups. The differences between the 2 allograft groups were usually not significant, except for the resorption index. PRP-augmented allografts behaved similarly to autografts for tibial defect reconstruction in rabbits. PRP increased bone union and bone resorption.

The Influence of Soft Tissue Trauma on Bone Regeneration after Acute Limb Shortening

Reconstructing posttraumatic tibial defects is often challenging. Some authors recommend acute limb shortening. We determined whether soft tissue trauma affects the formation of regenerated bone after acute shortening and monofocal lengthening. Twenty-two rabbits were divided into two equal groups. In the test group, 90 minutes of ischemia and 30 minutes of tibialis anterior muscle contusion at 100 kPa induced substantially elevated pressure as an onset of compartment syndrome. The untreated hind limb acted as the paired control. An external fixator was applied and the limb was shortened 10 mm through bone resection. After a latency period, distraction was performed for 10 days until the natural length was restored. New bone formation was evaluated mechanically, radiographically, and histomorphometrically. Osseous consolidation occurred in all animals. Normalized mechanical values of the newly reconstructed tibia indicated torsional strength was lower in the trauma group than in controls (46% +/- 18.5% versus 64% +/- 16.7%). Average normalized callus diameters were smaller in the trauma group than in controls (1.27 +/- 0.14 versus 1.6 +/- 0.16), as were callus volumes (37% +/- 5.9% versus 44% +/- 10.3%). Although soft tissue trauma affected the formation of regenerated bone, our results suggest reconstruction of tibial defects using a monofocal technique is consistent, even in the presence of blunt trauma and elevated compartment pressure.