OTA 1997 Posters - Scientific Basis for Fracture Care

Vascularized Fibula Bone Transplant for Limb Salvage following Long Bone Fracture with Subsequent Chronic Osteomyelitis and Nonunion

Iris Yaron, MD, Robert J. Strauch, MD, Harold M. Dick, MD, Melvin P. Rosenwasser, MD, Maurico F. Herrara, MD

Columbia-Presbyterian Medical Center, New York, New York, USA

Purpose: Fracture of long bones may result in nonunion secondary to osteomyelitis. Chronic osteomyelitis is a persistent and debilitating disease which may be complicated by pathologic fracture, bone lengthening, muscle contracture, or limb loss. Function of the involved limb and activities of daily living are greatly affected. Vascular fibular transplant for limb salvage has been successfully used for the past 20 years after en bloc excision of bone tumors, congenital pseudoarthrosis, and nonunion secondary to trauma.

Methods: Eight patients with nonunion and chronic osteomyelitis and resistant nonunion who underwent reconstruction at our institution were identified. The series consisted of 5 men and 3 women with an average age of 35.1 years (range 19-76 years), and an average of 1.8 medical comorbidities. Etiology of osteomyelitis included trauma (motor vehicle accident [7], fall [1]); five patients sustained open fractures. Types of bone reconstructed included humerus (1), femur (3), and tibia (4). Patients had undergone at least 3 prior procedures with an average duration of nonunion of 4.1 yrs (range 1 to 11 yrs). Three patients had an average bone deficit of 8.3 cm (range 7-10 cm). All reconstruction techniques utilized autologous vascular fibula grafts and one patient had adjunctive autologous iliac bone graft at the time of fibular transplant. Bony fixation consisted of external fixation (3), screws (8), and supplemental cast immobilization (5). Four patients received postoperative electrical stimulation.

Results: Six patients had full graft incorporation, one had partial incorporation. One patient had not healed and continued to have nonunion at the site of transplant 1.5 years following reconstruction and required iliac bone grafting to the site of fibula nonunion. Subsequently, the patient healed (total of 100% limb salvage rate). All patients who had union reported good to excellent function of the involved extremity. None of the patients had donor site morbidity. Complications included reoperation for acute graft revision (2) and hardware revision (1). Three patients had recurrence of infection, two requiring irrigation and debridement and excision of sinus tract; suppression of infection occurred in 80% of patients.

Discussion and Conclusion: Our results indicate that vascularized fibula transplant can results in 100% limb salvage rate in this patient population with good to excellent function of the involved limb. This procedure allows for bridging of the nonunion site with a more radical debridement and subsequent hypertrophy and remodeling of the vascular fibula graft leading to normal load-bearing characteristics of the transplanted bone.