Abstract
Purpose: Management of extensive tibial loss raises the question of indications for vascularised grafts. These techniques depend on the number of functional vascular trunks available. We developed a modified technique which allows using this type of graft without sacrificing the tibial pedicle, making it usable when only one trunk remains functional. We use the fibular arterial supply to bridge the remaining axis. The purpose of this work was to detail the modalities of this technique and provide early results.
Material and method: Since 2000, we have reserved this technique for infected nonunion with loss of tibial tissue extending over 5 cm in patients who decline amputation. Four patients (four men, mean age 30 years) underwent the procedure. The initial trauma resulted from a motorcycle (n=3) or firearm (n=1) accident. The patients were referred to our unit within three months on the average. Prior treatments (cancellous graft in an open or intrafocal procedure) had failed in all patients who presented persistent infection. Antibiotics were administered until bone healing in all patients. Mean length of the gap was 10 cm (7 – 15 cm). The composite graft (skin and fibula with a vascularised fibular bundle) was raised from the contralateral limb and cross-leg anastomosed proximally and distally on the receiver anterior tibial bundle (all four cases).
Results: All fractures consolidated between six and twelve months after initiating management of this technique. Bone and soft tissue losses healed without shortening. There were not repeated fractures after mean follow-up of twelve months (range eight months to two years). No complementary bone graft was necessary. Infection resolved in all patients.
Discussion and conclusion: As for classical vascularised fibula grafts, this technique enables controlling bone and soft tissue problems together (composite graft). The graft is vascularised favouring antibiotic diffusion. The mechanical quality is better than with a pure cancellous graft but longer follow-up would be required to determine the rate of repeated fractures. This technique broadens indications for vascularised fibula grafts which can be used in unfavourable vascular contexts where only one or two leg trunks persist.
The abstracts were prepared by Docteur Jean Barthas. Correspondence should be addressed to him at Secrétariat de la Société S.O.F.C.O.T., 56 rue Boissonade, 75014 Paris.
