Einsatzmöglichkeiten der freien mikrochirurgischen Fibulatransplantation in der Rekonstruktion komplexer ossärer Defekte an den Extremitäten – Literaturübersicht und Fallserie

Zusammenfassung

Hintergrund Langstreckige ossäre Defekte der Extremitäten nach Trauma und Tumorresektion stellen eine große Herausforderung an das plastisch-rekonstruktiv tätige Chirurgenteam dar. Die Defektrekonstruktion mittels freier mikrochirurgischer Fibulatransplantation ist eine Standardmethode, bleibt jedoch mit einer nicht unerheblichen Komplikationsrate behaftet. Ziel der vorliegenden Arbeit ist es, eine aktuelle Übersicht zu den diversen Rekonstruktionsverfahren zu geben und anhand einer persönlichen Fallserie die eigenen Erfahrungen mit der freien Fibulatransplantation mitzuteilen.

Patienten und Methoden Die Literaturrecherche zum Thema erfolgte über Pubmed und Web of Science, die retrospektive Datenerhebung des Eigenkollektivs des Seniorautors (MS) unter Einbeziehung von klinischen und radiologischen Daten.

Ergebnisse Von 2007 bis 2018 wurde bei 11 Patienten eine freie Fibulatransplantation durchgeführt. In 4 Fällen war eine Pseudarthrose, in 3 eine Osteitis und in 2 Fällen ein Tumor für die Defektentstehung an den Extremitätenknochen ursächlich. Bei 2 Patienten lag eine Defektfraktur infolge eines Hochenergietraumas vor. In 9 Fällen war die obere, in 2 die untere Extremität betroffen. Bei 4 Patienten wurde ein osteoseptokutanes Transplantat entnommen, bei 2 davon kam es zum Verlust der Hautinsel postoperativ. Die Längen der Fibulatransplantate betrugen zwischen 5 und 22 cm. In allen Fällen war die knöcherne Integration des Transplantats vollständig. Das nach Physiotherapie erzielte Bewegungsausmaß der betroffenen Extremität war sehr gut bis befriedigend.

Schlussfolgerung Die langstreckige ossäre Defektrekonstruktion mittels freier Fibula ist zweifelsohne eine Standardmethode, bedarf bei beschriebener hoher Komplikationsrate eine strenge Indikationsstellung unter Berücksichtigung alternativer Verfahren. Eine enge Kooperation zwischen plastisch-rekonstruktiven und unfallchirurgisch-orthopädischen Disziplinen ist unverzichtbar.

Abstract

Background Extensive osseous defects of the extremities following trauma and tumour resection represent a major challenge for plasticreconstructive surgical teams. Defect reconstruction by free microsurgical fibula transplantation has become a standard method but is associated with a considerable rate of complications. The aim of the present work is to provide an up-to-date overview of the various reconstruction methods and to report our personal experiences with free fibula transplantation in a case series.

Patients and Methods The literature search on the subject was performed on Pubmed and Web of Science, and a retrospective collection of data was conducted based on our own cases, including clinical and radiological data.

Results From 2007 to 2018, free fibula transplantation was performed in 11 patients under the guidance of the senior author (MS). The defects were a result of pseudarthrosis in four cases, osteitis in three, and a tumour in two cases. Two patientssustained a primary defect due to a high-energy trauma. In nine cases the upper limb was affected; only two had the defect in the lower limb. No graft failure was observed. In eight cases, an osteoseptocutaneous graft was taken; in two cases there was a post-operative loss of the skin island. Fibula length ranged between 5 and 22 cm. In all cases, bony integration of the graft was complete. The range of motion in the affected limb after physiotherapy was very good to satisfactory.

Conclusion Extensive bone defect reconstruction using free fibula flaps is undoubtedly the gold standard method, but the high rate of complications described in the literature necessitates a strict indication in due consideration of possible alternatives. Close cooperation between the disciplines of plastic reconstructive surgery and trauma orthopaedics is indispensable.

Schlüsselwörter

freie Fibula - freie vaskularisierte Fibula - Knochentransplantation - Extremitätenrekonstruktion bei Osteomyelitis - Rekonstruktion langstreckiger Knochendefekte

Key words

Free fibula - bone transfer - limb reconstruction in osteomyelitis - free vascularised fibula - reconstruction of long-segment bone defects

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