Free Fibula Transfer in the Treatment of Difficult Distal Tibia Fractures

ABSTRACT

Management of the high-grade open distal tibia fracture remains problematic. The authors reviewed the charts of 14 cases of distal tibia and tibial plafond fractures reconstructed with a free fibula transfer. Six cases involved a plafond defect, and the fibula was used to arthrodese the tibio-talar joint. Seven cases included a skin paddle. Three of the four patients with osteomyelitis cleared their infection. Twelve patients went on to osseous union, and two were ultimately treated with amputation. Patients who went on to union had an average of 1.1 subsequent procedures, began full weightbearing in an average of 5.8 months, and were weightbearing without any assistive devices by an average of 8.5 months. There was no significant correlation between the time to full weightbearing and either the presence of infection or the length of the original defect. In this series, 86 percent success was obtained when a free fibula transfer was used either to bridge a tibial non-union or to promote arthrodesis of the tibio-talar joint.

Free fibula - distal tibia fracture - tibial plafond fracture

REFERENCES

• 1 Burgess A R, Poka A, Brumback R J, Flagle C L, Loeb P E, Ebraheim N A. Pedestrian tibial injuries.  J Trauma. 1987;  27 596-601
• 2 Weiland A J. Current concepts review: vascularized free bone transplants.  J Bone Joint Surg Am. 1983;  63 166-169
• 3 Yaremchuk M J, Brumback R J, Manson P N, Burgess A R, Poka A, Weiland A J. Acute and definitive management of traumatic osteocutaneous defects of the lower extremity.  Plast Reconstr Surg. 1987;  80 1-14
• 4 Esterhai Jr J L, Sennett B, Gelb H et al.. Treatment of chronic osteomyelitis complicating nonunion and segmental defects of the tibia with open cancellous bone graft, posterolateral bone graft, and soft-tissue transfer.  J Trauma. 1990;  30 49-54
• 5 Papineau L J. Excision-graft with deliberately delayed closing in chronic osteomyelitis [in French].  Nouv Presse Med. 1973;  2 2753-2755
• 6 Christian E P, Bosse M J, Robb G. Reconstruction of large diaphyseal defects, without free fibular transfer, in Grade-IIIB tibial fractures.  J Bone Joint Surg Am. 1989;  71 994-1004
• 7 Green S A. Skeletal defects. A comparison of bone grafting and bone transport for segmental skeletal defects.  Clin Orthop Relat Res. 1994;  (301) 111-117
• 8 Ilizarov G A. The tension-stress effect on the genesis and growth of tissues. Part I. The influence of stability of fixation and soft-tissue preservation.  Clin Orthop Relat Res. 1989;  (239) 249-281
• 9 Dendrinos G K, Kontos S, Lyritsis E. Use of the Ilizarov technique for treatment of non-union of the tibia associated with infection.  J Bone Joint Surg Am. 1995;  77 835-846
• 10 Garcia-Cimbrelo E, Olsen B, Ruiz-Yague M, Fernandez-Baillo N, Munuera-Martinez L. Ilizarov technique. Results and difficulties.  Clin Orthop Relat Res. 1992;  (283) 116-123
• 11 Osterman A L, Bora F W. Free vascularized bone grafting for large-gap nonunion of long bones.  Orthop Clin North Am. 1984;  15 131-142
• 12 Ueba Y, Fujikawa S. Nine year' follow-up of a free vascularized fibular graft in neurofibromatosis: a case report and literature review.  Jpn J Orthop Trauma Surg. 1983;  26 595-600
• 13 Taylor G I, Miller G D, Ham F J. The free vascularized bone graft. A clinical extension of microvascular techniques.  Plast Reconstr Surg. 1975;  55 533-544
• 14 Doi K, Tominaga S, Shibata T. Bone grafts with microvascular anastomoses of vascular pedicles: an experimental study in dogs.  J Bone Joint Surg Am. 1977;  59 809-815
• 15 Bishop A T, Wood M B, Sheetz K K. Arthrodesis of the ankle with a free vascularized autogenous bone graft. Reconstruction of segmental loss of bone secondary to osteomyelitis, tumor, or trauma.  J Bone Joint Surg Am. 1995;  77 1867-1875
• 16 Kusakabe N, Takagi M, Tsuzuki N. Tibio-talo-calcaneal fusion with a free vascularized fibular graft in comminuted open fractures of the talus and the calcaneus.  J Orthop Trauma. 1992;  6 386-390
• 17 Jones N F, Swartz W M, Mears D C, Jupiter J B, Grossman A. The “double barrel” free vascularized fibular bone graft.  Plast Reconstr Surg. 1988;  81 378-385
• 18 O'Brien B M, Gumley G J, Dooley B J, Pribaz J J. Folded free vascularized fibula transfer.  Plast Reconstr Surg. 1988;  82 311-318
• 19 Yajima H, Tamai S. Twin-barrelled vascularized fibular grafting to the pelvis and lower extremity.  Clin Orthop Relat Res. 1994;  (303) 178-184
• 20 Chung Y K, Chung S. Ipsilateral island fibula transfer for segmental tibial defects: antegrade and retrograde fashion.  Plast Reconstr Surg. 1998;  101 375-382
• 21 Chen Z W, Yan W. The study and clinical application of the osteocutaneous flap of fibula.  Microsurgery. 1983;  4 11-16
• 22 Harrison D H. The osteocutaneous free fibular graft.  J Bone Joint Surg Br. 1986;  68 804-807
• 23 Anthony J P, Rawnsley J D, Benhaim P, Ritter E F, Sadowsky S H, Singer M I. Donor leg morbidity and function after fibula free flap mandible reconstruction.  Plast Reconstr Surg. 1995;  96 146-152
• 24 Lee K S, Park J W. Free vascularized osteocutaneous fibular graft to the tibia.  Microsurgery. 1999;  19 141-147
• 25 Doi K, Kawakami F, Hiura Y, Oda T, Sakai K, Kawai S. One-stage treatment of infected bone defects of the tibia with skin loss by free vascularized osteocutaneous grafts.  Microsurgery. 1995;  16 704-712
• 26 Malizos K N, Nunley J A, Goldner R D, Urbaniak J R, Harrelson J M. Free vascularized fibula in traumatic long bone defects and in limb salvaging following tumor resection: comparative study.  Microsurgery. 1993;  14 368-374
• 27 Carroll W R, Esclamado R. Preoperative vascular imaging for the fibular osteocutaneous flap.  Arch Otolaryngol Head Neck Surg. 1996;  122 708-712
• 28 Young D M, Trabulsy P P, Anthony J P. The need for preoperative leg angiography in fibula free flaps.  J Reconstr Microsurg. 1994;  10 283-287
• 29 Kim D, Orron D E, Skillman J J. Surgical significance of popliteal arterial variants. A unified angiographic classification.  Ann Surg. 1989;  210 776-781
• 30 Disa J J, Cordeiro P G. The current role of preoperative arteriography in free fibula flaps.  Plast Reconstr Surg. 1998;  102;  1083-1088
• 31 Jones N F. The need for preoperative leg angiography in fibula free flaps.  J Reconstr Microsurg. 1994;  10 287-289
• 32 Lutz B S, Wei F C, Ng S H, Chen I H, Chen S H. Routine donor leg angiography before vascularized free fibula transplantation is not necessary: a prospective study in 120 clinical cases.  Plast Reconstr Surg. 1999;  103 121-127