Two-stage reconstruction with free vascularized soft tissue transfer and conventional bone graft for infected nonunions of the tibia: 6 patients followed for 1.5 to 5 years

Background Vascularized soft tissue transfer may give better results of treatment of infected nonunions of the tibia. Methods 6 patients with infected nonunion of the tibia and combined soft tissue (70–170 cm2) and bony (5–8 cm) defects underwent staged reconstruction. Initial surgery consisted of soft tissue and bone debridement, external fixation, filling of the bony defect with a gentamicin-impregnated cement spacer, and reconstruction of the soft tissue with a free microsurgical muscle flap and skin graft. Second-stage surgery consisted of removal of the cement spacer and osseous reconstruction with nonvascularized bone graft. Results All patients except 1 achieved full weight-bearing and radiographic consolidation after 7–10 months. This patient required repeated bone grafting and internal plate fixation to heal. There were no cases of recurrence of infection at the latest follow-up, after a mean of 3 (1.5–5) years. Interpretation Staged reconstruction with free vascularized soft tissue transfer and conventional bone grafting within a cement-induced membrane is a low-risk surgical strategy resulting in a high rate of bone healing.   ▪

[1]  A C Masquelet,et al.  Induced membranes secrete growth factors including vascular and osteoinductive factors and could stimulate bone regeneration , 2004, Journal of orthopaedic research : official publication of the Orthopaedic Research Society.

[2]  M. Pirela-Cruz,et al.  Management of Posttraumatic Segmental Bone Defects , 2004, The Journal of the American Academy of Orthopaedic Surgeons.

[3]  S. Lindequist.  Bone grafting in femoral neck fractures: Results in 28 cases operated on with multiple pinning and cancellous bone grafting , 2004, Archives of Orthopaedic and Trauma Surgery.

[4]  V. Alt,et al.  The Proximal Tibia Metaphysis: A Reliable Donor Site for Bone Grafting? , 2003, Clinical orthopaedics and related research.

[5]  P. Boireau,et al.  Bone Reconstruction of the Lower Extremity: Complications and Outcomes , 2003, Plastic and reconstructive surgery.

[6]  S. Lepreux,et al.  Behaviour of cancellous bone graft placed in induced membranes. , 2002, British journal of plastic surgery.

[7]  B. Dhaon,et al.  The Ilizarov method in infected nonunion of fractures. , 2000, Injury.

[8]  F. Fitoussi,et al.  [Reconstruction of the long bones by the induced membrane and spongy autograft]. , 2000, Annales de chirurgie plastique et esthetique.

[9]  R. Musharafieh,et al.  Efficacy of Microsurgical Free‐Tissue Transfer in Chronic Osteomyelitis of the Leg and Foot: Review of 22 Cases , 1999, Journal of reconstructive microsurgery.

[10]  G. Hosny,et al.  The treatment of infected non-union of the tibia by compression-distraction techniques using the Ilizarov external fixator , 1998, International Orthopaedics.

[11]  S. Ueng,et al.  Management of large infected tibial defects with radical debridement and staged double-rib composite free transfer. , 1996, The Journal of trauma.

[12]  A. Ekkernkamp,et al.  Die infizierte Pseudarthrose , 1996, Der Unfallchirurg.

[13]  M. Pirela-Cruz,et al.  Vascularized bone grafts. , 1994, Orthopedics.

[14]  R. Hertel,et al.  Double Vascularized Fibulas for Reconstruction of Large Tibial Defects , 1993, Journal of reconstructive microsurgery.

[15]  E. E. Johnson,et al.  The treatment of infected nonunions and segmental defects of the tibia by the methods of Ilizarov. , 1992, Clinical orthopaedics and related research.

[16]  P. Flory,et al.  [Combination of cancellous bone grafts and free microvascular bone transplantation in large osseous defects]. , 1989, Handchirurgie, Mikrochirurgie, Plastische Chirurgie.

[17]  G. Robb,et al.  Reconstruction of large diaphyseal defects, without free fibular transfer, in Grade-IIIB tibial fractures. , 1989, The Journal of bone and joint surgery. American volume.

[18]  E. Chiu,et al.  Treatment of infected non-unions and segmental defects of the tibia with staged microvascular muscle transplantation and bone-grafting. , 1988, The Journal of bone and joint surgery. American volume.

[19]  T. Kristiansen,et al.  Noncommercial fabrication of antibiotic-impregnated polymethylmethacrylate beads. Technical note. , 1987, Clinical orthopaedics and related research.

[20]  A. Weiland,et al.  Clinical applications of vascularized bone autografts. , 1987, The Orthopedic clinics of North America.

[21]  R. Maurer,et al.  Multistaged surgical management of posttraumatic segmental tibial bone loss. , 1987, Clinical orthopaedics and related research.

[22]  A. Weiland,et al.  Free vascularized bone and muscle flaps for osteomyelitis. , 1986, Orthopedics.

[23]  A. Weiland,et al.  The efficacy of free tissue transfer in the treatment of osteomyelitis. , 1984, The Journal of bone and joint surgery. American volume.

[24]  J. Abzug,et al.  The Difficult Supracondylar Humerus Fracture: Flexion-Type Injuries. , 1983 .

[25]  H. Buncke,et al.  Free Latissimus Dorsi Muscle Flap with Split‐Thickness Skin Graft Cover: A Report of 16 Cases , 1982, Plastic and reconstructive surgery.

[26]  S. Mathes,et al.  Use of the Muscle Flap in Chronic Osteomyelitis: Experimental and Clinical Correlation , 1982, Plastic and reconstructive surgery.

[27]  S. Mathes.  The muscle flap for management of osteomyelitis. , 1982, The New England journal of medicine.

[28]  L. Lidgren,et al.  Antibiotic containing bone cement beads in the treatment of deep muscle and skeletal infections. , 1980, Acta orthopaedica Scandinavica.

[29]  E. Dingeldein,et al.  The release of gentamicin from polymethylmethacrylate beads. An experimental and pharmacokinetic study. , 1978, The Journal of bone and joint surgery. British volume.

[30]  C E Holden,et al.  The role of blood supply to soft tissue in the healing of diaphyseal fractures. An experimental study. , 1972, The Journal of bone and joint surgery. American volume.

[31]  H. Buchholz,et al.  [Depot effects of various antibiotics mixed with Palacos resins]. , 1970, Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen.