Using A Free Fibular Flap and Fibular Graft Double-Strut Tunneling for an Infected Proximal Tibial Non-Union
Skeletal defects secondary to osseous tumors, trauma, and chronic osteomyelitis present numerous challenges for surgeons due to the avascular nature of the remaining tissue postresection1. Taylor et al first described an approach to bone defects using a free vascularized fibular graft as a structural and vascular donor, known as free fibular flaps (FFFs).2 Since its original description, the use of FFFs has become a viable option in limb-sparing bone reconstruction, providing options other than amputation.3 In this report, the authors present a case of FFFs tunneled within the proximal tibial plateau in combination with a nonvascularized fibular graft and morselized autografted bone to fill a large bony defect secondary to chronic osteomyelitis.
A 60-year-old male presented with an infected proximal tibial nonunion and bony defect following an open reduction and internal fixation of a traumatic left tibial plateau fracture due to a motor vehicle collision. Initial management took place at an outside institution with serial debridement and antibiotic spacers and the providers considered the patient a candidate for amputation. After transfer to our center, we elected to proceed with a limb salvage procedure. The first stage included removal of hardware, debridement of infected and necrotic bone of the tibial plateau, and placement of an antibiotic-eluting cement spacer.
A left medial hemigastrocnemius and hemisoleus flap along with fasciocutaneous flaps helped reconstruct the proximal tibial soft tissue defect. Multiple bone biopsies were sent to be cultured to ensure infection resolution, and the patient received parenteral antibiotics for 6 weeks.
Following preoperative discussions with the orthopedic and plastic surgery teams, the decision was made to perform a free fibular flap with the idea of introducing vascularized bone into the defect to optimize healing potential. An incision on the lateral aspect of the leg exposed the peroneal muscles, which we elevated and meticulously dissected circumferentially around the fibula. The osteotomy then left approximately 7 cm of fibula both proximally at the knee and distally at the ankle. We divided the interosseous septum. Once identifying the peroneal vessels, the dissection proceeded cephalad to create a fibular flap that elevated from the surrounding tissue on its pedicle. We removed the cement spacer from the defect, and contoured a 4.5-mm proximal tibial plate to match the shape of the patient’s proximal tibia.
After optimizing the contouring and femorotibial alignment, we osteotomized the FFF to match the defect. We tunnelled the length-adjusted FFF through the soft tissues and inserted it into the tibial defect. A proximal portion of the fibula also served as a bone graft to fill the gap, effectively creating a double-strut fibular flap and fibular graft within the tibial space. A combination of 100 mL of autograft, 10 mL of allogenic bone with cellular bone matrices (ViviGen, DePuy Synthes), and remaining fragments of the fibula packed to fill the rest of the defect. Fluoroscopic imaging confirmed the alignment and safe positioning of all implants. Reapproximation of the previous soft tissue flaps covered the bone and orthopedic hardware. An additional split-thickness skin graft from the left thigh measuring approximately 150 cm2 covered the remaining open left leg wounds.
At approximately 4-months postoperatively, the patient’s incisions appear well-healed with evidence of bony consolidation at the FFF insertion site. The patient’s overall limb alignment is in slight valgus; however, there is successful progress from partial weight-bearing of the operative extremity to weight-bearing as tolerated. No postoperative complications have emerged thus far with minimal pain, and the flap appears well-perfused.
Reconstruction of large bone defects can prove quite challenging for surgeons. In defects secondary to tumor resection, chronic osteomyelitis, and high-energy trauma, a patient-specific management strategy is planned. This case report is unique in that it represents an innovative FFF technique that further expands the applications of the fibula flaps. The FFF displayed important characteristics necessary to fulfill the treatment requirements for this patient’s large bony defect.
In this patient, the authors utilized a combination of the FFF, a nonvascularized fibular graft, morselized autograft, and allogeneic allograft with viable cells. Compared to a conventional single-strut vascularized fibular graft, a double-strut complex can support more mechanical stress as well as higher torque.15 Since this technique was first used by Jupiter et al in 1987, it became widely adopted for reconstructing defects in the lower extremities, including avascular necrosis of the femoral head.16,17 The presented tibial defect was also packed with morselized autograft collected from the remaining segments of the fibula. The use of bone grafting is shown to be associated with superior results in smaller defects.18 The combination of FFFs with a nonvascularized bone graft along with autografted morselized bone provides both biological stimulation, as well as solid structural support for the tibial plateau, ensuring hypertrophy and osteogenesis, while maintaining the integrity of the construct.
The versatility of the FFF has allowed for the expansion of its application to reconstruct a tibial plateau defect created by infected nonunion. As such, this technique should be considered as part of limb preservation efforts as a reconstructive option for the treatment of challenging large defects of the tibial plateau.
This blog was adapted with permission from an original article (found here) appearing with ePlasty.
Mr. Hamati is a fourth-year medical student at Rush Medical College of Rush University Medical Center in Chicago.
Dr. Siotos is a Resident in the Division of Plastic and Reconstructive Surgery at Rush University Medical Center in Chicago.
Dr. Terhune is an Orthopaedic Surgery Resident at Rush University Medical Center in Chicago.
Dr. Williams is an Assistant Professor and Chief of the Division of Orthopaedic Trauma at Rush University Medical Center in Chicago.
Dr. Dorafshar is Professor and Chief, Division of Plastic and Reconstructive Surgery, Rush University Medical Center in Chicago.
Financial disclosure: Dr. Dorafshar receives royalties from Elsevier and KLS Martin and indirect research support from DePuy Synthes.
