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ORIGINAL ARTICLE
Year : 2011  |  Volume : 10  |  Issue : 1  |  Page : 25-28  

Use of non-vascularized autologous fibula strut graft in the treatment of segmental bone loss


1 Department of Trauma and Orthopaedics, Ahmadu Bello University Zaria, Nigeria
2 Department of Surgery, Ahmadu Bello University Zaria, Nigeria
3 National Orthopedic Hospital Dala Kano, Nigeria

Date of Web Publication9-Feb-2011

Correspondence Address:
Y Z Lawal
Department of Trauma and Orthopaedics, Ahmadu Bello University Zaria
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1596-3519.76571

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   Abstract 

Background : Fractures resulting in segmental bone loss challenge the orthopedic surgeon. Orthopedic surgeons in developed countries have the option of choosing vascularized bone transfers, bone transport, allogenic bone grafts, bone graft substitutes and several other means to treat such conditions. In developing countries where such facilities or expertise may not be readily available, the surgeon has to rely on other techniques of treatment. Non-vascularized fibula strut graft and cancellous bone grafting provides a reliable means of treating such conditions in developing countries.
Materials and Methods : Over a period of six years all patients with segmental bone loss either from trauma or oncologic resection were included in the study. Data concerning the type of wound, size of gap and skin loss at tumor or fracture were obtained from clinical examination and radiographs.
Result : Ten patients satisfied the inclusion criteria for the study. The average length of the fibula strut is 7 cm, the longest being 15 cm and the shortest 3 cm long. The average defect length was 6.5 cm. Five patients had Gustillo III B open tibial fractures. One patient had recurrent giant cell tumor of the distal radius and another had a polyostotic bone cyst of the femur, which was later confirmed to be osteosarcoma. Another had non-union of distal tibial fracture with shortening. One other patient had gunshot injury to the femur and was initially managed by skeletal traction. The tenth patient had a comminuted femoral fracture. All trauma patients had measurement of missing segment, tissue envelope assessment, neurological examination, and debridement under general anesthesia with fracture stabilization with external fixators or casts. Graft incorporation was 80% in all treated patients.
Conclusion : Autologous free, non-vascularized fibula and cancellous graft is a useful addition to the armamentarium of orthopedic surgeon in developing countries attempting to manage segmental bone loss, whether created by trauma or excision of tumors.

   Abstract in French 

Fond : Fractures résultant dans le défi de perte osseuse segmentaires le chirurgien orthopédiste. Les chirurgiens orthopédistes dans les pays développés ont la possibilité de choisir les transferts vascularisée os, os transport, greffes osseuses allogènes, substituts de greffe osseuse et plusieurs autres moyens pour traiter de telles conditions. Dans les pays en développement où ces installations ou l'expertise peut-être pas facilement disponible, le chirurgien doit compter sur les autres techniques de traitement. Greffe d'entretoise péroné non-vascularisé et le greffage d'os spongieux fournit un moyen fiable de traiter de telles conditions dans les pays en développement.
Méthode : Sur une période de six ans, tous les patients avec perte osseuse segmentaire de traumatisme ou de résection oncologic ont été inclus dans l'étude. Données concernant le type de blessure, taille de la perte de l'écart et de la peau à la tumeur ou fracture proviennent de l'examen clinique et radiographies.
Résultat : Dix patients satisfait les critères d'inclusion pour l'étude. La durée moyenne de la jambe du péroné est 7 cm, la plus longue étant de 15 cm et la plus courte de 3 cm de long. La longueur moyenne des défauts est 6,5 cm. cinq patients avaient Gustillo III B ouvrir tibiales fractures. Un patient a eu tumeur récurrente géant du radius distal et un autre avait un kyste d'os polyostotic du fémur, qui a été confirmé par la suite être ostéosarcome. Un autre a non syndiqués de fracture tibiale distal avec raccourcissement. Un autre patient avait des blessures par balle le fémur et était initialement géré par traction du squelette. Le patient dixième avait une fracture fémorale broyée. Tous les patients traumatisés qui avait mesure des disparus segment, tissu enveloppe évaluation, l'examen neurologique et parage sous anesthésie générale avec la stabilisation de la fracture avec fixations externes ou de moulages. Incorporation de greffe était de 80% de tous les patients traités.
Conclusion : Autologous libre, non vascularisé péroné et spongieux greffe est un ajout utile à l'arsenal de chirurgien orthopédiste dans les pays en développement, tenter de gérer la perte osseuse segmentaires, si créé par un traumatisme ou l'excision des tumeurs.
Mots clés : Os perte, une allogreffe fibulaire, segment, reconstruction du squelette

Keywords: Bone loss, fibular allograft, segment, skeletal reconstruction


How to cite this article:
Lawal Y Z, Garba E S, Ogirima M O, Dahiru I L, Maitama M I, Abubakar K, Ejagwulu F S. Use of non-vascularized autologous fibula strut graft in the treatment of segmental bone loss. Ann Afr Med 2011;10:25-8

How to cite this URL:
Lawal Y Z, Garba E S, Ogirima M O, Dahiru I L, Maitama M I, Abubakar K, Ejagwulu F S. Use of non-vascularized autologous fibula strut graft in the treatment of segmental bone loss. Ann Afr Med [serial online] 2011 [cited 2020 Oct 20];10:25-8. Available from: https://www.annalsafrmed.org/text.asp?2011/10/1/25/76571


   Introduction Top


Fractures resulting in segmental bone loss challenge the orthopedic surgeon. These are commonly seen as the result of increasing civil strife and motor vehicular accidents. Such defects may also result from resection of segments of bone during treatment of tumors or tumor-like conditions. Non-vascularized fibula strut graft and cancellous bone grafting provides a reliable means of treating such conditions in developing countries.

Orthopedic surgeons in developed countries have the option of choosing vascularized bone transfers, bone transport, allogenic bone grafts, bone graft substitutes and several other means to treat such conditions. [1] However, in developing countries where such facilities or expertise may not be readily available, the surgeon has to rely on other techniques of treatment. The aim of this study is to determine the efficacy of the use of non-vascularized fibular strut grafts combined with cancellous grafts to re-establish bone continuity for the purpose of weight bearing in lower limbs or allow for function in the upper limbs. This is an age-old technique, first reported in 1911. [2] Fractures with segmental bone loss are more likely to be open than closed and often occur because of high-energy trauma or missile injuries. These fractures can be classified into three categories with subtypes A or B depending on whether the fracture is open or closed [3] [Table 1].
Table 1 :Classification of fractures with missing segments according to Salai

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   Materials and Methods Top


This study was conducted at the Ahmadu Bello University Teaching Hospital Zaria between 2003 and 2009; all patients with segmental bone loss either from trauma or oncologic resection were included in the study. Data concerning the type of wound, size of gap and skin loss at tumor or fracture were obtained from clinical examination and radiographs.


   Results Top


Ten patients satisfied the inclusion criteria for the study. The average length of the fibula strut is 7 cm, the longest being 15 cm and the shortest 3 cm long. The average defect length was 6.5 cm. Five patients had Gustilo III B open tibial fractures. One patient had recurrent giant cell tumor of the distal radius and another had a polyostotic bone cyst of the femur which was later confirmed to be osteosarcoma. Another had non-union of distal tibial fracture with shortening. One other patient had gunshot injury to the femur and was initially managed by skeletal traction. The tenth patient had a comminuted femoral fracture. All trauma patients had measurement of missing segment, tissue envelope assessment, neurological examination, and debridement under general anesthesia with fracture stabilization with external fixators or casts. They also had split thickness skin grafting to achieve skin cover. None required flap transfer. The osteoclastoma of the distal radius had excision twice before the current operation with recurrence. The tumor was noticed to be encircling the radial and ulnar arteries, thus making amputation a likely option. The gap created was filled by ipsilateral fibula and cancellous graft. Stability was achieved by a combination of Kirchner wire and small fragment plate and screws.

The patient with a polyostotic bone cyst had compartmental excision with ipsilateral fibula strut and cancellous grafting and stabilization with a 14-hole broad dynamic compression plates and screws.


   Discussion Top


Vascularized fibula combined with cancellous graft provides probably best means of dealing with fractures with gap or gaps created after removal of tumors or tumor-like conditions. However, in our environment the expertise and facilities required for this operation are not available or are in short supply. Autologous cancellous graft is osteogenic and osteoinductive but is not osteoconductive. [4] It is also easily revascularized and is not immunogenic; all desirable attributes of a good graft. [5] It does not allow for transmission of viral or bacterial agents from one patient to another. The main drawback of cancellous grafting is the finite number of harvest sites and volume available as well as high failure rate when used alone. [6] Donor site morbidity is another problem. Allografts have no problem of donor site morbidity but can transmit infections, require a tissue bank which is not available in developing countries and have lower graft incorporation rates compared to autografts.

In our series, the main complication was that of infection which led to graft lysis in two patients. In both cases, osteosynthesis with plates and screws were used which agree with the finding of Jaffe and Dunham. [7] Graft was incorporated in 80% of patients treated. This technique requires high patient compliance but not to the extent required by patients treated by Ilizarov technique, which is usually used for treatment of congenital anomalies. [8],[9] It is important that during fibular harvest, the proximal and distal 5 cm are preserved to prevent injury to the common peroneal nerve and to retain the stability of the ankle joint. [10],[11] Functional outcome in those who had successful graft incorporation was generally good. It is noteworthy that none of our patient had stress fracture which is said to be common when the grafts are greater or equal to 12 cm long. [12] One of our patients had shortening of 6 cm. The results are summarized in [Table 2].
Table 2 :Summary of patients and their outcome

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   Conclusion Top


It can be drawn from the findings above that autologous free, non-vascularized fibula and cancellous graft is a useful addition to the armamentarium of orthopaedic surgeon in developing countries attempting to manage segmental bone loss, whether created by trauma or excision of tumors.

 
   References Top

1.Taylor GI, Milller GD, Ham FJ. The free vascularised bone: A clinical extension of microvascular techniques. Plast Reconstr Surg 1975;55:533-44.  Back to cited text no. 1
    
2.Walter M. Resection de'lextremite inferieure du radius pour Osteosarcome: Graffe del'extermite superiue du Perone. Bullet Mem Soc de Chir de Par 1911;37:739-47.  Back to cited text no. 2
    
3.Salai M, Horozowski H, Prittsch M, Amit Y. Primary reconstruction of traumatic bony defects using allografts. Arch Orthop Trauma Surg 1999;119:435-9.   Back to cited text no. 3
    
4.Finkemier CG. Bone grafting and bone graft substitutes. J Bone Joint Surg Am 2002;84-A:454-64.  Back to cited text no. 4
    
5.Dell PC, Burchardt H, Glowsczewski FP Jr. A roentegenographic, biomechanical and histological evaluation of vascularised and non-vascularised segmental fibula canine autografts. J bone Joint Surg Am 1985;67-A:105-12.  Back to cited text no. 5
    
6.Enneking WF, Gearen PF. Fibrous dysplasia of the femoral neck: Treatment by cortical bone grafting. J Bone Joint Surg Am 1986;68:1415-22.  Back to cited text no. 6
[PUBMED]    
7.Jaffe KA, Dunham WK. Treatment of benign lesions of the femoral head and neck. Clin Orhop 1990;257:134-7.  Back to cited text no. 7
    
8.Ilizarov GA. The principles of Ilizarov method. Bull Hosp Jt Dis Orthop Inst 1988;48:1-11.  Back to cited text no. 8
[PUBMED]    
9.Dahl MT, Gulli B, Berg T. Complications of limb lengthening: A learning curve. Clin Orthop Relat Res 1994;301:10-8.  Back to cited text no. 9
[PUBMED]    
10.George B, Abudu A, Grimer RJ, Carter SR, Tilman RM. The treatment of benign lesions of the proximal femur with non-vascularised autologous fibular strut grafts. J Bone Joint Surg Br 2008;90:648-51.   Back to cited text no. 10
    
11.Springfield D. Autograft reconstructions. Orthop Clin North Am 1996;27:483-92.  Back to cited text no. 11
[PUBMED]    
12.De Boer HH, Wood MB. Bone changes in the vascularised fibula graft. J Bone Joint Surg Br 1989;71B:374-8.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2]


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