Free Vascularized Fibula Grafting as Management for Large Skeletal Defects in Humeral Osteomyelitis in Northern Ireland

Abstract

IntroductionThe purpose of this study is to evaluate the radiological and clinical outcomes in Northern Ireland of free vascularised fibular bone grafting for the treatment of humeral bone loss secondary to osteomyelitis. Upper limb skeletal bone loss due to osteomyelitis is a devastating and challenging complication to manage for both surgeon and patient. Patients can be left with life altering disability and functional impairment. This limb threatening complication raises the question of salvage versus amputation and the associated risk and benefits of each. Free vascularised fibula grafting is a recognised treatment option for large skeletal defects in long bones but is not without significant risk. The benefit of vascularised over non-vascularised fibula grafts include preservation of blood supply lending itself to improved remodeling and osteointegration.Materials & MethodsSixteen patients in Northern Ireland had free vascularised fibula grafting. Inclusion criteria included grafting to humeral defects secondary to osteomyelitis. Six patients were included in this study. Patients were contacted to complete DASH (Disabilities of the Arm, Shoulder and Hand) questionnaires as our primary outcome measure. Secondary outcome measures included radiological evaluation of osteointegration and associated operative complications. Complications were assessed via review of Electronic Care Record outpatient and in-patient documents.ResultsSix patients in Northern Ireland have been treated with free fibula grafting for humeral defects secondary to osteomyelitis. Regarding aetiology of osteomyelitis, five patients had sustained humeral fractures which were initially managed with open reduction internal fixation and complicated by infected non-union. These cases required removal of metalwork, segmental resection and placement of cement spacer with prolonged antibiotic therapy before return to theatre for vascularised fibula grafting. One patient developed native humeral osteomyelitis, the exact cause of which was unclear. Four patients were contactable for outcome score completion. The average DASH score was 45.5. (range 11.1 – 70.4). The median score was 50.2. With regard to post-operative complications, four of the six patients required return to theatre. Reasons were flap congestion, failure of metalwork at three months, donor site skin grafting for delayed healing and external fixation of graft fracture following trauma. Three patients experienced donor site morbidity in the form of delayed healing or infection requiring admission for intravenous antibiotics. One patient died due to cerebrovascular accident (CVA) within one month of return to theatre for a graft related complication - radiographic osteointegration was not assessed for this patient. At the time of this study, three of the remaining five patients have achieved graft osteointegration. Two patients are within 6 months of grafting procedure therefore too early to comment on radiographic osteoingreration. Radiographs to date are encouraging.ConclusionsFree vascularised fibula grafting for humeral shaft bone defects is a viable option for limb salvage but carries significant risk of complications. Our study highlights the need for proper informed consent regarding risk for this uncommon complex procedure which should only be undertaken by a multidisciplinary team in a specialist orthoplastic unit. This procedure is performed infrequently and our study has given us more information on risk and clinical outcomes to provide full and informed consent for patients in the future.