Ipsilateral vascularised fibular transport for massive defects of the tibia

Abstract

T he ipsilateral and contralateral fibulae have been used as a vascularised bone graft for loss of tibial bone usually by methods which have involved specialised microvascular techniques to preserve or re-establish the blood supply.We have developed a method of tibialisation of the fibula using the Ilizarov fixator system, ipsilateral vascularised fibular transport (IVFT), and have used it in five patients with massive loss of tibial bone after treatment of an open fracture, infected nonunion or chronic osteomyelitis. All had successful transport, proximal and distal union, and hypertrophy of the graft without fracture. One developed a squamous-cell carcinoma which ultimately required amputation of the limb.The advantage of IVFT is that the fibular segment retains its vascularity without the need for microvascular dissection or anastomoses. Superiosteal formation of new bone occurs if the tibial periosteal bed is retained. Other procedures such as corticotomy and lengthening can be carried out concurrently.

Ipsilateral Fibular Transport Using Ilizarov–Taylor Spatial Frame for a Limb Salvage Reconstruction: A Case Report

“…Each of these methods is effective depending on the circumstances. They have drawbacks including the possibility of donor site morbidity, deep infection [13], peroneal nerve injury [1], and ankle instability on the contralateral previously unaffected limb. They may be at a high risk of failure [1,9,10] as infection, rejection, fracture, and nonunion all have been described with these techniques.…”

“…The fibula is a straight cortical bone and is long enough to bridge most defects. While it normally carries only one sixth of the static loading of the leg [7], the fibula will undergo hypertrophy [5,6,10,13,16] when it is subjected to greater loading stresses. This was our rationale for maintaining the patient in a dynamized frame for an extended period of time.…”

“…Ilizarov described two methods [13,25] for treating large defects with his fine wire fixator. In the first method, the fibular segment is translated medially, creating a proximal and distal, side-to-side tibiofibular synostosis.…”

“…A large graft of ipsilateral fibula raised on a pedicle of peroneal tibial muscles, anterior tibial muscles, and the peroneal vessels, which are aligned and fixed with the tibia in its posterior long axis, could provide a sound mechanical and biological basis of union. However, open methods require large surgical dissections and skeletal stability could be difficult to accomplish [3,4,7,[13][14][15].…”

“…A less common application of the Ilizarov technique is transverse bone transport [13,15,25]. The frame allows for gradual transport of the fibula into the adjacent tibial defect site, precise proximal and distal alignment of the fibula, and compression at tibial contact sites.…”