Annals of African Medicine Annals of African Medicine Society ISSN: 1596-3519 Vol. 10, Num. 1, 2011, pp. 25-28

Annals of African Medicine, Vol. 10, No. 1, January-March, 2011, pp. 25-28

Original Article

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

YZ Lawal¹, ES Garba², MO Ogirima¹, IL Dahiru¹, MI Maitama¹, K Abubakar³, FS Ejagwulu¹

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

Correspondence Address: Y Z Lawal, Department of Trauma and Orthopaedics, Ahmadu Bello University Zaria, Nigeria, lawalyau@yahoo.co.uk

Code Number: am11005

PMID: 21311151

DOI: 10.4103/1596-3519.76571

Abstract

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

Introduction

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].

Materials and Methods

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

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

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].

Conclusion

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

Copyright 2011 - Annals of African Medicine

The following images related to this document are available:

Photo images