Open tibial fracture with severe soft tissue injury and bone loss managed with ipsilateral fibular transport and its complications: a case report
DOI:
https://doi.org/10.18203/issn.2455-4510.IntJResOrthop20213162Keywords:
Open tibial fracture, Ipsilateral fibular transport, Ilizarov external fixatorAbstract
Massive segmental bone defects of tibia present as a challenging task to manage specially when associated with extensive soft tissue injury. A 30 year old male presented to Paras HMRI hospital, Patna, post road traffic accident with Gustilo Anderson 3B comminuted open tibia shaft fracture and with an external fixator in situ with a grossly inflamed and infected wound. Initially patient was managed with serial wound debridement and skin grafting was done early to obtain adequate soft tissue coverage. The patient then underwent application of Ilizarov external fixator with plan of one level fibular osteotomy for ipsilateral fibular transport. With good outcome of the procedure clinically and radiologically, Ilizarov fixator was removed after time duration of about 1.3 years and limb was immobilized in plaster of Paris (POP) cast which was removed after 8 weeks. Within 1 month of removal of POP cast the patient presented to hospital again with complaints of pain and instability when his leg was run over by his child’s bicycle while playing. Diagnosed as fracture of proximal (transported) fibula he was managed then with locking plates; one of which was used as an internal fixator and the other as external fixator which was outside the body and acted as a support to the operated limb. After about 1 year the external locking plate was removed and patient was able to bear weight on his extremities. Despite various modalities to treat massive tibial gap, fibular transport procedure with Ilizarov external fixator seems to be the most viable option.
References
Hansen ST Jr. Overview of the severely traumatized lower limb: reconstruction versus amputation. Clin Orthop Relat Res. 1989;243:17-9.
Bondurant FJ, Cotler HB, Buckle R, Miller-Crotchett P, Browner BD. The medical and economic impact of severely injured lower extremities. J Trauma. 1988;28:1270-3.
Williams MO. Long term cost comparison of major limb salvage using Ilizarov method versus amputation. Clin Orthop Relat Res. 1994;301:156-8.
Kim HS, Jahng JS, Han DY, Park HW, Chun CH. Immediate ipsilateral fibular transfer in a large tibial defect using a ring fixator: a case report. Int Orthop. 1998;22:321-4.
MacKenzie EJ, Bosse MJ, Castillo RC, Smith DG, Webb LX, Kellam JF, et al. Functional outcomes following trauma-related lower-extremity amputation. J Bone Joint Surg. 2004;86:1636-45.
Enneking WF, Eady JL, Burchardt H. Autogenous cortical bone grafts in the reconstruction of segmental skeletal defects. J Bone Joint Surg Am. 1980;62:1039-58.
Hertel R, Pisan M, Jakob RP. Use of the ipsilateral vascularised fibula for tibial reconstruction. J Bone Joint Surg Br. 1995;77:914-9.
Mankin HJ, Hornicek FJ, Raskin KA. Infection in massive bone allografts. Clin Orthop Relat Res. 2005;432:210-6.
Ottaviani G, Randelli P, Catagni MA. Segmental cement extraction system (SEG-CES) and the Ilizarov method in limb salvage procedure after total knee cemented prosthesis removal in a former osteosarcoma patient. Knee Surg Sports Traumatol Arthrosc. 2005;13:557-63.
Hanh E. Eine methode. Pseudoarthrosen der Tibia mit grossen Knochendefekt zur Heilung zu Gringen. Zentrab f Chir. 1884;11:337-41.
Huntington TW. Case of bone transference. Use of a segment of fibula to supply a defect in the tibia. Ann Surg. 1905;41:249-51.
Zahiri CA, Zahiri H, Tehrany F. Limb salvage in advanced chronic osteomyelitis in children. Int Orthop. 1997;21:249-52.
Shapiro MS, Endrizzi DP, Cannon RM. Treatment of tibial defects and nonunions using ipsilateral vascularized fibular transposition. Clin Orthop Relat Res. 1993;296:207-12.
Rozbruch SR, Pugsley JS, Fragomen AT. Repair of tibial nonunions and bone defects with the Taylor spatial frame. J Orthop Trauma. 2008;22:88-95.
Cattaneo R, Catagni M, Johnson EE. The treatment of infected nonunions and segmental defects of the tibia by the methods of Ilizarov. Clin Orthop Relat Res. 1992;280:143-52.
Sen C, Kocaoglu M, Eralp L. Bifocal compression– distraction in the acute treatment of grade III open tibial fractures with bone and soft-tissues: a report of cases. J Orthop Trauma. 2004;18:150-7.
Atkins RM, Madhaven P, Sudhaker J. Ipsilateral vascularized fibular transport for massive defects of the tibia. J Bone Joint Surg Br. 1999;81:1035-40.
Catagni MA, Ottaviani G, Camagni M. Treatment of massive tibial bone loss due to chronic draining osteomyelitis: fibula transport using the Ilizarov frame. Orthopedics. 2007;30:608-11.
Ueng SW, Chuang DC, Cheng SL, Shih CH. Management of large infected tibial defects with radical debridement and staged doublerib composite free transfer. J Trauma. 1996;40:345-50.
Eisenschenk A, Dihlmann SW, Weber U. Indications, results and complications in connection with free vascularized bone transplants for extremity preservation. Chir Organi Mov. 1993;78:207-12.
Brien EW, Terek RM, Healey JH, Lane JM. Allograft reconstruction after proximal tibial resection for bone tumors: an analysis of function and outcome comparing allograft and prosthetic reconstructions. Clin Orthop Relat Res. 1994;303:116-27.
Lange RH. Limb reconstruction versus amputation decision making in massive lower extremity trauma. Clin Orthop Relat Res. 1989;243:92-9.
Amr SM, El-Mofty AO, Amin SN. Anterior versus posterior approach in reconstruction of infected nonunion of the tibia using the vascularized fibular graft: potentialities and limitations. Microsurgery. 2002;22:91-107.