International Orthopaedics (SICOT) (2010) 34:425430

DOI 10.1007/s00264-009-0761-x

ORIGINAL PAPER

Free vascularised fibular grafting in the treatment of large

skeletal defects due to osteomyelitis
Yuan Sun & Changqing Zhang & Dongxu Jin &
Jiagen Sheng & Xiangguo Cheng & Xudong Liu &
Shengbao Chen & Bingfang Zeng

Received: 27 November 2008 / Revised: 13 February 2009 / Accepted: 14 February 2009 / Published online: 24 March 2009
# Springer-Verlag 2009

Abstract Treatment of skeletal defects secondary to limited. Moreover, in infected defects, scarring of the soft-
osteomyelitis is a challenging problem. The purpose of tissue envelope compromises revascularisation of the graft
this study was to present our experience of the use of free [14].
vascularised fibular grafts to treat such defects. Ten Vascularised bone grafts, such as the vascularised fibular
patients with a mean age of 31 years (range 1650 years) graft, retain their intrinsic blood supply, hasten bone-
and a skeletal defect with a mean length of 9.5 cm (range healing and hypertrophy [6], and have been widely used
617 cm) were managed with a protocol which included for reconstruction of large skeletal defects following
radical debridement of the lesion and a vascularised trauma, tumour resection, or congenital diseases [5, 910,
fibular graft. The mean follow-up time was 26 months. 15]. Bone defects of an infectious aetiology constitute a
Union of the graft occurred in all patients, at a mean of 4.5 particularly challenging and important subgroup; however,
months. No recurrence of osteomyelitis was observed. The only a few studies in the literature have focussed on the
mean time to full weight bearing was ten months, and all application of the free vascularised bone graft for the
patients were pain-free and able to walk without supportive treatment of infected bone defects [4, 16, 18]. To
devices. A free vascularised fibular graft is a viable option investigate this question, we evaluated the use of a
for the management of large skeletal defects resulting from vascularised fibular graft to treat such a defect due to
osteomyelitis. osteomyelitis.

Introduction Materials and methods

Despite modern advances in antibiotics and surgical This study was reviewed and approved by our institutional
techniques, the long bone defect complicated by osteomy- review board, and informed consent was obtained from all
elitis usually presents a challenging problem for the treating patients. From January 2005 to June 2007, ten patients who
surgeon [3]. had infected nonunion and bone defects were treated with
Conventional autogenous bone-grafting is preferably used the vascularised fibular graft at our institution. There were
for defects of <6 cm, but it has limitations for the treatment nine men and one woman whose average age was 31 years
of larger defects; the time-period for graft incorporation is (range 1650 years). All defects (including seven tibial
prolonged, and the quantity of available autogenous graft is defects and three femoral defects) were located in the lower
extremity. The mean length of the skeletal defects was
9.5 cm (range 617 cm). The defect was the result of
Y. Sun : C. Zhang (*) : D. Jin : J. Sheng : X. Cheng : X. Liu : surgical debridement for the treatment of osteomyelitis in
S. Chen : B. Zeng all patients. The osteomyelitis was post-traumatic in six
Department of Orthopaedic Surgery, Shanghai Sixth Peoples
patients and postoperative in four patients. Staphylococcus
Hospital, School of Medicine, Shanghai Jiao Tong University,
Shanghai 200233, China aureus was the most common organism, identified in seven
e-mail: [email protected] of the ten cases.
426 International Orthopaedics (SICOT) (2010) 34:425430

All patients were initially treated elsewhere and then bearing was restricted not only until healing of the
referred to our institution. An average of 12 months (range vascularised bone graft but also until hypertrophy of the
824 months) elapsed from the time of initial injury to graft had occurred.
presentation at our institution for treatment. During this The mean duration of follow-up was 26 months (range 14
interval, the patients had undergone three to seven 40 months). The outcome variables for the purposes of this
operations, or an average of 3.9 operations each. On study included the union rate, the time to healing of the
presentation, three patients had a limb-length discrepancy vascularised bone graft, the rate of limb salvage, and the
ranging from 1.5 to 4 cm (mean 2.6 cm). The median infection rate. We also assessed the prevalence of complica-
duration of infection was 6.5 months (range 312 months). tions, the time to full weight bearing, and the range of motion
of the adjacent joints.
Management protocol

Before operation, we performed a careful preoperative Results

preparation that included assessment of size of the bone
defect, identification of the infecting organisms, and The early postoperative course was uneventful; no patients
evaluation of the condition of both the adjacent soft tissue experienced acute complications.
and the neighbouring joints. According to microbiological Bony union was achieved after our treatment in all
sensitivity tests, appropriate antibiotic was selected and patients. Primary union of the vascularised bone graft
used until there were no clinical signs of acute infection occurred in eight of the nine patients, at a mean of 4.5
(erythema, swelling, or drainage) or laboratory signs of months (range 38 months), as determined by evidence of
infection (an elevated erythrocyte sedimentation rate, bridging of three of the four cortices on plain radiographs.
C-reactive protein level, or leukocyte count). Once surgical There was one nonunion of the distal grafthost junction
treatment was decided upon, the patients were admitted to site in a patient with a femoral defect. The nonunion was
the osteomyelitis ward, where they were managed and repaired with autogenous iliac crest bone grafting, and bony
reviewed prospectively. union was achieved three months later. There were no stress
In the operation, debridement and reconstruction with fractures seen.
the vascularised bone graft were performed in one stage. No deep infection recurred. One superficial wound
First, a thorough debridement was done. All infected infection that responded well to limited debridement and
hardware was removed; an extensive resection of all antibiotic therapy was observed.
avascular infected bone was performed back to bleeding The mean time to full weight bearing following the
tissue. Bone, soft tissue, and fluid samples were sent for reconstructions was ten months (range, 717 months)
aerobic, anaerobic, mycobacterial, and fungal cultures. overall.
The wound was copiously irrigated with physiological At the time of final follow-up, limb salvage and control
saline. Second, reconstruction of the defect with the of the infection had been achieved in all patients. All ten
vascularised fibular graft was carried out. Fibular dissec- patients were able to fully bear weight on the lower
tion was done through a lateral approach under tourniquet extremity, and none was using any assistive device or
control according to our previous technique [19]. It was brace. A limb-length discrepancy of 2 cm was present in
important to leave at least 6 cm of the distal fibula to one patients, who used a shoe raise.
maintain ankle stability. The contralateral fibula was the At the time of the latest follow-up, no patient reported
donor bone in all cases. The mean graft length was 11.5 cm pain in the reconstructed extremity. Nine patients had a full
(range 620 cm). In the recipient site, the fibular graft was range of motion of the adjacent joints. One patient had
inserted into the medullary canal of the tibia or femur. limitation of knee flexion (090); however, the limitation
Additional stability was provided by an external fixator or had been present prior to the vascularised bone graft
locking plate. Then, end-to-end or end-to-side arterial procedure.
anastomosis was performed under an operating micro-
scope. Finally, the wound was closed directly after insertion
of drain tubes and covered with a dressing. After one week Illustrative case reports
of postoperative intravenous antibiotics, the patients were
discharged from the hospital. Case 1 The first case was a 37-year-old man with chronic
The patients were followed up clinically and radiograph- infected nonunion after plate internal fixation for his left
ically at regular intervals. The external skeletal fixator was tibial shaft fracture. On referral, there was an open wound
removed when union was demonstrated roentgenographi- on his left leg through three debridement procedures
cally. The involved extremity was braced, and weight performed at another hospital. After radical debridement,
International Orthopaedics (SICOT) (2010) 34:425430 427

we performed free vascularised fibular graft combined with Discussion

locking compression plate (LCP) fixation. The postopera-
tive course was uneventful, bone union was satisfactory in Infected nonunion of a long bone remains a therapeutic
four months. Two years after operation, union remained challenge. The infection of the lesion site not only prevents
sound and there had been no recurrence of the osteomylitis stable internal fixation but also slows bone healing.
(Fig. 1). Infection has been reported to be the main cause of delayed
union or nonunion [1]. Thus, complete cure of the infection
Case 2 The second case was a 41-year-old man who was is the mainstay of treatment in such patients. As we know,
in a car accident that caused left tibia and fibular the most effective cure for infection is radical debridement
fracture. The fractures were fixated with plates in the [2]. However, the extent of radical debridement necessary
local hospital. The tibial fracture was infected and had to obtain live and uninfected bone usually results in large
nonunion nine months later. It was re-explored and bone defects, which require complex reconstruction [13].
transplanted with bone substitute. But the bone substitute Although this challenge can often be addressed by
was absorbed and a large bone defect occurred four distraction osteogenesis, this treatment modality needs a
months later. We did a free vascularised fibular graft prolonged consolidation period, causing great patient
combined with LCP fixation. In the operation, bone discomfort. Many patients and surgeons do not like this
defect and sclerosis at the broken ends were observed. approach.
After removing the sclerotic bone from the broken ends, With the advent of microvascularised tissue transfer,
the bone defect was 6 cm (Fig. 2). extensive bone defects resulting from radical debridement

Fig. 1 a Roentgenograms on
referral. b Roentgenograms
after our debridement showed a
9-cm tibial defect. A microvas-
cular fibular transfer with
locking compression plate
(LCP) was performed to recon-
struct the tibial bone defect. c
Roentgenograms after 4 months
showed good union of the
grafted fibular bone. d Roent-
genograms after 2 years showed
good hypertrophy of the grafted
fibular bone

A B

C D
428 International Orthopaedics (SICOT) (2010) 34:425430

can be repaired by this method [7]. The main purpose of achieves a good result in treating infected nonunion of the
this article is to present our experience of the use of free long bone (Figs. 1 and 2). But at the same time, this
vascularised fibular grafting in the treatment of segmental technique may enhance the risk of infection, especially in
defects resulting from debridement of osteomyelitis. active infection.
In this study, we used a one-stage treatment protocol.
The goal of infection elimination was achieved via radical Reconstruction of bone defects by free vascularised fibular
debridement until live and bleeding bone was reached. The graft
bone and soft tissue reconstruction was performed in one
stage until we were confident that infection could be In the past, some authors thought that the free vascularised
controlled and extensive soft and bone defects could be fibular graft could only be done at specialised centres and
repaired by free vascularised fibular grafting. This treatment was time consuming. These grafts took years to hypertro-
protocol provided rapid recovery from osteomyelitis and phy and often fractured one or more times before
predictable recovery from nonunions. During the course of remodelling was complete. The grafts often failed to unite
treatment, the wound care was simple and comfortable, to the recipient osseous tissue at one or both ends. The
with no need for a prolonged period of treatment with incorporation of microvascular osseous transplant in host
systemic antibiotics. bed is 40% in patients with osseous sepsis [8].
From our experience, we found that application of rigid However, in our study, fatigue fracture and nonunion of
fixation, the technique of free vascularised fibular transfer the vascularised fibular grafts have seldom been encoun-
and antibiotic treatment were very helpful in the treatment tered, and there has been no donor site morbidity in any
of infected bone defects. The bone healing occurs if patient. We modified the surgical technique of harvesting
bacterial activity is contained, the vascular environment at the fibula. The operating time necessary to transfer a viable
the lesion site is ensured, and stable fixation and soft tissue bone graft, as compared with a conventional graft, is not
coverage are provided with early and adequate bone excessive. The time to harvest the fibula and to close the
grafting. This can all be achieved by adequate debridement donor wound has averaged 0.51.0 hours, and the time spent
and stabilisation of the lesion and reconstruction of the microscopically anastomosing blood vessels is usually less
bone defect. than one hour.
The free vascularised bone graft offers some particular
Debridement advantages for the reconstruction of major skeletal defects.
It has unique anatomical and biological properties [5, 910,
Thorough and adequate debridement is the most important 15]. The size and straight configuration of the fibular graft
principle in eradicating osteomyelitis. The sinus tract, allow it to fit into the medullary canal of the femur or tibia,
infected soft tissue, and unhealthy granulation tissue must facilitating reconstruction of extensive defects up to 26 cm
be excised and subjected to microbiological and histolog- [1, 12]. The fibula has dual vascularity, derived from
ical examination. Loose and sequestrated bone should be endosteal and periosteal vessels, which is retained when
removed. Excision of bone is guided by the punctate successful microvascular anastomoses are performed be-
bleeding test [11]. tween the graft pedicle and the recipient-site vessels [17].
As a result, the vascularised bone graft bypasses the process
Stable fixation of creeping substitution, which characterises healing of
avascular grafts, and involves graft necrosis, resorption, and
Generally, stability of the lesion site was achieved with an new bone formation. The vascularised bone graft maintains
external fixator. Stabilisation of the lesion by external its mass and architecture to a greater degree, is biomechan-
fixator decreases interfragmentary motion, reduces inflam- ically stronger than an avascular fibular graft, and demon-
mation, and provides an improved milieu for graft strates enhanced healing potential and hypertrophy [3]. In
incorporation and bone union. But the external fixator was addition, the vascularised bone graft provides an important
inconvenient for daily life of patients and runs the risk of source of vascularity in scarred and avascular recipient
pin tract infection. Thus, in this study, in nondraining and sites. Thus, for some infected defects of <4 cm with poor
inactive infections, locking plate fixation could also be soft tissue and blood supply, vascularised fibular graft can
done when radical debridement had been performed. be used (as shown in Fig. 2).
Locking plate is like an internal fixator system which
combines both the advantages of external fixation techni- Antibiotics
ques and the early advances of the so-called biological
plating technique into one system. In our practice, this The appropriate antibiotics should be chosen after isolation,
approach not only brings convenience to patients, but also identification, and antibiotic susceptibility testing of the
International Orthopaedics (SICOT) (2010) 34:425430 429

Fig. 2 a Roentgenograms
before surgery. b Roentgeno-
grams after first internal fixation
c Roentgenograms after 10
months showed nonunion.
Debridement and artificial bone
graft were performed. d After 4
months roentgenograms showed
that artificial bones were
absorbed. e Anteroposterior and
lateral radiographs postopera-
tively showing free vascularised
fibular grafts combined with
locking compression plate
(LCP). f Anteroposterior and
lateral radiographs at 7 months
showing the solid union of the
graft A B

C D

E F

infectious agent. An antibiotic specific for staphylococcus antibiotic properties. Six weeks of antibiotic therapy is
(nafcillin, fusidic acid, cloxacillin, vancomycin, teicopla- advocated largely by experience with childhood chronic
nin) should be started while waiting for the results of the haematogenous osteomyelitis. It may not be applicable in
culture report. The duration that antibiotics are given treating continuous focus osteomyelitis after trauma in
depends on the duration of infection, infective organism, adults. The treatment should be monitored for potential
adequacy of surgical treatment, host resistance, and adverse effects. The surgical debridement converts
430 International Orthopaedics (SICOT) (2010) 34:425430

an infection with dead bone to a vascularised tissue that is 7. Gordon L, Chiu EJ (1988) Treatment of infected non-unions and
segmental defects of the tibia with staged microvascular muscle
penetrated better by systemic antibiotics.
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In this series, by using the free vascularised fibular graft, we 8. Green SA, Jackson JM, Wall DM et al (1992) Management of
have successfully reconstructed ten infected defects (617 cm). segmental defects by Ilizarov intercalary bone transport method.
The osseous unions occurred within 4.5 months, and all of the Clin Orthop Relat Res 280:136141
9. Malizos KN, Zalavras CG, Soucacos PN et al (2004) Free
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315:192198
12. Stevanovic M, Gutow AP, Sharpe F (1999) The management of
bone defects of the forearm after trauma. Hand Clin 15:299318
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