Early Outcomes Managing Segmental Bone Loss Secondary to

Early Outcomes Managing Segmental Bone Loss Secondary to Haematogenous Osteomyelitis in Children Using free Vascularized Fibula Flaps- the Co. RSU experience-a 2 year Follow- up Robert Ayella et. al Co. RSU Rehabilitation Hospital Kisubi - Uganda

Introduction Treatment of haematogenous osteomyelitis in children is challenging -advent of antibiotics yet chronic disease with significant loss of bone segment is quite common -laborious prolonged attempt to control infection and salvage the limb by the attending limb reconstruction surgeon

Vascularized fibula flap • conventional autologous bone graft preferably cover defect< 6 cm (1) • Other techniques of defect coverage Papineau’s, Bone transport, Tibiofibular synostosis, and Allografts(2) • VFG: preserve the intrinsic vascularity; consolidate faster, resisting infection and hypertrophy (3) • Coverage of the complex extremeity wounds involving both bone and soft tissues. (4, 5, 6)

Why? • literature reporting vascularized fibula flap to reconstruct large segmental bone defect secondary to haematogenous osteomyelitis in children is limited. (7) • To our knowledge no one has reported outcome of vascularized fibula flap in reconstruction of large segmental bone loss purely to haematogenous osteomyelitis in children • In this study we aimed at assessing integration rate and outcomes in reconstructed extremity

Methods + Materials • Retrospective data review: Oct 2013 -Oct 2015 • Child: 0 -17 yrs, open physes; haematogenous osteo defect • 14 patients (9 M, 5 F) • Average on admission: 6 years (2 -13 years) • Average time at presentation: 6 months(1 -24 months) • Average time involved in preparation for free fibular bone graft: 8 months(5 -19) • Location: Tibia in 3, Femur in 4, Humerus in 3 and Radius in 4

materials • Ave. segment defect 7. 7 cm (range, 4 to 12 cm) • Flap length harvested: 6 -14 cm mean (8. 3 cm) constituents: shaft + head-5 shaft only-9, (4 osseous +5 osteocut. /skin paddle) stabilization method: external fixators Castaman 5, Orthofix 2, AO 1; or K-wires 5; 1 plate + screws • Flap integration time and outcomes

Management Techniques • Segmental defect size >4 cm • Staged: • 1 st phase-extensive debridement- pyogenic tissues and necrotic ends, flap-bed prep • 2 nd phase: Fibula graft harvesting Flap insetting. Microvascular anastomosis Stabilization

Results

Reconstruction then lengthening

Reconstr + lengthening Radius

Results • All 6 (100%) upper limb reconstr; 7 of 8(87. 5%) lower limb reconstructed • Ave. graft integration 3. 5 months(2 -6 months); • Mean follow up 11 months (2 -26 months) • Time to full wt. bearing 5. 8 months(414 months) • Good functional outcomes-wt. bearing, limb equalization,

Reconstructed femur

WJ

WJ

WJ

Summary table Case 1 Gender 2 F 3 M 4 M 5 M 6 F 7 M 8 M 9 M 10 F 11 F 12 M 13 M 14 M F Age (years) 4 6 10 2 7 14 4 8 6 3 10 11 3 6 Duration of infection at surgery(months) Site 19 6 4 12 5 6 6 8 9 6 7 4 12 5 Right Humeru s Bone defect (cm) 8. 5 Right Femu r 8. 5 Right Left Radius us 9 5 Right Tibia Right Femur Right Radius 9. 5 7 Left Humeru Radius s 6 6 Left Tibia 11. 5 Left Right Tibi Femur a 9 7 12 Left Humeru s 4 Lt Fem ur 5 Limb length difference(cm) 6 6 7 Fibula flap 9. 5 length used (cm) 10 11 6. 5 13 10 8 10. 5 9 8 6. 5 14 6 7 Ischaemia time (min) Fibula flap constituents 600 345 360 480 410 400 458 420 305 425 470 490 Shaft with head Shaft only with head Shaft with skin Shaft with head Shaft ft with only head Shaft with skin Shaft only Flap integration (weeks) 5 20 16 8 24 16 8 15 9 8 10 13 12 24 Follow up (months) 25 26 4 2 8 8 26 10 9 12 11 3 6 9 Outcomes Faile d 10 600

Discussion • The fibula flap configuration, size and dual vascularity insets well in the medullary canal of the tibia, femur, humerus, radius or ulna providing greater healing and hypertorphy potential with strong biomechanical properties. (8, 9, 10) • Reconstruction achieved in 13 of 14 cases (93%), lengthened 1 forearm reconsruction • Average time FWB 5. 8 months for all the five reconstructed LL (range, 3 to 14 months) and walking with no devices. • Charalampos et. al - primary union of graft in 7 of the 8 patients with a mean of 3. 5 months - one patient needing augmentation with ilica crest graft. -The mean time for full weight bearing 8. 4 months - pain free and able to walk without supportive devices (7) • Complications: 5 cases pin tract infections, one graft fracture, one nerve palsy and one graft resolution • Literature reported complications: pin-site infections, graft fractures, transient nerve palsy, ankle valgus deformity, RSD, joint contractures and stiffness have been reported especially where lengthening with Ilizarov apparatus was done (11, 12, 13, 14, 15),

Conclusions • autologous vascularized fibula flap(osseous/osteocut) -a reliable technique despite prolonged period involved and it restores limb function in children. • reconstruction of extensive bone and soft tissue defect in both the upper and lower limbs. • in the upper limb juxta-articular segmental defects fibula flap with epiphysis application should be considered.

References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Toh CL, Jupiter JB. The infected nonunion of the tibia. Clin Orthop Relat Res. 1995; 315: 176 -91. (Medline) Herring JA, Tachdjian MO, Children TSRHf. Tachdjian’s paediatric orthopaedics. Saunders; 2008 Goldberg VM, Shaffer JW, Field G, Davy DT. Biology of vascularized bone grafts. Orthop Clin North Am. 1987; 18: 197 -205 Minami A, Kasashima T, Iwasaki N, Kato H, Kaneda K. Vascularized fibular grafts. An experience of 102 patients. J Bone Joint Surg Br. 2000; 82 -5 De Boer HH, Wood MB, Hermans J. Reconstruction of large skeletal defects by vascularized fibula transfer. Factors that influenced the outcome of union in 62 cases. Int Orthop. 1990; 14: 121 -8 Tu YK, Yen CY, Yeh WL, Wang IC, Wang KC Ueng WN. Reconstruction of posttraumatic long bone defect with free vascularized bone graft: good outcome in 48 patients with 6 years’ follow up. Acta Orthop Scand. 2001; 72: 359 -64. (Medline) Charalampos GZ, Dominic F Rachel T, Lewis Z, Milan S. Reconstruction of large skeletal defects due to osteomyelitis with vascularized fibular graft in children. J Bone Joint Surg Am. 2007; 89: 2233 -2240 Dormans JP, Krajbich JI, Zuker R, Demuynk M. Congenital pseudoarthrosis of the tibia: treatment with free vascularized fibular grafts. J Pediatr Orthop. 1990; 10: 623 -8 Weiland AJ, Weiss AP, Moore JR, Tolo VT. Vascularized fibular grafts in the treatment of congenital pseudoarthrosis of the tibia. J Bone Joint Surg Am. 1990; 72: 654 -62 Weiland AJ, Moore JR, Daniel RK. The efficacy of free tissue transfer in the treatment of osteomyelitis. J Bone Joint Surg Am. 1984; 66: 181 -93 Kucukkaya M, Kabukcuoglu Y, Tezer M, Kuzgun U. Management of childhood chronic tibial osteomyelitis with Ilizarov method. J Pediatr Orthop. 2002; 22: 632 -7 Naudie D, Hamdy RC, Fassier F, Duhaime M. Complications of limb-lengthening in children who have an underlying bone disorder. J Bone Joint Surg Am. 1998; 80: 18 -24 Velazquez RJ, Bell DF, Armstrong PF, Babyn P, Tibshirani R. Complications of use of the Ilizarov technique in the correction of limb deformities in children. J Bone Joint Surg Am. 1993; 75: 1148 -56 Bell DF, Boyer MI, Armstrong PF. The use of the Ilizarov technique in the correction of limb deformities associated with skeletal dysplasia. J Pediatr Orthp. 1992; 12: 283 -90 Heikkinen ES, Poyhonen MH, Kinnunen PK, Seppanen UI. Congenital pseudoarthrosis of the tibia. Treatment and outcome at skeletal maturity in 10 children. Acta Orthop Scand. 1990; 70: 275 -82

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