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Handchir Mikrochir Plast Chir 2019; 51(06): 444-452
DOI: 10.1055/a-0893-6718
Originalarbeit
© Georg Thieme Verlag KG Stuttgart · New York

Bone Defect Management with Vascularized Fibular Grafts in the Treatment of Grade III-IV Osteomyelitis

Management von Knochendefekten durch vaskularisierte Fibula-Transplantate bei der Behandlung von Osteomyelitis vom Grad III-IV
Andrea Antonini
1   ASL2 Savonese Malattie Infettive e Ortopedia Settica
,
Carlo Rossello
2   Ospedale San Paolo Hand Surgery
,
Carlo Salomone
1   ASL2 Savonese Malattie Infettive e Ortopedia Settica
,
Paolo Iacoviello
3   Ente Ospedaliero Ospedali Galliera Chirurgia Maxillo-Facciale e Plastica Ricostruttiva
,
Francesco Chiarlone
1   ASL2 Savonese Malattie Infettive e Ortopedia Settica
,
Giorgio Burastero
1   ASL2 Savonese Malattie Infettive e Ortopedia Settica
› Author Affiliations
Further Information

Publication History

31 January 2019

06 April 2019

Publication Date:
07 November 2019 (online)

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Abstract

Purpose This study is a retrospective analysis of our experience in microsurgical bone transfers for complex limb reconstructions. The aim of this study is to evaluate reliability of the vascularized fibula technique: infection recurrence, hypertrophy, time to bone union, complications, and time to healing in severe osteomyelitis (Cierny-Mader III and IV) cases over a 38 to 93 month follow-up.

Patients and Methods From March 2010 until December 2015, 18 patients’ limbs (6 females and 1 2 males; mean age 48.7 years) were reconstructed with 10 free fibula flaps, 5 pedicled fibula flaps, 3 peroneus brevis osteomuscular flaps. We reconstructed 2 radiuses, 2 ulnae, 4 femurs, 4 tibiae, 1 acetabulum and 3 fibular malleoli.

Results We considered as successful results all cases where patients had successful functional bone reconstruction with no recurrence of infection during the follow up (mean time 63.6 months). We obtained 14 complete functional reconstructions, 2 limb salvages with impaired function, and 2 failures which underwent major amputations. In only one case there was an infection recurrence.

Conclusions The bone defect reconstruction with vascularized fibula grafts in severe bone infections is an effective option, but requires a well trained multidisciplinary team to manage the high rate of complications. Complications, in our series, were demonstrated to be significantly associated to patients defined as B-hosts according to Cierny-Mader’s classification (P < 0.05), and caliber discrepancy between fibula and reconstructed bones such as Tibia and Femur (P < 0.005). Furthermore, stress fractures in the grafted fibulae were prognostic indicators for overall treatment failure (P < 0.05).

Zusammenfassung

Zielsetzung Bei dieser Studie handelt es sich um eine retrospektive Analyse unserer Erfahrungen mit mikrochirurgischen Knochentransfers für komplexe Rekonstruktionen von Gliedmaßen. Ziel der Studie war es, die Zuverlässigkeit der Technik der vaskularisierten Fibula-Transplantation zu beurteilen: Infektionsrezidive, Hypertrophie, Zeit bis zur knöchernen Durchbauung, Komplikationen und Zeit bis zur Heilung bei Patienten mit schwerer Osteomyelitis (Grad III und IV nach Cierny- Mader) über einen Nachbeobachtungszeitraum von 38 bis 93 Monaten.

Patienten und Methoden Von März 2010 bis Dezember 2015 wurden Gliedmaßen von 18 Patienten (6 Frauen und 12 Männer; mittleres Alter 48,7 Jahre) mit 10 freien Fibula-Flaps, 5 gestielten Fibula-Flaps und 3 osteomuskulären Peroneus-brevis-Flaps rekonstruiert. Wir rekonstruierten 2 Radien, 2 Ulnae, 4 Femora, 4 Tibiae, 1 Acetabulum und 3 laterale Malleoli.

Ergebnisse Ein Operationsergebnis wurde als erfolgreich gewertet, wenn der Patient eine erfolgreiche funktionelle Knochenrekonstruktion erreichte und während der Nachbeobachtung (mittlerer Zeitraum 63,6 Monate) keine erneute Infektion auftrat. Unsere Ergebnisse waren wie folgt: 14 vollständige funktionelle Rekonstruktionen, 2 Gliedmaßenrettungen mit eingeschränkter Funktion und 2 fehlgeschlagene Eingriffe mit größeren Amputationen. Nur in einem Fall kam es zu einer erneuten Infektion.

Schlussfolgerungen Die Rekonstruktion von Knochendefekten mit vaskularisierten Fibula-Transplantaten bei schweren Knocheninfektionen ist eine effektive Behandlungsoption. Sie erfordert jedoch ein versiertes multidisziplinäres Team zur Beherrschung der hohen Komplikationsrate. In unserer Studie traten Komplikationen in erster Linie bei Patienten auf, die gemäß der Cierny-Mader-Klassifikation als Wirte vom Typ B definiert wurden (p < 0,05), und bei Patienten mit einer Diskrepanz des Durchmessers zwischen Fibula und rekonstruiertem Knochen, z. B. Tibia und Femur (p < 0,005). Des Weiteren erwiesen sich Stressfrakturen als prognostische Indikationen für ein allgemeines Behandlungsversagen (p < 0,05).

Key words

Osteomyelitis - fibula flap - free flap - peroneus brevis flap - infection

Schlüsselwörter

Fibula-Flap - freies Flap - Infektion - Pathologie - Peroneus-brevis-Flap
 

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