A New Reconstructive Technique for Intercalary Defects of Long Bones: The Association of Massive Allograft with Vascularized Fibular Autograft. Long-Term Results and Comparison with Alternative Techniques

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Surgical technique

An intercalary fibular segment with the nutrient fibular vessels and its periosteal cuff is harvested from the opposite limb. The fibular length should be 6 cm longer than the bone defect to be replaced. In cases of long resections, the distal fibular osteotomy may be very close to the ankle joint. In these cases, screw fixation of the distal fibular stump with a bone fragment interpositioned in the tibiofibular space is recommended to prevent instability and valgus deformity of the ankle

Results

From 1988 to 2002, 90 patients were treated in two different orthopedic units (Florence and Bologna, Italy). Thirty-three cases involved intercalary resection of the femur, and 57 involved resection of the tibia. The average resection length was 16 cm (range, 7–26 cm). The average follow-up was 9 years (range, 3–17 years).

Complications related to the reconstruction included infection in seven cases (7.5%). Infection was more frequent in tibial reconstructions (8.5%) than at the femoral level

Discussion

In intercalary skeletal bone loss, synthetic reconstructions are rarely employed.

An acrylic cement spacer associated with a metallic osteosynthesis (locked nail, single or double orthogonal plate) is indicated:

  • As a temporary spacer mixed with antibiotics to sterilize an infected surgical bed

  • As a palliative reconstruction in patients with a short life expectancy (eg, bone metastases from carcinoma)

More recently, modular and custom-made spacers with a porous (ceramic, fibrometal, or titanium)

Summary

The authors believe the excellent final results and the ability to avoid further salvage surgical procedures justify the primary application of a more complicated technique requiring longer surgical times.

The purposed technique is indicated in intercalary bone loss of the lower limb and especially in long resections (> 15 cm), intraepiphyseal resections, and cases of minimal residual bone stock. The technique is not indicated in cases with an infected surgical field (in which the allograft is

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