Reconstruction of osteomyelitis defects

Abstract

Reconstruction of large skeletal defects secondary to osteomyelitis remains a challenging problem. Osteomyelitis can result from a variety of etiologies; most often, it is a consequence of trauma to a long bone. Despite advances in antibiotic therapy, treatment of chronic osteomyelitis requires adequate surgical debridement, which can often lead to large soft tissue and bone loss. Free vascularized bone can be used to reconstruct large skeletal defects greater than 6 cm or bone defects of smaller size that failed to heal with nonvascularized bone grafting. The length, cortical strength, and anatomic configuration of the free vascular fibular graft make it an ideal bone graft to bridge extremity defects, and it can be transferred with skin, fascia, and muscle to fill soft tissue defects in the recipient site.

Keywords: Osteomyelitis; osteocutaneous flaps; skeletal defects; vascularized fibular graft.

Figure 1

Latex injection of the peroneal artery demonstrating a rich arterial plexus supplying the periosteum of the fibula and the numerous perforating branches to the skin and surrounding muscle. Numbers denote perforating arteries.

Figure 2

Magnetic resonance angiography of lower extremity demonstrating peroneal arteria magna with hypoplastic anterior tibial and posterior tibial arteries.

Figure 3

(A, B) Anteroposterior and lateral radiographs of left tibial hematogenous osteomyelitis. (C) After multiple debridements, an intramedullary placement of a free VFG was performed. (D) Complete union and hypertrophy of graft at 10 months. (E, F) Seven years later, a corrective osteotomy was performed.

Figure 4

(A) Anteroposterior radiograph of an 11-year-old child with left femur osteomyelitis with severe shortening. (B) Lengthening was performed with external fixation. (C) Subsequent transfer of 17-cm free VFG was performed. (D) Eighteen months postoperative with union at the junction sites (arrows).

Figure 5

(A) Anteroposterior radiograph of right humeral osteomyelitis after multiple debridements. (B, C) Anteroposterior and lateral radiographs of the same humerus after successful transfer of free VFG. Note proximal intramedullary placement with transfixing screw stabilization and distal fixation with plates and screws.