Gap nonunion of tibia treated by Huntington's procedure

Abstract

Background: Gap nonunion that may occur following trauma or infection is a challenging problem to treat. The patients with intact or united fibula, preserved sensation in the sole, and adequate vascularity, were managed by tibialization (medialization) of the fibula (Huntington's procedure), to restore continuity of the tibia. The goal of this retrospective analysis study is to report the mid-term results following the Huntington's procedure.

Materials and methods: 22 patients (20 males and two females) age 16-34 years with segmental tibial loss more than 6 cm were operated for tibialization of fibula. The procedure was two-staged in seven and single-staged in the rest 15 patients, where the lateral aspect of the leg was relatively supple. In the two-staged procedure, the distal tibiofibular synostosis was performed six-to-eight weeks after the proximal procedure. Weightbearing (protected) was started in a long leg cast after six-to-eight weeks of the second stage and continued for six-to-eight months, followed by the use of a brace.

Results: The fibula started showing signs of hypertrophy within the first year after the procedure and it was more than double in breath after the four-year period. Full and unprotected weightbearing on the operated leg was achieved at an average time of 16 months. At the final followup, ten patients were very satisfied, seven satisfied, and five fairly satisfied. One patient had persistent nonunion at the proximal synostotic site even after bone grafting and secondary fixation.

Conclusion: Huntington's procedure is a safe and simple salvage procedure and remains an excellent option for treating difficult infected nonunion of the tibia in the selected indications.

Keywords: Gap nonunion; tibia; tibialization of the fibula.

Figure 1

Roentgenograms showing (a) anteroposterior and lateral views a big gap in the tibia; (b) The fibula was approximated and compressed to tibia above and below the defect with screws; (c) Hypertrophy of the fibula after six years, almost three times the original girth of the fibula (d) Clinical photograph of patient showing weight bearing on hypertrophied fibula

Figure 2

Roentgenograms showing (a) anteroposterior view a large gap in distal tibia and nonunion of fibula with deformity; (b) Fibula medialized to tibia above the defect with two screws and in the distal part the deformity was corrected, bone grafted, and stabilized with Kirschner wires (removed in followup as they became symptomatic); (c) Hypertrophy of fibula after seven years; (d) Clinical photograph of same patient showing full weight bearing on hypertrophied fibula

Figure 3

(a) Roentgenogram anteroposterior and lateral views (b) clinical photograph of same patient showing complication as cut out of screw in a patient with a big tibial gap