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Augmentation with a non-vascularized autologous fibular graft for the management of Cierny-Mader type IV chronic femoral osteomyelitis: a salvage procedure

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Abstract

Purpose

The study aimed to evaluate preliminary clinical and radiographic results of patients with Cierny-Mader type IV chronic femoral osteomyelitis and augmented with a non-vascularized fibular autograft as a salvage procedure because of the poorly regenerated new bone after bone transport over an intramedullary nail (BTON).

Methods

Patients diagnosed with CM type IV chronic femoral bone infection and treated with BTON procedure between 2003 and 2020 were retrospectively reviewed. Seven patients were included in the study whose distraction gap was poorly regenerated and then augmented with a non-vascularized fibular autograft. A three-stage treatment was administered. First, the infection was eradicated. Second, BTON was performed. Third, the poorly regenerated distraction gap was augmented with a fibular autograft before removing the external fixator (EF). Clinical and radiological results were evaluated based on the criteria described by Paley-Maar and Li classification.

Results

The mean patient age was 52 years. The mean treatment time was 24.8 months, with a mean femoral lengthening of 12.6 cm. The mean EF and bone healing indexes were 0.57 months/cm and 0.8 months/cm, respectively. The mean length of the fibular graft was 13 cm. The bone healing of new bones was achieved in all patients with good quality after grafting. Functional scores were excellent in four patients. No patients experienced any sequelae.

Conclusions

Non-vascularized fibular autograft augmentation may be an effective salvage procedure for poorly regenerated new bone after BTON to manage chronic femoral bone infection.

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All the data are stored in the hospital database.

Code availability

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Author information

Authors and Affiliations

  1. Department of Orthopaedics and Traumatology, Koç University Hospital, Maltepe Mahallesi Topkapı Cd. No:4, 34010 Zeytinburnu, İstanbul, Turkey

    Ali Bas

  2. Department of Orthopaedics and Traumatology, İstanbul University, İstanbul Faculty of Medicine, Turgut Özal Millet Cd. 34093, Çapa, Fatih, İstanbul, Turkey

    Halil Ibrahim Balci, Mehmet Kocaoglu & Mehmet Demirel

  3. Department of Orthopaedics and Traumatology, Sakarya University Faculty of Medicine, Korucuk Mahallesi Konuralp Bulvarı No:81/1, 54290, Adapazarı, Sakarya, Turkey

    Alauddin Kochai

Authors
  1. Ali Bas
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  2. Halil Ibrahim Balci
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  3. Mehmet Kocaoglu
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  4. Mehmet Demirel
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  5. Alauddin Kochai
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Contributions

AB: Conceptualization; Data curation; Methodology;Investigation; Supervision

HIB: Validation; Writing - original draft

MK: Methodology; Formal analysis; Writing - original draft,

MD: Formal analysis; Supervision; Validation; Writing - review & editing

AK: Formal analysis; Supervision; Validation

Corresponding author

Correspondence to Mehmet Demirel.

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Level of evidence: IV, Retrospective case series

Supplementary information

ESM 1

Supplemental Figure 1. Preoperative radiographs of patient 1 (37 years old, female) with chronic femoral shaft osteomyelitis underwent the combined technique comprising the bone transport over an intramedullary nail using the external fixator. The preoperative radiographs show an infected non-union of the left femur shaft. Supplemental Figure 2. The clinical photos of patient 1 demonstrates multiple scars on their left lower limb from previous procedures. The orthoroentgenography shows that during the first stage, infected bone was removed, and an IM antibiotic-impregnated rod and beads were inserted. Supplemental Figure 3. Anteroposterior follow-up radiographs of patient 1 shows the procedure's second stage comprising a combined technique consisting of the retrograde IM femoral nail and monolateral external fixator for bone segment transport and lengthening. However, for this patient, there is a poor regeneration of new bone in the distraction zone at the end of the stage. Supplemental Figure 4. Anteroposterior and lateral follow-up radiographs of patient 1 demonstrates the third stage of the procedure, the salvage procedure, which is used to treat poorly regenerated new bone, consisting of autologous fibular and cancellous bone grafting, followed by the IM nail locking and external fixator removal. The image on the right depicts the incisions made during the postoperative stage on the lower extremity. Supplemental Figure 5. Three months after the salvage procedure of patient 1, there is a clear improvement in both the clinical and radiological appearance. Ossification is observed at the distraction zone, and union is evident at the docking site. Supplemental Figure 6. After six months of follow-up of patient 1, plain radiographs and orthoroentgenography show a union at the anterior and lateral sites of new bone formation, and there is no limb length discrepancy. Supplemental Figure 7. Two years follow up after the procedure, the final images of patient 1 reveal excellent radiological healing at the new bone and docking site, and clinical depict excellent functional outcomes.

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Bas, A., Balci, H.I., Kocaoglu, M. et al. Augmentation with a non-vascularized autologous fibular graft for the management of Cierny-Mader type IV chronic femoral osteomyelitis: a salvage procedure. International Orthopaedics (SICOT) 48, 439–447 (2024). https://doi.org/10.1007/s00264-023-05954-z

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  • DOI: https://doi.org/10.1007/s00264-023-05954-z

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