[Treatment of substance loss of the bones of the leg in traumatology by transfer of the free vascularized iliac crest. Apropos of 13 cases]

R Legré, P Samson, F Tomei, J L Jouve
Revue de Chirurgie Orthopédique et Réparatrice de L'appareil Moteur 1998, 84 (3): 264-71

PURPOSE OF THE STUDY: Free iliac crest transfer as described by Taylor is an option for tibial bone reconstruction in traumatology. Our purpose was to evaluate results, bone reconstruction quality and delay for bone healing using microsurgical technique.

MATERIAL: 13 men were operated on between December 1986 and January 1994, mean aged 31 years (extreme 18-58) Bone lesion was localized at the middle third in 5 cases and at the lower third in 8 cases. The bone defect was directly related to traumatism in 2 cases, and secondary to resection of infected or necrotic bone in 11 cases. Limb neurologic and vascular problems have always been evaluated before reconstruction and amputation always been discussed. Preoperative limb arteriography showed only one major vessel of the limb in 6 cases. Delay between injury and bone reconstruction averaged 11 months.

METHODS: Bone debridement and bone stabilization by external fixator was performed on a first step. Resection of the fibula was performed to allow secondary compression at the reconstruction site. All necrotic and infected bone was "en bloc" resected using an oscillating saw. Bone reconstruction was performed in a second step when the wound was clean. Surgical team included a plastic surgeon for the micro surgical procedure and an orthopedic surgeon for bone fixation. Osteo-musculo-cutaneous flap and osteo-muscular flap were used according to the size of the skin defect. Bone osteosynthesis was achieved by direct fitting after distraction applied by the external fixator. Vessel anastomosis was performed under microscope.

RESULTS: One patient had to be amputated due to a lesion of a single vessel by an llizarov wire. In the remaining 12 cases, bone healing has been achieved after 10 months on average. Bone reconstruction averaged 8 centimeters. A secondary procedure has had to be performed in 9 cases. Two stress fractures have been observed.

DISCUSSION: "Carcinologic" resection of infected bone is one of the key of this procedure, as described by Weiland. Many techniques had been described to treat traumatic bone defects. Papineau's technique is a long procedure and leads to instable scars on the leg. Use of cancellous bone covered with a free or a pedicled muscular flap gives good results, but it may appear logical to treat a composite defect with a composite graft. Progressive bone lengthening using Ilizarov technique is not an easy procedure among adults. Use of vascularized bone graft is known to be a good procedure for treatment of osteomyelitis, but this type of technique is technically demanding. Fibula transfers are useful especially when defect are more than 10 cm. long, but this bone is fragile and stress fractures are frequent. Iliac crest is closer to the tibia and appears to be a good donor site when bone defect is 5 to 10 cm. long.

CONCLUSION: Free iliac crest transfer appears to be a reliable procedure for traumatic tibial loss ranging from 5 to 10 cm long although amputation must always be discussed in such difficult traumatic cases, especially if there is a posterior tibial nerve lesion.

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