Two-stage reconstruction with free vascularized soft tissue transfer and conventional bone graft for infected nonunions of the tibia: 6 patients followed for 1.5 to 5 years

Figures & data

Table 1.  Clinical data before the first stage of reconstruction

Case	Age	Sex	Side	Initial tibial lesion	Level of the nonunion	Initial treatment	Number of previous tibial surgeries	Delay since bone infection
1	56	m	R	Open grade-II fracture	Distal third	ORIF	3	1 month
2	61	m	R	Open grade-I fracture	Middle-distal third	External fixation	0	1 month
3	46	m	L	Open grade-I fracture	Distal third	ORIF	4	1 month
4	49	f	L	Open grade-IIIB fracture	Distal third	External fixation	1	3 months
5	48	m	L	Open grade-IIIA fracture	Distal third	ORIF	4	6 months
6	37	m	L	Closed fracture	Distal third	Nailing	2	4 months

ORIF open reduction and internal fixation

Figure 1. Condition of soft tissue in case 4:chronic wound surrounded by scarred soft tissues on admission (A).Soft tissue defect after debridement and prior to coverage with a serratus anterior free flap.The cement spacer inlay has been implanted after a thorough bone debridement and stabilized with wires to the bony stumps.Tibial shaft stabilization is obtained with an external fixator (B).Complete skin graft healing over the free flap prior to removal of the cement spacer and bone reconstruction with iliac crest bone (C).

Figure 2. Case 4.Infected nonunion of the distal third of the tibia and nonunion of the fibula.The external fixator that was used initially had been removed before the patient was referred to us (A).After completion of the first-stage surgery (B).Bone healing at the last follow-up, 40 months after second-stage surgery (C).

Table 2.  Procedures and follow-up

A	B	C	D	E	F	G	H	I
1	6	80	SA	98	Iliac bone	7	Flap recipient site hematoma	Drainage, ORIF fibula
2	8	70	SA	112	50% Iliac bone, 50% allograft	–	Flap recipient site hematoma, tibial nonunion	Drainage, Illizarov external fixation, then then autologous bone graft and plate
3	5	170	LD	105	Iliac bone	6	–	–
4	6	70	SA	91	Iliac bone	7	Flap recipient site hematoma, 1.5 cm leg shortening	Popliteal artery reconstruction, drainage
5	8	80	SA	119	Iliac bone	8	Flap pedicle thrombosis	Free flap reconstruction, drainage
6	6	140	LD	105	Iliac bone	7	Flap donor site hematoma	Drainage

A Case

B Bone defect, cm

C Soft tissue defect, cm²

D Type of free flap

  SA –Serratus anterior

  LA –Latissimus dorsi

E Delay between 1 and 2 stage reconstruction, days

F Type of bone graft

G Time between bone graft and complete bone healing, months

H Complications

I Other procedures