J Korean Fract Soc.  2017 Jan;30(1):1-8. 10.12671/jkfs.2017.30.1.1.

Treatment of Wide Gap Non-Unions in Lower Extremities

• Sun D
• Park BS
• Jeon T
• Rhee SK

• KMID: 2367346
• DOI: http://doi.org/10.12671/jkfs.2017.30.1.1

Abstract

PURPOSE
To analyze the end results of the treatment for patients with wide gap non-unions of the long bones in the lower extremities.
MATERIALS AND METHODS
A total of 62 cases of wide gap unions, with a mean age of 38 years, were included for analysis. Study cohort included six children under the age of seven years. The average size of established bone defect was 7 cm (4-23 cm). Bone defects under 7 cm were treated with plating and various bone grafts, and those over 7 cm were managed with vascularized fibular graft (VFG), distraction-osteogenesis, tibial strut, plating and etc. Two boys with a defect of the whole tibia but with an intact fibula were treated with tibialization of intact fibula and with rotation-plasty of the leg. Their end results were evaluated by the time of bony union in accordance with the treatment of defect size of the long bone as well as their age.
RESULTS
Bony unions were obtained for an average period of at least 27 months. Fifty-one cases showed an average leg-length discrepancy of 2.8 cm, and 11 cases showed no leg-length discrepancy. The VFG, distraction-osteogenesis, and tibial cortical-strut graft and plating were the most effective methods for non-unions of wide, long bone defections (>7 cm). The prognosis was more favorable in children, muscular femur, and in cases with tibial defect but intact fí bula.
CONCLUSION
Various bone union techniques should be considered carefully, considering the ages of patients and the size of bone defects. Due to severe physical and mental disabilities of patients during the long-treatment period, specialized orthopedic doctors for trauma and mental care were necessary.

Keyword

Wide gap non-unions; Compound fracture; Long bone

MeSH Terms

Child
Cohort Studies
Femur
Fibula
Fractures, Open
Humans
Leg
Lower Extremity*
Orthopedics
Prognosis
Tibia
Transplants

Figure

• 

  Fig. 1 A 46-year-old male. (A) An open segmental 6 cm defect of tibiawas treated with two trials of sauscerization. Finally, an 8 cm defect was noted (B) and distraction osteogenesis for 4 months was performed (C). During the process, no skin problems on pin tracts, and pain was tolerable. (D) Nine months after the trauma, bony union was successful, knee motions were normal, with limited ankle motions, 0° dorsiflexion and 20° palmar flexion only.

• 

  Fig. 2 A 19-year-old female. A severe compound fracture on the proximal femur from a gun shot injury (A); sauscerization was performed 6 times and split skin grafts was done 2 times (B). (C) After cessation of chronic osteomyelitis, a tibial cortico-strut and cancellous chip bone grafts (arrow) with heavy duty condylar plate fixation was performed. Four-and-half years later, a solid bony union was obtained (D, E), but a shortening of the limb by 2 cm was noted (F).

• 

  Fig. 3 A 34-year-old male. A 6 cm of tibial (A) and wide skin defects (B) was treated by a 12 cm osteo-cutaneous vascularized fibular graft after 8 weeks of trauma; 7 months later, the grafted fibula was united well and hypertrophied (C), and partial weight bearing was possible (D).

• 

  Fig. 4 An 8-year-old boy. A staged medial transport (tibialization) of intact fibula with a 6-week interval (B, C) for the whole defected tibial shaft but intact fibula (A) was observed after performing a wide-split thickness skin graft two times, 3 months after a traffic accident. (D) Six months after the operations, the grafted fibular was united and hypertrophied well, but limping, serious edema by venous stasis on leg was noted. The knee and ankle joint motions were very limitted—nearly stiff—but walking was also possible with a cane. However, the patient and parents were happy for saving the leg.

• 

  Fig. 5 A 52-year-old male. An open comminuted fracture on proximal tibia (A) was treated with sauscerization, rotational skin flap, and the 12 cm vascularized fibular graft for 5 cm of bone defect two months after a traffic accident (B). The fracture was occurred because it was too weak to bear any weight, and so a condylar plate with cancellous chip bone graft was performed 4 months after the trauma (C), and the knee range of motion was 10° to 60°.

• 

  Fig. 6 (A) A 7-year-old boy had suffered from an uncontrollable osteomyelitis of the femur, with a 14 cm wide segmental defect, despite 6 attempts of sauscerization and 2 attempts of vascularized fibular graft. Initially, an above-the-knee amputaion was seriously considered. However, we performed the Van-Ness's operation associated with a sacrifice of the knee joint, including the infected distal femur and the proximal tibia, and performrd a 180° rotation-plasty of the leg (B, C) to aquire the knee function with ankle. (D, E) He was well tolerated with the rotated foot, which was good to control the brace as a below–knee stump, and the heel functioned as a patella to support the body weight. Nonetheless, psychosocial attention will be required later. We revieved an agreement by patient to carry photoes exposed the face in this paper.

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