Orthopaedics.
Management of infected gap non-unions of long bones has always been a challenging undertaking. Issues like compromised vascularity of bone, poor soft tissue envelop, persistent infection along with bone gap makes treatment complex. Staged treatment with fibular graft is a promising method for bridging the gap in bone defects created by debridement and sequestrectomy. Therefore, the objective of our study was to evaluate the outcome of non-vascularized fibular strut grafting in the management of infected gap non-union of long bones in paediatric patients. The prospective study included patients ≤ 14 years, with an infected gap non-union of long bones due to haematogenous osteomyelitis. Non-unions due to trauma, tumour, or other causes were excluded. Pre-operative evaluation of the patient included age, sex, anatomic site, and size of the bone gap. Staged treatment protocol for adequate healing of the infection as well as non-union was undertaken. The primary outcome measure was bone healing which was defined as complete fracture union with fibular graft incorporation and hypertrophy. Secondary outcome measures were mal-union, delayed union, peri-implant fracture, and re-activation of infection. Nine patients underwent staged treatment for infected gap non-unions with a mean age of 5.78 years. The average size of the bone gap was 5.83 cm. The average time between stage I and II surgeries was 3.56 months. The mean follow-up was 32 months. The most common bone involved was the femur (n = 6). Successful eradication of infection and consequent healing of non-union occurred in 7 (77.8%) patients. Non-union was seen in two (22.2%) patients. Stable fixation of graft with plate resulted in better outcome. Average time of radiological union was 6.5 months (range 5 - 9 months). Hypertrophy of fibula was evident radiologically at one-year follow-up in all of the patients, except two with graft failure. Delayed union and reactivation of infection were seen in one patient each. Limb-length discrepancy (mean = 5.5 cm) was seen in all patients with lower-limb involvement. Regrowth of the fibula was seen in all patients, and no patient developed common peroneal palsy. The use of non-vascularized fibular graft as a staged procedure for the treatment of infected gap non-union in children is a promising technique, which brings forth predictable and reproducible outcomes in all hands without the need for any microsurgical expertise. In addition, it has a minimal complication rate. Finally, the role of stable fixation in graft incorporation warrants further study.
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