VASCULARIZED ILIAC CREST TRANSFER FOR POS T TRAUMATIC TIBIAL RECONSTRUCTION - A SERIES OF 13 CASES

Purpose of the study Free iliac crest transfer as described by Taylor is an option for tibial bone reconstruction in traumatology. Our purpo se was to evaluate results, bone reconstruction quality and delay for bone healing using microsurgical technique. Material 13 men were opera ted on between December 1986 and January 1994, mean aged 31 years (ext reme 18-58) Bone lesion was localized at the middle third in 5 cases a nd 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 n ecrotic bone in 11 cases. Limb neurologic and vascular problems have a lways been evaluated before reconstruction and amputation always been discussed. Preoperative limb arteriography showed only one major vesse l of the limb in 6 cases. Delay between injury and bone reconstruction averaged 11 months. Methods Bone debridement and bone stabilization b y external fixator was performed on a first step. Resection of the fib ula was performed to allow secondary compression at the reconstruction site. All necrotic and infected bone was ''en bloc'' resected using a n 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 fixat ion, Osteo-musculo-cutaneous flap and osteo-muscular flap were used ac cording to the size of the skin defect. Bone osteosynthesis was achiev ed by direct fitting after distraction applied by the external fixator . Vessel anastomosis was performed under microscope. Results One patie nt had to be amputated due to a lesion of a single vessel by an Ilizar ov wire. In the remaining 12 cases, bone healing has been achieved aft er 10 months on average. Bone reconstruction averaged 8 centimeters. A secondary procedure has had to be performed in 9 cases. Two stress fr actures have been observed. Discussion ''Carcinologic'' resection of i nfected bone is one of the key of this procedure, as described by Weil and. Many techniques had been described to treat traumatic bone defect s. Papineau's technique is a long procedure and leads to instable scar s 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 lengthenin g using Ilizarov technique is not an easy procedure among adults. Use of vascularized bone graft is known to be a good procedure for treatme nt of osteomyelitis, but this type of technique is technically demandi ng. Fibula transfers are useful especially when defect are more than 1 0 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 si te when bone defect is 5 to 10 cm, long. Conclusion Free iliac crest t ransfer appears to be a reliable procedure for traumatic tibial loss r anging from 5 to 10 cm long although amputation must always be discuss ed in such difficult traumatic cases, especially if there is a posteri or tibial nerve lesion.