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Comparative analysis of free vascularized fibula grafting and Ilizarov bone transport in management of segmental long bone defect of the lower limb: A systematic review and meta-analysis
∗Corresponding author: Madhubari Vathulya. madhubari@yahoo.co.in
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Reconstruction of segmental defects of long bones is a daunting task for surgeons. Bone transport with the help of Illizarov external fixator and vascularized free fibula flap are some of the most discussed and valid options for the same. Both techniques have their limitations and overlapping indications. However, there has been no objective evidence in the manner of a systematic review supporting one treatment method over the other.
This systemic review is aimed to compare the bony union, functional outcomes, and complications of Illizarov bone lengthening and free fibula flap performed for segmental bone defects of long bones of the leg.
A comprehensive search was done for all studies published before May 2023. Any observational study comparing bone transport based on Illizarov external fixator and free vascularized fibula grafting techniques for treating lower limb long bone segmental defects was entailed in this study.
This systematic review comprised of five retrospective studies. A total of 96 patients were treated by the Illizarov-based bone transport technique and 72 patients were treated by the free vascularized fibula grafting technique. The free vascularized fibula grafting technique yielded a shorter mean time to union (average difference 9.3 months), relatively shorter external fixator time (average difference 5.32 months), and external fixator index (average difference 0.57 months/cm). However, there was no difference in terms of bony and functional outcomes between both techniques when used for the reconstruction of bony defects in the lower limb. Total number of complications was 68 % higher in bone transport with Illizarov external fixator. However, the rates of non-union didn't differ between the groups.
The free vascularized fibula grafting technique had a lesser time to bony union, shorter time for external fixator application, and lower incidence of complications. However, the functional and bony outcomes didn't differ between both techniques.
Level 4.
Keywords
External fixator
Fibula
Non-union
Tibia
Open fracture
Distraction osteogenesis
1 Introduction
Reconstructive options for segmental defects of long bones are numerous yet controversial.1–3 Various popular techniques include cancellous bone grafting,4 induced membrane technique,5,6 Ilizarov bone transport (IBT),3,7–9 non-vascularized,10 free vascularized fibula grafting (FVFG),11 posterolateral bone grafting,12 tibiofibular synostosis or fibular bypass,13 and internal fixation-assisted bone transport.14 However, among them, IBT and FVFG have been proven to be the most effective and acceptable techniques to treat large segmental long bone defects.7 Both these techniques rely on providing mechanical support with a direct or indirect increase in vascularity at the non-union site.
The overlapping indications for either of the technique make it more difficult for the surgeon to choose among them. Studies comparing these two procedures have been seldom performed.3,7–9,15 Despite being heterogeneous in nature these studies have compared the bony union,3,7–9,15 functional outcomes,3,7–9,15 perioperative parameters like blood loss or operative time,3,7 details regarding use of external fixator,3,7–9,15 and complications3,7,9 between IBT and FVFG in treating segmental defects of long bones of lower limb. In addition to that El-Gammal et al.3 in their study charted the duration to full weight-bearing (months) and full weight-bearing index (months/cm) as well to assess the time needed for the bony union. Although one of these studies recommended using IBT in defects more than 12 cm and FVFG in defects less than 12 cm,3 most of them failed to recommend one procedure over the other. Thus, this study was planned to fulfil the lacunae of amalgamation of information in the manner of a systematic review to demonstrate the superiority of one technique over the other for the management of segmental bone defects of lower limb.
The aim of this article is to study the bony union, functional outcomes, and complications of IBT and FVFG performed for segmental defects of long bones of lower limb. The null hypothesis was that there is no difference between these two procedures.
2 Material and methods
The Preferred Reporting Items for Systematic Reviews, and Meta-Analyses (PRISMA) guidelines was followed to carry out a systematic search with Cochrane collaboration.16 All online databases like Cochrane database, EMBASE, Google Scholar, and the PubMed were scrutinized for all researches published from the date of commencement to May 2023. The search was performed using keywords like “Ilizarov, Ilizarov fixator, ring fixator, distraction osteogenesis, free fibula, fibula flap, vascularized fibula, nonunion, open fracture, long bones”. Boolean operators were used to connect different keywords. References of all selected articles were also thoroughly examined. The ‘Similar article’ add-on on PubMed was utilised to find other significant articles.
2.1 Selection criteria for articles
All observational studies comparing IBT and FVFG techniques for treating lower limb long bone segmental defects were included in this study. However, letters to editors, biomechanical studies, studies in languages other than English, expert opinions, reviews, editorials, meta-analyses, and studies with incomplete information were excluded. EndNote ×7 (Thomson and Reuters) was used to analyse data and remove duplicates by using the “duplicates” tool and then sorted manually.
2.2 Data abstraction
Data extraction was done with a set format from the inclusive articles by two separate authors (M.J. and S.P.). The information that was excerpted included: study design, patient details like age, gender, details about external fixator like external fixator time or external fixator index, details about the bone defect, time to union, outcomes related to bony union, functional outcomes, duration of follow up and complications. Data extraction was done by two authors independently (M.J. and S.P.). A third author (P.K) was incorporated to evaluate any disagreements between the two authors to reach a final conclusion.
2.3 Quality assessment
The possibility for any bias was evaluated by two separate authors (M.V. and S.P.) and a final consensus was made after consultation with the third author (P.K.) in matters of disagreement. Newcastle-Ottawa Quality Assessment Form for the observational study was utilised to assess the adequacy of the included studies.17 MINORS (Methodological index for non-randomized studies) criteria were also used to evaluate the articles.18 A score of zero means not reported, one equates to reported but inadequate and 2 means reported and adequate. The target score would be 16 for non-comparative studies and 24 for comparative studies.
2.4 Outcomes of interest
The basic characteristics of all the studies were noted carefully with all baseline demographic variables. All perioperative parameters including blood loss, operation time, or hospital stay were noted. The details regarding bony union were noted which may have been expressed in terms of time to bony union, full weight-bearing time, or full weight-bearing index were assessed thoroughly. A detailed search was conducted to include all information regarding the external fixation application and complications of the procedures. Moreover, all of the studies were screened for parameters denoting functional outcome or quality of life of the patients.
2.5 Synthesis of evidence
No randomized comprartive studes exist on this topic. Thus, all prospective or retrospective case-control, cohort, and cross-sectional studies were included. A fixed-effect model was used to assess pooled outcome parameters for meta-analysis. The study designs, methods, and results of the included articles were assessed to ensure heterogeneousness of the studies incorporated in the meta-analysis. Moreover, a statistical test of heterogeneity (I2 statistics) was utilised. Statistical significance was defined as a p-value <0.05. External fixator time and external fixator index were expressed as continuous variables with means and 95 % CI (Confidence interval). Whereas the complications and bony union or functional outcome were expressed as events in this study. Statistical analysis was performed by Review Manager, version 5.4.1 (The Cochrane Collaboration, Copenhagen, Denmark). The average means from all studies were analysed using the following formula:Averagemean=∑{(n1xmean1)}+(n2xmean2)+∙∙∙+(nnxmeann)∑(n1+n2+⋯+nn)n=studypopulation(study1,study2etc)mean=overallmeanofthestudypopulation
3 Results
3.1 Search results
The total of 1266 articles were evaluated (Fig. 1). After evaluation, 5 studies were selected for the analysis. One of the studies by Abdelkhalek et al.10 was excluded from the study as they compared the IBT technique with non-vascularized fibula grafting for defects in the tibia. A detailed description of the study parameters has been summarized in Table 1. A total of 96 patients were treated by the IBT technique and 72 patients were treated by the FVFG technique.
| Parameters | Ren 2020 | Abdel-razek 2012 | El-Gammal (3) 2008 | Song 2003 | Yokoyama 2001 | Total |
| Total cases in IBT group | 43 | 17 | 12 | 20 | 4 | 96 |
| Total cases in FVFG group | 23 | 15 | 13 | 17 | 4 | 72 |
| Long bone defect | Traumatic femur defect-11, tibia defect-32 | Traumatic tibia defects | Traumatic tibia defects (6–25 cm) | Traumatic femoral defects >6 cm | Traumatic tibia defects | |
| Type of study | Retrospective | Retrospective | Retrospective | Retrospective | Retrospective | |
| Level of evidence | 3 | 3 | 3 | 3 | 3 | |
| IBT group | ||||||
| Mean age in years | 37.35 | 39.9 | 31.5 | 36 | 20 | 32.9 |
| Sex M: F | 28:15 | 10:7 | 11:2 | 19:1 | 4:0 | |
| Location of defect | Shaft-32, metaphyseal- 11 | Proximal 6, middle 8, Distal 6 | NA | Proximal 6, mid-diaphysis 7, distal diaphysis in 7 | NA | |
| Mean length of defect (cm) | 8.74 | 4.1 | 12.6 | 10 | 4.5 | 7.9 |
| Mean duration since trauma (months) | NA | NA | 4.7 | NA | 11.5 | 8.1 |
| Mean number of previous operations | NA | NA | 2.2 | 8 | 4.3 | 4.8 |
| Mean follow up duration (months) | 34.14 | 9.2 | 51.6 | 38.4 | NA | 33.3 |
| Mean operative time in hours | 3.12 | NA | 1.3 | NA | NA | 2.2 |
| Mean blood loss in ml | 386.05 | NA | 169.17 | NA | NA | 277.6 |
| Mean external fixator time (months) | 13.16 ± 2.92 | 6.9 ± 1.39 | 10.58 ± 4.81 | 9.7 | 8.71 ± 2.2 | 12.4 |
| Mean external fixator index (month/cm) | 1.55 ± 0.28 | NA | 1.14 ± 0.41 | 1.4 | NA | 1.36 |
| Mean full weight bearing time (months) | NA | NA | 11.88 | NA | NA | 11.88 |
| Mean full weight bearing index (months/cm) | NA | NA | 1.28 | NA | NA | 1.28 |
| Mean hospital stay (days) | NA | NA | 28.08 | NA | NA | 28.08 |
| Rate of distraction | 0.5–1 mm/day (2–4 times/day) | 1 mm/day (0.25mm/6 h) | NA | 1 mm/day (0.25mm/6 h) | 0.5–1 mm/day (0.25 mm/6 or 12 h) | |
| Mean number of secondary procedures | 0.78 | NA | 1.08 | NA | NA | 0.93 |
| Excellent bony outcome or healing | 25 | 11 | NA | 13 | 2 | 0.67 |
| Excellent and good functional outcome (Number of patients) | 36 | 3 | 8 | 9 | 3 | 0.61 |
| Time to union/healing (months) | NA | 6.9 | NA | NA | 36.5 | 21.7 |
| Puno functional score | NA | NA | 84 ± 15.86 | NA | 88.75 ± 6.3 | 86.3 |
| SF 36 physical component | NA | NA | NA | 45.1 | NA | 45.1 |
| SF 36 mental component | NA | NA | NA | 43.5 | NA | 43.5 |
| Knee ROM loss | NA | NA | 8.75 | NA | NA | 8.75 |
| Ankle ROM loss | NA | NA | 6.67 | NA | NA | 6.67 |
| Pin tract infection (numbers) | NA | NA | 10 | 5 | 2 | 0.42 (number/case) |
| Complications (numbers in total) | 95 | NA | 35 | 14 | NA | 1.92 (number/case) |
| Nonunion (numbers) | 7 | 2 | NA | 5 | 2 | 0.19 (number/case) |
| FVFG group | ||||||
| Mean age in years | 36.13 | 29.7 | 32.7 | 36 | 40 | 34.9 |
| Sex M: F | 16:7 | 11:4 | 11:1 | 16:1 | 4:0 | |
| Location of defect | Shaft-12, metaphyseal- 11 | Proximal 13, middle 2 | NA | Proximal diaphysis 3, mid diaphysis 6, distal diaphysis 8 | NA | |
| Mean length of defect (cm) | 9.96 | 7.6 | 9.7 | 8.9 | 7.3 | 8.7 |
| Mean duration since trauma (months) | NA | NA | 12 | 3.2 | 17.8 | 11 |
| Mean number of previous operations | NA | NA | 2.3 | 9.5 | 3.8 | 5.2 |
| Mean follow up duration (months) | 31.83 | 17.6 | 3.2 | 3.2 | NA | 13.9 |
| Mean operative time in hours | 6.6 | NA | 10.54 | NA | NA | 8.577 |
| Mean blood loss in ml | 873.91 | NA | 846.15 | NA | NA | 860.02 |
| Method of fibula fixation | External fixation + screws | Plate or screws | External fixation | External fixation + screws | External fixation | |
| Mean external fixator time (months) | 7.04 ± 1.72 | NA | 6.92 ± 1.81 | 8.5 | 5.86 ± 1.04 | 7.08 |
| Mean external fixator index (month/cm) | 0.73 ± 0.28 | NA | 0.65 ± 0.33 | 1 | NA | 0.79 |
| Mean full weight bearing time (months) | NA | NA | 9.04 ± 2.83 | NA | NA | 9.04 |
| Mean full weight bearing index (months/cm) | NA | NA | 0.86 ± 0.42 | NA | NA | 0.86 |
| Mean hospital stay (days) | NA | NA | 17.92 | NA | NA | 17.92 |
| Mean number of secondary procedures | 0.98 | NA | 0.85 | NA | NA | 0.9 |
| Excellent fracture healing (Number of patients) | 15 | 11 | NA | 6 | 3 | 8.75 |
| Excellent and good functional outcome (Number of patients) | 18 | 2 | 9 | 8 | 1 | 7.6 |
| Mean time to union/healing (months) | NA | 4.8 | NA | NA | 20 | 12.4 |
| Puno functional score | NA | NA | 80.85 ± 16.32 | NA | 69.5 ± 7.7 | 75.17 |
| SF 36 physical component | NA | NA | NA | 41.4 | NA | 41.4 |
| SF 36 mental component | NA | NA | NA | 45.4 | NA | 45.4 |
| Knee ROM loss | NA | NA | 11.54 | NA | NA | 11.54 |
| Ankle ROM loss | NA | NA | 20 | NA | NA | 20 |
| Pin tract infection (number of patients) | NA | NA | 6 | 5 | 2 | 0.38 (number/case) |
| Complications (numbers in total) | 20 | NA | 25 | 21 | NA | 1.24 (number/case) |
| Graft fracture | NA | 8 | 6 | 3 | 1 | 0.37 (number/case) |
| Nonunion (number of patients) | 3 | 1 | NA | 6 | 1 | 0.18 (number/case) |
3.2 Study characteristics
All of the included studies were retrospective comparative studies (level of evidence, 3). Three studies included only post-traumatic tibial defects. While the study by Song et al.9 included only femoral defects, the study of Ren et al.7 included both tibial and femoral defects. In the study by Song et al.,9 double-barrel FVFG was used in six patients, two patients with bone defects more than 14 cm were treated by bilateral FVFG and a single barrel fibular graft was used in the rest of the patients. Whereas, Ren et al.7 used single barrel FVFG for all their cases with delayed rehabilitation. Inclusion and exclusion criteria were mentioned in all of the studies except for the study by Abdel-Razek et al.15 Most of the studies had included long bone defects of more than 6 cm. However, Abdel-Razek et al.15 and Yokoyama et al.8 didn't mention any size of bone defects in the inclusion criteria. The average mean size of the defect was 7.9 cm in IBT group and 8.7 cm in FVFG group. The IBT and FVFG groups were matched only in the study by Ren et al.7 and the demographic parameters were similar between the two groups.
3.3 Quality assessment
The quality of the inclusive studies was assessed by both Newcastle-Ottawa Quality Assessment Form for Cohort Studies17 and MINORS criteria for non-randomized comparative studies.18 The Newcastle-Ottawa Quality Assessment results concluded studies by Ren et al.(2020), Song et al.(2003) and Yokoyama et al.(2001) as good; El-Gammal et al.(2008) as fair and Abdel-razek et al.(2012) as poor. As per the quality assessment done by MINORS scoring, studies by Song et al., El-Gammal et al. and Abdel-razek et al. had a scoring of 18/24 whereas Ren et al. and Yokoyama et al. gave scores of 16/2 and 14/24 respectively.
3.4 Outcome analysis
3.4.1 External fixator time (EFT) and external fixator index (EFI)
External fixation was chosen as the sole method of stabilization after reconstruction with vascularized fibula in the studies by El-Gammal et al.3 and Yokoyama et al.8 However, internal fixation in form of screws was used as a method of additional stabilization along with external fixators in the studies by Ren et al.7 and Song et al.9 Whereas screws and plates were used as a method of stabilization in the study by Abdel-razek et al.15 The EFT was defined as the duration of the external fixator application and the EFI was defined as EFT divided by the length of the defect. The EFT was reported in three and EFI was reported in two among the five included studies. The comparative pooled analysis between studies reporting EFT reveals a significantly longer EFT in IBT group (I2 = 73 %, Z = 10.9, p < 0.00001) (Fig. 2). Moreover, a meta-analysis comparing the studies reporting the EFI revealed IBT group to have a significantly higher EFI compared to FVFG group (I2 = 75 %, Z = 11.63, p < 0.00001) (Fig. 3).
3.4.2 Bony union
The bony union in IBT group was defined as the consolidation of the callus between distracted segments after which the external fixator was removed. Whereas in FVFG group it was defined as the completion of bridging callus at the graft and recipient bone. The time to bony union was reported in two studies by Yokoyama et al.8 and Abdel-Razek et al.15 The pooled average time to union was 21.7 months in IBT group and 12.4 months in FVFG group. The excellent bony outcome was defined as a union with sufficient thickness of the bone (regenerate in IBT or the fibula graft in FVFG) without any infection or significant deformity or LLD. It was reported in all studies except the study by El-Gammal et al.3 who assessed the bony outcome by full weight-bearing time (FWBT) and full weight-bearing index (FWBT/length of the defect). A meta-analysis was performed comparing all studies reporting excellent bony outcomes using the fixed-effect model (I2 = 29 %) (Fig. 4). No significant difference was observed between the IBT and FVFG groups (Z = 0.17, p = 0.24).
3.4.3 Functional outcome
The studies by El-Gammal et al.3 and Yokoyama et al.8 assessed the functional outcome using a seven-scale scoring system for open fracture tibia as described by Puno et al.19 These scales include the patient's emancipation from pain, restoration of daily life living activity (ADL), range of motion of adjacent joints, residual deformity, radiographic changes suggestive of degeneration and malalignment, ankle and toe muscle strength, and sensation. The other studies had categorized the functional outcome with the help of similar criteria like pain, need for support while walking, deformity, stiffness or range of motion of adjacent joints, ability to return to ADL, no sensorimotor abnormality, no reflex sympathetic dystrophy. Thus, all of the studies had comparable criteria for assessing the functional outcomes and it was graded into 4 grades: excellent, good, fair, and poor. The excellent and good functional outcomes were compared between all studies using the fixed-effect model in a meta-analysis which revealed no difference in functional outcomes between IBT and FVFG groups (I2 = 0 %, Z = 0.66, p = 0.51) (Fig. 5). Range of motion (ROM) loss was assessed in the study by El-Gammal et al.3 and they noted higher knee and ankle ROM loss in FVFG group but the values didn't reach statistical significance.
3.4.4 Complications
The total number of complications was mentioned in three articles. The pooled average of complications (total number of complications/number of patients) was 1.92 in IBT group and 1.24 in FVFG group. Moreover, the pooled average of pin tract infection and non-union were higher in IBT group (Table 1). The meta-analysis conducted included studies reporting the number of non-union revealed no difference between the two groups (I2 = 0 %, Z = 0.2, p = 0.84) (Fig. 6). The study by El-Gammal et al.3 reported the loss in the range of motion of the knee and ankle, which was higher in FVFG group (Table 1).
4 Discussion
Segmental long bone defects are nightmares for any limb reconstruction surgeon and it imparts a catastrophic effect on the quality of life of the patient. It may arise from an open fracture with bone loss, chronic osteomyelitis, tumor resection, or developmental deformities. In his systematic review, all of the studies have focussed on post-traumatic bone defects of femur or tibia, although some of these patients were having an infected non-union as well. The most important results of this systematic review are that, although IBT and FVFG don't differ in terms of union or functional outcomes, the average mean time to union was 9.3 months earlier in FVFG group. Moreover, there were shorter EFT (External fixator time) and EFI (External fixator Index) in FVFG group. No difference was identified in the rates of non-union between the two groups. However, the total number of complications was more in IBT group (1.92 and 1.24 number/case in IBT and FVFG respectively).
Evidence from this meta-analysis is restricted by the quality and number of studies included. All studies were retrospective in nature (level 3 evidence) with heterogeneity in patient selection, methodology, and expression of outcomes. Both femoral and tibia bone defects were included in this study due to the fewer comparative study available for comparison. There are numerous case series or reports describing outcomes of these two procedures separately or combined (FVFG with Ilizarov ring fixator application) in a different cohort of patients. These studies were out of scope for inclusion in this meta-analysis due to the lack of sufficient data and comparable patient groups in the same study.
Apart from the loss of mechanical support, segmental bone defects are also complicated by a dearth of vascularity of the bone and surrounding soft tissues.20,21 Thus, FVFG is one of the best treatment choices in these cases to provide both mechanical support as well as biological support through its internal vascular network.22–25 However, this technique has its disadvantages like graft non-union or graft fracture, a prolonged period of non-weight-bearing, and donor site morbidity.22,24,25 The Ilizarov external fixator works on the principle of distraction osteogenesis which allows early weight-bearing and allows an increase in local vascularity.26,27 However, poor patient compliance, pin tract infection, and long duration of treatment are common complications associated with this technique.23,26,27
The duration of treatment with the external fixator is cumbersome for any patient in both techniques. The pooled average EFT was much higher in IBT cases (5.32 months difference) and the meta-analysis also revealed the same (p < 0.00001). The duration of external fixator application is needed only till the union has been achieved in FVFG cases which is much earlier compared to IBT cases where external fixator is retained till the consolidation of regenerate. Thus, EFT may not be a reliable indicator of the time needed for healing in these cases.7–9,15 However, EFI may indicate how much time the external fixator was needed per unit of bone defect present.3,7,9 El-Gammal et al.3 have also explored the time to full weight-bearing (months) and full weight-bearing index (months/cm) to assess the time needed for union which was 2.84 months and 0.5 months/cm higher in IBT group respectively. Moreover, the average mean time to union was reported to be 9.3 months longer in IBT group. This meta-analysis comparing the excellent bony outcome also revealed no significant difference between these two techniques. A few experimental studies have shown that principal blood vessels and nerves may show temporary degenerative changes due to traction during IBT technique which resolves after 2 months of stopping distraction.28,29 Whereas in the case of FVFG, the vascular anastomosis of the graft directly enhances the vascularity at the bony defect site.21,22,24,30 That may be the plausible reason behind the early bony union time of FVFG technique.
The functional outcome of the limb was reported by the scaling system devised by Puno et al.19 in two among the five included studies. The other studies also reported the functional outcome based on similar criteria to reveal no significant difference in excellent or good functional outcomes in the meta-analysis (p = 0.51). The mean average Puno functional scores were found to be lower in FVFG group (Table 1). El-Gammal et al.3 had attributed the lower functional scores in FVFG group to the fact that there was delayed mobilization resulting in stiffness of the knee and ankle in FVFG group (Total ROM loss). Moreover, three ankle arthrodesis were also performed in this group in their study. Yokoyama et al.8 had also noted the same findings probably due to septic non-union in one among the four patients undergoing FVFG. Thus, the early mobilization of the adjacent joints and the patient as a whole can be attributed to a relatively better functional outcome in cases of IBT technique. However, IBT has been shown to cause muscle tethering and pin tract infections which can affect the functional outcome of the patients.
The total number of complications was 68 % higher in IBT technique. El-Gammal et al.3 and Ren et al.7 had divided the complications into major, moderate and minor categories where minor complications needed no surgical interventions, moderate needed surgical interventions and major ones were residual complications that could not be corrected. They noted the minor and moderate complications were much higher in IBT group (total 110 in IBT and 34 in FVFG group), but the major complication rates were comparable between groups (total 19 in IBT and 11 in FVFG group). Similarly, Song et al.9 classified the complications into major and minor complications where major complications needed surgical interventions and minor ones needed surgical management. They noted 5 major, 9 minor complications for IBT group and 6 major and 15 minor complications in FVFG group. The other two studies named the complications in two groups separately. Pin tract infection was the most common complication in both groups with higher rates of infection in IBT group (42 % in IBT and 38 % in FVFG) and fibula graft fracture was the second most common complication in.
FVFG group (37 %). The higher rates of complications in IBT technique may be attributed to prolonged external fixator time and longer time to bony union. However, the rates of non-union didn't differ between groups (p = 0.84).
The comparison between intraoperative parameters between these two techniques indicates a longer operation time (average difference of 6.37 h) and higher blood loss (average difference of 582.4 ml) in the FVFG group, which is expected as there is the time needed for vascular exploration as well as anastomosis with recipient vessels. The mean hospital stay was mentioned in only one study and it was 10.16 days longer in IBT group. The methods of fixation of vascularized fibula were comparable between the studies as most of them used external fixators with or without screws except the study by Abdel-Razek et al.15 had used plates and screws.
This study highlights the benefits of FVFG over IBT technique having a lesser external fixator time, lesser time to healing, and a lesser overall number of minor or moderate complications. However, the functional and bony outcomes don't differentiate between these two techniques.
5 Conclusion
There is no difference in terms of bony or functional outcomes between IBT or FVFG techniques when used for the reconstruction of long bone defects in lower limb. However, the average mean time to union was 9.3 months earlier in FVFG group. FVFG technique also yielded shorter external fixator time and external fixator index. The total number of complications was 68 % higher in IBT technique. However, the rates of non-union didn't differ between the groups. Higher quality comparative studies with a larger sample size are needed to draw a final consensus on this ongoing debate.
Funding
No funding was received to assist with the preparation of this manuscript.
Ethics approval
No ethical approval.
Availability of data and material
Data transparency maintained. There are no published claims and comply with field standards.
Code availability
No published claims and comply with field standards.
Informed consent to participate
Informed consent was obtained from all individual participants included in the study.
Informed consent for publication
Patients signed informed consent regarding publishing their data and photographs.
Patient’s Consent
Informed consent was obtained from all individual participants included in the study.
CRediT authorship contribution statement
Souvik Paul: Conceptualization, Methodology, Formal analysis, Data curation, Writing – original draft, Writing – review & editing, Visualization, Supervision, Project administration. Madhubari Vathulya: Conceptualization, Methodology, Formal analysis, Data curation, Writing – original draft, Writing – review & editing, Visualization, Supervision, Project administration. Pankaj Kandwal: Conceptualization, Methodology, Formal analysis, Data curation, Writing – review & editing, Visualization, Supervision, Project administration. Manish Jagtap: Conceptualization, Formal analysis, Data curation, Writing – review & editing, Visualization, Supervision, Project administration. Ridima Behl: Conceptualization, Formal analysis, Data curation, Writing – review & editing, Visualization, Supervision, Project administration.
References
- Intercalary defects reconstruction of the femur and tibia after primary malignant bone tumour resection. A series of 13 cases. Orthop. Traumatol. Surg. Res.. 2011;97:512-519.
- [Google Scholar]
- Segmental transports for posttraumatic lower extremity bone defects: are femoral bone transports safer than tibial? Arch Orthop Trauma Surg. 2011;131:229-234.
- [Google Scholar]
- Management of traumatic tibial defects using free vascularized fibula or ilizarov bone transport: a comparative study. Microsurgery 2009:504-506.
- [Google Scholar]
- Biological facet of segmental bone loss reconstruction. J Orthop Trauma. 2017;31(Suppl 5):S27-S31.
- [Google Scholar]
- Induced membrane technique using enriched bone grafts for treatment of posttraumatic segmental long bone defects. J Orthop Traumatol. 2019;20
- [Google Scholar]
- Management of segmental skeletal defects by the induced membrane technique. Indian J Orthop. 2015;49:643-648.
- [Google Scholar]
- Treatment options for infected bone defects in the lower extremities: free vascularized fibular graft or Ilizarov bone transport? J Orthop Surg Res. 2020;15:1-11.
- [Google Scholar]
- Free vascularized fibular graft vs. Ilizarov method for post-traumatic tibial bone defect. J Reconstr Microsurg. 2001;17:17-25.
- [Google Scholar]
- Comparison of internal bone transport and vascularized fibular grafting for femoral bone defects. J Orthop Trauma. 2003;17:203-211.
- [Google Scholar]
- Ilizarov bone transport versus fibular graft for reconstruction of tibial bone defects in children. J Pediatr Orthop Part B. 2016;25:556-560.
- [Google Scholar]
- Vascularized fibular grafts for the reconstruction of segmental tibial bone defects. Arch Orthop Trauma Surg. 1997;116:404-407.
- [Google Scholar]
- Treatment of non-unions of fractures of the tibial diaphysis by posterolateral cortical cancellous bone-grafting. J. Bone Joint Surg. Am.. 1980;62:936-941.
- [Google Scholar]
- Early fibular bypass procedures (tibiofibular synostosis) for massive bone loss in war injuries. J Trauma. 1979;19:177-181.
- [Google Scholar]
- Bone transport with magnetic intramedullary nails in long bone defects. Eur J Orthop Surg Traumatol. 2021;31:1243-1252.
- [Google Scholar]
- Ilizarov bone transport versus vascularized fibular graft in reconstruction of post-traumatic tibial bone defects. J Pediatr Orthop Part B. 2016;25:556-560.
- [Google Scholar]
- The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009;339
- [Google Scholar]
- Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg. 2003;73:712-716.
- [Google Scholar]
- Functional outcome of patients with salvageable limbs with grades III-B and III-C open fractures of the tibia. Microsurgery. 1996;17:167-173.
- [Google Scholar]
- The ‘diamond concept’ for long bone non-union management. J Orthop Traumatol. 2019;201(20):1-13.
- [Google Scholar]
- Segmental bone defects: from cellular and molecular pathways to the development of novel biological treatments. J Cell Mol Med. 2010;14:2561.
- [Google Scholar]
- One-stage treatment of infected bone defects of the tibia with skin loss by free vascularized osteocutaneous grafts. Microsurgery. 1995;16:704-712.
- [Google Scholar]
- Reconstruction of traumatic tubular bone defects using vascularized fibular graft. Injury 2019
- [Google Scholar]
- Management of critical-sized bone defects in the treatment of fracture-related infection: a systematic review and pooled analysis. Arch Orthop Trauma Surg. 2020;1417(141):1215-1230.
- [Google Scholar]
- Two stage reconstruction versus bone transport in management of resistant infected tibial diaphyseal nonunion with a gap. Arch Orthop Trauma Surg. 2016;136:1233-1241.
- [Google Scholar]
- Ilizarov treatment protocols in the management of infected nonunion of the tibia. J Orthop Trauma. 2017;31(Suppl 5):S47-S54.
- [Google Scholar]
- Histology and ultrastructure of arteries, veins, and peripheral nerves during limb lengthening. Clin Orthop Relat Res 1994:54-62.
- [Google Scholar]
- Changes in blood flow during tibial thickening by the Ilizarov method. Bull Exp Biol Med. 2002;134:525-527.
- [Google Scholar]
- Free vascularized fibular graft salvage of complications of long-bone allograft after tumor reconstruction. J. Bone Jt Surg. - Ser A. 2008;90:93-100.
- [Google Scholar]