Kemal ÖZAKSAR, Tahir S. SÜGÜN, Tulgar TOROS, Yusuf GÜRBÜZ, Murat KAYALAR, Fuat ÖZERKAN

Tip 3 açık tibia kırıklarında serbest damarlı fibula grefti uygulamaları

Amaç: Bu çalışmanın amacı Gustilo Tip 3 açık tibia kırıkları sonrası gelişen kemik defektlerinin serbest damarlı fibula grefti (SDFG) ile rekonstrüksiyonunun sonuçlarını ve komplikasyonlarını değerlendirmekti. Çalışma planı: Açık tibia kırığı nedeniyle ortalama yaşı 32 (dağılım: 16-47) olan 21 hastaya (19 erkek, 2 kadın) ortalama 10 (dağılım: 6-18) cm’lik kemik defekti için SDFG uygulandı. Hastaların 15’ine açık kırık sonrası primer, 6’sına açık kırık sonrası gelişen osteomiyelit veya defektli kaynamama nedeni ile sekonder SDFG yapıldı. Kemik kaynamaları geriye dönük olarak değerlendirildi. On sekiz hastanın ortalama 74 (dağılım: 18-216) aylık takip sürecinde dizilim kusuru, kısalık, hareket açıklığı incelendi. Yaşam kalitesi Kısa Form 36 (KF-36) ile sorgulandı. Bulgular: Kaynama zamanı proksimal fibulada ortalama 19 (dağılım: 16-24), distal fibulada ise 20 (dağılım: 16-28) hafta idi. Üç hastada proksimalde kaynamama saptandı. Ortalama eksternal fiksatör çıkarma zamanı 6.3 (dağılım: 3-14) ay idi. Fiksatör çıkarıldıktan sonra 15 hastada stres kırığı saptandı. Yedi hastada 5° üzerinde dizilim kusuru, 4 hastada 2 cm üzerinde kısalık saptandı. KF-36 skorlarında fiziksel fonksiyon, fiziksel rol kısıtlılığı, vücut ağrısı, genel sağlık algısı, sosyal fonksiyon ve emosyonel rol kısıtlılığı anlamlı düzeyde toplum değerlerinin altında bulunur iken, mental sağlık ve yaşam enerjisi değerleri toplumdan farklı bulunmadı. Çıkarımlar: Serbest damarlı fibula grefti açık tibia kırıklarında kemik defektlerinin ve yumuşak doku defektlerinin tek seansta rekonstrüksiyonunda güvenilir ve etkili bir yöntemdir.

Free vascularized fibular grafts in Type 3 open tibia fractures

Objective: The aim of this study was to evaluate the results and complications of free vascularized fibular grafting (FVFG) for the reconstruction of bone defects in Gustilo Type 3 open tibia fractures. Methods: Free vascularized fibular grafting was performed on open tibia fractures with a bone defect of an average of 10 (range: 6 to 18) cm in 21 patients (19 males, 2 females; mean age: 32 years; range: 16 to 47 years). Primary FVFG was performed for 15 patients with open fractures and secondary FVFG in 6 patients with osteomyelitis due to open fractures or defective nonunions. Bony unions were evaluated retrospectively. At a mean follow-up time of 74 (range: 18 to 216) months, 18 patients were examined for malalignment, shortness, and range of motion. Quality of life was evaluated using the Short Form 36 (SF-36). Results: Mean bony union times for the proximal and distal fibula were 19 (range: 16 to 24) weeks and 20 (range: 16 to 28) weeks, respectively. Proximal nonunion was detected in three patients. Mean external fixation removal time was 6.3 (range: 3 to 14) months. Stress fractures occurred in 15 patients following fixator removal. Malalignment of over 5 degrees was detected in 7 patients and shortness over 2 cm was detected in 4 patients. SF-36 scores were significantly lower in the domains of physical functioning, role limitation due to physical problems, bodily pain, general perception of health, social function, and role limitation due to emotional problems. Mental health, energy and vitality were similar to the healthy reference group. Conclusion: Free vascularized fibular grafting appears to be a reliable and effective method for reconstructing bone defects and soft tissue defects in a single session in open tibia fractures.

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1. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classi- fication of type III open fractures. J Trauma 1984;24:742-6.
2. Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986;78:285- 92.
3. Beris AE, Lykissas MG, Korompilias AV, Vekris MD, Mitsionis GI, Malizos KN, et al. Vascularized fibula transfer for lower limb reconstruction. Microsurgery 2011;31:205- 11.
4. Weiland AJ, Moore JR, Daniel RK. Vascularized bone auto- grafts. Experience with 41 cases. Clin Orthop Relat Res 1983;(174):87-95.
5. Taylor GI, Miller GD, Ham FJ. The free vascularized bone graft. A clinical extension of microvascular technique. Plast Reconstr Surg 1975;55:533-44.
6. Yazar S, Lin CH, Wei FC. One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities. Plast Reconstr Surg 2004;114:1457-66.
7. Tu YK, Yen CY, Yeh WL, Wang IC, Wang KC, Ueng WN. Reconstruction of posttraumatic long bone defect with free vascularized bone graft: good outcome in 48 patients with 6 years' follow-up. Acta Orthop Scand 2001;72:359-64.
8. Han CS, Wood MB, Bishop AT, Cooney WP 3rd. Vascularized bone transfer. J Bone Joint Surg Am 1992;74: 1441-9.
9. Arai K, Toh S, Tsubo K, Nishikawa S, Narita S, Miura H. Complications of vascularized fibula graft for reconstruction of long bones. Plast Reconstr Surg 2002;109:2301-6.
10. Ware JE Jr, Shelbourne CD. The MOS 36-item short-form health survey (SF-36). 1. Conceptual framework and item selection. Med Care 1992;30:473-83.
11. Kocyigit H, Aydemir O, Fisek G, Olmez N, Memis A. Validity and reliability of Turkish version of Short form 36: a study of patients with rheumatoid disorder. [Article in Turkish] Journal of Drug and Therapy 1999;12:102-06.
12. Demiral Y, Ergör G, Ünal B, Semin S, Akvardar Y, K›v›rc›k B, et al. Normative data and discriminative properties of short form 36 (SF-36) in Turkish urban population. BMC Public Health 2006;6:247.
13. Parmaksizoglu F, Koprulu AS, Unal MB, Cansu E. Early or delayed limb lengthening after acute shortening in the treat- ment of traumatic below-knee amputations and Gustilo and Anderson type IIIC open tibial fractures: The results of a case series. J Bone Joint Surg Br 2010;92:1563-7.
14. Lee KS, Chung HK, Kim KH. Vascularised osteocutaneous fibular transfer to the tibia. Int Orthop 1991;15:199-203.
15. Kıral A, Arpac›o¤lu ÖM, Sar›o¤lu A, Kuflkucu M, Rodop O, Kaplan H. Treatment of large segmental bone defects with free, vascularized fibular grafts. [Article in Turkish] Acta Orthop Traumatol Turc 1997;31:216-24.
16. El-Gammal TA, El-Sayed A, Kotb MM. Hypertrophy after free vascularized fibular transfer to the lower limb. Microsurgery 2002;22:367-70.
17. Miniami A, Kasashima T, Iwasaki N, Kato H, Kaneda K. Vascularized fibular grafts. An experience of 102 patients. J Bone Joint Surg Br 2000;82:1022-5.
18. Doi K, Kawakami F, Hiura Y, Oda T, Sakai K, Kawai S. One-stage treatment of infected bone defects of the tibia with skin loss by free vascularized osteocutaneous grafts. Microsurgery 1995;16:704-12.
19. Yajima H, Kobata Y, Shigematsu K, Kawamura K, Kawate K, Tamai S, et al. Vascularized fibular grafting in the treatment of methicillin-resistant Staphylococcus aureus osteomyelitis and infected nonunion. J Reconstr Microsurg 2004;20:13-20.
20. Lee KS, Park JW. Free vascularized osteocutaneous fibular graft to the tibia. Microsurgery 1999;19:141-7.
21. Zhen P, Hu YY, Luo ZJ, Liu XY, Lu H, Li XS. One-stage treatment and reconstruction of Gustilo Type III open tibial shaft fractures with a vascularized fibular osteoseptocuta- neous flap graft. J Orthop Trauma 2010;24:745-51.
22. De Boer HH, Wood MB. Bone changes in the vascularized fibular graft. J Bone Joint Surg Br 1989;71:374-8.
23. Ihara K, Doi K, Yamamato M, Kawai S. Free vascularized fibular grafts for large bone defects in the extremities after tumor excision. J Reconstr Microsurg 1998;14;371-6.
24. Low CK, Pho RW, Kour AK, Satku K, Kumar VP. Infection of vascularized fibular grafts. Clin Orthop Relat Res 1996;(323):163-72.
25. Dagum AB, Best AK, Schemitsch EH, Mahoney JL, Mahomed MN, Blight KR. Salvage after severe lower- extremity trauma: are the outcomes worth the means? Plast Reconstr Surg 1999;103:1212-20.
26. Saddawi-Konefka D, Kim HM, Chung KC. A systematic review of outcomes and complications of reconstruction and amputation for type IIIB and IIIC fractures of the tibia. Plast Reconstr Surg 2008;122:1796-805.