The young man, worked as a ‘turn boy’ for a truck driver, to assist the driver with complex manoeuvres of the truck, and with on and off loading of the cargo. Accidentally he was run over by the truck when helping the driver to turn, leading to bilateral lower-leg injury.

He had never been admitted to a hospital before and was not on any medication. 

On the day of the accident, bystanders helped him onto a motorbike and brought him to a small local hospital, where Plaster of Paris (POP) was applied. Weeks later, he was referred to Mulago Hospital, where orthopaedic surgeons applied an external fixator, but the large wound with exposed bone could not be managed there. He had refused amputation several times during this period. He was then referred to Kiruddu Hospital, where the reconstructive orthoplastic team reviewed him three months after the accident.

At the plastic surgery ward, the patient was not in pain and was afebrile, but he did have conjunctival pallor. Examination revealed an exposed right tibia with bone exposed over 12 cm. The exposed part of the bone was dry and did not look vital. The soft tissue defect was mid-tibia, starting 14 com below the knee joint, until 30 cm below the knee joint. Pulsations of the artery tibialis posterior (ATP) were palpable. The Artery tibialis anterior (ATA) and dorsalis pedis were not palpable. Sensation in the foot was intact, and all essential lower-leg muscles were functioning, including those of the anterior compartment. During the first year after the injury there had been some weakness, but there was no foot drop and peroneal nerve function remained intact. None of the pins had loosened. At the back of the knee there was a granulating wound as well. Knee and ankle had full range of motion.

The left leg also sustained a Gustilo–Anderson grade 3b open tibial fracture at the time of injury. This side had been stabilised with an external fixator and reconstructed using a medial gastrocnemius flap with split-skin grafting, which healed uneventfully.

Laboratory investigations showed a hemoglobin level of 7 g/dL.

The X-ray of the right leg showed nothing new compared with the physical examination with good positioning of the pins. 

Doppler of the peroneal artery showed an intact signal of the artery until 7 cm above the ankle joint.

Considerations

Because of the substantial soft tissue defect and a large expected bone defect after removal of the dead bone, a pedicled fibula was proposed for this patient in this setting. Masquelet technique and bone transport were also discussed but we believed that that pedicled fibula would be the best option. The intact ATP and peroneal artery enable this procedure with the advantage of using a large skin paddle together with the fibula to close the wound.

Preoperative

Surgery was scheduled with a team of orthopedic and plastic surgeons. Two units of blood were given. Preoperatively ABs were administered: 2 gram Ceftriaxon according to local protocol 30 minutes before surgery. The patient went for surgery under spinal anesthesia. External fixator clamps and bars were removed.

Debridement

Necrotic tissue at the wound edges was resected and contamination was removed by flushing with 1L saline through the wound site. After debridement of the bone there was a bone defect of 10 cm tibia. The remaining bone ends were still not very good quality but we didn’t want to remove more because of creating a very large bone defect for the fibula to bridge. The anterior soft tissue defect was 18x8cm. The defect on the dorsal side of the knee was 12x13 cm with only muscle exposed. Five samples were sent for cultures.

Harvesting the fibula

We designed a skin paddle with similar size on top of the fibula on the lateral side of the lower leg (see Fig.3-4). Dissection of the fibula was performed starting dorsally to confirm the position of the perforators and the quality of the peroneal artery. The fibula was freed from the posterior lateral and anterior muscle compartments and osteotomies were performed 7 cm above the distal end of the fibula and 4 cm below the proximal end. Afterwards the vascular pedicle was liberated.

Positioning and fixation 

Once only connected to its blood supply proximally, the fibula was turned upside down and partially inserted in the intramedullary canal of the proximal and distal ends of the tibia, bridging the gap. Fixation was performed only with external fixation because of risk of infection with the tibia bone ends still not without infection. 

The first night, hourly Doppler checks of the peroneal perforator signal in the skin paddle were done (see Video 1). The X-rays showed a good position of the fibula and the external fixation (photos 9 and 10). After 5 days: inspection of the skin grafts showing 70 percent take, we continued with daily dressings. Ceftriaxon was continued after the surgery. The patient was allowed to mobilise with crutches after the first five days including ankle and knee exercises.

The first weeks, some pus discharged between the stitches. The wound was flushed daily. Cultures were lost in the system, so he was treated with Ampicilline/cloxacilline for three months. The patient mobilised with two crutches during the first six weeks, allowing partial weight bearing. Little by little, the wounds showed more healthy tissue.

Discharge

After 8 weeks the patient was discharged home with instructions not to start full weight bearing and to come back in 6 weeks. 

Six month follow-up

Unfortunately, the patient did not show up until 6 months later when we could convince him to visit the clinic again. The external fixator had been removed elsewhere quite soon after discharge and although walking went well initially, he had experienced a sudden pain again three months ago and experienced more difficulties with walking since then (see Fig. 11-13). X-rays of the leg were ordered and showed a new fracture with a hypertrophic non-union of the fibula graft (see Fig. 14-15).

During a multidisciplinary meeting between the orthopedic and plastic surgeons the need to fixate the hypertrophic non-union was discussed. Options were internal fixation using a plate or external fixation again.

We were able to raise funds for him to buy a bridging plate and screws and the fracture was fixed with a bridging plate and screws at the orthopedic OR in Mulago hospital with the plastic surgeons joining online in a video call to guide the approach without risking the skin paddle of the fibula.

1.5 year follow-up

The patient was lost in follow-up again just after the post-operative pictures were taken. Only 12 months later we were able to find him again. He came to the hospital. Able to walk but still with pus discharge and pain in his leg. He explained that this started a few weeks after surgery and never stopped. But he was able to walk with little pain. Examination showed a small discharging sinus, confirming a fracture related infection (FRI) (see Fig. 19). The x-ray showed full consolidations and now signs of osteolysis, a varus deformity was seen (see Fig. 20).

It was decided to remove the plate without further treatment (photos 21 and 22) and the young man was able to walk without pain afterwards (video 2). The patient did not complain about the varus deformity, it did not affect his walking pattern much and he was happy with the outcome after all.

This story tells us that even in big soft tissue and bone defects with late presentation, an ipsilateral pedicled fibula graft can be a good option. However, a patients' understanding of the healing process is key in the aftercare and patience is required, taking time to explain the situations extensively and ensuring follow up. The external fixator should not be removed too early. And only partially weight bearing should be started afterwards with support of a cast or brace because it takes approximately a year before hypertrophy of the fibula will be enough. Nevertheless, it is a success story at the end with a happy patient that can walk normally on the reconstructed leg without pain.

Authors S. Kazibwe, R.Wierper, M. Botman, E. Kalanzi, P. Sekimpi, J. Bramer, P. Bongers, J. Wernand, E. Alkemade, L. Burlage