Challenges in Healing Open and Comminuted Tibial Fractures: Surgical Options Explained

Open and comminuted fracture of the right tibia with poor fracture healing?

Hello Dr.
Wang, I was involved in a car accident on November 26, 2019, which resulted in an open and comminuted fracture of my right tibia.
On December 2, 2019, Dr.
A performed intramedullary nailing surgery.
It has now been over two years, and the fracture site has still not healed (the physician estimates a bone defect length of 5 cm).
I have consulted several other orthopedic surgeons who provided me with a few surgical options: 1.
Iliac bone grafting 2.
Fibula grafting from the left leg 3.
Vascularized fibula grafting from the left leg 4.
Bone transport surgery (the exact name of the procedure is uncertain, but the physician explained that a segment of the tibia would be cut from above the right tibia, combined with an external fixator, and the bone would be gradually transported during follow-up visits).
I would like to ask Dr.
Wang: (1) For options 1, 2, and 3, do we need to remove the intramedullary nail first and then re-apply a plate? (2) If the bone defect length is 5 cm, what is the success rate of iliac bone grafting? (3) Since I have poor healing of the right tibia, can I use the right fibula for grafting? (4) After autologous fibula grafting, what impact or complications might arise from the absence of one fibula in my daily life? (5) After autologous fibula grafting, will the absence of one fibula affect my ability to run, weight train, play basketball, jump, or engage in other high-impact activities that require significant leg strength? Thank you very much for your patient answers, doctor.

Lin Xiansheng, 30~39 year old female. Ask Date: 2022/04/03

Dr. Wang Shouji reply Orthopedics

Hello,
1.
Generally, it is not necessary to remove the intramedullary nail; using a steel plate for fixation carries a higher risk of plate fracture if healing does not occur.

2.
It is important to assess the overall volume of the defect; if the volume is significant, there is indeed concern that insufficient filling may affect the success rate.

3-1.
If the fibula bears approximately 1/6 of the body weight, it cannot provide long-term support on its own without the tibia.

3-2.
Generally, this is not the case for the reasons mentioned above.

4.
In general, particularly vigorous activities are not recommended.

Changhua Hospital cares about your health.

Wang Shou-ji

Reply Date: 2022/04/03

More Info

When dealing with open and comminuted tibial fractures, especially those that have not healed after a significant period, there are several surgical options and considerations to weigh. Your situation, having sustained a severe injury in 2019 with ongoing non-union, presents a complex challenge that requires careful evaluation of the available surgical interventions.

1. Surgical Options: The options presented to you include:
- Iliac Crest Bone Grafting: This involves harvesting bone from the iliac crest (the top of the pelvis) to fill the defect in the tibia. This is a common procedure for addressing significant bone loss, and it can be effective, especially if the surrounding tissue is healthy and well-vascularized.

- Fibula Grafting: This option involves taking a portion of the fibula (the smaller bone in the lower leg) and using it to bridge the gap in the tibia. This can be particularly useful if the fibula is intact and can afford to lose a segment.

- Vascularized Fibula Grafting: This is a more complex procedure where a segment of the fibula is taken along with its blood supply. This method enhances the chances of successful healing due to improved blood flow to the grafted bone.

- Bone Transport: This technique involves cutting a segment of the tibia and using an external fixator to gradually move the bone segment across the defect. This method can be effective for large defects but requires a commitment to a lengthy rehabilitation process.

2. Removal of Intramedullary Nail: For options 1, 2, and 3, it is generally necessary to remove the existing intramedullary nail before proceeding with the grafting procedures. This is because the presence of the nail can interfere with the healing process and the integration of the graft.

3. Success Rates of Iliac Crest Grafting: The success rate for iliac crest bone grafting can be quite high, especially in cases where the defect is well-defined and the surrounding tissue is healthy. However, the success also depends on factors such as the patient's overall health, the presence of infection, and the quality of the bone graft.

4. Using the Fibula for Grafting: It is possible to use the fibula for grafting, but this should be done with caution. The fibula plays a supportive role in ankle stability and weight-bearing. If a segment is removed, it may affect the structural integrity of the leg, but many individuals adapt well and can still engage in normal activities.

5. Impact on Physical Activities: After a fibula graft, while many individuals can return to activities such as running, weight training, and jumping, it is essential to approach these activities gradually. The absence of a section of the fibula may lead to some instability, and the individual may need to focus on strengthening the surrounding muscles to compensate. Consulting with a physical therapist post-surgery will be crucial to developing a safe and effective rehabilitation plan.

In conclusion, the decision on which surgical option to pursue should be made in collaboration with your orthopedic surgeon, considering your specific circumstances, the extent of the bone loss, and your personal goals for recovery. Each option has its risks and benefits, and understanding these will help you make an informed choice. It is also essential to discuss the potential for complications, such as infection or further non-union, and to ensure that you have a robust post-operative rehabilitation plan in place.

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