Case Report: Large bone defect reconstruction in lower extremities with ipsilateral transposition fibular graft with combined inlay and onlay technique using plate and screw fixation (fibula pro tibia technique)

Abstract

Introduction: Management of large bone defect is a challenging problem. Hahns, in 1884, introduced the first use of fibula pro tibia to bridge a large defect of the tibia due to chronic osteomyelitis. In this case, we did a transposition of the ipsilateral fibular with inlay and onlay technique using a locking plate and screw into the defect of the tibia. Case presentation: A 20-year-old male came to our emergency department at RSUD Dr. Saiful Anwar, Malang, Indonesia with an open fracture grade III B of his left lower leg. We found a large defect of the tibia approximately 7.5 cm after regular wound care for ten months. Then, we performed ipsilateral transposition fibular graft with combined inlay and onlay technique using a locking plate and screw fixation. No infections occurred and there was progressive callus formation with extending ossification along the periosteal tissue in the four-month postoperative evaluation. There was no leg length discrepancy, and the union sign showed that the patient could achieve full range of movement (ROM) and walk with crutches without pain with a Lower Extremity Functional Scale (LEFS) score of 62. Discussion: Contralateral fibula graft carries a high risk of endangering the unaffected limb. The ipsilateral fibula can be utilized to replace the missing segment with minimal morbidity. The purpose of combining ipsilateral fibular transport with the inlay and onlay technique is to minimalize the gap defect between fracture fragments, therefore enhancing the union rate of the bone. Conclusion: The fibula pro tibia technique can be used as an alternative treatment option for large gap bone defects in lower extremities with minimal complication.