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Reconstruction of Bone Defects After Osteomyelitis with Nonvascularized Fibular GraftA Retrospective Study in Twenty-six Children
Sandeep Patwardhan, MS(Orth)1; Ashok K. Shyam, MS(Orth)1; Rustom Adi Mody, MCh, MS(Orth)2; Parag K. Sancheti, MCh, MS(Orth)1; Rujuta Mehta, MS(Orth)3; Hardik Agrawat, MS(Orth)1
1 Sancheti Institute for Orthopaedics and Rehabilitation, 16 Shivaji Nagar, Pune 411 005, Maharashtra, India. E-mail address for A.K. Shyam: drashokshyam@yahoo.co.uk
2 B.D. Petit Parsee General Hospital, Bomanjee Petit Road, Cumballa Hill, Mumbai 400 036, India
3 Dr. Balabhai Nanavati Hospital, S.V. Road, Vile Parle (West), Mumbai 400 056, India
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Investigation performed at the Sancheti Institute for Orthopaedics and Rehabilitation, Pune, India

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 May 01;95(9):e56 1-6. doi: 10.2106/JBJS.K.01338
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Persistent infection, soft-tissue fibrosis, and damage to periosteum compound the treatment of children with a bone defect following osteomyelitis. We report on a series of twenty-six patients treated with nonvascularized fibular graft and intramedullary fixation.


The series included eleven boys and fifteen girls (mean age, 6.8 years; range, three to twelve years) with gap nonunion after osteomyelitis. Initial treatment involved thorough debridement and sequestrectomy. When the infection was quiescent as indicated by inflammatory parameters, nonvascular fibular grafting with intramedullary Kirschner wire fixation (with or without additional external fixation) was performed. The time to union was noted, and a subgroup analysis was performed to correlate the size of the bone defect with the time to union.


The mean duration of follow-up was 3.02 ± 0.74 years (range, 1.3 to 4.2 years), and the mean time to union was 38.76 ± 12.02 weeks (range, fifteen to sixty weeks). There was a weak positive correlation between the time to union and the preoperative bone defect size (Pearson correlation coefficient, 0.699). The mean time to union was 31.7 ± 11.5 weeks for a defect of <4 cm, 36.6 ± 9 weeks for a defect of 4 to 6 cm, and 51 ± 6.7 weeks for a defect of >6 cm. Delayed union was seen at one end of the fibular graft in four (15%) of the patients and was treated with plate fixation. One patient had recurrence of infection. Limb-length discrepancy (range, 2 to 5 cm) was seen in all patients in whom the lower limb was involved and was treated with a shoe lift.


This series illustrates the potential benefits of staged sequestrectomy and nonvascular fibular grafting for the treatment of gap nonunion following osteomyelitis in children. The procedure is simple, does not require specialized training or equipment, and has a low complication rate.

Level of Evidence: 

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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