Efficacy of Non-Vascularized Fibular Grafts in the Reconstruction of Large Long Bone Defects in the Paediatric Population

Abstract

Background: Management of large long bone defects in the pediatric population remains a significant challenge in orthopedic surgery. These defects often arise secondary to chronic osteomyelitis, high-energy open fractures, or resection of benign and malignant bone tumors. Various reconstructive strategies have been employed, including cancellous bone grafting, free vascularized fibular grafting, and bone transport using external ring fixators. Although non-vascularized fibular grafts (NVFG) have demonstrated promising outcomes in adults, their utility in children is less clearly defined due to limited data on safety, efficacy, and long-term outcomes. Objectives: This study aims to evaluate the clinical and radiological outcomes of non-vascularized autologous fibular grafts in the management of large long bone defects (>4 cm) in children, with specific focus on graft incorporation, time to union, preservation of the physis, and functional recovery. Materials and Methods: An observational study was conducted on 20 children presenting with large long bone defects exceeding 4 cm. All patients underwent reconstruction using autologous non-vascularized fibular strut grafts. Grafts were fixed via internal fixation (plates or nails) or external fixation based on the bone affected, soft-tissue condition, and stability needs. Patients were followed for a minimum period of 6 months. Outcome measured included radiological union, graft resorption or remodeling, limb-length discrepancy, joint range of motion, and complications (graft fracture, non-union, and physeal injury). Results: Of the twenty children, radiographic union was achieved in 18 by a mean of 9.4 ± 2.1 weeks (range: 7–13 weeks). Two cases demonstrated delayed union; one of which required an additional surgical procedure (revision grafting and fixation) to achieve union. At final follow-up, most patients regained full joint function; minor complications included one graft fracture, one physeal separation, and one implant failure. All patients were ambulatory and pain-free, with no recurrence of infection or graft failure. Conclusion: NVFG, when employed in conjunction with rigorous infection control and suitable fixation, is a safe, effective, and technically feasible reconstructive option for large bone defects in children. There is relatively rapid incorporation of the graft with high union rates and low donor-site morbidity. Special caution is needed in larger defects and some cases may require revision. Keywords: Non-vascularised fibular graft, pediatric gap non-union.