Ipsilateral fibular transfer as a salvage procedure for large traumatic tibial defects in children in an austere environment.

Large tibial defects present a challenging scenario for the orthopaedic surgeon, particularly in the paediatric patient. Most management options, such as the vascularised fibular graft or Ilizarov technique, require microsurgical techniques or specialist equipment. In an austere environment, acute shortening or limb amputation may be most appropriate. However, limb salvage may be achieved by ipsilateral fibular transfer. In a one-stage operation, the fibular graft is harvested and either placed in the tibial defect in an intramedullary position or secured to the tibia with screws. We present two paediatric cases where this approach was used to preserve the lower limb despite extensive explosive trauma. In the first case, an 11 cm tibial defect was managed with an ipsilateral fibular graft. The graft was placed in an intercalary position proximally, with medial displacement of the ankle and fixation of the fibula as a strut graft. In the second case, a 10 cm tibial defect was managed with an ipsilateral fibular graft, using intercalary placement proximally and distally. Both children returned to weight bearing with crutches within several months of surgery. For large tibial defects, ipsilateral fibular transfer is an effective one-stage operation that represents a viable alternative to amputation in austere environments.

Older age and female gender are independent predictors of early conversion to total knee arthroplasty after high tibial osteotomy.

BACKGROUND: The primary aim was to assess survival of opening wedge high tibial osteotomy (HTO) for medial compartment osteoarthritis. The secondary aim was to identify independent predictors of early conversion to total knee arthroplasty (TKA). METHODS: During the 18-year period (1994-2011) 111 opening wedge HTO were performed at the study centre. Mean age was 45 years (range 18-68) and the majority male (84%). Mean follow-up was 12 (range six to 21) years. Failure was defined as conversion to TKA. Kaplan-Meier, Cox regression and receiver operating curve (ROC) analyses were performed. RESULTS: Forty (36.0%) HTO failed at a mean of 6.3 years (range one to 15). By Kaplan-Meier analysis, the five-year survival rate was 84% (95% confidence interval (CI) 82.6-85.4), 10-year rate 65% (95% CI 63.5-66.5) and 15-year rate 55% (95% CI 53.3-56.7). Cox regression analysis identified older age (hazard ratio (HR) 1.07 for each additional year, 95% CI 1.03-1.11, p b 0.001) and female gender (HR 2.37, 95% CI 1.06-5.33, p = 0.04) as independent predictors of failure. ROC analysis identified a threshold age of 47 years above which the risk of failure increased significantly (area under curve 0.72, 95% CI 0.62-0.81, p b 0.001). Cox regression analysis, adjusting for covariates, identified a significantly greater (HR 2.49, 95% CI 1.26-4.91, p = 0.01) risk of failure in patients aged 47 years old or more. CONCLUSION: The risk of early conversion to TKA is significantly increased in females and those older than 47. These risk factors should be considered pre-operatively when planning intervention for isolated medial compartment osteoarthritis.