Horizontal Fibula Transport with 3D Scaffold and Autologous Bone Grafting for Massive Tibial Defects: A Novel Approach

Research Type: Level 5 - Case report, Expert opinion, Personal observation Introduction/Purpose: Managing large tibial defects remains a significant challenge in orthopedic surgery. Traditional reconstructive techniques such as longitudinal tibial bone transport, the Masquelet technique, allograft, and autograft each carry limitations including the risk of infection, delayed union, graft rejection, non-union, and donor site morbidity. This case report presents an innovative approach combining ipsilateral transverse fibula transport with a 3D-printed scaffold and autologous bone grafting to treat a 14.5 cm distal tibial defect, highlighting the potential of merging traditional and advanced techniques for complex defect reconstruction. Methods: A 53-year-old diabetic male with a distal tibial non-union resulting from osteomyelitis presented with a 14.5 cm tibial defect after debridement. In a two-stage surgical procedure, Stage 1 involved a double-level fibular osteotomy with the application of a custom horizontal transport frame. Gradual fibula-to-tibia transport was performed using a circular frame with olive wires and a motorized device, directing the fibula from posterolateral to anteromedial. Stage 2, performed after 12 weeks, included docking of the transported fibula, insertion of a 3D-printed resorbable polycaprolactone scaffold (Osteopore™, Singapore), and autologous bone grafting from the ipsilateral femur using RIA (Synthes). Results: The patient was able to bear weight immediately after the application of the circular external fixator. Radiographic evaluation at 6 months demonstrated complete union of the fibula graft and scaffold consolidation. Conclusion: This approach, utilizing distraction osteogenesis for horizontal fibula transport, offers an effective alternative to traditional techniques such as longitudinal bone transport or free fibular transfer. By ensuring vascularization through ipsilateral fibula transfer without the need for microvascular surgery, this technique reduces surgical complexity and avoids donor site morbidity. The combined use of a 3D-printed scaffold and autologous bone grafting provides a promising solution for managing large tibial defects, with no implants remaining post-treatment, thereby minimizing the risk of reinfection.