Bone Transport in the Management of Post-Osteomyelitis Tibial Defects in Pediatric Population. A Long Term Follow-up Study in Uganda

Research Article

J Pediatr & Child Health Care. 2023; 8(1): 1058.

Bone Transport in the Management of Post-Osteomyelitis Tibial Defects in Pediatric Population. A Long Term Follow-up Study in Uganda

Loro A*, Franceschi F, Loro F and Brown N

Orthopedic Department, CoRSU Rehabilitation Hospital, P.O.BOC 46, Kisubi, Uganda

*Corresponding author: Loro ADepartment of Orthopedic, CoRSU Rehabilitation Hospital, P.O.BOC 46, Kisubi, Uganda

Received: January 23, 2023; Accepted: February 20, 2023; Published: February 27, 2023


Background: This study was designed to evaluate the long-term results and complications of using the bone transport technique in the management of post-osteomyelitis tibial defects in a low income country.

Design: Retrospective study in a cohort of pediatric patients.

Methods: Twenty-two patients were included in the study; all patients were treated between 2005 and 2014. The mean age at time of surgery was 9.5 years. The mean bone defect was 8.2 cm. Transport was done using both ring and monolateral external fixators; the fixator stayed in place for 290 days on average. Clinical and radiological evaluations were performed after a minimum follow-up period of 7 years. Patients were interviewed by social workers with focus on the psychosocial and economic costs of the procedure.

Results: The bone and soft tissues management required a total of ninety-one surgeries, with an average of four surgeries per child. Eradication of infection was obtained in all patients. Bone results were graded as excellent in 10, good in 7, fair in 2 and poor in 3. Functional results were graded as excellent in 8, good in 6, fair in 7 and poor in 1. Major and minor complications were numerous during the bone transport procedure. Three cases of non-union at the docking point were observed. Twelve patients had a limb length discrepancy, four had slight angular deformities. Reduced range of motion was observed both in the ankle (n=4) and knee (n=2). Seven joint fusions were noted, two knees and five ankles.

Conclusion: Bone transport is a valid option in the management of bone defects in children, providing satisfactory long-term outcomes. Bone gaps, soft tissue defects, limb discrepancy and joint disorders can be managed concurrently. The procedure is lengthy and prone to complications.

Keywords: Bone defects; Osteomyelitis; Bone transport; Pediatric osteo-articular infections; External fixator


In sub-Saharan Africa, haematogenous osteomyelitis represents a common condition in pediatric populations [1-3]. The tibia is the most commonly affected bone, followed by the femur, radius and humerus. In our facility, children most commonly present with complications of neglected or undertreated chronic osteomyelitis. The uncontrolled clinical course of the disease frequently leads to segmental bone defects that are difficult to manage, especially in settings with limited resources.

Osteoarticular Infections (OAI) display a higher incidence in children from lower socioeconomic groups [3]. In Uganda, with no universal health coverage, all costs related to diagnosis and treatment are taken on by the family; with 41.7% of the population under the international poverty line, OAIs are not always seen as a financial priority [4]. Furthermore, in some regions, OAI are believed to be related to extra-natural forces and so access to health facilities is often delayed by first attending non-medical bone setters or healers. As a result, the disease progresses leading to the complex clinical presentations that attend our institution.

The therapeutic strategies for filling bone gaps are dictated by several clinical and radiological key elements, such as the site of the defect, its size, and the quality of the residual bone stock. Thought must also go to previous surgeries, status of the soft tissues, involvement of the adjacent joints, limb discrepancy and axial deformities [5]. Experienced surgeons working in equipped facilities may choose from various management options, including conventional bone graft [6], Vascularized Fibula Flap (VFF) [7,8], transference of the fibula [9] and internal Bone Transport (BT) [10-13].

Literature exploring the applicability of these different options in low resource settings is limited. Considering the rising pediatric population of sub-Saharan Africa [14] and the significant physical, social and economic implications of neglected osteomyelitis, it is increasingly important to further examine this topic.

This retrospective study was designed to evaluate the outcomes and complications of bone transport in the treatment of pediatric post-osteomyelitis tibial defects managed in our facility in Uganda.

Materials and Methods

The surgical records of two authors (AL and FF) were reviewed in order to identify cases of post-osteomyelitis tibial bone defects that were treated with the bone transport technique between 2005-2014. Twenty-two cases were recorded and included. Clinical notes and radiographs were reviewed; patient characteristics, operative protocols and complications were recorded. Post-operative difficulties were divided into problems, obstacles and complications as per Paley [15].

Patients were asked to voluntarily attend a follow-up consultation in 2021 with our orthopedic team, where the long term bone and functional outcomes were assessed according to the criteria proposed by Paley et al. [13]. Bone outcomes are based on union, infection, deformity, Limb Length Discrepancy (LLD) and cross-sectional area of union of the regenerate bone and docking site. Functional outcomes are based on pain, need for walking aids, joint contracture, loss of range of motion as compared to pre-operative range and ability to return to Activities of Daily Living (ADLs) and/or work [13].

Patient Characteristics

There was a 1:1 male to female ratio, with an average age at presentation of 9.5 years (range 3 to 15). The left tibia was involved in 12 cases.

All bone defects were secondary to debridement for haematogenous osteomyelitis. Six children presented with quiescent infection, referred for limb salvage procedures after initial surgeries were carried out in other institutions. The remaining sixteen presented with active infections; 14 underwent surgical treatments before the BT procedure and 2 received prior conservative treatment.

At presentation, all showed severe clinical signs caused by delay and/or poor management in terms of overzealous debridement (Figure 1-3a). Pathological fractures were seen in 15 children, exposed sequestra with skin loss in 11, joint contracture and stiffness in 10, limb discrepancy in 11, axial deformity in 7 and skin disorders in 8. Nine were unable to walk and a further nine needed walking aids to mobilize safely.