High velocity trauma is very frequently associated with comminuted fractures and open fractures. Many times the problem is further escalated by the fact that the patient comes in with a high velocity trauma along with a comminuted open fracture with a big bone loss. This bone gap is large enough not to be filled completely by cancellous iliac crest bone. This bone gap non-union is extremely difficult to manage. There have been devised multiple options for the treatment of these fractures /gap non-unions including LRS and IIizarov and also bone grafting with RIA (Reamer Irrigator Aspirator) system but all of the procedures are technically demanding and require procedure specific training and implant system. Also with all these methods it takes a lot of time for union and consolidation and multiple surgeries may be required as in repeated alignment procedures, seen in both Ilizarov and LRS application. Even with all these efforts many times the union cannot be achieved and in many of the cases delayed amputation is later done by the surgeon to prevent morbidity of the patient. Additionally long period of absence from work and poor cosmetic appearance of the limb with the frame, makes these procedures difficult to tolerate for the patients. So here we present our preferred method of treatment of gap non-union, which provides us with what we can describe as a single stage solution to gap non-unions.

It is a retrospective study including 5 patients with gap non-unions operated between January 2021 to December 2024. All were male patients with high velocity trauma leading to gap non-union. Four patients had a complex comminuted compound fracture femur at different levels and one of them had a gap non-union of the shaft of tibia. In all the patients as they were open fractures primary management by debridement and external fixator application was done. Once the wound was clean and dry the patients were reviewed and the fixator removed. The patients were allowed time for the pin tracts to heal properly. Once the pin tracts were completely healed and blood investigations CRP, ESR ,WBC counts done, to see that there was no infection, the patients were taken for single stage ipsilateral fibula strut grafting with cancellous iliac crest grafting along with internal fixation by a locking plate. Patient 1 A 32 years old male patient, presented to us in the casualty with a history of high velocity trauma resulting in an olecranon fracture (Fig 2) with a comminuted proximal tibia fracture with an open distal femur fracture with a big bone loss (Fig 1). He was advised amputation at another center.

All our patients with gap non-union united and were able to walk independently. There were no cases of non-union following procedure. There was one case which developed infection and we had to put in antibiotic loaded cement beads which were removed at 6 weeks and the infection settled and has yet not come back. One of the patients of the study, the one with a gap non-union in tibia was an irritable person and he did not much comply with instructions or come to regular follow ups. He developed wound complications but all complications settled. His fracture also united and was able to walk and even drive a two wheeler independently. However as last heard from him, he had a fall again and has developed a fracture in the same operated leg at a different site as reported by him. He is taking treatment from the local nearby hospital.

The incidence of road traffic accidents is on the rise and this in turn has increased the occurrence of long bone fractures and complex non-unions1. Non-unions are extremely difficult to treat and are a big problem for orthopaedic surgeons2. Gap non-unions are even more difficult to treat and results are uncertain even with best treatments. Studies have advocated high healing rates with autologous non vascularized fibular grafts with compression plates. There are various challenges in treating gap non-unions following high velocity trauma. They include primarily a big bone defect which needs to be filled up bridging the two available ends. Most of them have extensive soft tissue damage due to high velocity trauma resulting in open fractures. Poor soft tissue status over the fracture site and risk of infections further make them more difficult to manage. Many of these patients would need repeated surgeries which are financially burdening to the patient and take a lot of time due to which the patient and the surgeons lose hope. Additionally, most of these patients have multiple fractures or polytrauma which makes the treatment all the more difficult. Multiple options for treatment have emerged but ipsilateral non vascularized autologous fibula grafting in the gap along with cancellous iliac crest bone graft supplementation with locking plate application has a special role in management of these injuries. Fibula, as per Wolff’s law, has immense remodeling potential when subjected to sustained mechanical load3. As observed in our study the fibula was well incorporated into femur or tibia when put in to bridge the gap. Our study findings are in accordance with the results obtained by Latif et al4 wherein they managed ten cases of complex non-union with autologous non vascularized fibula grafting with compression plating. They observed that all their patients at last follow up were doing well and were satisfied with the treatment. They advocated that the method is a reliable method for treatment of complex non-unions. In a slightly different scenario vascularized ipsilateral fibula graft (Huntington’s Procedure) was used in four cases of bridging tibial defects following high velocity trauma, tumour or pseudoarthrosis of tibia in the study by Pawan Agarwal et al5 . All their patients united giving good results advocating that vascularized fibula graft is a rational choice for treatment of large tibial defects. Their study supports our finding by advocating the use of fibular graft for defects. In a case report by Ashutosh Bhosale6 ,the surgeon obtained union with an ipsilateral non vascularized fibula graft following masquelets technique in the reconstruction of a post traumatic tibial defect of 10 cm in a 25 year old man. He used a locking plate for supplementing the fibular autograft leading to solid union and full weight bearing in the patient. In another related study from china Xueiliang Cui et al compared 25 elderly patients of 3 part or 4 part proximal humeral fractures with a fibula strut allograft and plating with 35 other elderly patients with a similar fracture treated with LCP alone and found that fibula allograft along with LCP gave better radiological outcomes, clinical outcomes and low complication rate as compared to LCP alone in 3 part or 4 part proximal humeral fractures. They further advocated that fibular allograft helps in reduction and additionally supports the humeral head leading to better results7. Subramaniam Gannamani8 et al included 11 patients in their study with compound fractures of the distal femur with bone defects. Two staged surgery was performed. In the first stage Masquelet induced membrane technique by placing an antibiotic loaded cement spacer in defect to create biologically active membrane along with lateral locking plate was done. After 8 weeks or more, in the second stage, antibiotic spacer was removed and gap filled with non-vascularised fibula graft combined with cancellous bone graft. All fractures included in the study healed with an average time taken to be 6.6 months with no infection no non-union and no implant failure. They also concluded that fibular graft provides structural support, reduces the quantity of cancellous graft required. It also results in early weight bearing and led to good functional outcomes. Meignanaguru M9 et al in their case report of a 20 year old patient managed a case of infected gap non-union distal femur in the similar two staged approach wherein they obtained union in a gap of 8 cms in distal femur by fibular grafting along with cancellous bone grafting. Dhaniwala NS10 et al in their study managed a case of infected non-union of distal femur by debridement and Vacuum assisted closure (VAC) application followed by fibular grafting with cancellous iliac crest bone grafting and fixation with a rush nail. They concluded that fibula grafting is a technically simple and useful method of filling the bone gaps in fracture and non-union cases. Barakat El Alfy11 et al in their study included 15 patients with segmental post traumatic bone defects. All were managed by two stage technique -membrane induction followed by non-vascularized fibular grafting and cancellous bone grafting with plate fixation. Thirteen out of fifteen patients achieved union without the need of any secondary procedures indicating good results. Multiple other studies have advocated the use of Fibular strut grafting with fixation to achieve union in complex non-unions or defects. Our study supports the recommendations of these studies.

Gap non-union is a very difficult entity to address and still poses a significant challenge to the orthopaedic surgeons. Fibula strut graft for non-union is an effective method in treatment of gap non-unions yielding good results. The procedure has the advantage of being done in a single stage as compared to other modalities which take multiple readjustments and a longer time to achieve union. It is a relatively simple orthopaedic procedure and does not need any special equipment or special training and can give good results if done properly.

1. Seenappa HK, Shukla MK and Narasimhaiah M. Management of complex long bone nonunions using limb reconstruction system. Indian J Orthop 2013; 47: 602-7. 2. Bolkvadze S, Avazashvili N, Nozadze T and Tomadze G. Cortical intramedullary fibular graft in surgical treatment of long bones nonunion. Georgian Med News 2019; 11-15. 3. Ruff C, Holt B, Trinkaus E. Who's afraid of big bad Wolff? ‘‘Wolff's law’’ and bone functional adaptation. Am J Phys Arthropol. 2006;129:484e498. 4. Latif Zafar Jilani , Yasir Salam Siddiqui, Abdul Qayyum Khan, Mohammad Istiyak Autologous non-vascularized fibula with compression plating in the management of aseptic complex non-union of long bones Int J Burn Trauma 2024;14(4):75-83 5. Pawan Agarwal , Rajiv Savant , Dhananjaya Sharma Huntington's procedure revisited Journal of Clinical Orthopaedics and Trauma 10 (2019) 1128e1131 6. Ashutosh H. Bhosale Reconstruction of a post-traumatic tibial defect of 10 cm in a 6 month old induced membrane by non-vascularized fibula autograft – A case report Trauma Case Reports Volume 37, February 2022, 100576 7. Xueliang Cui, Hui Chen , Binbin Ma, Wenbin Fan and He Li “Fibular strut allograft influences reduction and outcomes after locking plate fixation of comminuted proximal humeral fractures in elderly patients: a retrospective study” BMC Musculoskeletal Disorders (2019) 20:511 https://doi.org/10.1186/s12891-019-2907-3 8. Subramaniam Gannamani ,Kamalakar Rao Rachakonda,Yeseswi Tellakula. Combining non vascularised fibula and cancellous graft in the masquelet technique : a promising approach to distal femur compound fracture management with large defects. Journal of Injury. https://doi.org/10.1016/j.injury2023.111233 9. Meignanaguru M, Shetty GR, Dhakshinamurthi Y, Srivasan D. Management of Infected Gap Nonunion of Distal Femur with Induced Membrane Technique Using Limb Reconstruction System Followed by Augmentation Plating and Bone Grafting: A Case Report. Journal of Orthopaedic Case Reports 2024 August,14(8):30-35 10. Dhaniwala NS, Khan KK, Ahmed S. Reconstruction of juxta articular bone defect in an infected fracture distal right femur using autologous fibular strut and iliac crest graft. J Evolution Med Dent Sci 2021; 10(39): 3501-3504 Doi: 10.14260/Jemds/2021/709 11. Barakat El Alfy, Mazen Abulsaad,Wail Lotfy Abdelnaby. The use of free non vascular fibular graft in the induced membrane technique to manage post traumatic bone defects. European Journal of Orthopaedic Surgery and Traumatology. https://Doi.org/10.1007/s00590-018-2153-7