The condition at the heart of the study, infected non-union, is defined by the combination of two failures: the bone has not consolidated for at least six months with no radiographic progress over the preceding three months, and a fracture-related infection has been confirmed according to international consensus criteria. Confirmation requires at least one hard finding, such as a sinus tract communicating with the fracture, purulent drainage, identical microorganisms cultured from at least two deep tissue samples, or histopathological evidence of infection. At surgery, the Marseille team routinely obtained at least five deep tissue specimens, incubating cultures for a minimum of ten days to capture slow-growing organisms. The stakes are high because bacterial biofilms on implants and dead bone shield pathogens from both the immune system and antibiotics, making spontaneous healing essentially impossible without major surgery.

The 22 patients in the cohort illustrate just how refractory these cases can be. Ninety-five percent had post-traumatic infected non-unions, mostly after high-energy road traffic accidents, and 82 percent had originally sustained open fractures, which carry a high risk of contamination. The median patient was 45 years old, and the median interval between the initial trauma and the reconstructive procedure was 14 months, with one patient not reaching reconstruction until more than 15 years after the original injury. Before arriving at the vascularized graft option, patients had undergone a median of four previous operations, and 41 percent had already failed a Masquelet induced-membrane reconstruction, a two-stage technique that coaxes the body to grow a membrane around a cement spacer before bone grafting. These were, in short, patients for whom conventional reconstruction had already run out of road.

Vascularized fibular grafting, first described in the 1970s, takes advantage of the fibula, the slender bone running alongside the tibia, which can be harvested with its feeding vessel, the peroneal artery, and transplanted as free living tissue. In a single operative session, a combined orthopedic and plastic surgery team first performed radical debridement of infected bone and soft tissue, then harvested the graft from the opposite leg in most cases, preserving at least five centimeters of proximal fibula and seven centimeters of distal fibula to protect knee and ankle stability. The graft was inserted into the healthy bone segments bridging the defect, fixed with internal or external hardware, and connected to recipient vessels through microsurgical anastomoses, with the posterior tibial vessels preferred when anatomy allowed. The median bone defect measured 90 millimeters and the median graft 115 millimeters, lengths that exceed what most non-vascularized techniques can reliably bridge.

The biological rationale for this approach is what makes it so appealing in infected fields. Because the transplanted fibula arrives with intact microcirculation, it does not depend on the often scarred and poorly vascularized recipient bed for survival. Living bone maintains its own osteogenic potential, remodels under load, and, crucially, its preserved blood flow may improve local immune defense and the delivery of antibiotics to the infected site, a decisive advantage against biofilm-associated organisms such as Staphylococcus aureus, coagulase-negative staphylococci, Pseudomonas aeruginosa, and, in one case, even Candida albicans. Eighty-two percent of the infections were polymicrobial, and antimicrobial therapy, individualized by infectious-disease specialists according to intraoperative cultures, continued for a median of 22 weeks after surgery. Notably, no patient remained on suppressive antibiotics at final follow-up, suggesting that in successfully treated cases the infection was truly eradicated rather than merely contained.

The headline results are encouraging but come with an important caveat about time. Bone consolidation, defined as radiographic bridging of at least three of four cortices on orthogonal views together with painless full weight-bearing, was achieved in 17 of 22 patients, or 77 percent. Infection remission occurred in 16 patients, and overall treatment success, the combination of both, in 16 patients, or 73 percent. Nine patients healed with the vascularized graft alone, at a median of 14 months, while seven required a secondary bone graft because consolidation was delayed, and their median time to union stretched to 38 months. Strikingly, all seven patients who underwent secondary grafting ultimately achieved union, although the authors caution that because the procedure was performed selectively at varying time points, this observation cannot be interpreted as proof of a causal benefit.

The methodological heart of the paper lies in its competing-risk analysis, a statistical framework that treats amputation and death not as censored observations, as traditional Kaplan-Meier methods do, but as genuine alternative outcomes that permanently preclude consolidation. This distinction matters because Kaplan-Meier curves can overestimate healing rates when patients leave the risk set for reasons other than the event of interest. Using cumulative incidence functions, the team calculated that the probability of consolidation was only about 18 percent at 12 months, rising to 41 percent at 24 months, 59 percent at 36 months, and roughly 76 percent by the end of follow-up. In other words, judging the success of a vascularized fibular graft at the one-year mark dramatically understates what the procedure can eventually deliver, a finding with direct implications for surgeons and patients deciding whether to persist with reconstruction or abandon the limb.

Not every story ended well, and the study is candid about the price of failure. Six patients, 27 percent of the cohort, had unfavorable outcomes: four amputations, one persistent non-union, and one death. The amputations stemmed from distinct pathways, including persistent infection despite early radiographic progress, ongoing pain and major depression in one patient who requested the procedure, and vascular thrombosis compromising the flap in another. Complications were documented on both the recipient and donor sides, including leg length discrepancies in five patients with a maximum of 65 millimeters, lower-limb malformation in two, a fractured fixation plate, graft non-union requiring multiple reoperations, and arteriovenous thrombosis in two patients, one of whom ultimately lost the limb. These numbers underline that vascularized fibular grafting is a technically demanding microsurgical undertaking that requires careful patient selection and multidisciplinary backup.

The authors are appropriately measured about the limits of their evidence. The study was retrospective, single-center, and small, precluding regression analyses to identify predictors of success, and follow-up duration was heterogeneous, with a median observation time of 21.5 months but a range extending to 90 months. Functional outcomes, quality of life, and patient satisfaction were not systematically collected, and donor-site complications may have been underestimated because they were not prospectively recorded. Consolidation rates in the broader literature, which range from 70 to 90 percent in mixed cohorts that include tumor and congenital reconstructions, are not directly comparable to this exclusively infected, multiply-failed population. Still, the central message stands: for selected patients with infected non-union of the femur or tibia, a living bone transplant can save a limb that would otherwise be amputated, but healing is a marathon measured in years, not months, and only long-term follow-up with methods that respect competing risks can reveal the true odds.

Subject of Research: Long-term outcomes of vascularized fibular grafting as limb-salvage surgery for infected non-union of the lower limb

Article Title: Long-term outcomes of vascularized fibular grafting for infected non-union of the lower limb: a competing-risk analysis

Article References: Le Hir, A., Seng, P., Delarbre, D., Ambrosino, R., Kachouh, N., Legré, R., & Stein, A. (2026). Long-term outcomes of vascularized fibular grafting for infected non-union of the lower limb: a competing-risk analysis. Journal of Bone and Joint Infection, 11(5), 579-590. https://doi.org/10.5194/jbji-11-579-2026

Image Credits: AI Generated

DOI: 10.5194/jbji-11-579-2026

Keywords: vascularized fibular graft, infected non-union, fracture-related infection, limb salvage, bone consolidation, competing-risk analysis, osteomyelitis, microsurgery, bone grafting, amputation, biofilm infection, orthopedic surgery

The clinical problem the surgeons confronted is enormous. Lower extremity injuries, particularly those caused by road traffic accidents, are the second leading cause of morbidity and mortality in Kenya, and open fractures with extensive soft tissue loss are among the most difficult injuries in all of trauma surgery. These are dynamic wounds that evolve over hours after the initial insult, and their management demands a multidisciplinary approach involving both orthopaedic and plastic surgeons, rigorous infection control, skeletal stabilization, and ultimately durable soft tissue coverage. When local tissue is insufficient to cover exposed bone, tendons, and hardware, the gold standard is free tissue transfer: harvesting a segment of muscle or skin, along with its artery and vein, from a distant part of the body and reconnecting its blood vessels to vessels at the recipient site under magnification.

Free flap surgery of this kind routinely achieves success rates exceeding 90 per cent in high-income countries, and it has measurably reduced amputation rates for severely injured limbs. Yet the barriers to replicating these outcomes in low- and middle-income countries are formidable. Operating microscopes are expensive to purchase and maintain, microsurgical instruments are costly, and trained microsurgeons are scarce. Many reconstructive units in sub-Saharan Africa lack access to even the basic infrastructure required, and patients frequently receive suboptimal treatment, delayed referrals, or primary amputation as the default option. The Kenyan team set out to show what is achievable when a well-equipped tertiary centre, staffed by experienced microsurgeons, exists within an otherwise resource-limited system.

The series comprised fourteen adult patients, ten male and four female, all of whom underwent lower extremity free flap reconstruction with at least one month of follow-up. Eleven had Gustilo-Anderson type 2-3b open fractures, two had degloving injuries in which skin and underlying tissue were torn away from the limb, and one required reconstruction after removal of a tumour of the hallux, the big toe. Preoperative vascular assessment included computed tomography angiography and handheld Doppler ultrasonography—diagnostic resources that are rarely available in comparable settings and that proved critical for mapping recipient vessels before the operating room. All procedures were performed by a consultant microsurgeon at a Level 1 trauma facility, under general anaesthesia, with wound debridement conducted under tourniquet control.

The technical details of the operations reveal the precision the procedure demands. Fasciocutaneous free flaps, which carry skin and its underlying fascia, were used in nine patients, while muscle flaps were used in five. Recipient vessels were selected according to wound configuration, local anatomy, and the mechanism of injury, with surgeons carefully examining the vessel wall, the extent of injury, and the quality of the adventitia before committing to an anastomosis. Crucially, all arterial connections were performed proximal to the zone of injury, following the principle that vessels damaged by trauma provide unreliable inflow. Thirteen cases used end-to-end anastomoses to the anterior tibial artery, the dorsalis pedis artery, or the superior medial genicular artery, while one case used an end-to-side connection to the posterior tibial artery. Where a surgical microscope was unavailable, surgeons achieved comparable results using loupe magnification in five cases.

The case series includes vivid individual examples that illustrate the range of reconstructive options. One middle-aged woman suffered a left ankle degloving injury, a distal tibia fracture, and complex bilateral midfoot fracture-dislocations in a road traffic accident. After initial washout, external fixation, and vacuum-assisted closure dressings, the team performed delayed definitive closure using a free gracilis muscle flap—the posterior-most adductor muscle of the thigh, supplied by the medial circumflex femoral artery with a pedicle roughly seven centimetres long—combined with a skin graft and internal fixation of the fractures. A two-team approach allowed simultaneous harvest and recipient-site preparation, shortening operative time and reducing donor-site morbidity. The flap integrated fully, with satisfactory functional and aesthetic outcomes at follow-up.

Another patient, a soldier with blast injuries to the right foot, presented with segmented fractures of the metatarsals and midfoot bones, bony defects at the second and third metatarsals, and loss of Lisfranc alignment. After debridement, K-wire stabilization, and temporary vacuum dressings, the surgeons planned a latissimus dorsi free muscle flap based on the thoracodorsal artery, whose single dominant pedicle can reach twelve centimetres in length and 2.5 millimetres in diameter. The flap was designed with a lazy-S skin paddle oriented along the pedicle, the serratus branch was preserved for venous anastomosis, and intraoperative imaging confirmed the muscle flap in place alongside antibiotic bone cement. A third patient, who developed chronic osteomyelitis after a high-energy motor vehicle collision, underwent a first-stage Masquelet procedure with a cement spacer and soft tissue coverage using a parascapular free flap harvested through the triangular space of the back. A fourth, whose foot was crushed in an industrial accident, received a free anterolateral thigh flap over a transmetatarsal amputation stump, with a total ischemic time of just one hour.

Postoperative care followed a rigorous, standardized protocol. Patients were admitted to the critical care unit for forty-eight hours, where flaps were assessed hourly by an attending consultant and a senior registrar, with checks of colour, capillary refill, temperature, and Doppler signals to detect early vascular compromise. Venous thromboembolism prophylaxis consisted of enoxaparin 40 milligrams subcutaneously once daily, alongside aspirin 75 milligrams, and limbs were elevated and immobilized in splints. Mobilization began on postoperative day five with individualized protocols and compression bandaging. This intensity of monitoring is itself notable: in many low-resource settings, patients are not routinely admitted to critical care, and flaps are monitored on general wards using clinical parameters alone, including pinprick testing for bleeding quality.

Outcomes were strong but not flawless. Twelve of the fourteen flaps survived without complication. Two flaps failed—one attributed to suspected underlying peripheral arterial disease, detected intraoperatively as weak dorsalis pedis flow and dark venous bleeding despite an intact pedicle, and the other to multifactorial causes—both necessitating debridement and skin graft reconstruction. Definitive management ranged from ten to fifty-six days, with an average hospital stay of two to three weeks. All patients completed at least one month of follow-up without delayed flap failures. The authors acknowledge limitations, including the absence of diagnostic angiograms for preoperative detection of peripheral arterial disease, the inability to formally assess functional outcomes, and loss of some patients to long-term follow-up.

The broader significance of the study lies in what it suggests about global surgical equity. The flap survival rates achieved in Nairobi matched those reported in high-income countries, demonstrating that successful microsurgical reconstruction is possible in resource-limited settings when expertise and infrastructure converge in a well-equipped tertiary centre. The authors argue that expanding fellowship opportunities for reconstructive surgeons in low- and middle-income countries is essential, and that surgeons returning from such training can practise microsurgical techniques using basic materials and shared local resources. They also call for structured retrospective and prospective observational studies to build the evidence base further. For the millions of patients worldwide who suffer devastating limb injuries each year, the message is clear: the decision between salvage and amputation should depend on clinical factors and access to skilled teams—not on geography or the wealth of the health system a patient happens to be born into.

Subject of Research: Lower extremity free flap reconstruction for traumatic limb injuries in a resource-limited health system

Article Title: Lower extremity free flap reconstructions in a tertiary trauma centre within a resource-limited health system: a case series

Article References: Otieno, D. O., Okello, A. W., Gathura, E. W., Gebremariyam, Z. T., Nang’ole, F. W., Sulemanji, D. S., & Wabwire, B. (2026). Lower extremity free flap reconstructions in a tertiary trauma centre within a resource-limited health system: a case series. BMC Plastic and Reconstructive Surgery, 2(1), Article 3. https://doi.org/10.1186/s44452-026-00015-x

Image Credits: AI Generated

DOI: 10.1186/s44452-026-00015-x

Keywords: free flap reconstruction, microsurgery, lower extremity trauma, limb salvage, resource-limited settings, Kenya, open fractures, reconstructive surgery, trauma surgery, fasciocutaneous flaps, muscle flaps, global surgery