Comparative analysis of free vascularized fibula grafting and Ilizarov bone transport in management of segmental long bone defect of the lower limb: A systematic review and meta-analysis

Introduction: Reconstruction of segmental defects of long bones is a daunting task for surgeons. Bone transport with the help of Illizarov external fixator and vascularized free fibula flap are some of the most discussed and valid options for the same. Both techniques have their limitations and overlapping indications. However, there has been no objective evidence in the manner of a systematic review supporting one treatment method over the other. Aim: This systemic review is aimed to compare the bony union, functional outcomes, and complications of Illizarov bone lengthening and free fibula flap performed for segmental bone defects of long bones of the leg. Methods: A comprehensive search was done for all studies published before May 2023. Any observational study comparing bone transport based on Illizarov external fixator and free vascularized fibula grafting techniques for treating lower limb long bone segmental defects was entailed in this study. Results: This systematic review comprised of five retrospective studies. A total of 96 patients were treated by the Illizarov-based bone transport technique and 72 patients were treated by the free vascularized fibula grafting technique. The free vascularized fibula grafting technique yielded a shorter mean time to union (average difference 9.3 months), relatively shorter external fixator time (average difference 5.32 months), and external fixator index (average difference 0.57 months/cm). However, there was no difference in terms of bony and functional outcomes between both techniques when used for the reconstruction of bony defects in the lower limb. Total number of complications was 68 % higher in bone transport with Illizarov external fixator. However, the rates of non-union didn't differ between the groups. Conclusion: The free vascularized fibula grafting technique had a lesser time to bony union, shorter time for external fixator application, and lower incidence of complications. However, the functional and bony outcomes didn't differ between both techniques. Level of evidence: Level 4.