Nonunion of the femoral shaft associated with limb shortening treated with a combined technique of external fixation over an intramedullary nail versus the Ilizarov method

Combined monolateral external fixation and intramedullary nailing for oligotrophic femoral nonunion with limb length discrepancy: a case series of technical strategy and surgical outcomes

Bone lengthening using a monolateral external fixator is an effective technique for treating femoral nonunion associated with limb length discrepancy (LLD). This method involves gradual femoral lengthening to correct shortening and rotational deformities, while promoting bone healing through compression at the nonunion site. We present a case series of three patients demonstrating the successful integration of monolateral external fixation with intramedullary nailing for oligotrophic nonunions (4-8 cm LLD). Preoperative planning includes assessment of limb length discrepancy, evaluation the cause of nonunion, and selection of appropriate implant and surgical strategies. During surgery, a controlled corticotomy and correction of rotational deformity were performed, followed by application of a monolateral external fixator. Gradual distraction was initiated after a latency period, allowing for simultaneous correction of the limb length and compression at the nonunion site. All patients achieved radiographic union and LLD correction within 6-8 months, returning to pain-free ambulation. This combined approach offers biological and mechanical advantages in the management of complex femoral nonunions, while preserving patient mobility during treatment.

Femoral malalignment deformity acute correction and gradual limb-lengthening by bifocal osteosynthesis with a monorail external fixator

Background. Patients with limb-length discrepancies often present with concomitant distal femoral varus or valgus deformities. With the development of distraction osteogenesis, both deformity correction and limb-lengthening can be performed simultaneously. This novel procedure is being increasingly preferred not only by experts due to the technical advance it implies, but also by patients. The aim of this study was to identify the clinical efficacy of distal femoral malalignment deformity correction and gradual limb-lengthening by bifocal osteotomies. Methods. We analyzed 32 femurs from 30 patients (mean age — 23.8 years) who had undergone bifocal osteotomies followed by the use of the monorail external fixator to correct the distal femoral malalignment deformity acutely and limb-length discrepancy gradually from June 2012 to May 2020. Pre-operative clinical and radiographic data were also obtained. During the follow-up period, deformity correction and bone healing were assessed, complications were identified, and functional outcomes were evaluated. Results. The mean follow-up period was 57.2 months for all the patients. The mean mechanical axis deviation improved from 66.4 mm pre-operatively to 7.5 mm. In patients with varus deformity, the mean mechanical lateral distal femoral angle (mLDFA) decreased from 121.2° pre-operatively to 90.2° after surgery; whereas in patients with valgus deformity, the mean mLDFA improved from 59.2 to 87.1°. The magnitude of lengthening achieved averaged 6.3 cm, and the mean bone healing index was 34.8 days/cm. The final scores defined by the Association for the Study and Application of the Methods of Ilizarov (ASAMI)-Paley were excellent in 93.3% of patients. Conclusions. Acute correction of femoral deformities and gradual lengthening with a monorail external fixator following bifocal osteotomies can be used to treat femoral shortening and distal malalignment deformity. Functional and cosmetic improvements are expected after surgery and post-operative rehabilitation.

A systematic review and meta-analysis:comparing the efficacy of the Ilizarov technique alone with lengthening over a nail for lower extremity bone defects

PURPOSE

The task faced by surgeons becomes significantly more challenging when they encounter lower extremity bone defects due to a variety of causes requiring lengthening. The most discussed and successful approach is the Illizarov technique, or lengthening over a nail (LON):distraction osteogenesis is also widely performed with monoliteral external fixators and intramedullarylengthening nails have increasingly been used in the last decade.

METHODS

The data were collected from PubMed, Cochrane Library, Embase, and the Web of Science for all available studies comparing the outcomes of Ilizarov technique alone and LON technique (from January 1, 1997, to November 30, 2023). The outcomes of interest encompassed the external fixation index (EFI) (month/cm), mean duration of follow-up (MFT) (month), length gained (LG) (cm), consolidation index (CIx) (month/cm), and bone healing index (BHI) (month/cm).Complications include pin tract infection rate (PTI), axial deviation rate (AD), occurrence of intramedullary infection (II), delayed consolidation rate (DC), as well as data categorized into three levels of problems, obstacles, and sequelae based on the severity of complications.Two reviewers independently assessed each study for quality and extracted data. The case-control or respective cohort studies were evaluated using the Newcastle-Ottawa scale (NOS) to determine their techniqueological rigor.The Cochrane Collaboration's risk assessment tool was employed to perform quality evaluations for randomized controlled trials.

RESULTS

This review included thirteen studies comprising a total of 629 patients.The external fixation index (month/cm) was significantly smaller in the LON technique compared to the Ilizarov technique alone [Mean Difference(MD) = -29.59, 95% CI -39.68--19.49, P < 0.00001].In terms of the mean follow-up time(month) (MD = -0.92, 95% CI -3.49-1.65, P = 0.57), length gained (cm) (MD = -0.87, 95%CI -2.80-1.07, P = 0.38), consolidation index (month/cm) (MD = 0.66, 95% CI -3.44-4.77, P = 0.75), and bone healing index (month/cm) (MD = -3.33, 95% CI -13.07-6.41, P = 0.5), there were no significant differences observed. The LON technique exhibited a lower incidence of axial deviation [Odds Ratio(OR) = 0.06, 95%CI 0.03-0.16, P < 0.00001] and pin tract infection (OR = 0.30, 95%CI 0.18-0.50, P < 0.00001) compared to the Ilizarov technique alone.The remaining complications, such as intramedullary infection rate (OR = 0.93, 95%CI 0.42-2.06, P = 0.85) and delayed consolidation rate(OR = 0.61, 95%CI 0.20-1.86, P = 0.38), did not exhibit statistically significant differences.Our findings demonstrated that the LON technique results in lower incidences of problems (38.5%vs.58.6%) and sequelae (16.6% vs.30.9%) when compared to the Ilizarov technique alone. However, the rates of obstacles (32.4% vs.32.3%) were comparable between the two methods.

CONCLUSIONS

Our findings indicate that patients treated with the LON technique experienced significantly shorter external fixation durations and a lower incidence of complications (e.g., pin tract infections and axial deviation) compared to those treated with the Ilizarov technique alone. Other outcome metrics showed no significant differences between the two techniques. However, the LON technique offers substantial benefits, including reduced external fixation times and increased comfort, which enhance patient compliance. In conclusion, the LON technique is a safe, reliable, and effective method for treating tibial and femoral defects.

3D-printed titanium porous prosthesis combined with the Masquelet technique for the management of large femoral bone defect caused by osteomyelitis

BACKGROUND

The treatment of infected bone defects remains a clinical challenge. With the development of three-dimensional printing technology, three-dimensional printed implants have been used for defect reconstruction. The aim of this study was to investigate the clinical outcomes of three-dimensional printed porous prosthesis in the treatment of femoral defects caused by osteomyelitis.

METHODS

Eleven patients with femoral bone defects following osteomyelitis who were treated with 3D-printed porous prosthesis at our institution between May 2017 and July 2021, were included. Eight patients were diagnosed with critical-sized defects, and the other three patients were diagnosed with shape-structural defects. A two-stage procedure was performed for all patients, and the infection was eradicated and bone defects were occupied by polymethylmethacrylate spacer during the first stage. The 3D-printed prosthesis was designed and used for the reconstruction of femoral defects in the second stage. Position of the reconstructed prostheses and bone growth were measured using radiography. The union rate, complications, and functional outcomes at the final follow-up were assessed.

RESULTS

The mean length of the bone defect was 14.0 cm, union was achieved in 10 (91%) patients. All patients showed good functional performance at the most recent follow-up. In the critical-sized defect group, one patient developed a deep infection that required additional procedures. Two patients had prosthetic dislocations. Radiography demonstrated good osseous integration of the implant-bone interface in 10 patients.

CONCLUSION

The 3D printed prostheses enable rapid anatomical and mechanically stable reconstruction of extreme femur bone defects, effectively shortens treatment time, and achieves satisfactory clinical outcomes.

Delayed Union and Nonunion: Current Concepts, Prevention, and Correction: A Review

Surgical management of fractures has advanced with the incorporation of advanced technology, surgical techniques, and regenerative therapies, but delayed bone healing remains a clinical challenge and the prevalence of long bone nonunion ranges from 10 to 15% of surgically managed fractures. Delayed bone healing arises from a combination of mechanical, biological, and systemic factors acting on the site of tissue remodeling, and careful consideration of each case's injury-related, patient-dependent, surgical, and mechanical risk factors is key to successful bone union. In this review, we describe the biology and biomechanics of delayed bone healing, outline the known risk factors for nonunion development, and introduce modern preventative and corrective therapies targeting fracture nonunion.

Treatment of tibial bone defects caused by infection: a retrospective comparative study of bone transport using a combined technique of unilateral external fixation over an intramedullary nail versus circular external fixation over an intramedullary nail

BACKGROUND

The purpose of the study was to assess and compare the clinical efficacy of bone transport with either circular or unilateral external fixators over an intramedullary nail in the treatment of tibial bone defects caused by infection.

METHODS

Between May 2010 and January 2019, clinical and radiographic data were collected and analyzed for patients with bone defects caused by infection. Thirteen patients underwent bone transport using a unilateral external fixator over an intramedullary nail (Group A), while 12 patients were treated with a circular external fixator over an intramedullary nail (Group B). The bone and functional outcomes of both groups were assessed and compared using the Association for the Study and Application of the Method of the Ilizarov criteria, and postoperative complications were evaluated according to the Paley classification.

RESULTS

A total of 25 patients were successfully treated with bone transport using external fixators over an intramedullary nail, with a mean follow-up time of 31.63 ± 5.88 months. There were no significant statistical differences in age, gender, previous surgery per patient, duration of infection, defect size, and follow-up time between Group A and Group B (P > 0.05). However, statistically significant differences were observed in operation time (187.13 ± 21.88 min vs. 255.76 ± 36.42 min, P = 0.002), intraoperative blood loss (39.26 ± 7.33 mL vs. 53.74 ± 10.69 mL, P < 0.001), external fixation time (2.02 ± 0.31 month vs. 2.57 ± 0.38 month, P = 0.045), external fixation index (0.27 ± 0.08 month/cm vs. 0.44 ± 0.09 month/cm, P = 0.042), and bone union time (8.37 ± 2.30 month vs. 9.07 ± 3.12, P = 0.032) between Group A and Group B. The excellent and good rate of bone and functional results were higher in Group A compared to Group B (76.9% vs. 75% and 84.6% vs. 58.3%). Statistically significant differences were observed in functional results (excellent/good/fair/poor, 5/6/2/0 vs. 2/5/4/1, P = 0.013) and complication per patient (0.38 vs. 1.16, P = 0.012) between Group A and Group B.

CONCLUSIONS

Bone transport using a combined technique of external fixators over an intramedullary nail proved to be an effective method in treating tibial bone defects caused by infection. In comparison to circular external fixators, bone transport utilizing a unilateral external fixator over an intramedullary nail resulted in less external fixation time, fewer complications, and better functional outcomes.