Tetrafocal (three osteotomies) and pentafocal (four osteotomies) bone transport using Ilizarov technique in the treatment of distal tibial defect-preliminary outcomes of 12 cases and a description of the surgical technique

Trifocal versus Pentafocal bone transport in segmental tibial defects: a matched comparative analysis for posttraumatic osteomyelitis treatment

PURPOSE

The objective of this study was to evaluate and compare the effectiveness and clinical results of trifocal bone transport (TBT) and pentafocal bone transport (PBT) in treating distal tibial defects > 6 cm resulting from posttraumatic osteomyelitis, highlighting the potential advantages and challenges of each method.

METHODS

A retrospective assessment was conducted on an overall population of 46 eligible patients with distal tibial defects > 6 cm who received treatment between January 2015 and January 2019. Propensity score analysis was used to pair 10 patients who received TBT with 10 patients who received PBT. The outcomes assessed included demographic information, external fixation time (EFT), external fixation index (EFI), bone and functional outcomes assessed using the Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system, and postoperative complications evaluated using the Paley classification.

RESULTS

The demographic and baseline data of the two groups were comparable. Following radical debridement, the average tibial defect was 7.02 ± 0.68 cm. The mean EFT was significantly shorter in the PBT group (130.9 ± 16.0 days) compared to the TBT group (297.3 ± 14.3 days). Similarly, the EFI was lower in the PBT group (20.67 ± 2.75 days/cm) than in the TBT group (35.86 ± 3.69 days/cm). Both groups exhibited satisfactory postoperative bone and functional results. Pin site infection was the most common complication and the rates were significantly different between the groups, with the PBT group demonstrating a higher incidence.

CONCLUSION

Both TBT and PBT effectively treat posttraumatic tibial defects greater than 6 cm, with PBT offering more efficient bone regeneration. However, PBT is associated with a higher rate of pin site infections, highlighting the importance of careful management in these complex procedures and emphasizing the need for expert surgical execution and tailored treatment approaches in orthopedic reconstructive surgery.

Critical size bone defects managed with modern techniques of bone transport: An update

Bone transport is one of several techniques that has been proven to be effective in addressing critical bone loss. While it was first described over 100 years ago, modifications to this technique coupled with advances in technology have allowed us to perform bone transport with higher success rates and reduced complication rates. Modern techniques of bone transport aim to shorten the duration of time an external fixator is utilized to reduce its associated complications and burden to patients. We present an update on modern techniques of bone transport for critical size defects and methods to shorten the external fixation time.

Debridement-Reconstruction-Docking Management System Versus Ilizarov Technique for Lower-Extremity Osteomyelitis

BACKGROUND

Osteomyelitis causes marked disability and is one of the most challenging diseases for orthopaedists to treat because of the considerable rate of infection recurrence. In this study, we proposed and assessed the debridement-reconstruction-docking (DRD) system for the treatment of lower-extremity osteomyelitis. This procedure comprises 3 surgical stages and 2 preoperative assessments; namely, pre-debridement assessment, debridement, pre-reconstruction assessment, reconstruction, and docking-site management. We evaluated the use of the DRD system compared with the Ilizarov technique, which is defined as a 1-stage debridement, osteotomy, and bone transport.

METHODS

This retrospective cohort included 289 patients who underwent either DRD or the Ilizarov technique for the treatment of lower-extremity osteomyelitis at a single institution between January 2013 and February 2021 and who met the eligibility criteria. The primary outcome was the rate of infection recurrence. Secondary outcomes included the external fixator index (EFI), refracture rate, and the Paley classification for osseous and functional results. An inverse-probability-weighted regression adjustment model was utilized to estimate the effect of the DRD system and Ilizarov technique on the treatment of lower-extremity osteomyelitis.

RESULTS

A total of 131 and 158 patients underwent DRD or the Ilizarov technique, respectively. The inverse-probability-weighted regression adjustment model suggested that DRD was associated with a significant reduction in infection recurrence (risk ratio [RR], 0.26; 95% confidence interval [CI], 0.13 to 0.50; p < 0.001) and EFI (-6.9 days/cm, 95% CI; -8.3 to -5.5; p < 0.001). Patients in the DRD group had better Paley functional results than those in the Ilizarov group (ridit score, 0.55 versus 0.45; p < 0.001). There was no significant difference between the 2 groups in the rate of refracture (RR, 0.87; 95% CI, 0.42 to 1.79; p = 0.71) and Paley osseous results (ridit score, 0.51 versus 0.49; p = 0.39).

CONCLUSIONS

In this balanced retrospective cohort of patients with lower-extremity osteomyelitis, the use of the DRD system was associated with a reduced rate of infection recurrence, a lower EFI, and better Paley functional results compared with the use of the Ilizarov technique.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Ilizarov technique in the treatment of bone defects of the radius and ulna: a systematic review and meta-analysis

PURPOSE

The objective of this systematic review and meta-analysis was to assess the efficacy of the Ilizarov method in the treatment of radius and ulna bone defects.

METHODS

The PubMed, Embase, Web of Science, Cochrane Library, Ovid MEDLINE, and Scopus databases were searched for articles published up to May 2023. The quality of the studies was evaluated using a modified version of the Newcastle-Ottawa scale. The effect size and confidence intervals at 95% for the main results were calculated. The heterogeneity was evaluated. The demographic data, defect size (DS), external fixation time (EFT), external fixation index (EFI), and complications were extracted and analyzed using the Stata version 16.

RESULTS

This meta-analysis identified and included seven studies involving 98 patients. The union rate of 100% was reported in all studies. According to the findings of the single-arm meta-analysis, the pooled DS was 3.42 cm (95% CI [2.64, 4.21], I2 = 53.5%, P = 0.045), EFT was 148.43 days (95% CI [97.49, 199.38], I2 = 91.9%, P = 0.000), and EFI was 41.32 days/cm (95% CI [35.72, 46.91], I2 = 62.2%, P = 0.021). Pin tract infection was the most common complication, as reported in six studies.

CONCLUSION

The findings of the present meta-analysis indicate that the Ilizarov technique is a successful treatment option for bone defects in the radius and ulna. This method has demonstrated efficacy in achieving expected clinical outcomes.

A modified hybrid transport technique combined with a retrograde tibiotalocalcaneal arthrodesis nail for the management of distal tibial periarticular osteomyelitis and associated defects

BACKGROUND

This paper aimed to propose a modified technique of bone transport. An annular frame combined with a retrograde tibiotalocalcaneal arthrodesis nail was used in this novel technique for treating large distal tibial periarticular osteomyelitis and associated defects.

METHODS

Our team conducted a retrospective research. Forty-three patients with large distal tibial periarticular bone loss were involved in this study. Sixteen patients were treated using the modified hybrid transport technique (MHT group) while 27 were subjected to traditional bone transport (BT group). The mean bone loss was 7.8 ± 2.4 cm in the MHT group and 7.6 ± 2.6 cm in the BT group. The external fixation index, time in transport frame, self-rating anxiety scale, bone healing results and postoperative complications were recorded.

RESULTS

The mean time in frame for the MHT group was 3.6 ± 1.5 months, while that of the BT group was 10.3 ± 2.7 months (p < 0.05). The mean external fixation index of MHT group was 0.46 ± 0.08 months/cm versus 1.38 ± 0.24 months/cm of the BT group (p < 0.05). There was no statistical difference for the bone healing results between the MHT and BT groups (p = 0.856). The self-rating anxiety scale and total complication incidence of the MHT group were significantly lower than that of BT patients (p < 0.05).

CONCLUSION

Compared to the traditional BT technique, our modified hybrid transport technique showed better clinical outcomes for treating large distal tibial periarticular bone loss, including less time in transport frame, lower external fixation index and complication incidence. Therefore, this modified technique should be further promoted and developed.

Complex Ankle Fusion With Circular Frames: Factors Influencing Outcomes, Complications, and Patient Satisfaction

BACKGROUND

Circular frames for ankle fusion are reserved for complex clinical scenarios. The literature is heterogenous and conflicting. We aim to present the indications and outcomes of this procedure.

METHODS

A retrospective cohort study based on a prospective database of frame surgeries performed in a tertiary institution. Inclusion criteria were patients undergoing complex ankle fusion with circular frames between 2005 and 2020, with a minimum 12-month follow-up. Data were collected on patient demographics, surgical indications, comorbidities, surgical procedures, external fixator time (EFT), length of stay (LOS), radiologic and clinical outcomes, and adverse events. Factors influencing radiologic and clinical outcomes were analyzed.

RESULTS

47 patients were included, with a median follow-up of 30 months (interquartile range [IQR] 20-40). The median age at time of surgery was 63.5 years (IQR 58-71). Patients had a median of 2 previous surgeries (IQR 1-3). The median LOS was 8.5 days, and median EFT was 237 days (IQR 166-280). Simultaneous limb lengthening (median 3.3 cm, IQR 1.9-3.5) was performed in 11 patients, increasing the EFT by a mean of 4 months. Primary and final union rates were 91.5% and 95.7%, respectively. At last follow-up, ASAMI bone scores were excellent or good in 87.2%. ASAMI functional scores were good in 79.1%. Patient satisfaction was 83.7%. In addition, 97.7% of patients experienced adverse events, most commonly pin-site related, with major complications in 30.2% and reoperations in 60.5%. There were 3 amputations. Adverse events were associated with increased age, poor soft tissue condition, severe deformities, subtalar fusions, peripheral neuropathy, peripheral vascular disease, and prolonged EFT.

CONCLUSION

Complex ankle fusion using circular frames can achieve good outcomes, however time in frame may be prolonged with a high rate of adverse events. Identified risk factors for poorer outcomes should be considered in patient counselling and prognostication.

LEVEL OF EVIDENCE

Level III, prognostic.

Bifocal versus trifocal bone transport for the management of tibial bone defects caused by fracture-related infection: a meta-analysis

BACKGROUND

The purpose of this meta-analysis was to compare the efficacy and outcomes of bifocal bone transport (BFT) and trifocal bone transport (TFT) for the treatment of tibial bone defects caused by fracture-related infection (FRI).

METHODS

The literature searches of Cochrane Library, Embase, Google Scholar databases, PubMed/Medline, and Web of Science for literature published up to September 20, 2022, were performed. The quality of the included studies was evaluated according to the MINORS scale. Patients were divided into the BFT group and the TFT group, depending on the site of the osteotomy. The demographic data, defect size (DS), external fixation time (EFT), external fixation index (EFI), bone and functional results, complications, and autologous bone grafting (ABG) were extracted and analyzed using the Review Manager software (version 5.3).

RESULTS

Five studies included 484 patients with tibial bone defects treated by bone transport investigated in this meta-analysis, with a mean bone defect of 9.3 cm. There were statistical differences in DS (MD =  - 2.38, 95% CI - 3.45 to - 1.32, P < 0.0001), EFT (MD = 103.44, 95% CI 60.11 to 146.77, P < 0.00001), and EFI (MD = 26.02, 95% CI 14.38 to 37.65, P < 0.00001) between BFT group and TFT group. There was no statistical difference in bone results (RR = 0.98, 95% CI 0.91 to 1.06, P = 0.67), functional results (RR = 0.94, 95% CI 0.82 to 1.07, P = 0.37), complications (OR = 1.57, 95% CI 0.59 to 4.14, P = 0.36), and ABG (RR = 1.2, 95% CI 0.78 to 1.84, P = 0.42) between two groups.

CONCLUSIONS

TFT was a feasible and practical method in the treatment of massive tibial bone defects caused by FRI to receive shorter EFT and satisfactory bone and functional results.

Clinical outcomes of bone transport using rail fixator in the treatment of femoral nonunion or bone defect caused by infection

Purpose

The rail fixator can improve the treatment outcome and provide good stability in patients with femoral bone transport. The purpose of this study is to investigate the clinical outcomes of bone transport using the Ilizarov technique by rail fixator in the treatment of femoral nonunion or bone defects caused by infection.

Methods

Clinical feature and treatment outcomes of 32 consecutive adult patients with femoral nonunion or bone defect caused by infection from January 2012 to January 2019 at a minimum of 2 years of follow-ups were retrospectively analyzed. Data were collected on participants' demographic details. All difficulties related to bone transport were documented according to Paley's classification. The clinical outcomes were evaluated using ASAMI criteria at the last clinical visit.

Results

All 32 patients with an average follow-up of 33.5 months. There were 17 problems, 21 obstacles, and 8 complications, and the complication rate per patient was 1.4. The main complications were pin-site infection (53.1%), axial deviation (21.9%), joint stiffness (18.8%), the delayed union of the docking site (18.8%), soft tissue incarceration(15.6%), delayed consolidation(6.3%), malunion(6.3%), and refracture (3.1%). All the patients achieved bone union, and no recurrence of infection was observed. The excellent and good rates of ASAMI bone and functional results were 87.5% and 81.3%, respectively.

Conclusion

Bone transport using the Ilizarov technique is an effective method for the treatment of femoral nonunion or bone defect caused by infection, and rail fixators have obtained satisfactory results in terms of bone and functional results.

Bone Transport Treatment of Osteomyelitis Due to Thermal Osteonecrosis After IM Nailing of Tibial Stress Fracture Nonunion: A Case Report

CASE

We present a case of a female athlete who sustained a nonunion of a tibial stress fracture and was treated with intramedullary nailing (IMN). The patient developed osteomyelitis likely secondary to a thermal osteonecrosis during the index procedure and required resection of the necrotic tibia and bone transport using the Ilizarov technique.

CONCLUSIONS

The authors believe that all actions should be taken to avoid thermal osteonecrosis during reaming for tibial IMN, especially in patients with a small medullary canal. We believe that bone transport with the Ilizarov technique is an effective treatment method for patients who develop tibial osteomyelitis after treatment of tibial shaft fractures.