Tibial bone loss and soft-tissue defect treated simultaneously with llizarov-technique--a case report

Acute shortening and angulation for complex open fractures: an updated perspective

Reestablishing an intact, healthy soft tissue envelope is a critical step in managing lower extremity injuries, particularly high-grade open tibia fractures. Acute shortening and angulation can be used independently or together to address complex soft tissue injuries, particularly when bone loss is present. These techniques facilitate management of difficult wounds and can be combined with local soft tissue rearrangement or pedicled flaps as needed, avoiding the need for free tissue transfer. After angular deformity correction, adjacent bone loss can be addressed with bone grafting or distraction histogenesis. This article discusses the indications for, surgical technique for, and limitations of acute shortening and angulation for management of open lower extremity fractures.

Acute Shortening for Open Tibial Fractures with Bone and Soft Tissue Defects: Systematic Review of Literature

Introduction

The presence of massive soft tissue loss in open tibial fractures is a challenging problem. Acute limb shortening is an alternative solution in situations where the use of flaps is limited.

Materials and methods

A review was conducted following the Preferred Reported Items for Systematic Reviews and Meta-analyses checklist (PRISMA) guidelines. A complete search of PubMed, EMBASE and MEDLINE was undertaken. Twenty-four articles related to closure of soft tissue defects through acute limb shortening were identified and included in this review.

Results

All report on restoration of limb function without or with minimal residual shortening. The authors note a decrease in the need for microsurgery. The external fixation devices used for deformity correction after closure of the soft tissue defect by acute shortening, angulation and rotation were the Ilizarov apparatus and circular fixator hexapods mainly.

Conclusion

Acute shortening is an alternative to microsurgical techniques. A ring external fixator is useful for restoring limb alignment after closing the soft tissue defect through creating a temporary deformity. The use of circular fixator hexapods can enable accurate correction of complex multicomponent deformities without the need to reassembly of individual correction units.

How to cite this article

Plotnikovs K, Movcans J, Solomin L. Acute Shortening for Open Tibial Fractures with Bone and Soft Tissue Defects: Systematic Review of Literature. Strategies Trauma Limb Reconstr 2022;17(1):44–54.

Reconstruction of massive tibial bone and soft tissue defects by trifocal bone transport combined with soft tissue distraction: experience from 31 cases

BACKGROUND

Large post-traumatic tibial bone defects combined with soft tissue defects are a common orthopedic clinical problem associated with poor outcomes when treated using traditional surgical methods. The study was designed to investigate the safety and efficacy of trifocal bone transport (TFT) and soft-tissue transport with the Ilizarov technique for large posttraumatic tibial bone and soft tissue defects.

METHODS

We retrospectively reviewed 31 patients with massive posttraumatic tibial bone and soft tissue defects from May 2009 to May 2016. All of the eligible patients were managed by TFT and soft-tissue transport. The median age was 33.4 years (range, 2-58 years). The mean defect of bone was 11.87 cm ± 2.78 cm (range, 8.2-18.2 cm) after radical resection performed by TFT. The soft tissue defects ranged from 7 cm × 8 cm to 24 cm × 12 cm. The observed results included bone union time, wound close time and true complications. The Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system was used to assess bone and functional results and postoperative complications were evaluated by Paley classification.

RESULTS

The mean duration of follow-up after frame removal was 32 months (range, 12-96 months). All cases achieved complete union in both the elongation sites and the docking sites, and eradication of infection. The mean bone transport time was 94.04 ± 23.33 days (range, 63.7-147 days). The mean external fixation time was 22.74 ± 6.82 months (range, 14-37 months), and the mean external fixation index (EFI) was 1.91 ± 0.3 months/cm (range, 1.2-2.5 months/cm). The bone results were excellent in 6 patients, good in 14 patients, fair in 8 patients and poor in 3 patients. The functional results were excellent in 8 patients, good in 15 patients, fair in 5 patients and poor in 3 patients.

CONCLUSION

TFT, in conjunction with soft tissue transport technique, can give good results in most patients (in this article, good and excellent results were observed in 64% of patients). Soft tissue transport is a feasible method in providing good soft tissue coverage on the bone ends. Although it has no advantages over microvascular techniques, it might be an good alternative in the absence of an experienced flap surgeon. Nonetheless, high-quality controlled studies are needed to assess its long-term safety and efficacy.

Knee Sepsis after Suprapatellar Nailing of an Open Tibia Fracture: Treatment with Acute Deformity and External Fixation

Case

A 31-year-old male was involved in a dirt bike accident and sustained an isolated type II open mid-distal tibia fracture. The patient underwent suprapatellar intramedullary nailing and subsequently developed knee sepsis.

Conclusion

This patient was managed with irrigation and debridements of the knee, fracture site, and intramedullary canal. A resultant soft-tissue defect over the fracture site obviated primary closure. Creation of an acute deformity stabilized by a Taylor spatial frame allowed primary wound closure. After soft tissue healing occurred, the frame was used to correct the intentional deformity and maintain reduction until full healing occurred.

Definitive management of significant soft tissue loss associated with open diaphyseal fractures utilising circular external fixation without free tissue transfer, a comprehensive review of the literature and illustrative case

Accepted management of diaphyseal fractures associated with significant tissue loss is rigid intramedullary stabilisation with free or rotational musculocutaneous flap coverage. Circular external fixation is a powerful tool in the management of limb trauma and with recent advances has been developed to provide multiple techniques for which even massive tissue loss can be addressed without the need for free tissue transfer. Gradual and acute shortening, acute fracture deformation and gradual lengthening with restoration of deformity combined with distraction tissue histiogenesis can provide the surgeon with an array of options which can be precisely tailored to the particular personality of a severe open diaphyseal fracture.

Management of traumatic bone loss in the lower extremity

Segmental bone loss represents a difficult clinical entity for the treating orthopedic surgeon. This article discusses the various treatment modalities available for limb reconstruction, with a focus on the indications, potential complications, and the outcomes of available treatment options.

Acute emergency tibialization of the fibula: reconstruction of a massive tibial defect in a type IIIC open fracture

Gustilo type IIIC open fractures of the tibia are high-energy injuries necessitating long treatment periods and usually multiple surgical procedures and eventually resulting in high morbidity rates and even amputations. We present here a case involving a type IIIC open tibial fracture with massive loss of the entire tibial diaphysis, which we treated by performing acute tibialization of the fibula after revascularization of the posterior tibial artery in a single-stage emergency operation.

Conversion of open tibial IIIb to IIIa fractures using intentional temporary deformation and the Taylor Spatial Frame

The closure of small-to-moderate-sized soft tissue defects in open tibial fractures can be successfully achieved with acute bony shortening. In some instances, it may be possible to close soft tissue envelope defects by preserving length and intentionally creating a deformity of the limb. As the soft tissue is now able to close, this manoeuvre converts an open IIIb to IIIa fracture. This obviates the need for soft tissue reconstructive procedures such as flaps and grafts, which have the potential to cause donor-site morbidity and may fail. In this article, the authors demonstrate the technique for treating anterior medial soft tissue defects by deforming the bone at the fracture site, permitting temporary malalignment and closure of the wound. After healing of the envelope, the malalignment is gradually corrected with the use of the Taylor Spatial Frame. We present two such cases and discuss the technical indications and challenges of managing such cases.

Angular shortening and delayed gradual distraction for the treatment of asymmetrical bone and soft tissue defects of tibia: a case series

BACKGROUND

Acute shortening is reported to be an effective method for the treatment of open fractures with bone and soft tissue defects. Little is known about primary skin closure with angulation to the side of the defect and distraction at the fracture site.

METHODS

We present a series of three cases treated for defective fractures of tibia by angular shortening and delayed gradual distraction with hinged circular external fixator. Two cases were type IIIB open fractures and one case was an infected nonunion. Bone and soft tissue defects were managed by adaptation of edges and primary skin closure with angulation to the side of the defect. Axial alignment was restored by gradual distraction after a 2 to 3 weeks interval. Residual limb length discrepancy was lengthened through a separate corticotomy in two cases.

RESULTS

Bone formation at both the fracture and corticotomy sites were sufficient to achieve union in all patients. Fixation time averaged 261 (182-392) days and average bone healing index was 42 days/cm. No further surgical intervention was necessary for soft tissue reconstruction after primary skin closure. Infection was eradicated in the case of infected nonunion.

CONCLUSIONS

Angular compression to the side of the defect is a safe and reliable method of treatment for asymmetrical bone or soft tissue defects of tibia. It eliminates the need for complex soft tissue reconstruction procedures. Unnecessary debridement of bone is prevented by angular adaptation of edges. Definitive treatment of complex injuries is possible with a circular external fixator.

Management of traumatic tibial defects using free vascularized fibula or Ilizarov bone transport: a comparative study

There are several options for the treatment of traumatic tibial defects. Among these options, free vascularized fibula and Ilizarov bone transport are well-known and effective techniques. The differences between both techniques and the indications for each of them are not well studied in the literature. Between September 1995 and December 2004, Ilizarov bone transport and free vascularized fibula were used to treat 25 traumatic bone. Patients were divided into two groups, Ilizarov group (12) and free fibula group (13). Preoperative data, operative data, duration of treatment, functional outcome, range of motion loss, number of secondary procedures, and type and rate of complications were compared in both groups. All the cases were ultimately united in both groups. Operative time and blood loss were significantly higher in the free fibula group. Although external fixation time was longer in the Ilizarov group, the overall duration of treatment was similar. Range of motion loss was less in the Ilizarov group, but the overall functional outcome was similar. There was no difference in complication rate, or number secondary procedures. Defect size was found to have the most significant effect on the results. Results were much better in the free fibula group when the defect length was 12 cm or more while the results were better in Ilizarov group when the defect length was less than 12 cm. We recommend using free vascularized fibula for traumatic tibial defects of 12 cm or more, whenever experience is available.

Combined single-stage osseous and soft tissue reconstruction of the tibia with the Ilizarov method and tissue transfer

OBJECTIVE

To determine the outcome of single-stage soft tissue and osseous reconstruction using the Ilizarov method and soft-tissue transfer.

DESIGN

A retrospective review.

SETTING

: A university-affiliated, tertiary-care center.

PATIENTS/INTERVENTION

We identified 11 patients from a retrospective review from January 1994 to July 1999 who underwent single-stage soft tissue and osseous reconstruction using the Ilizarov method. All 11 patients had an initial traumatic mechanism to their tibia and had previous operative intervention before the combined procedure. The Ilizarov procedure was performed for infected tibial nonunion (8 cases), or complex fracture with soft-tissue loss (3 cases).

MAIN OUTCOME MEASUREMENTS

Soft tissue transplant survival, union, range of motion, leg length discrepancy, the Association for the Study and Application of the Method of Ilizarov (ASAMI) score, radiographic parameters.

RESULTS

There were 8 concomitant free tissue flaps and 3 local pedicled flaps. Two patients had primary bone grafting, and 5 others had addition of an antibiotic impregnated bone substitute. There were 8 cases of elective reconstructive surgery and 3 cases of acute traumatic fracture. The mean duration of Ilizarov application was 26 weeks (range, 7 to 42). Eight tibiae united primarily, and 3 healed after delayed bone grafting. There were 2 major flap complications. Both were successfully managed with repeat surgery. One patient sustained a repeat open fracture and subsequently received an amputation. According to the ASAMI score, there were 9 excellent results, 1 good result, and 1 poor result.

CONCLUSION

Our study suggests that concomitant osseous and soft-tissue reconstruction with the Ilizarov technique and free or pedicled flaps is a viable option for patients with composite tissue defects.

Temporary intentional leg shortening and deformation to facilitate wound closure using the Ilizarov/Taylor spatial frame

Infected tibial nonunions with bone loss pose an extremely challenging problem for the orthopaedic surgeon. A comprehensive approach that addresses the infection, bone quality, and overlying soft-tissue integrity must be considered for a successful outcome. Acute shortening with an Ilizarov frame has been shown to be helpful in the treatment of open tibia fractures with simultaneous bone and soft-tissue loss. Cases in which the soft-tissue defect considerably exceeds bone loss may require an Ilizarov frame along with a concomitant soft-tissue procedure; however, there are a number of potential difficulties with vascularized pedicle flaps and free tissue flaps, including anastomotic complications, partial flap necrosis, and flap failure. The technique described in this report involves acute shortening and temporary bony deformation with the Ilizarov apparatus to facilitate wound closure and does not require a concomitant soft-tissue reconstructive procedure. Once the wound is healed, osseous deformity and length are gradually corrected by distraction osteogenesis with the Ilizarov/Taylor Spatial frame.

Simultaneous treatment of tibial bone and soft-tissue defects with the Ilizarov method

OBJECTIVES

To evaluate the potential for limb salvage using the Ilizarov method to simultaneously treat bone and soft-tissue defects of the leg without flap coverage.

DESIGN

Retrospective study.

SETTING

Level I trauma centers at 4 academic university medical centers.

PATIENTS/PARTICIPANTS

Twenty-five patients with bone and soft-tissue defects associated with tibial fractures and nonunions. The average soft-tissue and bone defect after debridement was 10.1 (range, 2-25) cm and 6 (range, 2-14) cm respectively. Patients were not candidates for flap coverage and the treatment was a preamputation limb salvage undertaking in all cases.

INTERVENTION

Ilizarov and Taylor Spatial Frames used to gradually close the bone and soft-tissue defects simultaneously by using monofocal shortening or bifocal or trifocal bone transport.

MAIN OUTCOME MEASUREMENTS

Bone union, soft-tissue closure, resolution or prevention of infection, restoration of leg length equality, alignment, limb salvage.

RESULTS

The average time of compression and distraction was 19.7 (range, 5-70) weeks, and time to soft-tissue closure was 14.7 (range, 3-41) weeks. Bony union occurred in 24 patients (96%). The average time in the frame was 43.2 (range, 10-82) weeks. Lengthening at another site was performed in 15 patients. The average amount of bone lengthening was 5.6 (range, 2-11) cm. Final leg length discrepancy (LLD) averaged 1.2 (range, 0-5) cm. Use of the trifocal approach resulted in less time in the frame for treatment of large bone and soft-tissue defects. There were no recurrences of osteomyelitis at the nonunion site. All wounds were closed. There were no amputations. All limbs were salvaged.

CONCLUSIONS

The Ilizarov method can be successfully used to reconstruct the leg with tibial bone loss and an accompanying soft-tissue defect. This limb salvage method can be used in patients who are not believed to be candidates for flap coverage. One also may consider using this technique to avoid the need for a flap. Gradual closure of the defect is accomplished resulting in bony union and soft-tissue closure. Lengthening can be performed at another site. A trifocal approach should be considered for large defects (>6 cm). Advances in technique and frame design should help prevent residual deformity.

Extreme bone lengthening using distraction osteogenesis after trauma: a case report

We are reporting herein the result of a 22 cm tibial lengthening after using an acute shortening technique with acute temporary angulation for salvage of a posttraumatic lower limb injury. The patient was referred to our center 2 weeks after a Gustilo IIIB open complex injury to the lower limb that included bone and soft-tissue loss. After surgical debridement, the tibial gap was 22 cm and the soft-tissue defect on the anterior aspect of the calf measured 12 x 20 cm. An acute shortening using a 50 degrees angulation (apex posteriorly) of the tibia in an Ilizarov frame was done after a full assessment of all reconstructive surgical options. After complete wound healing, a progressive correction of the angulation was done. Bilevel tibial distraction at a rate of 1.75 mm/day restored the original lower limb length. The 22 cm tibial elongation included 17 cm proximal lengthening and 5 cm distal lengthening. The fractures consolidated after 371 days, all wounds had closed, and no signs of osteomyelitis were present. Good aesthetic and functional results were obtained. The patient had no leg discrepancy compared to his normal limb and he returned to his previous occupation as a garage mechanic and to his favorite sport, boxing. To our knowledge, this is the first report in the English literature of tibial lengthening of this magnitude following acute trauma.

Acute shortening: modular treatment modality for severe combined bone and soft tissue loss of the extremities

BACKGROUND

Acute shortening, using the Ilizarov technique followed by progressive lengthening, is one of the methods used to deal with complex fractures combined with severe soft tissue injuries.

METHODS

We have summarized 12 patients who underwent acute shortening and stabilization using the Ilizarov frame. Nine of them underwent progressive lengthening to restore the length. For three patients, angulation of the bone segments was performed to save them from excessive bone debridement.

RESULTS

Total wound closure and bone regeneration were achieved in all our patients. Five patients had pin-tract infection without involvement of the bone, and no major complications were noted.

CONCLUSION

Using this technique, we found some advantages. First, there is less need for free and local flaps. Second, there is a decrease in the operating time and donor-site morbidity (important for patients with multiple organ trauma). Third, it provides a good option for restoring defects in severe cases with combined bone and soft tissue defects in the same session. Fourth, its implementation for short bone defects (< 3 cm) gives acceptable aesthetic and functional results. Fifth, angulation of the segments and subsequent graduated correction of misalignment reduces the length of shortening needed in patients with severe soft tissue loss by sparing the bone from unnecessary debridement. Sixth, it permits definitive treatment using an external fixator device, enabling the possibility of early functional loading. On the basis of our experience, we suggest adopting this method for functional limb salvage after extensive complex high-energy injuries.

Orthopedic considerations in wound healing of the lower extremity

The advancing technologies available to the orthopedist are a necessary adjunct to heal wounds about the foot and ankle successfully. Successful wound healing should be viewed as a multidisciplinary approach, using the strengths of each discipline. Critical to an integrated method is communication preoperatively between the orthopedist and the plastic surgeon to create a streamlined process. This leads not only to improved rates of wound healing, but also to improved functional outcomes while reducing risks for recurrence.