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

Distraction Osteogenesis Reconstruction Following Resection of Bone Sarcomas: Surgical, Functional, and Oncological Outcomes from a Prospective Trial Analysis

BACKGROUND

While sustainable long-term function has been established for biological reconstruction with distraction osteogenesis (DO) following osseous resections, there is a paucity of published data informing surgeons and patients on important milestones in the reconstructive process. The objectives of this study were to determine when to expect complete bone healing and full weight-bearing as well as to quantify the influence of chemotherapy on the osseous regeneration process.

METHODS

Prospectively, pathological and clinical data were collected for 30 consecutive patients who underwent primary or secondary DO-based reconstruction following osseous resection from 2018 to 2021. Serial radiographs indicated the times to cortex formation and full union. An unpaired t test was used to compare the time required for full bone remodeling of segments transported with and without concurrent chemotherapy.

RESULTS

The average resection length was 13.6 cm (range, 4 to 22 cm). Patients underwent an average of 6.1 procedures (range, 1 to 14 procedures). Half (50%) of all procedures were planned, while half were unplanned procedures. All patients achieved full, independent weight-bearing at a median of 12 months (interquartile range [IQR], 9 to 16 months). For the 34 segments transported concurrently with chemotherapy, the mean bone healing index (BHI) was 2.3 ± 0.7, and the mean BHI was 1.2 ± 0.4 for the 25 segments without chemotherapy at any point during their transport (p < 0.0001).

CONCLUSIONS

All 30 patients achieved full bone healing and independent weight-bearing at a median of 1 year postoperatively and continued to show functional improvement afterward. Surgeons and patients can expect bone healing to be nearly twice as fast for segments transported after completion of systemic chemotherapy compared with segments transported concurrently with adjuvant chemotherapy.

LEVEL OF EVIDENCE

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

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.

Treatment of Posttraumatic Tibial Diaphyseal Bone Defects: A Systematic Review and Meta-Analysis

OBJECTIVE

To describe evidenced-based treatment options for patients who sustained trauma and/or posttraumatic osteomyelitis of the tibia resulting in diaphyseal bone defects and to compare outcomes between patients treated with nonvascularized bone grafts (NBGs), bone transport (BT), or vascularized bone grafts (VBGs).

DATA SOURCE

The Preferred Reporting Items for Systematic Review and Meta-Analyses of individual participant data and Cochrane guidelines were followed. PubMed, EMBASE, Cochrane Library, Web of Science, Scopus, and CINAHL were searched from inception to June 2020.

STUDY SELECTION

Patients who were ≥18 years, had sustained trauma to the tibia resulting in fracture and/or osteomyelitis with measurable diaphyseal bone defects, and were treated by interventions such as NBGs, BT, or VBGs were eligible. Excluded studies were non-English, reviews, nonreviewed literature, cadavers, animals, unavailable full texts, nondiaphyseal defects, atrophic nonunions, malignancy, and replantations.

DATA EXTRACTION

A total of 108 studies were included with 826 patients. Two reviewers systematically/independently screened titles/abstracts, followed by full texts to ensure quality, accuracy, and consensus among authors for inclusion/exclusion of studies. A third reviewer addressed disagreements if investigators were unable to reach a consensus. Studies were quality assessed using "Methodological Quality and Synthesis of Case Series and Case Reports".

DATA SYNTHESIS

Analyses were performed with IBM SPSS version 25.0 (IBM Corporation, Armonk, NY) and G*Power3.1.9.2.

CONCLUSIONS

NBGs may be considered first line for trauma defect sizes ≤ 10 cm or posttraumatic osteomyelitis defect sizes <5 cm. BT may be considered first line for posttraumatic osteomyelitis defect sizes <5 cm. VBGs may be considered first line for trauma and posttraumatic osteomyelitis defect sizes ≥5 cm.

LEVEL OF EVIDENCE

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

Ilizarov segmental bone transport of infected tibial nonunions requiring extensive debridement with an average distraction length of 9,5 centimetres. Is it safe?

OBJECTIVES

To evaluate the results of one stage radical debridement and segmental bone transport with circular fixator in the treatment of infected tibial non-union requiring extensive debridement with an average defect size of 8 cm and distraction length of 9,5 cm.

DESIGN

Retrospective study.

SETTING

Level I trauma centre at an academic university hospital.

PATIENTS

Thirty patients with infected tibial non-union with an average of 2,9 previous failed operations after a mean 12,5 months post-injury were treated consecutively. The mean age was 39,5 years (R:16-68). After radical debridement and irrigation, all patients were treated with segmental bone transport using Ilizarov circular fixator. All patients except 3, managed with an open docking protocol without bone grafting. In 2 patients a planned ankle arthrodesis with transport was done.

MAIN OUTCOME MEASUREMENTS

Bone union, resolution of infection, external fixation index (EFI), external fixation time (EFT), bone and functional results for this big defect size.

RESULTS

Union and eradication of infection was achieved in all patients. Mean follow-up was 32,5 months (R: 12-72 mo.) The average bone defect after debridement was measured 8.1 cm (R, 6-15). The total distraction length to restore the debridement defect and previous LLD was 9,5 cm (R, 6-15). The mean external fixation time was 13,7 months; the mean external fixation index was 1,49 mo./cm. One non-union, one refracture and one late valgus deformity was managed successfully with plating or nailing and all were healed uneventfully at the completion of the treatment. According to Paley & Maar and Katsenis criteria, the bone results were excellent in 24 and good in 6, functional scores were excellent in 21, good in 7, and fair in 2 patients. Minor complications were 1,36 per patient, major complications were 0,4 per patient and permanent complications were 0,2 per patient in the study group.

CONCLUSION

In the management of large post-infectious bone defects requiring an average 9,5 cm distraction; segmental bone transport is safe in terms of union and eradication of infection. The EFI, EFT, complications, bone and functional results do not differ from the other published studies with smaller defect size.

Unprecedented tibial bone lengthening of 33.5 cm by distraction osteogenesis for the reconstruction of a subtotal tibial bone defect. A case report and literature review

Background

We present a case of an immense unprecedented tibial bone lengthening of 33.5 cm. The management of chronic osteomyelitis of the right tibia with subtotal tibial bone defect, talus defect and equinus ankle deformity. We demonstrate limb reconstruction by distraction osteogenesis and correction of ankle deformity with the Ilizarov technique. Limb salvage was preferred as an alternative to amputation to restore basic limb function.

Case presentation

A 16-year-old male patient fell and injured his right lower leg. He attempted to treat the symptoms with traditional home remedies. During 15 months of self-treating, he developed osteomyelitis of the right tibia and had lost function in his foot. Radiology revealed immense bone defect of the right tibia, including talus bone defect and equinus deformity of the calcaneus. The patient’s right tibia was non weight-bearing, had drainage sinus just below his knee and a large scar anteriorly along the entire length of the tibia.

Conclusion

Upon completion of treatment, the patient was able to avoid amputation of his leg with partially restored function for weight-bearing. He carried himself without assistance after 3 years of lost function in his right leg. Tibial bone distraction osteogenesis of 33.5 cm was done after 90% of the tibial length was defected. To the best of our best knowledge, this case is one of a kind to achieve distraction of tibial bone to such length.

Clinicoradiological outcomes following single-stage treatment using external fixator, copious bone grafting and high dose antibiotics for infected postosteomyelitic nonunion of femoral shaft

We aimed to study clinical and radiological outcomes following a 'single-stage protocol' in postosteomyelitic-infected nonunion of the femur in children. The report is based on a retrospective chart review (2010-2018) of 10 children below 12 years of age presenting with nonunion following a pathological fracture after osteomyelitis of hematogenous origin treated with above-mentioned operative modality. All patients were grade A (normal host) on the basis of the physiological classification. Patients with posttraumatic or surgical osteomyelitis were excluded. All patients were treated with a combination of debridement of dead bone and necrotic tissues, acute bone docking, use of external fixator and addition of copious nonvascularized autogenous bone graft obtained from fibula/tibia. The postsurgical period was covered by high dose broad spectrum antibiotics for 6 weeks. At follow up, union, infection, deformity, leg-length discrepancy, motion of hip and knee and ability to perform unaided walking was recorded. Mean age for studied patients (five males and five females) was 6.6 years. Average time elapsed since pathological fracture was 7.7 months (range: 3-15 months). MRSA and MSSA were cultured in three and four patients, respectively. Union occurred in all patients with average time of 3.7 months and total follow up being 2.9 years (range: 1-7 years). There was persistence of deep infection despite union in three patients. Average limb shortening was 4.3 cm (range: 2-7 cm). The knee motion was severely restricted (≤30°) in three patients. According to Paley's criteria, there were 2 excellent, 4 good, 2 fair and 2 poor results. Single-stage protocol as described above is a usable option for postosteomyelitic femoral nonunions in children. Union occurred in all cases. Healing occurred in three patients despite the persistence of infection. The restriction of range of motion at knee and limb length discrepancy was main complication encountered with this procedure.

Extreme bone lengthening by bone transport with a unifocal tibial corticotomy: a case report

Background

Bone transport is used for the treatment of extensive limb bone defects. The application of ring or unilateral external fixators combined with single or double corticotomy are well documented; however, there are few cases adopting a single corticotomy to repair bone defects > 24 cm.

Case presentation

The present case study describes an 18-year-old male, who was involved in a traffic accident and was diagnosed with open fracture of the right tibia. The patient received emergency surgery in a local hospital and was transferred to The Second People’s Hospital of Yunnan for further treatment 3 months later. The patient was diagnosed with fracture nonunion and infection following admission. Complete debridement was performed three times to control the infection. The infection was resolved after 26 days and the 24.5 cm massive tibia defect remained the biggest challenge. The bone transport technique involving a unilateral external fixator and single corticotomy was employed to treat the bone defect. Docking site union was achieved and bone consolidation was complete 40 months after corticotomy. The external fixator was subsequently removed. The bone healing index was 1.6 months/cm. The Association for the Study and Application of the Method of Ilizarov criteria (ASAMI) revealed a good functional and bone repair result. Similarly, Knee Society Score (KSS) yielded good result and the The Lower Extremity Functional Scale (LEFS) was 65. A total of 45 months after injury, the patient was able to walk painlessly without ambulatory assistive devices and resumed daily activities successfully. Eighteen months after the bone and soft tissue wound have healed, the SF-36 score was 86, and the LEFS was 70.

Conclusion

To the best of the authors’ knowledge, the present study described the longest bone defect repair performed using bone transport with single level corticotomy.

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.

Shortening and Angulation Strategies to Address Composite Bone and Soft Tissue Defects

Gustilo-Anderson IIIB tibial fractures and infected tibial nonunions represent particular challenges for the orthopaedic trauma surgeon. Debridement of dysvascular bone and soft tissues can create composite bone and soft tissue defects. Restoring the soft tissue envelope is a critical step in preventing or treating ongoing infection and in restoring local blood supply. Shortening and angulation techniques, including the gradual expansion muscle flap, rely on distraction histogenesis to address composite bone and soft tissue loss. These strategies can be used to treat large soft tissue defects when flap coverage or free tissue transfer is not available.

Lower Extremity Limb Salvage: Lessons Learned From 14 Years at War

American survivability during the current conflicts in Iraq and Afghanistan continues to improve, though the rate of extremity injury remains quite high. The decision to proceed with amputation versus limb salvage remains controversial. Exposure to combat wound with severe high-energy lower extremity trauma during the previous 14 years at war has incited important advances in limb salvage technique and rehabilitation.

Ilizarov bone transport after massive tibial trauma: Case report

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Successful unifocal tibial lengthening of 14.5 cm without using intramedullary nail guide.

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Bone transport demands high compliance from the patient to achieve optimal results.

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Bone transport proves to be an excellent alternative in managing massive bone loss.

Introduction

This is a case report of extreme lengthening of the tibia of about 14.5 cm using bone transport technique following road traffic accident trauma to the lower limbs. The management of the subsequent massive skeletal defects was challenging to orthopedic surgeons. Based on reported cases, the highest tibial lengthening was 22 cm using bifocal transport, while the highest unifocal tibial lengthening reached 14.5 cm.

Case presentation

A 20-year-old male driver was brought to the emergency department after a road traffic accident. The patient had a right Gustilo IIIA segmental open tibia fracture with bone loss and other severe injuries. The tibial defect was 14.5 cm and the patient was then admitted for Ilizarov application six months after the accident. Although this case was particularly complicated, full limb length was restored.

Discussion

The management of this case was directed to correct the deformities and achieve equal length of both limbs to restore the normal function. Several new techniques have been developed recently to fill large bone defects. Limb lengthening using bone transport technique by application of Ilizarov ring fixator has been suggested as the leading option in filling massive bone gaps.

Conclusion

The use of bone transport technique using Ilizarov external rings has proved to be a minimally invasive and reliable method in managing massive bone defects. Accurate application of the Ilizarov frame and proper transport of the middle segment are important factors alleviating the risk for deviation of the transported segment. However, due to the need for regular follow-ups and monitoring, it demands high compliance from the patient to achieve optimal results.

Quantitative and temporal differential recovery of articular and muscular limitations of knee joint contractures; results in a rat model

Joint contractures alter the mechanical properties of articular and muscular structures. Reversibility of a contracture depends on the restoration of the elasticity of both structures. We determined the differential contribution of articular and muscular structures to knee flexion contractures during spontaneous recovery. Rats (250, divided into 24 groups) had one knee joint surgically fixed in flexion for six different durations, from 1 to 32 wk, creating joint contractures of various severities. After the fixation was removed, the animals were left to spontaneously recover for 1 to 48 wk. After the recovery periods, animals were killed and the knee extension was measured before and after division of the transarticular posterior muscles using a motorized arthrometer. No articular limitation had developed in contracture of recent onset (≤2 wk of fixation, P > 0.05); muscular limitations were responsible for the majority of the contracture (34 ± 8° and 38 ± 6°, respectively; both P < 0.05). Recovery for 1 and 8 wk reversed the muscular limitation of contractures of recent onset (1 and 2 wk of fixation, respectively). Long-lasting contractures (≥4 wk of fixation) presented articular limitations, irreversible in all 12 durations of recovery compared with controls (all 12 P < 0.05). Knee flexion contractures of recent onset were primarily due to muscular structures, and they were reversible during spontaneous recovery. Long-lasting contractures were primarily due to articular structures and were irreversible. Comprehensive temporal and quantitative data on the differential reversibility of mechanically significant alterations in articular and muscular structures represent novel evidence on which to base clinical practice.

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.

A treatment strategy for complex cases of osteomyelitis in children and its applicability on three exemplary cases

The aim of this study was to carry out a two-step surgical approach for complex cases of pediatric osteomyelitis. The surgical technique used here involved initial bone debridement and stabilization by a customized spacer (intramedullary Kirschner wires mantled with refobacin-palacosa cement). After infection eradication, the spacer was removed and distraction osteogenesis performed. This study included one boy and two girls (aged 7-10 years) with severe osteomyelitis (tibia: two, femur: one). At least 50% of the bone was initially resected, and either a bifocal physeal distraction (tibia) or callus distraction (subtrochanteric osteotomy) was performed. At discharge they were able to walk without assistance. Complete infection eradication and load restraining reconstruction was achieved in all three children.

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.

The morphologic characteristics of nerve shortening following traumatic bone loss

Little is known about peripheral nerve shortening secondary to joint contracture or traumatic bone loss. We used the rat sciatic nerve as a model to study nerve shortening secondary to leg shortening. Nerve shortening was induced by surgically removing 16 mm of the femur. The histology of the ipsilateral and contralateral (control) sciatic nerves were compared at 1 h, 3 weeks, and 6 weeks. Transverse semithin sections of sciatic nerve were prepared and examined; single fibers also were teased from the nerve for study. The epineurium was shortened about 25% at 6 weeks. Axonal diameter was unchanged at 1 h, but increased over time, and was 0.68 microm larger than controls at 6 weeks (p < 0.05). In teased-fiber preparations, internodal length decreased 2.3% at 6 weeks, but not significantly. Peripheral nerve shortening secondary to leg shortening shortens the epineurium, but does not effect on internodal length.

The influence of soft tissue trauma on bone regeneration after acute limb shortening

Reconstructing posttraumatic tibial defects is often challenging. Some authors recommend acute limb shortening. We determined whether soft tissue trauma affects the formation of regenerated bone after acute shortening and monofocal lengthening. Twenty-two rabbits were divided into two equal groups. In the test group, 90 minutes of ischemia and 30 minutes of tibialis anterior muscle contusion at 100 kPa induced substantially elevated pressure as an onset of compartment syndrome. The untreated hind limb acted as the paired control. An external fixator was applied and the limb was shortened 10 mm through bone resection. After a latency period, distraction was performed for 10 days until the natural length was restored. New bone formation was evaluated mechanically, radiographically, and histomorphometrically. Osseous consolidation occurred in all animals. Normalized mechanical values of the newly reconstructed tibia indicated torsional strength was lower in the trauma group than in controls (46% +/- 18.5% versus 64% +/- 16.7%). Average normalized callus diameters were smaller in the trauma group than in controls (1.27 +/- 0.14 versus 1.6 +/- 0.16), as were callus volumes (37% +/- 5.9% versus 44% +/- 10.3%). Although soft tissue trauma affected the formation of regenerated bone, our results suggest reconstruction of tibial defects using a monofocal technique is consistent, even in the presence of blunt trauma and elevated compartment pressure.