Complications of bone transport technique using the Ilizarov method in the lower extremity: a retrospective analysis of 282 consecutive cases over 10 years

Floating the Flap: Suspension of Soft Tissue Free Flap Over External Fixation-Guided Bone Transport: A Novel Technique

CASE

Wide resection of a synovial sarcoma of the anteromedial distal leg involving the dimetaphyseal tibia and posterior tibial tendon produced an 8.5-cm osseous defect. To keep the free flap from invaginating into the defect and prevent kinking of the anastomosis, six 1.5-mm Ilizarov wires (held in place by the external fixator) were placed under the flap to suspend it over the defect. No problems resulted with the vascularity or healing of the flap or with consolidation of the defect.

CONCLUSION

Suspending the flap over the defect with Ilizarov wires can prevent tissue invagination while avoiding need for additional procedures.

Locking compression plate as a sequential external fixator following the distraction phase for the treatment of tibial bone defects caused by fracture-related infection: experiences from 22 cases

BACKGROUND

The purpose of this study was to report the clinical and psychological outcomes of using a locking compression plate (LCP) as a sequential external fixator following the distraction phase in the treatment of tibial bone defects caused by fracture-related infection (FRI).

METHODS

We retrospectively analyzed the clinical records and consecutive X-ray images of patients with tibial bone defects who were treated with an LCP as a sequential external fixator following the distraction phase, between June 2017 and December 2022. The ASAMI criteria were applied to assess the bone and functional outcomes, and postoperative complications were evaluated by using the Paley classification. The SCL-90-R questionnaire was used to evaluate patients' psychological symptoms, documented and compared at Time 1 (before bone transport), Time 2 (after distraction phase), and Time 3(final follow-up). Statistical significance was set at P < 0.05.

RESULTS

This study included 22 participants with a mean age of 37.72 ± 9.65 years, comprising 17 males (77.2%) and 5 females (22.7%). The mean postoperative follow-up time was 29 ± 2.65 months. The mean number of previous surgical interventions per patient was 5.22 ± 1.26. Twenty-two patients with tibial bone defects caused by FRI were successfully treated using an LCP as a sequential external fixator following the distraction phase, with a mean bone union time of 9.95 ± 1.52 months. Bone union was achieved in all cases (100%) without the use of bone grafts at the docking sites. Following the completion of distraction, the Ilizarov apparatus or monorail fixator was retained for an additional 2.20 ± 0.53 weeks before being exchanged for the external locking compression plate (ELCP). The mean external fixation time (EFT) was 12.29 ± 1.67 months, with a mean external fixation index (EFI) of 1.83 ± 0.22 month/cm (Table 2). At the final follow-up, bone and functional outcomes were evaluated using the ASAMI criteria. Bone outcomes included 10 excellent and 12 good results, while functional outcomes included 12 excellent, 9 good, and 1 fair result. Statistically significant differences in psychological impacts were observed among the three time points (Time 1 vs. Time 2, P = 0.034; Time 2 vs. Time 3, P = 0.020; Time 1 vs. Time 3, P = 0.012). Complications were observed in 6 patients (27.2%), including joint stiffness (n = 3), pin-track infection (n = 3), and refracture (n = 1). All complications were successfully managed.

CONCLUSION

LCP used as a sequential external fixator following the distraction phase is an effective method for treating massive tibial bone defects caused by FRI and is also suitable for patients with scars and poor tissue conditions resulting from multiple previous debridement. Furthermore, this combined technique could be more beneficial in alleviating psychological burdens, supporting patients' engagement in rehabilitation, and facilitating a return to normal life.

CLINICAL TRIAL NUMBER

Not applicable.

Optimizing bone transport strategies: a pixel value ratio-based evaluation of regeneration rates in bifocal and trifocal techniques

Background

Bone transport techniques are crucial for managing large bone defects, but the optimal approach for different defect lengths remains unclear. This study aimed to compare bone regeneration rates between short bifocal bone transport (SBBT), long bifocal bone transport (LBBT), and trifocal bone transport (TBT) using pixel value ratio (PVR) as an objective quantitative measure.

Methods

This retrospective study included 60 patients undergoing lower limb bone transport, divided into SBBT (n = 22, defects <6 cm), LBBT (n = 20, defects ≥6 cm), and TBT (n = 18, defects ≥6 cm) groups. PVR was measured at 4, 8, and 12 weeks postoperatively using standardized digital radiographs. Healing index (HI) and external fixation index (EFI) were calculated to assess treatment efficiency. Demographic data, surgical characteristics, and complications were also analyzed.

Results

TBT showed significantly higher PVR values compared to LBBT at all time points (4 weeks: 0.779 ± 0.036 vs. 0.719 ± 0.027, p < 0.001; 8 weeks: 0.822 ± 0.027 vs. 0.787 ± 0.025, p = 0.008; 12 weeks: 0.866 ± 0.024 vs. 0.835 ± 0.016, p = 0.023) and to SBBT at 4 and 8 weeks (p < 0.001 and p = 0.016, respectively). The TBT group demonstrated significantly lower HI and EFI compared to both SBBT and LBBT groups (p < 0.05), indicating faster healing and shorter treatment times. Although SBBT showed slightly higher PVR values than LBBT, the differences were not statistically significant.

Conclusion

Trifocal bone transport leads to faster bone regeneration and shorter treatment times compared to bifocal techniques, particularly for longer bone defects. The study demonstrates that defect length alone may not be the primary factor influencing regeneration rates in bifocal transport. PVR proves to be a reliable and cost-effective tool for assessing bone regeneration in different bone transport techniques, offering potential for guiding clinical decision-making. These findings suggest that trifocal transport should be considered as a preferred method for treating larger bone defects, especially when minimizing treatment time is crucial.

Comparing Patient Communication Event Demand for External Ring Fixators to Other Common Foot and Ankle Orthopaedic Procedures: A Retrospective Study

BACKGROUND

Surgeons may hesitate to apply external ring fixators (ERFs) due to perceived high clinical burden. This study aims to quantify the relative demand of ERFs compared with other common foot and ankle procedures. Understanding the demand of ERFs can provide insights into postoperative experiences, potentially decreasing intimidation of their use.

METHODS

Patients undergoing ERF treatment, hallux valgus osteotomy (HVO), or lateral ligamentous reconstruction (LLR) were identified using current procedural terminology code search in a single surgeon database. A retrospective review at a single institution included patients undergoing one of the three surgeries between 2017 and 2023. Clinical burden was quantified using points of contact for each procedure, which included phone calls, portal messages/documented emails, in-person visits, and surgeries. Visits and surgeries were categorized as routine or unexpected. Quantified burden was then compared among the three groups.

RESULTS

One hundred ninety-four patients were included in the study (81 LLR, 64 HVO, 49 ERF), and data were collected within 6-month postoperation. ERFs had 2.27 more total clinic visits than HVO (6.91 vs. 4.64; P < 0.0001) and 2.80 more than LLR (6.91 vs. 4.11; P < 0.0001). Overall, 0.42 more unexpected clinic visits were observed for ERF than for HVO (0.94 vs. 0.52; P = 0.06) and 0.84 more than LLR (0.94 vs. 0.1; P < 0.0001). An average of 0.6 unexpected surgeries were observed for ERF, compared with 0.09 for HVO (P < 0.0001) and 0 for LLR (P < 0.0001).

CONCLUSION

Patients with an ERF did have more frequent encounters compared with control groups. This study provides guidance about the extent of potential clinical burden of ERF. Whether this increase is clinically notable would be to the discretion of the treating surgeon.

Ilizarov method combined with accordion technique for treating long bone defects in the lower limbs: a systematic review

BACKGROUND

Bone defects and nonunion following initial treatment remain significant clinical challenges. The Ilizarov method constitutes a fundamental approach for addressing bone defects, and its integration with adjunctive techniques, such as the accordion maneuver, antibiotic spacers, or internal fixation, has become increasingly widespread. Despite this, limited research exists on the clinical outcomes specifically related to the use of the Ilizarov method combined with the accordion technique for treating long bone defects in the lower limbs.

OBJECTIVE

This study seeks to systematically review the application of the Ilizarov method in combination with the accordion technique for addressing long bone deficiencies in the lower limbs.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review was performed in alignment with the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), involving searches of Medline, Embase, Web of Science, and the Cochrane Library, with the search process concluding on August 20, 2024. The study population consisted of patients with bone defects who underwent treatment using the Ilizarov method in conjunction with the accordion technique. The methodological quality of the included studies was evaluated using the MINORS (Methodological Index for Non-Randomized Studies) scoring system. This study recorded and analyzed the participant count for each study that met the inclusion criteria, along with the number of patients who achieved bone healing, the bone and functional outcomes, and complications such as pin infections, pain, and refracture.

RESULTS

Drawing from eight studies involving 80 patients with bone defects treated through the Ilizarov method combined with the accordion technique, this systematic review evaluated the method's impact on bone regeneration. Of these patients, 24% presented with femoral defects, while 76% had tibial defects. The mean patient age was 32.8 years, with an average follow-up of 25.2 months. The accordion technique involved daily distraction and compression adjustments ranging from 0.25 to 1 mm, typically in more than two cycles, effectively promoting bone healing. The bone healing rate was high, with the majority of patients rated as having excellent or good functional recovery, according to standards such as ASAMI and Paley. Common complications included superficial pin tract infections (33.75%) and deep pin tract infections (6.25%), both of which were generally manageable with routine treatment. The accordion technique showed promising results in shortening healing time and enhancing the quality of bone healing.

CONCLUSION

This systematic review demonstrates that despite variations in parameter settings across studies, the Ilizarov method combined with the accordion technique consistently shows strong efficacy and safety in promoting bone regeneration and functional recovery. While some complications may arise, they are generally well-managed with standard care. This approach represents a reliable option for complex bone reconstruction, with future research needed to optimize parameters and further enhance clinical outcomes.

Integrating 3D-printed customized guides with hemicorticotomy bone transport: clinical outcomes in chronic osteomyelitis management

PURPOSE

Chronic osteomyelitis with large bone defects remains a challenging condition in orthopedic surgery. This study aimed to evaluate the clinical efficacy of hemicorticotomy bone transport assisted by 3D-printed customized guides in the treatment of chronic osteomyelitis with bone defects.

METHODS

A retrospective analysis was conducted on 21 patients with chronic osteomyelitis treated with hemicorticotomy bone transport with 3D-printed guide assistance between January 2015 and January 2021. Preoperative planning utilized 3D CT reconstruction for precise guide design and osteotomy placement. The surgical technique involved hemicorticotomy, placement of the 3D-printed guide, and gradual bone transport using a monolateral external fixator. Clinical outcomes were assessed using the Association for the Study and Application of Methods of Ilizarov (ASAMI) scoring system. The external fixation time (EFT), external fixation index (EFI), and complications evaluated using the Paley classification were recorded.

RESULTS

The mean bone defect size was 7.9 ± 2.0 cm. The average follow-up period was 28.6 ± 6.4 months. The mean external fixation time was 289.4 ± 52.7 days, with an external fixation index of 36.8 ± 4.2 days/cm. According to the ASAMI criteria, the bone results were excellent in 17 patients (81%), good in 3 (14%), and fair in 1 (5%). The functional results were excellent in 15 patients (71%), good in 4 (19%), and fair in 2 (10%). Complete eradication of the infection and union at the docking site were achieved in all patients. The complication rate was 38% and all of which were successfully managed.

CONCLUSION

Hemicorticotomy bone transport assisted by 3D-printed customized guides is an effective treatment for chronic osteomyelitis with bone defects. This technique offers excellent bone healing, favorable functional results, and a relatively low complication rate. Further studies with larger sample sizes are warranted to validate these findings.

Objective assessment of docking site consolidation in bone transport: the role of pixel value ratio in predicting healing outcomes

BACKGROUND

The management of docking site healing in bone transport remains a significant challenge in orthopedic surgery. Traditional assessment methods rely heavily on qualitative radiographic evaluations. This study investigates the utility of pixel value ratio (PVR), an objective quantitative measure, in assessing bone healing at the docking site during bone transport.

METHODS

This retrospective study included 47 patients who underwent bone transport for lower limb reconstruction between January 2015 and January 2020. Patients were categorized into bone union (n = 35) and nonunion (n = 12) groups based on docking site outcomes. PVR was calculated using two methods (PVR1 and PVR2) at six time points over 24 months post-docking. Subgroup analyses were performed based on gender, age, and surgical site.

RESULTS

Of 47 patients, 35 achieved bone union and 12 experienced nonunion. Both PVR1 and PVR2 were consistently lower in the union group compared to the nonunion group at all time points (p < 0.001). In the union group, PVR1 ranged from 1.064 ± 0.050 to 1.108 ± 0.062, while PVR2 ranged from 0.926 ± 0.079 to 0.946 ± 0.062. In the nonunion group, PVR1 ranged from 1.204 ± 0.057 to 1.273 ± 0.020, and PVR2 from 1.039 ± 0.060 to 1.148 ± 0.022. Subgroup analyses revealed that males had significantly lower PVR values compared to females, and tibial cases had lower PVR values compared to femoral cases in both union and nonunion groups (p < 0.05). All juvenile patients achieved union, compared to 71.4% of adults (p < 0.01).

CONCLUSION

PVR demonstrates significant potential as an objective tool for assessing docking site healing in bone transport procedures. The distinct patterns observed between union and nonunion cases provide a foundation for developing clinical guidelines to monitor and predict healing outcomes. Integration of PVR assessment into clinical practice could improve decision-making and optimize treatment protocols in bone transport procedures.

Can limb length discrepancies be corrected with the Masquelet technique? A technical trick

Masquelet technique is a well-established procedure for reconstruction of bone defects secondary to such causes as infections, non-unions, tumors or open fractures with bone loss. The management of limb length discrepancies following bone defects has been well established using bone transport and remains the preferred choice amongst reconstruction surgeons. One of the criticisms of the Masquelet technique has been its limitation to address limb length discrepancies. We describe a technique for the correction of limb length discrepancies using the Masquelet technique.

Effective Compression and a Minimally Invasive Rail Plate to Optimize Bone Transport in Distraction Osteogenesis: New Concepts

Background

Bone transport in distraction osteogenesis is an effective, well-known procedure. However, bone compression is an aspect of this technique for which there is no objective information. The lack of direct bone compression measurements may result in a lack of uniformity in the bone transport process, which can result in its ineffective application and may be contributing to its underutilization. This study describes the results of applying objectively measured compressions to achieve a distraction regeneration zone and docking site consolidation during bone transport in distraction osteogenesis.

Methods

This prospective study describes the results of a single cohort of 32 patients who underwent distraction osteogenesis with bone transport utilizing a combination of a minimally invasive rail plate and monolateral external fixation. The patients were categorized into 2 groups: (1) those with hypertrophic, atrophic, or infectious pseudarthrosis-nonunion (the pseudarthrosis-nonunion group), and (2) those with bone loss due to trauma or osteomyelitis (the bone loss group). The initial bone compression was measured during the latency phase, and the final compression was measured during the distraction phase. The healing index, external fixation index, healing time, consolidation time, and docking time were calculated for each patient. The Mann-Whitney U and Kruskal-Wallis tests were used for comparisons between and within groups.

Results

In this study, 28 (88%) of the patients were male. The mean patient age was 44.93 ± 16.21 years. The median values were 3.2 Nm for the initial compression and 3.4 Nm for the final compression, with no significant difference between or within groups of patients. The osseous results were excellent in 29 patients (91%), and the functional results were good or excellent in 31 patients (97%).

Conclusions

This study is the first to objectively measure compression in the bone transport process. Our findings showed that all patients who had an initial compression of ≥3.2 Nm achieved 100% consolidation of the distraction regeneration zone, and those who had a final compression of ≥2.9 Nm achieved complete docking site consolidation without complications. These 2 values thus represent effective compression and highlight the role of bone compression in bone transport.

Level of Evidence

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

Orthoplastic Reconstruction of Distal Tibia High-Energy Fractures Using a Circular External Fixator-A Systematic Review

Background: Compound fractures of the distal tibia (with or without the middle third) represent a challenge for orthopedic and plastic surgeons because of the scarcity of available soft tissue reconstruction and the important comminution of the fractures that usually appear. Methods: The design of this study is based on the PRISMA guidelines. Databases were searched for articles published and available until the first half of 2023. Articles that presented the evolution of patients treated by combining circular external fixators with reconstructive methods were selected. Results: After searching the literature using keywords, we obtained 3355 articles, out of which 14 articles met all the inclusion criteria, with a total number of participants of 283. The bone loss varied between 0.7 and 18.2 cm, while the soft tissue defect was between 3/3 cm and 16/21 cm. The average period of fixation ranged from 4 to 22.74 months. The most used reconstruction methods were 80 free flaps and 73 pedicled flaps out of 249 interventions. Complete flap loss appeared only in 3/283 patients. Regarding the bone union, the percentage of non-union was low, and in all cases, it was achieved after reintervention. A low rate of major complications was observed. Conclusions: The orthoplastic team is the key to successfully treating the high-energy traumatism of the distal tibia (with or without a middle third). The Ilizarov external fixator can be used as a definitive limb-salvage treatment (secondary to the standard primary methods of fixation) in combination with a flap to cover the defects because it does not damage the pedicle, and it helps stabilize the soft tissues and bones around the flap to lower the complications.

Bone Transport for Large Segmental Tibial Defects Using Taylor Spatial Frame versus the Ilizarov Circular Fixator

OBJECTIVE

Bone transport has become the gold standard for treating large segmental tibial bone defects. The technique for application the Ilizarov circular fixator (ICF) has a long learning curve and is associated with many complications. There are few clinical studies on bone transport via the Taylor spatial frame (TSF). The main purpose of this study was to compare the radiological and clinical and outcomes of bone transport by using the TSF and the ICF.

METHODS

There were 62 patients included in this retrospective study from June 2011 to June 2021 and distributed to two groups according to the fixation method: a TSF group consisting of 30 patients and an ICF group consisting of 32 patients. Demographic information, surgical duration, external fixation times, external fixation index, final radiographic results, complications, and clinical outcomes were recorded and examined. The clinical outcomes were assessed using the ASAMI criteria during the most recent clinical visit. Then, statistical analysis such as independent-samples t tests or chi-Square test was performed.

RESULTS

The mean surgical duration in the TSF group was 93.8 ± 7.3 min, which was shorter than that in the ICF group (109.8 ± 1.4 min) (p < 0.05). Compared to the ICF group (10.2 ± 2.0 months), the TSF group (9.7 ± 1.8 months) had a shorter average external fixation time (p > 0.05). The external fixation index was 1.4 ± 0.2 m/cm and 1.5 ± 0.1 m/cm in the two groups. Moreover, there was no significant difference between the two groups. At the last follow-up visit, the medial proximal tibial angle (MPTA) and posterior proximal tibial angle (PPTA) in the TSF group were 88.1 ± 12.1° and 80.9 ± 1.3°, respectively. The MPTA and PPTA in the ICF group were 84.4 ± 2.4° and 76.2 ± 1.9°, respectively. There were statistically significant differences between the two groups (all p < 0.05). The complication rate was 50% in the TSF group and 75% in the ICF group. Moreover, the ASAMI score between the two groups was no statistically significant difference (p > 0.05).

CONCLUSION

No statistically significant difference was found in clinical outcomes between the use of Taylor spatial frame and Ilizarov circular fixator for treating large segmental tibial bone defects. However, TSF is a shorter and simpler procedure that causes fewer complications and improves limb alignment.

[Effect of accordion technique and deferoxamine on promoting bone regeneration in distraction osteogenesis]

Objective

To compare the effects of hypoxia-inducible drugs using deferoxamine (DFO) and accordion technique (AT) on activating the hypoxia-inducible factor 1α (HIF-1α)/vascular endothelial growth factor (VEGF) signaling pathway to promote bone regeneration and remodelling during consolidation phase of distraction osteogenesis (DO).

Methods

Forty-five specific-pathogen-free adult male Sprague-Dawley (SD) rats were randomly divided into the control group, DFO group, and AT group, with 15 rats in each group. All rats underwent osteotomy to establish a right femur DO model. Then, continuous distraction was started for 10 days after 5 days of latency in each group. During the consolidation phase after distraction, no intervention was performed in the control group; DFO was locally perfused into the distraction area in the DFO group starting at the 3rd week of consolidation phase; cyclic stress stimulation was given in the AT group starting at the 3rd week of consolidation phase. The general condition of rats in each group was observed. X-ray films were conducted at the end of the distraction phase and at the 2nd, 4th, and 6th weeks of the consolidation phase to observe the calcification in the distraction area. At the 4th and 6th weeks of the consolidation phase, peripheral blood was taken for ELISA detection (HIF-1α, VEGF, CD31, and Osterix), femoral specimens were harvested for gross observation, histological staining (HE staining), and immunohistochemical staining [HIF-1α, VEGF, osteopontin (OPN), osteocalcin (OCN)]. At the 6th week of the consolidation phase, Micro-CT was used to observe the new bone mineral density (BMD), bone volume/tissue volume (BV/TV), trabecular separation (Tb.Sp), trabecular number (Tb.N), and trabecular thickness (Tb.Th) in the distraction area, and biomechanical test (ultimate load, elastic modulus, energy to failure, and stiffness) to detect bone regeneration in the distraction area.

Results

The rats in all groups survived until the termination of the experiment. ELISA showed that the contents of HIF-1α, VEGF, CD31, and Osterix in the serum of the AT group were significantly higher than those of the DFO group and control group at the 4th and 6th weeks of the consolidation phase ( P<0.05). General observation, X-ray films, Micro-CT, and biomechanical test showed that bone formation in the femoral distraction area was significantly better in the DFO group and AT group than in the control group, and complete recanalization of the medullary cavity was achieved in the AT group, and BMD, BV/TV, Tb.Sp, Tb.N, and Tb.Th, as well as ultimate load, elastic modulus, energy to failure, and stiffness in the distraction area, were better in the AT group than in the DFO group and control group, and the differences were significant ( P<0.05). HE staining showed that trabecular bone formation and maturation in the distraction area were better in the AT group than in the DFO group and control group. Immunohistochemical staining showed that at the 4th week of consolidation phase, the expression levels of HIF-1α, VEGF, OCN, and OPN in the distraction area of the AT group were significantly higher than those of the DFO group and control group ( P<0.05); however, at 6th week of consolidation phase, the above indicators were lower in the AT group than in the DFO group and control group, but there was no significant difference between groups ( P>0.05).

Conclusion

Both continuous local perfusion of DFO in the distraction area and AT during the consolidation phase can activate the HIF-1α/VEGF signaling pathway. However, AT is more effective than local perfusion of DFO in promoting the process of angiogenesis, osteogenesis, and bone remodelling.

Nomogram construction and validation of axial deviation in patients with tibial defects treated with the Ilizarov bone transport technique

INTRODUCTION

The Ilizarov bone transport technique is widely recognised as an effective method for treating large segment bone defects in clinical practice. However, axial deviation is a common complication in the treatment of tibial large segment bone defects, which can have a serious impact on the clinical efficacy of bone transport. Our study aims to construct and validate a nomogram for predicting axial deviation of tibial bone transport.

METHOD

This study retrospectively collected data from 363 patients who underwent the tibial Ilizarov technique for bone transport. Univariate and multivariate logistic regression analyses were performed to determine the independent risk factors for axial deviation, which were later used to construct a nomogram. The nomogram was evaluated using the decision curve analysis (DCA), the calibration curve, and the area under the receiver operating characteristic curve (AUC).

RESULTS

Of the 363 patients who underwent Ilizarov tibial bone transport, 31.7% (115/363) experienced axial deviation. Multivariate logistic regression analysis showed that gender, height, defect site, and external fixation index were important risk factors for axial deviation. The AUC value of the nomogram model was 0.705. The calibration curve and the decision curve analysis showed a good consistency between the actual axial deviation and the predicted probability.

CONCLUSION

The model assigns a quantitative risk score to each variable, which can be used to predict the risk of axial deviation during tibial bone transport.

Refracture-related bone transport of tibia: technical notes and preliminary clinical results in nineteen cases

PURPOSE

Refracture is one of the main complications of bone transport, which brings additional physical and mental burden to surgeries and patients. We aimed to raise a new classification system of refracture-related bone transport based on the Simpson classification and to present our experience on treatment.

METHODS

This retrospective analysis included 19 patients with refracture-related bone transport (average age of 37.7 years; 18 men). We developed a modified Simpson classification system to assist decision-making (conservative versus surgical). The ASAMI criteria were used to assess the outcomes at last follow-up.

RESULTS

The mean follow-up was 12.3 ± 3.2 months. Complete union was achieved in all patients, with no reinfection. Based on the modified Simpson classification, refracture was Ia type (within regeneration area) in three cases, Ib (collapsed fracture at the regeneration area) in one case, Ic (stress fracture) in three cases, II (at the junction between the regenerate and original bone) in one case, III (at the docking site) in nine cases, and V (at distant site) in two cases. Refracture was managed conservatively in six cases and surgically in 13 cases. Average time to bone union was 2.8 ± 1.2 months in the conservative group versus 4.4 ± 1.4 months in the surgery group. Assessment at the final follow-up using the ASAMI criteria revealed excellent bone result in all patients, excellent functional results in six patients (31.6%), and good functional results in 13 patients.

CONCLUSIONS

The modified Simpson classification could include refracture at the docking site and stress fracture in the regeneration zone and provide some guidance in determining the appropriate treatment strategy.

Application of the Modified RUST Score in Tibial Bone Transport and Factors Associated with Docking Site Complications

Aim

Reconstruction of segmental bone defects with bone transport is a well-established treatment. Mechanical complications at the docking site after frame removal are common. These complications include malunion, non-union, axial deviation and refracture. A simple tool to assess the healing of the docking site is currently lacking. The aim of this study is to evaluate the use of the modified RUST (mRUST) score in the setting of bone transport and to identify factors associated with an increased risk of docking site complications.

Methods

This retrospective study was conducted at a single tertiary centre in South Africa, included 24 patients with a tibial bone defect treated with bone transport and a circular frame between 2014 and 2023. Demographic data, clinical and bone transport characteristics were recorded. Mechanical complications, such as fracture, non-union, any angulation >5°, shortening >5 mm, or any other complication requiring reoperation, were recorded. The mRUST was adapted as a ratio for the purpose of this study to overcome the common occurrence of cortices being obscured by the frame. The mRUST ratio was applied before and after frame removal for each patient by three appraisers. Comparison between the groups with and without complications was performed regarding bone transport characteristics, docking site configuration and mRUST ratio. The correlation of the score between radiographs before and after frame removal was assessed. The inter-rater reliability of the mRUST was analysed using Fleiss Kappa statistics for each cortex individually and the intraclass correlation coefficient (ICC) for the mRUST ratio.

Results

In this study, 20 men and 4 women with a median age of 26 years were included. The overall rate of mechanical complications after frame removal was 21.7%. Complications were all related to the docking site, with two angulations, two fractures and one non-union. Demographics, bone transport characteristics and mRUST ratio before and after frame removal were similar between the two groups. Regarding the configuration of the docking site, an angle of 45° or more between the bone surfaces was associated with the occurrence of mechanical complications (p < 0.001). The correlation of the mean mRUST ratio before and after frame removal showed a moderate relationship, with a Spearman correlation coefficient of 0.50 (p-value 0.13). The inter-rater reliability of the mRUST was "fair" (kappa 0.21-0.40) for the scoring of individual cortices, except for one score which was "slight" (kappa 0.00-0.20). The ICC of the mRUST ratio was 0.662 on radiographs with the frame, and 0.759 after frame removal.

Conclusion

This study did not find the mRUST or mRUST ratio useful in assessing the healing of the docking site to decide on the best time to remove the frame. However, a notable finding was that the shape and orientation of the bone ends meeting at the docking site might well be relevant to decrease complication rates. If the angle between the bony surfaces is 45° or more, it may be associated with an increased risk of complications. It may be worthwhile considering reshaping these bone ends at the time of debridement or formal docking procedure to be more collinear, in order to reduce the potential for mechanical complications such as non-union, axial deviation or refracture at the docking site.

How to cite this article

Kummer A, Nieuwoudt L, Marais LC. Application of the Modified RUST Score in Tibial Bone Transport and Factors Associated with Docking Site Complications. Strategies Trauma Limb Reconstr 2024;19(2):73-81.

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.

Docking site interventions following bone transport using external fixation: a systematic review of the literature

PURPOSE

Although bone transport is a well-recognised technique to address segmental bone defects, optimal management of docking sites is not absolutely determined. Some surgeons routinely intervene in all cases, and others prefer to observe and intervene only if spontaneous union does not occur. Primary aim of the study was to compare rates of docking site union between patients who underwent routine docking site intervention and those who did not.

METHODS

A systematic literature review using the keywords "bone transport", "docking", "tibia", and "femur" was performed in PubMed using PRISMA guidelines. Studies published in English from January 2000 to August 2022 were included and assessed independently by two reviewers. Pooled analysis was undertaken dividing patients into two groups: those managed by routine intervention and those initially observed.

RESULTS

Twenty-three clinical studies met the eligibility criteria for pooled analysis, including 1153 patients, 407 in the routine intervention and 746 in the observed group. The rate of union after initial treatment was 90% in the routine intervention group and 66% in the observed group (p < 0.0001). Overall union rates at the end of treatment were similar at 99% in both groups. Patients in the observed group required an average of 2.2 procedures to achieve union overall compared with 3.8 in the routine intervention group. Time in frame was similar between groups.

CONCLUSION

Based on the current literature, routine docking site interventions cannot be recommended, since this may lead to unnecessary interventions in two thirds of patients. Timely selective intervention in those at high risk or after a defined period of observation would appear to be a logical approach.

Effect of concomitant deformity correction on patient outcomes following femoral (OTA type 32) nonunion repair

INTRODUCTION

The purpose of this study was to determine what effect, if any, concomitant deformity correction has on outcomes following femoral nonunion repair.

METHODS

605 consecutive patients who presented to our center with a long bone nonunion treated by one of 3 surgeons was queried. Sixty-two patients (10 %) with complete follow up were treated for a fracture nonunion following a Type 32 femur fracture (subtrochanteric, femoral shaft or distal third metaphysis) over an 11-year period. Twenty of these patients underwent a deformity correction (DC)-angular, rotational, or a combination of both-as part of their femoral reconstruction. Patient demographics and initial injury information was reviewed and compared. Outcomes including radiographic healing, time to union, postoperative complications, patient reported pain scores, and functional outcome scores using the Short Musculoskeletal Functional Assessment (SMFA) were recorded. Patients with and without deformity correction were analyzed and compared using independent T-tests and Chi-Square tests.

RESULTS

Compared to the non-deformity correction (NDC) cohort, the DC cohort demonstrated a worse complication profile. Notably, the DC cohort had longer time to union (11.6 ± 7.3 months vs 7.6 ± 8.5 months, P = 0.042), reported significantly higher VAS pain scores at 1-year post-op (4.2 ± 2.8 vs 2.3 ± 2.6, P = 0.007), experienced more complications (25 % vs 4.8 %, P = 0.019), and had a higher rate of secondary procedures (30 % vs 4.8 %, P = 0.006). The DC patients reported less improvement in functional capability as displayed by a smaller average improvement in initial and final SMFA scores (P = 0.042) There was no difference in ultimate bone healing (P = 0.585), baseline SMFA (P = 0.294), and latest SMFA (P = 0.066).

CONCLUSION

Deformity correction, if needed as part of femoral nonunion repair, is associated with an increased time to heal, greater rate of complications and diminished improvement of functionality. Eventual healing and patient reported outcomes were similar whether a deformity correction is necessary or not.

LEVEL OF EVIDENCE

III.

Application of Ortho-Bridge System after Femoral Bone Transport

The bone transport technique uses the principle of distraction-osteogenesis and fill bone defects with the aid of an external fixator. In order to evaluate the clinical effect of femoral internal fixation with Ortho-Bridge System after bone transport, 4 patients after femoral bone transport from October 2020 to October 2022 are studied in this paper. Among them, 3 patients ran refracture of femur after removal of the Limb reconstruction system, 1 patient just finish femoral bone transport and request internal fixation. The surgery results show that Ortho-Bridge System can be used in the situation that conventional Locking compression plate and intramedullary nail are not suitable due to anatomical variation after femoral bone transport. Key words: femoral fracture; Ortho-Bridge System; bone transport; postoperative complications of bone transport.

Advances in the Application of Bone Transport Techniques in the Treatment of Bone Nonunion and Bone Defects

Bone nonunion and bone defects frequently occur following high-energy open injuries or debridement surgeries, presenting complex challenges to treatment and significantly affecting patients' quality of life. At present, there are three primary treatment options available for addressing bone nonunion and bone defects: vascularized bone grafts, the Masquelet technique, and the Ilizarov technique. The Ilizarov technique, also known as distraction osteogenesis, is widely favored by orthopedic surgeons because of several advantages, including minimal soft tissue requirements, low infection risk, and short consolidation time. However, in recent years, the application of the Masquelet technique has resulted in novel treatment methods for managing post-traumatic bone infections when bone defects are present. Although these new techniques do not constitute a panacea, they continue to be the most commonly employed options for treating complex large bone nonunion and bone defects. This review evaluates the currently available research on the Ilizarov and Masquelet bone transport techniques applied at various anatomical sites. Additionally, it explores treatment durations and associated complications to establish a theoretical foundation that can guide clinical treatment decisions and surgical procedures for the management of bone nonunion and bone defects.

Complications analysis of Ilizarov bone transport technique in the treatment of tibial bone defects-a retrospective study of 199 cases

BACKGROUND

The clinical treatment of long bone defets in the extremities caused by trauma, infection, tumours, and nonunion has been a challenge for orthopaedic surgeons. Bone transport techniques have become the only way to treat such bone defects. However, inevitable difficulties and complications related to bone transport techniques have been reported in many studies.

AIM

The purpose of this study was to investigate the risk factors for complications and the effectiveness of the Ilizarov bone transport technique in the treatment of tibial bone defects.

METHODS

The study was conducted in 199 patients who underwent treatment with the Ilizarov bone transport technique at our institution from May 2012 to September 2019. Patient demographic data, complications and clinical outcomes after a minimum of 2 years of follow-up were collected and retrospectively analysed. Additionally, a risk factor analysis was performed for the top three major complications. The clinical outcomes were evaluated using the Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria at the last clinical follow-up.

RESULTS

A total of 199 patients underwent follow-up for 12-40 months, with an average of 23.5 months, and all achieved bone healing. A total of 310 complications occurred, with an average of 1.04 minor complications and 0.48 major complications per patient. The top three complications were pin tract infection in 48 cases (61.3%), axial deviation in 86 cases (43.2%), and delayed union in 50 cases (25.13%). Multivariate analysis showed that the bone defect length (P = 0.02, OR = 5.489), the number of previous surgeries (P = 0.003, OR = 2.204), and the external fixation index (P = 0.01, OR = 1.202) were significantly correlated with pin tract infection. Bone defects of the middle 1/3 (P < 0.001, OR = 23.769), the bone defect length (P < 0.001, OR = 2.776), and the external fixation index (P < 0.001, OR = 1.154) were significantly correlated with axial deviation. The bone defect length (P = 0.003, OR = 1.242), soft tissue defects (P = 0.013, OR = 0.312) and bone defects of the distal 1/3 (P = 0.023, OR = 4.257) were significantly correlated with delayed healing. The ASAMI bone score at the last follow-up showed a rate of excellent and good bone results of 95.48% and a rate of excellent functional results of 87.94%.

CONCLUSION

The Ilizarov bone transfer technique is an effective method for treating tibial bone defects, and shortening the treatment period can reduce the incidence of complications. Older patients and those with longer bone defects, a higher external fixation index, more previous operations, and defects of the middle and distal 1/3 had a higher incidence of complications.

Management of Segmental Tibial Bone Defects With the Magnetic Motorized Intramedullary Transport Nail: A Case Series

SUMMARY

Critical-sized bone defects in the tibia can arise as sequelae of trauma, infection, tumor, or the treatment of congenital limb deficiencies. Treatment of these defects often requires bone transport, which has traditionally been accomplished using circular external fixators. The development of a bone transport nail facilitated tibia reconstruction through distraction osteogenesis using an all-internal device, thus avoiding the complications associated with chronic external fixation. Given the rarity of these cases, few studies have been published on the reconstruction outcomes using this implant. We sought to investigate the bone healing indices (including regenerate consolidation and time to docking site union) associated with the use of a magnetically controlled all-internal bone transport nail for the reconstruction of 4 patients treated for posttraumatic tibial bone loss. Perioperative and device-related complications are also reported.

The accordion technique enhances bone regeneration via angiogenesis factor in a rat distraction osteogenesis model

Objective: The purpose of this study was to observe the effect of the accordion technique (AT) during the distraction phase on chondrogenesis and bone regeneration in a rat femoral distraction osteogenesis (DO) model, and investigate its potential mechanism for reducing the total treatment time of DO. Methods: Fifty-four male Sprague-Dawley (SD) rats that were specific-pathogen-free (SPF) were subjected to DO surgery on the right femur. The distraction rate was 0.5 mm/day for 10 days, following a latency period of 5 days. Rats were randomly divided into Control (no AT, n = 18), Group LA (low amplitude with AT, n = 18), and Group HA (high amplitude with AT, n = 18) according to different AT protocols in the distraction phase. Rats were respectively euthanized by anesthesia overdose at 2, 4 and 6 weeks of the consolidation phase, and the femurs were harvested. Digital radiography, micro-computed tomography (micro-CT), biomechanical tests, and histomorphological analysis were used to assess the quality of regenerated bone in the distraction area. Results: Digital radiographic, micro-CT, biomechanical tests, and histological analysis revealed an increase in early-stage callus formation (p < 0.05) and improved blood supply to the callus tissue in Group LA, as compared to both the Control and Group HA. The enhanced differentiation of fibrous and cartilaginous tissue into bone tissue was also observed in Group LA, leading to improved strength and stiffness (p < 0.05) of the regenerated bone at 6 weeks of the consolidation phase. The angiogenic (hypoxia-inducible factor-1α (HIF-1α) and vascular endothelial growth factor (VEGF), p < 0.05) and osteogenic (runt-related transcription factor 2 (RUNX2), osteocalcin (OCN) and osteopontin (OPN), p < 0.05) biomarkers were higher expressed in Group LA at 2 and 4 weeks of consolidation phase, whereas decreased at 6 weeks of consolidation phase. Conclusion: The application of AT with low amplitude during the distraction phase can enhance chondrogenesis and bone regeneration by activating the angiogenesis factor pathway and upregulating the expression of osteogenic-related biomarkers such as HIF-1α, VEGF, RUNX2, OCN, and OPN.

Bone Transport Through Induced Membrane Versus Conventional Bone Transport in Management of Infected Long-Bone Defects of Lower Limbs: A Randomized Controlled Trial

OBJECTIVES

To compare bone transport through induced membrane (BTM) and conventional bone transport (BT) regarding docking site union and infection recurrence in the management of infected long-bone defects.

DESIGN

Prospective, randomized, controlled study.

SETTING

Tertiary-level center.

PARTICIPANTS

Thirty patients with infected nonunited long-bone fractures of lower limbs were included.

INTERVENTION

Fifteen patients were treated by BTM in group A, and 15 patients were treated by BT in group B.

OUTCOME MEASUREMENTS

The outcome measures were external fixation time, external fixation index, and docking time. Bone and functional outcomes were evaluated by the Association for the Study and Application of the Method of Ilizarov scoring system. Postoperative complications were evaluated according to the Paley classification.

RESULTS

The mean docking time was significantly lower in the BTM group than in the BT group (3.6 ± 0.82 months vs. 4.8 ± 0.86 months, respectively; P value 0.001). Docking site nonunion and infection recurrence were significantly lower in the BTM group than in the BT group (0% vs. 40%; P value 0.02 and 0% vs. 33.3%; P value 0.04, respectively), with no significant difference in the external fixation index ( P value 0.08).

CONCLUSIONS

This is the first prospective, randomized, controlled study comparing BTM and BT techniques, showing that BTM had significantly faster docking site union, lower incidence of postoperative complications including docking site nonunion and infection recurrence rates, and lower number of additional procedures needed at the expense of 2-staged operation in comparison with BT.

LEVEL OF EVIDENCE

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

Preliminary Outcomes of a Staged Percutaneous Retrograde Prefabricated Gentamicin-coated Intramedullary Nail to Manage Complications after Ankle Fusion through Tibial Bone Transport

Aim

Distal tibial injuries combining bone loss, articular destruction and infection can be treated through distraction osteogenesis combined with ankle fusion. Bone transport is not without complications. This study investigates our preliminary results using a retrograde prefabricated gentamicin-coated nail (ETN PROtect®) to treat complications after infected bone defects of the distal tibial were managed by ankle arthrodesis and distraction osteogenesis.

Materials and methods

This is a retrospective case series study. All consecutive patients with bone transport complications after ankle arthrodesis and distraction osteogenesis who were subsequently operated on using a retrograde ETN PROtect® nail were analysed. The cases occurred between 2017 and 2020. The primary objective was to report on the resolution of the clinical problem and the risk of deep infection after nail implantation.

Results

Five patients have included: two docking site non-unions, two regenerated bone fractures and one hypotrophic regenerated bone. These complications were resolved in all patients (5/5, 100%). A painless, stable and plantigrade ankle arthrodesis was achieved in all cases. No patient developed a local infection or required nail removal (mean follow-up: 35.2 months). The mean LEFS score was 46.8 ± 13.8 and the mean knee ROM was 112 ± 12.7°. All patients tolerated full weight-bearing. All patients were very satisfied with the procedure (mean SAPS score was 93.8 points).

Conclusion

The staged retrograde nailing technique using the ETN PROtect® nail may represent an effective and safe treatment for bone transport complications in high-infection-risk patients. Furthermore, the technique allows simultaneous achievement of ankle arthrodesis. The patients had good functional outcomes and were satisfied with the procedure.

Clinical significance

This strategy of using retrograde gentamicin-coated tibial nails offers a solution to resolve bone transport complications while simultaneously achieving functional ankle arthrodesis.

How to cite this article

Pujol O, Vicente M, Castellanos S, et al. Preliminary Outcomes of a Staged Percutaneous Retrograde Prefabricated Gentamicin-coated Intramedullary Nail to Manage Complications after Ankle Fusion through Tibial Bone Transport. Strategies Trauma Limb Reconstr 2023;18(3):155-162.

Effect of transported segment size on the new bone formation of the rabbit femur in the Ilizarov bone transport method

OBJECTIVE

This study aimed to compare histological and radiological union in the bone transport of 3 segments of different sizes to reconstruct the rabbit femur's bone defects.

METHODS

Thirty rabbits were divided into 3 groups; a 1-cm defect was created in the femur in all rabbits. The length of the segment to be transferred was 10% of the femur length in group 1, 15% in group 2, and 20% in group 3. All defects were reconstructed by applying bone transport. At the end of the consolidation period, the distraction zone was compared radiologically and histologically.

RESULTS

While there was no radiological difference between the groups, the highest histological scores were obtained from group 3. Osteocalcin staining revealed similar involvement in groups 2 and 3, butless involvement in group 1.

CONCLUSION

Evidence from this study has shown that as the size of the segment used for bone transport increases, more stable fixation and better histological union tissue can be obtained in the rabbit femoral defect model.

Surgical debridement in long bone chronic osteomyelitis: is wide tumour-like resection necessary?

Aims

The standard of wide tumour-like resection for chronic osteomyelitis (COM) has been challenged recently by adequate debridement. This paper reviews the evolution of surgical debridement for long bone COM, and presents the outcome of adequate debridement in a tertiary bone infection unit.

Methods

We analyzed the retrospective record review from 2014 to 2020 of patients with long bone COM. All were managed by multidisciplinary infection team (MDT) protocol. Adequate debridement was employed for all cases, and no case of wide resection was included.

Results

A total of 53 patients (54 bones) with median age of 45.5 years (interquartile range 31 to 55) and mean follow-up of 29 months (12 to 59) were included. In all, ten bones were Cierny-Mader type I, 39 were type III, and five were type IV. All patients were treated with single-staged management, except for one (planned two-stage stabilization). Positive microbial cultures grew in 75%. Overall, 46 cases (85%) had resolution of COM after index procedure, and 49 (90.7%) had resolution on last follow-up. Four patients (7%) underwent second surgical procedure and six patients (11%) had complications.

Conclusion

We challenge the need for wide tumour-like resection in all cases of COM. Through detailed preoperative evaluation and planning with MDT approach, adequate debridement and local delivery of high concentration of antibiotic appears to provide comparable outcomes versus radical debridement.

Complications associated with single-level bone transport for the treatment of tibial bone defects caused by fracture-related infection

BACKGROUND

The purpose of this study was to report the outcomes of single-level bone transport with a unilateral external fixator for treatment of proximal, intermediate and distal tibial bone defects caused by fracture-related infection (FRI) and compare their complications.

METHODS

The clinical records and consecutive X-ray photographs of patients with tibial bone defects treated by single-level bone transport using a unilateral external fixator (Orthofix Limb Reconstruction System) were analyzed retrospectively, from January 2012 to December 2018. Patients were divided into the proximal group (P, n = 19), intermediate group (I, n = 25), and distal group (D, n = 18) according to the location of the tibial bone defect. The Association for the Study and Application of the Method of Ilizarov (ASAMI) standard was applied to assess the bone and functional outcomes and postoperative complications evaluated by the Paley classification.

RESULTS

A total of 62 participants were included in this study, with a median age of 36 ± 7.14 years. Sixty patients with tibial bone defects caused by FRI were successfully treated by single-level bone transport using a unilateral external fixator, with a mean bone union time (BUT) of 7.3 ± 1.71 months. According to the ASAMI criteria, there were statistical differences in bone and function results between the three groups (P vs. I vs. D, P < 0.001). The excellent and good rate of bone result in the intermediate group was higher than the other (P vs. I vs. D, 73.6% vs. 84% vs. 66.7%), and the excellent and good rate of function result in the proximal group was the highest (P vs. I vs. D, 84.2% vs. 80% vs. 73.3%). Complications were observed in 29 out of 62 patients (46.7%), with pin tract infection being the most common (14.8%), followed by axial deviation (14.8%), muscle contractures (12.7%), joint stiffness (12.7%), and soft tissue incarceration (12.7%). Other complications included delayed consolidation (12.7%), delayed union (6.3%), nonunion (4.2%), and neurological injury (8.5%). Two patients (3.2%) required below-knee amputation due to uncontrollable infection and previous surgery failure.

CONCLUSIONS

Pin tract infection was the most common complication in tibial bone transport using an external fixator. Complications of distal tibial bone transport are more severe and occur at a higher rate than in other parts. Axial deviation mostly occurred in the intermediate tibial bone transport.

The Use of Ilizarov Method at the Lower Extremity Deformity Management

Objectives

Complications are common in the treatment of lower extremity congenital or acquired deformities by Ilizarov method. The results to be obtained vary in specific patient groups. In this study, deformities who developed before the age of 16 were compared with those developed after this age regardless of the type of aetiology, in terms of results obtained, treatment durations and complications encountered.

Methods

53 bone deformities with an average of 9.5 (7.5-18) years of follow-up treated by the same surgeon were divided into 2 groups according to the age of deformity onset. Demographics and deformity characteristics of patients were defined, treatment times, bone healing indexes, consolidation/correction rates, problems encountered and results obtained were compared retrospectively. The results were compared with ASAMI functional and bone scoring. Complications were rated according to Paley and relative risk increases between groups were calculated.

Results

26 of the patients were men and 22 were women. The average age was 26.47 (7-57). The mean deformity was 23.98° (7-60) and the mean shortness in 39 patients was 38.65 (10-110)mm. Mechanical axis deviation was corrected in 83% of patients. The Lengthening index was 54.13days/cm in the development group and 63.69 days/cm in adults. Consolidation/correction rate was 2.54 in developmental age and 2.4 (p=0.698) in adults. The risk increased by 1.02 times in terms of problems encountered, 2 for obstacles, 3 times in complications and 1.34 times in total difficulties per case, according to Paley. The duration of stay in the fixator was higher in developmental group (p=0.023). ASAMİ functional (p=0.000148) and anatomical (p=0.000242) scores were better in the adult group.

Conclusion

Congenital or acquired deformities in the lower extremity can be treated with satisfactory results by Ilizarov method. The development of deformity at an early age makes treatment difficult. Although the bone healing index is lower in this group of patients, which usually has a higher amount of shortness, the treatment is usually longer than that of adult deformities; complications are more frequent and serious. Functional and anatomical results are more unsuccessful.

Septic Tibial Nonunions on Proximal and Distal Metaphysis-A Systematic Narrative Review

BACKGROUND

Infected nonunion of the tibia represents a challenging complication for orthopedic surgeons and poses a major financial burden to healthcare systems. The situation is even more compounded when the nonunion involves the metaphyseal region of long bones, a rare yet demanding complication due to the poor healing potential of infected cancellous bone; this is in addition to the increased likelihood of contamination of adjacent joints. The purpose of this study was to determine the extent and level of evidence in relation to (1) available treatment options for the management of septic tibial metaphyseal nonunions; (2) success rates and bone healing following treatment application; and (3) functional results after intervention.

METHODS

We searched the MEDLINE, Embase, and CENTRAL databases for prospective and retrospective studies through to 25 January 2021. Human-only studies exploring the efficacy of various treatment options and their results in the setting of septic, quiescent, and metaphyseal (distal or proximal) tibia nonunions in the adult population were included. For infection diagnosis, we accepted definitions provided by the authors of source studies. Of note, clinical heterogeneity rendered data pooling inappropriate.

RESULTS

In terms of the species implicated in septic tibial nonunions, staphylococcus aureus was found to be the most commonly isolated microorganism. Many authors implemented the Ilizarov external fixation device with a mean duration of treatment greater than one year. Exceptional or good bone and functional results were recorded in over 80% of patients, although the literature is scarce and possible losses of the follow-up were not recorded.

CONCLUSION

A demanding orthopedic condition that is scarcely studied is infected metaphyseal tibial nonunion. External fixation seems promising, but further research is needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO No. CRD42020205781.

Treatment of Angular Deformity and Limb Length Discrepancy With a Retrograde Femur Magnetic Intramedullary Nail: A Fixator-assisted, Blocking Screw Technique

BACKGROUND

Fixator-assisted nailing techniques that incorporate magnetic internal lengthening nails (MILNs) permit acute deformity correction and then gradual limb lengthening without needing postoperative external fixators.

PURPOSES

We sought to investigate the safety and accuracy of a fixator-assisted, blocking screw technique using retrograde MILNs for the correction of LLD and limb malalignment.

METHODS

Forty-one patients (13 patients with genu varum and 28 patients with genu valgum) with LLD treated with fixator-assisted, blocking screw retrograde MILN reconstruction were included. Preoperative LLD, mechanical axis deviation, and joint orientation angles were compared with values at the end of treatment, and bone healing indices were calculated. Perioperative complications were tracked.

RESULTS

Preoperatively, the mean mechanical lateral distal femoral angle of the varus cohort was 98 ± 12°, whereas the mean lateral distal femoral angle of the valgus cohort was 82±4°. Both cohorts had an average 3-cm LLD. 99% of the planned limb lengthening was achieved. Final LDFAs were 91 ± 6° and 89 ± 4° in the varus and valgus cohorts, respectively, and the limb mechanical axis angles were normalized. 10 patients underwent a total of 21 returns to the operating room. Most commonly, this involved percutaneous injection of bone marrow aspirate concentrate to bone regenerate exhibiting delayed union (6 patients).

CONCLUSIONS

The use of a retrograde MILN with a fixator-assisted, blocking screw technique is an effective means of acute deformity correction and gradual limb lengthening through minimal incisions. The accuracy of deformity correction relies on intraoperative execution of the appropriate nail start site, osteotomy location, and placement of blocking screws.

Long Bone Defect Filling with Bioactive Degradable 3D-Implant: Experimental Study

Previously, 3D-printed bone grafts made of titanium alloy with bioactive coating has shown great potential for the restoration of bone defects. Implanted into a medullary canal titanium graft with cellular structure demonstrated stimulation of the reparative osteogenesis and successful osseointegration of the graft into a single bone-implant block. The purpose of this study was to investigate osseointegration of a 3D-printed degradable polymeric implant with cellular structure as preclinical testing of a new technique for bone defect restoration. During an experimental study in sheep, a 20 mm-long segmental tibial defect was filled with an original cylindrical implant with cellular structure made of polycaprolactone coated with hydroxyapatite. X-ray radiographs demonstrated reparative bone regeneration from the periosteum lying on the periphery of cylindrical implant to its center in a week after the surgery. Cellular structure of the implant was fully filled with newly-formed bone tissue on the 4th week after the surgery. The bone tissue regeneration from the proximal and distal bone fragments was evident on 3rd week. This provides insight into the use of bioactive degradable implants for the restoration of segmental bone defects. Degradable implant with bioactive coating implanted into a long bone segmental defect provides stimulation of reparative osteogenesis and osseointegration into the single implant-bone block.

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.

Trends and Practices in Limb Lengthening: An 11-year US Database Study

Aim

Over the past couple of decades, limb lengthening has evolved to encompass various implants and techniques. The purpose of this study was to (1) determine trends in the utilisation of various limb lengthening techniques for the femur and tibia in the United States, (2) determine trends in 1-year readmission rate following limb lengthening procedures and (3) to study the relationship of limb lengthening implant used and payment method used with the underlying diagnosis associated with limb shortening.

Materials and methods

Inpatient data were acquired using the Healthcare Cost and Utilisation Project (HCUP) database from 2005 to 2015 from seven states in the United States. Patients with an International Classification of Diseases (ICD)-9 code for limb lengthening of the femur or tibia were included. A total of 2,563 patients were included. Data were analysed using descriptive statistics, and chi-square test was used for comparison of subcategories. Linear regression analysis was used to examine trends over time.

Results

There was a strong linear trend towards increasing proportional use of internal lengthening of the femur from 2011 to 2015 (R2 = 0.99) with an increase of 10.2% per year. A similar trend towards increasing proportional use of internal lengthening of the tibia was seen from 2011 to 2015 (R2 = 0.87) with an increase of 4.9% per year. There was a moderate correlation showing a decrease in readmission rate of 1.07% per year from 2005 to 2015 (R2 = 0.55). Patients with short stature had increased use of internal lengthening and self-payment compared to patients with congenital, post-traumatic or other diagnoses.

Conclusion

There was increasing use of internal lengthening techniques from 2011 to 2015. Patients with short stature had higher use of internal lengthening technique and self-pay for payment method.

Clinical significance

Intramedullary devices have seen increasing use for limb lengthening procedures. Lengthening technique and payment method may differ by underlying diagnosis.

How to cite this article

Mittal A, Allahabadi S, Jayaram R, et al. Trends and Practices in Limb Lengthening: An 11-year US Database Study. Strategies Trauma Limb Reconstr 2023;18(1):21-31.

A comparative study of bone union and nonunion during distraction osteogenesis

BACKGROUND

The clinical characteristics of bone nonunion during distraction osteogenesis (DO) were rarely discussed. This study was employed to specify the difference between bone union and nonunion during DO.

METHODS

The patients with bone lengthening were recruited in our study. The bone union cases indicated the ones that remove the external fixator successfully, whereas the bone nonunion represented the bridging callus did not appear even after 9 months (an absence of bridging callus for at least three out of four cortices on plain radiographs) that needs autogenous bone transplantation. The differences in the pixel value ratio (PVR) growth of regenerated callus, lengthening index (LI), healing index (HI), external fixation index (EFI) and blood biochemical indexes between bone union and nonunion were analyzed.

RESULTS

A total of 8 bone nonunion and 27 bone union subjects were included in this study. The PVR growth in bone nonunion was significantly lower than that in bone union (0.19 ± 0.06 vs. 0.32 ± 0.16, P = 0.048). Interestingly, the HI and EFI in bone nonunion was significantly higher than that in bone union (62.0 ± 31.4 vs. 37.0 ± 27.4, P = 0.036; 75.0 ± 30.9 vs. 49.9 ± 16.1, P = 0.006). However, no significant difference with regard to LI was identified (0.76 ± 0.52 vs. 0.77 ± 0.32, P = 0.976). Moreover, the circulating level of urea and lymphocyte count in bone union was significantly lower than that in bone nonunion (4.31 ± 1.05 vs. 5.17 ± 1.06, P = 0.049; 2.08 ± 0.67 vs. 2.73 ± 0.54, P = 0.018). On the contrary, the circulating level of magnesium in bone union was significantly higher than that in bone nonunion (0.87 ± 0.07 vs. 0.80 ± 0.07, P = 0.014).

CONCLUSION

Compared to the bone union, the PVR growth was significantly lower, whereas the HI and EFI was significantly higher in the bone nonunion. Moreover, the circulating level of urea, magnesium and lymphocyte count was also different between these two. Therefore, the PVR, HI and EFI seems to be reliable and sensitive indicators to reflect the bone nonunion during DO, which might be considered in bone lengthening. Further prospective studies are still needed to elaborate the concerned issues.

Risk factors of transport gap bending deformity in the treatment of critical-size bone defect after bone transport

Background

The purpose of this study was to investigate the risk factors of transport gap bending deformity (TGBD) in the treatment of critical-size bone defect (CSBD) after the removal of the external fixator.

Methods

From January 2008 to December 2019, 178 patients with bone defects of the lower extremity caused by infection were treated by bone transport using a unilateral external fixator in our medical institution. TGBD was defined as the bone callus in the distraction area with a deviation to the force line of the femur (> 10°) or tibia (> 12°) after removal of the external fixator. The Association for the Study and Application of the Method of Ilizarov (ASAMI) standard was applied to assess the bone and functional outcomes. After the data were significant by the T-test or Pearson’s Chi-square test was analyzed, odds ratios were calculated using logistic regression tests to describe factors associated with the diagnosis of TGBD.

Results

A total of 178 patients were enrolled in the study, with a mean follow-up time of 28.6 ± 3.82 months. The positive result of the bacteria isolated test was observed in 144 cases (80.9%). The rate of excellent and good in the bone outcomes (excellent/good/fair/poor/failure, 41/108/15/14/0) was 83.7%, and 92.3% in the functional results (excellent/good/fair/poor/failure, 50/98/16/14/0) according to the ASAMI criteria. TGBD after removal of external fixator occurred in twenty-two patients (12.3%), including 6 tibias, and 16 femurs. Age > 45 years, BMI > 25 kg/m², femoral defect, diabetes, osteoporosis, glucocorticoid intake, duration of infection > 24 months, EFT > 9 months, EFI > 1.8 month/cm were associated significantly with a higher incidence of TGBD in the binary logistic regression analysis (P < 0.05). The incidence more than 50% was found in patients with femoral defect (76.1%), osteoporosis (72.7%), BMI > 25 kg/m² (69.0%), diabetes (59.5%), glucocorticoid intake (54.7%). In the multivariate logistic regression analyses, the following factors were associated independently with TGBD, including age > 45 years, BMI > 25 kg/m², femoral defect, diabetes, and osteoporosis.

Conclusions

Bone transport using a unilateral external fixator was a safe and practical method in the treatment of CSBD caused by infection. The top five risk factors of TGBD included femoral defect, BMI > 25 kg/m², duration of bone infection > 24 months, age > 45 years, and diabetes. Age > 45 years, BMI > 25 kg/m², femoral defect, osteoporosis, and diabetes were the independent risk factors. The higher incidence of TGBD may be associated with more risk factors.

Repair of segmental ulnar bone defect in juvenile caused by osteomyelitis with induced membrane combined with tissue-engineered bone: A case report with 4-year follow-up

Introduction and importance

We used induced membrane combined with tissue-engineered bone (TEB) to repair the 14-cm juvenile ulnar defect formed after osteomyelitis debridement. The TEB was completely transformed into autologous bone after 4-year follow-up.

Case presentation

A 13-year-old male was hospitalized because of right ulna chronic osteomyelitis. After focal debridement, the total length of ular defect was 14 cm. Anti-infective bone cement was filled in the bone defect area. β-Tricalcium phosphate (β-TCP) was used as TEB scaffold. Autologous iliac bone marrow stromal cells (BMSCs) were cultured in vitro and were planted on β-TCP scaffold to form TEB 3 weeks later. 47 months after implantation of TEB, the repaired ulna had continuous and smooth bone cortex, completely ossification of TEB, completely recanalization of medullary cavity. The upper limb function DASH score was 35.

Clinical discussion

Masquelet put forward the concept of “induced membrane” and applied this technique on bone defects treatment formed after debridement of osteomyelitis. β-Tricalcium phosphate (β-TCP) is artificial bone materials commonly used in clinical. In this case, the seed cells used were autologous BMSCs and the culture medium was autologous serum. Cytokines promoting cell growth and differentiation were not used.

Conclusion

The results of this case showed that TEB combined with induced membrane could repair ulna segmental bone defects as long as 14 cm in adolescents. This technique gives one alternative method to repair juvenile bone defects caused by osteomyelities of trauma. More clinical cases are needed to verify the effectiveness of this technique in the next.

•

It's the first report of using induced membrane combined with TEB to repair a 14cm bone defect caused by osteomyelities.

•

In vitro cultured autologous BMSCs implanted in β-TCP scaffold could repair segmental bone defect.

•

BMSCs were cultured with autologous serum without additional cytokines, which is safe and effective.

•

This technique gives one alternative method to treat juvenile bone defects caused by osteomyelitis or trauma.

What Factors Correlate With Length of Stay and Readmission After Limb Lengthening Procedures? A Large-database Study

BACKGROUND

Indications and techniques for limb lengthening procedures have evolved over the past two decades. Although there are several case series reporting on the complications and efficacy of these techniques, limited data are available on length of stay and hospital readmission rates after these procedures.

QUESTIONS/PURPOSES

(1) What is the median length of stay after lower limb lengthening procedures, and is variability in patient demographics, preoperative diagnosis, and surgical technique associated with length of stay? (2) What is the 1-year readmission rate after lower limb lengthening procedures? (3) Is variability in patient demographics, preoperative diagnosis, and surgical technique associated with varying rates of hospital readmission?

METHODS

Patients who underwent femoral or tibial lengthening from 2005 to 2015 in seven states were identified using the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases. These databases include a large, diverse group of patients across a wide range of hospitals and socioeconomic backgrounds with inclusion of patients regardless of payer. Between 2005 and 2015, there were 3979 inpatient admissions that were identified as involving femoral and/or tibial lengthening procedures based on ICD-9 procedure codes; of those, 2% (97 of 3979) of the inpatient admissions were excluded from analysis because they had ICD-9 procedure codes for primary or revision hip or knee arthroplasty, and 10% (394 of 3979) of the inpatient admissions were excluded because they involved repeated admissions of patients with previous hospitalization data within the database. This yielded 3488 patients for analysis. The median (interquartile range) age of patients was 18 years (12 to 41), and 42% (1481 of 3488) of patients were women. A total of 49% (1705 of 3469) of patients were children (younger than 18 years), 19% (675 of 3469) were young adults (18 to 34 years), 24% (817 of 3469) were adults (35 to 59 years), and 8% (272 of 3469) were seniors (60 years and older). Length of stay and rates of readmission at 1 year after the lengthening procedure were calculated. Univariate analysis was performed to examine associations between age, race, payment method, underlying diagnosis, bone lengthened, and lengthening technique with length of stay and readmission rate. Factors found to be significantly associated with the outcome variables (p < 0.05) were further examined with a multivariate analyses.

RESULTS

Included patients had a median (IQR) length of hospital stay of 3 days (2 to 4). Given the poor explanatory power of the multivariate model for length of stay (R 2 = 0.03), no meaningful correlations could be drawn between age, race, underlying diagnosis, lengthening technique, and length of stay. The overall 1-year readmission rate was 35% (1237 of 3488). There were higher readmission rates among adult patients compared with pediatric patients (odds ratio 1.78 [95% confidence interval 1.46 to 2.18]; p < 0.001), patients with government insurance compared with commercial insurance (OR 1.28 [95% CI 1.05 to 1.54]; p = 0.01), and patients undergoing lengthening via external fixation (OR 1.61 [95% CI 1.29 to 2.02]; p < 0.001) or hybrid fixation (OR 1.81 [95% CI 1.38 to 2.37]; p < 0.001) compared with lengthening with internal fixation only.

CONCLUSION

When counseling patients who may be candidates for limb lengthening, providers should inform individual patients and their caretakers on the anticipated length of hospital stay and likelihood of hospital readmission based on our findings. Adult patients, those with government insurance, and patients undergoing hybrid or external fixator limb lengthening procedures should be advised that they are at greater risk for hospital readmission. The relationship of specific patient-related factors (such as severity of deformity or associated comorbidities) and treatment-related variables (such as amount of lengthening, compliance with physical therapy, or surgeon's experience) with clinical outcomes after lower limb lengthening and the burden of care associated with hospital readmission needs further study.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Current Perspectives on the Management of Bone Fragments in Open Tibial Fractures: New Developments and Future Directions

Open tibial fractures may be associated with bone loss at the time of the injury or following surgical debridement of the fracture. This article discusses the various treatment options available and the latest developments surrounding the management of free bone fragments in open tibial fractures.

A meta-analysis of the Masquelet technique and the Ilizarov bone transport method for the treatment of infected bone defects in the lower extremities

Purpose:To compare the clinical outcomes of the Masquelet technique and Ilizarov bone transport method for the treatment of patients with infected bone defects in the lower extremities. Methods: Eligible studies were searched from six databases until 12 April 2021. Data extraction was independently conducted by two investigators, which was followed by a quality assessment. Weighted mean difference (WMD) and 95% confidence interval (CI) were used to analyze continuous variables, while odds ratio (OR) and 95% CI were used to analyze categorical variables. All statistical analyses were conducted using RevMan 5.3 and Stata 12.0. Results: Thirteen articles were included in this meta-analysis. There was a significant difference observed in hospitalization costs (WMD [95% CI] = -1.75 [-2.50, -0.99] thousand US dollar, p < 0.00,001), final union time (WMD [95% CI] = -4.54 [-6.91, -2.17] months, p = 0.0002), time to full weight bearing (WMD [95% CI] = -1.73 [-3.36, -0.10] months, p = 0.04), quality of life (WMD [95% CI] = 7.70 [4.74, 10.67], p < 0.00,001), and the risk of complications (OR [95%CI] = 0.39 [0.19, 0.79], p = 0.009) between the Masquelet and Ilizarov groups. No significant differences in other outcomes were observed between the two groups. Conclusion: Masquelet technique exhibited the advantages in the lower hospitalization cost, shorter final union time, shorter time to full weight bearing, lower rate of complications, and better post-operative quality of life, compared with Ilizarov bone transport method. However, this finding should be confirmed in large-scale clinical samples.

The progress in quantitative evaluation of callus during distraction osteogenesis

The manual monitoring of callus with digital radiography (X-ray) is the primary bone healing evaluation, assessing the number of bridged callus formations. However, this method is subjective and nonquantitative. Recently, several quantitative monitoring methods, which could assess the recovery of the structure and biomechanical properties of the callus at different stages and the process of bone healing, have been extensively investigated. These methods could reflect the bone mineral content (BMC), bone mineral density (BMD), stiffness, callus and bone metabolism at the site of bone lengthening. In this review, we comprehensively summarized the latest techniques for evaluating bone healing during distraction osteogenesis (DO): 1) digital radiography; 2) dual-energy X-ray scanning; 3) ultrasound; 4) quantitative computed tomography; 5) biomechanical evaluation; and 6) biochemical markers. This evidence will provide novel and significant information for evaluating bone healing during DO in the future.

Retrospective clinical outcomes in the definitive treatment of high-energy tibial diaphyseal fractures using hexapod external fixator versus monolateral external fixator

BACKGROUND

External fixation, which can preserve the biomechanical microenvironment of fracture healing, plays an important role in managing the high-energy fractures with poor surrounding soft tissues. The purpose of this study was to determine the differences of clinical outcomes, if any, between hexapod external fixator and monolateral external fixator in the definitive treatment of high-energy tibial diaphyseal fractures.

METHODS

A total of 53 patients with high-energy tibial diaphyseal fractures and definitively treated by the hexapod external fixator (HEF) or monolateral external fixator (MEF) were retrospectively collected and analyzed, from March 2015 to June 2019. There were 31 patients in the HEF treatment, and the other 22 patients were managed by the MEF. The demographic data, surgical duration, external fixation time, final radiological results, complications, and clinical outcomes were documented and analyzed. Difficulties that occurred during the treatment were classified according to Paley. The clinical outcomes were evaluated by the Association for the Study and Application of the Method of Ilizarov criteria (ASAMI) at the last clinical visit.

RESULTS

The mean surgical duration in the HEF group (62.4 ± 8.3 min) was shorter than that in the MEF group (91.4 ± 6.9 min) (P < 0.05). All patients acquired complete bone union finally. Patients in the HEF group (24.2 ± 3.1 weeks) underwent a shorter average external fixation time than that in the MEF group (26.3 ± 3.8 weeks) (P < 0.05). Satisfactory alignment was achieved in all patients without the need for remanipulation. The residual sagittal plane deformities in the HEF group were all less than that in the MEF group (P < 0.05). The complication rate was 35.5% in the HEF group, while 45.5% in the MEF group. There was no statistically significant difference between the two groups in ASAMI scores (P > 0.05).

CONCLUSION

There is no statistically significant difference in finally clinical outcomes between hexapod external fixator and monolateral external fixator in the definitive treatment of high-energy tibial diaphyseal fractures. The hexapod external fixation treatment is a superior effective method, including advantages of stable fixation, less surgical duration, postoperatively satisfactory fracture reduction, and fewer complications.

Induced membrane technique for acute bone loss and nonunion management of the tibia

Objectives:

To report our experience and clinical results of using the Masquelet technique for the treatment of tibial nonunions and acute traumatic tibial bone defects.

Design:

Retrospective study of prospectively collected data (Level IV).

Setting:

Level I trauma center in the UK.

Patients/Participants:

Consecutive patients with tibial nonunions and open fractures associated with bone loss.

Intervention: Two-stage Masquelet Procedure for the tibia.

Main Outcome Measurements:

Clinical and imaging assessment at 6 weeks, 3,6,9,12 months, or until pain-free mobilization and union.

Results:

There were 17 eligible patients, with a mean size of bone defect of 6 cm (range, 4–8 cm) and an 88.2% union rate at a mean of 8 months (range 5–18 months). Mean range of motion was 95 degrees of knee flexion (range 80°–130°). All patients but 2 returned to their previous occupation.

Conclusions:

The Masquelet technique is simple, effective, and has a high rate of success for the management of a variety of situations including acute bone loss or infected nonunions and is associated with a low incidence of complications.

Ilizarov bone transport combined with the Masquelet technique for bone defects of various etiologies (preliminary results)

BACKGROUND

The Ilizarov bone transport (IBT) and the Masquelet induced membrane technique (IMT) have specific merits and shortcomings, but numerous studies have shown their efficacy in the management of extensive long-bone defects of various etiologies, including congenital deficiencies. Combining their strong benefits seems a promising strategy to enhance bone regeneration and reduce the risk of refractures in the management of post-traumatic and congenital defects and nonunion that failed to respond to other treatments.

AIM

To combine IBT and IMT for the management of severe tibial defects and pseudarthrosis, and present preliminary results of this technological solution.

METHODS

Seven adults with post-traumatic tibial defects (subgroup A) and nine children (subgroup B) with congenital pseudarthrosis of the tibia (CPT) were treated with the combination of IMT and IBT after the failure of previous treatments. The mean number of previous surgeries was 2.0 ± 0.2 in subgroup A and 3.3 ± 0.7 in subgroup B. Step 1 included Ilizarov frame placement and spacer introduction into the defect to generate the induced membrane which remained in the interfragmental gap after spacer removal. Step 2 was an osteotomy and bone transport of the fragment through the tunnel in the induced membrane, its compression and docking for consolidation without grafting. The outcomes were retrospectively studied after a mean follow-up of 20.8 ± 2.7 mo in subgroup A and 25.3 ± 2.3 mo in subgroup B.

RESULTS

The "true defect" after resection was 13.3 ± 1.7% in subgroup A and 31.0 ± 3.0% in subgroup B relative to the contralateral limb. Upon completion of treatment, defects were filled by 75.4 ± 10.6% and 34.6 ± 4.2%, respectively. Total duration of external fixation was 397 ± 9.2 and 270.1 ± 16.3 d, including spacer retention time of 42.4 ± 4.5 and 55.8 ± 6.6 d, in subgroups A and B, respectively. Bone infection was not observed. Postoperative complications were several cases of pin-tract infection and regenerate deformity in both subgroups. Ischemic regeneration was observed in two cases of subgroup B. Complications were corrected during the course of treatment. Bone union was achieved in all patients of subgroup A and in seven patients of subgroup B. One non-united CPT case was further treated with the Ilizarov compression method only and achieved union. After a follow-up period of two to three years, refractures occurred in four cases of united CPT.

CONCLUSION

The combination of IMT and IBT provides good outcomes in post-traumatic tibial defects after previous treatment failure but external fixation is longer due to spacer retention. Refractures may occur in severe CPT.

Technical considerations for the management of segmental osseous defects with an internal bone transport nail

INTRODUCTION

Traditionally, distraction osteogenesis has been accomplished with an external fixator. All internal transport utilizing magnetic intramedullary nails is a newer technique for bone reconstruction. The Precice Bone Transport Nail is a new implant that allows for noninvasive transport via a magnetically driven motor.

AREAS COVERED

This report describes the function of the Bone Transport Nail along with the technical considerations on how to successfully manage bone defects with this new technology. Appropriate use of the nail, preoperative planning, intraoperative considerations, and postoperative management are discussed in detail.

EXPERT OPINION

The Precice Bone Transport Nail utilizes the technology of the original Precice nail to provide an all-internal option for reconstruction of intercalary defects. This obviates the need for an additional plate with a standard Precice nail when performing bone transport and allows for a less invasive option that decreases operating room time. It provides a more cosmetic result than external fixation and avoids the risks of pin tract infection. Preoperative planning is essential to appropriate execution of the operative procedure and to perform a successful transport. A thorough understanding of the nail design and limitations are a prerequisite as this implant is significantly different from a standard intramedullary nail.

Evaluation of complications associated with bifocal bone transport as treatment for either proximal, intermediate or distal femoral defects caused by infection: outcome analysis of 76 patients

BACKGROUND

The purpose of this study was to evaluate the outcomes of bifocal bone transport in the treatment of femoral bone defects caused by infections.

METHODS

Clinical and radiographic data of patients with infected femoral nonunion treated by the bifocal bone transport at our hospital were analyzed retrospectively, from January 2008 to December 2019. Depending on the location of bone defects, the patients were divided into three groups (proximal, intermediate, and distal). The Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria was applied to assess the bone and functional outcomes. Postoperative complications of three groups were documented and compared.

RESULTS

Seventy-six cases of infected femoral bone defects (31 cases of proximal, 19 cases of intermediate, and 26 cases of distal) were managed by bifocal bone transport successfully with a mean follow-up time of 30.8 months (range, 23 to 41 months). There were 58 men (76.3%) and 18 women (23.6%), with a mean age of 38.8 years (range, 23 to 60 years). The bone union was received in 76 cases with a mean of 6.9 months (range, 5 to 8 months). Pin tract infection was observed in twenty-nine cases (38.1%), 7 cases (9.2%) of muscle contractures, 3 cases (7.9%) of joint stiffness, 13 cases (17.1%) of axial deviation, 2 cases (2.6%) of delayed union, one case (1.3%) of nonunion, and none (0%) of transport gap re-fracture. One patient (1.3%) was scheduled for knee arthroplasty when bone transport treatment ended.

CONCLUSIONS

Bone transport using an external rail fixator was a practical method to treat the femoral bone defects, since the satisfactory rate of bone union and limb function recovery. Complications of distal femoral bone transport were more severe than the proximal and intermedia, but the rate of complication was the least of the three groups. Soft-tissue-related complications were more likely to occur in the intermediate bone transport.

Cyclic Distraction–Compression Dynamization Technique Enhances the Bone Formation During Distraction Osteogenesis

Background: Interfragmentary movements have benefits in the improvement of bone formation during distraction osteogenesis (DO). Although several clinical studies reported positive outcomes regarding the application of the cyclic distraction–compression (CDC) dynamization technique in cases with poor bone formation during DO, they are mostly anecdotal without a detailed description. The purpose of this study was to investigate the effectiveness and potential mechanism of different amplitudes and rates of the CDC technique on bone regeneration in a rat femur DO model.

Methods: A total of 60 adult male Sprague-Dawley rats underwent right femoral mid-diaphysis transverse osteotomy and were randomly and evenly divided into Control (no manipulation), Group1 (CDC therapy), Group2 (CDC therapy with larger amplitude), and Group3 (CDC therapy with a slower rate) after distraction. The CDC technique was performed during the middle phase of the consolidation period according to different protocols. Animals were sacrificed after 4 and 6 weeks of consolidation. The process of bone formation was monitored by digital radiographs, and the regenerate bone was evaluated by micro-computed tomography (micro-CT), biomechanical test, and histological analysis. The serum contents of hypoxia-inducible factor (HIF)-1α and vascular endothelial growth factor (VEGF) were measured by enzyme-linked immunosorbent assay (ELISA).

Results: Bone regeneration after the CDC technique was improved significantly during DO. The digital radiograph, micro-CT, histomorphological analysis, and biomechanical evaluation showed better effects regarding volume, continuity, and mechanical properties of the regenerate bone in Group2 and Group3 when compared to Group1. The angiogenic and osteogenic markers were more highly expressed in Group2 and Group3 than in Group1 according to the immunohistochemical analysis. As for ELISA, the serum contents of HIF-1α and VEGF were also increased after the CDC technique, especially in Group2 and Group3.

Conclusion: The CDC dynamization technique has benefits on the improvement of bone formation during DO, and the mechanism may be due to tissue hypoxia activating the HIF pathway followed by the augmentation of osteogenic–angiogenic coupling. Better outcomes may be achieved by moderately increasing the amplitude and slowing down the rate of the CDC technique.

Reconstruction of Ipsilateral Femoral and Tibial Bone Defect by 3D Printed Porous Scaffold Without Bone Graft: A Case Report

CASE

This study reported the case of a 42-year-old woman with traumatic ipsilateral critical bone defect of right femur and tibia after a motor accident. Three-dimensional (3D) printed porous titanium scaffolds were innovatively used to reconstruct this challenging situation. The initial stability was safe enough for early exercise and partial weight bearing. The 26-month follow-up showed osseous integration of the prosthesis-bone interface with short-term satisfactory clinical result.

CONCLUSION

The custom-designed 3D-printed porous scaffold has the potential to become an effective option for reconstructing the segmental irregular-shaped bone defect.

An Uncommon Complication of Ankle Varus During Tibial Transport in an Ilizarov Frame: A Case Report

CASE

We treated a 22-year-old man with an infected fracture of the tibia by resection of necrosed bone and bone transport with an Ilizarov device. Four weeks after initiation of transport, an ankle varus deformity from distal migration of the fibula was noticed. A wire that had been incorrectly placed through both the fibula and the transport fragment of the tibia was identified as responsible for this complication. It was changed after an acute reversal of the transport.

CONCLUSION

Errors in the surgical technique during the insertion of Ilizarov wires can result in unusual complications. Attention to details is a must to avoid them.