Compound tibial fractures with bone loss treated by the Ilizarov technique

A comparative evaluation of the time to frame removal for tibia fractures treated with hexapod and Ilizarov circular frames

INTRODUCTION

Traditional Ilizarov and hexapod frames have different biomechanical properties and there is limited literature regarding their effect on time to fracture union or time to frame removal.

METHODS

Tibial fractures managed with a circular frame at a tertiary limb reconstruction referral centre between 2011 and 2018 were retrospectively identified from a prospectively maintained database. They were classified into three treatment groups; Ilizarov style, Taylor Spatial Frame (TSF) and TrueLok Hex (TL-Hex). Data were extracted from electronic patient records and digital radiographs. The primary outcome was time to frame removal, which was seen as an indicator of clinical and radiological fracture union. Odds ratios were calculated with the clinical significance set at 30 days.

RESULTS

274 patients (median age 49 years, 36% female) were included in the analysis. 8.4% Ilizarov, 10.5% TSF and 13.5% TL-Hex frames required further surgery to aid fracture healing (p = 0.38). 30% of patients had open fractures. Median time to removal for Ilizarov, TSF & TL Hex frames was 167, 198 and 185 days respectively. There was a significant difference between Ilizarov and hexapod frames. Both TSF (OR 2.2, p<0.003) and TL-Hex (OR 1.8, p<0.04) had a significantly increased time to removal of 30 days or more compared with Ilizarov frames.The time to frame removal in metaphyseal fractures was significantly shorter for Ilizarov frame fixation than hexapod frames (p = 0.04). Open fractures were significantly more likely to require at least 30 days extra time to removal than closed fractures (OR 3.3, p<0.001). There was no significant difference in the time to frame removal between fracture location, age or sex.

CONCLUSION

Ilizarov frames have demonstrated a reduced time to frame removal in the management of tibial fractures than hexapod frames. Differences in the time to frame removal, an indicator of time to fracture union, may be due to the different mechanical properties of the frame, or early disruption of the fracture haematoma through secondary frame manipulation and fracture reduction, increased proportion of metaphyseal fractures treated with Ilizarov, or patient selection. The healing time was comparable across the tibia. Pooled meta-analyses may be able to further quantify these associations.

Temporary spacer rod and plate technique: a novel intraoperative technical tip for minimizing the docking site malalignment during bone transport for bone loss in Gustilo IIIb open tibial fractures

INTRODUCTION

Distraction osteogenesis is a safe and reliable option for managing bone defects of the tibia following major open fractures. Even though the Limb Reconstruction System (LRS) is a popular option, it may result in malalignment, necessitating an additional procedure to correct the alignment. The objective of the study is to assess the efficacy of a novel surgical technique in minimising malalignment.

METHODS

This was a retrospective cohort study conducted at a level 1 tertiary trauma centre consisting of 35 patients with primary bone loss following open tibia fractures. A uniplanar LRS frame was applied using a combined spacer rod with plate technique. Radiological assessment of docking site characteristics (translation, angulation) and functional assessment using ASAMI score was done.

RESULTS

The mean distraction regenerate length was 8.4 ± 3.45 cm. At the docking site, 18 patients did not have any deformity, 13 had a minor deformity of ≤ 5°, 2 had a moderate deformity of 6°-10° and 2 with a severe deformity > 10°. Circumferential docking was seen in 88.5% (31/35). According to the ASAMI functional scoring, 13 patients had excellent outcomes, 19 had good, one had fair, and two had poor outcomes. Six patients had pin tract infections, three had deep infections, and 17 had a delayed union. Our study had a lower incidence of malalignment compared to similar studies in the literature.

CONCLUSION

The use of this simple and economical intra-operative technique allowed for much higher precision in aligning the fracture ends, thus minimising the docking site malalignment.

LEVEL OF EVIDENCE

III.

LEVEL OF CLINICAL CARE

Level I Tertiary trauma centre.

Plate-Assisted Bone Segment Transport Versus Precice Bone Transport Nail

Management of segmental long bone defects is a complex and challenging undertaking for orthopaedic surgeons. These defects can be encountered in cases of high-energy trauma, tumor resection, or infection, and they are often associated with significant soft tissue injury. Traditional approaches of bone transport rely on external fixation and principles of distraction osteogenesis. Plate-assisted bone segment transport (PABST) using the Precice limb lengthening nail has been adapted for use in bone transport with the use of a plate in an effort to eliminate the need for external fixation and its associated complications. Recently, the arrival of the Precice Bone Transport (PBT) System intramedullary nail eliminates the need for plating and some of the problems encountered in PABST; however, it also introduces some new issues. PABST and the PBT nail have become viable alternatives to bone transport using a frame; however, each has its own unique set of advantages and disadvantages. Although the problems of using external fixation devices are eliminated with these techniques, there is less forgiveness in execution and very little chance of correcting as the transport is underway. The arrival of the PBT nail does not eliminate the need for PABST as seen by the difficulty maintaining alignment in short metaphyseal segments. This review reflects the current state of these methods based on available evidence; however, optimization of the protocol for transport using PABST and the PBT nail will require additional cases and data.

A Novel Treatment of a 65-Year-Old Woman with a Neglected Type IIIB Open Fracture of the Tibia with Inadequate Soft Tissue Coverage and Periosteal Stripping Requiring an Ilizarov Approach to Bone and Soft Tissue Lengthening and Reconstruction: A Case Report and Review of the Literature

BACKGROUND Type IIIB open bone fractures include loss of soft tissue with periosteal stripping and need rapid surgical repair. The Ilizarov method of bone lengthening and reconstruction offers limb salvage as an alternative to amputation. CASE REPORT We report a case of a neglected type IIIB open fracture of the tibia with inadequate soft tissue coverage and periosteal stripping requiring an Ilizarov approach for limb salvage in a 65-year-old woman. Surgical debridement resulted in a large bone deficit of 13 cm. Acute shortening facilitated wound closure, and the remaining skin defect was treated with skin grafting. Bone transport and limb lengthening techniques, in addition to skin expansion and support, were used to restore the length of the tibia. The regenerated bone had to be fused with the talus since the tibial plafond was excised during debridement. The external fixator was removed after 643 days of treatment. An external fixation index of 49.6 d/cm was estimated. Excellent bone and good functional results were obtained according to the criteria of the Association for the Study and Application of the Method of Ilizarov. Skin invagination, bone translocation, and pin tract infection were the major postoperative issues. CONCLUSIONS This case showed that a multidisciplinary approach may be required for the successful management of neglected open fractures of the tibia and that the Ilizarov approach to both bone and soft tissue lengthening and reconstruction should be considered to ensure limb salvage and improve the final cosmetic appearance.

Combined Technique for the Treatment of Infected Nonunions of the Distal Femur With Bone Loss: Short Supracondylar Nail-Augmented Acute Shortening/Lengthening

OBJECTIVE

To evaluate a combined technique for treating distal femoral bone defects after debridement of osteomyelitis, using an external fixator together with a short supracondylar nail.

DESIGN

Retrospective study.

SETTING

Single tertiary referral center.

METHODS

Between 2003 and 2018, 23 patients with a mean age of 37.2 years (26-56) underwent surgery with the same technique to manage postdebridement defects in the distal femur due to osteomyelitis. This involved acute shortening and intramedullary fixation of the defect site, together with relengthening from a proximal osteotomy using simultaneous external fixation. Radiographic union, range of motion of the hip and knee, external fixation time and external fixation index, and limb length discrepancy were assessed.

RESULTS

The mean follow-up was 51 months (18-192). Union was achieved in all patients without recurrence of infection during this follow-up period. The mean knee flexion was 120 degrees, and the mean extension deficit was 5 degrees at final follow-up. The mean limb length discrepancy improved from 5.5 cm (3-7) to 0.5 cm (0-2). The mean external fixation index was 29.2 d/cm (20-50), and the mean external fixation time was 115 days (90-150). Radiographic scores were excellent in 15 cases, good in 6, and fair in 2. Functional scores were excellent in 14 cases, good in 7, and fair in 2.

CONCLUSION

This combined strategy was an effective method for treating distal femoral segmental bone defects after debridement of osteomyelitis, with a high rate of union and acceptable complication rates.

LEVEL OF EVIDENCE

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

Comparison of Clinico-radiological Outcomes of Monolateral Fixator in Infected Non-union of Tibia Based on Bone Gap Quantification

INTRODUCTION

Monolateral rail fixators are more comfortable to the patients and have a lesser learning curve compared to ring fixators. Guidelines are still lacking for rational use of monolateral fixator for bone transport. This retrospective study aimed to analyze and compare the clinico-radiological outcomes of monolateral fixator in infected non union of tibia based on bone gap quantification.

MATERIALS AND METHODS

This retrospective study included 35 patients of post traumatic infected osteocutaneous defects of tibia operated from May 2013 to May 2016. Group I having bone gap of 6 cm or less (n = 20) and group II with > 6 cm bone gap (n = 15). The mean age was 29.56 (range 18-62) years in group I and 29.67 (range 20-65) years in group II. The mean bone gap was 4.62 (2-6 cm) in group I and 7.6 cm (6.5-10 cm) in group II (P < 0.00001, Mann-Whitney test). The results were assessed by Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria.

RESULTS

Union was achieved primarily in 90% (n = 18) cases in group I and 73.34% (n = 11) cases in group II. The bone result was excellent, good, fair/poor in 14, 5, 1 in group I; and in 4, 6, 5 in group II, respectively (P = 0.020, Chi-square test). The functional results were excellent, good, fair/poor in 15, 4, 1 in group I; and 5, 8, 2 in group II, respectively (P = 0.0479, Chi-square test).

CONCLUSION

We recommend use of monolateral fixator in patients with infected diaphyseal non union of tibia with bone gap ≤ 6 cm. Use of monolateral fixator in patients with bone gap > 6 cm is associated with higher incidence of residual problems and complications.

[Application of bone transport with unilateral external fixator combined with locked plate internal fixation in treatment of infected tibial nonunion]

Objective

To summarize the effectiveness of bone transport with unilateral external fixator combined with locked plate internal fixation in treatment of infected tibial nonunion.

Methods

Between January 2010 and December 2014, 23 patients with infected tibial nonunion were treated with bone transport with unilateral external fixator combined with locked plate internal fixation. There were 19 males and 4 females with an average age of 37.8 years (range, 19-54 years). The mean length of the bone defect was 6.5 cm (range, 5.2-8.1 cm). The number of previous operations ranged from 2 to 4 times, with an average of 2.5 times. The time from injury to this treatment was 7-23 months, with an average of 11.8 months. The time of bone transport, time of the external fixation, fracture healing time, external fixation index, healing index, and complication were recorded; and the Association for the Study and Application of the Methods of Ilizarov (ASAMI) bone healing and function scores were used to evaluate the effectiveness.

Results

All patients were followed up 3-6 years with an average of 4.8 years. Wounds and bone defects healed in all patients. No complication such as infection recurrence, nonunion, re-fracture, malunion, iatrogenic nerve paralysis, or stiffness of knee and ankle joints occurred. Five patients had needle infections which were treated by local care and no deep infection occurred. The time of bone transport was 65-120 days (mean, 75.6 days); the time of the external fixation was 75-145 days (mean, 97.8 days); the fracture healing time was 4-17 months (mean, 8.7 months); the external fixation index was 18-28 days/cm (mean, 22.4 days/cm); and the healing index was 31-52 days/cm (mean, 40.2 days/cm). At last follow-up, according to ASAMI criteria, the result of bone healing was excellent in 15 cases and good in 8 cases, and the result of function was excellent in 18 cases and good in 5 cases, all with the excellent and good rate of 100%.

Conclusion

For infected tibial nonunion, bone transport with unilateral external fixator combined with locked plate internal fixation can reduce the time of external fixation and related complications, with a satisfactory effectiveness.

Prevalence and patterns of traumatic bone loss following open long bone fractures at Mulago Hospital

Introduction:

Significant traumatic bone loss in developed countries occurs in a high proportion of open fractures ranging from 11.4% to 40%. However, literature from developing countries such as Uganda scarcely documents the prevalence and patterns of traumatic bone loss. Direct trauma and iatrogenic factors have been associated with traumatic bone loss as possible etiologies.

Objective:

The study was aimed at establishing the prevalence and patterns of traumatic bone loss following open long bone fractures, and identifying factors associated with traumatic bone loss among patients presenting to Mulago Hospital within 24 hours of sustaining the injury up to completion of the initial fracture debridement, reduction, and fixation.

Methodology:

It was a prospective cohort study conducted at Mulago Hospital. A total of 136 open long bone fractures were registered and physically examined for traumatic bone loss. Patients who consented were recruited consecutively to participate in the study. Data on the patients’ sociodemographics and fracture patterns were collected using pretested questionnaires and analyzed using Stata version 12.

Results:

From 123 patients, a total of 136 open long bone fractures were registered. The prevalence of traumatic bone loss following open long bone fractures was 26.5%. Of the 36 open long bone fractures with traumatic bone loss, the more common pattern (61.1%) was significant traumatic bone loss (≥ 2.5 cm long). Commercial motorcycle riders (22.0%) and traders (20.3%) were the most common occupations associated with open long bone fractures. Gunshot injuries were the leading cause of traumatic bone loss in open long bone fractures.

Conclusion:

Our setting has a high prevalence of traumatic bone loss among open long bone fractures with the majority occurring in Gustilo type IIIB injuries of the tibia. The likelihood of traumatic bone loss is higher in open fractures caused by gunshots.

The management of infected nonunion of tibia with a segmental defect using simultaneous fixation with a monorail fixator and a locked plate

Aims

The aims of this study were to establish whether composite fixation (rail-plate) decreases fixator time and related problems in the management of patients with infected nonunion of tibia with a segmental defect, without compromising the anatomical and functional outcomes achieved using the classical Ilizarov technique. We also wished to study the acceptability of this technique using patient-based objective criteria.

Patients and Methods

Between January 2012 and January 2015, 14 consecutive patients were treated for an infected nonunion of the tibia with a gap and were included in the study. During stage one, a radical debridement of bone and soft tissue was undertaken with the introduction of an antibiotic-loaded cement spacer. At the second stage, the tibia was stabilized using a long lateral locked plate and a six-pin monorail fixator on its anteromedial surface. A corticotomy was performed at the appropriate level. During the third stage, i.e. at the end of the distraction phase, the transported fragment was aligned and fixed to the plate with two to four screws. An iliac crest autograft was added to the docking site and the fixator was removed. Functional outcome was assessed using the Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria. Patient-reported outcomes were assessed using the Musculoskeletal Tumor Society (MSTS) score.

Results

The mean age of patients was 38.1 years (sd 12.7). There were 13 men and one woman. The mean size of the defect was 6.4 cm (sd 1.3). the mean follow-up was 33.2 months (24 to 50). The mean external fixator index was 21.2 days/cm (sd 1.5). The complication rate was 0.5 (7/14) per patient. According to the classification of Paley, there were five problems and two obstacles but no true complications. The ASAMI bone score was excellent in all patients. The functional ASAMI scores were excellent in eight and good in six patients. The mean MSTS composite score was 83.9% (sd 7.1), with an MSTS emotional acceptance score of 4.9 (sd 0.5; maximum possible 5).

Conclusion

Composite fixation (rail-plate) decreases fixator time and the associated complications, in the treatment of patients of infected nonunion tibia with a segmental defect. It also provides good anatomical and functional results with high emotional acceptance. Cite this article: Bone Joint J 2018;100-B:1094-9.

Bone transport versus acute shortening for the management of infected tibial non-unions with bone defects

INTRODUCTION

This study compared bone transport to acute shortening/lengthening in a series of infected tibial segmental defects from 3 to 10cm in length.

METHODS

In a retrospective comparative study 42 patients treated for infected tibial non-union with segmental bone loss measuring between 3 and 10cm were included. Group A was treated with bone transport and Group B with acute shortening/lengthening. All patients were treated by Ilizarov methods for gradual correction as bi-focal or tri-focal treatment; the treating surgeon selected either transport or acute shortening based on clinical considerations. The principle outcome measure was the external fixation index (EFI); secondary outcome measures included functional and bone results, and complication rates.

RESULTS

The mean size of the bone defect was 7cm in Group A, and 5.8cm in Group B. The mean time in external fixation in Group A was 12.5 months, and in Group B was 10.1 months. The external fixation index (EFI) measured 1.8 months/cm in Group A and 1.7 months/cm in Group B (P=0.09). Minor complications were 1.2 per patient in the transport group and 0.5 per patient in the acute shortening group (P=0.00002). Major complications were 1.0 per patient in the transport group versus 0.4 per patient in the acute shortening group (P=0.0003). Complications with permanent residual effects (sequelae) were 0.5 per patient in the transport group versus 0.3 per patient in the acute shortening group (P=0.28).

CONCLUSIONS

While both techniques demonstrated excellent results, acute shortening/lengthening demonstrated a lower rate of complications and a slightly better radiographic outcome. Bone grafting of the docking site was often required with both procedures.

LEVEL OF EVIDENCE

Level III; Retrospective comparative study.

Current treatment of infected non-union after intramedullary nailing

Non-union is a devastating consequence of a fracture. Non-unions cause substantial patient morbidity with patients suffering from loss of function of the affected extremity, increased pain, and a substantial decrease in the quality of life. The management is often associated with repeated, unsuccessful operations resulting in prolonged hospital stays, which has social and economic consequences to both the patient and the healthcare system. The rates of non-union following intramedullary (IM) nailing vary according to anatomical location. There is currently no consensus regarding the treatment of infected non-unions following IM nailing, but the most common procedures reported are; exchange IM nail with antibiotic suppression or excision of the non-union, (stabilisation with external fixation or less commonly plate or IM nail) and then reconstruction of the bone defect with distraction osteogenesis or the Masquelet technique. This article explores the general principles of treatment, fixation modalities and proposes a treatment strategy for the management of infected non-unions following intramedullary nailing.

Monofocal bone transport technique for bone defects greater than 5 cm in tibia: our experience in a case series of 24 patients

BACKGROUND

As the tibial bone defect increases in size, the problems in treatment also increase. The treatment may be problematic but different treatment approaches can be used. Among these approaches, distraction osteogenesis is a method an orthopedic surgeon with limited conditions can use although it has a longer treatment period. In our case series, we evaluated current treatment approaches.

METHOD

Retrospective study based on patient records and radiographs. We evaluated our cases with tibial bone defects Type B and greater than 5 cm. Twenty four cases were operated between 1995 and 2013. Clinical follow-up consisted of physical examination, review of radiographs, and Association for the Study of the Method of Ilizarov (ASAMI) scoring system of bone and functional results.

RESULTS

The defects had an average lenght of 7.01 cm (SD:2.88) (range, 5-18). The mean follow-up time from removal of the apparatus to the time of the last clinic visit averaged 74.08 ±24.17 months (range: 39-122). The Ilizarov frame was placed for transport and until bone was solid, average of 275.5 ± 70.6 days (range: 190-437 days). The mean external fixator time (EFT) was 350.91 ± 89.22 days (range: 261-627 days). The mean external fixator index (EFI) was 52 days/cm (range: 34.8-62.8 days/cm). Bone union was obtained in 23/24 (95.8%) patients. Seven patients suffered from stiffness (2 knee, 5 ankle) from which 3 patients developed equinus deformity and required tenoplasty (Achilles tendon lengthening at the time of frame removal. After reaching docking site, 5 patients needed intramedullary nailing to speed up union. Twelve (50%) cases had excellent radiological results, 8 (33%) cases had good, 2 (8%) cases fair and 2 (8%) cases had poor results. Regarding the functional ASAMI scoring system 14 (58%) cases had excellent, 9 (38%) cases had good and one case (4%) had fair result.

CONCLUSION

According to our experience, the Ilizarov bone transport technique remains a reliable method to repair bone defects. However, the treatment time is lengthy with a considerable risk of complications. We found closed intramedullary nailing as an effective and easy solution for cases without pin tract infections to manage the nonunion problem of the docking site and this option should be considered where the surgeon envisages difficulties of healing or the patient has lost patience with the frame. Careful selection of case and patient profile can optimize the outcomes.

Acute Limb Shortening for Major Near and Complete Upper Extremity Amputations with Associated Neurovascular Injury: A Review of the Literature

In the setting a near or complete upper extremity amputations with significant soft tissue loss and neurovascular compromise, upper extremity surgeons are faced with the challenge of limb salvage. There are a multitude of treatment options for managing skeletal and soft tissue injuries including provisional fixation, staged reconstruction, and an acute shortening osteotomy with primary rigid internal fixation. However, many complications are associated with these techniques. Complications of provisional fixation include pin tract infection and loosening, tethering of musculotendinous units, nonunion, and additional surgeries. Staged reconstruction includes a variety of techniques: distraction osteogenesis, bone transport, or vascularized and non-vascularized structural autograft or allograft, but the risks often outweigh the benefits. Risks include nonunion, postoperative vascular complications necessitating reoperation, and the inability to return to the previous level of function at an average of 24 months. Acute shortening osteotomy with internal fixation offers the advantage of a single-stage procedure that provides for decreasing the soft tissue loss, provides a rigid platform to protect the delicate neurovascular repair, and alleviates unwanted tension at the repair sites. This review discusses the literature on the surgical treatment of severe upper extremity trauma with associated neurovascular injury over the past 75 years, and aims to evaluate the indications, surgical techniques, clinical and functional outcomes, and complications associated with acute shortening osteotomy with rigid internal fixation. Although this technique is not without risks, it is well-tolerated in the acute setting with a complication profile comparable to other techniques of fixation while remaining a single procedure.

Outcome of application of primary versus secondary Illizarov's fixator in open tibial shaft fractures

BACKGROUND

The present study aimed to compare outcome of primary and secondary Illizarov's fixator application as a treatment method for type III open tibial fractures in terms of non-union and wound infection.

METHODS

This prospective study was done in a tertiary care center. Forty-eight type III tibial fractures were treated with Illizarov's apparatus between 2008 and 2011. The patients were divided into two groups depending on the treatment protocol, timing of wound closure and Illizarov's application, primary (n=28) and secondary (n=20).

RESULTS

In the primary group, healing was achieved in all 28 patients. The median time to recovery was 24 weeks, and the median number of operations was 3. There were 6 patients with a bone defect. In the secondary group, complete recovery was achieved in 18 out of 20 patients. The median time to recovery was 30 weeks, and the median number of operations 5. There were 9 patients with a bone defect. The median time to recovery and the number of operations were significantly smaller in patients undergoing primary operation. Union was 100% in the primary group and more than 95% in the secondary group. Chronic osteomyelitis persisted in one patient and below amputation was done in one patient in the secondary group.

CONCLUSION

Primary wound closure and Illizarov's fixation required a smaller number of operations and shorter time to recovery than secondary wound closure and Illizarov's fixation, mostly due to a significantly less number of patients with a bone defect in the primary group.

Does Integrated Fixation Provide Benefit in the Reconstruction of Posttraumatic Tibial Bone Defects?

BACKGROUND

Limb salvage in the presence of posttraumatic tibial bone loss can be accomplished using the traditional Ilizarov method of distraction osteogenesis with circular external fixation. Internal fixation placed at the beginning of the consolidation phase, so-called integrated fixation, may allow for earlier removal of the external fixator but introduces concerns about cross-contamination from the additional open procedure and maintenance of bone regenerate stability.

QUESTIONS/PURPOSES

Among patients deemed eligible for integrated fixation, we sought to determine: (1) Does integrated fixation decrease the time in the external fixator? (2) Is there a difference in the rate of complications between the two groups? (3) Are there differences in functional and radiographic results between integrated fixation and the traditional Ilizarov approach of external fixation alone?

METHODS

Between January 2006 and December 2012, we treated 58 patients (58 tibiae) with posttraumatic tibial bone loss using the Ilizarov method. Of those, 30 patients (52%) were treated with the "classic technique" (external fixator alone) and 28 (48%) were treated with the "integrated technique" (a combination of an external fixator and plating or insertion of an intramedullary nail). During that period, the general indications for use of the integrated technique were closed physes, no active infection, and a healed soft tissue envelope located at the intended internal fixation site; the remainder of the patients were treated with the classic technique. Followup on 30 (100%) and 28 (100%) patients in the classic and integrated techniques, respectively, was achieved at a minimum of 1 year (mean, 3 years; range, 1-8 years). Adverse events were reported as problems, obstacles, and complications according to the publication by Paley. Problems and obstacles are managed by nonoperative and operative means, respectively; in addition, they resolve completely with treatment. Complications, according to the Paley classification, result in permanent sequelae. Functional and radiographic results were reported using the Association for the Study and Application of Methods of Ilizarov scoring system.

RESULTS

Overall, there was a mean of four (range, 2-5) surgical procedures to complete the tibial reconstruction with a similar incidence of unplanned surgical procedures (obstacles) between the two groups (p = 0.87). Patients treated with integrated fixation spent less time in the external fixator, 7 months (range, 5-20 months) versus 11 months (range, 1-15 months; p < 0.001). There were seven problems, 15 obstacles, and zero complications in the classic group. Ten problems, 15 obstacles, and one complication occurred in the integrated fixation group. There was no difference in the severity (p = 0.87) or number (p = 0.40) of complications between both groups. Good to excellent Association for the Study and Application of Methods of Ilizarov function and bone scores were obtained in 100% and 98% of patients, respectively.

CONCLUSIONS

The integrated fixation method allows for a more efficient limb salvage surgical reconstruction in patients carefully selected for that approach, whereas the frequency of adverse events and ability to restore limb lengths was not different between the groups with the numbers available. Careful placement of external fixation pins is critical to decrease cross-contamination with planned internal fixation constructs. In this study of posttraumatic tibial bone defect reconstruction, good/excellent results were found in all patients after a mean of four surgical procedures; however, a larger multicenter prospective study would allow for more robust and generalizable conclusions.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Management of high-energy tibial pilon fractures

Tibial pilon fractures result from high-energy trauma unlike usual ankle fractures. Their management provides numerous challenges to the orthopaedic surgeon including obtaining anatomic reduction of articular surface and the management of associated soft tissue injuries. This article aims to review major advances and principles that guide our practice today. We also discuss a treatment algorithm based on a staged approach to the fracture: initial spanning external fixation followed by definitive fixation.

Segmental bone loss in pediatric lower extremity fractures: indications and results of bone transport

BACKGROUND

In this study, we evaluated the results of external bone transport, which was applied to 11 patients with traumatic bone loss who had not completed their bone development.

METHODS

The average age of the 9 male and 2 female patients was 10.6 (range, 8 to 16) years. Eight of the defects were located in the tibia, whereas the other 3 were in the femur. The average defect was 5.4 (range, 4.5 to 8.5) cm. External bone transport was applied in the early period in 7 patients, whereas in 4 patients it was performed due to nonunion. Bifocal osteosynthesis and single osteotomy were performed in 2 patients with type B2 nonunion. Compression to the nonunion region and lengthening in the osteotomy region were applied. In 2 patients with type B1 nonunion, and the other 9 patients who had external bone transport, the gap was eliminated by bifocal osteosynthesis, single osteotomy, and bone transport to the osteotomy line.

RESULTS

The mean follow-up period was 21 (range, 13 to 48) months. Complete union was achieved in all patients without any bone operation or graft application. No refracture was observed after the removal of the external fixator, and the average hospitalization time was 16 (range, 7 to 65) days. The average external fixation time was 4.2 (range, 3.5 to 5.5) months, and the mean external fixator index was 0.8 months (23 d/cm). The mean bone healing time was 5.1 (range, 4.6 to 6) months.

CONCLUSIONS

To initially consider the open fractures with true or in situ bone loss in children as "anticipated nonunion," and determine the treatment strategies regarding this fact, may prevent nonunion and shorten the healing period. Bone transport in the treatment of traumatic bone defects in children is an easy biological procedure, with lower complications but higher success ratios.

LEVEL OF EVIDENCE

Level IV-therapeutic.

Management of Composite Tissue Defect of the Midfoot With a Free Anterolateral Thigh Flap and Iliac Bone Graft: A Case Report

Composite tissue defects of the midfoot with extensive bone and soft tissue loss represent a unique challenge because they can lead to primary amputation if not reconstructed. One should repair both the bone structure and the soft tissue to obtain satisfactory foot function for basic daily activities. In the present study, we report on a case in which we successfully reconstructed an extensive midfoot defect with iliac bone grafts for metatarsal reconstruction and an anterolateral thigh flap for soft tissue coverage. This technique is a safe, reliable, and functional method, offering single-stage reconstruction compared with other microsurgical techniques used for such defects.

Treatment of an open distal tibia fracture with segmental bone loss in combination with a closed proximal tibia fracture: a case report

The treatment of open distal tibia fractures remains challenging, particularly when the fracture is infected and involves segmental bone loss. We report the case of a 38-year-old man who sustained an open distal tibiofibular fracture with segmental bone loss and a closed proximal tibial fracture. The fractures were initially fixed with a temporary external fixator. The open distal tibial fracture was infected, and the skin was covered after the wound became culture negative. The tibia was then internally transported with a ring external fixator; the closed fracture of the proximal tibia served as the corticotomy for internal transport without conventional corticotomy. After 5 cm internal transport, the docking site of the distal tibia was fixed with a locking plate and autogenous cancellous bone graft. Bone graft was also used to the distal tibiofibular space to achieve distal tibiofibular synostosis. We describe one treatment option for an infected open fracture of the distal tibia with segmental bone loss that is accompanied by a closed fracture of the proximal tibia. This method can treat two fractures simultaneously.

Inter-tibiofibular graft for traumatic segmental bone defect of the tibia

INTRODUCTION

The present study sought to assess the interest of inter-tibiofibular graft (ITFG), alternatively called posterolateral bone graft, in traumatic segmental tibial bone defect.

MATERIAL AND METHODS

Twenty-eight ITFGs were performed in 125 tibial reconstructions for traumatic bone defect. Patient's records were reviewed retrospectively in a multicenter study. Tibial reconstruction with and without ITFG was compared for bone healing and patient's return to full weight-bearing status.

RESULTS

There were no failures of bone healing in the ITFG group, versus 14 (14%) in the non-ITFG group. Graft-to-consolidation delays were shorter with first-line ITFG, at a mean 10 months (range, 3-20 months) versus 16.5 months (range, 3-63 months) in the non-ITFG group (P<0.05). Weight-bearing was likewise more quickly resumed, with full weight-bearing at a mean 9 months (range, 3-19 months) versus 15 months (range, 1-34 moths) respectively (P<0.05). Return to work was also quicker, at a mean 15 months (range, 4-28 months) versus 27 months (range, 8-56 months) respectively (P<0.05).

DISCUSSION

This study confirmed the interest of ITFG in tibial bone defect reconstruction. ITFG may singly be used for small defects less than 4 cm, or in conjunction with another tibial reconstruction technique; ITFG in the present series achieved consolidation in all cases and significantly shortened the times to return to full weight-bearing status and to work.

LEVEL OF EVIDENCE

III: retrospective case-control study.

Bone transport techniques in posttraumatic bone defects

INTRODUCTION

The treatment of posttraumatic diaphyseal bone defects (BD) calls on a number of techniques including bone transport techniques: isolated shortening, compression-distraction at the fracture site, shortening followed by lengthening in a corticotomy distant from the site and segmental bone transport.

PATIENTS AND METHODS

The multicenter retrospective study combined 38 cases: 22 cases of initial diaphyseal bone defect and 16 cases of secondary diaphyseal BD, sometimes associated with metaphyseal or metaphyseal-epiphyseal BD, involving the humerus, the forearm, the femur and the tibia. These techniques were mainly used on the lower extremity (33 cases), for the most part on the tibia (22 cases) in young men.

RESULTS

Bone healing was acquired in 37 cases out of 38 after a mean 14.9 months (range, 6-62 months). A mean 4.3 secondary interventions were required to obtain final union; most notably, a bone graft was necessary at the docking site for the segmental bone transport procedures.

DISCUSSION

Many reconstruction techniques can be proposed to treat posttraumatic BD. None responds to all situations. Bone transport techniques have their place and their indications. Isolated shortening is intended for bone loss not exceeding 3cm, notably in the humerus and to a lesser degree in the lower extremity. Shortening associated with lengthening is valuable in the femur and the tibia for bone loss up to 6cm. Segmental bone transport is the only technique that can treat bone defects associated with shortening in the lower limb. For substantial bone loss beyond 10cm, segmental bone transport is particularly indicated. However, these cases of substantial bone loss tend to be resolved by a hybridization of the procedures. The distraction gap of a bone segment can, for example, be prepared using an induced-membrane technique.

LEVEL OF EVIDENCE

Level IV. Retrospective study.

Surgical membranes as directional delivery devices to generate tissue: testing in an ovine critical sized defect model

Purpose

Pluripotent cells residing in the periosteum, a bi-layered membrane enveloping all bones, exhibit a remarkable regenerative capacity to fill in critical sized defects of the ovine femur within two weeks of treatment. Harnessing the regenerative power of the periosteum appears to be limited only by the amount of healthy periosteum available. Here we use a substitute periosteum, a delivery device cum implant, to test the hypothesis that directional delivery of endogenous periosteal factors enhances bone defect healing.

Methods

Newly adapted surgical protocols were used to create critical sized, middiaphyseal femur defects in four groups of five skeletally mature Swiss alpine sheep. Each group was treated using a periosteum substitute for the controlled addition of periosteal factors including the presence of collagen in the periosteum (Group 1), periosteum derived cells (Group 2), and autogenic periosteal strips (Group 3). Control group animals were treated with an isotropic elastomer membrane alone. We hypothesized that periosteal substitute membranes incorporating the most periosteal factors would show superior defect infilling compared to substitute membranes integrating fewer factors (i.e. Group 3>Group 2>Group 1>Control).

Results

Based on micro-computed tomography data, bone defects enveloped by substitute periosteum enabling directional delivery of periosteal factors exhibit superior bony bridging compared to those sheathed with isotropic membrane controls (Group 3>Group 2>Group 1, Control). Quantitative histological analysis shows significantly increased de novo tissue generation with delivery of periosteal factors, compared to the substitute periosteum containing a collagen membrane alone (Group 1) as well as compared to the isotropic control membrane. Greatest tissue generation and maximal defect bridging was observed when autologous periosteal transplant strips were included in the periosteum substitute.

Conclusion

Periosteum-derived cells as well as other factors intrinsic to periosteum play a key role for infilling of critical sized defects.

The use of Papineau technique for the treatment of diabetic and non-diabetic lower extremity pseudoarthrosis and chronic osteomyelitis

The treatment of 31 consecutive adult patients, ages 25–67 years with chronic draining osteomyelitis (12 cases) or infected pseudarthrosis (19 cases) by the Papineau technique was retrospectively reviewed. The initial injury was an open fracture in 24 patients and a closed fracture in 7 patients. In all cases an Ilizarov circular external fixation device was used for the stabilization of the fracture or for bone lengthening. Mean follow-up for the group was 20 months (range, 10 months to 5 years) and there was successful limb salvage in all cases with eradication of infection and bone consolidation was achieved. The Ilizarov circular external fixation was removed at a mean of 18 weeks (range, 14–24 weeks). The mean time to bone union was 5 months (range, 4–10 months). All patients returned to their pre-treatment activity levels or better.

Vascularized fibular graft in infected tibial bone loss

BACKGROUND

The treatment options of bone loss with infections include bone transport with external fixators, vascularized bone grafts, non-vascularized autogenous grafts and vascularized allografts. The research hypothesis was that the graft length and intact ipsilateral fibula influenced hypertrophy and stress fracture. We retrospectively studied the graft hypertrophy in 15 patients, in whom vascularized fibular graft was done for post-traumatic tibial defects with infection.

MATERIALS AND METHODS

15 male patients with mean age 33.7 years (range 18 - 56 years) of post traumatic tibial bone loss were analysed. The mean bony defect was 14.5 cm (range 6.5 - 20 cm). The mean length of the graft was 16.7 cm (range 11.5 - 21 cm). The osteoseptocutaneous flap (bone flap with attached overlying skin flap) from the contralateral side was used in all patients except one. The graft was fixed to the recipient bone at both ends by one or two AO cortical screws, supplemented by a monolateral external fixator. A standard postoperative protocol was followed in all patients. The hypertrophy percentage of the vascularized fibular graft was calculated by a modification of the formula described by El-Gammal. The followup period averaged 46.5 months (range 24 - 164 months). The Pearson correlation coefficient (r) was worked out, to find the relationship between graft length and hypertrophy. The t-test was performed to find out if there was any significant difference in the graft length of those who had a stress fracture and those who did not and to find out whether there was any significant difference in hypertrophy with and without ipsilateral fibula union. The Chi square test was performed to identify whether there was any association between the stress fracture and the fibula union. Given the small sample size we have not used any statistical analysis to determine the relation between the percentage of the graft hypertrophy and stress fracture.

RESULTS

Graft union occurred in all patients in a mean time of 3.3 months, at both ends. At a minimum followup of 24 months the mean hypertrophy noted was 63.6% (30 - 136%) in the vascularized fibular graft. Ten stress fractures occurred in seven patients. The mean duration of the occurrence of a stress fracture in the graft was 11.1 months (2.5 - 18 months) postoperatively. The highest incidence of stress fractures was when the graft hypertrophy was less than 20%. The incidence of stress fractures reduced significantly after the graft hypertrophy exceeded 20%.

CONCLUSION

In most cases hypertrophy of the vascularized fibular graft occurs in response to mechanical loading by protected weight bearing, and the amount of hypertrophy is variable. The presence or absence of an intact fibula has no bearing on the hypertrophy or incidence of stress fracture. The length of the fibular graft has no bearing on the hypertrophy or stress fracture.

The treatment of open femoral fractures with bone loss

The results of the treatment of 31 open femoral fractures (29 patients) with significant bone loss in a single trauma unit were reviewed. A protocol of early soft-tissue and bony debridement was followed by skeletal stabilisation using a locked intramedullary nail or a dynamic condylar plate for diaphyseal and metaphyseal fractures respectively. Soft-tissue closure was obtained within 48 hours then followed, if required, by elective bone grafting with or without exchange nailing. The mean time to union was 51 weeks (20 to 156). The time to union and functional outcome were largely dependent upon the location and extent of the bone loss. It was achieved more rapidly in fractures with wedge defects than in those with segmental bone loss. Fractures with metaphyseal defects healed more rapidly than those of comparable size in the diaphysis. Complications were more common in fractures with greater bone loss, and included stiffness of the knee, malunion and limb-length discrepancy. Based on our findings, we have produced an algorithm for the treatment of these injuries. We conclude that satisfactory results can be achieved in most femoral fractures with bone loss using initial debridement and skeletal stabilisation to maintain length, with further procedures as required.

Combined distraction osteogenesis and Papineau technique for an open fracture management of the distal lower extremity

Despite modern surgical techniques and advanced antimicrobial therapy, open lower-extremity fracture management and osteomyelitis remain a challenge for reconstructive surgeons. Posttraumatic composite bone and soft tissue defects are usually the result of high-energy trauma and are often associated with concomitant injuries, therefore making complex reconstruction more difficult. This article presents a case report of an open distal tibial fracture managed by a simultaneous distraction osteogenesis and Papineau technique with a long term follow-up and literature review.

Role of early Ilizarov ring fixator in the definitive management of type II, IIIA and IIIB open tibial shaft fractures

We evaluated the results of patients with Gustilo types II, IIIA and IIIB open tibial fractures managed early with the Ilizarov external fixator (IEF). Sixty patients (51 males, nine females; age range 20-62 years; mean age 32.8 years) with type II (11 patients), type IIIA (13) and type IIIB (36) tibial diaphyseal fractures underwent emergency debridement and minimal bone fixation (with external fixator), followed by definite fixation with the IEF after three to five days. Average duration of the hospital stay was 8.6 days. All fractures united with an average union time of 21.1 weeks (standard deviation [SD] 3.18) in type II, 21.7 weeks (SD 3.57) in IIIA and 24. 9 weeks (SD 5.14) in IIIB fractures. The difference between union time in type II and IIIA was not significant (p > 0.05), but that between IIIA (and also type II) and IIIB was significant (p < 0.05). The healing index in patients who underwent lengthening was 1.5 months/cm. The wounds in 27 patients were managed by delayed primary closure, in 19 patients with second intent (all IIIB), in 11 patients with skin grafting (mostly type IIIB fractures) and in three patients with musculocutaneous flaps. The most common complications of the procedure were pin tract infection and pain at the fracture site. Most of the patients were able to achieve good knee and ankle range of motion. Early application of the Ilizarov fixator constitutes an excellent management of open tibial fractures, especially types II, IIIA and IIIB, due to good functional and radiological results. Despite the technical difficulties and some complications (which are mostly minor) IEF may be the preferred method in open tibial fractures, especially types II and III.

Tibial segmental bone defect reconstruction by Ilizarov type bone transport in an induced membrane

The management of combined loss of skin coverage and bone substance in the lower third of the leg is problematic. A recommended sequential strategy associates removal of infected tissue and coverage followed by treatment of the bone defect. We report a technique without microsurgery, using Masquelet's induced membrane technique to manage the bone loss, associated to bone transport and coverage by a fasciocutaneous flap with distal pedicle. In a patient presenting with a 10 cm defect with bone exposure, this 2-step procedure allowed consolidation at 7 months without functional sequelae; the fixator was kept in place for 9 months. Neither microsurgery nor cancellous bone graft was required. Using a spacer to induce a membrane facilitated bone transport and distal consolidation.

Treatment of large segmental bone defects with reamer-irrigator-aspirator bone graft: technique and case series

Treatment of large segmental defects using conventional autogenous iliac crest bone graft can be limited by volume of cancellous bone and donor site morbidity. The reamer-irrigator-aspirator (RIA) technique allows access to a large volume of cancellous bone graft containing growth factors with potency equal to or greater than autograft material from the iliac crest. The purpose of this study was to evaluate the effectiveness of RIA-harvested autogenous bone graft for treating large segmental defects of long bones.

Salvage of a lower extremity by microsurgical transfer of tibial bone from the contralateral extremity traumatically amputated at the ankle level

The authors present a case of free vascularized transfer of the tibial bone as an osteomyocutaneous flap based on the posterior tibial vessels. A 42-year-old man presented with severe crush injury to bilateral legs. The left tibial bone and soft tissue defect required reconstruction with an osteomyocutaneous free flap. Since the contralateral leg was traumatically amputated at the level of the ankle, a decision was made to harvest a free tibial osteomyocutaneous flap with below-knee-amputation completed. The transfer was achieved successfully with complete survival of the flap and bony union. This report describes the technical and healing aspects of such a unique transfer which may rarely be indicated.

Taylor Spatial Frame application with the aid of a fine wire half frame

The Taylor Spatial Frame has become an important part of the trauma and reconstruction surgeon's armamentarium. We describe a technique to assist in the application of this device that does not hinder the use of the image intensifier or rely on an assistant to hold a constant position and aids provisional fracture reduction.

Taylor spatial frame in the treatment of open tibial shaft fractures

BACKGROUND

The Taylor spatial frame (TSF) is a modern multiplanar external fixator that combines the ease of application and computer accuracy in the reduction of fractures. A retrospective review of our prospective TSF database for the use of this device for treating open tibial fractures in pediatric, adolescent, and adult patients was carried out to determine the effectiveness and complications of TSF in the treatment of these fractures.

MATERIALS AND METHODS

Nineteen male patients with open tibial fractures were included. Of these fractures, 10 were Gustilo Type II, five were Gustilo Type IIIA (two had delayed primary closure and three had split thickness skin grafting), and four were Gustilo Type IIIB (all had rotational flaps). Twelve of our patients presented immediately to the emergency room, and the remaining seven cases presented at a mean of 3 months (range, 2.2-4.5 months) after the initial injury. The fractures were located in proximal third (n=1), proximal/middle junction (n=2), middle third (n=3), middle/distal junction (n=8), distal third (n=3), and segmental fractures (n=2). Patients were of an average age of 26 years (range, 6-45years). Mean duration of follow-up was 3.5 years.

RESULTS

All fractures healed over a mean of 25 weeks (range, 9-46 weeks). All were able to participate in the activities of daily living without any difficulty and most were involved in sports during the last follow-up. Postoperative complications included pin tract infection in 12 patients.

CONCLUSION

The TSF is an effective definitive method of open tibial fracture care with the advantage of early mobilization, ease of soft tissue management through gradual fracture reduction, and the ability to postoperatively manipulate the fracture into excellent alignment.

Appraisal of the role of external skeletal fixation in the management of sequelae of open tibial fractures

BACKGROUND

Severe open tibial fractures are more apt to be followed by complications even with the universally accepted lines of treatment. The present study investigated the role of external skeletal fixation, based on Ilizarov techniques, in the management of the sequelae of open tibial fractures with modifications to meet the requirements of each case.

MATERIALS AND METHODS

We reviewed the results of treatment of 148 cases of late presentation with complicated open tibial fractures. Their ages ranged from 12 to 74 years (average, 34 years). Active infection was present in 40 cases. We performed acute shortening and relengthening in 60 cases; excision of nonunion, acute deformity correction, and lengthening for nonunion with deformity in 30 cases; segmental excision and bone transport in 20 cases; gradual deformity correction after osteotomy in 15 cases; and distraction and gradual deformity correction for hypertrophic nonunion with deformity in 23 cases. Ilizarov external fixator was used in 96 (65%) cases, and monolateral fixator was used in 52 (35%) cases. The mean follow-up was 35 months (range 24 to 118 months).

RESULTS

Fracture union was achieved in all cases (100%). Evaluation of results were based on both objective (clinical and radiological) and subjective criteria and patients' satisfaction. The results were satisfactory in 139 cases (94%) and unsatisfactory in nine (6%) cases because of residual leg length discrepancy, joint stiffness, and persistent pain.

CONCLUSIONS

The use of external fixation, based on Ilizarov techniques, is invaluable in the management of difficult open tibia fractures. However, the technique should be tailored to the requirements of each case. The functional outcome is predetermined by the soft tissue status before treatment.

Traumatic segmental bone loss in a pediatric patient treated with bifocal bone transport

Bone transport is a method of distraction osteogenesis that allows the creation of regenerate bone using a dynamic external fixator. We report on the use of bifocal bone transport to treat a skeletally immature patient with 15 cm of post-traumatic segmental bone loss from the distal tibia.

Acute compression and lengthening by the Ilizarov technique for infected nonunion of the tibia with large bone defects

PURPOSE

To assess the Ilizarov technique in treating large infected tibial defects by resection of the infected focus, its acute compression, and gradual distant site lengthening.

METHODS

27 men (mean age, 39 years) with infected nonunion and large bone defects of the tibia underwent complete resection of the nonunion site, debridement, sequestrectomy, lavage, and Ilizarov ring fixator application. Patients underwent acute compression of the defect site, followed by distant site metaphyseal corticotomy for simultaneous lengthening. The mean length of resection was 10 (range, 6-17) cm. The mean follow-up was 27 (range, 25-39) months.

RESULTS

The mean lengthening achieved was 10 cm, mean union time 6.3 months, and mean duration of consolidation 10.2 months. Functional results were excellent in 19 patients and good in 5. The union time was longer in older patients.

CONCLUSION

Acute compression and simultaneous lengthening can be used safely for treatment of large bone defects in the tibia. This avoids secondary operations at the docking site and reduces the duration of treatment.

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

OBJECTIVES

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

DESIGN

Retrospective study.

SETTING

Level I trauma centers at 4 academic university medical centers.

PATIENTS/PARTICIPANTS

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

INTERVENTION

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

MAIN OUTCOME MEASUREMENTS

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

RESULTS

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

CONCLUSIONS

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

The thoracodorsal artery perforator flap with a vascularized scapular segment for reconstruction of a composite lower extremity defect

High-energy trauma resulting in a composite defect of the lower extremity confronts the microvascular surgeon with more difficulties than do free flap reconstruction elsewhere in the body, since the choice of distant recipient vessels is particularly difficult. Combining principles of perforator flap surgery with those of composite tissue transfer, we designed a thoracodorsal artery perforator flap with a vascularized bone segment from the scapula for reconstruction of a composite lower extremity defect in a patient following a paragliding accident. This is the first report on the application of a composite thoracodorsal artery perforator flap with vascularized scapula in lower extremity reconstruction. Among its multiple advantages, such as preservation of latissimus dorsi function, it is a good tool for one-stage reconstruction of traumatic composite lower extremity defects because its low donor site morbidity and long vascular pedicle enables anastomosis placement outside the zone of injury.

Preliminary results of tibial bone transports with pulsed low intensity ultrasound (Exogen)

OBJECTIVE

This study assessed whether the use of noninvasive, pulsed low intensity ultrasound (Exogen) reduced external fixation time for bone transport patients with large, segmental tibial defects.

DESIGN

This was a prospective study compared to a previously treated control group.

SETTING

All surgeries and postoperative care were done at the senior author's hospital facilities.

PATIENTS/PARTICIPANTS

Eight patients with large tibial segmental defects, acute or chronic, were studied. All patients were male, mean age 34 years (range 18-50).

INTERVENTION

All patients were treated with a single-level bone transport. Bone transports started 5 to 10 days after a metaphyseal corticotomy and progressed with one-quarter millimeter advancement 2 to 4 times per day. Exogen was applied to the regenerate site in the second postoperative week and to the docking site after docking was complete. The treatment was used for 20 minutes daily at each site. The patients were followed weekly for the first 4 weeks. They were then followed bimonthly for 2 months and then monthly until consolidation had occurred.

MAIN OUTCOME MEASURES

The 2 main outcome measures used were the external fixation time measured in months and the external fixation index (time in the frame per cm of bone transported) measured in months per cm.

RESULTS

The mean follow-up from frame removal to the time of the last clinic visit was 12.4 months (range 4-32). The mean external fixation time was 13.91. The mean external fixation index was 1.34 months per cm transported for the Exogen group and 2.02 months per cm for the control group. Although not statistically significant because of small numbers, the external fixation index was reduced by 17.21%.

CONCLUSION

These data further confirm already published data on the acceleration of fracture healing by low intensity pulsed ultrasound and, in our case, regenerate consolidation. Shorter treatment periods reduce complications and expenses and return patients back to regular activities more quickly.

Bone transport in the management of posttraumatic bone defects in the lower extremity

BACKGROUND

The aim of this study was to evaluate the clinical and functional outcomes of traumatic bone defects of the lower extremity managed by internal bone transport using the Ilizarov technique.

METHODS

We retrospectively reviewed 19 patients who underwent internal bone transport for traumatic bone defects in the lower extremity. Mean follow-up was 68.7 months (5.7 years). Eighteen cases were open: grade IIIA, 10 cases; grade IIIB, 4 cases; and grade IIIC, 4 cases.

RESULTS

Clinical outcome was 2 excellent, 11 good, 4 fair, and 2 poor. Eighteen of 19 patients reported being satisfied. The results of the SF-36 Health Survey showed a significant difference between the population norm and the mean of the study group in Physical Functioning, Bodily Pain, and Role-Emotional. The mean length of time in external fixation for all patients was 13.8 months. The mean length of regenerate was 5.7 cm (range, 0.8-20.4 cm). The total number of complications was 39 (20 minor and 19 major). Major complications included two transtibial amputations and four fractures at the docking site.

CONCLUSION

Although the number of complications was high, the patients in this study were satisfied to have their limbs preserved. The SF-36 Health Survey showed that patients suffer mainly from physical and emotional consequences after these major injuries. Their general, social, and mental health is usually not affected. Infection significantly increased the healing index. The limb should be protected for a long time, with careful evaluation to avoid fracture at the docking site after fixator removal.

Bifocal compression-distraction in the acute treatment of grade III open tibia fractures with bone and soft-tissue loss: a report of 24 cases

OBJECTIVE

To evaluate the results of bifocal compression-distraction method for the acute treatment of open tibia fractures with bone and soft-tissue loss.

DESIGN

Patients were selected for bifocal compression-distraction (shortening and lengthening) who had open tibia fractures with bone and soft-tissue loss and a Mangled Extremity Severe Score of 6 and below indicating good leg viability.

PATIENTS

Bifocal compression-distraction osteogenesis using the Ilizarov type circular external fixator was applied to 24 patients with 14 grade IIIA and 10 grade IIIB open tibia fractures with bone and soft-tissue loss. Mean age of the patients was 30.6 years (range 18-53). The mean bone defect was 5 cm (range 3-8.5). The mean soft tissue defect was 2.5 x 3.5 (1 x 2-10 x 5) cm.

INTERVENTIONS

Acute shortening at the fracture site was done for patients with bone defects up to 3 cm to achieve apposition of bone ends. Gradual shortening at a rate of 2 mm/d was done for patients who had bone defects more than 3 cm. Leg length discrepancy was overcome by lengthening at the same time through a corticotomy at a proximal or distal level depending on fracture localization, until there was equalization of leg lengths.

RESULTS

Mean follow-up period was 30 months (range 18-60). Mean bone healing time was 7.5 months (range 4-11). The mean time in external fixation was 7.1 months (range 3-10), and the average external fixator index was 1.4 months/cm. Results were evaluated using the Paley bone and functional assessment scores. The bone assessment results were excellent in 21 and good in 3 patients. Functional assessment scores were excellent in 19, good in 4, and fair in 1 patient. Pin site infections were present in 10.7% of the pin sites. There were 52 complications in 24 patients, for a complication rate per patient of 2.08. Of the complications, 48.1% were problems (minor complications), 38.5% obstacles (major complications requiring a surgical solution), and 13.4% sequelae (true complications). Minor complications included soft tissue inflammation and infection, translation/angulation, and delayed maturation during distraction and transient knee contracture and loss of motion. All grade 1 and 2 soft tissue inflammations and infections healed with nonoperative therapy. Major complications included pin tract infection and reinfection, equinus deformity, frame failure, and premature consolidation, all of which required additional surgery to correct the problem. Sequelae included leg length discrepancy, loss of knee/ankle range of motion, knee flexion contracture, malalignment, and chronic osteomyelitis.

CONCLUSION

Bifocal compression-distraction osteogenesis is a safe, reliable, and largely successful method for the acute treatment of open tibia fractures with bone and soft-tissue loss. Further nonoperative or operative treatment can correct most complications.

Bone reconstruction of the lower extremity: complications and outcomes

A study was performed to analyze the results and final outcomes of bone reconstruction of the lower extremity. Twenty-six patients presented with type IIIB open fractures, nine with type IIIC open fractures, and 15 with chronic osteomyelitis. Seven patients underwent primary amputation, and reconstruction was attempted for 43 patients. The mean bone defect size was 7.7 cm (range, 3 to 20 cm). Bone reconstruction was achieved with conventional bone grafts in 16 cases, in association with either local (13 cases) or free (three cases) flaps. Vascularized bone transfer was performed in 24 cases, with either osteocutaneous groin flaps (10 cases), soleus-fibula flaps (12 cases), or osteocutaneous lateral arm flaps (two cases). For three patients, bone reconstruction was performed with a technique that combines the induction of a membrane around a cement spacer with the use of an autologous cancellous bone graft. Infections were observed to be responsible for prolonged hospital stays and treatment failures. The cumulative rates of sepsis were 4.6 percent at 1 week after injury and 62.8 percent at 2 months. Vascular complications were also related to infections and were responsible for four secondary amputations. One patient asked for secondary amputation because of a painful nonfunctional lower limb. Bone healing occurred in 37 of 43 cases, and the average time to union was 9.5 months, with an average of 8.7 procedures. The mean lengths of stay were 49 days for conventional bone grafts and 62 days for vascularized bone grafts. All of the 50 patients were able to walk, with an average time of 14 months. All of the patients with amputations underwent prosthetic rehabilitation. Patients mostly complained about the reconstructed limb (62.8 percent). Joint stiffness was present in 40 percent of the cases. Other long-term complications were pain (nine cases), lack of sensation (five cases), infection (five cases), and pseudarthrosis (one case). However, all of the patients with successful reconstructions preferred their salvaged leg to an amputation. Of 41 patients who were working before the injury, 26 returned to work.