Distal tibial reconstruction with use of a circular external fixator and an intramedullary nail. Surgical technique

Treatment of tibial large bone defects: A comparative study of bone transport over an intramedullary nail in combination with antibiotic-impregnated calcium sulphate versus bone transport alone with antibiotic-impregnated calcium sulphate

PURPOSE

To compare the bone transport over an intramedullary nail in combination with antibiotic-impregnated calcium sulphate versus bone transport alone with antibiotic-impregnated calcium sulphate for the treatment of tibial large bone defects.

METHODS

A retrospective analysis was conducted by enroling 33 surgically treated patients with tibial large bone defects after the debridement for tibial infection or osteomyelitis who were admitted in Lower Limb Surgery Ward of Traumatic orthopaedic Department, Xi'an Honghui Hospital from January 2018 to January 2021. All the patients were categorized in Group A (transport over intramedullary nail, 12 cases) and Group B (transport alone, 21 cases) based on the surgery strategy. The collected clinical materials and data included gender, age, injury mechanism, smoking habits, comorbidity diseases, initial fracture type (open or close), bone defect size, surgical duration, intraoperative bleeding loss, resorption time of calcium sulphate, bone transport time, external fixation time, external fixation index, weight bearing time, complications and Paley bone and functional criteria.

RESULTS

Thirty-three patients were enroled and successfully followed up with an average time of 15.25±4.31 months ranged from 8 to 21 months in Group A and an average time of 17.09±5.64 months ranged from 9 to 31 months in Group B. No significantly statistical differences of the demographic data were discovered between the two groups. There were no significantly statistical differences of the average bone defect size, intraoperative bleeding loss, resorption time of calcium sulphate and bone transport time between the two groups. However, the average surgical duration (P = 0.002) was significantly longer in Group A than Group B and the average external fixation time (P<0.001), external fixation index(P = 0.002) and weight bearing time (P = 0.030) were significantly shorter in Group A than Group B. No significantly statistical difference of excellent and good rate of bone outcomes and complication rate was observed, however, the excellent and good rate of functional outcomes (P = 0.041) was significantly higher in Group A than Group B.

CONCLUSION

Compared with the conventional Ilizarov technique combining with antibiotic-impregnated calcium sulphate for large tibial bone defects, bone transport over an intramedullary nail in combination with antibiotic-impregnated calcium sulphate had favourable external fixation time, external fixation index, weight bearing time and clinical functional outcomes which effectively suppressed the infection and allowed patients earlier removal of the external fixator and weight bearing for rehabilitation.

Novel "double-strut" fibula ankle arthrodesis for large tumor-related bone defect of distal tibia

Background

Reconstruction for large bone defect of distal tibia after wide resection of tumor is difficult, and the best option remains controversial. This study presents a novel “double-strut” fibula ankle arthrodesis for this issue.

Methods

Nine patients with malignant or aggressive tumors of distal tibia underwent novel “double-strut” fibula ankle arthrodesis after wide tumor resection were retrospectively reviewed. We assessed the bone union time, complications and oncology outcome clinically and radiographically. The Musculoskeletal Tumor Society (MSTS) score and the Foot and Ankle Outcome Score (FAOS) were used to evaluate the functional outcome.

Results

The average followup period was 53 ± 46 months. There was no deep infection or graft fracture observed in this series. Internal fixation loosening was found in one case. In these patients, eight achieved union at both proximal and distal junctions, while one achieved union only distally. The mean union time of the proximal junctions and distal junctions was 10.5 ± 1.6 months and 8.7 ± 2.3 months, respectively. The mean postoperative MSTS score was 83% ± 8%. The subscales of FAOS indicating the most problem was Sport and Recreation Function with a mean score of 18 ± 11. At the final follow-up, one of them (1/9, 11%) experienced local recurrence in soft tissue and received another resection surgery, and four (4/9, 44%) patients developed lung metastases.

Conclusions

For large bone defect of distal tibia, this novel “double-strut” fibula reconstruction can be a viable alternative, which is capable of achieving durable ankle fusion and functional salvaged limb with low rate of complications.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2742-6) contains supplementary material, which is available to authorized users.

Ankle Salvage Following Nonunion of Distal Tibia Fractures

BACKGROUND

Nonunions of the distal tibia in close proximity to the ankle joint can be a challenge to treat. The purpose of this study was to evaluate radiographic and clinical outcomes of patients who underwent ankle-sparing bone transport for periarticular distal tibial nonunions.

METHODS

Twenty-one patients underwent ankle-sparing bone transport between January 2006 and July 2016. The mean age of the patients was 48.6 years, and 71% (15/21) were male. Patients were followed for an average of 14.6 months (range, 10.6-17.7 months), with an average of 8.6 months in-frame. Thirteen of 21 patients had infected nonunions. Primary endpoints included time to union and American Orthopaedic Foot & Ankle Society (AOFAS) score.

RESULTS

All fractures achieved union. Mean time to union was 37.4 weeks. Mean AOFAS score was 86.3 points (range, 37-100). A score of 37 was observed in 1 patient with preexisting Charcot foot. Radiographic evaluation at 6 months revealed a mean lateral distal tibial angle of 89.2 degrees and a mean anterior distal tibial angle of 76 degrees. Leg length discrepancy was less than 1.2 cm in all patients. Superficial pin infection was observed in 7 patients, and operative wound infection at the level of bone resection was observed in 3 patients.

CONCLUSION

The ankle-sparing bone transport technique was an effective alternative to bone graft and arthrodesis for the treatment of periarticular nonunions of the distal tibia and was safe for use in patients with infected nonunions in close proximity to the ankle joint.

LEVEL OF EVIDENCE

Level IV, case series.

Tibial Lengthening Using a Fixator-Assisted Lengthening Plate: A New Technique

Background

There are many techniques that are used for limb lengthening. Lengthening a limb over a plate is an alternative choice used in children or when using an intramedullary nail is difficult.

Objectives

In this study, we presented a new technique for tibial lengthening using a monolateral external fixator over a lengthening plate.

Materials and Methods

For tibial lengthening, a monolateral external fixator was attached to the composite bone model medially. After a corticotomy was performed, the lengthening plate was placed laterally. Three locking screws were inserted proximally, and two cortical screws were inserted into a lengthening hole that was 1 cm below the osteotomy site. We avoided contact between the screws of the lengthening plate and the pins of the external fixator. During bone lengthening with the monolateral external fixator, the screws at the lengthening hole were able to slide distally with the distal segment of the tibia to allow for tibial elongation. Two locking screws were fixed at the distal locking holes of the plate when the bone elongation was complete. The external fixator was then removed.

Results

The fixator-assisted lengthening plate allowed bone lengthening without malalignment. There were no mechanical problems associated with the external fixator during the lengthening process. Plate osteosynthesis was stable after the fixator was removed. There was no contact between the screws of plate and the Schanz pins of the external fixator under C-arm fluoroscopy.

Conclusions

The fixator-assisted lengthening plate technique helps to maintain the stability and alignment at both sides of an osteotomy during tibial elongation. It allows the early removal of the external fixator immediately after lengthening is completed. This technique can be applied in children with open physes and in patients with a narrow medullary canal who are unsuitable for limb lengthening over an intramedullary nail.

Tibial lengthening over intramedullary nails: A matched case comparison with Ilizarov tibial lengthening

Objectives

The purpose of this study was to compare the results and complications of tibial lengthening over an intramedullary nail with treatment using the traditional Ilizarov method.

Methods

In this matched case study, 16 adult patients underwent 19 tibial lengthening over nails (LON) procedures. For the matched case group, 17 patients who underwent 19 Ilizarov tibial lengthenings were retrospectively matched to the LON group.

Results

The mean external fixation time for the LON group was 2.6 months and for the matched case group was 7.6 months. The mean lengthening amounts for the LON and the matched case groups were 5.2 cm and 4.9 cm, respectively. The radiographic consolidation time in the LON group was 6.6 months and in the matched case group 7.6 months. Using a clinical and radiographic outcome score that was designed for this study, the outcome was determined to be excellent in 17 and good in two patients for the LON group. The outcome was excellent in 14 and good in five patients in the matched case group. The LON group had increased blood loss and increased cost. The LON group had four deep infections; the matched case group did not have any deep infections.

Conclusions

The outcomes in the LON group were comparable with the outcomes in the matched case group. The LON group had a shorter external fixation time but experienced increased blood loss, increased cost, and four cases of deep infection. The advantage of reducing external fixation treatment time may outweigh these disadvantages in patients who have a healthy soft-tissue envelope.

Cite this article: J. E. Herzenberg. Tibial lengthening over intramedullary nails: A matched case comparison with Ilizarov tibial lengthening. Bone Joint Res 2016;5:1–10. doi: 10.1302/2046-3758.51.2000577

Metaphyseal locking compression plate as an external fixator for the distal tibia

PURPOSE

Recently we coined the term supercutaneous plating using a locking compression plate (LCP) as an external fixator. The use of this technique in peri-articular areas is facilitated by the development of anatomical plates with various screw sizes. The purpose of this report is to describe our results using the metaphyseal locking plate (LCP) as an external fixator in the treatment of infected post-traumatic problems of the distal tibia.

METHODS

Between August 2008 and January 2012 a total of seven patients underwent external plating ("supercutaneous plating") of the distal tibia using a metaphyseal locking plate. Average age was 43 years (range 20-79). Six out of seven patients had a documented infection at the time of external plate application. All patients in this cohort were followed prospectively at regular intervals by the senior author (PK).

RESULTS

The plate was in situ for an average of 17.5 weeks (range 6-60). There were no clinically significant pin site infections. In four patients the plate was kept in place until there was complete consolidation. In three patients the external plate was exchanged for formal internal fixation once the infection had subsided. At the latest follow-up (average 12.8 months, range 4-31), all patients were fully weight bearing with a fully healed tibia. All patients were infection-free with well-healed wounds.

CONCLUSION

Infection of the distal tibia after treatment of traumatic and post-traumatic problems is a challenging problem. It is common practice that after initial debridement and hardware removal, temporary bony stabilisation is provided by external fixation. Most external frames for the lower leg are bulky and cumbersome, causing significant problems for the patient. To circumvent these issues, we have successfully used an anatomically-contoured metaphyseal locking compression plate as external fixator in a series of seven patients for acute or post-traumatic problems of the tibia.

Fixator-assisted nailing and consecutive lengthening over an intramedullary nail for the correction of tibial deformity

We report the results of using a combination of fixator-assisted nailing with lengthening over an intramedullary nail in patients with tibial deformity and shortening. Between 1997 and 2007, 13 tibiae in nine patients with a mean age of 25.4 years (17 to 34) were treated with a unilateral external fixator for acute correction of deformity, followed by lengthening over an intramedullary nail with a circular external fixator applied at the same operating session. At the end of the distraction period locking screws were inserted through the intramedullary nail and the external fixator was removed.

The mean amount of lengthening was 5.9 cm (2 to 8). The mean time of external fixation was 90 days (38 to 265). The mean external fixation index was 15.8 days/cm (8.9 to 33.1) and the mean bone healing index was 38 days/cm (30 to 60).

One patient developed an equinus deformity which responded to stretching and bracing. Another developed a drop foot due to a compartment syndrome, which was treated by fasciotomy. It recovered in three months. Two patients required bone grafting for poor callus formation.

We conclude that the combination of fixator-assisted nailing with lengthening over an intramedullary nail can reduce the overall external fixation time and prevent fractures and deformity of the regenerated bone.