Osteocutaneous thermal necrosis of the leg salvaged by TSF/Ilizarov reconstruction. Report of 7 patients

Surgical Drill Bit Design and Thermomechanical Damage in Bone Drilling: A Review

As drilling generates substantial bone thermomechanical damage due to inappropriate cutting tool selection, researchers have proposed various approaches to mitigate this problem. Among these, improving the drill bit design is one of the most feasible and economical solutions. The theory and applications in drill design have been progressing, and research has been published in various fields. However, pieces of information on drill design are dispersed, and no comprehensive review paper focusing on this topic. Systemizing this information is crucial and, therefore, the impetus of this review. Here, we review not only the state-of-the-art in drill bit designs-advances in surgical drill bit design-but also the influences of each drill bit geometries on bone damage. Also, this work provides future directions for this topic and guidelines for designing an improved surgical drill bit. The information in this paper would be useful as a one-stop document for clinicians, engineers, and researchers who require information related to the tool design in bone drilling surgery.

Comparison of the use of antibiotic-loaded calcium sulphate and wound irrigation-suction in the treatment of lower limb chronic osteomyelitis

AIMS

We sought to compare the efficacy of antibiotic-loaded calcium sulphate with wound irrigation-suction in patients with lower limb chronic osteomyelitis.

PATIENTS AND METHODS

Adult patients with lower limb chronic osteomyelitis treated at our hospital by means of segmental bone resection, antibiotic-loaded calcium sulphate implantation or wound irrigation-suction, followed by bone transport with external fixator from January 2011 to July 2015 were retrospectively evaluated. The clinical presentation, laboratory results, complications, docking obstruction, infection recurrence were compared.

RESULTS

There were totally 74 patients met the inclusion criteria. Docking obstruction rate and infection recurrence were higher in the irrigation group with significant difference. The success rate of the first operation was 90.74% in the calcium sulphate group compared with 45% in the irrigation group. Postoperaton leakage of the incision happened more in the calcium sulphate group, but it wasn't a risk factor for docking obstruction and infection recurrence. Patients in the calcium sulphate group had shorter hospital stay and systemic antibiotic treatment, also with less external fixator index.

CONCLUSIONS

The findings of our study suggest that antibiotic-loaded calcium sulphate implantation for lower chronic limb osteomyelitis was a more successful method than wound irrigation-suction, it greatly decreased infection recurrence and docking obstruction. Postoperative leakage after implantation didn't worsen patient's outcome.

Measuring outcomes following tibial fracture

AIM

The aim of this study was to determine how outcome is measured following adult tibial fracture in the modern era of functional outcome measurement and patient reported outcomes.

METHODS

A systematic review of publications since 2009 was performed, looking specifically at acute, adult tibial shaft fractures. Ovid Medline, Embase, PubMed and PsycINFO databases were searched for relevant titles which were then screened by two authors with adjudication where necessary by a third. Relevant articles were reviewed in full and data was extracted concerning the study participants, study design and any measures that were used to quantify the results following fracture. The results were collated and patient reported outcome measures were assessed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) standards.

RESULTS

A total of 943 titles and articles were reviewed, with 117 included for full analysis. A wide range of clinical and radiological "outcomes" were described, along with named clinician- and patient-reported outcome measures. There was considerable heterogeneity and lack of detail in the description of the simplest outcomes, such as union, infection or reoperation. Reported clinician and patient reported outcome measures are variably used. None of the identified patient reported outcome measures have been validated for use following tibial fracture.

CONCLUSION

We recommend definition of a core outcome set for use following tibial fracture. This will standardise outcome reporting following these injuries. Furthermore, there is need for a validated patient reported outcome measure to better assess patient important outcomes in this patient group.

Salvage of an osteocutaneous thermonecrosis secondary to tibial reaming by the induced membrane procedure

Osteocutaneous thermonecrosis is a rare but devastating complication of tibial reaming, which can cause large and infected bone and cutaneous defects. The case presented here illustrates that the induced membrane technique described by Masquelet is a valuable option in treating this complication.

Distraction osteogenesis for tibial nonunion with bone loss using combined Ilizarov and Taylor spatial frames versus a conventional circular frame

This retrospective review assesses 55 tibial nonunions with bone loss to compare union achieved with combined Ilizarov and Taylor spatial frames (I–TSF) versus a conventional circular frame with the standard Ilizarov procedure. Seventeen (31 %) of the 55 nonunions were infected. Thirty patients treated with I–TSF were compared with 25 patients treated with a conventional circular frame. In the I–TSF group, an average of 7.6 cm of bone was resected and the lengthening index (treatment time in months divided by lengthening amount in centimeters) was 1.97. In the conventional circular frame group, a mean of 6.5 cm was resected and the lengthening index was 2.1. Consolidation at the docking site and at the regenerate bone occurred in 49 (89 %) of 55 cases after the first procedure. No statistically significant difference was shown between the two groups. Superiority of one modality of treatment over the other cannot be concluded from our data. Application of combined Ilizarov and Taylor spatial frames for bone transport is useful for treatment of tibial nonunion with bone loss.

Level of evidence Case series, Level III.

Nailing treatment in bone transport complications

A series of cases of reamed intramedullary nailings carried out after complications in regenerated bone and docking site had occurred in bone transport is presented here. Nine patients (femur = 5; tibia = 4) had treatment with resection after open fractures or infection and underwent bone transport. The mean length of regenerated bone was 9.5 cm (range 6–18 cm). After bone transport, the fixator remained in place for a mean period of 12.8 months (range 8–24 months). In six cases (femur 4; tibia 2), the thickness of the cortical wall of the regenerate column was insufficient, and in two of these, there was, in addition, nonunion of the docking site. In the two tibial cases, nailing was carried out shortly after the fixator had been removed and after refracture of the regenerated bone had occurred due to insufficient cortical thickness. In one femur, nailing was carried out for nonunion of the docking site. Follow-up involved clinical and X-ray checks. The mean follow-up was 3.9 years (range 2–6 years). In all cases, union and with complete corticalization of the regenerate column was observed at an average 6 months after nailing (range 4–11 months). Infection occurred in one tibia 4 months after nailing. The infection was treated with antibiotics, and the nail was subsequently removed. We conclude that nailing is a potential solution for regenerated bone and docking site problems but, if used after prolonged periods of external fixation, may necessitate antibiotic therapy for at least 10 days after the fixator has been removed.

The Ilizarov paradigm: thirty years with the Ilizarov method, current concerns and future research

The Ilizarov method of bone lengthening, reconstruction and osteosynthesis has developed immensely since its introduction by G.A. Ilizarov in the Soviet Union in the 1960s and in the Western countries in the early 1980s. It has become an integral part of the arsenal used by the orthopaedic community worldwide. The evolutionary development of the method and its current role has considerably improved the quality of life for millions of people around the whole world. Despite the great versatility of its possible applications for bone injuries and diseases, the Ilizarov method could not and cannot be the alternative to a range of other methods that are applied for some specific bone conditions, but rather is a method of choice. Its combination with the current methods of internal fixation or the means of internal fixation that use the biological principles that were laid down by G.A. Ilizarov have demonstrated the importance of tension stress, blood supply, functional loading, and fragment control during bone treatment. The objective of this study was to present an overview of the current state and concerns in the application of the Ilizarov method and define the prospective research trends aimed at regeneration stimulation, better control of treatment, infection barriers and patient comfort.

Clinical strategies at the docking site of distraction osteogenesis: are open procedures superior to the simple compression of Ilizarov?

This retrospective review reports on forty-five tibial non-unions who underwent docking site treatment for non-union using closed versus open and endoscopic strategies. In this cohort of patients, all but twelve were infected non-unions. Sixteen patients initially treated with single compression were compared to twenty-three patients treated with open revision of the docking site, and six endoscopic procedures. In the single compression group, an average of 6.4 cm of bone was resected and index lengthening was 2.01. In the open revision group, a mean of 9.4 cm was resected and the index lengthening was 1.72. In the endoscopic group, an average of 8.6 cm of bone was resected and index lengthening was 1.71. Consolidation at the docking site occurred in 41 cases out of 45 following the first procedure. There was no statistical difference between the three groups. Conclusive evidence of superiority of one modality of treatment over the other cannot be drawn from our data. The simple compression procedure requires less invasive surgery and is probably less demanding and more cost-effective in short transports, although the two cases of failure due to recurrence of sepsis were observed after this procedure. Further studies are desirable to investigate the effectiveness of open docking site grating procedures.

Clinical reliability of closed techniques and comparison with open strategies to achieve union at the docking site

PURPOSE

This retrospective review follows 31 tibial nonunions to compare union at the docking site using closed versus open strategies. In this cohort of patients, all but five were infected nonunions.

METHODS

Thirteen patients initially treated with single compression were compared with 18 patients treated by open revision of the docking site. In the single compression group, an average of 6.5 cm of bone was resected and index lengthening was 2.04. In the open revision group, a mean of 9.4 cm was resected and the index lengthening was 1.73.

RESULTS

Consolidation at the docking site occurred in all subjects in both groups. There was no statistical difference between the two groups. Conclusive evidence of superiority of one modality of treatment over the other cannot be drawn from our data.

CONCLUSIONS

The simple compression procedure requires less invasive surgery and is probably less demanding and more cost-effective in short transports.

Thermal necrosis after simultaneous tibial osteotomy and total knee arthroplasty using press-fit extension-stem

One-staged tibial corrective osteotomy and total knee arthroplasty is a challenging but effective treatment for arthritic knees with extra-articular deformity. Although osteocutaneous thermal necrosis is accepted as a complication of intramedullary reamed nailing following long bone fractures, only 15 cases have been reported in the English literature at present. This report illustrates a rare case of thermal necrosis in a patient undergoing tibial corrective osteotomy coincident with long-stemmed total knee arthroplasty. Excessive reaming with a machine reamer is hypothesized as the cause of this serious complication. In this report, we highlight this rare but serious complication after long-stemmed total knee arthroplasty.

Comparison of 39 post-traumatic tibia bone transports performed with and without the use of an intramedullary rod: the long-term outcomes

Bone transport can be performed with an external fixator alone or with the monorail technique which entails the combination of a fixator and an intramedullary nail. The purpose of this study was to compare the complication rates and long-term outcomes of these methods. Two groups of patients, the external fixator (n = 21) and the monorail group (n = 18), were compared. The average follow-up period was 7.9 ± 5.6 years and the mean defect length 8.3 ± 3.1 cm. Healing was achieved in 19 (90%) and 13 (72%) of the fixator and monorail patients, respectively. Six patients underwent amputations because of persistent infections (two in the fixator and four in the monorail group). The rate of deformities was significantly higher in the fixator group (p = 0.049). No statistically significant difference was found when comparing categories of the SF-36 test or the ability to work or do sports. The main advantages of the monorail method are reduction of the external fixation time and the lower rate of deformities. However, the authors recommend segmental transport with external fixator in patients with chronic infections.