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Zhang Q, Kang Y, Wu Y, Ma Y, Jia X, Zhang M, Lin F, Rui Y. Masquelet combined with free-flap technique versus the Ilizarov bone transport technique for severe composite tibial and soft-tissue defects. Injury 2024; 55:111521. [PMID: 38584076 DOI: 10.1016/j.injury.2024.111521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/29/2024] [Accepted: 03/30/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND The treatment of bone and soft-tissue defects after open fractures remains challenging. This study aimed to evaluate the clinical efficacy of the Masquelet technique combined with the free-flap technique (MFFT) versus the Ilizarov bone transport technique (IBTT) for the treatment of severe composite tibial and soft-tissue defects. METHODS We retrospectively analysed the data of 65 patients with tibial and soft-tissue defects and Gustilo type IIIB/C open fractures treated at our hospital between April 2015 and December 2021. The patients were divided into two groups based on the treatment method: group A (n = 35) was treated with the MFFT and internal fixation, and group B (n = 30) was treated with the IBTT. RESULTS The mean follow-up period was 28 months (range 13-133 months). Complete union of both soft-tissue and bone defects was achieved in all cases. The mean bone-union times were 6 months (range 3-12 months) in group A and 11 months (range 6-23 month) in group B, with a significant difference between the two groups (Z = -4.11, P = 0.001). The mean hospital stay was 28 days (range 14-67 d) in group A which was significantly longer than the mean stay of 18 days (range 10-43 d) in group B (Z = -2.608, P = 0.009). There were no significant differences in the infection rate between group A (17.1 %) and group B (26.7%) (χ2 = 0.867, P = 0.352). The Total Physical Health Scores were 81.51 ± 6.86 (range 67-90) in group A and 75.83±16.14 (range 44-98) in group B, with no significant difference between the two groups (t = 1.894, P = 0.063). The Total Mental Health Scores were significantly higher in group A (90.49 ± 6.37; range 78-98) than in group B (84.70 ± 13.72; range 60-98) (t = 2.232, P = 0.029). CONCLUSION Compared with IBTT, MFFT is a better choice of treatment for open tibial and soft-tissue defects with Gustilo IIIB/C fractures. IBTT is the preferred option when the tibial bone defect is large or if the surgeon's expertise in microsurgery is limited.
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Affiliation(s)
- Qingqing Zhang
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital affiliated to Soochow University, Wuxi, Jiangsu, China
| | - Yongqiang Kang
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital affiliated to Soochow University, Wuxi, Jiangsu, China; Medical College, Soochow University, Suzhou, Jiangsu, China
| | - Yongwei Wu
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital affiliated to Soochow University, Wuxi, Jiangsu, China
| | - Yunhong Ma
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital affiliated to Soochow University, Wuxi, Jiangsu, China
| | - Xueyuan Jia
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital affiliated to Soochow University, Wuxi, Jiangsu, China
| | - Mingyu Zhang
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital affiliated to Soochow University, Wuxi, Jiangsu, China
| | - Fang Lin
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital affiliated to Soochow University, Wuxi, Jiangsu, China
| | - Yongjun Rui
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital affiliated to Soochow University, Wuxi, Jiangsu, China.
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Wakefield SM, Papakostidis C, Giannoudis VP, Mandía-Martínez A, Giannoudis PV. Distraction osteogenesis versus induced membrane technique for infected tibial non-unions with segmental bone loss: a systematic review of the literature and meta-analysis of available studies. Eur J Trauma Emerg Surg 2024; 50:705-721. [PMID: 37921889 PMCID: PMC11249469 DOI: 10.1007/s00068-023-02375-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 09/29/2023] [Indexed: 11/05/2023]
Abstract
INTRODUCTION Infected tibial non-unions with associated bone loss can be challenging to manage. At present, the two main methods utilized in the management of these fractures include the Ilizarov technique of Distraction Osteogenesis (DO) using external fixator devices, or alternatively, the Induced Membrane Technique (IMT), devised by Masquelet. As there is a paucity of data directly comparing the outcomes of these techniques, there is no universal agreement on which strategy a surgeon should choose to use. AIMS This systematic review and meta-analysis aimed to summarize the outcomes of both DO and IMT, in terms of primary outcomes (bone union and infection elimination), and secondary outcomes (complication rates and functional outcomes). METHODS A PRISMA strategy was used. Medline, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar library databases were interrogated using pre-defined MeSH terms and Boolean operators. Quality of evidence was evaluated using OCEBM and GRADE systems. RESULTS Thirty-two studies with 1136 subjects met the inclusion criteria. With respect to the primary outcomes of interest, union was observed in 94.6% (DO method) and 88.0% (IMT method); this difference, however, was not significant between the two techniques (p = 0.45). In addition, infection elimination rates were also higher in the Ilizarov DO group when compared to Masquelet (Mq) IMT (93.0% vs 80.4% respectively). Again, no significant difference was observed (p = 0.06). For all secondary outcomes assessed (unplanned re-operations, re-fracture rates amputation rate), no statistically significant differences were documented between the treatment options. CONCLUSION This study demonstrated that there is no clinical difference in outcomes for patients treated with Ilizarov DO versus Mq IMT techniques. The evidence base at present is relatively sparse and, therefore, we would recommend for further Level I studies to be conducted, to make more meaningful conclusions.
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Affiliation(s)
- Sophia M Wakefield
- Academic Department of Trauma and Orthopaedics Surgery, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon Wing, Floor D, Great George Street, Leeds, LS1 3EX, UK
| | - Costas Papakostidis
- Academic Department of Trauma and Orthopaedics Surgery, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon Wing, Floor D, Great George Street, Leeds, LS1 3EX, UK
| | - Vasileios P Giannoudis
- Academic Department of Trauma and Orthopaedics Surgery, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon Wing, Floor D, Great George Street, Leeds, LS1 3EX, UK
| | - Alfonso Mandía-Martínez
- Academic Department of Trauma and Orthopaedics Surgery, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon Wing, Floor D, Great George Street, Leeds, LS1 3EX, UK
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics Surgery, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon Wing, Floor D, Great George Street, Leeds, LS1 3EX, UK.
- NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, UK.
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Akhoundzadeh D, Bloemers FW, Verhofstad MHJ, Schoonmade LJ, Geeraedts LMG. Which surgical technique may yield the best results in large, infected, segmental non-unions of the tibial shaft? A scoping review. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02478-y. [PMID: 38446155 DOI: 10.1007/s00068-024-02478-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 02/19/2024] [Indexed: 03/07/2024]
Abstract
PURPOSE Infected nonunion of the tibia with a large segmental bone defect is a complex and challenging condition for the patient and surgeon. This scoping review was conducted to identify existing evidence and knowledge gaps regarding this clinical scenario. Secondly, the objective of this study was to search for a valid recommendation on the optimal treatment. METHODS A comprehensive search was conducted in the bibliographic databases: PubMed, Embase.com, and Web of Science Core Collection. Studies reporting on bone transport techniques, the Masquelet technique, and vascularized fibular grafts in bone defects greater than 5 cm were included. Bone healing results and functional results were compared according to duration of nonunion, infection recurrence, bone consolidation, complication rate, external fixation time, and time until full weight-bearing. RESULTS Of the 2753 articles retrieved, 37 studies could be included on bone transport techniques (n = 23), the Masquelet technique (n = 7), and vascularized fibular grafts (n = 7). Respective bone union percentages were 94.3%, 89.5%, and 96.5%. The percentages of infection recurrence respectively were 1.6%, 14.4% and 7.0%, followed by respectively 1.58, 0.78, and 0.73 complications per patient. CONCLUSION Bone transport was found to be the most widely studied technique in the literature. Depending on the surgeon's expertise, vascularized fibular grafts may be held as a favourable alternative. This review indicates that further high-quality research on large bone defects ( ≥ 5 cm) in patients with infected tibial nonunions is necessary to gain more insight into the potentially beneficial results of vascularized fibular grafts and the Masquelet technique.
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Affiliation(s)
- Dena Akhoundzadeh
- Department of Surgery, Section Trauma Surgery, Amsterdam UMC, location VUmc, De Boelelaan 1117, P.O. Box 7057, 1007, Amsterdam, MB, Netherlands.
| | - Frank W Bloemers
- Department of Surgery, Section Trauma Surgery, Amsterdam UMC, location VUmc, De Boelelaan 1117, P.O. Box 7057, 1007, Amsterdam, MB, Netherlands
| | | | - Linda J Schoonmade
- University Library, VU University, Amsterdam UMC, Amsterdam, Netherlands
| | - Leo M G Geeraedts
- Department of Surgery, Section Trauma Surgery, Amsterdam UMC, location VUmc, De Boelelaan 1117, P.O. Box 7057, 1007, Amsterdam, MB, Netherlands
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Zhang Y, Tian S, Liu M, Zhai W, Zhou Y, Peng A. Comparison of antibiotic-impregnated bone cement coverage versus vacuum sealing drainage in semi-open bone grafting using for tibial fracture with infected bone and soft tissue defect: a retrospective analysis. BMC Musculoskelet Disord 2023; 24:401. [PMID: 37208629 DOI: 10.1186/s12891-023-06475-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 04/28/2023] [Indexed: 05/21/2023] Open
Abstract
OBJECTIVE To compare antibiotic-impregnated bone cement coverage (bone cement surface technique; BCS-T) versus vacuum sealing drainage (VSD) for tibial fracture with infected bone and soft tissue defect. METHOD This retrospective analysis compared the clinical outcomes in patients undergoing BCS-T (n = 16) versus VSD (n = 15) for tibial fracture with infected bone and soft tissue defect at the Third Hospital of Hebei Medical University from March 2014 to August 2019. For BCS-T group, osseous cavity was filled with autograft bone graft after debridement, and then the wound was covered with a 3-mm layer of bone cement impregnated with vancomycin and gentamycin. The dressing was changed every day in the first week, and every 2 ~ 3 days in the second week. For VSD group, a negative pressure of -150 ~ -350 mmHg was maintained, and the dressing was changed every 5-7 days. All patients received antibiotics treatment based on bacterial culture results for 2 weeks. RESULTS The 2 groups did not differ in age, sex and key baseline characteristics, including type of Gustilo-Anderson classification, size of the bone and soft tissue defect, the percentage of primary debridement, bone transport, and the time from injury to bone grafting. The median follow-up was 18.9 months (range:12-40). The time to complete coverage of bone graft by granulation tissue was 21.2 (15.0-44.0) and 20.3 (15.0-24.0) days in the BCS-T and VSD groups, respectively (p = 0.412). The 2 groups also did not differ in wound healing time (3.3 (1.5-5.5) versus 3.2(1.5-6.5) months; p = 0.229) and bone defect healing time (5.4(3.0-9.6) versus 5.9(3.2-11.5) months; p = 0.402). However, the cost of covering material was significantly reduced in the BCS-T group (2071 ± 134 versus 5542 ± 905 yuan; p = 0.026). Paley functional classification at 12 months did not differ between the 2 groups (excellent in 87.5% versus 93.3% in the 2 groups; p = 0.306). CONCLUSION BCS-T could achieve clinical outcomes similar to VSD in patients receiving bone graft for tibial fracture with infected bone and soft tissue defect, but material cost was significantly reduced. Randomized controlled trials are needed to verify our finding.
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Affiliation(s)
- Yanlong Zhang
- Trauma Center, The First Hospital of Hebei Medical University, Shijiazhuang, 050031, Hebei, China
| | - Shuwei Tian
- Hebei Provincial General Hospital, Shijiazhuang, 050057, Hebei, China
| | - Meiyu Liu
- The Second Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Wenfang Zhai
- Department of Orthopaedics, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Yujie Zhou
- Trauma Center, The First Hospital of Hebei Medical University, Shijiazhuang, 050031, Hebei, China
| | - Aqin Peng
- Department of Orthopaedics, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China.
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Maheshwari V, Raja BS, Bahadur B, Regmi A, Dhingra M, Gowda AK. Outcome analysis of ilizarov and monorail fixators in the treatment of nonunion of long bones: A systematic review and proportion meta-analysis. J Clin Orthop Trauma 2023; 40:102170. [PMID: 37293684 PMCID: PMC10245124 DOI: 10.1016/j.jcot.2023.102170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/23/2023] [Accepted: 05/11/2023] [Indexed: 06/10/2023] Open
Abstract
Introduction Nonunion of long bones is a major complication following fractures that requires a substantial amount of investment both monetary and time from patients and surgeons. The need to comprehensively understand the complications, outcomes and distraction capability is profound, which necessitates a review of current evidence on special fixators used for distraction. The current systematic review aims to study the available literature on distraction osteogenesis using special fixators (Ilizarov and Limb Reconstruction System) in the management of nonunion (infected and non-infected). Methods Cochrane Library, PubMed, Scopus were searched until January 2022. The review included all original studies which used Ilizarov or Monorail Fixators/LRS in the treatment of nonunion of long bones. The quality of studies was assessed using the Modified Coleman Methodology Score. Results A total of 35 original studies with Ilizarov (n = 29) and LRS (n = 8) were selected including two comparative studies. The pooled data meta-analysis and the subgroup analysis of these studies found both Ilizarov and LRS fixator yield similar functional outcomes for the treatment of long bones nonunion. Conclusion The review was conducted to understand the scenario of nonunion in long bones. Pin tract infection is found to be the most common complication followed by adjacent joint stiffness and deformity. In our review we observed that both external fixator time and index were lower in LRS compared to Ilizarov group. Further RCT are required comparing Ilizarov and LRS fixators to effectively comment upon the superiority of the implants.
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Affiliation(s)
- Vikas Maheshwari
- Department of Orthopeaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Balgovind S. Raja
- Department of Orthopaedics, All India Institute of Medical Sciences, Patna, India
| | - Bom Bahadur
- Department of Orthopeaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Anil Regmi
- Department of Orthopeaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Mohit Dhingra
- Department of Orthopeaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Aditya K.S. Gowda
- Department of Orthopeaedics, All India Institute of Medical Sciences, Rishikesh, India
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Zheng H, Wang L, Jiang W, Qin R, Zhang Z, Jia Z, Zhang J, Liu Y, Gao X. Application of 3D printed patient-specific instruments in the treatment of large tibial bone defects by the Ilizarov technique of distraction osteogenesis. Front Surg 2023; 9:985110. [PMID: 36684263 PMCID: PMC9852528 DOI: 10.3389/fsurg.2022.985110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 10/31/2022] [Indexed: 01/09/2023] Open
Abstract
Background The Ilizarov technique of distraction osteogenesis is an effective treatment for tibia defect. However, repeated attempts to reduce due to the complexity of the bone defect during the operation will increase the operation time and iatrogenic injury, and excessive radiation exposure. Three-dimensional (3D)-printed patient-specific instrument (PSI) for preoperative 3D planning and intraoperative navigation have the advantages of accuracy and visualization. The purpose of this study is to investigate whether 3D-printed PSI is helpful to correct tibial bone defects accurately and effectively. Method From May 2019 to September 2022, 19 patients with tibial bone defects were treated, including 9 males and 10 females, aged 37 to 64 years. There were 4 cases in proximal tibia, 9 in midshaft tibia and 6 in distal tibia. All were treated with Ilizarov technique of distraction osteogenesis. 3D-printed PSI was used in 9 cases, while traditional surgery was used in 10 cases. All patients underwent computed tomography before surgery. Computer software was used to analyze the measurement results, design and print PSI. During the operation, PSI was used to assist in reduction of tibia. Operation times were recorded in all cases, the number of fluoroscopy during the operation, and the varus/valgus, anteversion/reversion angle after the operation were measured. All measurement data were expressed by means ± SD, and Student's t test was used to examine differences between groups. The chi square test or Fisher's precise test was used to compare the counting data of the two groups. Result All PSI matched well with the corresponding tibia bone defect, and were consistent with the preoperative plan and intraoperative operation. The affected limb had a good reduction effect. The operation time from the beginning of PSI installation to the completion of Ilizarov ring fixator installation was 31.33 ± 3.20 min, while that in the traditional operation group was 64.10 ± 6.14 min (p < 0.001). The times of fluoroscopy in the PSI group during operation was 10.11 ± 1.83, and that in the traditional operation group was 27.60 ± 5.82. The reduction effect of tibia in PSI group was better than that in traditional operation group, with the average angle of PSI group is 1.21 ± 0.24°, and that of traditional operation group is 2.36 ± 0.33° (p < 0.001). Conclusion The PSI simplifies procedures, reduces the difficulty of the operation, improves the accuracy of the operation, and provides a good initial position when used in distraction osteogenesis to treat the tibial defects.
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Affiliation(s)
- Hao Zheng
- Department of Trauma Surgery, Affiliated Hospital of Weifang Medical University, Weifang, China,School of Clinical Medicine, Weifang Medical University, Weifang, China
| | - Lili Wang
- Department of Trauma Surgery, Affiliated Hospital of Weifang Medical University, Weifang, China,School of Clinical Medicine, Weifang Medical University, Weifang, China
| | - Wenbo Jiang
- Clinical and Translational Research Center for 3D Printing Technology, Shanghai Ninth People’ s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ruiqing Qin
- Clinical and Translational Research Center for 3D Printing Technology, Shanghai Ninth People’ s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhiyu Zhang
- Department of Trauma Surgery, Affiliated Hospital of Weifang Medical University, Weifang, China,School of Clinical Medicine, Weifang Medical University, Weifang, China
| | - Zhuqing Jia
- Department of Trauma Surgery, Affiliated Hospital of Weifang Medical University, Weifang, China,School of Clinical Medicine, Weifang Medical University, Weifang, China
| | - Jian Zhang
- Department of Trauma Surgery, Affiliated Hospital of Weifang Medical University, Weifang, China,School of Clinical Medicine, Weifang Medical University, Weifang, China
| | - Yong Liu
- Department of Trauma Surgery, Affiliated Hospital of Weifang Medical University, Weifang, China,School of Clinical Medicine, Weifang Medical University, Weifang, China,Correspondence: Xuejian Gao Yong Liu
| | - Xuejian Gao
- Department of Trauma Surgery, Affiliated Hospital of Weifang Medical University, Weifang, China,School of Clinical Medicine, Weifang Medical University, Weifang, China,Correspondence: Xuejian Gao Yong Liu
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7
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Jain RP, Meteke S, Gaffey MF, Kamali M, Munyuzangabo M, Als D, Shah S, Siddiqui FJ, Radhakrishnan A, Ataullahjan A, Bhutta ZA. Delivering trauma and rehabilitation interventions to women and children in conflict settings: a systematic review. BMJ Glob Health 2020; 5:e001980. [PMID: 32399262 PMCID: PMC7204922 DOI: 10.1136/bmjgh-2019-001980] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 12/12/2019] [Accepted: 01/06/2020] [Indexed: 12/02/2022] Open
Abstract
Background In recent years, more than 120 million people each year have needed urgent humanitarian assistance and protection. Armed conflict has profoundly negative consequences in communities. Destruction of civilian infrastructure impacts access to basic health services and complicates widespread emergency responses. The number of conflicts occurring is increasing, lasting longer and affecting more people today than a decade ago. The number of children living in conflict zones has been steadily increasing since the year 2000, increasing the need for health services and resources. This review systematically synthesised the indexed and grey literature reporting on the delivery of trauma and rehabilitation interventions for conflict-affected populations. Methods A systematic search of literature published from 1 January 1990 to 31 March 2018 was conducted across several databases. Eligible publications reported on women and children in low and middle-income countries. Included publications provided information on the delivery of interventions for trauma, sustained injuries or rehabilitation in conflict-affected populations. Results A total of 81 publications met the inclusion criteria, and were included in our review. Nearly all of the included publications were observational in nature, employing retrospective chart reviews of surgical procedures delivered in a hospital setting to conflict-affected individuals. The majority of publications reported injuries due to explosive devices and remnants of war. Injuries requiring orthopaedic/reconstructive surgeries were the most commonly reported interventions. Barriers to health services centred on the distance and availability from the site of injury to health facilities. Conclusions Traumatic injuries require an array of medical and surgical interventions, and their effective treatment largely depends on prompt and timely management and referral, with appropriate rehabilitation services and post-treatment follow-up. Further work to evaluate intervention delivery in this domain is needed, particularly among children given their specialised needs, and in different population displacement contexts. PROSPERO registration number CRD42019125221.
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Affiliation(s)
- Reena P Jain
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sarah Meteke
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michelle F Gaffey
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mahdis Kamali
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mariella Munyuzangabo
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Daina Als
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shailja Shah
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Fahad J Siddiqui
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada.,Health System and Services Research, Duke-NUS Medical School, Singapore
| | - Amruta Radhakrishnan
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Anushka Ataullahjan
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada.,Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
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Affiliation(s)
- Meng Mi
- Department of Orthopaedics and Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | | | - Xinbao Wu
- Department of Orthopaedics and Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedic, School of Medicine, University of Leeds, Leeds General Infirmary, Leeds, UK; NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, UK.
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Relevant advances in bone lengthening research: a bibliometric analysis of the 100 most-cited articles published from 2001 to 2017. J Pediatr Orthop B 2019; 28:495-504. [PMID: 30312248 DOI: 10.1097/bpb.0000000000000557] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
This study aimed to assess the scientific production of bone lengthening research by identifying the most-cited papers. All articles including the term 'bone lengthening' published between 2001 and 2017 were retrieved through the Web of Science database. The 100 most-cited articles on bone lengthening included a total of 4244 citations, with 414 (9.7%) citations in 2017. There was an average of 249.6 citations per year. The articles predominantly addressed biomechanics and bone formation (38). Different surgical techniques, including intramedullary nail (14), Ilizarov (nine), intramedullary skeletal kinetic distractor (ISKD) (six), Taylor spatial frame (6), the PRECICE device (three), and lengthening and submuscular locking plate (three), were the second most-studied topic. Most studies were therapeutic (58), whereas 30 studies were experimental investigations using animal models. Among the clinical studies, case series were predominant (level of evidence IV) (57). This study presents the first bibliometric analysis of the most relevant articles on bone lengthening. The list is relatively comprehensive in terms of identifying the top issues in this field. However, the most influential clinical studies have a poor level of evidence, although a slight tendency toward a better level of evidence has been observed in more recent years.
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Abstract
Non-union of bone following fracture is an orthopaedic condition with a high morbidity and clinical burden. Despite its estimated global prevalence of nine million annually, the limit of bone regeneration therapy still results in patients living with pain, a reduced quality of life and associated psychological, social and financial repercussions. This review provides an overview of the current epidemiological and aetiological data, and highlights where the clinical challenges in treating non-union lie. Current treatment strategies are discussed as well as promising future research foci. Development in biotechnologies to treat non-union provides exciting scope for more effective treatment for this debilitating condition.
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Affiliation(s)
- S K Stewart
- Department of Bioengineering, Imperial College London, United Kingdom
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11
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Simpson AHRW, Robiati L, Jalal MMK, Tsang STJ. Non-union: Indications for external fixation. Injury 2019; 50 Suppl 1:S73-S78. [PMID: 30955871 DOI: 10.1016/j.injury.2019.03.053] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 03/28/2019] [Indexed: 02/02/2023]
Abstract
External fixation is currently used as the definitive mode of fracture stabilisation in the management of ˜50% of long-bone non-unions. Distinction between non-union and delayed union is a diagnostic dilemma especially in fractures healing by primary bone repair. This distinction is important, as non-unions are not necessarily part of the same spectrum as delayed unions. The aetiology of a fracture non-union is usually multifactorial and the factors can be broadly categorized into mechanical factors, biological (local and systemic) factors, and infection. Infection is present in ˜40% of fracture non-unions, often after open fractures or impaired wound healing, but in 5% of all non-unions infection is present without any clinical or serological suspicion. General indications for external fixation include clinical scenarios where; 1) percutaneous correction of alignment, or mechanical stimulation of the non-union site is required; 2) fixation of juxta-articular or 'emmental' bone fragments is necessary; and 3) staged bone or soft tissue reconstruction is anticipated. Specific anatomical indications include infected non-unions of the tibia, humerus, and juxta-articular bone. External fixation is an essential tool in the management of fracture non-unions. However, with greater understanding of the outcomes associated with both external and internal fixation the relative indications are now being refined.
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Affiliation(s)
- A H R W Simpson
- Department of Trauma and Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, United Kingdom.
| | - L Robiati
- Department of Trauma and Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, United Kingdom
| | - M M K Jalal
- Department of Trauma and Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, United Kingdom
| | - S T J Tsang
- Department of Trauma and Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, United Kingdom
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Aktuglu K, Erol K, Vahabi A. Ilizarov bone transport and treatment of critical-sized tibial bone defects: a narrative review. J Orthop Traumatol 2019; 20:22. [PMID: 30993461 PMCID: PMC6468024 DOI: 10.1186/s10195-019-0527-1] [Citation(s) in RCA: 107] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 03/20/2019] [Indexed: 12/23/2022] Open
Abstract
Background Critical-sized bone defects of the tibia are complex injuries associated with significant problems that are difficult to treat, and they are associated with a significant burden of disease in clinical practice; however, the treatment of these cases has still been a challenge for orthopedic surgeons. The aim of this review was to evaluate the current available studies reporting on classical Ilizarov methods in the treatment of infected or noninfected critical-sized bone defects of the tibia, and to perform an analysis of treatment period and complications. Methods This is a narrative review based on a comprehensive literature search among the studies in Pubmed, Scopus and Web of Science articles. The studies included were written in the English language or translated to English and they were published between 2008 and 2018. They were appraised with narrative data synthesis. The primary outcome measures were the external fixation time (EFT), bone union rate, and bone and functional results. Secondary outcomes were complications including docking site problems and solutions. The heterogeneity of the data in the studies which were taken into consideration allowed a narrative analysis. Results Twenty-seven articles with 619 patients were included in this study. These included 6 prospective and 21 retrospective case series. Mean age was 36.1 (range 13–89) years. Of the cases, 88.8% were infected and the remaining 11.2% were noninfected. The external fixation time was 10.75 (range 2.5–23.2) months. The mean bone union rate was 90.2% (range 77–100)%. Radiographic outcome measures were reported in 20 studies. Functional outcome measures were reported in 18 studies. ASAMI (Association for the Study of the Method of Ilizarov) criteria are useful and give reproducible data on patient outcome measurements. Data collected from these studies showed excellent radiological outcomes in 303, good in 143, fair in 31, and poor in 25 patients. Functional outcomes were excellent in 200, good in 167, fair in 58, and poor in 19, where reported. The excellent and good rate in bone results and functional results were 88.8% and 82.6%, respectively. The poor rate in bone results and functional results were 5% and 4.5%. Mean complication rate per patient was 1.22 (range 3–60). The most common complication was pin tract infection (PTI). Its occurrence was 46.6%. Joint stiffness followed PTI with a 25% incidence. The rates of refracture, malunion, infectious recurrence, and amputation, were 4%, 8.4%, 4.58%, and 1%, respectively. Conclusions This narrative review shows that the patients with infected or noninfected critical-sized tibial bone defects treated by Ilizarov methods had a low rate of poor bone and functional results. Therefore, Ilizarov methods may be a good choice for the treatment of infected or noninfected tibial bone defects. The small number of cases in some studies, the absence of homogenity between studies and the fact that most data available are derived from retrospective studies are some of the difficulties encountered in the evaluation of evidence. Level of evidence V.
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Affiliation(s)
- Kemal Aktuglu
- Department of Orthopedics and Traumatology, Ege University, Talatpasa Bulvari, Sezik Apt., No: 61/3 Alsancak, Izmir, Turkey.
| | - Kubilay Erol
- Department of Orthopedics and Traumatology, Ege University, Talatpasa Bulvari, Sezik Apt., No: 61/3 Alsancak, Izmir, Turkey
| | - Arman Vahabi
- Department of Orthopedics and Traumatology, Ege University, Talatpasa Bulvari, Sezik Apt., No: 61/3 Alsancak, Izmir, Turkey
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Bakhsh K, Atiq-Ur-Rehman, Zimri FK, Mohammad E, Ahmed W, Saaiq M. Presentation and management outcome of tibial infected non-union with Ilizarov technique. Pak J Med Sci 2019; 35:136-140. [PMID: 30881411 PMCID: PMC6408636 DOI: 10.12669/pjms.35.1.67] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Objective: To document the presentation of tibial infected non-union and analyze the management outcome with Ilizarov technique in terms of bone results, functional outcome, bone transport time, external fixation time, external fixation index and any complications. Methods: This case series was conducted at the Departments of Orthopedic Surgery, National Institute of Rehabilitation Medicine (NIRM), Islamabad and Civil hospital, Quetta over a period of 3-years. Results: There were 56 patients with 53(94.64%) males and 3(5.35%) females. The age range was 16-50 years with a mean of 32.58±9.98years. According to ASAMI criteria, bone results were excellent in 37(66%), good in 10(17.85%), fair in 6(10.71%) and poor in 3(5.35%). The functional results were excellent in 37(66%), good in 9(16%), fair in 7(12.5%) and poor in 3(5.35%). The bone union rate was 98.21%. Conclusion: Ilizarov method beautifully addresses the formidable issue of infected non union of tibia with good outcome in terms of bone healing and infection eradication. The treatment period is relatively lengthy and hence patience on part of patient as well as the surgical team is imperative for achieving favourable outcomes.
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Affiliation(s)
- Karim Bakhsh
- Dr. Karim Bakhsh FCPS, Department of Orthopedics, Civil Hospital, Bolan Medical College, Quetta, Pakistan
| | - Atiq-Ur-Rehman
- Dr. Atiq-Ur-Rehman FCPS, Department of Orthopedics, Civil Hospital, Bolan Medical College, Quetta, Pakistan
| | - Faridullah Khan Zimri
- Dr. Faridullah Khan Zimri FCPS, Department of Orthopedics, National Institute of Rehabilitation Medicine (NIRM), Islamabad, Pakistan
| | - Eid Mohammad
- Dr. Eid Mohammad FCPS, Department of Orthopedics, Civil Hospital, Bolan Medical College, Quetta, Pakistan
| | - Wazir Ahmed
- Dr. Wazir Ahmed MS, Department of Orthopedics, Civil Hospital, Bolan Medical College, Quetta, Pakistan
| | - Muhammad Saaiq
- Dr. Muhammad Saaiq FCPS, Department of Orthopedics, National Institute of Rehabilitation Medicine (NIRM), Islamabad, Pakistan
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Zhang Z, Swanson WB, Wang YH, Lin W, Wang G. Infection-free rates and Sequelae predict factors in bone transportation for infected tibia: a systematic review and meta-analysis. BMC Musculoskelet Disord 2018; 19:442. [PMID: 30545342 PMCID: PMC6293587 DOI: 10.1186/s12891-018-2363-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 11/27/2018] [Indexed: 02/05/2023] Open
Abstract
Background Tibia infected nonunion and chronic osteomyelitis are challenging clinical presentations. Bone transportation with external or hybrid fixators (combined external and internal fixators) is versatile to solve these problems. However, the infection-free rates of these fixator systems are unknown. Additionally, the prognosis factors for results of bone transportation are obscure. Therefore, this systematic review and meta-analysis was conducted to answer these questions. Methods A systematic review was conducted following the PRISMA-IPD guidelines. Relevant publications from January 1995 to September 2018 were compiled from Medline, Embase, and Cochrane. The infection-free rates of external and hybrid fixators were achieved by synthesizing aggregate data and individual participant data (IPD). IPD was analyzed by two-stage method with logistical regression to identify prognosis factors of sequelae. Results Twenty-two studies with 518 patients were identified, including 11 studies with 167 patients’ IPD, and 11 studies with 351 patients’ aggregate data. The infection-free rate of hybrid fixator group was 86% (95%CI: 79–94%), lower than that of external fixator which was 97% (95%CI: 95–98%,). The number of previous surgeries was found predict factor of bone union sequelae (p = 0.04) and function sequelae(p < 0.01); The external fixation time was found predict factor of function sequelae (p = 0.015). Conclusions Hybrid fixators may be associated with a greater risk of infection-recurrence in the treatment of tibia infected nonunion and chronic osteomyelitis. The number of previous surgeries and external fixation time can be used as predictors of outcomes. Proper fixators and meticulously designed surgery are important to avoid unexpected operations and shorten external fixation time.
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Affiliation(s)
- Zhen Zhang
- Department of Orthopedics, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Wuhou District, Chengdu, 610041, Sichuan Province, China.,Department of Biologic and Materials Sciences, School of Dentistry, University of Michigan, Ann Arbor, USA
| | - W Benton Swanson
- Department of Biologic and Materials Sciences, School of Dentistry, University of Michigan, Ann Arbor, USA
| | - Yan-Hong Wang
- Department of Neonatology, Beijing Gynecology & Obstetrics Hospital, Capital Medical University, Beijing, China
| | - Wei Lin
- Department of Gynecology, West China Second Hospital, Sichuan University, Chengdu, China
| | - Guanglin Wang
- Department of Orthopedics, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Wuhou District, Chengdu, 610041, Sichuan Province, China.
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Wu Y, Yin Q, Rui Y, Sun Z, Gu S. Ilizarov technique: Bone transport versus bone shortening-lengthening for tibial bone and soft-tissue defects. J Orthop Sci 2018; 23:341-345. [PMID: 29290472 DOI: 10.1016/j.jos.2017.12.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 12/04/2017] [Accepted: 12/06/2017] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To compare the outcomes of bone transport and bone shortening-lengthening by Ilizarov technique for treatment of tibial bone and soft-tissue defects. METHODS Fifty patients with tibial bone and soft-tissue defects were treated by Ilizarov technique from January 2007 to June 2016. Two subgroups were treated by either bone transport (group A) containing 28 cases or bone shortening-lengthening (group B) including 22 cases. RESULTS Bony union was achieved at the distracted sites with a mean of 236 days in group A, while 240 days in group B, showing no significant difference (t = -0.931, P = 0.308). The mean fixation index was 3.91 d/mm and 3.92 d/mm, respectively. There was no obvious difference (t = 2.839, P = 0.006) of the mean union time at the docking sites with 376 days and 320 days, respectively. According to the Paley's criterion, 21 patients had excellent bony union and 5 good in group A, as compared to 18 excellent and 4 good in group B, but no significant difference (X2 = -0.308, P = 0.741) was observed. The functional results were excellent in 11 patients, good in 10 and fair in 7, as well as 15 complications in group A, compared with 7 excellent, 10 good and 5 fair, together with 12 complications in group B, and there were no remarkable difference (X2 = -0.323, P = 0.751; X2 = -0.590, P = 0.562). CONCLUSION Overall, the outcomes are similar of bone transport or bone shortening-lengthening by using Ilizarov technique for treatment of tibial bone and soft-tissue defects, although the latter has less union time and higher healing rate.
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Affiliation(s)
- Yongwei Wu
- Department of Orthopaedics, The Ninth People's Hospital of Wuxi Affiliated to Soochow University, Wuxi 214062, Jiangsu, China
| | - Qudong Yin
- Department of Orthopaedics, The Ninth People's Hospital of Wuxi Affiliated to Soochow University, Wuxi 214062, Jiangsu, China.
| | - Yongjun Rui
- Department of Orthopaedics, The Ninth People's Hospital of Wuxi Affiliated to Soochow University, Wuxi 214062, Jiangsu, China.
| | - Zhenzhong Sun
- Department of Orthopaedics, The Ninth People's Hospital of Wuxi Affiliated to Soochow University, Wuxi 214062, Jiangsu, China
| | - Sanjun Gu
- Department of Orthopaedics, The Ninth People's Hospital of Wuxi Affiliated to Soochow University, Wuxi 214062, Jiangsu, China
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Abstract
OBJECTIVES We present a treatment algorithm comprising 4 Ilizarov methods in managing infected tibial nonunion, using nonunion mobility and segmental defect size to govern treatment choice. DESIGN Decision protocol analysis study. SETTING A university-affiliated teaching hospital. PATIENTS/PARTICIPANTS Seventy-nine patients were treated with 1 of 4 Ilizarov protocols. All patients had undergone at least one previous operation, 38 had associated limb deformity, and 49 had nonviable nonunions. Twenty-six had a new muscle flap at the time of Ilizarov surgery, and 25 had preexisting flaps reused. INTERVENTION Twenty-six cases were treated with monofocal distraction, 19 with monofocal compression, 16 with bifocal compression/distraction, and 18 with bone transport. MAIN OUTCOME MEASUREMENTS The primary outcome measure was the absence of recurrent infection. Secondary outcomes included bone union, complications, the Association for the Advancement of Methods of Ilizarov (ASAMI) bone and functional classification scores, and any need for further unplanned surgery. RESULTS Infection was eradicated in 76 cases (96.2%) with a mean follow-up duration of 40.8 months (range 6-131). All 3 infection recurrences occurred in the monofocal compression group. Following the initial Ilizarov method alone, union was achieved in 68 cases (86.1%) and was highest among the monofocal distraction (96.2%) and bifocal compression/distraction groups (93.8%). Monofocal compression achieved the lowest union rate (73.7%), significantly lower ASAMI scores, and a refracture rate of 31.6%. Bone transport secured union in 77.8% with a 44.4% unplanned reoperation rate. However, infection-free union was 100% after further treatment. CONCLUSIONS Monofocal compression is not recommended for treating infected, mobile nonunions. Distraction (monofocal or bifocal) was effective and achieved higher rates of union and infection clearance. LEVEL OF EVIDENCE Level III.
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Treatment Options for Nonunion With Segmental Bone Defects: Systematic Review and Quantitative Evidence Synthesis. J Orthop Trauma 2017; 31:111-119. [PMID: 27611666 DOI: 10.1097/bot.0000000000000700] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine which reconstruction treatment of long bones nonunion with segmental bone defects (SBDs) is effective to restore bone length and union with good function. DATA SOURCES PubMed was used to identify published literature on treatment of SBD caused by fracture nonunion regardless of infection between January 1975 and December 2014. STUDY SELECTION We included retrospective cohort studies with a minimum sample size of 10 consecutive patients with minimum follow-up of 18 months and available data on radiographic and functional outcomes. DATA EXTRACTION Literature review revealed 24 publications with a sample size of 504 patients (395 males, 109 females). Data on bone union and functional outcome and complications were collected and analyzed based on validated classification systems. DATA SYNTHESIS Two outcome groups were categorized for bone union and functional outcome, success, and failure. We then performed heterogeneity test to examine the variability or differences in the methods used by these studies and based on that we determined whether the fixed effect or random effect method is appropriate in examining the summary or pool estimate. Pool estimate was examined for bone union and functional outcome in each surgical modality and in each anatomic location when data were available. CONCLUSIONS Treatment of SBD can be challenging. This quantitative evidence synthesis shows that bone union was achieved by different procedures with variable bone union and functional outcomes. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Sahu RL, Ranjan R. Treatment of complex nonunion of the shaft of the tibia using Ilizarov technique and its functional outcome. Niger Med J 2016; 57:129-33. [PMID: 27226689 PMCID: PMC4872491 DOI: 10.4103/0300-1652.182076] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND A complex nonunion of the shaft of the tibia is a major cause of morbidity and mortality in patients with lower extremity injuries. AIMS The aim of this study was to evaluate the outcome of the functional and radiological outcome of complex nonunion shaft of tibia, treated by radical debridement, Ilizarov ring fixator with compression and distraction osteogenesis. METHODS From 2005 to 2010, sixty cases of complex nonunion shaft of tibia were included in our study. All infected nonunions were managed by radical debridement, fixed with Ilizarov ring fixator, monofocal/bifocal compression, and distraction osteogenesis. The average duration of follow-up is 36 months (26-50 months). The functional evaluation was done by using Association for the Study and Application of Methods of Ilizarov (ASAMI) scoring system and bone union with serial radiographs. RESULTS All patients had a successful union. The mean time for union was 7 months (5-9 months). The mean time of fixator removal is 12 months (8-14 months). Every patient had pin tract infections which were successfully treated with oral antibiotics. Four patients had an equinus deformity, one patient had insignificant limb shortening (1.5 cm), and three patients had soft tissue dystrophy. Using the ASAMI scoring system, we obtained 45 excellent, 10 good, 3 fair, and 2 poor functional results. CONCLUSIONS The Ilizarov technique for complex nonunions has a high rate of success in achieving union and eradicating infection, bone loss, and malalignment. Radical debridement is the key step to control bone infection.
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Affiliation(s)
- Ramji Lal Sahu
- Department of Orthopaedics, SMS and R, Sharda University, Noida, Uttar Pradesh, India
| | - Rajni Ranjan
- Department of Orthopaedics, SMS and R, Sharda University, Noida, Uttar Pradesh, India
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Hernigou P, Trousselier M, Roubineau F, Bouthors C, Chevallier N, Rouard H, Flouzat-Lachaniette CH. Local transplantation of bone marrow concentrated granulocytes precursors can cure without antibiotics infected nonunion of polytraumatic patients in absence of bone defect. INTERNATIONAL ORTHOPAEDICS 2016; 40:2331-2338. [PMID: 26928724 DOI: 10.1007/s00264-016-3147-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 02/16/2016] [Indexed: 01/03/2023]
Abstract
PURPOSE Infected, long bone non-unions present a significant clinical challenge. New and alternative therapies are needed to address this problem. The purposes of this study were to compare the number of circulating granulocyte-macrophage colony-forming units (CFU-GM) in the peripheral blood of polytraumatic patients with infected tibial non-unions and in the peripheral blood of control patients with the hypothesis that their number was decreased in polytraumatic patients; and to treat their infection without antibiotics and with local transplantation of bone marrow concentrated granulocytes precursors. METHODS Thirty (18 atrophic and 12 hyperthrophic ) infected tibial non-unions (without bone defect) that occurred after open fractures in polytraumatic patients were treated without antibiotics and with percutaneous injection of autologous bone marrow concentrate (BMC) containing granulocytes precursors (CFU-GM). CFU-GM progenitors were assessed in the bone marrow aspirate, peripheral blood, and fracture site of these patients. The number of these progenitors was compared with the CFU-GM progenitors of control patient samples (healthy donors matched for age and gender). Outcome measures were: timing of union, callus formation (radiographs and CT scan), and recurrence of clinical infection. RESULTS As compared to control patients, the number of CFU GM derived colonies was lower at peripheral blood in patients with infected nonunions. The bone marrow graft injected in nonunions contained after concentration 42 621 ± 20 350 CFU-GM-derived colonies/cc. Healing and cure of infection was observed at six months for 25 patients and at one year follow up for 30 patients. At the median ten year follow-up (range: 5 to 15), only one patient had clinical recurrent infection after healing (between 6 months and last follow-up). CONCLUSION The peripheral blood of these polytraumatic patients with infected nonunions had a remarkable decrease in CFU-GM-derived colonies as compared with normal controls. Local transplantation of concentrated CFU-GM-derived colonies aspirated from bone marrow allowed cure of infection and healing without antibiotics.
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Affiliation(s)
- Philippe Hernigou
- Orthopaedic Surgery, University Paris East (UPEC), Hôpital Henri Mondor, 94010, Creteil, France.
| | - Matthieu Trousselier
- Orthopaedic Surgeon, University Paris East (UPEC), Hôpital Henri Mondor, 94010, Creteil, France
| | - François Roubineau
- Orthopaedic Surgery, University Paris East (UPEC), Hôpital Henri Mondor, 94010, Creteil, France
| | - Charlie Bouthors
- Orthopaedic Surgeon, University Paris East (UPEC), Hôpital Henri Mondor, 94010, Creteil, France
| | - Nathalie Chevallier
- EFS Cell Therapy Facility, University Paris East (UPEC), Hôpital Henri Mondor, 94010, Creteil, France
| | - Helene Rouard
- EFS Cell Therapy Facility, University Paris East (UPEC), Hôpital Henri Mondor, 94010, Creteil, France
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Rohilla R, Siwach K, Devgan A, Singh R, Wadhwani J, Ahmed N. Outcome of distraction osteogenesis by ring fixator in infected, large bone defects of tibia. J Clin Orthop Trauma 2016; 7:201-209. [PMID: 28053385 PMCID: PMC5197053 DOI: 10.1016/j.jcot.2016.02.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 02/27/2016] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Salvage of large, infected bone defects in tibia poses a formidable problem. The present prospective study aimed to evaluate radiologic and functional outcome of ring fixator in infected, large (≥6 cm) bone defects of tibia treated with distraction osteogenesis. MATERIALS AND METHODS The study included 35 patients (30 males and 5 females) who had minimum of 6 cm gap after radical resection of necrotic bone and presence or history of active infection. Mean age was 36.1 years. Mean bone gap was 7.27 cm. Mean follow-up period was 25.4 months. RESULTS Fracture united primarily in 17 cases and after fixator adjustment with freshening of fracture margins in 15 cases. Fixator adjustment with bone grafting was done in one patient to achieve union. One patient had nonunion and another had amputation. The bone result was excellent, good, and poor in 19, 13, and 3 patients, respectively. The functional results were excellent, good, fair and failure in 14, 19, 1, and one patient, respectively. 24 patients had superficial pin tract infection and 18 patients had ankle stiffness. CONCLUSION Ring fixator systems reliably achieve union in infected, large bone defects of tibia and help in treating infection, shortening, bone and soft tissue loss simultaneously. We advocate early freshening of fracture ends and removal of interposed soft tissue at docking sites to achieve union. Superficial pin tract infection and ankle stiffness are common problems in managing large tibial defects. But good to excellent functional outcomes can be achieved in majority of patients.
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Affiliation(s)
- Rajesh Rohilla
- Professor, Department of Orthopaedics, PGIMS, Rohtak, Haryana 124001, India,Corresponding author. Tel.: +91 09812662814.
| | - Karan Siwach
- Resident, Department of Orthopaedics, PGIMS, Rohtak, Haryana 124001, India
| | - Ashish Devgan
- Professor, Department of Orthopaedics, PGIMS, Rohtak, Haryana 124001, India
| | - Roop Singh
- Professor, Department of Orthopaedics, PGIMS, Rohtak, Haryana 124001, India
| | - Jitendra Wadhwani
- Resident, Department of Orthopaedics, PGIMS, Rohtak, Haryana 124001, India
| | - Naseem Ahmed
- Resident, Department of Orthopaedics, PGIMS, Rohtak, Haryana 124001, India
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A Systematic Review and Meta-Analysis of Ilizarov Methods in the Treatment of Infected Nonunion of Tibia and Femur. PLoS One 2015; 10:e0141973. [PMID: 26529606 PMCID: PMC4631548 DOI: 10.1371/journal.pone.0141973] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 10/15/2015] [Indexed: 01/03/2023] Open
Abstract
Background Infected nonunion of tibia and femur are common in clinical practice, however, the treatment of these diseases has still been a challenge for orthopaedic surgeons. Ilizarov methods can eradicate infection, compensate bone defects and promote the bone union through progressive bone histogenesis. The objective of this systematic review was to review current available studies reporting on Ilizarov methods in the treatment of infected nonunion of tibia and femur, and to perform meta-analysis of bone and functional results and complications to evaluate the efficacy of Ilizarov methods. Methods A comprehensive literature search was performed from the SCI, PubMed, Cochrane Library; and Embase between January 1995 and August 2015. Some major data were statistically analyzed using weighted means based on the sample size in each study by SPSS 13.0, including number of patients, mean age, mean previous surgical procedures, mean bone defects, mean length of follow-up, bone union, complications per patient, external fixation time, and external fixation index(EFI). Bone results (excellent, good, fair and poor rate), functional results (excellent, good, fair and poor rate) and complications were analyzed by Stata 9.0. Findings A total of 590 patients from 24 studies were included in this systematic review. The average of bone union rate was 97.26% in all included studies. The poor rate in bone results and functional results was 8% (95%CI, 0.04–0.12; I2 = 44.1%, P = 0.065) and 10% (95%CI, 0.05–0.14; I2 = 34.7%, P = 0.121) in patients with infected nonunion of tibia and femur treated by Ilizarov methods. The rate of refracture, malunion, infectious recurrence, knee stiffness, amputation, limb edema and peroneal nerve palsy was respectively 4%, 7%, 5%, 12%, 4%, 13% and 13%. Conclusions Our systematic review showed that the patients with infected nonunion of tibia and femur treated by Ilizarov methods had a low rate of poor bone and functional results. Therefore, Ilizarov methods may be a good choice for the treatment of infected nonunion of tibia and femur.
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Yin P, Zhang L, Li T, Xie Y, Li J, Li Z, Liu J, Zhang L, Zhang Q, Tang P. Ipsilateral fibula transport for the treatment of massive tibial bone defects. Injury 2015; 46:2273-7. [PMID: 26321119 DOI: 10.1016/j.injury.2015.08.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 08/11/2015] [Accepted: 08/15/2015] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The objective of the study was to evaluate the effectiveness of the treatment of massive tibial bone defects by ipsilateral fibula transport. MATERIALS AND METHODS Nine patients with massive tibial bone defects were retrospectively reviewed. There were 7 males and 2 females with an average age of 32.22 years. The mean length of bone defect was 15.67cm (range 13-25cm). RESULTS All patients were followed up and the mean time of follow up was 40.11 months (range 26-60 months). All the patients achieved bone union and the average external fixation time was 11.67 months (range 9-14 months). The mean degrees of knee extension were 2.2°(range 0-5°) and the mean degrees of knee flexion were 131.7° (range 120-140°). The mean degrees of ankle dorsiflexion were 8.9° (range 0-15°) and the mean degrees of ankle plantar flexion were 30° (range 20-40°). CONCLUSION Our study suggested that ipsilateral fibula transport in the treatment of massive tibial bone defects acquired satisfying functional results. It may be a better choice for the patients without suitable proximal or distal tibia remnant to transport.
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Affiliation(s)
- Peng Yin
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing 100853, PR China; Medical College, Nankai University, No. 94 Weijin Road, Tianjin 300071, PR China
| | - Lihai Zhang
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing 100853, PR China
| | - Tongtong Li
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing 100853, PR China; Medical College, Nankai University, No. 94 Weijin Road, Tianjin 300071, PR China
| | - Yong Xie
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing 100853, PR China
| | - Jiantao Li
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing 100853, PR China
| | - Zhirui Li
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing 100853, PR China
| | - Jianheng Liu
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing 100853, PR China
| | - Lining Zhang
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing 100853, PR China
| | - Qun Zhang
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing 100853, PR China.
| | - Peifu Tang
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing 100853, PR China.
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Yin P, Zhang L, Zhang L, Li T, Li Z, Li J, Zhou J, Yao Q, Zhang Q, Tang P. Ilizarov bone transport for the treatment of fibular osteomyelitis: a report of five cases. BMC Musculoskelet Disord 2015; 16:242. [PMID: 26342841 PMCID: PMC4561167 DOI: 10.1186/s12891-015-0708-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Accepted: 09/03/2015] [Indexed: 11/10/2022] Open
Abstract
Background The objective of this study was to evaluate the effectiveness of the treatment of fibular osteomyelitis by Ilizarov bone transport. Methods We retrospectively reviewed 5 patients with fibular osteomyelitis treated by Ilizarov bone transport. Our study included 4 males and 1 female with a mean of age 29.2 years. The average length of the bone defects after radical debridement was 7.6 cm (range 6.5-10 cm). Results The mean follow-up was 24.8 months (range 14–34 months). No patient was lost to follow-up. All the patients had bone union and no recurrence of infection was observed. The mean external fixation time was 8.8 months (range 8-10 months), and the mean external fixation index was 1.18 months/cm (range 0.90-1.43 months/cm). There was no sign of knee or ankle instability by clinical examination in all the patients. According to Association for the Study and Application of the Method of Ilizarov (ASAMI) classification, bone results were excellent in 3 patients, good in 2 patients; functional results were excellent in 3 patients, good in 2 patients. Conclusions Our study suggested that Ilizarov bone transport may be a good choice for the treatment of fibular osteomyelitis, especially for the patient with distal fibular loss.
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Affiliation(s)
- Peng Yin
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853, P.R. China. .,Medical College, Nankai University, No. 94 Weijin Road, Tianjin, 300071, P.R. China.
| | - Lihai Zhang
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853, P.R. China.
| | - Lining Zhang
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853, P.R. China.
| | - Tongtong Li
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853, P.R. China. .,Medical College, Nankai University, No. 94 Weijin Road, Tianjin, 300071, P.R. China.
| | - Zhirui Li
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853, P.R. China.
| | - Jiantao Li
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853, P.R. China.
| | - Jianfeng Zhou
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853, P.R. China.
| | - Qi Yao
- Department of Orthopaedics, Beijing Shijitan Hospital, Beijing, P.R. China.
| | - Qun Zhang
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853, P.R. China.
| | - Peifu Tang
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853, P.R. China.
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Bose D, Kugan R, Stubbs D, McNally M. Management of infected nonunion of the long bones by a multidisciplinary team. Bone Joint J 2015; 97-B:814-7. [PMID: 26033062 DOI: 10.1302/0301-620x.97b6.33276] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Infected nonunion of a long bone continues to present difficulties in management. In addition to treating the infection, it is necessary to establish bony stability, encourage fracture union and reconstruct the soft-tissue envelope. We present a series of 67 infected nonunions of a long bone in 66 patients treated in a multidisciplinary unit. The operative treatment of patients suitable for limb salvage was performed as a single procedure. Antibiotic regimes were determined by the results of microbiological culture. At a mean follow-up of 52 months (22 to 97), 59 patients (88%) had an infection-free united fracture in a functioning limb. Seven others required amputation (three as primary treatment, three after late failure of limb salvage and one for recalcitrant pain after union). The initial operation achieved union in 54 (84%) of the salvaged limbs at a mean of nine months (three to 26), with recurrence of infection in 9%. Further surgery in those limbs that remained ununited increased the union rate to 62 (97%) of the 64 limbs treated by limb salvage at final follow-up. The use of internal fixation was associated with a higher risk of recurrent infection than external fixation.
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Affiliation(s)
- D Bose
- Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK
| | - R Kugan
- Gloucester Royal Infirmary, 8 Meadow Close, Sutton Coldfield B76 2QQ, UK
| | - D Stubbs
- Oxford University Hospitals NHS Trust, Windmill Road, Oxford OX3 7HE, UK
| | - M McNally
- Oxford University Hospitals NHS Trust, Windmill Road, Oxford OX3 7HE, UK
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25
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Al Shahrani AA, Tedla JS, Ahmad I. Effectiveness of ilizarov frame fixation on functional outcome in aseptic tibial non-union cases at Abha, Kingdom of Saudi Arabia: An experimental study. J Taibah Univ Med Sci 2015. [DOI: 10.1016/j.jtumed.2014.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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26
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Krappinger D, Lindtner R, Zegg M, Dal Pont A, Huber B. Die Masquelet-Technik zur Behandlung großer dia- und metaphysärer Knochendefekte. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2015; 27:357-68. [DOI: 10.1007/s00064-014-0300-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Revised: 03/17/2014] [Accepted: 03/21/2014] [Indexed: 02/07/2023]
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Hu C, Zhang T, Ren B, Deng Z, Cai L, Lei J, Ping A. Effect of vacuum-assisted closure combined with open bone grafting to promote rabbit bone graft vascularization. Med Sci Monit 2015; 21:1200-6. [PMID: 25913359 PMCID: PMC4428317 DOI: 10.12659/msm.892939] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background Patients with composite bone non-union and soft tissue defects are difficult to treat. Vacuum-assisted closure (VAC) combined with open bone grafting is one of the most effective treatments at present. The aim of the present study was to preliminarily investigate the effect and mechanism of VAC combined with open bone grafting to promote rabbit bone graft vascularization, and to propose a theoretical basis for clinical work. Material/Methods Twenty-four New Zealand white rabbits were randomly divided into an experimental and a control group. Allogeneic bones were grafted and banded with the proximal femur with a suture. The experimental group had VAC whereas the control group had normal wound closure. The bone vascularization rate was compared based on X-ray imaging, fluorescent bone labeling (labeled tetracycline hydrochloride and calcein), calcium content in the callus, and expression of fibroblast growth factor-2 (FGF-2) in bone allografts by Western blot analysis at the 4th, 8th, and 12th week after surgery. Results At the 4th, 8th, and 12th week after surgery, the results of the tests demonstrated that the callus was larger, contained more calcium (p<0.05), and expressed FGF-2 at higher levels (p<0.05) in the experimental group than in the control group. Fluorescent bone labeling showed the distance between the two fluorescent ribbons was significantly shorter in the control group than in the experimental group at the 8th and 12th week after surgery. Conclusions VAC combined with open bone grafting promoted rabbit bone graft vascularization.
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Affiliation(s)
- Chao Hu
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Taogen Zhang
- Department of Orthopedics, People' Hospital of Daye City, Daye, Hubei, China (mainland)
| | - Bin Ren
- Department of Radio-Chemo Therapy, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Zhouming Deng
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Lin Cai
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Jun Lei
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Ansong Ping
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
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Yin P, Zhang L, Li T, Zhang L, Wang G, Li J, Liu J, Zhou J, Zhang Q, Tang P. Infected nonunion of tibia and femur treated by bone transport. J Orthop Surg Res 2015; 10:49. [PMID: 25889513 PMCID: PMC4415215 DOI: 10.1186/s13018-015-0189-5] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2014] [Accepted: 01/27/2015] [Indexed: 12/19/2022] Open
Abstract
Objective The objective of this study was to evaluate the effectiveness of the treatment of infected nonunion of tibia and femur by bone transport. Material and methods We retrospectively reviewed 110 patients with infected nonunion of tibia and femur treated by bone transport. Our study included 92 males and 18 females with a mean age of 38.90 years. The site of infected nonunion involved 72 tibias and 38 femurs. The mean length of the bone defects after radical debridement was 6.15 cm (range 3–13 cm). Results The mean follow-up after removal of the apparatus was 23.12 months (14–46 months). Ten patients including seven patients with infected tibia nonunion and three patients with infected femur nonunion were lost to follow-up. All the patients achieved bone union, and no recurrence of infection was observed. The time of bone transport took a mean of 67.50 days (range 33 to 137 days), and the mean external fixation index was 1.48 months/cm (range 1.15–1.71 months/cm). According to Association for the Study and Application of the Method of Ilizarov (ASAMI) classification, bone results were excellent in 68, good in 28, fair in 12, and poor in 2; functional results were excellent in 37, good in 42, fair in 21, and no poor. Conclusions Our study and the current evidence suggested that Ilizarov methods in the treatment of infected nonunion of tibia and femur acquired satisfied results. Radical debridement is the key step to control bone infection.
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Affiliation(s)
- Peng Yin
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853, P.R. China. .,Medical College, Nankai University, No. 94 Weijin Road, Tianjin, 300071, P.R. China.
| | - Lihai Zhang
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853, P.R. China.
| | - Tongtong Li
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853, P.R. China. .,Medical College, Nankai University, No. 94 Weijin Road, Tianjin, 300071, P.R. China.
| | - Licheng Zhang
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853, P.R. China.
| | - Guoqi Wang
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853, P.R. China.
| | - Jiantao Li
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853, P.R. China.
| | - Jianheng Liu
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853, P.R. China.
| | - Jianfeng Zhou
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853, P.R. China.
| | - Qun Zhang
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853, P.R. China.
| | - Peifu Tang
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853, P.R. China.
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Ajmera A, Verma A, Agrawal M, Jain S, Mukherjee A. Outcome of limb reconstruction system in open tibial diaphyseal fractures. Indian J Orthop 2015; 49:429-35. [PMID: 26229164 PMCID: PMC4510797 DOI: 10.4103/0019-5413.159638] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Management of open tibial diaphyseal fractures with bone loss is a matter of debate. The treatment options range from external fixators, nailing, ring fixators or grafting with or without plastic reconstruction. All the procedures have their own set of complications, like acute docking problems, shortening, difficulty in soft tissue management, chronic infection, increased morbidity, multiple surgeries, longer hospital stay, mal union, nonunion and higher patient dissatisfaction. We evaluated the outcome of the limb reconstruction system (LRS) in the treatment of open fractures of tibial diaphysis with bone loss as a definative mode of treatment to achieve union, as well as limb lengthening, simultaneously. MATERIALS AND METHODS Thirty open fractures of tibial diaphysis with bone loss of at least 4 cm or more with a mean age 32.5 years were treated by using the LRS after debridement. Distraction osteogenesis at rate of 1 mm/day was done away from the fracture site to maintain the limb length. On the approximation of fracture ends, the dynamized LRS was left for further 15-20 weeks and patient was mobilized with weight bearing to achieve union. Functional assessment was done by Association for the Study and Application of the Methods of Illizarov (ASAMI) criteria. RESULTS Mean followup period was 15 months. The mean bone loss was 5.5 cm (range 4-9 cm). The mean duration of bone transport was 13 weeks (range 8-30 weeks) with a mean time for LRS in place was 44 weeks (range 24-51 weeks). The mean implant index was 56.4 days/cm. Mean union time was 52 weeks (range 31-60 weeks) with mean union index of 74.5 days/cm. Bony results as per the ASAMI scoring were excellent in 76% (19/25), good in 12% (3/25) and fair in 4% (1/25) with union in all except 2 patients, which showed poor results (8%) with only 2 patients having leg length discrepancy more than 2.5 cm. Functional results were excellent in 84% (21/25), good in 8% (2/25), fair in 8% (2/25). Pin tract infection was seen in 5 cases, out of which 4 being superficial, which healed to dressings and antibiotics. One patient had a deep infection which required frame removal. CONCLUSION Limb reconstruction system proved to be an effective modality of treatment in cases of open fractures of the tibia with bone loss as definite modality of treatment for damage control as well as for achieving union and lengthening, simultaneously, with the advantage of early union with attainment of limb length, simple surgical technique, minimal invasive, high patient compliance, easy wound management, lesser hospitalization and the lower rate of complications like infection, deformity or shortening.
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Affiliation(s)
- Anand Ajmera
- Department of Orthopaedics, Mahatma Gandhi Memorial Medical College and M.Y. Hospital, Indore, Madhya Pradesh, India
| | - Ankit Verma
- Department of Orthopaedics, Mahatma Gandhi Memorial Medical College and M.Y. Hospital, Indore, Madhya Pradesh, India
| | - Mukul Agrawal
- Department of Orthopaedics, Mahatma Gandhi Memorial Medical College and M.Y. Hospital, Indore, Madhya Pradesh, India
| | - Saurabh Jain
- Department of Orthopaedics, Mahatma Gandhi Memorial Medical College and M.Y. Hospital, Indore, Madhya Pradesh, India,Address for correspondence: Dr. Saurabh Jain, A-2, Mahavir Hospital, Footi-Khothi Square, Indore, Madhya Pradesh - 452 009, India. E-mail:
| | - Arunangshu Mukherjee
- Department of Orthopaedics, Mahatma Gandhi Memorial Medical College and M.Y. Hospital, Indore, Madhya Pradesh, India
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Deng Z, Cai L, Jin W, Ping A, Wei R. One-stage reconstruction with open bone grafting and vacuum-assisted closure for infected tibial non-union. Arch Med Sci 2014; 10:764-72. [PMID: 25276163 PMCID: PMC4175757 DOI: 10.5114/aoms.2013.34411] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Revised: 05/24/2012] [Accepted: 06/14/2012] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Non-union of the tibia complicated by osteomyelitis is one of the most challenging problems in orthopaedic surgery. There remains a significant amount of debate and controversy regarding the optimal medical management of infected tibial non-union. There are few articles which have reported the outcomes of treatment for infected non-union of tibia from single-stage reconstruction with open bone grafting plus vacuum-assisted closure (VAC). MATERIAL AND METHODS Our report covers experience between March 2007 and February 2010 of open bone grafting plus VAC in one stage for patients with infected tibial non-union. The time for bone union and wound healing to occur, the duration of hospitalisation, and the rate of resolution of infection were all analysed. The main outcome measures were based on a clinical scoring system that assessed functional ability, range of knee and ankle motion, shortening, infection and pain. Fifteen patients were involved in this study. RESULTS All patients were followed up for an average of 22.6 months (range: 14-42 months). Bone union was achieved in 93.3% (14/15) of patients after a mean of 5.93 months (range: 3-10 months). All wounds healed within an average period of 5 weeks (range: 3-10 weeks), and the function and appearance of all limbs were satisfactory. CONCLUSIONS Open bone grafting combined with VAC in a one-stage procedure can be a feasible alternative to the treatment of infected tibial non-union, especially for those wounds which are not good candidates for microsurgery; however, further studies are required to confirm the likely benefits.
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Affiliation(s)
- Zhouming Deng
- Department of Orthopaedics, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Lin Cai
- Department of Orthopaedics, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Wei Jin
- Department of Orthopaedics, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Ansong Ping
- Department of Orthopaedics, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Renxiong Wei
- Department of Orthopaedics, Zhongnan Hospital of Wuhan University, Wuhan, China
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Papakostidis C, Bhandari M, Giannoudis PV. Distraction osteogenesis in the treatment of long bone defects of the lower limbs: effectiveness, complications and clinical results; a systematic review and meta-analysis. Bone Joint J 2014; 95-B:1673-80. [PMID: 24293599 DOI: 10.1302/0301-620x.95b12.32385] [Citation(s) in RCA: 127] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
We carried out a systematic review of the literature to evaluate the evidence regarding the clinical results of the Ilizarov method in the treatment of long bone defects of the lower limbs. Only 37 reports (three non-randomised comparative studies, one prospective study and 33 case-series) met our inclusion criteria. Although several studies were unsatisfactory in terms of statistical heterogeneity, our analysis appears to show that the Ilizarov method of distraction osteogenesis significantly reduced the risk of deep infection in infected osseous lesions (risk ratio 0.14 (95% confidence interval (CI) 0.10 to 0.20), p < 0.001). However, there was a rate of re-fracture of 5% (95% CI 3 to 7), with a rate of neurovascular complications of 2.2% (95% CI 0.3 to 4) and an amputation rate of 2.9% (95% CI 1.4 to 4.4).The data was generally not statistically heterogeneous. Where tibial defects were > 8 cm, the risk of re-fracture increased (odds ratio 3.7 (95% CI 1.1 to 12.5), p = 0.036). The technique is demanding for patients, illustrated by the voluntary amputation rate of 1.6% (95% CI 0 to 3.1), which underlines the need for careful patient selection.
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Affiliation(s)
- C Papakostidis
- "G. Hatzikostas" General Hospital, Department of Trauma and Orthopaedics, Makriyianni Av., 45 001, Ioannina, Greece
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Treatment of large posttraumatic tibial bone defects using the Ilizarov method: a subjective outcome assessment. Arch Orthop Trauma Surg 2013; 133:789-95. [PMID: 23463259 DOI: 10.1007/s00402-013-1712-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Indexed: 02/09/2023]
Abstract
BACKGROUND The treatment of large posttraumatic tibial bone defects using the Ilizarov method was shown to be successful in several studies. These studies, however, typically focus on the radiological and functional outcome using objective parameters only. The aim of the present study was therefore to assess the objective and subjective outcome of a consecutive series of patients with large posttraumatic tibial bone defects using the Ilizarov method. Additionally, it was our goal to assess the physical and mental stress for the patients and their relatives during the long treatment period and the general health status at final follow-up. METHODS A consecutive series of 15 patients with posttraumatic tibial bone defects of >30 mm after sustaining open tibial fractures and failure of internal fixation was included. The objective outcome was assessed at final follow-up using Paley's criteria. For the assessment of the subjective outcome, all patients were asked to evaluate their satisfaction with the function of the lower leg, the cosmetic appearance and overall outcome as well. The physical and mental stress of the treatment for the patients and the nearest relative of patients were assessed at the time of frame removal using a custom-made questionnaire. The SF-36 was used to evaluate the general health status at final follow-up. RESULTS Solid bone union with stable soft tissue coverage and eradication of infection was achieved in all patients despite a high complication rate. The functional outcome at final follow-up was excellent or good in all patients. The patients' satisfaction with the overall outcome and the function of the lower extremity was high as well. The fear of amputation and complications was the major subjective burden for both the patients and their relatives. The long external fixation time is another relevant issue. CONCLUSION The Ilizarov method is a safe option for the treatment of large posttraumatic tibial bone defects after failure of internal fixation despite the high complication rate. It is essential to comment this to the patients and their relatives prior to the application of the frame increase their compliance with the long and emotionally draining treatment. The Ilizarov method is worth the effort only in patients, who will presumably comply with this treatment option and all of its drawbacks.
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Prince DE. The use of distraction osteogenesis for reconstruction of bone defects after tumor resection of high-grade lesions. CURRENT ORTHOPAEDIC PRACTICE 2013. [DOI: 10.1097/bco.0b013e31829413d5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Clinical reliability of closed techniques and comparison with open strategies to achieve union at the docking site. INTERNATIONAL ORTHOPAEDICS 2011; 36:817-25. [PMID: 21505801 DOI: 10.1007/s00264-011-1260-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 01/09/2011] [Accepted: 03/27/2011] [Indexed: 10/18/2022]
Abstract
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.
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Sabharwal S, Green S, McCarthy J, Hamdy RC. What's New in Limb Lengthening and Deformity Correction. J Bone Joint Surg Am 2011; 93:213-21. [PMID: 21248221 DOI: 10.2106/jbjs.j.01420] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Sanjeev Sabharwal
- Department of Orthopaedics, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, NJ 07103, USA.
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