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Feltri P, Solaro L, Errani C, Schiavon G, Candrian C, Filardo G. Vascularized fibular grafts for the treatment of long bone defects: pros and cons. A systematic review and meta-analysis. Arch Orthop Trauma Surg 2023; 143:29-48. [PMID: 34110477 DOI: 10.1007/s00402-021-03962-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 05/16/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To quantify union rate, complication rate, reintervention rate, as well as functional outcome after vascularized fibular bone grafts (VFGs) for the treatment of long-bone defects. METHODS A comprehensive search was performed in the PubMed, Web of Science, and Cochrane databases up to August 18, 2020. Randomized controlled trials, comparative studies, and case series describing the various techniques available involving VFGs for the reconstruction of segmental long-bone defects were included. A meta-analysis was performed on union results, complications, and reinterventions. Assessment of risk of bias and quality of evidence was performed with the Downs and Black's "Checklist for Measuring Quality". RESULTS After full-text assessment, 110 articles on 2226 patients were included. Among the retrieved studies, 4 were classified as poor, 83 as fair, and 23 as good. Overall, good functional results were documented and a union rate of 80.1% (CI 74.1-86.2%) was found, with a 39.4% (CI 34.4-44.4%) complication rate, the most common being fractures, non-unions and delayed unions, infections, and thrombosis. Donor site morbidity represented 10.7% of the total complications. A 24.6% reintervention rate was documented (CI 21.0-28.1%), and 2.8% of the patients underwent amputation. CONCLUSIONS This systematic review and meta-analysis documented good long-term outcomes both in the upper and lower limb. However, VFG is a complex and demanding technique; this complexity means an average high number of complications, especially fractures, non-unions, and vascular problems. Both potential and limitations of VFG should be considered when choosing the most suitable approach for the treatment of long-bone defects.
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Affiliation(s)
- Pietro Feltri
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, 6900, Lugano, Switzerland
| | - Luca Solaro
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli, 1/10, 40136, Bologna, Italy.
| | - Costantino Errani
- Orthopaedic Service, Musculoskeletal Oncology Department, IRCCS Istituto Ortopedico Rizzoli, 40136, Bologna, Italy
| | - Guglielmo Schiavon
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, 6900, Lugano, Switzerland
| | - Christian Candrian
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, 6900, Lugano, Switzerland.,Facoltà Di Scienze Biomediche, Università della Svizzera Italiana, Via Buffi 13, 6900, Lugano, Switzerland
| | - Giuseppe Filardo
- Applied and Translational Research Center, IRCCS Istituto Ortopedico Rizzoli, 40136, Bologna, Italy.,Facoltà Di Scienze Biomediche, Università della Svizzera Italiana, Via Buffi 13, 6900, Lugano, Switzerland
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Marongiu G, Dolci A, Verona M, Capone A. The biology and treatment of acute long-bones diaphyseal fractures: Overview of the current options for bone healing enhancement. Bone Rep 2020; 12:100249. [PMID: 32025538 PMCID: PMC6997516 DOI: 10.1016/j.bonr.2020.100249] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 01/11/2020] [Accepted: 01/26/2020] [Indexed: 02/06/2023] Open
Abstract
Diaphyseal fractures represent a complex biological entity that could often end into impaired bone-healing, with delayed union and non-union occurring up to 10% of cases. The role of the modern orthopaedic surgeon is to optimize the fracture healing environment, recognize and eliminate possible interfering factors, and choose the best suited surgical fixation technique. The impaired reparative process after surgical intervention can be modulated with different surgical techniques, such as dynamization or exchange nailing after failed intramedullary nailing. Moreover, the mechanical stability of a nail can be improved through augmentation plating, bone grafting or external fixation techniques with satisfactory results. According to the "diamond concept", local therapies, such as osteoconductive scaffolds, bone growth factors, and osteogenic cells can be successfully applied in "polytherapy" for the enhancement of delayed union and non-union of long bones diaphyseal fractures. Moreover, systemic anti-osteoporosis anabolic drugs, such as teriparatide, have been proposed as off-label treatment for bone healing enhancement both in fresh complex shaft fractures and impaired unions, especially for fragility fractures. The article aims to review the biological and mechanical principles of failed reparative osteogenesis of diaphyseal fractures after surgical treatment. Moreover, the evidence about the modern non-surgical and pharmacological options for bone healing enhancement will discussed.
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Affiliation(s)
- Giuseppe Marongiu
- Orthopaedic and Trauma Clinic, Department of Surgical Sciences, University of Cagliari, Lungomare Poetto, Cagliari 09126, Italy
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Marongiu G, Contini A, Cozzi Lepri A, Donadu M, Verona M, Capone A. The Treatment of Acute Diaphyseal Long-bones Fractures with Orthobiologics and Pharmacological Interventions for Bone Healing Enhancement: A Systematic Review of Clinical Evidence. Bioengineering (Basel) 2020; 7:bioengineering7010022. [PMID: 32102398 PMCID: PMC7148449 DOI: 10.3390/bioengineering7010022] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 02/17/2020] [Accepted: 02/20/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The healing of long bones diaphyseal fractures can be often impaired and eventually end into delayed union and non-union. A number of therapeutic strategies have been proposed in combination with surgical treatment in order to enhance the healing process, such as scaffolds, growth factors, cell therapies and systemic pharmacological treatments. Our aim was to investigate the current evidence of bone healing enhancement of acute long bone diaphyseal fractures. METHODS A systematic review was conducted by using Pubmed/MEDLINE; Embase and Ovid databases. The combination of the search terms "long-bones; diaphyseal fracture; bone healing; growth factors; cell therapies; scaffolds; graft; bone substitutes; orthobiologics; teriparatide". RESULTS The initial search resulted in 4156 articles of which 37 papers fulfilled the inclusion criteria and were the subject of this review. The studies included 1350 patients (837 males and 513 females) with a mean age of 65.3 years old. CONCLUSIONS General lack of high-quality studies exists on the use of adjuvant strategies for bone healing enhancement in acute shaft fractures. Strong evidence supports the use of bone grafts, while only moderate evidence demineralized bone matrix and synthetic ceramics. Conflicting results partially supported the use of growth factors and cell therapies in acute fractures. Teriparatide showed promising results, particularly for atypical femoral fractures and periprosthetic femoral fractures.
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Affiliation(s)
- Giuseppe Marongiu
- Orthopaedic and Trauma Clinic, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy; (A.C.); (M.V.); (A.C.)
- Correspondence: or ; Tel.: +39-070-6094368
| | - Andrea Contini
- Orthopaedic and Trauma Clinic, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy; (A.C.); (M.V.); (A.C.)
| | - Andrea Cozzi Lepri
- Orthopaedic Traumatologic Center, University of Florence, 50121 Florence, Italy;
| | - Matthew Donadu
- Dipartimento di Chimica e Farmacia, University of Sassari, 07100 Sassari, Italy;
| | - Marco Verona
- Orthopaedic and Trauma Clinic, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy; (A.C.); (M.V.); (A.C.)
| | - Antonio Capone
- Orthopaedic and Trauma Clinic, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy; (A.C.); (M.V.); (A.C.)
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Abstract
PURPOSE To present our experience in the management of acute large bone defects treated with the use of vascularized fibular grafts supported by Ilizarov circular external frames. PATIENTS AND METHODS During a period of 6 years (from 2007 to 2013) 8 patients with acute large bone defects (IVB according to Winquist modified classification) were treated at our institution with early bone reconstruction by means of microvascular fibular grafts. All patients were evaluated by the use of the following parameters: X-ray consolidation, discharge time, duration of treatment, malalignment of the lower limb and final leg length discrepancy, knee and ankle mobility (ROM), pain (VAS), number of eventual additive treatments (plastic surgery, etc.), walking independence (use of crutches), possibility to get back to work, subjective evaluation about the treatment and the result (SF-36, personal feelings about circular external fixator dressing) RESULTS: The mean treatment time, often connected to the mean consolidation time, was 61 weeks and the mean number of operations was 7.6. Six of the eight patients got back to their previous daily activities and work, without any further issues. DISCUSSION based on our experience, Ilizarov and fibular vascular grafts are not alternatives, as often reported in literature. Their combined use, especially in lesions as those classified as Winquist IV B, can represent an effective tool in the surgeon's hands to solve the most difficult cases of acute bone loss caused by severe high-energy traumas.
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Affiliation(s)
- B Battiston
- Orthopaedic Dpt., Città della Salute e della Scienza, Torino, Italy.
| | - D Santoro
- Orthopaedic Dpt., Città della Salute e della Scienza, Torino, Italy
| | - R Lo Baido
- Orthopaedic Dpt., Città della Salute e della Scienza, Torino, Italy
| | - F Pasquero
- Orthopaedic Dpt., Città della Salute e della Scienza, Torino, Italy
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Morris R, Pallister I, Trickett RW. Measuring outcomes following tibial fracture. Injury 2019; 50:521-533. [PMID: 30482409 DOI: 10.1016/j.injury.2018.11.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 10/31/2018] [Accepted: 11/08/2018] [Indexed: 02/02/2023]
Abstract
AIM The aim of this study was to determine how outcome is measured following adult tibial fracture in the modern era of functional outcome measurement and patient reported outcomes. METHODS A systematic review of publications since 2009 was performed, looking specifically at acute, adult tibial shaft fractures. Ovid Medline, Embase, PubMed and PsycINFO databases were searched for relevant titles which were then screened by two authors with adjudication where necessary by a third. Relevant articles were reviewed in full and data was extracted concerning the study participants, study design and any measures that were used to quantify the results following fracture. The results were collated and patient reported outcome measures were assessed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) standards. RESULTS A total of 943 titles and articles were reviewed, with 117 included for full analysis. A wide range of clinical and radiological "outcomes" were described, along with named clinician- and patient-reported outcome measures. There was considerable heterogeneity and lack of detail in the description of the simplest outcomes, such as union, infection or reoperation. Reported clinician and patient reported outcome measures are variably used. None of the identified patient reported outcome measures have been validated for use following tibial fracture. CONCLUSION We recommend definition of a core outcome set for use following tibial fracture. This will standardise outcome reporting following these injuries. Furthermore, there is need for a validated patient reported outcome measure to better assess patient important outcomes in this patient group.
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Affiliation(s)
- R Morris
- Department of Trauma & Orthopaedics, Abertawe Bro Morgannwg University Health Board, Morriston Hospital, Swansea, SA6 6NL, UK
| | - I Pallister
- Department of Trauma & Orthopaedics, Abertawe Bro Morgannwg University Health Board, Morriston Hospital, Swansea, SA6 6NL, UK
| | - R W Trickett
- Department of Trauma & Orthopaedics, Abertawe Bro Morgannwg University Health Board, Morriston Hospital, Swansea, SA6 6NL, UK.
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Chimutengwende-Gordon M, Mbogo A, Khan W, Wilkes R. Limb reconstruction after traumatic bone loss. Injury 2017; 48:206-213. [PMID: 24332161 DOI: 10.1016/j.injury.2013.11.022] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2013] [Revised: 10/26/2013] [Accepted: 11/17/2013] [Indexed: 02/02/2023]
Abstract
A variety of options exist to reconstruct limbs following traumatic bone loss. The management of these injuries is challenging and often requires prolonged and potentially painful treatment. The Ilizarov technique of bone transport using circular external fixators is widely used for limb reconstruction of large bone defects. Other techniques include vascularised fibular grafting, the use of induced pseudosynovial membranes combined with cancellous autologous bone grafts and the use of autologous, allogeneic or synthetic bone grafts on their own for smaller defects. Future directions include further research on bone tissue engineering using stem cell therapy and growth factors such as bone morphogenetic proteins. The purpose of this Continuing Medical Education article is to describe the key limb reconstructive techniques that may be employed to treat traumatic bone loss. In particular, this article is intended to serve as a revision tool for those preparing for postgraduate examinations.
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Affiliation(s)
- Mukai Chimutengwende-Gordon
- Institute of Orthopaedics and Musculoskeletal Science, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore HA7 4LP, UK.
| | - Abubaker Mbogo
- North Manchester General Hospital, Delaunays Road, Crumpsall, Manchester M8 5RB, UK
| | - Wasim Khan
- Institute of Orthopaedics and Musculoskeletal Science, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore HA7 4LP, UK
| | - Richard Wilkes
- Limb Reconstruction Unit, Hope Hospital, Stott Lane, Salford, Lancashire M6 8HD, UK
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Pieroh P, Spindler N, Langer S, Josten C, Böhme J. A double-barrelled fibula graft restoring pelvic stability after late posterior ring instability related to a surgical treated osteitis pubis: a case report. Arch Orthop Trauma Surg 2016; 136:47-53. [PMID: 26506827 DOI: 10.1007/s00402-015-2355-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND Osteitis pubis or symphysitis pubis is a rare occurring non-infectious inflammation of the symphysis, the adjacent pubic bones and surrounding tissue. The therapy might be conservative or surgical by a resection of the symphysis and involved parts of the pubic bone. Nevertheless, this resection might lead to an anterior instability impairing the posterior arch and the sacroiliac joints in the aftermath. CASE PRESENTATION Here, we report about a 50-year-old women suffering from osteitis pubis treated by wedge resection of the symphysis and parts of the pubic bone. To maintain stability and for local antibiotic treatment a cement spacer was implemented. By clinical inconspicuous findings and the patient's desire, no further surgery was performed. However, 2 years after surgery the spacer dislocated and the patient complained about pain in the posterior arch due to an impaired mobility. Reconstruction surgery was planned including the bridging of the accrued space with a vascularized double-barrelled fibula graft, plate osteosynthesis and rectus abdominis flap coverage. The performed surgery led to pain relief and increased mobility. CONCLUSION The present case highlights the possible complication of surgical treated osteitis pubis leading to anterior arch instability affecting the posterior arch and thus impairing pelvic ring stability and patient mobility. Furthermore, we describe an opportunity to treat this complication or other etiologies contributing to anterior pelvic ring stability with large bone defects using a vascularized double-barrelled fibula graft to restore pelvic stability.
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Affiliation(s)
- Philipp Pieroh
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.
- Department of Anatomy and Cell Biology, Martin Luther University Halle-Wittenberg, Grosse Steinstrasse 52, 06097, Halle (Saale), Germany.
| | - Nick Spindler
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.
| | - Stefan Langer
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.
| | - Christoph Josten
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.
| | - Jörg Böhme
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.
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