Three-stage limb salvage in tibial fracture related infection with composite bone and soft-tissue defect

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

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.

Induced membrane technique with plate fixation has a lower complication rate than bone transport over a plate for segmental tibial defects larger than 5 cm

INTRODUCTION

The treatment of segmental tibial bone defects remains a surgical challenge. While Bone Transport (BT) and Induced Membrane Technique (IMT) are effective strategies for regenerating bone, there are few comparative studies between them. This investigation undertakes a comparative analysis of BT and IMT for large segmental tibial defects stabilised through plate fixation.

MATERIALS AND METHODS

Patients with segmental tibial defects exceeding 5 cm were prospectively enrolled from 2008 to 2021 in a single institution, with a minimum follow-up duration of two years. All patients underwent either BT or IMT with plate fixation of the tibia. Procedural success, primary union as well as bone and functional outcome scores were compared. Complications, including non-unions, joint contractures and deep infections requiring surgical intervention, were also compared.

RESULTS

41 patients were recruited in total. 28 patients underwent Bone Transport Over a Plate (BTOP), while 13 patients underwent IMT with Plate fixation (IMTP). The procedural success rate trended higher in IMTP compared to BTOP (100% vs. 85.7%). The primary union rate also trended higher in IMTP compared to BTOP (92.3% vs. 79.2%). BTOP and IMTP achieved similar rates of satisfactory bone outcome scores (78.6% vs. 84.6%) and functional outcome scores (75% vs. 76.5%). There was no statistical difference between procedural success, primary union, bone and functional outcome scores. The complication rate in BTOP was 78.6% (22 of 28), including five docking site or regenerate non-unions, eight deep infections and nine joint contractures. IMTP had a 38.5% (5 of 13) complication rate, including one non-union, two deep infections and two joint contractures. The complication rate was 2.04 times higher in BTOP compared to IMTP (p = 0.0117).

CONCLUSIONS

BTOP and IMTP are both equally effective techniques for regenerating bone in large tibial bone defects. However, IMTP may be a safer procedure than BTOP, with a lower probability of requiring additional procedures to address complications.

Orthoplastic management of distal tibia bone infection using Masquelet technique and PRECICE nail: A case report

The orthoplastic treatment of post-traumatic bone infections is complex and requires a multidisciplinary approach using both orthopedic and plastic surgery principles. Its primary goal is to achieve rapid control of the infection through aggressive debridement of the affected tissue, in order to perform a complete reconstruction of the limb. This allows both its salvage and restoration of function. We present a patient with septic non-union secondary to distal tibia fracture with a bone defect of 7 cm and severe soft tissue injury. The treatment was divided into three stages. First, the infection was controlled by radical debridement, limb shortening, and temporary stabilization. Second, early reconstruction was initiated utilizing the first stage of the Masquelet's induced membrane technique (MIMT), and soft tissue coverage with free flap. Third, MIMT was finalized, and bone lengthening with PRECICE nail was performed. We consider this approach effective as it can offer early recovery with optimal functional and aesthetic results in bone defects associated with coverage defects.

Pedicled Double-Barrel Fibular Transplantation Versus Bone Transport in the Treatment of Upper Tibial Osteomyelitis with Bone Defects: A Retrospective Study

Objective

This study aimed to compare the clinical effects of using pedicled double‐barrel fibular transplantation (PDBFT) and bone transport (BT) for the treatment of upper tibial osteomyelitis with bone defects.

Methods

A total of 83 patients with upper tibial osteomyelitis and bone defects were selected and retrospectively studied in Xi'an Hong Hui Hospital from January 2009 to January 2019. There were 52 males and 31 females, aged 19–72 years. The tibial defect range was 5–12 cm. Patients were divided into two groups, including the PDBFT (40 cases) and the BT group (43 cases). All patients were classified according to Cierny–Mader classification, including 48 cases of type III and 35 cases of type IV. Operation time, blood loss and cure time were compared. Ennecking score was used to evaluate limb functions, including pain, activity function, self‐perception, brace use, walking ability, and gait change, while self‐rating anxiety scale (SAS) was used for postoperative mental and psychological status. In addition, complications were recorded. All patients were followed for at least 2 years. SPSS 23.0 software was used to process data.

Results

There was no significant difference in demographic data between the two groups (p > 0.05). Operation time was 182.5 ± 22.7 min in PDBFT group vs, 124.2 ± 15.6 min in BT group, respectively (p < 0.05); intra‐operative blood loss was 286 ± 34 ml vs 45 ± 18 ml (p < 0.05); cure time was 7.3 ± 1.8 months vs 11.6 ± 3.7 months (p < 0.05); and Ennecking score was 87.3% and 76.0%, respectively (p < 0.05). So, the PDBFT group showed longer operation time, more blood loss, shorter cure time, and better Ennecking score than the BT group. Importantly, limb functions of the PDBFT group were better than that of the BT group. Moreover, the PDBFT group presented better postoperative mental status and fewer complications than that in BT group (p < 0.05).

Conclusions

Patients were successfully cured by both the PDBFT and BT techniques. Compared with the BT group, the PDBFT group brought better clinical effects and fewer complications which could be the first operative choice for the treatment of upper tibial osteomyelitis with bone defects.