Bone transport with magnetic intramedullary nails in long bone defects

Comparative analysis of free vascularized fibula grafting and Ilizarov bone transport in management of segmental long bone defect of the lower limb: A systematic review and meta-analysis

Introduction

Reconstruction of segmental defects of long bones is a daunting task for surgeons. Bone transport with the help of Illizarov external fixator and vascularized free fibula flap are some of the most discussed and valid options for the same. Both techniques have their limitations and overlapping indications. However, there has been no objective evidence in the manner of a systematic review supporting one treatment method over the other.

Aim

This systemic review is aimed to compare the bony union, functional outcomes, and complications of Illizarov bone lengthening and free fibula flap performed for segmental bone defects of long bones of the leg.

Methods

A comprehensive search was done for all studies published before May 2023. Any observational study comparing bone transport based on Illizarov external fixator and free vascularized fibula grafting techniques for treating lower limb long bone segmental defects was entailed in this study.

Results

This systematic review comprised of five retrospective studies. A total of 96 patients were treated by the Illizarov-based bone transport technique and 72 patients were treated by the free vascularized fibula grafting technique. The free vascularized fibula grafting technique yielded a shorter mean time to union (average difference 9.3 months), relatively shorter external fixator time (average difference 5.32 months), and external fixator index (average difference 0.57 months/cm). However, there was no difference in terms of bony and functional outcomes between both techniques when used for the reconstruction of bony defects in the lower limb. Total number of complications was 68 % higher in bone transport with Illizarov external fixator. However, the rates of non-union didn't differ between the groups.

Conclusion

The free vascularized fibula grafting technique had a lesser time to bony union, shorter time for external fixator application, and lower incidence of complications. However, the functional and bony outcomes didn't differ between both techniques.

Level of evidence

Level 4.

Docking site interventions following bone transport using external fixation: a systematic review of the literature

PURPOSE

Although bone transport is a well-recognised technique to address segmental bone defects, optimal management of docking sites is not absolutely determined. Some surgeons routinely intervene in all cases, and others prefer to observe and intervene only if spontaneous union does not occur. Primary aim of the study was to compare rates of docking site union between patients who underwent routine docking site intervention and those who did not.

METHODS

A systematic literature review using the keywords "bone transport", "docking", "tibia", and "femur" was performed in PubMed using PRISMA guidelines. Studies published in English from January 2000 to August 2022 were included and assessed independently by two reviewers. Pooled analysis was undertaken dividing patients into two groups: those managed by routine intervention and those initially observed.

RESULTS

Twenty-three clinical studies met the eligibility criteria for pooled analysis, including 1153 patients, 407 in the routine intervention and 746 in the observed group. The rate of union after initial treatment was 90% in the routine intervention group and 66% in the observed group (p < 0.0001). Overall union rates at the end of treatment were similar at 99% in both groups. Patients in the observed group required an average of 2.2 procedures to achieve union overall compared with 3.8 in the routine intervention group. Time in frame was similar between groups.

CONCLUSION

Based on the current literature, routine docking site interventions cannot be recommended, since this may lead to unnecessary interventions in two thirds of patients. Timely selective intervention in those at high risk or after a defined period of observation would appear to be a logical approach.

Advances in the Application of Bone Transport Techniques in the Treatment of Bone Nonunion and Bone Defects

Bone nonunion and bone defects frequently occur following high-energy open injuries or debridement surgeries, presenting complex challenges to treatment and significantly affecting patients' quality of life. At present, there are three primary treatment options available for addressing bone nonunion and bone defects: vascularized bone grafts, the Masquelet technique, and the Ilizarov technique. The Ilizarov technique, also known as distraction osteogenesis, is widely favored by orthopedic surgeons because of several advantages, including minimal soft tissue requirements, low infection risk, and short consolidation time. However, in recent years, the application of the Masquelet technique has resulted in novel treatment methods for managing post-traumatic bone infections when bone defects are present. Although these new techniques do not constitute a panacea, they continue to be the most commonly employed options for treating complex large bone nonunion and bone defects. This review evaluates the currently available research on the Ilizarov and Masquelet bone transport techniques applied at various anatomical sites. Additionally, it explores treatment durations and associated complications to establish a theoretical foundation that can guide clinical treatment decisions and surgical procedures for the management of bone nonunion and bone defects.

Tibial Bone Transport With a Single Implant All-Internal Bone Transport Nail

SUMMARY

A single implant all-internal magnet-driven bone transport nail (BTN-NuVasive Specialized Orthopaedics Inc) has recently been introduced as a treatment method for segmental tibial bone defects. This innovation provides promise in the management of segmental bone defects because it negates numerous complications associated with circular external fixation and the need for multiple implants when considering hybrid plate-assisted bone segment transport constructs. Given the novelty of the BTN, description of the surgical application and patient outcome measures are scarce in the current literature. To date, we have treated 4 patients with an average age of 27 years (range 19-44 years) using the BTN for segmental tibial defects ranging from 50 to 128 mm. We have accumulated data over an average follow-up of 18.07 months (range 12.96-25.13 months), demonstrating good patient tolerance of the device. Three patients successfully completed their treatment course with a calculated average bone healing index of 41.4 days/cm (range 31.41-54.82 days/cm). One patient was noted to experience an asymptomatic docking site nonunion requiring subsequent surgery for nonunion repair. Implant-associated complications included symptomatic implant, axial malalignment, docking site nonunion, and external remote control technical malfunction. Injury-related complications were encountered and noted to include: superficial infection, wound dehiscence, peroneal tendonitis, and joint rigidity. In this study, the authors present a case series using this implant to date and discuss our experiences with the BTN with reference to clinical indications, tibial bone preparation, BTN implantation, transport protocol, docking site procedure, and clinical/radiographic outcomes.

Predictive factors for docking site procedure in bone transport for large lower extremity segmental defects

BACKGROUND

Segmental bone transport is a common technique for treating large segmental bone defects. However, a docking site procedure is often necessary in segmental bone transport. To date, no prognostic factors for the need of docking site procedure have been reported. Thus, the decision is often made at random, based on the surgeon's subjective judgment and experience. The aim of this study was to identify prognostic factors for the need of docking site operation.

METHODS

Patients with segmental bone transport in lower extremity bone defects were included regardless of age, aetiology, and defect size. We excluded patients undergoing treatments that were not yet completed, and those who discontinued therapy by any reason. The need for docking site operation was modelled with logistical and linear regression as well as univariate analysis of variances (ANOVA). Receiver operating characteristics (ROC) curve analysis was also performed.

RESULTS

Twenty-seven patients from age 12 to 74 years (mean age: 39.07 ± 18.20 years) were included. The mean defect size was 76.39 ± 41.10 mm. The duration of transport (days) showed a significant influence (p = 0.049, 95%CI: 1.00-1.02) on the need for docking site operation. No other significant influences were detected.

CONCLUSION

A link between the duration of transport and the need for docking site operation was detected. Our data showed that if a threshold of about 188 days is exceeded, docking surgery should be considered.

[Development and principles of intramedullary and extramedullary segmental bone transport: overview and clinical results]

BACKGROUND

Segmental bone transport using intramedullary or extramedullary techniques is one of the most commonly used procedures for bone defect management in the diaphyseal region of long bones.

OBJECTIVE

The purpose of this work is to provide an overview of the historical development and general principles as well as the current status of extramedullary and intramedullary techniques of bone segment transport. In addition, own results on internal segmental bone transport are presented.

MATERIAL AND METHODS

A retrospective database analysis included all patients between May 2019 and January 2021 who underwent segmental bone transport via a fully implantable intramedullary segment transport nail system. In addition to the radiological outcome, the clinical outcome was assessed using the lower extremity functional scale (LEFS).

RESULTS

A total of 9 patients (8 male, 1 female; age 41.7 ± 3.9 years) could be included. The cause of the segmental bone defect was chronic fracture-related infection in all cases. The segmental defect size was 62 ± 10 mm. Sufficient bridging of the bone defect was achieved in all patients, with a mean distraction rate of 0.9 ± 0.1 mm per day. Bony consolidation of the regeneration was achieved after 292 ± 57 days, and final bony consolidation of the docking zone was achieved after 469 ± 116 days. At 22 ± 3 months after implantation of the segmental transport nail, the LEFS demonstrated a result of 59 ± 4 points. No recurrence of infection or regeneration failure occurred.

CONCLUSION

The aim of treating segmental bone defects, in addition to reconstructing a load-bearing bone, is to restore correct joint angles, leg length, and leg axis without torsional deviation and can be achieved via classical external segmental bone transport. In recent years, internal segmental bone transport has been developed as an alternative. It remains to be seen whether the preliminary and reproducibly good clinical and radiological results of segmental transport nails can be confirmed for widespread use in the future.

Treatment of tibial bone defects: pilot analysis of direct medical costs between distraction osteogenesis with an Ilizarov frame and the Masquelet technique

Purpose

The cost implications of limb reconstruction techniques have not been adequately investigated. Aim of this pilot study was to compare the direct medical cost of tibial bone defects managed with distraction osteogenesis–Ilizarov method (ILF), or with Masquelet technique (MIF).

Methods

Data of 20 random patients treated in a single centre were analysed. Inclusion criteria included acute tibial defects, or post-debridement of nonunions with complete follow-up and successful union. The endpoint of clinical efficacy was the time-to-defect union. Comparisons were made between equally sized subgroups (ILF vs. MIF).

Results

The average defect length was 5.6 cm (2.6–9.6 cm). The overall cost of 20 cases reached £452,974 (mean £22,339, range £13,459–£36,274). Statistically significant differences favoring the MIF were found regarding the average time-to-union; number of surgeries, of admissions and follow-up visits, as well as the mean intraoperative cost (£8857 vs. £14,087). These differences lead to significant differences of the mean cost of the overall treatment (MIF £18,131 vs. ILF £26,126). Power analysis based on these data indicated that 35 patients on each group would allow detection of a 25% difference, with an alpha value of 0.05 and probability (power) of 0.9.

Conclusions

The results and analysis presented highlight factors affecting the high financial burden, even in a best-case scenario, this type of surgery entails. Larger pivotal studies should follow to improve the cost efficiency of clinical practice.

An Update on the Intramedullary Implant in Limb Lengthening: A Quinquennial Review Part 2: Extending Surgical Indications and Further Innovation

The use of the intramedullary lengthening nail has gained in popularity over the last decade. The reduction in complications associated with the use of external fixators and excellent patient outcomes has resulted in the largest change in management of limb length discrepancy since the concept of distraction osteogenesis was accepted by the Western world in the 1980s. Success following "simple" limb lengthening has led to surgeons extending the indications for the lengthening nail, including different bone segments, lengthening associated with potential joint instability and lengthening combined with acute deformity correction. There has been a drive for further implant modification to reduce complications, and enable full weight bearing during the lengthening process. This would offer the opportunity to consider simultaneous limb lengthening. The aim of this review is to evaluate the literature published over the last five years and highlight important learning points and technical tips for these expanding indications.

Treatment of a tibial bone defect with a motorized intramedullary bone transport nail: A case review with 32 months follow up

Nowadays, massive segmental bone defects represent a surgical challenge for trauma surgeons. Most of these injuries appear in the context of high-energy trauma, not only significantly affecting the bones, but also involving severe injuries of the adjacent soft tissues. For these reasons, their treatment requires complex reconstruction surgeries.

There are multiple techniques to treat bone defects, bone transport being one of the most widely used. Historically, external fixators (monolateral and circular) have been and still are the gold standard for performing this technique, although they are not exempt from complications. By means of specific intramedullary nails for bone transport, it is possible to minimize the complications of external fixation, allowing large tibial bone defects to be treated through distraction osteogenesis (all-internal system), which is favoured by early weight bearing.

Use of the PRECICE Nail for distraction osteogenesis after tumor resection

INTRODUCTION

Reconstructing long bone defects following intercalary tumor resection presents an exciting challenge with a greater range of surgical solutions than more typical situations requiring arthroplasty. Segmental bone transport (distraction osteogenesis) is the least utilized option for intercalary reconstruction, however, it arguably provides patients with the most desirable result. Distraction osteogenesis can be used in the management of multiple skeletal conditions including deformity (either congenital or acquired), or in the presence of bone defects (by trauma or planned surgical excision). Lack of broader adoption of transport is likely due to the highly technical demands and common complications of utilizing fine-wire fixators via the Ilizarov method. More recently, internal lengthening nails such as the PRECICE nail have been employed to facilitate distraction osteogenesis without the added complexity of external fixation.

AREAS COVERED

This review will examine the literature on the indications, design, and safety of the PRECICE nail (NuVasive) for intercalary reconstruction after tumor resection.

EXPERT OPINION

Bone transport using the PRECICE nail represents a viable alternative to Ilizarov distraction and has the benefit of avoiding the complications of an external fixator. For large defects, the PRECICE nail can be supplemented with a locking plate for additional stability and maintenance of limb length.

Evaluation of the efficacy of ipsilateral fibular transfer for reconstruction of large tibial defects in children: a retrospective study

Background

Reconstruction of large tibial defects is often a major challenge in limb salvage. This study aimed to evaluate initial follow-up results of ipsilateral fibula transfer for the treatment of large tibial defects in children.

Methods

A retrospective study was performed between September 2014 and April 2021. Ten children were identified as having large tibial defects. The children underwent ipsilateral fibula transfer. We then evaluated initial healing, tibial length discrepancy, ankle varus/valgus, fibular position, refracture, infection, and function.

Results

Five boys and five girls, with an average age of 7.2 years, were evaluated. The transferred fibula was united in the patients. The mean follow-up period after fibular transposition was 43 months. The patients achieved primary bone union; the mean time to union was 8.4 months (range, 4–18 months). Complications included refracture (30%), infection (40%), tibia malunion (30%), ankle varus (30%), sensory loss of toes (10%), and ankle valgus (10%). No other major complications were observed. All 10 patients were able to perform activities of daily living and return to their normal activities.

Conclusion

Ipsilateral fibula transfer is a salvage surgery for the treatment of large tibial defects in children with congenital pseudoarthrosis of the tibia, traumatic nonunion of the tibia, and/or tibial defect after chronic osteomyelitis. However, long-term results still need to be followed up.

Reconstruction of Massive Segmental Distal Femoral Metaphyseal Bone Defects After Open Injury: A Study of 20 Patients Managed with Intercalary Gamma-Irradiated Structural Allografts and Autologous Cancellous Grafts

BACKGROUND

Our aim was to examine the outcome of gamma-irradiated intercalary structural allografts combined with autologous cancellous grafts in treating large metaphyseal bone defects of the distal femur following open injuries.

METHODS

We prospectively included 20 consecutive patients with large metaphyseal bone defects of >4 cm located in the region of the distal femur following open injuries treated between 2010 and 2018, with a mean follow-up of 2 years (range, 2 to 10 years). Of these patients,18 were men and 2 were women. The mean age was 39 years (range, 22 to 72 years). The mean length of the bone defects was 10.1 cm (range, 5.5 to 14.5 cm), and all were in the metaphysis of the distal femur. The surgical technique included initial early debridement and external fixation followed by reconstruction of the bone defect using structural allograft combined with autologous cancellous bone graft harvested from the iliac crest and locking plate fixation. Definitive fixation was performed at an average period of 22.5 days (range, 3 to 84 days) after injury. Osseous union, rate of infection, complications, need for secondary procedures, and functional outcome using the Lower Extremity Functional Scale (LEFS) at the final follow-up were assessed.

RESULTS

After excluding 1 patient who was lost to follow-up, 19 patients with complete follow-up were available for analysis. Of those, 13 patients (68%) achieved complete union at both ends of the allograft with host bone without any further intervention. Three patients (16%) developed aseptic nonunion of the proximal end of the allograft requiring 1 additional procedure each to achieve union. Four patients (21%) developed a deep surgical site infection. Of those, 1 elderly patient required above-the-knee amputation following uncontrolled diabetes and infection. A second patient required 2 additional procedures, and a third patient needed 4 additional procedures to achieve union. The fourth patient developed infection after achieving union, and the infection subsided after debridement and implant removal. The mean LEFS score for all 19 patients was 55 (range, 41 to 75).

CONCLUSIONS

Use of allograft was a reasonable single-stage alternative solution for massive distal femoral bone defects, which united without additional surgery in two-thirds of the patients and without limb-length discrepancy.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

[Progress of remote-control intramedullary lengthening nail and its clinical treatment concept]

Ilizarov's technology is an internationally recognized clinical treatment method for limb orthopedics, but there are many complications related to external fixation. With the development and progress of the times, the remote-control intramedullary lengthening nails had risen to prominence on the international stage as the second generation of orthomelic technology based on Ilizarov's technology. Since the first remote-control intramedullary lengthening nail appeared in the 1980s, after more than 40 years of development, there are currently more than 3 types of extension mechanisms in remote-control intramedullary lengthening nails and a mature and stable clinical treatment model has been formed during the past long-term clinical treatment and experiments, such as the End-Point-First (EPF) program proposed by Professor Peter H. Thaller in Germany. Compared with Ilizarov's technology, the remote-control intramedullary lengthening nail has obvious advantages in convenience, comfort, risk of infection, soft tissue injury, postoperative pain, and controllability of limb lengthening. This article mainly introduces the development and clinical treatment concept of remote-control intramedullary lengthening nail and the latest clinical treatment status of limb lengthening therapy abroad, hoping to provide new cognition and ideas for the further development of limb orthopedics in China.

Management of post-traumatic femoral defects with a monorail external fixator over an intramedullary nail

PURPOSE

The management of limb-length discrepancy secondary to traumatic femoral bone loss poses a unique challenge for surgeons. The Ilizarov technique is popular, but is associated with long external fixator time and many complications. This retrospective study assessed outcomes of post-traumatic femoral defects managed by monorail external fixation over an intramedullary nail.

METHODS

Eight patients were included from October 2015 to May 2019 with post-traumatic femoral defects that underwent treatment with monorail fixator-assisted intramedullary nailing. Primary outcome was time to bone union and bone results according to ASAMI classification. Secondary outcomes were lengthening index, consolidation time and index, external fixator index (EFI), time to partial weight bearing(PWB) and full weight bearing (FWB), and complications. Patient reported outcome measures including EQ-5D-5L, SF-36, Oxford knee scores (OKS), and Oxford hip scores (OHS) were recorded after recovery.

RESULTS

Mean follow-up time was 227 weeks. Average bone defect size was 9.69 cm. Average consolidation time and index were 11.35 months and 1.24 months/cm, respectively. Mean lengthening and external fixator index were 20.2 days/cm and 23.88 days/cm, respectively. On average, patients achieved FWB and bone union 56.25 weeks and 68.83 weeks after bone transport initiation, respectively. Two patients had docking site non-union, five patients had pin site infections, and two patients had osteomyelitis. EQ-5D-5L and EQ-VAS scores were compared to UK population norms (p = 0.104, p = 0.238, respectively). Average OKS was 32.17 and OHS was 34.00.

CONCLUSION

Monorail external fixation over an intramedullary nail is an effective option for post-traumatic femoral defects, reducing external fixator time and returning patients' quality of life to a level comparable with the normal population.

Fibula-Assisted Segment Transport (FAST) for Defect Reconstruction after Resection of Tibial Adamantinoma: Report of Two Treatments

Intramedullary limb lengthening via lengthening nails has been performed for more than three decades to overcome leg length inequalities. Plate-assisted bone segment transport (PABST) has recently been described for the reconstruction of segmental bone defects. We modified this procedure by using the ipsilateral fibula as a “biological plate” and report on its technical particularities and application in the reconstructive treatment of adamantinomas of the tibia in two patients. Both patients were successfully treated by wide resection and reconstruction of the tibial bone via bone segment transport through an expandable intramedullary nail using the remaining ipsilateral fibula to provide stabilization and guidance. This procedure was titled “fibula-assisted segment transport” (FAST). This is a new and promising technique that allows an entirely biological reconstruction of large bone defects of the tibia.