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

Critical size bone defects managed with modern techniques of bone transport: An update

Bone transport is one of several techniques that has been proven to be effective in addressing critical bone loss. While it was first described over 100 years ago, modifications to this technique coupled with advances in technology have allowed us to perform bone transport with higher success rates and reduced complication rates. Modern techniques of bone transport aim to shorten the duration of time an external fixator is utilized to reduce its associated complications and burden to patients. We present an update on modern techniques of bone transport for critical size defects and methods to shorten the external fixation time.

Shortening/re-lengthening and nailing versus bone transport for the treatment of segmental femoral bone defects

Segmental femoral bone defects are a severe challenge for orthopedic trauma surgeons. The objective of this study was to compare the efficacy of the shortening/re-lengthening and nailing (SRN) technique with the traditional bone transport (BT) technique in treating patients with such defects. A retrospective study was conducted involving 46 patients with segmental femoral bone defects, with 21 cases treated using the SRN technique (SRN group) and 25 cases managed with the traditional BT technique (BT group). The mean length of the bone defect was 5.8 ± 1.1 cm in the SRN group and 6.1 ± 1.6 cm in the BT group. Various parameters including time in frame, external fixation index, self-rating anxiety scale (SAS) scores, bone healing scores, limb function scores, and complications were recorded. The mean time in frame for the SRN group was 3.7 ± 1.4 months, significantly shorter than the 9.4 ± 3.7 months observed in the BT group (p < 0.05). Furthermore, the mean external fixation index for the SRN group was 0.62 ± 0.12 months/cm, significantly lower than the 1.50 ± 0.19 months/cm observed in the BT group (p < 0.05). There were no significant differences in bone healing scores between the SRN and BT groups (p = 0.237). The SAS scores and incidence of complications were significantly lower in the SRN group compared to the BT group (p < 0.05). Overall, the SRN technique demonstrated superior clinical efficacy compared to the traditional BT technique for the management of segmental femoral bone defects, with shorter time in frame, lower external fixation index, and reduced complications. Therefore, the SRN technique may be considered an optimal choice for treating patients with such conditions.

New insights in lower limb reconstruction strategies

High Energy Musculoskeletal Traumas (HEMTs) represent a relevant problem for healthcare systems, considering the high social costs, and both the high morbidity and mortality. The poor outcomes associated with HEMT are related to the high incidence of complications, including bone infection, fracture malunion and non-union. The treatment of each of these complications could be extremely difficult. Limb reconstruction often needs multiple procedures, rising some questions on the opportunity in perseverate to try to save the affected limb. In fact, theoretically, amputation may guarantee better function and lower complications. However, amputation is not free of complication, and a high long-term social cost has been reported. A comprehensive literature review was performed to suggest possible ways to optimize the limb preservation surgeries of HEMT's complications in order to ameliorate their management.

Outcome analysis of ilizarov and monorail fixators in the treatment of nonunion of long bones: A systematic review and proportion meta-analysis

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.

A modified hybrid transport technique combined with a retrograde tibiotalocalcaneal arthrodesis nail for the management of distal tibial periarticular osteomyelitis and associated defects

BACKGROUND

This paper aimed to propose a modified technique of bone transport. An annular frame combined with a retrograde tibiotalocalcaneal arthrodesis nail was used in this novel technique for treating large distal tibial periarticular osteomyelitis and associated defects.

METHODS

Our team conducted a retrospective research. Forty-three patients with large distal tibial periarticular bone loss were involved in this study. Sixteen patients were treated using the modified hybrid transport technique (MHT group) while 27 were subjected to traditional bone transport (BT group). The mean bone loss was 7.8 ± 2.4 cm in the MHT group and 7.6 ± 2.6 cm in the BT group. The external fixation index, time in transport frame, self-rating anxiety scale, bone healing results and postoperative complications were recorded.

RESULTS

The mean time in frame for the MHT group was 3.6 ± 1.5 months, while that of the BT group was 10.3 ± 2.7 months (p < 0.05). The mean external fixation index of MHT group was 0.46 ± 0.08 months/cm versus 1.38 ± 0.24 months/cm of the BT group (p < 0.05). There was no statistical difference for the bone healing results between the MHT and BT groups (p = 0.856). The self-rating anxiety scale and total complication incidence of the MHT group were significantly lower than that of BT patients (p < 0.05).

CONCLUSION

Compared to the traditional BT technique, our modified hybrid transport technique showed better clinical outcomes for treating large distal tibial periarticular bone loss, including less time in transport frame, lower external fixation index and complication incidence. Therefore, this modified technique should be further promoted and developed.

Long Bone Defect Filling with Bioactive Degradable 3D-Implant: Experimental Study

Previously, 3D-printed bone grafts made of titanium alloy with bioactive coating has shown great potential for the restoration of bone defects. Implanted into a medullary canal titanium graft with cellular structure demonstrated stimulation of the reparative osteogenesis and successful osseointegration of the graft into a single bone-implant block. The purpose of this study was to investigate osseointegration of a 3D-printed degradable polymeric implant with cellular structure as preclinical testing of a new technique for bone defect restoration. During an experimental study in sheep, a 20 mm-long segmental tibial defect was filled with an original cylindrical implant with cellular structure made of polycaprolactone coated with hydroxyapatite. X-ray radiographs demonstrated reparative bone regeneration from the periosteum lying on the periphery of cylindrical implant to its center in a week after the surgery. Cellular structure of the implant was fully filled with newly-formed bone tissue on the 4th week after the surgery. The bone tissue regeneration from the proximal and distal bone fragments was evident on 3rd week. This provides insight into the use of bioactive degradable implants for the restoration of segmental bone defects. Degradable implant with bioactive coating implanted into a long bone segmental defect provides stimulation of reparative osteogenesis and osseointegration into the single implant-bone block.

A retrospective analysis of the definitive management of open talus fractures at a major trauma centre, comparing ORIF to FUSION: cohort study and audit of BOAST 4 guidelines

PURPOSE

Open talus fractures are notoriously difficult to manage, and they are commonly associated with a high level of complications including non-union, avascular necrosis and infection. Currently, the management of such injuries is based upon BOAST 4 guidelines although there is no suggested definitive management, and thus, definitive management is based upon surgeon preference. The key principles of open talus fracture management which do not vary between surgeons are early debridement, orthoplastic wound care, anatomic reduction and definitive fixation whenever possible. However, there is much debate over whether the talus should be preserved or removed after open talus fracture/dislocation and proceeded to tibiocalcaneal fusion.

METHODS

A review of electronic hospital records for open talus fractures from 2014 to 2021 returned fourteen patients with fifteen open talus fractures. Seven cases were initially managed with ORIF, and five cases were definitively managed with FUSION, while the others were managed with alternative methods. We collected patient's age, gender, surgical complications, surgical risk factors and post-treatment functional ability and pain and compliance with BOAST guidelines. The average follow-up of the cohort was 4 years and one month. EQ-5D-5L and FAAM-ADL/Sports score was used as a patient reported outcome measure. Data were analysed using the software PRISM.

RESULTS

Comparison between FUSION and ORIF groups showed no statistically significant difference in EQ-5D-5L score (P = 0.13), FAAM-ADL (P = 0.20), FAAM-Sport (P = 0.34), infection rate (P = 0.55), surgical times (P = 0.91) and time to weight bearing (P = 0.39), despite a higher proportion of polytrauma and Hawkins III and IV fractures in the FUSION group.

CONCLUSION

FUSION is typically used as second line to ORIF or failed ORIF. However, there is a lack of studies that directly compared outcome in open talus fracture patients definitively managed with FUSION or ORIF. Our results demonstrate for the first time that FUSION may not be inferior to ORIF in terms of patient functional outcome, infection rate and quality of life, in the management of patients with open talus fracture patients. Of note, as open talus fractures have increased risks of complications such as osteonecrosis and non-union, FUSION should be considered as a viable option to mitigate these potential complications in these patients.

Management of femoral non-union with post-traumatic bone defect using second-generation PRECICE® nail - A case report

The management of post-traumatic bone defects with non-union remains a surgical challenge. Current techniques are often fraught with complications, posing a functional, economical, and psychological challenge for the patient. A 57 year-old gentlemen suffered an open femoral fracture after a motorcycle accident. Having previously undergone open reduction internal fixation, he presented to us with atrophic non-union and bone defects, which were simultaneously treated with a second-generation PRECICE nail. Our treatment protocol was based on the strain theory, and involved initial distraction by ~5 mm at the non-union site, compression of the non-union site, followed by distraction osteogenesis at the non-union site. The patient achieved union and the initially planned limb lengthening regime was achieved with minimal complications. Self-lengthening, magnetically-driven PRECICE nails can successfully restore union and manage limb length discrepancies with reasonable patient satisfaction and minimal complications.