Distraction osteogenesis for tibial nonunion with bone loss using combined Ilizarov and Taylor spatial frames versus a conventional circular frame

Tibial bone loss

Critical bone loss after open fractures, while relatively uncommon, occurs most frequently in high-energy injuries. Fractures of the tibia account for the majority of open fractures with significant bone loss. A number of different surgical strategies exist for treatment of tibial bone loss, all with different advantages and disadvantages. Care should be taken by the surgeon to review appropriate indications and all relevant evidence before selecting a strategy.

Trifocal versus Pentafocal bone transport in segmental tibial defects: a matched comparative analysis for posttraumatic osteomyelitis treatment

PURPOSE

The objective of this study was to evaluate and compare the effectiveness and clinical results of trifocal bone transport (TBT) and pentafocal bone transport (PBT) in treating distal tibial defects > 6 cm resulting from posttraumatic osteomyelitis, highlighting the potential advantages and challenges of each method.

METHODS

A retrospective assessment was conducted on an overall population of 46 eligible patients with distal tibial defects > 6 cm who received treatment between January 2015 and January 2019. Propensity score analysis was used to pair 10 patients who received TBT with 10 patients who received PBT. The outcomes assessed included demographic information, external fixation time (EFT), external fixation index (EFI), bone and functional outcomes assessed using the Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system, and postoperative complications evaluated using the Paley classification.

RESULTS

The demographic and baseline data of the two groups were comparable. Following radical debridement, the average tibial defect was 7.02 ± 0.68 cm. The mean EFT was significantly shorter in the PBT group (130.9 ± 16.0 days) compared to the TBT group (297.3 ± 14.3 days). Similarly, the EFI was lower in the PBT group (20.67 ± 2.75 days/cm) than in the TBT group (35.86 ± 3.69 days/cm). Both groups exhibited satisfactory postoperative bone and functional results. Pin site infection was the most common complication and the rates were significantly different between the groups, with the PBT group demonstrating a higher incidence.

CONCLUSION

Both TBT and PBT effectively treat posttraumatic tibial defects greater than 6 cm, with PBT offering more efficient bone regeneration. However, PBT is associated with a higher rate of pin site infections, highlighting the importance of careful management in these complex procedures and emphasizing the need for expert surgical execution and tailored treatment approaches in orthopedic reconstructive surgery.

Huntington procedure for the treatment of tibial nonunion in a 17-years old male: A case report

INTRODUCTION

Bone is considered a tissue with good healing properties, and many bone defects can heal spontaneously under appropriate conditions. Extreme bone loss can hinder remodeling and regenerative processes, leading to bone nonunion. This condition negatively impacts the patient's quality of life with a severe socioeconomic burden. Many treatment options have been proposed, but none can be defined as a gold standard, mainly due to the variety of clinical presentation, bone loss, and quality.

PRESENTATION OF CASE

We present a 15-year-old case of tibial nonunion following multiple traumas. The patient was treated non-surgically at the beginning, but the external fixator positioning was required due to a delay in the healing process. Following further trauma, the patient showed progressive anterolateral angulation, severe lateral procurvation, and a progressive worsening of the pseudoarthrosis. The severe bone loss and poor quality of the bone surrounding the defect required a special technique called Huntington procedure that consists in a vascularized bone autograft from the ipsilateral fibula to achieve mechanical and biological healing of the pseudoarthrosis. The patient recovered well and returned to full weight bearing without a mobility aid.

DISCUSSION

We report this case of complex tibial nonunion and malalignment, developed after subsequent traumas. Due to the multiple complications, and the poor biology a Huntington procedure was required to provide mechanical stability and a biological boost to the bone defect.

CONCLUSION

This case report shows a complicated case requiring several surgeries and treatment options and confirms the potential benefit of the Huntington procedure for treating a tibial severe bone loss.

The Management of Tibial Bone Defects: A Multicenter Experience of Hexapod and Ilizarov Frames

INTRODUCTION

Bone defects may be managed with bone transport or acute shortening and lengthening using circular external fixation devices. We performed a multicenter retrospective cohort study to compare the outcomes between the Ilizarov frames and hexapod frames for the management of bone defects.

METHODS

Patients treated for bone defects using either Ilizarov or hexapod frames were included for analysis in two specialist institutions. Primary outcomes were time to consolidation, bone healing index (BHI), and external fixator index (EFI). Radiographic parameters included the medial proximal tibial angle, lateral distal tibial angle, posterior proximal tibial angle, and anterior distal tibial angle.

RESULTS

There were 137 hexapods and 90 Ilizarov frames in total. The mean time to follow-up was 3.7 years in the hexapod group and 4.0 years in the Ilizarov group. Hexapods had a significantly lower time to consolidation (253 days versus 449 days) (P < 0.0001) and BHI (59.1 days/cm versus 87.5 days/cm) (P < 0.0001). Hexapods had a significantly better EFI (72.3 days/cm versus 96.1 days/cm) (P = 0.0009).

CONCLUSION

Hexapods may confer a significant advantage over Ilizarov frames in the management of bone defects. Time to consolidation, radiographic parameters, BHI, and EFI are all superior in hexapods.

Bone Transport with the Taylor Spatial Frame Technique: A Case Series

Aim

Bone transport is a beneficial reconstructive method for bone defects caused by infected non-unions or bone tumours. The Taylor Spatial Frame (TSF) is a three-dimensional corrective external fixator that can be used to achieve bone transport and correct any residual deformities easily at any time. This study reports the results of bone transport using TSF.

Materials and methods

This is a retrospective study of ten patients who underwent bone transport using the TSF. The mean age was 32.3 years; the femur was affected in one case and the lower leg in nine. Bone defects were due to infected non-unions in seven cases and bone tumours in three. The duration of external fixation, bone transport distance, distraction index (DI), alignment at the end of correction, leg length discrepancy, and complications were investigated.

Results

The average bone transport distance was 76.0 mm. The external fixation period averaged 367 days with the DI at 20.8 days/cm. Deformity at the docking site was assessed to have an average 2.6° deformity and 2.0 mm translation in the frontal view, as well as 3.3° deformity and 3.7 mm translation in the lateral view. The mean leg length discrepancy was 10.9 mm and the percentage of the mechanical axis (%MA) was 40.6%. Four patients underwent plate conversion after correction and two required additional surgery for non-union at the docking site. Bone union was achieved in all patients and there was no reaggravation of infection or tumour recurrence.

Conclusion

The TSF allowed for the correction of deformities and translations that occurred during bone transport giving excellent results. However, as with bone transport using this or other devices, additional procedures are often needed to obtain consolidation or docking site union.

How to cite this article

Shimokawa K, Matsubara H, Hikichi T, et al. Bone Transport with the Taylor Spatial Frame Technique: A Case Series. Strategies Trauma Limb Reconstr 2023;18(2):117-122.

Hexapod Circular Frame Fixation for Tibial Non-union: A Systematic Review of Clinical and Radiological Outcomes

Introduction

Tibial non-unions present with complex deformities, bone loss, infection, leg length discrepancy (LLD), and other features which influence function. Circular frame-based treatment is popular with the hexapod system used increasingly. This systematic review aims to determine the clinical and radiological outcomes of hexapod fixation when used for tibial non-unions.

Materials and methods

The review was performed in accordance with preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. The search strategy was applied to MEDLINE and Embase databases on 15 December 2021. Studies reporting either clinical or radiological outcomes following hexapod fixation on tibial non-unions were included. Primary outcomes were radiological union and patient-reported outcome measures (PROMs). Secondary outcomes included LLD, tibial alignment deformity (TAD), return to pre-injury activity and post-operative complications.

Results

After the abstract and full-text screening, 9 studies were included; there were 283 hexapod frame fixations for tibial non-unions. Infection (46.6%) and stiff hypertrophic non-union (39.2%) accounted for most non-unions treated. The average age and mean follow-up were 42.2 years and 33.1 months, respectively. The average time to union was 8.7 months with a union rate of 84.8%. A total of 90.3% of patients had TAD below 5° in all planes, with an LLD ≤1.5 cm of the contralateral leg in 90.5%. Bony and functional results were at least good in over 90% of patients when using the Association for the Study of the Method of Ilizarov (ASAMI) criteria. A total of 84% of patients returned to pre-injury activities. There were complications as follows: a total of 34% developed pin-site infection, almost 9% experienced half-pin breakage and 14% developed an equinus ankle contracture.

Conclusion

Hexapod frames for the treatment of tibial non-unions produce favourable functional outcomes. Complication rates are present and need to be discussed when this modality of treatment is proposed. Further comparative studies will allow for this option to be evaluated against that of the traditional Ilizarov frame and other methods of non-union surgery.

How to cite this article

Boksh K, Kanthasamy S, Divall P, et al. Hexapod Circular Frame Fixation for Tibial Non-union: A Systematic Review of Clinical and Radiological Outcomes. Strategies Trauma Limb Reconstr 2022;17(3):172-183.

Kinematic parameters after tibial nonunion treatment using the Ilizarov method

Background

Analysis of the outcomes of Ilizarov treatment of tibial nonunion shows functional deficits in the lower limbs of some patients. Biomechanical gait parameters are an important measure for assessing musculoskeletal disorder treatments that aim to restore normal gait. The purpose of our study was to compare the kinematic parameters in patients with tibial nonunion treated using the Ilizarov method and those in a control group of healthy volunteers.

Methods

The study population consisted of 23 patients (age 54.9 ± 16.4 years) who were treated for tibial nonunion using the Ilizarov method, as well as 22 healthy adult controls (age 52.7 ± 10.6 years). Kinematic parameters were measured using a Noraxon MyoMOTION System. We measured hip flexion and abduction, knee flexion, ankle dorsiflexion, inversion, and abduction during walking.

Results

Our analysis showed significant differences between the patients’ operated limbs (OLs) and the controls’ nondominant limbs (NDLs) in the ranges of hip flexion, hip abduction, and knee flexion. We observed no significant differences in knee flexion between the OL and the NOL in patients or between the dominant limb (DL) and NDL in controls. Our evaluation of the kinematic parameters of the ankle joint demonstrated significant differences between the patients’ OLs and the controls’ NDLs in the ranges of ankle dorsiflexion, ankle inversion, and ankle abduction. There were also significant differences in the range of ankle dorsiflexion and ankle abduction between the patients’ NOLs and the controls’ DLs.

Conclusion

Tibial nonunion treatment using the Ilizarov method does not ensure complete normalization of kinematic parameters assessed 24–48 months following the completion of treatment and rehabilitation.

Matched comparative study of trifocal bone transport versus induced membrane followed by trifocal bone transport in the treatment of segmental tibial defects caused by posttraumatic osteomyelitis

Objectives

To compare the efficacy and clinical outcomes of trifocal bone transport (TBT) versus induced membrane followed by trifocal bone transport (IM + TBT) in the treatment of tibial defects > 6 cm caused by posttraumatic osteomyelitis.

Methods

A total of 69 eligible patients with tibial defects > 6 cm who were treated between January 2010 and January 2018 were retrospectively reviewed. Overall, 18 patients treated by IM + TBT and 18 treated by TBT were matched by propensity score analysis. The mean tibial defect after radical debridement was 6.97 ± 0.76 cm (range, 6.0 to 8.9 cm). The measurements, including demographic data, external fixation index (EFI), external fixation time (EFT), duration of docking union, bone and functional outcomes evaluated by the Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system, and postoperative complications evaluated by Paley classification during follow-up were recorded.

Results

Age, gender, injury mechanism, affected side, defect size, previous operation time, and follow-up time were not significantly different between the two groups (P > 0.05). The mean EFT was 293.8 ± 12.1 days in the TBT group vs. 287.5 ± 15.3 days in the IM + TBT group. The mean EFI was 36.02 ± 2.76 days/cm vs. 34.69 ± 2.83 days/cm, respectively. The mean duration of docking union was 210.7 ± 33.6 days vs. 179.7 ± 22.9 days, respectively. There was no significant difference in postoperative bone and functional results between the two groups. Delayed union or nonunion and soft tissue incarceration were significantly reduced in the IM + TBT group compared to those in the TBT group.

Conclusion

Both TBT and IM + TBT achieved satisfactory postoperative bone and functional outcomes in patients with segmental tibial defects > 6 cm following posttraumatic osteomyelitis, while IM + TBT had a significantly lower incidence of postoperative complication in delayed union or nonunion and soft tissue incarceration, as well as faster docking union.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05501-8.

Evolution and Development of Ilizarov Technique in the Treatment of Infected Long Bone Nonunion with or without Bone Defects

The treatment of infected bone nonunion and bone defects is a considerable challenge in the orthopedics field. The standard clinical therapy methods include local free bone transplantation, vascularized bone graft, and the Ilizarov technique; the first two are controversial due to the iatrogenic self‐injury. The Ilizarov bone transport technique has been widely used to treat infected bone nonunion and bone defects, and good clinical effect has been demonstrated. Yet, it brings many related complications, which exerts additional suffering to the patient. The best treatment is to combine bone defect rehabilitation with infection control, intramedullary nail fixation, appropriate time for bone grafts, beaded type scaffold slippage and new Taylor fixation, reducing the external fixation time and the incidence of complications, thereby reducing the occurrence of patients' physical and psychological problems. This review focuses on the induction, summary and analysis of the Ilizarov bone transport technique in the treatment of infected long bone nonunion with or without bone defects, providing new ideas and methods for orthopedic disease prevention and treatment by the Ilizarov technique, which is following the development direction of digital orthopedics.

Staged correction trajectory with hexapod external fixator for the satisfactory reduction of long bone shaft fracture

Backgroud

When the reduction of long bone shaft fracture fragments is performed by a hexapod external fixator, the collision and interference between bony ends often results in an incomplete reduction and a time-consuming procedure. The purpose of this study was to present and determine the clinical effectiveness of staged correction trajectory with hexapod external fixator in the reduction of a long bone shaft fracture.

Methods

A total of 57 patients with tibial shaft fractures treated by hexapod external fixator were retrospectively analyzed from June 2016 to February 2020. Thirty-one cases (Group I) underwent a conventional one-step reduction trajectory from June 2016 to July 2018. Starting in September 2018, the other twenty-six patients (Group II) underwent staged correction trajectory (three key points reduction trajectory of “distraction-derotation-reduction”). The demographic data, residual deformities before and after correction, number of repeated X-rays after the first postoperative X-ray, duration of deformity correction process, and external fixation time were analyzed. Johner-Wruhs criteria were used to evaluate the final clinical outcomes.

Results

All the 57 patients achieved satisfactory fracture reduction and bone union. There were no significant differences between the two groups in demographic data, residual deformities before and after correction, external fixation time, and final clinical outcomes (p > 0.05). The average number of repeated X-rays after the first postoperative X-ray and mean duration of deformity correction process in Group II (1.3 times, 2.9 days) were all less than those in Group I (2.3 times, 5.1 days) (p < 0.05).

Conclusion

Compared with the conventional one-step reduction trajectory, there is no differences in final clinical outcomes, but the staged correction trajectory provides less repeated X-rays and shorter reduction process duration.

Reconstruction of massive tibial defect caused by osteomyelitis using induced membrane followed by trifocal bone transport technique: a retrospective study and our experience

OBJECTIVE

To evaluate clinical outcomes of the application of induced membrane followed by trifocal bone transport technique in the treatment of massive tibial defect caused by osteomyelitis.

METHOD

A total of 18 eligible patients with tibial defect > 6 cm caused by osteomyelitis who were admitted to our institution from January 2010 to January 2016 and treated by induced membrane followed by trifocal bone transport technique. There were 12 male and 6 females with an average age of 40.4 years old. A detailed demographic data (age, sex, etiology, previous operation time, defect size and location, interval from Masquelet technique to trifocal bone transport technique, external fixation index (EFI), duration of regenerate consolidation and docking union) were collected, bone and functional outcomes were evaluated by Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system. Complications during and in the period of follow up were recorded and evaluated by Paley classification at a minimum follow-up of 2 years.

RESULTS

The etiology include posttraumatic osteomyelitis in 13 cases and primary osteomyelitis in 5 cases. An average of previous operation time was 3.4 times. Mean tibial defect after radical debridement was 6.8 cm. An average interval duration from formation of induced membrane to trifocal bone transport was 4.8 weeks. An average of EFI was 37.1 days/cm, the duration of regenerate consolidation and docking union were 124.7 days and 186.4 days, respectively. An average time of follow-up after removal of external fixator was 28.5 month without recurrence of osteomyelitis. The bony outcome was excellent in 6 cases, good in 8 cases, fair in 3 cases and poor in 1 case, and functional outcome was excellent in 4 cases, good in 10 cases, fair in 2 cases and poor in 2 cases. The most common complication was pin tract infection which occurred in 15 cases and there were no major complications such as nerve or vascular injury.

CONCLUSION

Massive tibial defect caused by osteomyelitis can be successfully treated first stage using induced membrane followed by second stage using trifocal bone transport technique, which is an effective method in terms of radical elimination of osteomyelitis with expected clinical outcomes.

Dynamic Gait Parameters in Patients With Nonunion of the Tibia Following Treatment With the Ilizarov Method

The purpose of this study was a comprehensive assessment of the dynamic parameters of gait in patients who underwent Ilizarov treatment for nonunion of the tibia. The experimental group consisted of 24 individuals treated with the Ilizarov method for nonunion of the tibia. The control group comprised 31 healthy individuals, matched for BMI, sex, and age. The dynamic gait parameters in patients and in the control group were measured with a Zebris pedobarographic platform. The treatment group and the control group showed statistically significant differences in terms of the following gait parameters: maximum force during braking nonoperated-limb (NOL), time maximum force during braking operated-limb (OL), time maximum force during braking NOL, maximum force during push-off NOL, time maximum force during push-off OL, and maximum force forefoot OL. Most of the evaluated gait parameters were bilaterally similar in patients group. The only significant differences between the operated and nonoperated limb were seen in terms of Time maximum force during push-off and Maximum force forefoot. The most pronounced abnormalities in dynamic gait parameters were observed in the forefoot (maximum force forefoot OL was 13.3% lower than in the control group, maximum force forefoot OL was 12.4% lower than in NOL). The patients treated with the Ilizarov method did not achieve a complete normalization of dynamic gait parameters, as their gait parameters did not equal those measured in the control group. The Ilizarov method for the treatment of tibial nonunion helps restore a symmetrical distribution of gait parameter values between the affected limb and the healthy limb. Patients continue to show the following abnormalities in their dynamic gait parameters after treatment: higher values maximum force during braking NOL, Time maximum force during braking OL, time maximum force during braking NOL, maximum force during push-off NOL, contact time forefoot NOL, contact time midfoot NOL, contact time heel NOL and smaller values of time maximum force during push-off OL.

Intraoperative acute correction versus postoperative gradual correction for tibial shaft fractures with multiplanar posttraumatic deformities using the hexapod external fixator

BACKGROUND

The purpose of this study was to determine the differences in clinical outcomes, if any, between intraoperative acute correction and postoperative gradual correction for tibial shaft fractures with multiplanar posttraumatic deformities using the hexapod external fixator.

METHODS

We retrospectively analyzed 58 consecutive patients with tibial shaft fractures treated by the hexapod external fixator at our institution from January 2015 to April 2019. Twenty-three patients (Group I) underwent intraoperative acute correction, from January 2015 to October 2016. Starting in November 2016, the other 35 patients (Group II) all underwent postoperative gradual correction. The demographic data, operation duration, original residual deformities before correction, residual deformities after correction, and external fixation time were collected and analyzed. The clinical outcomes were evaluated by the Johner-Wruhs criteria at the last clinical visit.

RESULTS

All patients achieved complete bone union with a mean time of 28.7 ± 4.6 weeks (range 21 to 37 weeks) in Group I and 27.9 ± 4.8 weeks (range 19 to 38 weeks) in Group II (P > 0.05). The operation duration in Group I (88.9 ± 7.7 min) was longer than that in Group II (61.9 ± 8.4 min), and there was a statistically significant difference (P < 0.05). There were no statistically significant differences between the two groups in original residual deformities before correction and residual deformities after correction (P > 0.05). The rate of postoperative complication was similar between the two groups. There was no statistical significance in demographic data and clinical outcomes between the two groups (P > 0.05).

CONCLUSIONS

There is no difference in clinical outcomes between intraoperative acute correction and postoperative gradual correction for tibial shaft fractures with multiplanar posttraumatic deformities using the hexapod external fixator. Postoperative gradual correction may shorten the duration in the operation room and decrease the potential intraoperative risk.

Assessment of Lower Limb Load Distribution in Patients Treated with the Ilizarov Method for Tibial Nonunion

Background

Successful treatment of tibial nonunion should lead to a complete bone union, lack of pain, and pathological mobility of the lower extremity, as well as to the achievement of satisfactory joint mobility and muscle strength, which in turn improves its biomechanics. The objective of this study was to assess the load placed on the lower limbs in patients subjected to treatment with the Ilizarov method due to aseptic tibial nonunion.

Material/Methods

This research involved 24 participants (average age, 55 years). All were diagnosed with aseptic tibia nonunion and treated with the Ilizarov external fixator between 2000 and 2017. The control group was matched to the treated group in terms of sex and age. This study used pedobarography evaluation to assess lower limb load distribution.

Results

No differences were found in the distribution of the load over the entire foot or of the forefoot and hindfoot of the treated limb in comparison to the non-dominant limb of the controls, or in the healthy limb of the treated group compared to the dominant limb of the control group. Similarly, differences in load distribution between the operated and healthy limbs of the treated group were insignificant.

Conclusions

Patients subjected to treatment with the Ilizarov external fixator for aseptic tibial nonunion show symmetrical load distribution on both lower limbs following treatment, which does not differentiate them in this respect from healthy individuals. Treated patients presented with a symmetrical distribution of the load on the lower extremities over the entire foot surface, including the forefoot and hindfoot. Finally, the Ilizarov external fixator enables restoration of correct static biomechanics of the treated limbs over the period of aseptic tibial nonunion therapy.

Assessment of Gait after Treatment of Tibial Nonunion with the Ilizarov Method

Background: Tibial nonunion is a common bone union disorder leading to abnormal gait, and thus reducing quality of life in the social dimension. Research question: The aim of our work was to comprehensively assess gait parameters of patients who had undergone Ilizarov treatment for tibial nonunion compared to a control group of healthy individuals. Methods: This study evaluated patients treated for aseptic tibial nonunion with the Ilizarov method. 24 patients with a mean age of 55.0 years were included in the study. The control group consisted of 32 healthy volunteers with no significant medical history who were selected to match the gender and age of patients in the study group so that the groups were homogeneous. A Zebris Medical GmbH pedobarographic platform was used to assess the gait parameters. Results: For all gait parameters examined, force forefoot max, force backfoot max, step length, stance phase, swing phase and step time, we observed statistically significant differences between the group that had undergone treatment and the control group. In the group of patients, statistically significant differences between the operated lower limb and the non-operated limb were only observed for the force forefoot max and step time parameters (p = 0.029 and p = 0.045, respectively). Patients presented a longer loading of the operated limb (0.720 s) than the non-operated limb (0.635 s). For the stride time, step cadence and gait velocity parameters, healthy subjects achieved much better results during locomotion, and these differences were statistically significant at p < 0.001. Significance: Treatment of tibial nonunion with the Ilizarov method did not restore normal gait parameters in our group of patients. In fact, the gait parameters of patients were significantly worse than the healthy individuals in the control group. Furthermore, gait parameters following treatment were not symmetrical, and the dynamics of the musculoskeletal system remained impaired.

A new criterion for assessing Ilizarov treatment outcomes in nonunion of the tibia

INTRODUCTION

The purpose of this study was to assess a population of patients with nonunion of the tibia treated with the Ilizarov method in terms of achieved union rates and maintained union rates, determination of re-fracture factors, with a subsequent comparison of our findings with those reported in the available literature.

MATERIALS AND METHODS

This study was a retrospective assessment of 102 patients with nonunion of the tibia treated with the Ilizarov method in the period 2008-2015. The assessed parameters were bone union achieved during treatment, duration of stabilization with an Ilizarov external fixator, and maintained bone union at the last follow-up visit.

RESULTS

The mean age at the start of treatment was 46.7 years (11-84 years). The mean follow-up period was 7 years (2-12 years). Bone union was achieved in all patients. The mean duration of Ilizarov stabilization in the study group was 7.9 months (2.8-20.7 months). The rate of union maintained at the last follow-up visit was 95.1%.

CONCLUSIONS

All patients in our study achieved bone union, which constitutes a better outcome than those reported on average in the literature (73.7-100%). The mean length of time which the Ilizarov external fixator was in place in our patients was 8.3 months, which is consistent with the data from literature. Infection, atrophic nonunion, nonunion in 1/3 distal of tibia, and close surgery technique are risk factors of re-fracture. None of the analyzed studies assessed the proportion of patients with maintained bone union. In our study, maintained bone union was observed in 95.1% of patients at the follow-up visit at least 2 years after treatment, which indicates excellent long-term treatment outcomes in nonunion of the tibia treated with the Ilizarov method.

A novel way to dynamize a spatial frame and optimize fracture healing

BACKGROUND

Fracture site motion creates mechanical strains on the healing tissues which influences bone formation. Axial micro-motion maximizes dilatational strains, whereas shearing motions maximize deviatoric strains on the healing tissues. Dilatational strains optimize bone healing, deviatoric strains retard bone healing. Dynamization of external fixation using either an Ilizarov or Spatial Frame platform is used to increase loading on the limb which increases the mechanical stress and strain on the tissues to improve healing. The scientific literature does not address how dynamization of the spatial frame effects fracture site motion. The purpose of this study is to assess the effect of modified shoulder bolts incorporated into a spatial frame during dynamic loading.

METHODS

Five identical two-ring spatial frame constructed were mounted on Sawbones tibias with an osteotomy performed distal to the tibial tubercle. Sinusoidal load was applied at a rate of 0.25 Hz. Axial force and displacement, in addition to motion of the proximal and distal tibia segments were recorded. Eight constructs were tested: 1) All struts of the Spatial Frame rigid, 2) Strut #1 loose, 3) Struts #1 and #3 loose, 4) Struts #1, #3 and #5 loose, 5) All struts loose, 6) All struts rigid with dynamization bolts on the proximal end, 7) All struts rigid with dynamization bolts on alternating sides, 8) Threaded rods between the rings with two millimeters of dynamization.

RESULTS

No difference in vertical displacement was observed between the Ilizarov and all struts locked. No significant difference in shear values between all struts locked and modified shoulder bolt struts was observed. Increase in vertical movement with the modified shoulder bolts was an average of 1.83 mm. Significant shear forces at the fracture site were observed with unlocking single or multiple struts of the spatial frame.

CONCLUSION

Modified shoulder bolts can be used for spatial frame dynamization without increasing shear motion.

The outcomes of Ilizarov treatment in aseptic nonunions of the tibia stratified by treatment strategies and surgical techniques

Nonunions of the tibia, particularly those located in the distal third of the bone, are relatively common in clinical practice. There is no gold standard for the treatment of nonunions of the tibia. The purpose of our study was to assess the results of treatment with the Ilizarov method in patients with aseptic nonunions of the tibia, depending on the employed treatment strategies and surgical techniques. A total of 75 patients with Ilizarov treatment of aseptic nonunions of the tibia were evaluated in the study. The patients's mean age at the beginning of treatment was 46 years. The mean follow-up period was 10 years and 11 months. The evaluated patients underwent either closed technique or open technique. The operators used one of two treatment strategies: neutral fixation without compression or continued compression. The following were assessed: rates of union, ASAMI bone scores, ASAMI functional scores, treatment time, complications, duration of hospital stay. Bone union was achieved in all of the 75 evaluated patients. The results of most analyses showed no significant differences in the assessed variables, except for the ASAMI functional scores, which were higher in the group of patients who underwent closed surgery (Me = 6.00 vs. Me = 4.00). We observed better ASAMI functional score outcomes in the patients who underwent closed fixation than in the open fixation group. The different surgical techniques and treatment strategies had no effect on the number of complications, rates of bone union, length of hospital stay, duration of Ilizarov treatment, or ASAMI bone scores. For managing nonunions of the tibia we recommend the technique of closed fixation without continued compression. The Ilizarov method in the treatment of nonunions of the tibia gives good outcomes.

Role of the Ilizarov non-free bone plasty in the management of long bone defects and nonunion: Problems solved and unsolved

BACKGROUND

Ilizarov non-free bone plasty is a method of distraction osteogenesis using the Ilizarov apparatus for external fixation which originated in Russia and was disseminated across the world. It has been used in long bone defect and nonunion management along with free vascularized grafting and induced membrane technique. However, the shortcomings and problems of these methods still remain the issues which restrict their overall use.

AIM

To study the recent available literature on the role of Ilizarov non-free bone plasty in long bone defect and nonunion management, its problems and the solutions to these problems in order to achieve better treatment outcomes.

METHODS

Three databases (PubMed, Scopus, and Web of Science) were searched for literature sources on distraction osteogenesis, free vascularized grafting and induced membrane technique used in long bone defect and nonunion treatment within a five-year period (2015-2019). Full-text clinical articles in the English language were selected for analysis only if they contained treatment results, complications and described large patient samples (not less than ten cases for congenital, post-tumor resection cases or rare conditions, and more than 20 cases for the rest). Case reports were excluded.

RESULTS

Fifty full-text articles and reviews on distraction osteogenesis were chosen. Thirty-five clinical studies containing large series of patients treated with this method and problems with its outcome were analyzed. It was found that distraction osteogenesis techniques provide treatment for segmental bone defects and nonunion of the lower extremity in many clinical situations, especially in complex problems. The Ilizarov techniques treat the triad of problems simultaneously (bone loss, soft-tissue loss and infection). Management of tibial defects mostly utilizes the Ilizarov circular fixator. Monolateral fixators are preferable in the femur. The use of a ring fixator is recommended in patients with an infected tibial bone gap of more than 6 cm. High rates of successful treatment were reported by the authors that ranged from 77% to 100% and depended on the pathology and the type of Ilizarov technique used. Hybrid fixation and autogenous grafting are the most applicable solutions to avoid after-frame regenerate fracture or deformity and docking site nonunion.

CONCLUSION

The role of Ilizarov non-free bone plasty has not lost its significance in the treatment of segmental bone defects despite the shortcomings and treatment problems encountered.

Predicting Functional Outcomes Following Fracture Nonunion Repair-Development and Validation of a Risk Profiling Tool

OBJECTIVES

To develop a tool that can be used preoperatively to identify patients at risk of poor functional outcome following operative repair of fracture nonunion.

DESIGN

Retrospective analysis of prospectively collected data.

SETTING

Academic medical center.

PATIENTS/PARTICIPANTS

Three hundred twenty-eight patients who underwent operative repair of a fracture nonunion were prospectively followed for a minimum of 12 months post-operatively.

INTERVENTION

After randomization, 223 (68%) patients comprised an experimental cohort and 105 (32%) patients comprised a separate validation cohort. Within the experimental cohort, forward stepwise multivariate logistic regression was applied to 17 independent variables to generate a predictive model identifying patients at risk of having a poor functional outcome [Predicting Risk of Function in Trauma-Nonunion (PRoFiT-NU) Score].

MAIN OUTCOME MEASUREMENTS

Functional outcomes were assessed using the Short Musculoskeletal Function Assessment (SMFA). Poor outcome was defined as an SMFA function index greater than 10 points above the mean at 12 months post-operatively.

RESULTS

Significant predictors of poor outcome were lower extremity nonunion [odds ratio (OR) = 3.082; P = 0.021], tobacco use (OR = 2.994; P = 0.009), worker's compensation insurance (OR = 3.986; P = 0.005), radiographic bone loss (OR = 2.397; P = 0.040), and preoperative SMFA function index (OR = 1.027; P = 0.001). The PRoFiT-NU model was significant and a good predictor of poor functional outcome (χ(5) = 51.98, P < 0.0005; area under the receiver operating curve = 0.79). Within the separate validation cohort, 16% of patients had a poor outcome at a PRoFiT-NU score below 25% (low risk), 39% of patients had a poor outcome at a PRoFiT-NU score between 25% and 50% (intermediate risk), and 63% of patients had a poor outcome at a PRoFiT-NU score above 50% (high risk).

CONCLUSIONS

The PRoFiT-NU score is an accurate predictor of poor functional outcome following fracture nonunion repair.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence description of levels of evidence.

Short-term clinical effect of 3D printing techniques on the correction of complex malformations

BACKGROUND

To explore the clinical effects of 3D printing techniques on the correction of complex malformation.

METHOD

A computed tomography (CT) scan was used to collect data on malformations of patients and the orthopedic plan was made by virtual manipulation of the reality before surgery. The results of the virtual orthopedics were compared with the expected results. A guide plate for osteotomy was also utilized when necessary. The actual operation was carried out according to the plan.

RESULTS

The average age of the 11 patients was 19.09 years (19.09 ± 6.93 years) and the average follow-up was 16 months (16 ± 15.11 months). The symptoms were obviously improved. The preoperative World Health Organization Disability Assessment Schedule (WHODAS 2.0) score, modified Barthel index and Functional Independence Measure (FIM) score in patients were 70.45 ± 15.75, 96.55 ± 3.78 and 121.36 ± 4.15, respectively and correspondingly 53 ± 12.75, 98.82 ± 1.66 and 123.82 ± 4.60 after surgery, respectively. There were significant differences before and after surgery (P < 0.05).

CONCLUSION

The use of 3D printing technology can provide intuitive and accurate help for the correction of complex limb malformations and greatly facilitates the communication between doctors and patients. The FIM score is suitable for the evaluation of the curative effect before and after the treatment of patients with complex malformations.

[Closed reduction combined with Taylor three-dimensional space stent fixation for supracondylar femoral fracture in children]

OBJECTIVE

To explore the effectiveness and safety of closed reduction combined with Taylor three-dimensional space stent fixation in treatment of supracondylar femoral fractures in children.

METHODS

Between July 2008 and July 2016, 20 patients with supracondylar femoral fractures were treated with closed reduction combined with Taylor three-dimensional space stent fixation. There were 14 males and 6 females, with an average age of 10.3 years (range, 6-14 years). The cause of injury was traffic accident in 5 cases, falling from high place in 6 cases, and falling in 9 cases. All fractures were closed fractures. Among them, 12 cases were flexion type and 8 cases were straight type. According to AO classification, 12 cases were rated as type A1 and 8 cases as type A2. The fractures were over 0.5-5.0 cm (mean, 2.5 cm) of the epiphysis line. The time from injury to surgery was 2-8 days (mean, 3.5 days). Postoperative knee joint function was evaluated based on the Kolment evaluation criteria.

RESULTS

All children were followed up 6-24 months (mean, 18.1 months). There was no complication such as nail infection, vascular nerve injury, external fixation looseing, fracture displacement, or re-fracture. All fractures healed and the fracture healing time was 4-6 weeks with an average of 4.5 weeks. The stent removal time was 8-12 weeks (mean, 9.5 weeks). The gait and knee function recovered, and there was no abnormality of the epiphysis. At last follow-up, the knee joint function were excellent in 18 cases and good in 2 cases according to the Kolment evaluation criteria, and the excellent and good rate was 100%.

CONCLUSION

Closed reduction combined with Taylor three-dimensional space stent fixation is an effective treatment for the children with supracondylar femoral fractures, with small trauma and rapid recovery. It can avoid damaging the tarsal plate, be high fracture healing rate, and promote the recovery of limb function.

Ilizarov bone transport and treatment of critical-sized tibial bone defects: a narrative review

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.

Use of internal lengthening nails in post-traumatic sequelae

External fixators are a well-established modality for treating fractures with bone defects, leg-length discrepancy, malunion, nonunion and other post-traumatic consequences. However, use of internal lengthening rods has remarkably increased recently for post-traumatic conditions. The main advantage of internal lengthening rods is eliminating pin-site complications. Internal lengthening rods are also associated with less pain. Motorised internal lengthening rods show promising performance in post-traumatic cases. Rigorous pre-operative planning is paramount to reducing lengthening-related complications. Certain types of internal lengthening rods offer bidirectional movement capability. Nail mechanism malfunction is a possibility with all kinds of nails. Direct doctor supervision is required, especially in the initial stages while the nail is lengthening. Internal lengthening nails are not as stiff as regular nails, with intricate internal mechanisms that can be broken under inattentive weightbearing activities. Preliminary positive outcomes indicate the role of internal lengthening rods in treating post-traumatic problems of leg-length discrepancy, malunion and nonunion.