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Gui S, Xu W, Ouyang Z, Guo X, Shen Y, Tao H, Chen X, Peng D. Endoprosthetic replacement with preservation of the epiphysis for proximal tibial reconstruction after osteosarcoma resection in children: a case report. BMC Musculoskelet Disord 2024; 25:567. [PMID: 39033278 PMCID: PMC11264714 DOI: 10.1186/s12891-024-07651-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 07/01/2024] [Indexed: 07/23/2024] Open
Abstract
BACKGROUND Limb salvage surgery is an important method for treating malignant tumors of the bone involving the adjacent parts of the major joints in children. This technique allows for preservation of limb function, especially in the lower limb. However, the reconstruction of the proximal end of the tibia after removing the tumor mass with a rational scale to preserve the total knee joint and reduce limb length discrepancy presents a challenge. CASE PRESENTATION We present a case of osteosarcoma of the proximal tibia. After being treated with an extended tumor resection, the proximal tibia of the child was restructured using endoprosthetic replacement with epiphyseal preservation. This procedure preserves the entire articular surface and growth plate of the knee joint of the affected limb and provides a feasible alternative protocol for retaining the function and growth potential of the affected limb. The patient remained disease-free and normal limb motor function was observed during the 3.5 year follow-up since the initial surgery. CONCLUSIONS Preservation of the epiphysis enabled our patient to perform better limb function after limb-saving surgery as a result of his undamaged knee joint and minimized limb-length discrepancy. We believe that endoprosthetic replacement with preservation of the epiphysis can provide the best strategy for reconstruction after resection of focal malignant tumors in long bones without epiphytic involvement.
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Affiliation(s)
- Sijie Gui
- Department of Orthopedics, The Second Xiangya Hospital of Central South University, Changsha, Hunan, 410011, China
| | - Wangtong Xu
- Department of Orthopedics, The Second Xiangya Hospital of Central South University, Changsha, Hunan, 410011, China
| | - Zhengxiao Ouyang
- Department of Orthopedics, The Second Xiangya Hospital of Central South University, Changsha, Hunan, 410011, China
| | - Xiaoning Guo
- Department of Orthopedics, The Second Xiangya Hospital of Central South University, Changsha, Hunan, 410011, China
| | - Yi Shen
- Department of Orthopedics, The Second Xiangya Hospital of Central South University, Changsha, Hunan, 410011, China
| | - Huai Tao
- Department of Biochemistry and Molecular Biology, Hunan University of Chinese Medicine, Changsha, Hunan, 410208, China
| | - Xia Chen
- Department of Orthopedics, The Second Xiangya Hospital of Central South University, Changsha, Hunan, 410011, China.
| | - Dan Peng
- Department of Orthopedics, The Second Xiangya Hospital of Central South University, Changsha, Hunan, 410011, China.
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Bas A, Balci HI, Kocaoglu M, Demirel M, Kochai A. Augmentation with a non-vascularized autologous fibular graft for the management of Cierny-Mader type IV chronic femoral osteomyelitis: a salvage procedure. INTERNATIONAL ORTHOPAEDICS 2024; 48:439-447. [PMID: 37696991 DOI: 10.1007/s00264-023-05954-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 08/22/2023] [Indexed: 09/13/2023]
Abstract
PURPOSE The study aimed to evaluate preliminary clinical and radiographic results of patients with Cierny-Mader type IV chronic femoral osteomyelitis and augmented with a non-vascularized fibular autograft as a salvage procedure because of the poorly regenerated new bone after bone transport over an intramedullary nail (BTON). METHODS Patients diagnosed with CM type IV chronic femoral bone infection and treated with BTON procedure between 2003 and 2020 were retrospectively reviewed. Seven patients were included in the study whose distraction gap was poorly regenerated and then augmented with a non-vascularized fibular autograft. A three-stage treatment was administered. First, the infection was eradicated. Second, BTON was performed. Third, the poorly regenerated distraction gap was augmented with a fibular autograft before removing the external fixator (EF). Clinical and radiological results were evaluated based on the criteria described by Paley-Maar and Li classification. RESULTS The mean patient age was 52 years. The mean treatment time was 24.8 months, with a mean femoral lengthening of 12.6 cm. The mean EF and bone healing indexes were 0.57 months/cm and 0.8 months/cm, respectively. The mean length of the fibular graft was 13 cm. The bone healing of new bones was achieved in all patients with good quality after grafting. Functional scores were excellent in four patients. No patients experienced any sequelae. CONCLUSIONS Non-vascularized fibular autograft augmentation may be an effective salvage procedure for poorly regenerated new bone after BTON to manage chronic femoral bone infection.
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Affiliation(s)
- Ali Bas
- Department of Orthopaedics and Traumatology, Koç University Hospital, Maltepe Mahallesi Topkapı Cd. No:4, 34010 Zeytinburnu, İstanbul, Turkey
| | - Halil Ibrahim Balci
- Department of Orthopaedics and Traumatology, İstanbul University, İstanbul Faculty of Medicine, Turgut Özal Millet Cd. 34093, Çapa, Fatih, İstanbul, Turkey
| | - Mehmet Kocaoglu
- Department of Orthopaedics and Traumatology, İstanbul University, İstanbul Faculty of Medicine, Turgut Özal Millet Cd. 34093, Çapa, Fatih, İstanbul, Turkey
| | - Mehmet Demirel
- Department of Orthopaedics and Traumatology, İstanbul University, İstanbul Faculty of Medicine, Turgut Özal Millet Cd. 34093, Çapa, Fatih, İstanbul, Turkey.
| | - Alauddin Kochai
- Department of Orthopaedics and Traumatology, Sakarya University Faculty of Medicine, Korucuk Mahallesi Konuralp Bulvarı No:81/1, 54290, Adapazarı, Sakarya, Turkey
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Xu Y, Ma T, Ren C, Li M, Lu Y, Sun L, Huang Q, Wang Q, Xue H, Li Z, Zhang K. Treatment of tibial large bone defects: A comparative study of bone transport over an intramedullary nail in combination with antibiotic-impregnated calcium sulphate versus bone transport alone with antibiotic-impregnated calcium sulphate. Injury 2022; 54 Suppl 2:S78-S85. [PMID: 36192202 DOI: 10.1016/j.injury.2022.09.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 09/17/2022] [Accepted: 09/23/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the bone transport over an intramedullary nail in combination with antibiotic-impregnated calcium sulphate versus bone transport alone with antibiotic-impregnated calcium sulphate for the treatment of tibial large bone defects. METHODS A retrospective analysis was conducted by enroling 33 surgically treated patients with tibial large bone defects after the debridement for tibial infection or osteomyelitis who were admitted in Lower Limb Surgery Ward of Traumatic orthopaedic Department, Xi'an Honghui Hospital from January 2018 to January 2021. All the patients were categorized in Group A (transport over intramedullary nail, 12 cases) and Group B (transport alone, 21 cases) based on the surgery strategy. The collected clinical materials and data included gender, age, injury mechanism, smoking habits, comorbidity diseases, initial fracture type (open or close), bone defect size, surgical duration, intraoperative bleeding loss, resorption time of calcium sulphate, bone transport time, external fixation time, external fixation index, weight bearing time, complications and Paley bone and functional criteria. RESULTS Thirty-three patients were enroled and successfully followed up with an average time of 15.25±4.31 months ranged from 8 to 21 months in Group A and an average time of 17.09±5.64 months ranged from 9 to 31 months in Group B. No significantly statistical differences of the demographic data were discovered between the two groups. There were no significantly statistical differences of the average bone defect size, intraoperative bleeding loss, resorption time of calcium sulphate and bone transport time between the two groups. However, the average surgical duration (P = 0.002) was significantly longer in Group A than Group B and the average external fixation time (P<0.001), external fixation index(P = 0.002) and weight bearing time (P = 0.030) were significantly shorter in Group A than Group B. No significantly statistical difference of excellent and good rate of bone outcomes and complication rate was observed, however, the excellent and good rate of functional outcomes (P = 0.041) was significantly higher in Group A than Group B. CONCLUSION Compared with the conventional Ilizarov technique combining with antibiotic-impregnated calcium sulphate for large tibial bone defects, bone transport over an intramedullary nail in combination with antibiotic-impregnated calcium sulphate had favourable external fixation time, external fixation index, weight bearing time and clinical functional outcomes which effectively suppressed the infection and allowed patients earlier removal of the external fixator and weight bearing for rehabilitation.
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Affiliation(s)
- Yibo Xu
- Department of Orthopaedics Trauma, Honghui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an 710054, China
| | - Teng Ma
- Department of Orthopaedics Trauma, Honghui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an 710054, China
| | - Cheng Ren
- Department of Orthopaedics Trauma, Honghui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an 710054, China
| | - Ming Li
- Department of Orthopaedics Trauma, Honghui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an 710054, China
| | - Yao Lu
- Department of Orthopaedics Trauma, Honghui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an 710054, China
| | - Liang Sun
- Department of Orthopaedics Trauma, Honghui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an 710054, China
| | - Qiang Huang
- Department of Orthopaedics Trauma, Honghui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an 710054, China
| | - Qian Wang
- Department of Orthopaedics Trauma, Honghui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an 710054, China
| | - Hanzhong Xue
- Department of Orthopaedics Trauma, Honghui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an 710054, China
| | - Zhong Li
- Department of Orthopaedics Trauma, Honghui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an 710054, China.
| | - Kun Zhang
- Department of Orthopaedics Trauma, Honghui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an 710054, China.
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Copp J, Magister S, Napora J, Getty P, Sontich J. Dual Magnetically Expandable Intramedullary Nails for Treatment of a Large Bony Defect in a Patient with Sarcoma: A Case Report. Strategies Trauma Limb Reconstr 2022; 17:189-194. [PMID: 36756295 PMCID: PMC9886027 DOI: 10.5005/jp-journals-10080-1560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 06/16/2022] [Indexed: 01/01/2023] Open
Abstract
Aim To describe the surgical technique of performing an all-internal lengthening to address a large diaphyseal femur defect in the sarcoma patient. Background Various strategies exist to address large intercalary bone defects with various biomechanical and biological implications. Case description A 23-year-old female with high-grade osteosarcoma of her left femur underwent wide resection and an internal reconstruction of a 12.5-cm femoral defect using dual magnetic lengthening intramedullary nails resulting in restoration of leg lengths, and pre-resection function with minimal residual disability. Conclusion Preoperative chemotherapy, wide resection and post-operative chemotherapy for osteosarcoma are the current standard of care. Resection often leads to large bone defects requiring complex reconstruction. Following intercalary bone resection, biological reconstruction is a consideration. An all-inside technique was developed in an effort to minimise complications of long-term external fixation for distraction osteogenesis, or extensile secondary grafting procedures for induced membrane strategy. Clinical significance This previously unreported surgical technique allows for an all-internal lengthening of large diaphyseal bone defects. While specifically used in an oncologic post-resection setting, this technique is applicable to the broader limb reconstruction and lengthening practice and overcomes some inherent limitations to previously described techniques. How to cite this article Copp J, Magister S, Napora J, et al. Dual Magnetically Expandable Intramedullary Nails for Treatment of a Large Bony Defect in a Patient with Sarcoma: A Case Report. Strategies Trauma Limb Reconstr 2022;17(3):189-194.
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Affiliation(s)
- Jonathan Copp
- Department of Orthopaedics, University Hospitals, Cleveland, Ohio, United States of America
| | - Steven Magister
- Department of Orthopaedics, University Hospitals, Cleveland, Ohio, United States of America
| | - Joshua Napora
- Department of Orthopaedics, University Hospitals, Cleveland, Ohio, United States of America
| | - Patrick Getty
- Department of Orthopaedics, University Hospitals, Cleveland, Ohio, United States of America
| | - John Sontich
- Department of Orthopaedics, University Hospitals, Cleveland, Ohio, United States of America
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Union, complication, reintervention and failure rates of surgical techniques for large diaphyseal defects: a systematic review and meta-analysis. Sci Rep 2022; 12:9098. [PMID: 35650218 PMCID: PMC9160061 DOI: 10.1038/s41598-022-12140-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 04/25/2022] [Indexed: 12/20/2022] Open
Abstract
To understand the potential and limitations of the different available surgical techniques used to treat large, long-bone diaphyseal defects by focusing on union, complication, re-intervention, and failure rates, summarizing the pros and cons of each technique. A literature search was performed on PubMed, Web of Science, and Cochrane databases up to March 16th, 2022; Inclusion criteria were clinical studies written in English, of any level of evidence, with more than five patients, describing the treatment of diaphyseal bone defects. The primary outcome was the analysis of results in terms of primary union, complication, reintervention, and failure rate of the four major groups of techniques: bone allograft and autograft, bone transport, vascularized and non-vascularized fibular graft, and endoprosthesis. The statistical analysis was carried out according to Neyeloff et al., and the Mantel–Haenszel method was used to provide pooled rates across the studies. The influence of the various techniques on union rates, complication rates, and reintervention rates was assessed by a z test on the pooled rates with their corresponding 95% CIs. Assessment of risk of bias and quality of evidence was based on Downs and Black’s “Checklist for Measuring Quality” and Rob 2.0 tool. Certainty of yielded evidence was evaluated with the GRADE system. Seventy-four articles were included on 1781 patients treated for the reconstruction of diaphyseal bone defects, 1496 cases in the inferior limb, and 285 in the upper limb, with trauma being the main cause of bone defect. The meta-analysis identified different outcomes in terms of results and risks. Primary union, complications, and reinterventions were 75%, 26% and 23% for bone allografts and autografts, 91%, 62% and 19% for the bone transport group, and 78%, 38% and 23% for fibular grafts; mean time to union was between 7.8 and 8.9 months in all these groups. Results varied according to the different aetiologies, endoprosthesis was the best solution for tumour, although with a 22% failure rate, while trauma presented a more composite outcome, with fibular grafts providing a faster time to union (6.9 months), while cancellous and cortical-cancellous grafts caused less complications, reinterventions, and failures. The literature about this topic has overall limited quality. However, important conclusions can be made: Many options are available to treat critical-size defects of the diaphysis, but no one appears to be an optimal solution in terms of a safe, satisfactory, and long-lasting outcome. Regardless of the bone defect cause, bone transport techniques showed a better primary union rate, but bone allograft and autograft had fewer complication, reintervention, and failure rates than the other techniques. The specific lesion aetiology represents a critical aspect influencing potential and limitations and therefore the choice of the most suitable technique to address the challenging large diaphyseal defects.
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Klifto KM, Azoury SC, Klifto CS, Mehta S, Levin LS, Kovach SJ. Treatment of Posttraumatic Tibial Diaphyseal Bone Defects: A Systematic Review and Meta-Analysis. J Orthop Trauma 2022; 36:55-64. [PMID: 34633778 DOI: 10.1097/bot.0000000000002214] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To describe evidenced-based treatment options for patients who sustained trauma and/or posttraumatic osteomyelitis of the tibia resulting in diaphyseal bone defects and to compare outcomes between patients treated with nonvascularized bone grafts (NBGs), bone transport (BT), or vascularized bone grafts (VBGs). DATA SOURCE The Preferred Reporting Items for Systematic Review and Meta-Analyses of individual participant data and Cochrane guidelines were followed. PubMed, EMBASE, Cochrane Library, Web of Science, Scopus, and CINAHL were searched from inception to June 2020. STUDY SELECTION Patients who were ≥18 years, had sustained trauma to the tibia resulting in fracture and/or osteomyelitis with measurable diaphyseal bone defects, and were treated by interventions such as NBGs, BT, or VBGs were eligible. Excluded studies were non-English, reviews, nonreviewed literature, cadavers, animals, unavailable full texts, nondiaphyseal defects, atrophic nonunions, malignancy, and replantations. DATA EXTRACTION A total of 108 studies were included with 826 patients. Two reviewers systematically/independently screened titles/abstracts, followed by full texts to ensure quality, accuracy, and consensus among authors for inclusion/exclusion of studies. A third reviewer addressed disagreements if investigators were unable to reach a consensus. Studies were quality assessed using "Methodological Quality and Synthesis of Case Series and Case Reports". DATA SYNTHESIS Analyses were performed with IBM SPSS version 25.0 (IBM Corporation, Armonk, NY) and G*Power3.1.9.2. CONCLUSIONS NBGs may be considered first line for trauma defect sizes ≤ 10 cm or posttraumatic osteomyelitis defect sizes <5 cm. BT may be considered first line for posttraumatic osteomyelitis defect sizes <5 cm. VBGs may be considered first line for trauma and posttraumatic osteomyelitis defect sizes ≥5 cm. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kevin M Klifto
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Missouri School of Medicine, Columbia, MO
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Saïd C Azoury
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Christopher S Klifto
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC; and
| | - Samir Mehta
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Orthopaedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - L Scott Levin
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Orthopaedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Stephen J Kovach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Orthopaedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Park KH, Oh CW, Kim JW, Oh JK, Yoon YC, Seo I, Ha SS, Chung SH. Matched Comparison of Bone Transport Using External Fixator Over a Nail Versus External Fixator Over a Plate for Segmental Tibial Bone Defects. J Orthop Trauma 2021; 35:e397-e404. [PMID: 33967227 DOI: 10.1097/bot.0000000000002084] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/04/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare the outcomes and complications of bone transport over a nail (BTON) with those of bone transport over a plate (BTOP) for segmental tibial bone defects. DESIGN Retrospective matched study design. SETTING A major metropolitan tertiary referral trauma center. PATIENTS Thirty-six patients with segmental tibial bone defects of >4 cm were included in this study. INTERVENTION Either BTON or BTOP was performed on 18 patients. MAIN OUTCOME MEASUREMENTS We compared the healing of the distraction process and of the docking site between the techniques. Distraction parameters including external fixator (EF) time, external fixation index, and healing index were compared. Bone and functional results were compared according to the Paley-Maar classification. Complications associated with each procedure were compared. RESULTS Both BTON and BTOP achieved similar rates of primary union (83% vs. 89%) at the distraction or docking site. Significantly less time wearing an EF was needed for BTOP than for BTON (2.8 vs. 5.4 months; P < 0.01). The external fixation index was significantly lower for BTOP than for BTON (0.45 vs. 0.94 mo/cm; P < 0.01), whereas the healing indexes were similar. The final outcomes and complication incidences were not significantly different. CONCLUSIONS The EF time was significantly shorter for BTOP than for BTON; however, the final outcomes were similar. Therefore, BTOP could be considered an attractive option for bone transport in patients with segmental tibial defects. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kyeong-Hyeon Park
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Jung-gu, Daegu, Korea
| | - Chang-Wug Oh
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Jung-gu, Daegu, Korea
| | - Joon-Woo Kim
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Jung-gu, Daegu, Korea
| | - Jong-Keon Oh
- Department of Orthopaedic Surgery, School of Medicine, Korea University Guro Hospital, Seoul, Korea; and
| | - Yong-Cheol Yoon
- Orthopaedic Trauma Division, Trauma Center, Gachon University College of Medicine, Incheon, Korea
| | - Il Seo
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Jung-gu, Daegu, Korea
| | - Sung-Soo Ha
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Jung-gu, Daegu, Korea
| | - Seung-Ho Chung
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Jung-gu, Daegu, Korea
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Management of post-traumatic femoral defects with a monorail external fixator over an intramedullary nail. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:1119-1126. [PMID: 34363107 PMCID: PMC8345235 DOI: 10.1007/s00590-021-03082-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 07/26/2021] [Indexed: 11/01/2022]
Abstract
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.
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Rosteius T, Pätzholz S, Rausch V, Lotzien S, Behr B, Lehnhardt M, Schildhauer TA, Seybold D, Geßmann J. Ilizarov bone transport using an intramedullary cable transportation system in the treatment of tibial bone defects. Injury 2021; 52:1606-1613. [PMID: 33436268 DOI: 10.1016/j.injury.2020.12.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 12/15/2020] [Accepted: 12/27/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Segmental tibia defects remain challenging for orthopedic surgeons to treat. The aim of this study was to demonstrate bone-related and functional outcomes after treatment of complex tibial bone defects using Ilizarov bone transport with a modified intramedullary cable transportation system (CTS). PATIENTS AND METHODS We conducted a single-center, retrospective study including all 42 patients treated for tibial bone loss via Ilizarov bone transport with CTS between 2005 and 2018. Bone-related and functional results were evaluated according to the Association for the Study and Application of Methods of Ilizarov (ASAMI) scoring system. Complication and failure rates were determined by the patients' medical files. RESULTS Patients had a mean age of 45.5 ± 15.1 years. The mean bone defect size was 7.7 ± 3.4 cm, the average nonunion scoring system (NUSS) score was 59 ± 9.5 points, and the mean follow-up was 40.8 ± 24.4 months (range, 13-139 months). Complete bone and soft tissue healing occurred in 32/42 patients (76.2%). These patients had excellent (10), good (17), fair (2), and poor (3) results based on the ASAMI functional score. Regarding bone stock, 19 patients had excellent, 10 good, and 3 fair results. In total, 37 minor complications and 62 major complications occurred during the study. In 7 patients, bone and soft tissue healing occurred after CTS failure with either an induced membrane technique or classic bone transport; 3 patients underwent lower leg amputation. Patients with treatment failure were significantly older (57.6 vs. 41.8 years; p = 0.003). Charlson score and treatment failure had a positive correlation (Spearman's rho 0.43; p = 0.004). CONCLUSION Bone transport using both intramedullary CTS and Ilizarov ring fixation is viable for treating patients with bone loss of the tibia and complex infection or soft tissue conditions. However, a high number of complications and surgical revisions are associated with the treatment of this severe clinical entity and should be taken into account.
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Affiliation(s)
- Thomas Rosteius
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle- de- la- Camp Platz 1, 44789 Bochum, Germany.
| | - Simon Pätzholz
- Department of Radiological Diagnostics, Interventional Radiology and Nuclear Medicine, BG University Hospital Bergmannsheil, Bürkle- de- la- Camp Platz 1, 44789 Bochum, Germany
| | - Valentin Rausch
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle- de- la- Camp Platz 1, 44789 Bochum, Germany
| | - Sebastian Lotzien
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle- de- la- Camp Platz 1, 44789 Bochum, Germany
| | - Björn Behr
- Department of Plastic Surgery, BG-University Hospital Bergmannsheil, Buerkle-de-la-Camp-Platz 1, D-44789 Bochum, Germany
| | - Markus Lehnhardt
- Department of Plastic Surgery, BG-University Hospital Bergmannsheil, Buerkle-de-la-Camp-Platz 1, D-44789 Bochum, Germany
| | - Thomas Armin Schildhauer
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle- de- la- Camp Platz 1, 44789 Bochum, Germany
| | - Dominik Seybold
- OPND Orthopädie Unfallchirurgie Praxis/Klinik Neuss, Plange Mühle 1, 40221 Düsseldorf, Germany
| | - Jan Geßmann
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle- de- la- Camp Platz 1, 44789 Bochum, Germany
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Abstract
Introduction Segmental long bone defects are some of the most challenging to surgically reconstruct; however, there is no clear guidance on which of the myriad of techniques is superior in a given clinical context. We describe three cases of segmental bone loss presenting to a major trauma center and have use these to develop a treatment algorithm for the sub-acute management of such fractures. Case Report Case 1 - Acute shortening and delayed lengthening using lengthening intramedullary (IM) nail to treat diaphyseal non-union of the femur with associated 3 cm shortening. Case 2 - 15 cm traumatic bone loss of femur, failed Masquelet, treated with IM nail, monolateral external-fixation and cable with a mean lengthening rate of 46 days/cm. Case 3 - 12 cm tibial traumatic bone loss, failed Masquelet, treated with fine wire frame with a mean lengthening rate of 49 days/cm. Conclusion As our cases illustrate; attempting complicated, definitive management in the acute phase generates complications and necessitates re-intervention. As such, we have developed a treatment algorithm for traumatic segmental bone loss. We recommend waiting 6 weeks and reimaging to check for evidence of spontaneous bone formation before deciding on definitive treatment. First-line treatment for femoral defects <4 cm is acute limb shortening with delayed lengthening using lengthening IM nail. First-line treatment for femoral defects >4 cm is lengthening over nail with monolateral external fixator. First-line treatment of tibial segmental bone defects in our hands is fine wire circular frames which provide excellent scope for soft tissue coverage and deformity correction. Treatment times of over 2 years in a frame are not uncommon and patients must diligently comply with pin sites management and lengthening protocols. This is the first paper providing an algorithm to guide surgeons in choosing the best lower limb reconstruction options in the sub-acute setting; considering the skill set and resources of the center in which one works.
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Affiliation(s)
- Maria Tennyson
- Department of Trauma and Orthopaedic Surgery, Cambridge University Hospital, Cambridge, United Kingdom
| | - Ada Maria Krzak
- Department of Clinical Medicine, The University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Matija Krkovic
- Department of Trauma and Orthopaedic Surgery, Cambridge University Hospital, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Ali Abdulkarim
- Department of Trauma and Orthopaedic Surgery, Cambridge University Hospital, Cambridge, United Kingdom
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Abstract
OBJECTIVES To evaluate the results of the bone transport over an intramedullary nail (BTON) technique for the treatment of segmental bone defects. DESIGN Retrospective review of case series. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS We included 40 patients who underwent reconstruction of the lower limb with BTON technique between 2000 and 2018. The technique was performed in the tibial segments in 21 patients and in the femoral segments in 19 patients. INTERVENTION The surgical technique was performed in 2 stages for patients with infected nonunion. Infection was eradicated in all patients at the first stage. For the BTON at the second stage, monolateral external fixators and circular external fixators were used for femoral and tibial defects, respectively. In cases of defects without any infection, debridement with a single-stage BTON was performed. MAIN OUTCOME MEASUREMENTS Complications as well as radiological and clinical results were evaluated according to the criteria of Paley-Maar. RESULTS Minor complications occurred in 11 patients: pin site problems (9), cellulitis (1), and skin detachment due to Schanz screw (1). Major complications occurred in 8 patients: docking site nonunion (4), early consolidation and Schanz screw failure (1), knee flexion contracture (1), and ankle equinus contracture (2). Four patients had osteomyelitis as residual sequelae. Bone score was excellent in 27 patients. Excellent functional results were obtained in 31 patients. CONCLUSIONS The BTON technique is associated with low cost because of the short treatment period, low complication risk, and rapid rehabilitation and is not limited by the amount of bone transport. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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12
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Barnds B, Johnson A, Rosenthal H, Tilley M. Ipsilateral rotational double-barrel fibula autograft for limb salvage in a pediatric patient with lower extremity intramedullary osteosarcoma: A case report. Microsurgery 2019; 40:247-251. [PMID: 31283842 DOI: 10.1002/micr.30487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 05/15/2019] [Accepted: 06/18/2019] [Indexed: 11/07/2022]
Abstract
Osteosarcoma is a relatively uncommon diagnosis that often requires limb salvage techniques in young patients. Due to the potential long-life expectancy of these patients, techniques which avoid prostheses are preferred to limit the need for future revision surgeries. This case report presents a 9-year-old male diagnosed with intramedullary well-differentiated osteosarcoma of the tibial diaphysis. This limb salvage procedure utilized a rotational ipsilateral vascularized double barrel fibula autograft measuring a total of 24.5 cm when harvested but osteotomized to lengths of 11 and 12.5 cm limbs to reconstruct an 11 cm tibial shaft defect. Anterior chamfer cuts were performed on one limb allowing it to be inserted intramedullary while the second limb was then placed with an inlay technique posterolaterally and then compressed with a carbon fiber plate. The patient recovered well initially postoperatively but was taken back for revision of the carbon fiber plate 10 weeks postoperatively secondary to asymptomatic loosening of the proximal screws. The patient subsequently healed and experienced full graft incorporation with expected hypertrophy of the graft. At most recent follow-up at 19 months, the patient reported no pain and was utilizing the extremity in a normal fashion with no activity limitations. In this report, we present a case of the use of an ipsilateral rotational double-barrel fibula autograft for limb salvage in a pediatric patient with lower extremity intramedullary osteosarcoma.
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Affiliation(s)
- Brandon Barnds
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Ariel Johnson
- The University of Kansas School of Medicine, Kansas City, Kansas
| | - Howard Rosenthal
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Michael Tilley
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
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13
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Hamdy RC, Bernstein M, Fragomen AT, Rozbruch SR. What's New in Limb Lengthening and Deformity Correction. J Bone Joint Surg Am 2018; 100:1436-1442. [PMID: 30106829 DOI: 10.2106/jbjs.18.00584] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Reggie C Hamdy
- Shriners Hospital for Children, Montreal, Quebec, Canada
| | - Mitchell Bernstein
- Shriners Hospital for Children, Montreal, Quebec, Canada.,McGill University Health Center, Montreal, Quebec, Canada
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