Simultaneous treatment of tibial bone and soft-tissue defects with the Ilizarov method

An osteoinductive and biodegradable intramedullary implant accelerates bone healing and mitigates complications of bone transport in male rats

Bone transport is a surgery-driven procedure for the treatment of large bone defects. However, challenging complications include prolonged consolidation, docking site nonunion and pin tract infection. Here, we develop an osteoinductive and biodegradable intramedullary implant by a hybrid tissue engineering construct technique to enable sustained delivery of bone morphogenetic protein-2 as an adjunctive therapy. In a male rat bone transport model, the eluting bone morphogenetic protein-2 from the implants accelerates bone formation and remodeling, leading to early bony fusion as shown by imaging, mechanical testing, histological analysis, and microarray assays. Moreover, no pin tract infection but tight osseointegration are observed. In contrast, conventional treatments show higher proportion of docking site nonunion and pin tract infection. The findings of this study demonstrate that the novel intramedullary implant holds great promise for advancing bone transport techniques by promoting bone regeneration and reducing complications in the treatment of bone defects.

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.

Proximal versus distal bone transport for the management of large segmental tibial defect: a clinical case series

This retrospective study compared proximal bone transport and distal bone transport in a series of cases diagnosed with large segmental tibial defects. Patients with a tibial segmental defect (> 5 cm) were eligible for inclusion. Twenty-nine patients were treated using proximal bone transport technique (PBT group) and 21 cases were managed by distal bone transport technique (DBT group). We recorded the demographic information, operation indexes, external fixation index (EFI), visual analog score (VAS), limb function scores, and complications. Patients were followed for 24-52 months. There was no significant difference in operation time, blood loss, time in frame, EFI and HSS score between the two groups (p > 0.05). However, the PBT group displayed better clinical effects than the DBT group, including higher AOFAS scores, lower VAS, and complication incidence (p < 0.05). In particular, the incidence of Grade-II pin-tract infection, transient loss of ankle movement, and foot drop was significantly lower in PBT group than that in DBT group (p < 0.05). Although both methods could be used safely for the management of large segmental tibial defects, the proximal bone transport may confer greater patient satisfaction because of better ankle functions and lower complications.

Acute shortening and double-level lengthening versus bone transport for the management of large tibial bone defects after trauma and infection

OBJECTIVE

The aim of this study was to present our experience with a new modified Ilizarov technique of acute shortening and double-level lengthening (ASDL) for the management of large tibial bone defects after trauma and infection and compare it with bone transport (BT).

METHODS

A retrospective comparative study was performed on 47 patients with large tibial defects after trauma and infection from June 2014 to June 2018. Depending on different Ilizarov methods, these patients were divided into ASDL group (n = 21) and BT group (n = 26). The difference in bone lengthening time, time in frame, external fixation index, docking site healing time were recorded and compared between the two groups. Bone and functional results were evaluated according to the Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria. Complications encountered in both groups were categorized according to the classification of Paley, including problems (treated nonoperatively), obstacles (treated operatively), and sequelae (unresolved at last).

RESULTS

All patients were followed for at least two years since the lengthening frame was removed. All cases achieved complete union at the docking site and consolidation of the regenerate callus. The mean bone loss was 8.9 cm (range 6.5-16.0 cm) in ASDL group vs. 10.3 cm (range 5.2-18.5 cm) in BT group. The mean bone lengthening time was 2.4 ± 0.7 months in ASDL group vs. 4.1 ± 1.4 months in BT group (p<0.001); time in frame was 9.1 months (range 7.0-14.5 months) in ASDL group vs. 17.7 months (range 13.5-23.0 months) in BT group (p<0.001); and external fixation index was 1.04 months/cm (range 0.83-1.38 months/cm) in ASDL group vs. 1.91 months/cm (range 1.28-2.70 months/cm) in BT group (p<0.001). The incidence of obstacles occurred in ASDL group was significantly lower than that in BT group (p<0.001). There was no significant difference in the bone (p = 0.635) and functional results (p = 0.293) between the two groups.

CONCLUSION

Compared with bone transport, our modified technique of acute shortening and double-level lengthening could reduce bone lengthening time, time in frame, external fixation index and postoperative complications. It showed better clinical effects in patients with large tibial bone defects after trauma and infection.

Temporary spacer rod and plate technique: a novel intraoperative technical tip for minimizing the docking site malalignment during bone transport for bone loss in Gustilo IIIb open tibial fractures

INTRODUCTION

Distraction osteogenesis is a safe and reliable option for managing bone defects of the tibia following major open fractures. Even though the Limb Reconstruction System (LRS) is a popular option, it may result in malalignment, necessitating an additional procedure to correct the alignment. The objective of the study is to assess the efficacy of a novel surgical technique in minimising malalignment.

METHODS

This was a retrospective cohort study conducted at a level 1 tertiary trauma centre consisting of 35 patients with primary bone loss following open tibia fractures. A uniplanar LRS frame was applied using a combined spacer rod with plate technique. Radiological assessment of docking site characteristics (translation, angulation) and functional assessment using ASAMI score was done.

RESULTS

The mean distraction regenerate length was 8.4 ± 3.45 cm. At the docking site, 18 patients did not have any deformity, 13 had a minor deformity of ≤ 5°, 2 had a moderate deformity of 6°-10° and 2 with a severe deformity > 10°. Circumferential docking was seen in 88.5% (31/35). According to the ASAMI functional scoring, 13 patients had excellent outcomes, 19 had good, one had fair, and two had poor outcomes. Six patients had pin tract infections, three had deep infections, and 17 had a delayed union. Our study had a lower incidence of malalignment compared to similar studies in the literature.

CONCLUSION

The use of this simple and economical intra-operative technique allowed for much higher precision in aligning the fracture ends, thus minimising the docking site malalignment.

LEVEL OF EVIDENCE

III.

LEVEL OF CLINICAL CARE

Level I Tertiary trauma centre.

Single-cell RNA sequencing unravels heterogeneity of skeletal progenitors and cell–cell interactions underlying the bone repair process

Introduction

Activation of skeletal progenitors upon tissue injury and the subsequent cell fate specification are tightly coordinated in the bone repair process. Although known osteoimmunological signaling networks play important roles in the microenvironment of the bone defect sites, the molecular mechanism underlying the bone repair process has not been fully understood.

Methods

To better understand the behavior of the skeletal progenitors and the heterogeneity of the cells during bone repair at the microenvironmental level, we performed a combinatorial analysis consisting of lineage tracing for skeletal progenitors using the Sox9-CreERT2;R26R^tdTomato mouse line followed by single-cell RNA sequencing (scRNA-seq) analysis using a mouse model of calvarial bone repair. To identify a therapeutic target for bone regeneration, further computational analysis was performed focusing on the identification of the cell–cell interactions, followed by pharmacological assessments with a critical-size calvarial bone defect mouse model.

Results

Lineage tracing analysis showed that skeletal progenitors marked by Sox9 were activated upon bone injury and contributed to bone repair by differentiating into osteoblasts. The scRNA-seq analysis characterized heterogeneous cell populations at the bone defect sites; the computational analysis predicted a bifurcated lineage from skeletal progenitors toward osteogenic and adipogenic lineages. Chemokine C–C motif ligand 9 (Ccl9) was identified as a signaling molecule that regulates bone regeneration in the mouse model, possibly through the regulation of adipogenic differentiation at the bone defect site.

Conclusion

Multipotential skeletal progenitors and the direction of the cell differentiation were characterized at single cell resolution in a mouse bone repair model. The Ccl9 signaling pathway may be a key factor directing osteogenesis from the progenitors in the model and may be a therapeutic target for bone regeneration.

•

Sox9-positive skeletal progenitors contributed to the calvaria bone repair process.

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scRNA-seq analysis revealed a heterogeneous cell population at bone defect sites.

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Skeletal progenitors had a bifurcated lineages of osteogenesis and adipogenesis.

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Ccl9 was identified as an important signaling molecule regulating bone regeneration.

Ilizarov Bone Transfer for Treatment of Large Tibial Bone Defects: Clinical Results and Management of Complications

BACKGROUNDS

The purpose of this study is to present our clinical experience using the Ilizarov bone transfer technique and free-flap technique in the reconstruction of large tibial bone and soft tissue defects, including an evaluation of both the management of postoperative complications and long-term outcomes.

METHODS

From January 2010 to May 2020, 72 patients with tibia bone and soft tissue defects were retrospectively evaluated. Either an anterolateral thigh perforator flaps (ALTP) or latissimus dorsi musculocutaneous flaps (LD), solely or in combination, were used to cover soft tissue defects. Once the flap was stabilized, an Ilizarov external fixator was applied to the limb. Follow-up was postoperatively performed at 1, 3, 6, 9, and 12 months.

RESULTS

Postoperatively, there were two cases of total and five of partial flap necrosis, and two cases of subcutaneous ulcers, which were caused by vascular crisis, infection, and hematoma, respectively. All the patients underwent Ilizarov external fixator surgery after flap recovery. A total of 16 complications occurred, including 3 cases of simple needle tract infection (antibiotic treatment) and 13 cases of complications requiring reoperation. A correlation factor analysis revealed that the main factors affecting the healing time were the defect length and operative complications. All patients with complications treated with the vascularized iliac flap eventually healed completely.

CONCLUSIONS

The Ilizarov method used together with an ALTP, LD, or a combination thereof yields good clinical results for repairing large bone and soft tissue defects of the tibia, thus reducing the incidence of amputations. However, longer treatment times may be involved, and postoperative complications can occur. The vascularized iliac flap may be a suitable choice for the treatment of postoperative complications of this type of Ilizarov bone transport.

Tetrafocal (three osteotomies) and pentafocal (four osteotomies) bone transport using Ilizarov technique in the treatment of distal tibial defect-preliminary outcomes of 12 cases and a description of the surgical technique

OBJECTIVE

To evaluate the preliminary outcomes of tetrafocal (three osteotomies) and pentafocal (four osteotomies) bone transport using Ilizarov technique for the treatment of distal tibial defect and describe the surgical technique.

METHODS

A total of 12 eligible patients with distal tibial defect > 6 cm caused by direct trauma or posttraumatic osteomyelitis who were admitted to our institution from January 2017 to January 2019 were treated by tetrafocal or pentafocal bone transport using Ilizarov technique. Detailed demographic data, including age, sex, etiology, defect size, number of osteotomies (three or four), external fixation time (EFT) and external fixation index (EFI), were collected, and the bone and functional outcomes were evaluated by the Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system. Complications during the surgery and the follow-up period were recorded and evaluated by the Paley classification at a minimum follow-up of two years after removal of the fixator.

RESULTS

There were 9 men and 3 women with an average age of 37.4±7.8 years. The etiology included posttraumatic osteomyelitis in 8 cases and posttraumatic bone loss in 4 cases. The mean bone defect after radical debridement was 7.1±0.6 cm. Tetrafocal bone transport was applied in 9 cases, and pentafocal bone transport was applied in 3 cases. The average EFT and EFI were 5.2±0.8 months and 0.7±0.2 months/cm, respectively. The average time of follow-up after removal of the external fixator was 28.5±3.3 months without recurrence of osteomyelitis. The bone results were good in 7 cases, fair in 4 cases, and poor in 1 case, and the functional results were good in 5 cases, fair in 6 cases, and poor in 1 case. The most common complication was pin tract infection, which occurred in all cases, but there were no major complications, such as nerve or vascular injury.

CONCLUSION

Tetrafocal and pentafocal bone transport using Ilizarov technique could be an alternative treatment option in selected cases with distal tibial defect > 6 cm. It could shorten the distraction period, fasten regeneration, and reduce the associated complications.

Acute Shortening for Open Tibial Fractures with Bone and Soft Tissue Defects: Systematic Review of Literature

Introduction

The presence of massive soft tissue loss in open tibial fractures is a challenging problem. Acute limb shortening is an alternative solution in situations where the use of flaps is limited.

Materials and methods

A review was conducted following the Preferred Reported Items for Systematic Reviews and Meta-analyses checklist (PRISMA) guidelines. A complete search of PubMed, EMBASE and MEDLINE was undertaken. Twenty-four articles related to closure of soft tissue defects through acute limb shortening were identified and included in this review.

Results

All report on restoration of limb function without or with minimal residual shortening. The authors note a decrease in the need for microsurgery. The external fixation devices used for deformity correction after closure of the soft tissue defect by acute shortening, angulation and rotation were the Ilizarov apparatus and circular fixator hexapods mainly.

Conclusion

Acute shortening is an alternative to microsurgical techniques. A ring external fixator is useful for restoring limb alignment after closing the soft tissue defect through creating a temporary deformity. The use of circular fixator hexapods can enable accurate correction of complex multicomponent deformities without the need to reassembly of individual correction units.

How to cite this article

Plotnikovs K, Movcans J, Solomin L. Acute Shortening for Open Tibial Fractures with Bone and Soft Tissue Defects: Systematic Review of Literature. Strategies Trauma Limb Reconstr 2022;17(1):44–54.

Staged Ilizarov distraction histogenesis and corrective reconstruction for severe malunited calcaneal fractures

PURPOSE

Severe calcaneal malunion is a clinical conundrum for the difficulty of calcaneal reconstruction without soft tissue complications. The aim of this study is to introduce the treatment strategy and preliminary results of staged Illizarov distraction histogenesis and corrective reconstruction for severe malunion of calcaneal fractures.

METHODS

From June 2014 to May 2020, 14 patients with severe calcaneal malunion treated with the staged strategy were retrospectively analyzed. At the first stage, calcaneal osteotomy and external fixation with Ilizarov frame were performed. The restoration of the approximate configuration of calcaneus and the expansion of contractural soft tissue were achieved by gradual calcaneal distraction. At the second stage, corrective reconstruction was performed and autogenous iliac crest bone graft was used. Clinical and radiographic outcomes were evaluated at final follow-up.

RESULTS

The average time of Ilizarov distraction and total fixation was 21.4 days and 41.0 days at first-stage treatment. At a mean follow-up of 33.1 months, the average American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score increased significantly from 24.0 to 72.4 (p < 0.01). And the mean visual analogue scale (VAS) score had improved remarkably from 8.2 to 2.4 (p < 0.01). Radiographs showed that talocalcaneal height, calcaneal width, calcaneal tuberosity height, hindfoot alignment angle, and talar declination angle were improved to a great extent (p < 0.01). Only one patient had minor pin site infection at first-stage treatment and one got superficial wound infection after second-stage surgery. No wound dehiscence, skin necrosis, or deep infection occurred.

CONCLUSION

Staged Ilizarov distraction histogenesis and corrective reconstruction is a safe and effective treatment strategy for reducing soft tissue complications and improving reconstruction results in surgical correction of severe calcaneal malunion.

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.

Cranial Bone Transport Promotes Angiogenesis, Neurogenesis, and Modulates Meningeal Lymphatic Function in Middle Cerebral Artery Occlusion Rats

BACKGROUND

Ischemic stroke is a leading cause of death and disability worldwide. However, the time window for quickly dissolving clots and restoring cerebral blood flow, using tissue plasminogen activator treatment is rather limited, resulting in many patients experiencing long-term functional impairments if not death. This study aims to determine the roles of cranial bone transport (CBT), a novel, effective, and simple surgical technique, in the recovery of ischemic stroke using middle cerebral artery occlusion (MCAO) rat model.

METHODS

CBT was performed by slowly sliding a bone segment in skull with a special frame and a speed of 0.25 mm/12 hours for 10 days following MCAO. Morris water maze, rotarod test, and catwalk gait analysis were used to study the neurological behaviors, and infarct area and cerebral flow were evaluated during CBT process. Immunofluorescence staining of CD31 and Nestin/Sox2 (sex determining region Y box 2) was performed to study the angiogenesis and neurogenesis. OVA-A647 (ovalbumin-Alexa Fluor 647) was intracisterna magna injected to evaluate the meningeal lymphatic drainage function.

RESULTS

CBT treatment has significantly reduced the ischemic lesions areas and improved the neurological deficits in MCAO rats compared with the rats in the control groups. CBT treatment significantly promoted angiogenesis and neurogenesis in the brain of MCAO rats. The drainage function of meningeal lymphatic vessels in MCAO rats was significantly impaired compared with normal rats. Ablation of meningeal lymphatic drainage led to increased neuroinflammation and aggravated neurological deficits and ischemic injury in MCAO rats. CBT treatment significantly improved the meningeal lymphatic drainage function and alleviated T-cell infiltration in MCAO rats.

CONCLUSIONS

This study provided evidence for the possible mechanisms on how CBT attenuates ischemic stroke injury and facilitates rapid neuronal function recovery, suggesting that CBT may be an alternative treatment strategy for managing ischemic stroke.

The efficacy of ilizarov method for management of long tibial bone and soft tissue defect

INTRODUCTION

Patients with open fracture Gustillo-Anderson grade 3 had undergone several surgical procedures, but still ended up with expose long dead bone or infected. Illizarov method was used to address long bone and soft tissue defect after re-debridement with radical resection of long dead bone or infected segment.

METHODS

We included 14 patients (mean age: 30.86 ± 11.49) with non-union tibial fracture with long dead and infected bone segment who had undergone several debridement, bone grafting or spacer and soft tissue closure procedure due to open fracture of tibia grade 3. The subjects underwent re-debridement with radical resection of dead or infected bone segment followed by Illizarov method to perform bone transport procedure for bone defect filling and simultaneously restore severe soft tissue loss and bone lengthening procedure.

RESULTS

All subjects had achieved satisfactory results with mean docking period of bone transport 3.78 ± 0.54 months, union time at the docking side 7 (5.5-9) months. Soft tissue was covered and no recurrence of infection. Three subjects had Leg Length Discrepancy (LLD) of 1 cm, whereas the remaining had zero discrepancy. No significant pain was observed at final follow-up and 4 patients had ankle joint stiffness.

CONCLUSION

The Illizarov method can effectively address long bone and soft tissue defects by distraction osteogenesis through bone transport procedure that filling the defect gradually without bone graft and simultaneously enhancing soft tissue closure without tertiary soft tissue procedure subsequently followed with bone lengthening procedure to correct the limb length discrepancy.

Ilizarov segmental bone transport of infected tibial nonunions requiring extensive debridement with an average distraction length of 9,5 centimetres. Is it safe?

OBJECTIVES

To evaluate the results of one stage radical debridement and segmental bone transport with circular fixator in the treatment of infected tibial non-union requiring extensive debridement with an average defect size of 8 cm and distraction length of 9,5 cm.

DESIGN

Retrospective study.

SETTING

Level I trauma centre at an academic university hospital.

PATIENTS

Thirty patients with infected tibial non-union with an average of 2,9 previous failed operations after a mean 12,5 months post-injury were treated consecutively. The mean age was 39,5 years (R:16-68). After radical debridement and irrigation, all patients were treated with segmental bone transport using Ilizarov circular fixator. All patients except 3, managed with an open docking protocol without bone grafting. In 2 patients a planned ankle arthrodesis with transport was done.

MAIN OUTCOME MEASUREMENTS

Bone union, resolution of infection, external fixation index (EFI), external fixation time (EFT), bone and functional results for this big defect size.

RESULTS

Union and eradication of infection was achieved in all patients. Mean follow-up was 32,5 months (R: 12-72 mo.) The average bone defect after debridement was measured 8.1 cm (R, 6-15). The total distraction length to restore the debridement defect and previous LLD was 9,5 cm (R, 6-15). The mean external fixation time was 13,7 months; the mean external fixation index was 1,49 mo./cm. One non-union, one refracture and one late valgus deformity was managed successfully with plating or nailing and all were healed uneventfully at the completion of the treatment. According to Paley & Maar and Katsenis criteria, the bone results were excellent in 24 and good in 6, functional scores were excellent in 21, good in 7, and fair in 2 patients. Minor complications were 1,36 per patient, major complications were 0,4 per patient and permanent complications were 0,2 per patient in the study group.

CONCLUSION

In the management of large post-infectious bone defects requiring an average 9,5 cm distraction; segmental bone transport is safe in terms of union and eradication of infection. The EFI, EFT, complications, bone and functional results do not differ from the other published studies with smaller defect size.

Free flap transplantation combined with Ilizarov bone transport for the treatment of severe composite tibial and soft tissue defects

Objective

To evaluate the clinical efficacy of free flap transplantation combined with Ilizarov bone transport in the treatment of severe composite tibial and soft tissue defects.

Methods

We retrospectively analyzed the clinical data of 40 patients with severe composite tibial and soft tissue defects who underwent free flap transplantation combined with Ilizarov bone transport. The clinical efficacy was evaluated according to the following criteria: success rate of wound repair by free flap transplantation, incidence or recurrence rate of deep infection, healing rate of bone defects and external fixation index, incidence of complications, and functional score of affected extremities.

Results

All infections were generally well controlled by radical debridement and negative-pressure therapy, and all 40 patients’ wounds healed after repair and reconstruction of the tibia and soft tissues. Postoperative complications were alleviated by active treatment. The mean external fixation time was 12.83 ± 2.85 months, and the external fixation index was 1.55 m/cm. According to the Association for the Study and Application of Methods of Ilizarov (ASAMI) score, an excellent or good functional outcome was attained in 85% of patients.

Conclusion

Free flap transplantation combined with Ilizarov bone transport is an effective treatment for severe composite tibial and soft tissue defects.

Modified tibial transverse transport technique for the treatment of ischemic diabetic foot ulcer in patients with type 2 diabetes

Background

Ischemic diabetic foot ulcer is one of the terminal complications of diabetes. The high amputation rate, recurrence rate, and treatment cost have caused a huge burden on patients and society. This study designed the modified tibial transverse transport (mTTT) technology to treat diabetic ischemic diabetic foot ulcers in patients with type 2 diabetes and investigated the effectiveness and safety of this technique.

Methods

This was a retrospective analysis of patients with type 2 diabetes and ischemic diabetic foot ulcers at two hospitals during January 2016–October 2019. These patients underwent mTTT surgery combined with wound debridement and vacuum sealing drainage negative pressure drainage treatment. In-hospital follow-up was performed at 1 month after the operation, while outpatient follow-up was performed at 3, 6, and 12 months after the operation. The ulcer healing time, recurrence rate, major amputation rate, and complications were analysed.

Results

A total of 201 patients were enrolled in this study, including 107 males and 94 females (mean age: 68.3 ​± ​7.1 years). The wounds of all patients healed completely (mean healing time: 4.6 ​± ​1.6 months). There was no occurrence of major amputation, recurrence, and treatment-related complications in the patients.

Conclusion

mTTT can effectively and safely treat ischemic diabetic foot ulcers in patients with type 2 diabetes. This technology is an important part of the ischemic diabetic foot ulcer treatment system and warrants further research.

The Translational Potential of this Article

This study introduced a new method to treat the ischemic diabetic foot ulcer which was called modified tibial transverse transport. The promising outcomes of patients indicated that this surgical method had great potential for clinical application and was worthy of further clinical research with high evidence level.

Classification of Bone Defects: An Extension of the Orthopaedic Trauma Association Open Fracture Classification

OBJECTIVES

To develop a post-traumatic bone defect classification scheme and complete a preliminary assessment of its reliability.

DESIGN

Retrospective classification.

SETTING

Tertiary referral trauma center.

PATIENTS/PARTICIPANTS

Twenty open fractures with bone loss.

INTERVENTION

Assignment of a bone defect classification grade.

MAIN OUTCOME MEASUREMENTS

Open fractures were classified based on orthogonal radiographs, assessing the extent and local geometry of bone loss, including D1-incomplete defects, D2-minor/subcritical (complete) defects (<2 cm), and D3-segmental/critical-sized defects (≥2 cm). Incomplete defects (D1) include D1A-<25% cortical loss, D1B-25%-75% cortical loss, and D1C->75% cortical loss. Minor/subcritical (complete) defects (<2 cm) (D2) include D2A-2 oblique ends allowing for possible overlap, D2B-one end oblique/one end transverse, and D2C-2 transverse ends. Segmental/critical-sized Defects (≥2 cm) include D3A-moderate defects, 2 to <4 cm; D3B-major defects, 4 to <8 cm; and D3C-massive defects, ≥8 cm. Reliability was assessed among 3 independent observers using Fleiss' kappa tests.

RESULTS

Interobserver reliability demonstrated the classification scheme has very good agreement, κ = 0.8371, P < 0.0005. Intraobserver reliability was excellent, κ = 1.000 (standard error 0.1478-0.1634), P < 0.00001. Interobserver reliability for the distinction between categories alone (D1, D2, or D3) was also excellent, κ = 1.000 (standard error 0.1421-0.1679), P < 0.00001.

CONCLUSIONS

This classification scheme provides a robust guide to bone defect assessment that can potentially facilitate selection of the most appropriate treatment strategy to optimize clinical outcomes.

Functional outcome and complications after treatment of comminuted tibial fractures or deformities using Ilizarov bone transport: a single-center study at 15- to 30-year follow-up

INTRODUCTION

The aim of this retrospective study was to evaluate long-term outcomes and complications of a single-center and single-surgeon patient series of isolated and comminuted tibial fractures with bone defects or tibial deformities treated by Ilizarov bone transport.

MATERIALS AND METHODS

Data from a consecutive series of patients with isolated comminuted tibial fractures (Fracture Group: FG) or deformities (Deformity Group: DG) treated between 1987 and 2002 were included. For clinical assessment, the Lower Extremities Functional Scale was used; complications were recorded according to the Dindo classification and statistical analysis was performed.

RESULTS

Overall, 72 patients were enrolled with a mean follow-up of 21.6 years (range 15-30) a mean LEFS of 36.4 (range 0-100). In the FG, the mean LEFS was 21.3 (range 0-98.75), and the external fixation time (EFT) lasted 7.6 months (range 3-18 months) months. In the DG, the mean LEFS was 76.7 (range 55-100), and the EFT was 10.6 months (range 3-20 months). Between the two groups, the clinical evaluation was significantly different, while the EFT was not (p = 0.14). In the FG, the worst results were obtained in the cases of open fractures with a higher percentage of complications and the need for further surgical procedures. The cumulative rate of complications was 55.6% during the first 36 months and 66.7% at the minimum follow-up of 180 months.

CONCLUSIONS

Ilizarov bone transport, even at a long follow-up period, proved to be an effective technique for both definitive treatment of comminuted tibial fractures with bone defects or tibial deformities. Although our functional outcomes were lower in patients with exposed fractures, they were in line with the literature, but not influenced by the EFT when properly managed. Most complications occurred during the first 3 years; however, they could also arise much later, even until almost 30 years.

Simultaneous debridement, Ilizarov reconstruction and free muscle flaps in the management of complex tibial infection

Chronic bone infections often present with complex bone and soft tissue loss. Management is difficult and commonly delivered in multiple stages over many months. This study investigated the feasibility and clinical outcomes of reconstruction in one stage.

Fifty-seven consecutive patients with chronic osteomyelitis (n=27) or infected non-union (n=30) were treated with simultaneous debridement, Ilizarov method and free muscle flap transfer. 41 patients (71.9 %) had systemic co-morbidities (Cierny-Mader group Bs hosts). Infection was confirmed with strict criteria. 48 patients (84.2 %) had segmental defects.

The primary outcome was eradication of infection at final follow-up. Secondary outcomes included bone union, flap survival and complications or re-operation related to the reconstruction.

Infection was eradicated in 55/57 cases (96.5 %) at a mean follow-up of 36 months (range 12–146). No flap failures occurred during distraction but 6 required early anastomotic revision and 3 were not salvageable (flap failure rate 5.3 %).

Bony union was achieved in 52/57 (91.2 %) with the initial surgery alone. After treatment of the five un-united docking sites, all cases achieved bony union at final follow-up.

Simultaneous reconstruction with Ilizarov method and free tissue transfer is safe but requires careful planning and logistic considerations. The outcomes from this study are equivalent or better than those reported after staged surgery.

A Novel Treatment of a 65-Year-Old Woman with a Neglected Type IIIB Open Fracture of the Tibia with Inadequate Soft Tissue Coverage and Periosteal Stripping Requiring an Ilizarov Approach to Bone and Soft Tissue Lengthening and Reconstruction: A Case Report and Review of the Literature

BACKGROUND Type IIIB open bone fractures include loss of soft tissue with periosteal stripping and need rapid surgical repair. The Ilizarov method of bone lengthening and reconstruction offers limb salvage as an alternative to amputation. CASE REPORT We report a case of a neglected type IIIB open fracture of the tibia with inadequate soft tissue coverage and periosteal stripping requiring an Ilizarov approach for limb salvage in a 65-year-old woman. Surgical debridement resulted in a large bone deficit of 13 cm. Acute shortening facilitated wound closure, and the remaining skin defect was treated with skin grafting. Bone transport and limb lengthening techniques, in addition to skin expansion and support, were used to restore the length of the tibia. The regenerated bone had to be fused with the talus since the tibial plafond was excised during debridement. The external fixator was removed after 643 days of treatment. An external fixation index of 49.6 d/cm was estimated. Excellent bone and good functional results were obtained according to the criteria of the Association for the Study and Application of the Method of Ilizarov. Skin invagination, bone translocation, and pin tract infection were the major postoperative issues. CONCLUSIONS This case showed that a multidisciplinary approach may be required for the successful management of neglected open fractures of the tibia and that the Ilizarov approach to both bone and soft tissue lengthening and reconstruction should be considered to ensure limb salvage and improve the final cosmetic appearance.

Treatment options for infected bone defects in the lower extremities: free vascularized fibular graft or Ilizarov bone transport?

Abstract

Objective

The objective was to explore the relative indications of free vascularized fibular graft (FVFG) and Ilizarov bone transport (IBT) in the treatment of infected bone defects of lower extremities via comparative analysis on the clinical characteristics and efficacies.

Methods

The clinical data of 66 cases with post-traumatic infected bone defects of the lower extremities who underwent FVFG (n = 23) or IBT (n = 43) from July 2014 to June 2018 were retrieved and retrospectively analyzed. Clinical characteristics, operation time, and intraoperative blood loss were statistically compared between two groups. Specifically, the clinical efficacies of two methods were statistically evaluated according to the external fixation time/index, recurrence rate of deep infection, incidence of complications, the times of reoperation, and final functional score of the affected extremities.

Results

Gender, age, cause of injury, Gustilo grade of initial injury, proportion of complicated injuries in other parts of the affected extremities, and numbers of femoral/tibial defect cases did not differ significantly between treatment groups, while infection site distribution after debridement (shaft/metaphysis) differed moderately, with metaphysis infection little more frequent in the FVFG group (P = 0.068). Femoral/tibial defect length was longer in the FVFG group (9.96 ± 2.27 vs. 8.74 ± 2.52 cm, P = 0.014). More patients in the FVFG group presented with moderate or complex wounds with soft-tissue defects. FVFG treatment required a longer surgical time (6.60 ± 1.34 vs. 3.12 ± 0.99 h) and resulted in greater intraoperative blood loss (873.91 ± 183.94 vs. 386.08 ± 131.98 ml; both P < 0.05) than the IBT group, while average follow-up time, recurrence rate of postoperative osteomyelitis, degree of bony union, and final functional scores did not differ between treatment groups. However, FVFG required a shorter external fixation time (7.04 ± 1.72 vs. 13.16 ± 2.92 months), yielded a lower external fixation index (0.73 ± 0.28 vs. 1.55 ± 0.28), and resulted in a lower incidence of postoperative complications (0.87 ± 0.76 vs. 2.21±1.78, times/case, P < 0.05). The times of reoperation in the two groups did not differ (0.78 ± 0.60 vs. 0.98 ± 0.99 times/case, P = 0.615).

Conclusion

Both FVFG and IBT are effective methods for repairing and reconstructing infected bone defects of the lower extremities, with unique advantages and limitations. Generally, FVFG is recommended for patients with soft tissue defects, bone defects adjacent to joints, large bone defects (particularly monocortical defects), and those who can tolerate microsurgery.

[Trifocal bone transport by using monolateral rail system in treatment of bone defects caused by post-traumatic tibial osteomyelitis]

OBJECTIVE

To study the effectiveness of trifocal bone transport by using monolateral rail system in the treatment of bone defects caused by post-traumatic tibial osteomyelitis.

METHODS

The clinical data of 28 patients with tibial defects caused by post-traumatic osteomyelitis treated with trifocal bone transport technique by using monolateral rail system between January 2012 and June 2017 were retrospectively analyzed. There were 26 males and 2 females, aged 22-59 years (mean, 41.3 years). The causes of injury included 13 cases of traffic accident injury, 9 cases of falling from height, 4 cases of heavy object injury, and 2 cases of crushing injury. The disease duration was 4.5-17.0 months (mean, 7.1 months). The length of bone defect was 6.5-16.8 cm (mean, 10.3 cm). And the range of soft tissue defect ranged from 3.5 cm×2.0 cm to 18.0 cm×11.0 cm. The bone transporting time, external fixation time, duration of regenerate consolidation, and external fixation index were recorded, and the complications were observed. At last follow-up, the bone and functional results were evaluated according to the criteria given by Association for the Study and Application of the Method of the Ilizarov (ASAMI).

RESULTS

All patients were successfully followed up after removing the external fixator with an average of 35 months (range, 24-65 months). The bone transporting time was 41-136 days (mean, 60.2 days), the external fixation time was 7.5-20.0 months (mean, 13.4 months), the external fixation index was 1.1-1.9 months/cm (mean, 1.4 months/cm), the duration of regenerate consolidation was 6.0-16.5 months (mean, 10.5 months). Pin tract infection occurred in 12 cases, delayed union on docking site was occurred in 9 cases, axial deviation was observed in 2 cases, poor regenerate consolidation was presented in 1 case, and refracture on docking site after fixator removal was occurred in 1 case. There was no recurrence of infection, amputation, vascular and neurologic complications, and osteofascial compartment syndrome. At last follow-up, according to ASAMI criterion, the bone healing results were excellent in 17 cases, good in 7 cases, and fair in 4 cases, with an excellent and good rate of 85.7%; the functional results were excellent in 15 cases, good in 10 cases, and fair in 3 cases, with an excellent and good rate of 89.3%.

CONCLUSION

Trifocal bone transport by using monolateral rail system is an effective method in the treatment of bone defect caused by post-traumatic osteomyelitis which can reduce bone transport time, external fixation time, and complications.

Eccentric Taylor spatial frame placement for the correction of femoral fracture deformity: a novel technique

The treatment of post-traumatic femoral deformity with circular frames can be difficult both for the patient and for the surgeon. Patients frequently suffer from residual knee stiffness, and the cumbersome location of the frame can even result in psychiatric problems such as depression and anxiety during their treatment. Here we describe a novel technique of constructing the Taylor spatial frame (TSF) eccentrically from the femur to allow the same level of comfort as a monolateral external fixator, while applying trigonometric principles to successfully retain the utility of the TSF prescription software. Deformity correction and fracture compression can therefore still be achieved in a controlled and predictable manner on an outpatient basis.

Efficacy comparison of double-level and single-level bone transport with Orthofix fixator for treatment of tibia fracture with massive bone defects

PURPOSE

The aim of this study was to evaluate the clinical and functional outcomes of patients with large post-traumatic tibial bone defects managed by double-level bone transport using the Ilizarov technique and compare it with one-level bone transport technique.

METHODS

A retrospective cohort study was conducted on 26 patients with open tibial fracture from January 2010 to January 2017. All cases were Gustilo III. Depending on the site of osteotomy, the patients were divided into single-level (n = 13) and double-level groups (n = 13). The bone transport time, consolidation time of the distraction gap, docking site healing time, external fixation time, external fixation index, soft tissue defect area, soft tissue growth index, operating time, and surgical bleeding volume were recorded and compared between the two groups. Bone and functional results were evaluated according to the Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria.

RESULTS

The mean duration of follow-up was 28.5 ± 5.8 months (range 13-38 months) since the Orthofix fixator was removed, all patients achieved complete union in the docking site and consolidation in the regenerate bone; moreover, the wound was closed The mean bone defect length after debridement was 7.2 cm (range 5.8-9.0 cm) in single-level group vs. 10.7 cm (range 7.5-15.0 cm) in the double-level group (P < 0.05). The mean docking site healing time was 10.85 ± 1.52 months in the single-level group vs. 8.93 ± 2.29 months in the double-level group (P < 0.05); external frame time was 18.06 months (range 15-20 months) in single-level group vs. 12.71 months (range 9.5-16.0 months) in the double-level group (P < 0.05); external fixation index was 2.52 months/cm (range 2.15-2.94 months/cm) versus 1.22 months/cm (range 0.96-1.67 months/cm) in double-level group (P < 0.01); and soft tissue growth index was 0.29 months/cm² (range 0.21-0.45 months/cm²) in the single-level group versus 0.62 months/cm² (range 0.47-0.86 months/cm²) in the double-level group (P < 0.01). According to the ASAMI classification, the clinical and functional results in the double-level group were better than in the single-level group.

CONCLUSION

The Ilizarov technique of double-level bone transport with Orthofix external fixator can be used successfully to repair and reconstruct the tibial bone loss and accompanying soft tissue defect.

Bone Transport for Treatment of Traumatic Composite Tibial Bone and Soft Tissue Defects: Any Specific Needs besides the Ilizarov Technique?

Objective

To evaluate the surgical efficacy of bone transport (Ilizarov technique) plus “shortening-lengthening,” “flap surgery,” and “open bone transport” as individualized treatments for traumatic composite tibial bone and soft tissue defects.

Methods

We retrospectively analyzed sixty-eight cases (mean age: 35.69 years, (range, 16–65)) treated from July 2014 to June 2017, including 29 middle, 18 distal, and 21 proximal tibial bone defects (4–18 cm, mean: 7.97 cm) with soft tissue defects (2.5 cm × 4.0 cm to 30.0 cm × 35.0 cm after debridement). We adopted the bone transport external fixator to fix the fracture after debriding the defect parts. In the meantime, we adopted the “shortening-lengthening technique,” “flap surgery,” and “open bone transport” as individualized treatment based on the location, range, and severity of the composite tibial bone and soft tissue defects. Postoperative follow-up was carried out. Surgical efficacy was assessed based on (1) wound healing; (2) bone defect healing rate; (3) external fixation time and index; (4) incidence/recurrence of deep infection; (5) postoperative complications; and (6) Association for the Study and Application of the Methods of Ilizarov (ASAMI) score.

Results

The mean duration from injury to reconstruction was 22 days (4–80 d), and the mean postoperative follow-up period was 30.8 months (18–54 m). After the repair and reconstruction, 2 open bone transport patients required infected bone removal first before continuing the bone transport treatment. No deep infection (osteomyelitis) occurred or recurred in the remaining patients, and no secondary debridement was required. Some patients had complications after surgery. All the postoperative complications, including flap venous crisis, nail channel reaction, bone nonunion, mechanical axis deviation, and refracture, were improved or alleviated. External fixation time was 12.5 ± 3.41 months, and the index was 1.63 ± 0.44. According to the ASAMI score, 76.47% of the outcomes were good/excellent.

Conclusion

The Ilizarov technique yields satisfactory efficacy for composite tibial bone and soft tissue defects when combined with “shortening-lengthening technique,” “flap surgery,” and “open bone transport” with appropriate individualized treatment strategies.

Bone transport versus acute shortening for the management of infected tibial bone defects: a meta-analysis

Background

The treatment for infected tibial bone defects can be a great challenge for the orthopaedic surgeon. This meta-analysis was conducted to compare the safety and efficacy between bone transport (BT) and the acute shortening technique (AST) in the treatment of infected tibial bone defects.

Methods

A literature survey was conducted by searching the PubMed, Web of Science, Cochrane Library, and Embase databases together with the China National Knowledge Infrastructure (CNKI) and the Wanfang database for articles published up to 9 August 2019. The modified Newcastle-Ottawa scale (NOS) was adapted to evaluate the bias and risks in each eligible study. The data of the external fixation index (EFI), bone grafting, bone and functional results, complications, bone union time and characteristics of participants were extracted. RevMan v.5.3 was used to perform relevant statistical analyses. Standard mean difference (SMD) was used for continuous variables and relative risk (RR) for the binary variables. All of the variables included its 95% confidence interval (CI).

Results

Five studies, including a total of 199 patients, were included in the study. Statistical significance was observed in the EFI (SMD = 0.63, 95% CI: 0.25, 1.01, P = 0.001) and bone grafting (RR = 0.26, 95%CI: 0.15, 0.46, P < 0.00001); however, no significance was observed in bone union time (SMD = − 0.02, 95% CI: − 0.39, 0.35, P = 0.92), bone results (RR = 0.97, 95% CI: 0.91, 1.04, P = 0.41), functional results (RR = 0.96, 95% CI: 0.86, 1.08, P = 0.50) and complications (RR = 0.76, 95% CI: 0.41, 1.39, P = 0.37).

Conclusions

AST is preferred from the aspect of minimising the treatment period, whereas BT is superior to AST for reducing bone grafting. Due to the limited number of trials, the meaning of this conclusion should be taken with caution for infected tibial bone defects.

Chronic Osteomyelitis of the tibia and ankle treated with Limb Salvage Reconstruction

Introduction: To confirm the success of our limb salvage treatment protocol and determine what factors are predictive of success versus failure in limb salvage techniques for patients with chronic osteomyelitis of the tibia and ankle.

Methods: Retrospective case series analyzing factors and outcomes in patients who underwent limb salvage techniques for chronic osteomyelitis of tibia or ankle. Main outcome measurements included infection controlled without the need for amputation or chronic antibiotic suppression and union of infected non-unions.

Results: Mean follow-up was 3.9 years. Out of the sixty-seven patients (mean age: 51.4 years) treated for chronic osteomyelitis, fifty-four had an associated non-union. Sixty-one patients (91.0%) had their infection controlled by limb salvage. Five ultimately required amputation and one remained on daily chronic antibiotics. Diabetics complicated with neuropathy and increasing numbers of limb salvage surgeries were associated with a significantly higher failure rate. Forty-eight out of fifty-four patients (88.9%) also had successful healing of their infected non-union. Diabetes and need for more limb salvage surgeries were also found to have a significantly higher failure rate.

Conclusions: Limb salvage is a reliable and successful treatment for patients with chronic osteomyelitis and infected non-unions of the lower extremities. Diabetic neuropathy is a risk factor that impedes success.

Level of Evidence: Prognostic Level IV.

Relevant advances in bone lengthening research: a bibliometric analysis of the 100 most-cited articles published from 2001 to 2017

This study aimed to assess the scientific production of bone lengthening research by identifying the most-cited papers. All articles including the term 'bone lengthening' published between 2001 and 2017 were retrieved through the Web of Science database. The 100 most-cited articles on bone lengthening included a total of 4244 citations, with 414 (9.7%) citations in 2017. There was an average of 249.6 citations per year. The articles predominantly addressed biomechanics and bone formation (38). Different surgical techniques, including intramedullary nail (14), Ilizarov (nine), intramedullary skeletal kinetic distractor (ISKD) (six), Taylor spatial frame (6), the PRECICE device (three), and lengthening and submuscular locking plate (three), were the second most-studied topic. Most studies were therapeutic (58), whereas 30 studies were experimental investigations using animal models. Among the clinical studies, case series were predominant (level of evidence IV) (57). This study presents the first bibliometric analysis of the most relevant articles on bone lengthening. The list is relatively comprehensive in terms of identifying the top issues in this field. However, the most influential clinical studies have a poor level of evidence, although a slight tendency toward a better level of evidence has been observed in more recent years.

A Successful Limb Salvage of an Electrical Burned Patient With Extensive Soft Tissue and Femoral Bone Necrosis

Severe electrical injury presents a formidable therapeutic challenge for surgeons because of the requirement for complex soft tissue and bony reconstruction to restore functionality of the injured area. The authors report on the limb salvage procedure for a patient with extensive soft tissue and femoral bone necrosis from a high-voltage electrical burn. The right thigh and knee were burned, resulting in large areas of muscle necrosis and a long segment of distal femur exposure and necrosis. Complete debridement of the area resulted in a 20 × 35 cm soft tissue defect and an 18-cm long distal femoral bone defect. The wound was repaired through latissimus dorsi muscle transplantation and bony reconstruction using the sequential Ilizarov osteogenesis method. The injured limb was retained, and the functional recovery of the patient's leg was satisfactory. This experience indicates that the combination of flap transplantation and the Ilizarov osteogenesis method are good options for the treatment of large soft tissue and huge segmental bony defects.

Infection-free rates and Sequelae predict factors in bone transportation for infected tibia: a systematic review and meta-analysis

Background

Tibia infected nonunion and chronic osteomyelitis are challenging clinical presentations. Bone transportation with external or hybrid fixators (combined external and internal fixators) is versatile to solve these problems. However, the infection-free rates of these fixator systems are unknown. Additionally, the prognosis factors for results of bone transportation are obscure. Therefore, this systematic review and meta-analysis was conducted to answer these questions.

Methods

A systematic review was conducted following the PRISMA-IPD guidelines. Relevant publications from January 1995 to September 2018 were compiled from Medline, Embase, and Cochrane. The infection-free rates of external and hybrid fixators were achieved by synthesizing aggregate data and individual participant data (IPD). IPD was analyzed by two-stage method with logistical regression to identify prognosis factors of sequelae.

Results

Twenty-two studies with 518 patients were identified, including 11 studies with 167 patients’ IPD, and 11 studies with 351 patients’ aggregate data. The infection-free rate of hybrid fixator group was 86% (95%CI: 79–94%), lower than that of external fixator which was 97% (95%CI: 95–98%,). The number of previous surgeries was found predict factor of bone union sequelae (p = 0.04) and function sequelae(p < 0.01); The external fixation time was found predict factor of function sequelae (p = 0.015).

Conclusions

Hybrid fixators may be associated with a greater risk of infection-recurrence in the treatment of tibia infected nonunion and chronic osteomyelitis. The number of previous surgeries and external fixation time can be used as predictors of outcomes. Proper fixators and meticulously designed surgery are important to avoid unexpected operations and shorten external fixation time.

[Effectiveness of limbs shortening and re-lengthening in treatment of tibial infectious bone defect and chronic osteomyelitis]

Objective

To evaluate the limbs shortening and re-lengthening in the treatment of tibial infectious bone defect and chronic osteomyelitis.

Methods

Between January 2011 and April 2016, 19 cases of tibial infectious bone defect and chronic osteomyelitis were treated with the limbs shortening and re-lengthening technique. There were 13 males and 6 females, aged from 22 to 62 years (mean, 44 years). The causes of injury included traffic accident injury in 16 cases, crush injury in 1 case, and falling from height in 2 cases. One patient was infected after plate internal fixation of closed tibial fracture and 18 patients after external fixation of open tibial fractures (Gustilo type IIIB). The mean previous operation times was 3 times (range, 2-5 times). The time from injury to bone transport operation was 3-11 months (mean, 6.5 months). The bone defect length was 2.0-5.5 cm (mean, 4.3 cm) after debridement. After tibial shortening, limb peripheral blood supply should be checked after release of the tourniquet. Seven wounds were closed directly, 5 were repaired with adjacent skin flap, 5 were repaired with sural neurovascular flap, 1 was repaired with medial head of gastrocnemius muscle flap, and 1 underwent skin grafting. Single arm external fixator or ring type external fixator were used, and completely sawed off between 2 sets of external fixation screws at proximal and distal metaphysis of the tibia. Limb lengthening was performed after 1 week with the speed of 1 mm/d.

Results

All patients were followed up 10-36 months with an average of 14 months. Two cases delayed healing of the wound after operation, and the other wounds healed primarily. Natural healing of the opposite end of the bone were found in 18 cases, and 1 case had nonunion in the opposite end of the bone because of incomplete removal of lesion bone. There were 5 cases of slow growth of the callus, and healed smoothly by "accordion" technology and injecting red bone marrow in 4 cases, and by bone grafting and internal fixation in 1 case. The time of bone lengthening was 1-3 months, the prolongation index was 1.6-2.7 cm/month (2.20 cm/month). The bone healing time was 7-13 months (mean, 11.1 months). According to tibial stem diagnostic criteria Johner-Wruhs score, 9 cases were excellent, 8 cases were good, 2 cases were fair, with an excellent and good rate of 89.5%.

Conclusion

Limbs shortening and re-lengthening is an effective method for the treatment of tibial infectious bone defect and chronic osteomyelitis, with the advantages of improving the immediate alignment of the osteotomy ends, significantly shortening the bone healing time of opposite ends of bone.

Mechanical solutions to salvage failed distraction osteogenesis in large bone defect management

INTRODUCTION

Ilizarov bone transport for large bone defect is challenging and may end in distraction osteogenesis failure.

MATERIAL AND METHODS

Ten forearm and seven tibial defect cases with failed regeneration due to ischaemia during bone transport were studied retrospectively. Mean forearm and tibial defects were 5.5 ± 0.8 and 7.6 ± 1 cm respectively, or 22.3 ± 3.6 and 20 ± 2.3% as compared with healthy segments. Most patients had numerous previous operations (2.6 ± 0.5 and 3.4 ± 0.8 per patient, respectively), extensive scars locally and post-traumatic neuropathy. There were seven infected defects. Mechanical solutions used were (1) additional osteotomy and transport of the fragment to compact the ischaemic regenerate (10 forearms, 4 tibias) and (2) compaction of the connective tissue layer in the tibial regenerate with either two 5-mm steps (two cases) or gradually (one case).

RESULTS

Bone integrity was restored in all the cases. Complete compensation of the defects was achieved in 12 patients with the first technique. Two patients with 8-cm ulna defects remained with residual discrepancy. In the forearm, mean compaction was 1.7 ± 0.4 cm. It took 25.7 ± 5.4 days followed by an average fixation period of 107.1 ± 11.8 days. In the tibia, mean longitudinal compaction by distraction measured 1.7 ± 0.8 cm. The second technique ended up with an acceptable shortening of 1 cm in two cases. Four centimeters were compressed in the third case gradually.

CONCLUSION

The technical solutions used for mechanical effects on the ischaemic distraction regenerate resulted in its rescue and bone union in all the cases.

[Application of skin stretcher for repair of postoperative skin and soft tissue defects in tibial fractures]

Objective

To discuss the efficacy of skin stretcher applied for repair of postoperative skin and soft tissue defects in tibial fractures.

Methods

Between April 2016 and March 2017, 15 cases with skin and soft tissue defects after tibial fractures fixation were treated with the skin stretcher. There were 11 males and 4 females with an age of 24-59 years (mean, 37.5 years). The causes of injury included traffic accident in 7 cases, bruise in 3 cases, falling from height in 3 cases, and falling in 2 cases; without nerve and vascular injury in all patients. These cases were followed up 1-3 months after their first surgery, consisting of 3 closed fractures treated with open reduction and plate and screw fixation, 12 open fractures treated with external fixation after debridement. The area of skin defects ranged from 14 cm×5 cm to 20 cm×7 cm, all of which were stripped or spindle shaped skin defects. First, the skin was penetrated by two Kirschner wires which were locked by skin stretchers on both sides of the skin defect longitudinally. Then, the tension of skin stretchers was timely adjusted according to the skin flap blood supply and muscle compression. Finally, Kirschner wires and skin stretchers were removed when the edge of skin contacted and been sutured.

Results

All skin and soft tissue defects were covered after stretching for 6-13 days. The interrupted sutured wounds healed at 12 days. Clinical scores of wound healing decreased from 3.40±0.51 at immediate postoperatively to 1.27±0.46 at 12 days postoperatively, showing significant difference ( t=12.911, P=0.000). All the patients were followed up 4-12 months (mean, 6.5 months). After stretching, the skin color, elasticity, and pain and touch feeling were similar with the normal skin, and the hair growth was normal. After operation, 1 case of nail tract infection and 2 cases of calf discomfort occurred, and all were relieved after treatment.

Conclusion

It is an effective method for repairing postoperative skin and soft tissue defects in tibial fractures with the application of skin stretchers.

Ilizarov technique: Bone transport versus bone shortening-lengthening for tibial bone and soft-tissue defects

OBJECTIVE

To compare the outcomes of bone transport and bone shortening-lengthening by Ilizarov technique for treatment of tibial bone and soft-tissue defects.

METHODS

Fifty patients with tibial bone and soft-tissue defects were treated by Ilizarov technique from January 2007 to June 2016. Two subgroups were treated by either bone transport (group A) containing 28 cases or bone shortening-lengthening (group B) including 22 cases.

RESULTS

Bony union was achieved at the distracted sites with a mean of 236 days in group A, while 240 days in group B, showing no significant difference (t = -0.931, P = 0.308). The mean fixation index was 3.91 d/mm and 3.92 d/mm, respectively. There was no obvious difference (t = 2.839, P = 0.006) of the mean union time at the docking sites with 376 days and 320 days, respectively. According to the Paley's criterion, 21 patients had excellent bony union and 5 good in group A, as compared to 18 excellent and 4 good in group B, but no significant difference (X² = -0.308, P = 0.741) was observed. The functional results were excellent in 11 patients, good in 10 and fair in 7, as well as 15 complications in group A, compared with 7 excellent, 10 good and 5 fair, together with 12 complications in group B, and there were no remarkable difference (X² = -0.323, P = 0.751; X² = -0.590, P = 0.562).

CONCLUSION

Overall, the outcomes are similar of bone transport or bone shortening-lengthening by using Ilizarov technique for treatment of tibial bone and soft-tissue defects, although the latter has less union time and higher healing rate.

Forces associated with launch into space do not impact bone fracture healing

Segmental bone defects (SBDs) secondary to trauma invariably result in a prolonged recovery with an extended period of limited weight bearing on the affected limb. Soldiers sustaining blast injuries and civilians sustaining high energy trauma typify such a clinical scenario. These patients frequently sustain composite injuries with SBDs in concert with extensive soft tissue damage. For soft tissue injury resolution and skeletal reconstruction a patient may experience limited weight bearing for upwards of 6 months. Many small animal investigations have evaluated interventions for SBDs. While providing foundational information regarding the treatment of bone defects, these models do not simulate limited weight bearing conditions after injury. For example, mice ambulate immediately following anesthetic recovery, and in most cases are normally ambulating within 1-3 days post-surgery. Thus, investigations that combine disuse with bone healing may better test novel bone healing strategies. To remove weight bearing, we have designed a SBD rodent healing study in microgravity (µG) on the International Space Station (ISS) for the Rodent Research-4 (RR-4) Mission, which launched February 19, 2017 on SpaceX CRS-10 (Commercial Resupply Services). In preparation for this mission, we conducted an end-to-end mission simulation consisting of surgical infliction of SBD followed by launch simulation and hindlimb unloading (HLU) studies. In brief, a 2 mm defect was created in the femur of 10 week-old C57BL6/J male mice (n = 9-10/group). Three days after surgery, 6 groups of mice were treated as follows: 1) Vivarium Control (maintained continuously in standard cages); 2) Launch Negative Control (placed in the same spaceflight-like hardware as the Launch Positive Control group but were not subjected to launch simulation conditions); 3) Launch Positive Control (placed in spaceflight-like hardware and also subjected to vibration followed by centrifugation); 4) Launch Positive Experimental (identical to Launch Positive Control group, but placed in qualified spaceflight hardware); 5) Hindlimb Unloaded (HLU, were subjected to HLU immediately after launch simulation tests to simulate unloading in spaceflight); and 6) HLU Control (single housed in identical HLU cages but not suspended). Mice were euthanized 28 days after launch simulation and bone healing was examined via micro-Computed Tomography (µCT). These studies demonstrated that the mice post-surgery can tolerate launch conditions. Additionally, forces and vibrations associated with launch did not impact bone healing (p = .3). However, HLU resulted in a 52.5% reduction in total callus volume compared to HLU Controls (p = .0003). Taken together, these findings suggest that mice having a femoral SBD surgery tolerated the vibration and hypergravity associated with launch, and that launch simulation itself did not impact bone healing, but that the prolonged lack of weight bearing associated with HLU did impair bone healing. Based on these findings, we proceeded with testing the efficacy of FDA approved and novel SBD therapies using the unique spaceflight environment as a novel unloading model on SpaceX CRS-10.

The Combined Use of a Neurocutaneous Flap and the Ilizarov Technique for Reconstruction of Large Soft Tissue Defects and Bone Loss in the Tibia

BACKGROUND

Management of posttraumatic large soft tissue defects and bone loss remains a therapeutic and surgical challenge for orthopedic surgeons. We assessed the use of a neurocutaneous flap and the Ilizarov technique in the reconstruction of severe composite defects in the tibia.

METHODS

We retrospectively reviewed 18 consecutive patients with trauma-related soft tissue defects and bone loss. The size of the soft tissue defect ranges from 8 × 9 cm to 14 × 18 cm. The mean size of bone loss was 4.5 cm. A great saphenous neurocutaneous flap or sural neurocutaneous flap was created to reconstruct the soft tissue defect. The Ilizarov external fixator was applied to reconstruct bony loss by means of distraction osteogenesis.

RESULTS

The mean follow-up period was 38.8 months. All transferred flaps survived completely. The area covered ranged from 9 × 10 cm to 15 × 20 cm. The mean distraction length and duration of use of the external fixator were 6 cm and 11.4 months, respectively. All patients achieved final union. Complications of superficial pin-tract infections and mild Achilles tendon contracture were observed, but these were resolved over time. All patients were satisfied with the outcome of the surgery.

CONCLUSIONS

A well-vascularized neurocutaneous flap is a safe and effective option in lower extremity reconstruction under a stable mechanical environment, which can be created using the Ilizarov technique. It is a good option for reconstructing severe complex defects in the lower limb.

Double-level bone transport for large post-traumatic tibial bone defects: a single centre experience of sixteen cases

PURPOSE

The aim of this study was to evaluate the clinical and functional outcomes of patients with large post-traumatic tibial bone defects managed by double-level bone transport using the Ilizarov technique.

METHODS

We retrospectively reviewed 16 patients of 39.1 years (range, 16.0-65.0 years). The bone defects averaged 10.9 ± 3.8 cm (range: 6.0 cm-20.0 cm) after radical resection and were managed by double-level bone transport. Bone and functional results were evaluated according to the ASAMI criteria.

RESULTS

The mean duration of follow-up after frame removal was 29.5 ± 1.8 months (range, 12.0-36.0 months). All patients achieved complete union in both the regenerates and the docking site and eradication of infection. The mean bone transport time was 55.6 ± 23.7 days (range, 30.0-125.0 days). The mean external fixation time was 12.0 ± 3.9 months (range, 5.0-18.0 months), and the mean external fixation index was 1.1 ± 0.3 months/cm (rang, 0.8-2.0 months/cm). The bone results were excellent in ten patients and poor in six patients. The functional results were excellent in 12 patients and good in four patients.

CONCLUSION

Double-level bone transport is a safe, reliable, and successful method for large post-traumatic tibial bone defects. Furthermore, this technique can reduce bone transport time, time in frame, and total treatment time in one stage.

Bone transport versus acute shortening for the management of infected tibial non-unions with bone defects

INTRODUCTION

This study compared bone transport to acute shortening/lengthening in a series of infected tibial segmental defects from 3 to 10cm in length.

METHODS

In a retrospective comparative study 42 patients treated for infected tibial non-union with segmental bone loss measuring between 3 and 10cm were included. Group A was treated with bone transport and Group B with acute shortening/lengthening. All patients were treated by Ilizarov methods for gradual correction as bi-focal or tri-focal treatment; the treating surgeon selected either transport or acute shortening based on clinical considerations. The principle outcome measure was the external fixation index (EFI); secondary outcome measures included functional and bone results, and complication rates.

RESULTS

The mean size of the bone defect was 7cm in Group A, and 5.8cm in Group B. The mean time in external fixation in Group A was 12.5 months, and in Group B was 10.1 months. The external fixation index (EFI) measured 1.8 months/cm in Group A and 1.7 months/cm in Group B (P=0.09). Minor complications were 1.2 per patient in the transport group and 0.5 per patient in the acute shortening group (P=0.00002). Major complications were 1.0 per patient in the transport group versus 0.4 per patient in the acute shortening group (P=0.0003). Complications with permanent residual effects (sequelae) were 0.5 per patient in the transport group versus 0.3 per patient in the acute shortening group (P=0.28).

CONCLUSIONS

While both techniques demonstrated excellent results, acute shortening/lengthening demonstrated a lower rate of complications and a slightly better radiographic outcome. Bone grafting of the docking site was often required with both procedures.

LEVEL OF EVIDENCE

Level III; Retrospective comparative study.

Comparison of Intramedullary Nail Versus Conventional Ilizarov Method for Lower Limb Lengthening: A Systematic Review and Meta-Analysis

The objective of this systematic review and meta-analysis was to compare the lengthening and then nailing (LATN) technique to the conventional Ilizarov method for limb lengthening. A systemic search of potential relevant literature was performed in databases, including the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, and the ISI Web of Knowledge, from their inception to 22 May 2015 using medical subject heading (MeSH) terms "Ilizarov," "bone lengthening," or "intramedullary nail." A total of 89 titles and abstracts were preliminarily reviewed, of which 4 studies eventually satisfied the eligibility criteria, consisting of one randomized controlled trial (RCT), two clinical controlled trials and one retrospective cohort study. A total of 354 limbs were included in the study, among which 183 were lengthened over an intramedullary nail, and 171 limbs were lengthened conventionally. The mean difference (MD) was -50.21 for the external fixation index between the two groups (95% CI, -51.83 to -48.59; P < 0.00001) with high heterogeneity (I² = 99%); no significant difference in length was gained (MD = -0.30, 95% CI = -0.72 to 0.12; P = 0.16) with high heterogeneity (I² = 80%); and there was high significant difference for the consolidation index (MD = -19.97; 95% CI, -21.59 to -18.35; P < 0.00001) with high heterogeneity (I² = 100%). The overall rate of complications was relatively low, and differed significantly between the two groups. Through this meta-analysis, we find that LATN is superior to the conventional method in regards to the external fixation index and the consolidation index, which means that LATN is an effective technique that can decrease the time needed in external fixation.

A Prospective Randomized Trial to Assess Fixation Strategies for Severe Open Tibia Fractures: Modern Ring External Fixators Versus Internal Fixation (FIXIT Study)

The treatment of high-energy open tibia fractures is challenging in both the military and civilian environments. Treatment with modern ring external fixation may reduce complications common in these patients. However, no study has rigorously compared outcomes of modern ring external fixation with commonly used internal fixation approaches. The FIXIT study is a prospective, multicenter randomized trial comparing 1-year outcomes after treatment of severe open tibial shaft fractures with modern external ring fixation versus internal fixation among men and women of ages 18-64. The primary outcome is rehospitalization for major limb complications. Secondary outcomes include infection, fracture healing, limb function, and patient-reported outcomes including physical function and pain. One-year treatment costs and patient satisfaction will be compared between the 2 groups, and the percentage of Gustilo IIIB fractures that can be salvaged without soft tissue flap among patients receiving external fixation will be estimated.

[Tissue flap combined with sequential bone lengthening technique for repairing severe soft tissue and bone defects of lower extremity after burn injury]

Objective

To investigate the effectiveness of tissue flap grafting and sequential bone lengthening for repairing severe soft tissue and bone defects of the lower extremity after burn injury.

Methods

Between January 2010 and December 2015, 11 cases of large segmental bone and soft tissue defects in the leg were treated. There were 10 males and 1 female, with a mean age of 28 years (range, 19-37 years). The causes included traffic accident in 8 cases, high voltage electric burn in 2 cases, CO poisoning burn in 1 case. The time from injury to admission was 3-14 days (mean, 6.5 days). The bone defect length was 8-18 cm (mean,14 cm); the skin soft tissue defect ranged from 13 cm × 8 cm to 25 cm × 19 cm. After complete removal of necrotic tissue and lesions of the femur or the tibia, the tissue flaps were used to repair soft tissue defect of the lower extremity in one-stage operation; bone defect was treated by Orthofix single side external fixation or Ilizarov ring external fixation in two-stage operation.

Results

Eleven flaps survived completely, primary healing of incision was obtained in the others except for 1 patient who had necrotic bone infection, which was cured after removing necrosed femoral bone and filling with antibiotic bone cement spacer. During bone lengthening, pin tract infection occurred in 1 patient, and infection was controlled after dressing change. Bone lengthening ranged from 8 to 18 cm, with an average of 14 cm. After prolonged extension, the external fixator was retained for 4-12 months (mean, 6.5 months). All bone defects were repaired with bone healing time of 12-22 months (mean, 17 months). All patients were followed up 8-24 months (mean, 15 months). No vascular and neurological complication occurred during operation; no osteomyelitis or re-fracture occurred after operation, and the recovery of the lower extremity function was good.

Conclusion

Tissue flap grafting combined with bone lengthening is an effective method to repair severe bone and soft tissue defects of lower extremity.

Effectiveness of Treatment for Distal Tibial Nonunions With Associated Complex Deformities Using a Hexapod External Fixator

OBJECTIVE

To determine the efficacy of a hexapod external fixator (TSF) and its ability to perform 6-axis correction in restoring deformities associated with distal tibial nonunions.

DESIGN

Consecutive retrospective case review.

SETTING

St. Louis University Hospital. Level 1 Trauma Center.

PATIENTS/PARTICIPANTS

Thirty-seven patients with distal tibial nonunion with greater than 5 degrees of deformity in any plane. Patients were excluded who were less than 18 years of age, had tibial deformities less than 5 degrees, had proximal or middle tibial deformities, or had less than 1 year of follow-up.

INTERVENTION

Patients with distal tibial nonunions with combined deformities were treated by the senior author with a hexapod device. Preoperative mechanical axis deviation and union status were assessed. Postoperative parameters evaluated included anatomic and mechanical axis determination and adequacy of union. Metrics include long alignment films with routine clinical follow-up.

MAIN OUTCOME MEASUREMENTS

Assessment of deformity correction in 6 axes, restoration to union, and mechanical axis correction.

RESULTS

Average combined preoperative deformity was greater than 17.7 degrees. Average mechanical axis was restored within 5 degrees of the desired goal in all categories except in patients with severe preoperative valgus deformities. The complex nonunion group had a 94% union rate. Average time in the hexapod was 106.7 days. Average follow-up time was 2 years.

CONCLUSIONS

Hexapod external fixators can be used as an accurate modality to heal complex distal tibia nonunions with multifocal deformities and significant mechanical axis deviation. These difficult reconstructions are accomplished with minimum complications using these devices.

LEVEL OF EVIDENCE

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

Unhappy triad in limb reconstruction: Management by Ilizarov method

AIM

To evaluate the results of the Ilizarov method in management of cases with bone loss, soft tissue loss and infection.

METHODS

Twenty eight patients with severe leg trauma complicated by bone loss, soft tissue loss and infection were managed by distraction osteogenesis in our institution. After radical debridement of all the infected and dead tissues the Ilizarov frame was applied, corticotomy was done and bone transport started. The wounds were left open to drain. Partial limb shortening was done in seven cases to reduce the size of both the skeletal and soft tissue defects. The average follow up period was 39 mo (range 27-56 mo).

RESULTS

The infection was eradicated in all cases. All the soft tissue defects healed during bone transport and plastic surgery was only required in 2 cases. Skeletal defects were treated in all cases. All patients required another surgery at the docking site to fashion the soft tissue and to cover the bone ends. The external fixation time ranged from 9 to 17 mo with an average of 13 mo. The complications included pin tract infection in 16 cases, wire breakage in 2 cases, unstable scar in 4 cases and chronic edema in 3 cases. According to the association for study and application of methods of Ilizarov score the bone results were excellent in 10, good in 16 and fair in 2 cases while the functional results were excellent in 8, good in 17 and fair in 3 cases.

CONCLUSION

Distraction osteogenesis is a good method that can treat the three problems of this triad simultaneously.

Clinical evaluation of patients submitted to osteogenic distraction in the lower limb at a university hospital

Objective

To evaluate the clinical characteristics from patients submitted to osteogenic distraction to correct bone gap at a university hospital.

Methods

Retrospective transversal study, with a convenience sample, from 2000 to 2012, evaluating clinical aspects of patients treated, submitted to osteogenic distraction (bone transport) with Ilizarov's external fixation device. The chi-squared, Fisher's, and Mann–Whitney's U tests were used with a 5% level of significance (p < 0.05).

Results

33 patients were studied, of whom 28 men (84.8%). The more frequent age was from 21 to 40 years. Most patients were from the metropolitan region of the capital (57.6%). The leg was the most affected limb (75.8%), and the left side was the most affected (66.7%). The most common cause was infected pseudoarthrosis (75.8%). The most common bone transportation type was bifocal (75.8%). Mean previous surgery at others institutions were 2.62 (1.93 standard deviation), and mean surgeries after treatment were 1.89 (1.29 standard deviation). Ilizarov's external fixation device was used for 1.94 years (1.34 mean deviation), from one to six years. The most common complications were pin infection (57.6%), equinus (30.3%), deep infection (24.2%), and shortening (21.2%).

Conclusion

Osteogenic distraction for bone gaps were more frequent in young adults, men, in the leg, with bifocal transportation, after several previous surgeries, treated for a mean of two years, with many complications (infections were the most common).

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

This retrospective review assesses 55 tibial nonunions with bone loss to compare union achieved with combined Ilizarov and Taylor spatial frames (I–TSF) versus a conventional circular frame with the standard Ilizarov procedure. Seventeen (31 %) of the 55 nonunions were infected. Thirty patients treated with I–TSF were compared with 25 patients treated with a conventional circular frame. In the I–TSF group, an average of 7.6 cm of bone was resected and the lengthening index (treatment time in months divided by lengthening amount in centimeters) was 1.97. In the conventional circular frame group, a mean of 6.5 cm was resected and the lengthening index was 2.1. Consolidation at the docking site and at the regenerate bone occurred in 49 (89 %) of 55 cases after the first procedure. No statistically significant difference was shown between the two groups. Superiority of one modality of treatment over the other cannot be concluded from our data. Application of combined Ilizarov and Taylor spatial frames for bone transport is useful for treatment of tibial nonunion with bone loss.

Level of evidence Case series, Level III.

Bone Transport for Limb Reconstruction Following Severe Tibial Fractures

A common treatment of tibial defects especially after infections is bone transport via external fixation. We compare complications and outcomes of 25 patients treated with a typical Ilizarov frame or a hybrid system for bone reconstruction of the tibia. Average follow up was 5.1 years. Particular interest was paid to the following criteria: injury type, comorbidities, development of osteitis and outcome of the different therapies. The reason for segmental resection was a second or third grade open tibia fractures in 24 cases and in one case an infection after plate osteosynthesis. Average age of the patients was 41 years (range 19 to 65 years) and average defect size 6.6 cm (range 3.0 to 13.4 cm). After a mean time of 113 days 23 tibial defects were reconstructed, so we calculated an average healing index of 44.2 days/cm. Two patients with major comorbidities needed a below knee amputation. The presence of osteitis led to a more complicated course of therapy. In the follow up patients with an Ilizarov frame had better results than patients with hybrid systems. Bone transport using external fixation is suitable for larger defect reconstruction. With significant comorbidities, however, a primary amputation or other methods must be considered.