Temporary intentional leg shortening and deformation to facilitate wound closure using the Ilizarov/Taylor spatial frame

Intravenous Drug Abuser Treated for Chronic Infected Open Forearm Fracture with Shortening and Primary Wound Closure

Neglected and open forearm fracture wounds accompanied by shortening are complex injuries that are seldom reported in the known literature. We describe a patient with a history of chronic intravenous drug abuse (IVDA) and a neglected forearm wound with radius and ulna fractures with chronic osteomyelitis managed by limb salvage. The patient had a history of IVDA and a neglected forearm wound with fractures in both the radius and ulna, along with chronic osteomyelitis. The approach taken to manage this complex injury involved limb salvage. The case emphasizes the treatment challenges associated with patients who had IVDA and neglected their wounds. Thorough evaluation combining clinical and radiological assessments, followed by appropriate surgical planning and intervention, played a crucial role in restoring the functional status of the limb. Neglected open fracture wounds in the forearm are uncommon and have limited documentation in the existing literature. The described patient's chronic history of IVDA and the disregarded open forearm osteomyelitis exemplify the severe consequences that can arise from injectable drug abuse in the upper extremity. In such cases, limb preservation and optimization of functional outcomes become paramount. To the best of our knowledge, this is one among the few reported cases of this nature, highlighting the significance of sharing such experiences to enhance medical understanding and inform future treatment approaches.

Acute shortening and angulation for complex open fractures: an updated perspective

Reestablishing an intact, healthy soft tissue envelope is a critical step in managing lower extremity injuries, particularly high-grade open tibia fractures. Acute shortening and angulation can be used independently or together to address complex soft tissue injuries, particularly when bone loss is present. These techniques facilitate management of difficult wounds and can be combined with local soft tissue rearrangement or pedicled flaps as needed, avoiding the need for free tissue transfer. After angular deformity correction, adjacent bone loss can be addressed with bone grafting or distraction histogenesis. This article discusses the indications for, surgical technique for, and limitations of acute shortening and angulation for management of open lower extremity fractures.

Efficacy of Temporary Intentional Leg Shortening and Deformation for Treatment of Massive Bone and Soft Tissue Defects in Three Patients

Aim

This study describes the intentional deformation and shortening of a limb using external fixation (EF) in three patients with post-traumatic injury tibial defects and to assess the outcomes.

Case description

Three patients with infected non-unions and massive bone and soft tissue defects who were treated with temporary intentional leg shortening and deformation using a Taylor Spatial Frame (TSF) EF were retrospectively reviewed. The alignment was restored by gradual deformity correction and lengthening after a 2-week interval. No additional surgical intervention was required for soft tissue reconstruction after primary skin closure. Skin closure and good bone alignment were achieved in all patients. The functional outcomes and bone outcomes were evaluated for all cases according to the Paley criteria modified by the Association for the Study and Application of Methods of Ilizarov. All patients showed excellent bone outcomes. Two patients achieved excellent functional outcomes and one had a good outcome. The patient with a good outcome was unable to descend the stairs comfortably.

Conclusion

This technique is suitable for treating massive bone and soft tissue defects and should be considered as a treatment option.

How to cite this article

Ugaji S, Matsubara H, Aikawa T, et al. Efficacy of Temporary Intentional Leg Shortening and Deformation for Treatment of Massive Bone and Soft Tissue Defects in Three Patients. Strategies Trauma Limb Reconstr 2022;17(3):195-201.

Acute Intentional Deformation of Open Tibial Fractures for Complex Soft Tissue Closure in the Pediatric Patient

Background. Lower extremity injuries in the pediatric population that are associated with Gustillo 3B/3C fractures require special consideration. Limb salvage should be attempted in the pediatric patient if at all possible, and oftentimes the soft tissue defect that is present over the bony fracture is substantial. The traditional algorithm used in the management of Gustillo 3B/3C fractures in plastic surgery, referred to as the reconstructive ladder, would recommend flap reconstruction with free tissue transfer in most cases because regional options are often unavailable or do not provide adequate coverage. Free tissue transfer procedures are extensive and necessitate a donor site; they often require multiple procedures and subsequent revisions. Furthermore, when concomitant injuries or medical conditions are present, a patient may not be an appropriate candidate for a free flap. Another option, however, does exist for the pediatric patient with a significant lower extremity injury that is often overlooked by the plastic surgeon. Several articles in the orthopedic literature describe the utility of temporary limb deformation to allow for soft tissue closure, with gradual correction of the bony deformity over time. Although the healing process for these procedures take several months, there is no need for extensive soft tissue reconstruction and the ultimate result is a leg that is functional with adequate coverage. This article reports a case where this type of bone and soft tissue reconstruction was performed in a patient with an excellent overall outcome. This technique could be useful in select cases as an option in pediatric lower extremity reconstruction.

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.

Role of Perforating Artery Pedicled Neurotrophic Flap in the Treatment of Compound Tissue Defect of Tibia Using the Ilizarov Technique

OBJECTIVE

To describe our experience with the combined use of pedicled neurotrophic flap and distraction osteogenesis in the management of complex lower extremity injuries with composite bone and soft tissue defects and assess the functional and cosmetic results of this method.

METHODS

A pedicled flap with a marked perforator artery was applied for soft tissue coverage after radical debridement and temporary external fixation. In the second stage, the Ilizarov external fixator was used in place of the temporary external fixator for reconstruction of the segmental bone defect by distraction osteogenesis. Twenty-five patients (16 men and nine women; mean age, 39.2 years) were treated by using this combined technique between 2008 and 2016. All cases were graded initially as Gustilo-Anderson grade IIIB open fractures. The soft tissue defect after radical debridement ranged from 9 cm × 5 cm to 14 cm × 11 cm, and the average size of segmental defect was 5.2 (Range, 2.5-8.5) cm. Seventeen of these patients had a history of local infection. The bone structure and function were evaluated by two independent evaluators using Paley's criteria.

RESULTS

Twenty-five patients were followed up for an average of 28.96 (Range, 15-48) months. The distally based sural neurovascular flap was applied in 13 patients, and the greater saphenous neurocutaneous perforator flap in 12 patients. The flap area ranged from 10 cm × 5 cm to 14 cm × 12 cm. Sufficient coverage of soft tissue defect was achieved in all cases. All flaps survived completely without complications. The bone defects were corrected by a mean lengthening of 6.94 (Range, 4.5-9.5) cm. The residual discrepancy was <1 cm in all cases, which was not clinically significant. The function was evaluated as excellent in 12 patients and good in 13 patients. Bone results were graded as excellent in 18 patients and good in seven patients. Complications during treatment included pain, pin tract infections, ankle midfoot joint stiffness, and docking site nonunion. No recurrence of infection was observed in infected patients. All cases achieved successful limb salvage and satisfactory function recovery without recurrence of infection.

CONCLUSIONS

The combined technique of a perforator artery pedicled neurotrophic flap and distraction osteogenesis is an effective alternative approach in the salvage treatment of massively traumatized and chronically infected lower extremities.

Reconstructive Options for Tibial Bone Defects

Segmental bone defects of the tibia are amenable to multiple treatment options including classic bone transport, shortening and then lengthening, induced membrane technique, transport over a nail, free fibular grafting, and medial transport of the ipsilateral fibula. These treatment options have relative advantages and disadvantages, depending on defect size, soft-tissue characteristics, the presence or absence of infection, and associated morbidity. Relatively, few large comparative studies exist, and surgeons are left to their own experience and the opinion of experts within the field to guide surgical decision-making.

Intentional Temporary Limb Deformation for Closure of Soft-Tissue Defects in Open Tibial Fractures

OBJECTIVES

(1) Evaluate intentional temporary limb deformation for closure of soft-tissue defects as a reconstruction strategy in open tibia fractures and (2) analyze the deformity parameters required for such reconstruction.

DESIGN

Multicenter retrospective cohort.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

Nineteen patients 18 years of age and older at the time of initial trauma, with a Gustilo-Anderson type IIIB or IIIC open tibia fracture treated with hexapod external fixation and intentional bony deformity created to facilitate soft-tissue closure.

INTERVENTION

Intentional limb deformation for soft-tissue closure, followed by gradual correction with a hexapod external fixator.

OUTCOME MEASUREMENTS

Radiographic healing, radiographic assessment of limb alignment, and functional and bony Application of the Method of Ilizarov Group score.

RESULTS

The average age was 45.3 (20-70), and 79% of patients were men. The most common mechanism of injury was motor vehicle accidents. The distal 1 of 5 of the tibia was the most common fracture location, with 37% of these involving the articular surface at the plafond. After wound closure, deformity correction was initiated after 30 days on average. Varus and apex posterior were the most common initial deformity required for primary soft-tissue closure. Bony and functional Application of the Method of Ilizarov Group outcomes were good or excellent in 94% of patients.

CONCLUSION

Intentional deformation followed by a gradual correction can be an effective strategy to obtain bone union and soft-tissue coverage in certain open fractures. This technique, in essence, converts these injuries from type IIIB to IIIA. This strategy obviates the need for flap coverage and results in satisfactory outcomes.

LEVEL OF EVIDENCE

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

Acute limb shortening or creation of an intentional deformity to aid in soft tissue closure for IIIB/IIIC open tibia fractures

BACKGROUND

Ring fixator techniques can precisely correct complex long bone deformities. In select patients, controlled shortening or intentional fracture deformation with delayed correction can also aid in complex wound coverage and limb salvage.

METHODS

This retrospective cohort study analyzed all patients who underwent acute limb shortening or intentional temporary fracture deformation between 2005 and 2020. Patients were divided into three groups based on reason for acute shortening or intentional deformity: (1) skeletal indications alone, with traditional flap coverage; (2) skeletal and soft tissue indications, to augment traditional reconstructive measures; and (3) skeletal and soft tissue indications, to avoid microsurgery altogether. Comorbidities, orthopedic and reconstructive methods, and functional outcomes were recorded.

RESULTS

Eighteen patients were identified: six in Group 1, five in Group 2, and seven in Group 3. Fractures were primarily in the distal third of the tibia. On initial assessment, all wounds would have required free tissue transfer. Group 1 patients were reconstructed with free flaps. Among Group 2, closure was accomplished by skin grafting (N = 1), local flaps (N = 1), pedicled muscle flaps (N = 1), and free flaps (N = 2). In Group 3, five wounds were closed primarily and two were skin grafted. All limbs were shortened, averaging 25.1 mm; seven were intentionally deformed, most commonly varus (10-20°). After skeletal correction, residual leg length discrepancy averaged 5.7 mm. No patients required amputation.

CONCLUSIONS

Acute skeletal shortening with or without intentional temporary deformation in select IIIB/IIIC open tibial fractures can facilitate soft tissue coverage and limb salvage in patients who might otherwise require amputation.

High-Energy Pilon Fractures: Role of External Fixation in Acute and Definitive Treatment. What are the Indications and Technique for Primary Ankle Arthrodesis?

External fixation is an essential tool in the management of high-energy pilon fractures. Reduction techniques using the external fixator and fixation constructs for use with external fixation as a part of stage management are reviewed. The concepts of external fixation with limited articular fixation is discussed. The use of circular external fixation in both acute management of high-energy pilon fractures, as well as the indications and technique for acute ankle arthrodesis as part of primary treatment of pilon fractures are outlined.

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.

Transverse debridement and acute shortening followed by distraction histogenesis in the treatment of open tibial fractures with bone and soft tissue loss

This retrospective case series evaluates the technique of transverse debridement, acute shortening and subsequent distraction histogenesis in the management of open tibial fractures with bone and soft tissue loss, thereby avoiding the need for a soft tissue flap to cover the wound. Thirty-one patients with Gustilo grade III open tibial fractures between 2001 and 2011 were initially managed with transverse wound extensions, debridement and shortening to provide bony apposition and allowing primary wound closure without tension, or coverage with mobilization of soft tissue and split skin graft. Temporary monolateral external fixation was used to allow soft tissues resuscitation, followed by Ilizarov frame for definitive fracture stabilization. Leg length discrepancy was corrected by corticotomy and distraction histogenesis. Union was evaluated radiologically and clinically. Patients' mean age was 37.3 years (18.3-59.3). Mean bone defect was 3.2 cm (1-8 cm). Mean time to union was 40.1 weeks (12.6-80.7 weeks), and median frame index was 75 days/cm. Median lengthening index (time in frame after corticotomy for lengthening) was 63 days/cm. Mean clinic follow-up was 79 weeks (23-174). Six patients had a total of seven complications. Four patients re-fractured after frame removal, one of whom required a second frame. Two patients required a second frame for correction of residual deformity, and one patient developed a stiff non-union which united following a second frame. There were no cases of deep infection. Acute shortening followed by distraction histogenesis is a safe method for the acute treatment of open tibial fractures with bone and soft tissue loss. This method also avoids the cost, logistical issues and morbidity associated with the use of local or free-tissue transfer flaps and has a low rate of serious complications despite the injury severity.

The tibial bayonet method of wound closure

Management of open lower limb fractures with soft tissue defects can be a technically challenging orthopaedic problem. Limited availability of orthoplastic services means that alternatives to the fix and flap concept are required in order to prevent infected non-unions from developing. The proposed 'bayonet apposition' allows the surgeon to temporarily shorten the limb without angulating the limb or creating a bone defect and removing viable bone. The viable bone edges are overlapped in a bayonet-like manner in order to appose the wound and skin edges. The limb length is restored by gradually distracting the bone segments once the soft tissues have healed. This is facilitated with a hexapod fixator for stabilization of the fracture and distraction. Prerequisites for utilizing this method are circumferential soft tissue damage to the lower limb with viable distal tissue. The bayonet method allows primary closure of a wound and rapid restoration of the native length of the limb.

Management of Mangled Extremities and Orthopaedic War Injuries

In 16 years of conflict, primarily in Iraq and Afghanistan, wounded warriors have primarily been subjected to blast type of injuries. Evacuation strategies have led to unprecedented survival rates in blast-injured soldiers, resulting in large numbers of wounded warriors with complex limb trauma. Bone and soft tissue defects have resulted in increased use of complex reconstructive algorithms to restore limbs and function. In addition, in failed salvage attempts, advances in amputation options are being developed. In this review, we summarize state-of-the-art limb-salvage methods for both soft tissue and bone. In addition, we discuss advances in diagnostic methods with development of personalized clinical decision support tools designed to optimize outcomes after severe blast injuries. Finally, we present new advances in osteointegrated prostheses for above-knee amputations.

Shortening and Angulation Strategies to Address Composite Bone and Soft Tissue Defects

Gustilo-Anderson IIIB tibial fractures and infected tibial nonunions represent particular challenges for the orthopaedic trauma surgeon. Debridement of dysvascular bone and soft tissues can create composite bone and soft tissue defects. Restoring the soft tissue envelope is a critical step in preventing or treating ongoing infection and in restoring local blood supply. Shortening and angulation techniques, including the gradual expansion muscle flap, rely on distraction histogenesis to address composite bone and soft tissue loss. These strategies can be used to treat large soft tissue defects when flap coverage or free tissue transfer is not available.

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.

The Management of Soft Tissue and Bone Loss in Type IIIB and IIIC Pediatric Open Tibia Fractures

PURPOSE

Type III B and C open tibia fractures in children pose a challenge to the orthopaedic surgeon. Limb salvage is the initial goal for the majority of patients, but managing soft-tissue defects and bone loss can be a challenge. The purpose of this study was to evaluate the use of circular external fixation in the management of these injuries.

METHODS

In this retrospective review, we examined children with type IIIB and IIIC open tibial fractures treated with circular external fixation and soft-tissue coverage between 1990 and 2010. Chart review included: mechanism and severity of injury, degree of bone and soft-tissue loss, technique and duration of external fixation, additional procedures, clinical and radiographic outcomes, and complications.

RESULTS

Eight patients were identified whose average age at the time of injury was 10.4 years (range, 3.8 to 15.3 y). There were 7 type IIIB and 1 type IIIC fractures. All patients received free or rotational soft-tissue flaps. Average bone loss was 5.4 cm (range, 0 to 12 cm). Three techniques of circular external fixation were used, including: (1) static stabilization to allow for soft-tissue coverage and fracture healing, (2) acute shortening with plan for later limb lengthening, and (3) stabilization of the extremity for soft-tissue coverage and intended bone transport. Seven of 8 limbs were salvaged. Of those 7, all were followed to skeletal maturity and ambulating without assistive devices at final follow-up. Three patients had a clinically relevant leg-length discrepancy (≥2 cm). Four of 8 patients required secondary or contralateral procedures.

CONCLUSIONS

Pediatric type IIIB and IIIC tibia fractures are limb-threatening injuries that require dynamic thinking and management as the bone and soft-tissue injuries evolve. We have proposed a general algorithm to guide the treatment of these severe injuries. In our experience, circular external fixation, in conjunction with this algorithm, provides the appropriate stability and environment for managing soft tissue and bone loss and can facilitate limb salvage.

LEVEL OF EVIDENCE

Level IV.

Infected nonunion of tibia

Infected nonunions of tibia pose many challenges to the treating surgeon and the patient. Challenges include recalcitrant infection, complex deformities, sclerotic bone ends, large bone gaps, shortening, and joint stiffness. They are easy to diagnose and difficult to treat. The ASAMI classification helps decide treatment. The nonunion severity score proposed by Calori measures many parameters to give a prognosis. The infection severity score uses simple clinical signs to grade severity of infection. This determines number of surgeries and allows choice of hardware, either external or internal for definitive treatment. Co-morbid factors such as smoking, diabetes, nonsteroidal anti-inflammatory drug use, and hypovitaminosis D influence the choice and duration of treatment. Thorough debridement is the mainstay of treatment. Removal of all necrotic bone and soft tissue is needed. Care is exercised in shaping bone ends. Internal fixation can help achieve union if infection was mild. Severe infections need external fixation use in a second stage. Compression at nonunion site achieves union. It can be combined with a corticotomy lengthening at a distant site for equalization. Soft tissue deficit has to be covered by flaps, either local or microvascular. Bone gaps are best filled with the reliable technique of bone transport. Regenerate bone may be formed proximally, distally, or at both sites. Acute compression can fill bone gaps and may need a fibular resection. Gradual reduction of bone gap happens with bone transport, without need for fibulectomy. When bone ends dock, union may be achieved by vertical or horizontal compression. Biological stimulus from iliac crest bone grafts, bone marrow aspirate injections, and platelet concentrates hasten union. Bone graft substitutes add volume to graft and help fill defects. Addition of rh-BMP-7 may help in healing albeit at a much higher cost. Regeneration may need stimulation and augmentation. Induced membrane technique is an alternative to bone transport to fill gaps. It needs large amounts of bone graft from iliac crest or femoral canal. This is an expensive method physiologically and economically. Infection can resorb the graft and cause failure of treatment. It can be done in select cases after thorough eradication of infection. Patience and perseverance are needed for successful resolution of infection and achieving union.

Definitive Management of Distal Tibia and Simple Plafond Fractures With Circular External Fixation

Obtaining optimal results in the treatment of extraarticular distal tibia fractures can be challenging. Plate and screw and intramedullary fixation have proven to be effective treatments, but are associated with significant complication rates when used for open fractures and patient with severe medical comorbidities. External fixation is a third alternative that is less often employed, but provides a very effective means of treatment. Circular external fixation offers great flexibility in obtaining anatomic alignment and stable fixation for even the most challenging distal tibia fractures. In addition, it provides advantages in limiting the risk of deep infection, dealing with bone loss, and obtaining soft tissue coverage. The greater ease of treatment and potential economic advantage in patient cohorts with low complication rates, such as closed fractures, supports the preferential use of internal fixation. However, circular external fixation may be the preferred treatment for patients with higher-grade open fractures, a poor soft tissue envelope with limited fixation options distally, and major comorbidities (diabetes, immune deficiency) with an associated high risk of complications.

Acute Limb Shortening for Major Near and Complete Upper Extremity Amputations with Associated Neurovascular Injury: A Review of the Literature

In the setting a near or complete upper extremity amputations with significant soft tissue loss and neurovascular compromise, upper extremity surgeons are faced with the challenge of limb salvage. There are a multitude of treatment options for managing skeletal and soft tissue injuries including provisional fixation, staged reconstruction, and an acute shortening osteotomy with primary rigid internal fixation. However, many complications are associated with these techniques. Complications of provisional fixation include pin tract infection and loosening, tethering of musculotendinous units, nonunion, and additional surgeries. Staged reconstruction includes a variety of techniques: distraction osteogenesis, bone transport, or vascularized and non-vascularized structural autograft or allograft, but the risks often outweigh the benefits. Risks include nonunion, postoperative vascular complications necessitating reoperation, and the inability to return to the previous level of function at an average of 24 months. Acute shortening osteotomy with internal fixation offers the advantage of a single-stage procedure that provides for decreasing the soft tissue loss, provides a rigid platform to protect the delicate neurovascular repair, and alleviates unwanted tension at the repair sites. This review discusses the literature on the surgical treatment of severe upper extremity trauma with associated neurovascular injury over the past 75 years, and aims to evaluate the indications, surgical techniques, clinical and functional outcomes, and complications associated with acute shortening osteotomy with rigid internal fixation. Although this technique is not without risks, it is well-tolerated in the acute setting with a complication profile comparable to other techniques of fixation while remaining a single procedure.

Lower Extremity Limb Salvage: Lessons Learned From 14 Years at War

American survivability during the current conflicts in Iraq and Afghanistan continues to improve, though the rate of extremity injury remains quite high. The decision to proceed with amputation versus limb salvage remains controversial. Exposure to combat wound with severe high-energy lower extremity trauma during the previous 14 years at war has incited important advances in limb salvage technique and rehabilitation.

Hexapod External Fixation of Tibia Fractures in Children

Most tibia fractures in children can be treated nonoperatively. For fractures that do require surgery, however, the most common methods of management include plating or flexible nail insertion. Some fracture patterns, such as periphyseal fractures, fractures with bone and/or soft tissue loss, or fractures with delayed presentation, are not easily amenable to these techniques. Hexapod external fixators are especially helpful in these difficult cases. The purpose of this review is to discuss the principles of performing hexapod circular external fixation applied to pediatric tibia fractures. Some of the additional capabilities of the hexapod external fixator will also be highlighted.

Dead Space Management After Orthopaedic Trauma: Tips, Tricks, and Pitfalls

Dead space is defined as the residual tissue void after tissue loss. This may occur due to tissue necrosis after high-energy trauma, infection, or surgical debridement of nonviable tissue. This review provides an update on the state of the art and recent advances in the management of osseous and soft tissue defects. Specifically, our focus will be on the initial dead space assessment, provisional management of osseous and soft tissue defects, techniques for definitive reconstruction, and dead space management in the setting of infection.

LEVEL OF EVIDENCE

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

Definitive management of significant soft tissue loss associated with open diaphyseal fractures utilising circular external fixation without free tissue transfer, a comprehensive review of the literature and illustrative case

Accepted management of diaphyseal fractures associated with significant tissue loss is rigid intramedullary stabilisation with free or rotational musculocutaneous flap coverage. Circular external fixation is a powerful tool in the management of limb trauma and with recent advances has been developed to provide multiple techniques for which even massive tissue loss can be addressed without the need for free tissue transfer. Gradual and acute shortening, acute fracture deformation and gradual lengthening with restoration of deformity combined with distraction tissue histiogenesis can provide the surgeon with an array of options which can be precisely tailored to the particular personality of a severe open diaphyseal fracture.

The Ilizarov method for the treatment of complex tibial fractures and non-unions in a mass casualty setting: the 2005 earthquake in Pakistan

We report our experience in treating victims of the recent earthquake disaster in Pakistan. Our experience was based on two humanitarian missions to Islamabad: one in October 2005, 10 days after the earthquake, and the second in January 2006. The mission consisted of a team of orthopaedic surgeons and a second team of plastic surgeons. The orthopaedic team bought all the equipment for application of Ilizarov external fixators. We treated patients who had already received basic treatment in the region of the disaster and subsequently had been evacuated to Islamabad. During the first visit, we treated 12 injured limbs in 11 patients. Four of these patients were children. All cases consisted of complex multifragmentary fractures associated with severe crush injuries. All fractures involved the tibia, which were treated with Ilizarov external fixators. Nine fractures were type 3b open injuries. Eight were infected requiring debridement of infected bone and acute shortening. During a second visit, we reviewed all patients treated during our first mission. In addition, we treated 13 new patients with complex non-unions. Eight of these patients were deemed to be infected. All patients had previous treatment with monolateral fixators as well as soft tissue coverage procedures, except one patient who had had an IEF applied by another team. All these patients had revision surgery with circular frames. All patients from both groups were allowed to fully weight-bear post-operatively, after a short period of elevation to allow the flaps to take. Overall, all fractures united except one case who eventually had an amputation. Four patients had a corticotomy and lengthening, and three of them had a successful restoration of limb length. The fourth patient was the one with the eventual amputation.

"Ilizarov" external fixation: what the radiologist needs to know

Circular external fixation, including the Ilizarov method, is a complex and often long-term treatment used for various orthopedic conditions. Due to the complexity of the hardware, frequent postoperative complications, and the potential for significant radiographic changes between visits, it is important for the radiologist to have a basic understanding of ring fixators. This publication reviews indications for external fixation versus internal fixation and whether to use a circular or uniplanar construct if external fixation is elected. Indications for and characteristics of static circular frames, intercalary and non-intercalary transport frames, and deformity circular frames will also be discussed. While general similarities exist between frame types, each has unique components of which the radiologist must be aware. An emphasis is placed on the important features and complications that arise during treatment.

Knee arthrodesis as limb salvage for complex failures of total knee arthroplasty

Patients with multiple failures of total knee arthroplasty (TKA) are challenging limb salvage cases. Twenty one patients over the last 10 years were referred to our service for knee fusion by arthroplasty surgeons who felt they were not candidates for revision TKA. Active infection was present in 76.2% and total bone loss averaged 6.6 cm. Lengthening was performed in 7/22 patients. Total time in Ilizarov frames was 9 months, with 93.3% union. Patients treated with IM fusion nails had 100% union. Average LLD increased from 3.6 to 4.5 cm following intervention, while those with concurrent lengthening improved to 1.6 cm. Findings suggest that bone loss and the soft-tissue envelope dictate knee fusion method, and multiple techniques may be needed. A treatment algorithm is presented.

Management of traumatic bone loss in the lower extremity

Segmental bone loss represents a difficult clinical entity for the treating orthopedic surgeon. This article discusses the various treatment modalities available for limb reconstruction, with a focus on the indications, potential complications, and the outcomes of available treatment options.

Osteomyelitis of the foot and ankle: diagnosis, epidemiology, and treatment

Osteomyelitis of the foot and ankle is a common, potentially devastating condition with diagnostic and treatment challenges. Understanding the epidemiology and pathogenesis of osteomyelitis can raise clinical suspicion and guide testing and treatments. History and physical examination, laboratory studies, vascular studies, histologic and microbiologic analyses, and various imaging modalities contribute to diagnosis and treatment. Treatment including empiric broad-spectrum antibiotics and surgery should take a multidisciplinary approach to optimize patient factors, ensure eradication of the infection, and restore function. Optimization of vascular status, soft tissues, limb biomechanics, and physiologic state of the patient must be considered to accelerate and ensure healing.

Distal tibial periarticular nonunions: ankle salvage with bone transport

A nonunion of the distal tibial metaphysis in close proximity to the articular surface is a challenging clinical problem. Many of the commonly used techniques in a surgeon's treatment armamentarium can be ineffective because of the relative lack of distal bone stock. This study describes a technique of en bloc excision of all infected or nonunited distal tibial bone with an application of a circular external fixator and limb shortening. After treatment with parental antibiotics, when appropriate, and docking of the distal excision site, distraction osteogenesis of the proximal tibia is performed with a second circular frame.

Reverse sural flap with bifocal Ilizarov technique for tibial osteomyelitis with bone and soft tissue defects

Tibial osteomyelitis, in association with bone loss and a soft tissue defect, poses a significant reconstructive challenge, especially in high-risk patients. We describe a case of methicillin-resistant Staphylococcus aureus tibial osteomyelitis with intercalary bone loss successfully managed with bifocal Ilizarov compression osteogenesis at the bone resection site and proximal distraction osteogenesis, accompanied by a reverse sural fasciocutaneous flap performed with a delayed technique. When free tissue transfer is not a reconstructive option owing to medical comorbidities or patient refusal, the reverse sural flap combined with bifocal Ilizarov compression and distraction osteogenesis can provide a reconstructive option to achieve limb salvage for these challenging cases.

The gradual expansion muscle flap

High-energy open fractures of the tibia have traditionally been fraught with challenges to include bone comminution or loss, soft tissue loss, nonunion, and infection. A number of techniques have been implemented to treat the severe soft tissue loss typically involving the anteromedial surface of the tibia to include wet-to-dry dressings or Papineau techniques, negative pressure wound therapy, acellular dermal matrices, and rotational or free tissue transfer with Masquelet technique, primary shortening, and distraction osteogenesis to address bone loss. We present a novel technique and subsequent case series that obviates the need of free tissue transfer while treating high-energy type IIIB open tibia fractures by performing an acute shortening and angulation of the tibia and rotational muscle flap coverage and split-thickness skin grafting of the soft tissue defect. Distraction histiogenesis with circular external fixation is then used to correct the residual osseous deformity while stretching the rotational muscle flap.

Femoral fracture reduction with a parallel manipulator robot on a traction table

BACKGROUND

A parallel manipulator robot (PMR) on a traction table was developed to achieve better alignment of a fractured femur and reduce radiation exposure to both patients and physicians.

METHODS

A PMR was built with a disk platform and a two-thirds circular ring. Fracture reductions were performed on eight artificially broken sawbone models and a cadaveric model. Fracture reduction was achieved using six degrees of freedom (6-DOF) movements of the two-thirds circular ring, while the PMR disk platform and the proximal femur remained stationary.

RESULTS

Axial discrepancy, lateral translation and angulation had mean errors of 1.31 ± 0.45, 2.43 ± 0.49 and 2.26 ± 0.23 mm, respectively, when coarse adjustment was used. For the fine adjustment step, the mean errors were 0.63 ± 0.19 mm for axial discrepancy and 0.75 ± 0.26 mm for lateral translation.

CONCLUSION

Femoral shaft fracture reduction with PMR on a traction table is a feasible and accurate approach to fracture reduction.

Long-term results and costs of muscle flap coverage with Ilizarov bone transport in lower limb salvage

OBJECTIVES

To determine long-term outcomes and costs of Ilizarov bone transport and flap coverage for lower limb salvage.

DESIGN

Case series with retrospective review of outcomes with at least 6-year follow-up.

SETTING

Academic tertiary care medical center.

PATIENTS

Thirty-four consecutive patients with traumatic lower extremity wounds and tibial defects who were recommended amputation but instead underwent complex limb salvage from 1993 to 2005.

INTERVENTION

Flap reconstruction and Ilizarov bone transport.

MAIN OUTCOME MEASUREMENTS

Outcomes assessed were flap complications, infection, union, malunion, need for chronic narcotics, ambulation status, employment status, and need for reoperations. A cost analysis was performed comparing this treatment modality to amputation.

RESULTS

Thirty-four patients (mean age: 40 years) were included with 14 acute Gustilo IIIB/C defects and 20 chronic tibial defects (nonunion with osteomyelitis). Thirty-five muscle flaps were performed with 1 flap loss (2.9%). The mean tibial bone defect was 8.7 cm, mean duration of bone transport was 10.8 months, and mean follow-up was 11 years. Primary nonunion rate at the docking site was 8.8% and malunion rate was 5.9%. All patients achieved final union with no cases of recurrent osteomyelitis. No patients underwent future amputations, 29% required reoperations, 97% were ambulating without assistance, 85% were working full time, and only 5.9% required chronic narcotics. Mean lifetime cost per patient per year after limb salvage was significantly less than the published cost for amputation.

CONCLUSIONS

The long-term results and costs of bone transport and flap coverage strongly support complex limb salvage in this patient population.

Intentional deformation and closure of soft tissue defect in open tibial fractures with a taylor spatial frame--a simple technique

OBJECTIVES

We describe a way of using Taylor spatial frames (TSFs) for acute deformation of Gustilo IIIB tibial fractures and infected tibial nonunions to close the soft tissue defects and to gradually restore anatomical alignment. We use the Direct Scheduler Utility module of the web-based software for TSFs to successfully restore the anatomical alignment.

DESIGN

We report a case series of the above technique.

SETTING

Care was carried out at a tertiary referral center for limb reconstruction.

PATIENTS

Seven consecutive patients with significant soft tissue loss after tibial fractures were treated.

INTERVENTION

Defects were closed with acute deformation of the fracture followed by gradual correction to anatomical alignment with a 2-ring TSF.

MAIN OUTCOME MEASUREMENT

Successful closure of the soft tissue defect was our primary outcome measure.

RESULTS

Soft tissue defects ranged from 3 to 10 cm. All healed without additional plastic surgery to cover the exposed tibia. Only 1 patient required an additional TSF prescription to achieve anatomical alignment.

CONCLUSIONS

The use of the Direct Scheduler module of the web-based TSF software allows the complete correction of complex deformities without the need for obtaining complex mounting and frame parameters. We achieved successful closure of soft tissue defects and restored the anatomical tibial alignment in all our cases.

S-osteotomy with lengthening and then nailing compared with traditional Ilizarov method

PURPOSE

The purpose of this study was to explore the clinical effect of the novel method combined longitudinal S-osteotomy and Lengthen And Then Nail (LATN) technique for leg lengthening and compare with the classic Ilizarov method.

METHODS

This retrospective study was performed from March 2008 to April 2012. A total of 176 leg lengthenings (88 consecutive patients) were performed at our institution. The mean duration of follow-up was 2.2 years (range, one to four years). In group A, 78 tibial lengthenings were performed with longitudinal S-osteotomy and LATN technique. In group B, 98 tibial lengthenings were performed with the classic method. The final gain in length, mean surgical time for bilateral tibial osteotomy, the external fixation index and the radiographic consolidation index were calculated and compared. The complications encountered during operation and follow-up were documented.

RESULTS

There was no significant difference in the final gain in length between the two groups. Mean surgical time in group A (130.05 ± 6.60 min) was significantly longer than that in group B (91.4 ± 6.61 min; P < 0.05). External fixation index in group A (21.02 ± 3.16 days/cm) was significantly lower than that in group B (76.19 ± 8.32 days/cm; P < 0.05). Consolidation index was significantly lower (more rapid healing) in group A (43.38 ± 5.35 days/cm) than that in group B (76.19 ± 8.32 days/cm; P < 0.05). There was a significant difference in pin-tract problems and axial deviation between the two groups.

CONCLUSION

The novel method combined longitudinal S-corticotomy and LATN technique safely reduces the consolidation time, rate of pin-tract problems and axial deviation during leg lengthening, compared with the classic Ilizarov method.

Conversion of open tibial IIIb to IIIa fractures using intentional temporary deformation and the Taylor Spatial Frame

The closure of small-to-moderate-sized soft tissue defects in open tibial fractures can be successfully achieved with acute bony shortening. In some instances, it may be possible to close soft tissue envelope defects by preserving length and intentionally creating a deformity of the limb. As the soft tissue is now able to close, this manoeuvre converts an open IIIb to IIIa fracture. This obviates the need for soft tissue reconstructive procedures such as flaps and grafts, which have the potential to cause donor-site morbidity and may fail. In this article, the authors demonstrate the technique for treating anterior medial soft tissue defects by deforming the bone at the fracture site, permitting temporary malalignment and closure of the wound. After healing of the envelope, the malalignment is gradually corrected with the use of the Taylor Spatial Frame. We present two such cases and discuss the technical indications and challenges of managing such cases.

Use of a continuous external tissue expander in the conversion of a type IIIB fracture to a type IIIA fracture

Various methods have been used for soft tissue coverage of Gustilo-Anderson type IIIB open fractures. These injuries are often contaminated and, by definition, are associated with extensive periosteal stripping and inadequate soft tissue coverage. These characteristics predispose the patient to infection, delayed union, nonunion, and the likelihood of multiple surgeries to achieve durable soft tissue coverage. Although free tissue transfer and rotational flap coverage are the mainstay of treatment for Gustilo-Anderson type IIIB fractures, these procedures typically require additional modalities, such as local wound care, negative-pressure wound therapy, and skin grafting, to expedite wound coverage. Numerous undesirable aspects of these tissue coverage techniques exist, including the requirement for repeated application, potential anesthesia complications, near-constant surveillance, patient compliance, graft failure, and cost. External tissue expanders offer the surgeon a device that can rapidly facilitate closure of full-thickness soft tissue defects. This technique offers the benefit of a 1-time application that is easy to apply and cost-effective and can significantly improve fracture coverage options with a cosmetically acceptable result. Although this technique has been previously described for fasciotomy and ulcer coverage, to the authors' knowledge, continuous external expansion has never been reported in open fracture wound management, specifically in converting type IIIB to type IIIA open fractures. The authors' early success with this method indicates that it may be a valuable tool in the management of Gustilo-Anderson type IIIB open fractures.

Staged protocol for the treatment of chronic tibial shaft osteomyelitis with Ilizarov's technique followed by the application of intramedullary locked nail

Open tibial shaft fractures are the most common open fractures, and many complications can occur. During the treatment period, infection leading to osteomyelitis was the most common complication. However, no consensus exists regarding the ideal management for such cases in the literature.The purposes of this retrospective study were to review the treatment of patients with chronic tibial shaft osteomyelitis over the past 14 years who were referred to the authors' institution and to provide a staged protocol for spontaneous wound healing. The staged protocol included: (1) radical debridement for infected bone and soft tissue; (2) immediate application of Ilizarov's apparatus for all patients except those needing delayed application; (3) osteotomy in healthy bone; (4) simultaneous distraction-compression osteogenesis and histogenesis; (5) additional docking-site bone grafting; and (6) shifting the external fixator to a locked nail when callus formation was visible at the distraction site. Union was achieved in 15 of 16 patients, with an average external fixation time of 4.5 months (range, 3-6 months). No deformity or leg-length discrepancy greater than 1 cm occurred.In the treatment of chronic osteomyelitis, this staged protocol was safe and successful and allowed for union, realignment, reorientation, and leg-length restoration. Regarding the soft tissues, this technique provides a unique type of reconstructive closure for infected wounds. It is suggested that the staged protocol is reliable in providing successful simultaneous reconstruction for bone and soft tissue defects without flap coverage.

Novel 3D hexapod computer-assisted orthopaedic surgery system for closed diaphyseal fracture reduction

BACKGROUND

Long-bone fractures are very common in trauma centers. The conventional Arbeitsgemeindschaft fur Osteosynthesefragen (AO) technique contributes to most fracture healing problems, and external fixation technology also has several disadvantages, so new techniques are being explored.

METHOD

A novel hexapod computer-assisted fracture reduction system based on a 3D-CT image reconstruction process is presented for closed reduction of long-bone diaphyseal fractures. A new reduction technique and upgraded reduction device are described and the whole system has been validated.

RESULTS

Ten bovine femoral fracture models were used with random fracture patterns. Tests results were as follows: residual deviation 1.24 + 0.65 mm for the axial deflection, 1.19 + 0.37 mm for the translation, 2.34 + 1.79° for the angulation, and 2.83 + 0.9° for the rotation.

CONCLUSION

The reduction mechanism has the advantages of high positioning, reduction and computer accuracy, and intra-operative stability for both patients and surgical team. With further investigation, it could be applied in many kinds of long-bone diaphyseal fractures.

Staged bone grafting following placement of an antibiotic spacer block for the management of segmental long bone defects

Segmental long bone defects resulting from injury or surgical intervention are difficult problems to manage. Amputation, external fixators, vascularized fibular grafts, acute limb shortening, and various quantities of allograft and autograft have historically been the mainstays of treatment. Recently, the use of osteoinductive substances such as recombinant bone morphogenic proteins, and osteoconductive scaffolds such as calcium phosphate have found use in the treatment of these clinical situations. More recently, Masquelet described the use of a cement spacer placed within the osseous void followed by staged bone grafting within the induced biomembrane formed around the spacer as a potential treatment strategy to manage these large defects.This article describes a series of 11 patients for which we used this technique of staged bone grafting following placement of an antibiotic spacer to successfully manage osseous long bone defects ranging from 4 to 15 cm. The limbs were stabilized and aligned at the time of initial spacer placement with a plate and screw construct, intramedullary nail, or fine wire fixator. Osteoinductive substances including bone morphogenic protein-2 and platelet rich concentrate were used in addition to allograft to improve bony healing. In our series, osseous consolidation and full weight bearing was achieved in 10 of 11 patients. Two patients developed heterotopic ossification. There was 1 non-union and 1 infection, which occurred in the same patient. Staged bone grafting within an induced biomembrane created after the use of a cement spacer is a reasonable option in the management of both acute and delayed segmental long bone defects.

Supramalleolar osteotomy using circular external fixation with six-axis deformity correction of the distal tibia

BACKGROUND

Supramalleolar osteotomy using circular external fixation with six-axis deformity correction is a rarely reported treatment method particularly well-suited for complex multidimensional deformities of the adult ankle. The purpose of this study was to assess the accuracy of deformity correction and change in functional status using this technique.

METHODS

We present a retrospective review of 52 patients who underwent supramalleolar osteotomy with application of the Taylor Spatial Frame (Smith & Nephew, Memphis, TN). Mean age was 44 (range, 18 to 79) years. The primary outcome was change in preoperative to postoperative distal tibial joint orientation angles. Coronal and sagittal plane joint orientation angles were measured for all 52 enrolled patients. The secondary outcome was change in AOFAS scores which were available for 31 patients.

RESULTS

Twenty-two patients had oblique plane deformities. The mean time in frame was 4 (range, 2 to 11) months, and patients were followed for a mean of 14 months after frame removal. All aggregate postoperative distal tibial angles underwent a significant improvement (p < 0.05) and were within 0 degrees to 4 degrees of normal in the various deformity groups. Average preoperative AOFAS score was 40 (range, 12 to 67) and average postoperative AOFAS score was 71 (range, 34 to 97; p < 0.001). Complications included two patients with nonunions at the osteotomy site that healed with further treatment. Three patients went on to have ankle fusion.

CONCLUSION

We feel that supramalleolar osteotomy using circular external fixation with six-axis deformity correction was an effective method for correction of distal tibial deformities in the adult population, particularly for those patients with complex oblique-plane deformities, associated rotational deformity, a compromised soft tissue envelope, or a prior history of infection.

Electrophysiological and histological investigation on the gradual elongation of rabbit sciatic nerve

A basic study using animal models was performed to investigate whether the sciatic nerve retains physiological functions and normal morphology after the gradual elongation associated with adjacent bone elongation. Electrophysiological and histological studies were performed on the elongated sciatic nerve of rabbit accompanied by the femur bone elongation. Compound action potentials evoked by electrical stimulation of the sciatic nerve were recorded and histological specimens of elongated nerve fibers were obtained immediately after final bone elongation from 4 rabbits (immediate group). Three rabbits were allowed to recover for 8 weeks after the bone elongation (maintained group). Three rabbits without bone elongation were used as controls of the immediate and maintained groups (control group). In the immediate group, the average amplitude of evoked nerve potentials were 30.38 ± 1.58 mV before elongation and diminished significantly to 18.35 ± 1.25 mV immediately after elongation (P<0.01). The amplitude of evoked potentials was not significantly different between before (30.30 ± 0.61 mV) elongation and after elongation (27.47 ± 1.63 mV) in the maintained group. The axonal area of the myelinated nerve fibers of the proximal region of the sciatic nerve in the immediate group was significantly decreased after elongation (P<0.01). The decrease in the area of the distal region was greatest in the control group and was followed by that in the maintained group and the immediate group (P<0.05, 0.01). These results suggest that the sciatic nerve shows dysfunction immediately after elongation, but can recover electrophysiologically and histologically several weeks after elongation.

Calculating the mounting parameters for Taylor Spatial Frame correction using computed tomography

The Taylor Spatial Frame uses a computer program-based six-axis deformity analysis. However, there is often a residual deformity after the initial correction, especially in deformities with a rotational component. This problem can be resolved by recalculating the parameters and inputting all new deformity and mounting parameters. However, this may necessitate repeated x-rays and delay treatment. We believe that error in the mounting parameters is the main reason for most residual deformities. To prevent these problems, we describe a new calculation technique for determining the mounting parameters that uses computed tomography. This technique is especially advantageous for deformities with a rotational component. Using this technique, exact calculation of the mounting parameters is possible and the residual deformity and number of repeated x-rays can be minimized. This new technique is an alternative method to accurately calculating the mounting parameters.

Bone transport for postinfectious segmental tibial bone defects with a combined ilizarov/taylor spatial frame technique

OBJECTIVE

To assess and compare the results of trifocal (two-level bone lengthening with compression at the nonunion site) and bifocal (one-level bone lengthening with compression at the nonunion site) bone transport using the Taylor Spatial Frame (TSF; Smith and Nephew, Inc, Memphis, TN) for postinfectious segmental tibial bone defects.

DESIGN

Retrospective study of 12 patients with atrophic tibial nonunions. These patients were treated with resection of the nonunion followed by bone transport using the TSF for the segmental tibial bone defects. All patients were treated by the same surgeon (F.S.).

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

Twelve consecutive patients treated for postinfectious segmental tibial bone defects between November 2004 and September 2007.

INTERVENTION

All patients were treated using the TSF for a trifocal or bifocal technique of bone transport along with associated soft tissue reconstructive surgeries. All patients were additionally treated with 45 days of culture-specific antibiotics.

OUTCOME MEASUREMENT

All patients were evaluated by the guidelines of the Association for the Study of the Method of Ilizarov.

RESULTS AND CONCLUSION

All patients achieved complete union and eradication of infection. The results were evaluated according to Association for the Study of the Method of Ilizarov criteria: 83% were excellent and 17% were good in terms of bony outcomes; functional results were excellent in 50%, good in 42%, and fair in 8%. Combined Ilizarov/TSF trifocal and bifocal techniques for the treatment of segmental tibial bone defects achieve union without malalignment of the mechanical axis.