Hexapod Stacked Transport for Tibial Infected Nonunions With Bone Loss: Long-Term Functional Outcomes

Clinical features of chronic tibial osteomyelitis: a single-center retrospective study of 282 cases in Xinjiang, China

BACKGROUND

Chronic osteomyelitis is a highly prevalent and severe orthopaedic complication, representing a critical unresolved issue. The clinical symptoms of osteomyelitis are influenced by various factors, including geography, lifestyle, and pre-existing medical conditions.This study aims to provide theoretical basis for treatment and prevention of osteomyelitis by investigating and analyzing clinical features and pathogen distribution among 282 patients with chronic tibial osteomyelitis in xinjiang.

METHODS

A total of 282 patients with chronic tibial osteomyelitis from January 1, 2012 to January 1, 2022 in the First Affiliated Hospital of Xinjiang Medical University were retrospectively analyzed. All data were collected from electronic medical record (EMR) system including demographics, etiology, risk factors, osteomyelitis location and clinical classification.

RESULTS

Farmers, students, unemployed and retirees accounted for a relatively large proportion of the 282 patients. There were 233 males and 49 females with a gender ratio of 4.75:1. The average age was 40.21 ± 15.68 years and was mainly concentrated in 41-50 years, specifically, the mean age of females was slightly older than that of males. Education level was mostly primary and secondary school education, and illiteracy. Risk factors of chronic tibial osteomyelitis included history of smoking and drinking, history of multiple repeated surgeries, and impaired immunity. Frequent clinical symptoms were in the order of pain, local swelling, pus discharge and skin ulceration. Among all inflammatory markers, proportion of positive results were 30.85%, 59.93% and 53.90% for white blood cell (WBC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), respectively. Positive rate of pathogenic microorganism culture was low and the three most common bacteria were Staphylococcus aureus (S. aureus), Pseudomonas aeruginosa (P. aeruginosa) and Escherichia coli (E. coli). The most frequent site of infection was middle tibia. According to Cierny-Mader osteomyelitis classification, the most common types were type IIIA, IVA and IIA.

CONCLUSION

Number of visits due to chronic osteomyelitis increased year by year, with young and middle-aged male farmers and low education level as the main groups. Smoking and drinking were two considerable risk factors that should be attached to a great importance. No significant increase was found in inflammatory markers and lower positive rate of pathogenic microorganism culture was observed. Multi-drug resistant bacteria were common and S. aureus remained the most frequent pathogen. Elevated ESR had certain diagnostic value for osteomyelitis. Type III and type IV osteomyelitis accounted for a large proportion which posed great challenges for clinical diagnosis and treatment.

FixThePig: a custom 3D-printed femoral intramedullary nailing for preclinical research applications

Background

Critical-size bone defects (CSBDs) pose significant challenges in clinical orthopaedics and traumatology. Developing reliable preclinical models that accurately simulate human conditions is crucial for translational research. This study addresses the need for a reliable preclinical model by evaluating the design and efficacy of a custom-made 3D-printed intramedullary nail (IMN) specifically for CSBDs in minipigs. The study aims to answer the following questions: Can a custom-made 3D-printed IMN be designed for femoral osteosynthesis in minipigs? Does the use of the custom-made IMN result in consistent and reproducible surgical procedure, particularly in the creation and fixation of CSBDs? Can the custom-made IMN effectively treat and promote bone consolidation of CSBDs?

Hypothesis

The custom-made 3D-printed IMN can be designed to effectively create, fix and treat CSBDs in minipigs, resulting in consistent surgical outcomes.

Materials and Methods

The IMN was designed based on CT scans of minipig femurs, considering factors such as femoral curvature, length, and medullary canal diameters. It was 3D-printed in titanium and evaluated through both in vitro and in vivo testing. Female Aachen minipigs underwent bilateral femoral surgeries to create and fix CSBDs using the custom-made IMN. Post-operative follow-up included X-rays and CT scans every 2 weeks, with manual examination of explanted femurs to assess consolidation and mechanical stability after 3 months.

Results

The custom-made IMN effectively fitted the minipig femoral anatomy and facilitated reproducible surgical outcomes. Symmetric double osteotomies were successfully performed, and allografts showed minimal morphological discrepancies. However, proximal fixation faced challenges, leading to non-union in several cases, while most distal osteotomy sites achieved stable consolidation.

Discussion

The custom-made 3D-printed IMN demonstrated potential in modelling and treating CSBDs in minipigs. While the design effectively supported distal bone healing, issues with proximal fixation highlight the need for further refinements. Potential improvements include better screw placement, additional mechanical support, and adaptations such as a reduction clamp or a cephalic screw to enhance stability and distribute forces more effectively.

Bone Transport for Large Segmental Tibial Defects Using Taylor Spatial Frame versus the Ilizarov Circular Fixator

OBJECTIVE

Bone transport has become the gold standard for treating large segmental tibial bone defects. The technique for application the Ilizarov circular fixator (ICF) has a long learning curve and is associated with many complications. There are few clinical studies on bone transport via the Taylor spatial frame (TSF). The main purpose of this study was to compare the radiological and clinical and outcomes of bone transport by using the TSF and the ICF.

METHODS

There were 62 patients included in this retrospective study from June 2011 to June 2021 and distributed to two groups according to the fixation method: a TSF group consisting of 30 patients and an ICF group consisting of 32 patients. Demographic information, surgical duration, external fixation times, external fixation index, final radiographic results, complications, and clinical outcomes were recorded and examined. The clinical outcomes were assessed using the ASAMI criteria during the most recent clinical visit. Then, statistical analysis such as independent-samples t tests or chi-Square test was performed.

RESULTS

The mean surgical duration in the TSF group was 93.8 ± 7.3 min, which was shorter than that in the ICF group (109.8 ± 1.4 min) (p < 0.05). Compared to the ICF group (10.2 ± 2.0 months), the TSF group (9.7 ± 1.8 months) had a shorter average external fixation time (p > 0.05). The external fixation index was 1.4 ± 0.2 m/cm and 1.5 ± 0.1 m/cm in the two groups. Moreover, there was no significant difference between the two groups. At the last follow-up visit, the medial proximal tibial angle (MPTA) and posterior proximal tibial angle (PPTA) in the TSF group were 88.1 ± 12.1° and 80.9 ± 1.3°, respectively. The MPTA and PPTA in the ICF group were 84.4 ± 2.4° and 76.2 ± 1.9°, respectively. There were statistically significant differences between the two groups (all p < 0.05). The complication rate was 50% in the TSF group and 75% in the ICF group. Moreover, the ASAMI score between the two groups was no statistically significant difference (p > 0.05).

CONCLUSION

No statistically significant difference was found in clinical outcomes between the use of Taylor spatial frame and Ilizarov circular fixator for treating large segmental tibial bone defects. However, TSF is a shorter and simpler procedure that causes fewer complications and improves limb alignment.

Efficacy and safety of autologous or allogeneic mesenchymal stromal cells from adult adipose tissue expanded and combined with tricalcium phosphate biomaterial for the surgical treatment of atrophic nonunion of long bones: a phase II clinical trial

BACKGROUND

Autologous bone grafting is the standard treatment for the surgical management of atrophic nonunion of long bones. Other solutions, such as bone marrow mesenchymal stem cells (BM-MSC) combined with phospho-calcium material, have also been used. Here we evaluate the safety and early efficacy of a novel procedure using autologous or allogenic adipose tissue mesenchymal stromal cells (AT-MSC) seeded in a patented tricalcium phosphate-based biomaterial for the treatment of bone regeneration in cases of atrophic nonunion.

METHODS

This was a prospective, multicentric, open-label, phase 2 clinical trial of patients with atrophic nonunion of long bones. Biografts of autologous or allogenic AT-MSC combined with a phosphate substrate were manufactured prior to the surgical procedures. The primary efficacy was measured 6 months after surgery, but patients were followed for 12 months after surgery and a further year out of the scope of the study. All adverse events were recorded. This cohort was compared with a historical cohort of 14 cases treated by the same research team with autologous BM-MSC.

RESULTS

A total of 12 patients with atrophic nonunion of long bones were included. The mean (SD) age was 41.2 (12.1) years and 66.7% were men. Bone healing was achieved in 10 of the 12 cases (83%) treated with the AT-MSC biografts, a percentage of healing similar (11 of the 14 cases, 79%) to that achieved in patients treated with autologous BM-MSC. Overall, two adverse events, in the same patient, were considered related to the procedure.

CONCLUSIONS

The results of this study suggest that AT-MSC biografts are safe for the treatment of bone regeneration in cases of atrophic nonunion and reach high healing rates.

TRIAL REGISTRATION

Study registered with EUDRA-CT (2013-000930-37) and ClinicalTrials.gov (NCT02483364).

Advances in the Application of Bone Transport Techniques in the Treatment of Bone Nonunion and Bone Defects

Bone nonunion and bone defects frequently occur following high-energy open injuries or debridement surgeries, presenting complex challenges to treatment and significantly affecting patients' quality of life. At present, there are three primary treatment options available for addressing bone nonunion and bone defects: vascularized bone grafts, the Masquelet technique, and the Ilizarov technique. The Ilizarov technique, also known as distraction osteogenesis, is widely favored by orthopedic surgeons because of several advantages, including minimal soft tissue requirements, low infection risk, and short consolidation time. However, in recent years, the application of the Masquelet technique has resulted in novel treatment methods for managing post-traumatic bone infections when bone defects are present. Although these new techniques do not constitute a panacea, they continue to be the most commonly employed options for treating complex large bone nonunion and bone defects. This review evaluates the currently available research on the Ilizarov and Masquelet bone transport techniques applied at various anatomical sites. Additionally, it explores treatment durations and associated complications to establish a theoretical foundation that can guide clinical treatment decisions and surgical procedures for the management of bone nonunion and bone defects.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Protocol for the BONE-RECON trial: a single-arm feasibility trial for critical sized lower limb BONE defect RECONstruction using the mPCL-TCP scaffold system with autologous vascularised corticoperiosteal tissue transfer

INTRODUCTION

Reconstruction of critical bone defects is challenging. In a substantial subgroup of patients, conventional reconstructive techniques are insufficient. Biodegradable scaffolds have emerged as a novel tissue engineering strategy for critical-sized bone defect reconstruction. A corticoperiosteal flap integrates the hosts' ability to regenerate bone and permits the creation of a vascular axis for scaffold neo-vascularisation (regenerative matching axial vascularisation-RMAV). This phase IIa study evaluates the application of the RMAV approach alongside a custom medical-grade polycaprolactone-tricalcium phosphate (mPCL-TCP) scaffold (Osteopore) to regenerate bone sufficient to heal critical size defects in lower limb defects.

METHODS AND ANALYSIS

This open-label, single-arm feasibility trial will be jointly coordinated by the Complex Lower Limb Clinic (CLLC) at the Princess Alexandra Hospital in Woolloongabba (Queensland, Australia), the Australian Centre for Complex Integrated Surgical Solutions (Queensland, Australia) and the Faculty of Engineering, Queensland University of Technology in Kelvin Grove (Queensland, Australia). Aiming for limb salvage, the study population (n=10) includes any patient referred to the CLLC with a critical-sized bone defect not amenable to conventional reconstructive approaches, after discussion by the interdisciplinary team. All patients will receive treatment using the RMAV approach using a custom mPCL-TCP implant. The primary study endpoint will be safety and tolerability of the reconstruction. Secondary end points include time to bone union and weight-bearing status on the treated limb. Results of this trial will help shape the role of scaffold-guided bone regenerative approaches in complex lower limb reconstruction where current options remain limited.

ETHICS AND DISSEMINATION

Approval was obtained from the Human Research Ethics Committee at the participating centre. Results will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ACTRN12620001007921.

Precice Stryde® Magnetic Internal Lengthening Nail does not Impair Bone Healing Despite Radiographic and Clinical Symptoms

Aims

The Precice Stryde® internal magnetic lengthening nail allowed many patients a full weight-bearing experience during femur and tibia lengthening, but concerns over corrosion, pain and radiographic changes led to the implant's recall. Despite the recall, it is important to understand the rate of these occurrences and their influence on the overall success of the lengthening procedure. We aimed to investigate radiographic changes, patient-reported symptoms and bone healing indices for our cohort of Stryde lengthening.

Materials and methods

Our surgical database and electronic medical record system were used to review and document patient demographics, indications for lengthening, length achieved, bone healing index (BHI), location and type of radiographic changes, time until radiographic changes were first visible, presence of pain symptoms (not attributable to surgery or distraction), time to implant removal and if the pain symptoms resolved following implant extraction.

Results

From January 2019 to February 2021, 90 Stryde nails (78 femur and 12 tibia) were implanted in 63 patients. The cohort included 48 males and 15 females. The average length [± standard deviation (SD)] achieved was 58.4 ± 22.7 mm. The 66 bones (73%) developed radiographic changes and were found to be 58/78 (74%) femurs and 8/12 (67%) tibias. The average time to initial radiographic changes was 168 ± 108.1 days (femur) and 276 ± 126.8 days (tibia). Late-onset pain developed in 10 femur lengthening (11.1% of all nails) surgeries across eight patients (12.7% of all patients). All patients' pain resolved; three instances prior to nail removal and the remaining seven after nail removal. No patients were re-presented with worsening pain or radiographic changes following implant removal. Radiographic or symptomatic abnormalities did not impair bone formation. The BHI for femurs with (29.6 ± 16.6 days/cm, n = 58) vs without (29.4 ± 17.9 days/cm, n = 20) radiographic or symptomatic irregularity were nearly identical (p = 0.961). The difference between BHI for tibias with (39.3 ± 7.8 days/cm, n = 8) vs without (86.1 ± 38.2 days/cm, n = 4) radiographic changes was influenced by outliers and underpowered to draw a conclusion.

Conclusion

Bone lengthening with the Stryde nail was associated with high rates of radiographic abnormalities, but symptoms were uncommon and resolved with explantation. The radiographic changes did not affect bone healing in the femur.

Clinical significance

Radiographic changes including bone hypertrophy and osteolysis were common after bone lengthening with the Stryde nail, but the development of pain following consolidation was rare and resolved with implant removal.The BHI in femurs was not affected by radiographic changes.

How to cite this article

Reif TJ, Geffner A, Hoellwarth JS, et al. Precice Stryde® Magnetic Internal Lengthening Nail does not Impair Bone Healing Despite Radiographic and Clinical Symptoms. Strategies Trauma Limb Reconstr 2023;18(2):94-99.

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

Introduction

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

Materials and methods

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

Results

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

Conclusion

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

How to cite this article

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

Dual Magnetically Expandable Intramedullary Nails for Treatment of a Large Bony Defect in a Patient with Sarcoma: A Case Report

Aim

To describe the surgical technique of performing an all-internal lengthening to address a large diaphyseal femur defect in the sarcoma patient.

Background

Various strategies exist to address large intercalary bone defects with various biomechanical and biological implications.

Case description

A 23-year-old female with high-grade osteosarcoma of her left femur underwent wide resection and an internal reconstruction of a 12.5-cm femoral defect using dual magnetic lengthening intramedullary nails resulting in restoration of leg lengths, and pre-resection function with minimal residual disability.

Conclusion

Preoperative chemotherapy, wide resection and post-operative chemotherapy for osteosarcoma are the current standard of care. Resection often leads to large bone defects requiring complex reconstruction. Following intercalary bone resection, biological reconstruction is a consideration. An all-inside technique was developed in an effort to minimise complications of long-term external fixation for distraction osteogenesis, or extensile secondary grafting procedures for induced membrane strategy.

Clinical significance

This previously unreported surgical technique allows for an all-internal lengthening of large diaphyseal bone defects. While specifically used in an oncologic post-resection setting, this technique is applicable to the broader limb reconstruction and lengthening practice and overcomes some inherent limitations to previously described techniques.

How to cite this article

Copp J, Magister S, Napora J, et al. Dual Magnetically Expandable Intramedullary Nails for Treatment of a Large Bony Defect in a Patient with Sarcoma: A Case Report. Strategies Trauma Limb Reconstr 2022;17(3):189-194.

Plate-Assisted Bone Segment Transport Versus Precice Bone Transport Nail

Management of segmental long bone defects is a complex and challenging undertaking for orthopaedic surgeons. These defects can be encountered in cases of high-energy trauma, tumor resection, or infection, and they are often associated with significant soft tissue injury. Traditional approaches of bone transport rely on external fixation and principles of distraction osteogenesis. Plate-assisted bone segment transport (PABST) using the Precice limb lengthening nail has been adapted for use in bone transport with the use of a plate in an effort to eliminate the need for external fixation and its associated complications. Recently, the arrival of the Precice Bone Transport (PBT) System intramedullary nail eliminates the need for plating and some of the problems encountered in PABST; however, it also introduces some new issues. PABST and the PBT nail have become viable alternatives to bone transport using a frame; however, each has its own unique set of advantages and disadvantages. Although the problems of using external fixation devices are eliminated with these techniques, there is less forgiveness in execution and very little chance of correcting as the transport is underway. The arrival of the PBT nail does not eliminate the need for PABST as seen by the difficulty maintaining alignment in short metaphyseal segments. This review reflects the current state of these methods based on available evidence; however, optimization of the protocol for transport using PABST and the PBT nail will require additional cases and data.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Patient-reported Outcome and Quality of Life after Treatment with External Fixation: A Questionnaire-based Survey

Background

This survey aims to assess the satisfaction of patients who have had treatment using external fixation (EF).

Materials and methods

An original questionnaire and a Short Form 36 (SF-36) were distributed to 121 patients who underwent treatment using EF for deformity correction and lengthening between 2006 and 2016. A multivariate analysis was performed on the factors associated with satisfaction.

Results

Sixty patients returned a response. The average satisfaction score was 83.6 points. In the 5-point satisfaction survey, 43 of 60 patients (71.7%) responded “very satisfied” or “satisfied” and 27 patients (45.0%) responded “yes” to the question as to whether they would request EF treatment again if presenting with the original preoperative condition. In addition, the subjectively expressed tolerance for having an external fixator device on the limb was 92.1 days on average. A correlation was established with the ISOLS score.

Conclusion

The top three factors that determined subjective inconvenience with EF are pain, walking, and heaviness. Although EF treatment was stressful, the satisfaction scores were high. Furthermore, the satisfaction with EF treatment was improved by (1) pain control, (2) shortening the EF period, and (3) psychological support.

How to cite this article

Ugaji S, Matsubara H, Kato S, et al. Patient-reported Outcome and Quality of Life after Treatment with External Fixation: A Questionnaire-based Survey. Strategies Trauma Limb Reconstr 2021;16(1):27–31.

Can the TrueLok Hexapod System™ be used to accurately correct lower limb deformity in children?

INTRODUCTION

Progressive bone lengthening in children can be done using an external fixator, a lengthening nail, or plate with screws. The TrueLok Hexapod System™ (TL-HEX™) is the newest hexapod external fixator on the market. We hypothesized that the TL-HEX™ can accurately correct lower limb deformities in children. The goal of this study was to evaluate the clinical and radiographic outcomes after correcting lower limb deformities in children using the TL-HEX™ system.

MATERIAL AND METHODS

Data from 58 limbs that underwent bone lengthening with the TL-HEX™ were analyzed for this retrospective, single-center study. The average patient age was 11.4 years. The femur was lengthened in 23 limbs and the tibia in 35. The outcomes were evaluated using long leg standing radiographs preoperatively and at the final assessment. The variables of interest were the mechanical axis deviation (MAD), mechanical lateral distal femoral angle (mLDFA), mechanical lateral proximal tibia angle (mMPTA), healing index (HI) and accuracy of the correction. The complications were graded on a 4-point scale summarizing three broad goals: planned correction, duration of treatment and sequelae. The accuracy of the correction was defined as the difference between the planned correction and the actual correction achieved.

RESULTS

The mean HI was 37 days/cm. Significant correction was achieved for leg length discrepancy (LLD) (60 mm vs. 20 mm; p<0.01) and mLDFA (88.6° vs. 89.9°; p=0.04) but not the MAD (17.7 vs. 14.7; p= 0.17) or mMPTA (87.3 vs. 88.1; p=0.08). In the entire cohort, the difference from planned was 12.5 mm (p<0.01) for lengthening, 1.3° for the mLDFA (p=0.5) and 3° for the mMPTA (p=0.02). Relative to the initial goal, the mean lengthening achieved was 118%. In the sub-group where the plan did not need to be modified, the accuracy of the correction was better. There were 40 complications (69%).

CONCLUSION

The TL-HEX™ is an effective and accurate system. The complication rate associated with its use is the same as other hexapod external fixators. Surgeons and patients must be aware of the high complication rate, which may require the plan to be modified and could potentially compromise the outcome.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Nonunion - consensus from the 4th annual meeting of the Danish Orthopaedic Trauma Society

Nonunions are a relevant economic burden affecting about 1.9% of all fractures. Rather than specifying a certain time frame, a nonunion is better defined as a fracture that will not heal without further intervention.

Successful fracture healing depends on local biology, biomechanics and a variety of systemic factors. All components can principally be decisive and determine the classification of atrophic, oligotrophic or hypertrophic nonunions. Treatment prioritizes mechanics before biology.

The degree of motion between fracture parts is the key for healing and is described by strain theory. If the change of length at a given load is > 10%, fibrous tissue and not bone is formed. Therefore, simple fractures require absolute and complex fractures relative stability.

The main characteristics of a nonunion are pain while weight bearing, and persistent fracture lines on X-ray.

Treatment concepts such as ‘mechanobiology’ or the ‘diamond concept’ determine the applied osteosynthesis considering soft tissue, local biology and stability. Fine wire circular external fixation is considered the only form of true biologic fixation due to its ability to eliminate parasitic motions while maintaining load-dependent axial stiffness. Nailing provides intramedullary stability and biology via reaming. Plates are successful when complex fractures turn into simple nonunions demanding absolute stability. Despite available alternatives, autograft is the gold standard for providing osteoinductive and osteoconductive stimuli.

The infected nonunion remains a challenge. Bacteria, especially staphylococcus species, have developed mechanisms to survive such as biofilm formation, inactive forms and internalization. Therefore, radical debridement and specific antibiotics are necessary prior to reconstruction.

Cite this article: EFORT Open Rev 2020;5:46-57. DOI: 10.1302/2058-5241.5.190037

All Internal Bone Transport: Use of a Lengthening Nail and Double Plating for Management of Femoral Bone Loss

Background

Variety of techniques for management of segmental femoral bone loss have been described, each with different advantages and challenges during treatment. The development of motorized lengthening nails has provided a potential for all internal bone transport, avoiding some of the difficulties with external fixation in the femur. At present, there is limited published literature on experiences in this technique.

Aim

The development of this technique aimed to overcome the difficulties previously reported for internal bone transport in the femur, particularly varus deformity and joint stiffness.

Technique

We describe the technique of double plating with bone transport utilizing a magnetic lengthening nail to manage segmental femoral bone loss. The benefits of the technique are discussed, along with specific challenges and lessons that have been learned through experience of internal bone transport.

Conclusion

Use of a magnetic lengthening nail and double plating as a method of all internal bone transport provides an option for the management of massive femoral bone loss, while avoiding some of the challenges that have been reported with the existing techniques.

Clinical significance

This technique provides an additional method in the armamentarium of the trauma or limb reconstruction surgeon treating massive femoral bone loss.

How to cite this article

Wright J, Bates P, Heidari N, et al. All Internal Bone Transport: Use of a Lengthening Nail and Double Plating for Management of Femoral Bone Loss. Strategies Trauma Limb Reconstr 2019;14(2):94–101.