Treatment of Posttraumatic Tibial Diaphyseal Bone Defects: A Systematic Review and Meta-Analysis

Critical size bone defects managed with modern techniques of bone transport: An update

Bone transport is one of several techniques that has been proven to be effective in addressing critical bone loss. While it was first described over 100 years ago, modifications to this technique coupled with advances in technology have allowed us to perform bone transport with higher success rates and reduced complication rates. Modern techniques of bone transport aim to shorten the duration of time an external fixator is utilized to reduce its associated complications and burden to patients. We present an update on modern techniques of bone transport for critical size defects and methods to shorten the external fixation time.

Osteocutaneous superficial circumflex iliac perforator flap for the lower extremity bone and soft tissue reconstruction with perforator-to-perforator anastomosis after radical debridement of tibia osteomyelitis: A case report

Reconstruction of soft tissue and bone defects in tibia chronic osteomyelitis is challenging and often managed by free flap with bone graft. However, the use of osteocutaneous free flap combined with perforator-to-perforator anastomosis has not been reported. We report the case of a 62-year-old man presenting with soft tissue and bone defects with right tibial chronic osteomyelitis, which was successfully treated with an osteocutaneous superficial circumflex iliac perforator (SCIP) flap with perforator-to-perforator anastomosis. After radical debridement and excision of the sequestrum, a 17 × 10-cm skin defect and a 4 × 3-cm bone defect remained. An osteocutaneous SCIP flap, containing a 16 × 9-cm skin paddle and 4 × 2-cm iliac bone, was transferred and anastomosed to the posterior tibial perforator in an end-to-end fashion. An artificial dermis was placed to cover the soft tissue. At 1 week postoperatively, the artificial dermis was partially infected, which required small debridement. Full weight-bearing was permitted 5 weeks postoperatively, and the patient walked independently. No evidence of recurrence of osteomyelitis or skin ulcers was observed at 15 months postoperatively. Therefore, osteocutaneous SCIP flap with perforator-to-perforator anastomosis may be a potential alternative treatment for soft tissue and bone defects after radical debridement of tibia osteomyelitis.

Preventing biological waste: Effective use of viable tissue in traumatized lower extremities

Severe open lower extremity trauma requires debridement to remove contamination and devitalized tissues. Aggressive debridement should be balanced with preservation of viable tissue. These often damaged but preserved viable tissues are "spare parts" that augment the options available for reconstruction. The long-term goal of reconstruction should be functional limb restoration and optimization. Injury patterns, levels, and patient factors will determine whether this endeavor is better accomplished with limb salvage or amputation. This article reviews the rationale and strategies for preserving spare parts throughout debridement and then incorporating them as opportunistic grafts in the ultimate reconstruction to facilitate healing and maximize extremity function.

Level of Evidence

5.

Management of bone loss in acute severe open tibial fractures: a retrospective study of twenty nine cases-a treatment strategy with bone length preservation

PURPOSE

The present study investigated the outcomes of bone loss associated with acute open tibial fractures classified as Gustilo-Anderson classification grade III B (GIIIB) using a bone length preservation strategy.

METHODS

Among acute GIIIB open tibial fractures, 29 limbs of 29 patients requiring bone loss treatment were included. The reconstruction methods for bone loss were selected among the Masquelet technique (MT), bone transport (BT), acute shortening followed by gradual lengthening (ASGL), and free vascularized fibula graft (FVFG). Primary outcome measures were the rate of bone union and time to bone union.

RESULTS

The median radiographic apparent bone gap (RABG) was 46.75 mm. Bone loss was treated with ASGL only in two patients in whom it was not possible to cover large soft tissue defects by a single free latissimus dorsi (LD) myocutaneous flap (with the serratus anterior (SA) muscle). The other 27 patients underwent soft tissue reconstruction and bone loss treatment with the preservation of bone length, including the MT for 23, BT for six, and FVFG for one. The bone union rate was 75.9%, and the median time to bone union was six months. Salvage surgeries were performed on all seven patients with nonunion; all of whom eventually achieved bony union.

CONCLUSION

Bone loss associated with acute GIIIB open tibial fractures were treated with "bone length preservation" if the size of the soft tissue defect was less than the size that was covered by a single LD myocutaneous flap (with the SA muscle).

Convergence of scaffold-guided bone regeneration principles and microvascular tissue transfer surgery

A preclinical evaluation using a regenerative medicine methodology comprising an additively manufactured medical-grade ε-polycaprolactone β-tricalcium phosphate (mPCL-TCP) scaffold with a corticoperiosteal flap was undertaken in eight sheep with a tibial critical-size segmental bone defect (9.5 cm³, M size) using the regenerative matching axial vascularization (RMAV) approach. Biomechanical, radiological, histological, and immunohistochemical analysis confirmed functional bone regeneration comparable to a clinical gold standard control (autologous bone graft) and was superior to a scaffold control group (mPCL-TCP only). Affirmative bone regeneration results from a pilot study using an XL size defect volume (19 cm³) subsequently supported clinical translation. A 27-year-old adult male underwent reconstruction of a 36-cm near-total intercalary tibial defect secondary to osteomyelitis using the RMAV approach. Robust bone regeneration led to complete independent weight bearing within 24 months. This article demonstrates the widely advocated and seldomly accomplished concept of "bench-to-bedside" research and has weighty implications for reconstructive surgery and regenerative medicine more generally.

Masquelet Technique for the Tibia: A Systematic Review and Meta-Analysis of Contemporary Outcomes

OBJECTIVE

To systematically review outcomes of the Masquelet "induced membrane" technique (MT) in treatment of tibial segmental bone loss and to assess the impact of defect size on union rate when using this procedure.

DATA SOURCES

PubMed, EBSCO, Cochrane, and SCOPUS were searched for English language studies from January 1, 2010, through December 31, 2019.

STUDY SELECTION

Studies describing the MT procedure performed in tibiae of 5 or more adult patients were included. Pseudo-arthrosis, nonhuman, pediatric, technique, nontibial bone defect, and non-English studies were excluded, along with studies with less than 5 patients. Selection adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria.

DATA EXTRACTION

A total of 30 studies with 643 tibiae were included in this meta-analysis. Two reviewers systematically screened titles or abstracts, followed by full texts, to ensure quality, accuracy, and consensus among authors for inclusion or exclusion criteria of the studies. In case of disagreement, articles were read in full to assess their eligibility by the senior author. Study quality was assessed using previously reported criteria.

DATA SYNTHESIS

Meta-analysis was performed with random-effects models and meta-regression. A meta-analytic estimate of union rate independent of defect size when using the MT in the tibia was 84% (95% CI, 79%-88%). There was no statistically significant association between defect size and union rate ( P = 0.11).

CONCLUSIONS

The MT is an effective method for the treatment of segmental bone loss in the tibia and can be successful even for large defects. Future work is needed to better understand the patient-specific factors most strongly associated with MT success and complications.

LEVEL OF EVIDENCE

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

Comparison of the clinical outcomes between vascularized bone graft and the Masquelet technique for the reconstruction of Gustilo type III open tibial fractures

BACKGROUND

Gustilo type III tibial fractures commonly involve extensive soft tissue and bony defects, requiring complex reconstructive operations. Although several methods have been proposed, no research has elucidated the efficacies and differences between vascular bone graft (VBG) and the Masquelet technique (MT) to date. We aimed to evaluate and compare the clinical effectiveness of VBG and the MT for the reconstruction of Gustilo type III tibial fractures.

METHODS

This retrospective cohort study enrolled patients who underwent reconstruction for Gustilo type III tibial fractures using VBG or the MT in a single center from January 2000 to December 2020. The patients' demographics, injury characteristics, and surgical interventions were documented for analysis. The clinical outcomes including union status, time to union, postoperative infections, and the causes of union failure were compared between the two groups.

RESULTS

We enrolled 44 patients: 27 patients underwent VBG, and 17 underwent MT. The average union time was 20.5 ± 15.4 and 15.1 ± 9.0 months in the VBG and MT groups, respectively (p = 0.232). The postoperative deep infection rates were 70.4% and 47.1% in the VBG and MT groups (p = 0.122), respectively. Though not statistically significant, the VBG group had a shorter union time than did the MT group when the bone defect length was > 60 mm (21.0 ± 17.0 versus 23.8 ± 9.4 months, p = 0.729), while the MT group had a shorter union time than did the VBG group when the bone defect was length < 60 mm (17.2 ± 5.6 versus 10.7 ± 4.7 months, p = 0.067).

CONCLUSIONS

VBG and MT are both promising reconstruction methods for Gustilo type III tibial fractures. VBG appears to have more potential in reconstructing larger bone defects, while MT may play an important role in smaller bone defects, severe surgical site infections, and osteomyelitis. Therefore, flexible treatment strategies are required for good outcomes in Gustilo type III open tibial fractures.