Combined single-stage osseous and soft tissue reconstruction of the tibia with the Ilizarov method and tissue transfer

Outcome analysis of ilizarov and monorail fixators in the treatment of nonunion of long bones: A systematic review and proportion meta-analysis

Introduction

Nonunion of long bones is a major complication following fractures that requires a substantial amount of investment both monetary and time from patients and surgeons. The need to comprehensively understand the complications, outcomes and distraction capability is profound, which necessitates a review of current evidence on special fixators used for distraction. The current systematic review aims to study the available literature on distraction osteogenesis using special fixators (Ilizarov and Limb Reconstruction System) in the management of nonunion (infected and non-infected).

Methods

Cochrane Library, PubMed, Scopus were searched until January 2022. The review included all original studies which used Ilizarov or Monorail Fixators/LRS in the treatment of nonunion of long bones. The quality of studies was assessed using the Modified Coleman Methodology Score.

Results

A total of 35 original studies with Ilizarov (n = 29) and LRS (n = 8) were selected including two comparative studies. The pooled data meta-analysis and the subgroup analysis of these studies found both Ilizarov and LRS fixator yield similar functional outcomes for the treatment of long bones nonunion.

Conclusion

The review was conducted to understand the scenario of nonunion in long bones. Pin tract infection is found to be the most common complication followed by adjacent joint stiffness and deformity. In our review we observed that both external fixator time and index were lower in LRS compared to Ilizarov group. Further RCT are required comparing Ilizarov and LRS fixators to effectively comment upon the superiority of the implants.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

III.

LEVEL OF CLINICAL CARE

Level I Tertiary trauma centre.

Approach to Complex Lower Extremity Reconstruction

Composite injuries to the lower extremity from etiologies including trauma and infection present a complex dilemma for the reconstructive surgeon, and require multidisciplinary collaboration amongst plastic, vascular, and orthopaedic surgical specialties. Here we present our algorithm for lower-extremity reconstructive management, refined over the last decades to provide an optimized outcome for our patients. Reconstruction is predicated on the establishment of a clean and living wound, where quality of the wound-bed is prioritized over timing to soft-tissue coverage. Once established, soft-tissues and fractures are provisionally stabilized; our preference for definitive coverage is for microvascular free-tissue, due to the paucity of healthy soft-tissue available at the injury, and ability to avoid the zone of injury for microvascular anastomosis. Finally, definitive bony reconstruction is dictated by the length and location of long-bone defect, with a preference to utilize bone transport for defects longer than 5 cm.

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.

Single stage versus two-stage orthoplastic management of bone infection

INTRODUCTION

Bone infection cases with major soft tissue loss have conventionally been treated with a staged orthoplastic approach, addressing the infection first followed by definitive management to achieve bony stability and soft tissue cover. In the last few decades, specialist centers have advocated for single stage bony stabilization with soft tissue coverage. We aimed to investigate the outcomes of patients that underwent a single stage versus a two-stage orthoplastic intervention.

METHODS

Using an existing 2009-2019 database from a single major trauma centre, we identified all adults with a diagnosis of fracture related infection (FRI) or osteomyelitis (OM). The primary outcome was resolution of infection. Secondary outcomes included time to bony union, amputation, failure of orthopaedic fixation, mortality, and return to theatre.

RESULTS

A total of 96 patients were included. 71 patients (74%) underwent a single stage procedure; out of which 61 were FRI. 25 patients (26%) underwent a two-stage procedure; out of which 24 were FRI. The average follow up for the single stage and two-stage cohorts was 32.1 and 30.3 months, respectively. Resolution of infection without the need for an amputation was achieved in 67 (94.4%) patients in the single stage cohort and in 23 (92%) patients in the two-stage cohort. When compared to the two-stage group, the single stage cohort had less recurrence of infection (9.9% versus 12%, p = 0.72), lower rates of amputation (8.5% versus 12%, p = 0.69), lower rates of failure of orthopaedic fixation (11.1% versus 13%, p = 0.82), but higher average time to bony union (15.25 months versus 12.35, p = 0.42). The differences were not statistically significant. A total of 37 patients (52.1%) had an unplanned return to theatre in the single stage compared to 12 (48%) in the two-stage cohort. In subgroup analysis of FRI cases, open fractures had a longer time to bony union when compared to closed fractures (19.7 versus 11.6 months, p = 0.01). No mortality was observed in both cohorts.

CONCLUSIONS

The single stage orthoplastic approach to bone infection is effective if planned carefully with clinical outcomes comparable to the two-stage approach. Further research should examine factors associated with unplanned return to theatre and any variation in treatment of bone infection across regions.

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

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

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

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

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

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

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

Free Tissue Transfer with Distraction Osteogenesis and Masquelet Technique Is Effective for Limb Salvage in Patients with Gustilo Type IIIB Open Fractures

Osteocutaneous reconstruction can be challenging because of concomitant injuries and limited donor sites. There is a paucity of data on limb salvage outcomes following combined soft-tissue reconstruction and bone transport or Masquelet procedures. The authors reviewed a consecutive series of open tibia fracture patients undergoing soft-tissue reconstruction with either distraction osteogenesis or Masquelet technique. Endpoints were perioperative flap complications and bone union. Fourteen patients with Gustilo type IIIB open tibia fractures were included. Half of the group received muscle flaps and the remaining half received fasciocutaneous flaps. Ten patients (71.4 percent) underwent distraction osteogenesis and the remaining patients underwent Masquelet technique. Average bone gap length was 65.7 ± 31.3 mm (range, 20 to 120 mm). In the bone transport group, the average external fixation duration was 245 days (range, 47 to 686 days). In the Masquelet group, the average duration of the first stage of this two-stage procedure (i.e., time from cement spacer placement to bone grafting) was 95 days (range, 42 to 181 days). Bone union rate, as determined by radiographic evidence, was 85.7 percent. There was one complete flap failure (7.1 percent). One patient underwent below-knee amputation after failing bone transport and developing chronic osteomyelitis and subsequent infected nonunion. Our case series demonstrates that nonosteocutaneous flap methods of limb reconstruction are a viable option in patients with segmental long bone defects, with a bone union rate of 85 percent and a limb salvage rate over 90 percent in patients with Gustilo type IIIB fractures. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

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

Background

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

Methods

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

Results

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

Conclusions

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Can antibiotic impregnated cement nail achieve both infection control and bony union in infected diaphyseal femoral non-unions?

BACKGROUND

Infected non-union is complex and debilitating disorder affecting orthopaedic surgeon and patient in terms of cost and time. Many methods are described in the literature for treatment of infected non-union. Local high concentration of antibiotic and mechanical stability of antibiotic cement impregnated intramedullary nail (ACIIN) proves cost and time effective. Recently it was suggested that ACIIN can achieve both union and infection control in infected non-unions with bone gap less than 4cm. The aim of our study was to investigate this hypothesis and study the outcome of antibiotic cement impregnated intramedullary nail in term of both infection control and osseous union.

MATERIALS AND METHODS

We retrospectively studied 21 patients with infected diaphyseal femoral non-union. Inclusion criteria were bone gap less than 4cm after debridement and more than 1 year follow-up of the case. ACIIN prepared using K nail was used as primary procedure after adequate debridement. Infection control and osseous union was judged on the basis of clinical, radiological and haematological parameters. All patients were followed up with an average follow-up of 20.23±3.65 months (range 14-28 months).

RESULTS

Infection control was achieved in all 21 patients at end of 12 months follow-up, out of which 16 patients had osseous union and infection control without any secondary procedure. Of the remaining 5 patients: two patients had good infection control but had broken ACCIN due to non-compliance to weight bearing protocol. One patient underwent exchange nailing and plate augmentation whilst the other underwent simple exchange nailing, One more patient who had infection control but had persistent non-union had to undergo exchange nailing and augmented plating to achieve union. One other patient required debridement and implant removal and attained union and fifth patient required two additional debridements to control infection after which the fracture united. Apart from above 5 cases there were two further complications of knee stiffness.

CONCLUSION

In infected non-union with bone gap less than 4cm, ACIIN can achieve both infection control and osseous union in significant number of cases. All such cases should be primarily operated with aim to achieve this outcome and use of thicker nail and ensuring proper compliance from patients regarding weight bearing will improve the outcomes.

Definitive Management of Open Tibia Fractures Using Limb Reconstruction System

INTRODUCTION

Open fractures are treated as surgical emergency and early administration of intravenous antibiotic coupled with early irrigation and debridement decreases the infection rate dramatically. Limb Reconstruction System (LRS) is a unilateral rail system which consists of Shanz pins, rail rods and sliding clamps. It is specifically designed to enable the surgeon to perform simple and effective surgery as it offers rigid fixation of fracture fragments, allowing early weight bearing and reduces economic burden.

AIM

To determine the efficacy of Limb Reconstruction System for treatment of compound tibia fractures.

MATERIALS AND METHODS

A prospective study was carried out where in 54 cases out of 412 compound tibia fractures having Modified Gustilo Anderson Type IIIA and IIIB with a mean age of 42±5 years were treated using LRS over a period of 26 months. Limb reconstruction system was used in acute docking mode or with corticotomy and bone transport was done depending upon the bone loss. The soft tissue condition was assessed and split thickness skin grafting and flap repairs were done as per the need. Clinical and radiological assessment was done at every follow-up. Bony and functional assessment was done by Association for the Study and Application of the Methods of Illizarov (ASAMI) criteria.

RESULTS

Among 54 patients, bony results as per ASAMI score were excellent in 36, good in 14, fair in 2 and poor in 2 patients. Functional results were excellent in 43, good in 7, fair in 4 patients. The average fracture union time was 8 months. Post-surgery patient satisfaction was excellent since fixation allowed weight bearing immediately. Average hospital stay was 7 days and financial burden was reduced by 40% as compared to multi staged surgery. The average time of return to work was 20 days.

CONCLUSION

LRS is an easy, simple and definitive surgical procedure that allows immediate full weight bearing walking. It reduces hospital stay, is cost effective with excellent patient compliance and can also be used for bone lengthening/transportation.

Outcome of distraction osteogenesis by ring fixator in infected, large bone defects of tibia

BACKGROUND

Salvage of large, infected bone defects in tibia poses a formidable problem. The present prospective study aimed to evaluate radiologic and functional outcome of ring fixator in infected, large (≥6 cm) bone defects of tibia treated with distraction osteogenesis.

MATERIALS AND METHODS

The study included 35 patients (30 males and 5 females) who had minimum of 6 cm gap after radical resection of necrotic bone and presence or history of active infection. Mean age was 36.1 years. Mean bone gap was 7.27 cm. Mean follow-up period was 25.4 months.

RESULTS

Fracture united primarily in 17 cases and after fixator adjustment with freshening of fracture margins in 15 cases. Fixator adjustment with bone grafting was done in one patient to achieve union. One patient had nonunion and another had amputation. The bone result was excellent, good, and poor in 19, 13, and 3 patients, respectively. The functional results were excellent, good, fair and failure in 14, 19, 1, and one patient, respectively. 24 patients had superficial pin tract infection and 18 patients had ankle stiffness.

CONCLUSION

Ring fixator systems reliably achieve union in infected, large bone defects of tibia and help in treating infection, shortening, bone and soft tissue loss simultaneously. We advocate early freshening of fracture ends and removal of interposed soft tissue at docking sites to achieve union. Superficial pin tract infection and ankle stiffness are common problems in managing large tibial defects. But good to excellent functional outcomes can be achieved in majority of patients.

Limb salvage in a partially amputated distal femur with extensive segmental bone loss using the nailing after lengthening technique: a case report

Segmental long bone defects resulting from high-energy trauma with severe soft tissue loss are difficult problems to manage. Amputation was for a long time the primary mainstay of treatment. This is the report on a 15-year-old male patient who sustained a third-degree open, traumatic fracture with partial amputation of the left distal femur and extensive bone loss of 26 cm. Successful limb salvage was performed after vascular repair, shortening of the bone defect, primary placement of an antibiotic cement spacer and simple external fixation. This was followed by bifocal lengthening modifying the simple frame until limb equality was achieved and secondary intramedullary nailing 11 months after injury.

Outcome of limb reconstruction system in open tibial diaphyseal fractures

BACKGROUND

Management of open tibial diaphyseal fractures with bone loss is a matter of debate. The treatment options range from external fixators, nailing, ring fixators or grafting with or without plastic reconstruction. All the procedures have their own set of complications, like acute docking problems, shortening, difficulty in soft tissue management, chronic infection, increased morbidity, multiple surgeries, longer hospital stay, mal union, nonunion and higher patient dissatisfaction. We evaluated the outcome of the limb reconstruction system (LRS) in the treatment of open fractures of tibial diaphysis with bone loss as a definative mode of treatment to achieve union, as well as limb lengthening, simultaneously.

MATERIALS AND METHODS

Thirty open fractures of tibial diaphysis with bone loss of at least 4 cm or more with a mean age 32.5 years were treated by using the LRS after debridement. Distraction osteogenesis at rate of 1 mm/day was done away from the fracture site to maintain the limb length. On the approximation of fracture ends, the dynamized LRS was left for further 15-20 weeks and patient was mobilized with weight bearing to achieve union. Functional assessment was done by Association for the Study and Application of the Methods of Illizarov (ASAMI) criteria.

RESULTS

Mean followup period was 15 months. The mean bone loss was 5.5 cm (range 4-9 cm). The mean duration of bone transport was 13 weeks (range 8-30 weeks) with a mean time for LRS in place was 44 weeks (range 24-51 weeks). The mean implant index was 56.4 days/cm. Mean union time was 52 weeks (range 31-60 weeks) with mean union index of 74.5 days/cm. Bony results as per the ASAMI scoring were excellent in 76% (19/25), good in 12% (3/25) and fair in 4% (1/25) with union in all except 2 patients, which showed poor results (8%) with only 2 patients having leg length discrepancy more than 2.5 cm. Functional results were excellent in 84% (21/25), good in 8% (2/25), fair in 8% (2/25). Pin tract infection was seen in 5 cases, out of which 4 being superficial, which healed to dressings and antibiotics. One patient had a deep infection which required frame removal.

CONCLUSION

Limb reconstruction system proved to be an effective modality of treatment in cases of open fractures of the tibia with bone loss as definite modality of treatment for damage control as well as for achieving union and lengthening, simultaneously, with the advantage of early union with attainment of limb length, simple surgical technique, minimal invasive, high patient compliance, easy wound management, lesser hospitalization and the lower rate of complications like infection, deformity or shortening.

A staged surgical treatment outcome of type 3 open tibial fractures

Aim. In these case series which are about type 3 open tibial fractures formed with three different high energy trauma etiologies in different parts of tibia. We aimed to assess our three-stage treatment approach and discuss final results of our elective surgery management with three different fixation methods. Patients and Methods. We assessed 19 patients with type 3 open tibial fractures between 2009 and 2012. Our treatment protocol consisted of three stages. Early intervention in operating room, which including vascular repairs or soft tissue closure, was done if necessary. Definitive surgery was performed using internal or external fixation in the first 15 days. Patients were followed up for at least one year. Last conditions of all our cases were evaluated according to modified Johner and Wruhs criteria. Results. Nine cases were type 3A, seven cases were type 3B, and three cases were type 3C in terms of fracture typing. All patients were followed up for at least one year and mean follow up time was 15 months. In terms of functional and clinical outcome, six cases were evaluated as excellent, eight cases as good, two cases as fair, and three cases as poor. Discussion. Staged treatment option in type 3 open tibial fractures seems to be a good method in reducing complication and achieving the best result. We think that definitive staged treatment protocol including internal fixation with plating or intramedullary nailing (IMN) of the fractures is a reliable method, especially to avoid complications as a result of external fixator and to provide patient rapport.

Distraction osteogenesis in the treatment of long bone defects of the lower limbs: effectiveness, complications and clinical results; a systematic review and meta-analysis

We carried out a systematic review of the literature to evaluate the evidence regarding the clinical results of the Ilizarov method in the treatment of long bone defects of the lower limbs. Only 37 reports (three non-randomised comparative studies, one prospective study and 33 case-series) met our inclusion criteria. Although several studies were unsatisfactory in terms of statistical heterogeneity, our analysis appears to show that the Ilizarov method of distraction osteogenesis significantly reduced the risk of deep infection in infected osseous lesions (risk ratio 0.14 (95% confidence interval (CI) 0.10 to 0.20), p < 0.001). However, there was a rate of re-fracture of 5% (95% CI 3 to 7), with a rate of neurovascular complications of 2.2% (95% CI 0.3 to 4) and an amputation rate of 2.9% (95% CI 1.4 to 4.4).The data was generally not statistically heterogeneous. Where tibial defects were > 8 cm, the risk of re-fracture increased (odds ratio 3.7 (95% CI 1.1 to 12.5), p = 0.036). The technique is demanding for patients, illustrated by the voluntary amputation rate of 1.6% (95% CI 0 to 3.1), which underlines the need for careful patient selection.

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.

Treatment of large posttraumatic tibial bone defects using the Ilizarov method: a subjective outcome assessment

BACKGROUND

The treatment of large posttraumatic tibial bone defects using the Ilizarov method was shown to be successful in several studies. These studies, however, typically focus on the radiological and functional outcome using objective parameters only. The aim of the present study was therefore to assess the objective and subjective outcome of a consecutive series of patients with large posttraumatic tibial bone defects using the Ilizarov method. Additionally, it was our goal to assess the physical and mental stress for the patients and their relatives during the long treatment period and the general health status at final follow-up.

METHODS

A consecutive series of 15 patients with posttraumatic tibial bone defects of >30 mm after sustaining open tibial fractures and failure of internal fixation was included. The objective outcome was assessed at final follow-up using Paley's criteria. For the assessment of the subjective outcome, all patients were asked to evaluate their satisfaction with the function of the lower leg, the cosmetic appearance and overall outcome as well. The physical and mental stress of the treatment for the patients and the nearest relative of patients were assessed at the time of frame removal using a custom-made questionnaire. The SF-36 was used to evaluate the general health status at final follow-up.

RESULTS

Solid bone union with stable soft tissue coverage and eradication of infection was achieved in all patients despite a high complication rate. The functional outcome at final follow-up was excellent or good in all patients. The patients' satisfaction with the overall outcome and the function of the lower extremity was high as well. The fear of amputation and complications was the major subjective burden for both the patients and their relatives. The long external fixation time is another relevant issue.

CONCLUSION

The Ilizarov method is a safe option for the treatment of large posttraumatic tibial bone defects after failure of internal fixation despite the high complication rate. It is essential to comment this to the patients and their relatives prior to the application of the frame increase their compliance with the long and emotionally draining treatment. The Ilizarov method is worth the effort only in patients, who will presumably comply with this treatment option and all of its drawbacks.

The use of external fixation combined with vacuum sealing drainage to treat open comminuted fractures of tibia in the Wenchuan earthquake

PURPOSE

The purpose of this study was to review the results of external fixation combined with vacuum sealing drainage (VSD) to treat patients who sustained tibial and fibular fractures in the Wenchuan earthquake.

METHODS

We retrospectively analysed 179 cases (of which 85 were classified as Gustilo grade III) of open comminuted fracture of the tibia and fibula caused by the Wenchuan earthquake. The patients were followed up for an average of 15 months; detailed records were kept on their function and recovery.

RESULTS

After caring for the life-threatening injuries; fractures were treated by external fixation, with VSD used on the surface or in the cavity of the wound after debridement. Antibiotics were administered on the basis of drug sensitivity test results. After the infection had been controlled and healthy granulation tissue had developed, the patients underwent secondary suture, free skin grafting, or skin flap transfer.

CONCLUSION

Good results can be achieved when external fixation combined with vacuum sealing drainage were used to treat open comminuted fractures of tibia and fibula in the Wenchuan earthquake.

Experience of using local flaps to cover open lower limb injuries at an Indian trauma center

Background:

Optimal care of open, high-velocity, lower limb injury requires surgical skills in debridement, skeletal stabilization, and in providing appropriate soft tissue cover. Timely coordination between orthopedic and plastic surgeons, though ideal, is often difficult. In our center, orthopedic surgeons undertake comprehensive treatment of open fractures including soft tissue cover. We reviewed the results of the local flaps of lower limb, done by orthopedic surgeons.

Materials and Methods:

We retrospectively reviewed the results of the lower limb flaps done between January 2005 and December 2006. All flaps done at and below the level of knee were included.

Results:

There were 105 patients with 120 flaps during this period. Two patients with two flaps were lost to follow-up. The average age was 32 years. Sixty-four patients had Type IIIB Gustilo and Anderson injuries. Thirty-nine patients had isolated soft tissue injuries. The indications for flaps were exposed bone, tendon, and joint in 45, 11, and 12, respectively, or a combination in 35 patients. The flaps done were 51 reverse sural artery, 35 gastrocnemius, 25 local fasciocutaneous, and seven foot flaps. The flap dimensions ranged from 2 × 2 to 30 × 15 cm. Ninety-three flaps (79%) healed primarily. Among 25 flaps (21%) with necrosis, 14 flaps required secondary split skin graft for healing, while the other nine flaps healed without further surgery.

Conclusion:

Appropriate soft tissue cover provided by orthopedic surgeons can help in providing independent, composite care of lower limb injuries.

Use of antibiotic cement-impregnated intramedullary nail in treatment of infected non-union of long bones

BACKGROUND

In cases with infected non-union, the primary step is eradication of the infection before attempting to achieve union. Release of antibiotics from the bone cement at a high concentration and its penetration to the surrounding tissues, including cortical and cancellous bone, prompted the use of antibiotic cement in the control of bone infection. The aim of this study is to summarize our experience with the use of antibiotic cement-impregnated intramedullary nail (ACIIN) for control of infection in cases of infected non-union with bone defect.

MATERIALS AND METHODS

We prospectively studied 25 cases of infected non-union (23 femora and two tibiae). There were 24 males and one female, with the mean age being 33 years (range, 21-58 years). All patients had high-velocity road traffic accidents except one patient who had farmland injury. There were seven closed fractures, one grade I compound, two grade II compound fractures, five grade IIIA compound fractures, and 10 grade IIIB compound fractures. ACIIN was used in all cases after adequate debridement. Patients were classified according to the amount of bone defect present after debridement: group 1 with bone defect <4 cm (n=13), group 2 with bone defect >/=4-<6 cm (n=7), and group 3 with bone defect >/=6 cm (n=5). Infection control was judged on the basis of discharge through the wound and laboratory parameters. All patients were followed-up, with an average follow-up time of 29 months (range, 18-40 months). The mean duration of retention of the intramedullary rod was 8 weeks (range, 6-12 weeks).

RESULTS

In group 1, all cases achieved infection control, with three patients achieving bone union without any need of secondary procedure. In group 2, all cases achieved infection control but the time taken was significantly longer than for group 1 (P value 0.0002). All the cases required a secondary procedure in the form of either interlocking intramedullary nailing with iliac crest bone graft or Ilizarov ring fixator application to achieve union. None of the cases in group 3 achieved infection control.

CONCLUSION

ACIINs are useful for infection control in cases of infected non-union with bone defect <6 cm. In cases with defect >6 cm, other alternatives should be used.