The management of infected nonunion of tibia with a segmental defect using simultaneous fixation with a monorail fixator and a locked plate

A LDH-Derived Metal Sulfide Nanosheet-Functionalized Bioactive Glass Scaffold for Vascularized Osteogenesis and Periprosthetic Infection Prevention/Treatment

Periprosthetic infection and prosthetic loosing stand out as prevalent yet formidable complications following orthopedic implant surgeries. Synchronously addressing the two complications is long-time challenging. Herein, a bioactive glass scaffold (BGS) functionalized with MgCuFe-layered double hydroxide (LDH)-derived sulfide nanosheets (BGS/MCFS) is developed for vascularized osteogenesis and periprosthetic infection prevention/treatment. Apart from the antibacterial cations inhibiting bacterial energy and material metabolism, the exceptional near-infrared-II (NIR-II) photothermal performance empowers BGS/MCFS to eliminate periprosthetic infections, outperforming previously reported functionalized BGS. The rough surface topography and the presence of multi-bioactive metal ions bestow BGS/MCFS with exceptional osteogenic and angiogenic properties, with 8.5-fold and 2.3-fold enhancement in bone mass and neovascularization compared with BGS. Transcriptome sequencing highlights the involvement of the TGF-β signaling pathway in these processes, while single-cell sequencing reveals a significant increase in osteoblasts and endothelial cells around BGS/MCFS compared to BGS.

Which surgical technique may yield the best results in large, infected, segmental non-unions of the tibial shaft? A scoping review

PURPOSE

Infected nonunion of the tibia with a large segmental bone defect is a complex and challenging condition for the patient and surgeon. This scoping review was conducted to identify existing evidence and knowledge gaps regarding this clinical scenario. Secondly, the objective of this study was to search for a valid recommendation on the optimal treatment.

METHODS

A comprehensive search was conducted in the bibliographic databases: PubMed, Embase.com, and Web of Science Core Collection. Studies reporting on bone transport techniques, the Masquelet technique, and vascularized fibular grafts in bone defects greater than 5 cm were included. Bone healing results and functional results were compared according to duration of nonunion, infection recurrence, bone consolidation, complication rate, external fixation time, and time until full weight-bearing.

RESULTS

Of the 2753 articles retrieved, 37 studies could be included on bone transport techniques (n = 23), the Masquelet technique (n = 7), and vascularized fibular grafts (n = 7). Respective bone union percentages were 94.3%, 89.5%, and 96.5%. The percentages of infection recurrence respectively were 1.6%, 14.4% and 7.0%, followed by respectively 1.58, 0.78, and 0.73 complications per patient.

CONCLUSION

Bone transport was found to be the most widely studied technique in the literature. Depending on the surgeon's expertise, vascularized fibular grafts may be held as a favourable alternative. This review indicates that further high-quality research on large bone defects ( ≥ 5 cm) in patients with infected tibial nonunions is necessary to gain more insight into the potentially beneficial results of vascularized fibular grafts and the Masquelet technique.

Management strategies for Docking Site refractures: a comparative analysis of 19 patient cases

AIMS

This study aimed to compare the clinical effectiveness of intramedullary nailing (IMN), percutaneous external plate fixation (PEPF), and re-applied external fixation (REF) in the treatment of refracture at the consolidated docking site following the removal of external fixation in patients with tibial defects who had previously undergone the Ilizarov bone transport technique.

METHODS

A retrospective review was performed on patients who received IMN, PEPF, or REF for refracture at the consolidated docking site subsequent to the removal of external fixation. A collection of data was made regarding the following parameters: age, gender, defect size, treatment methods, external fixation time (EFT), external fixation index (EFI), time of refracture (TOR) subsequent to fixation removal, and docking reunion time (DRT). Bone and functional outcomes were evaluated by the Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system and the Lower Extremity Functional Scale (LEFS) questionnaire.

RESULTS

The study included 14 males and 5 females with an average age of 38.1 ± 8.9 years (range, 26 to 55 years). Etiologies included post-traumatic osteomyelitis in 11 cases and post-traumatic bone loss in 8 cases. The median bone defect was 5.11 ± 0.87 cm (range, 3.8 to 6.8 cm). Following docking site refracture, 6 cases were treated with IMN, 8 with PEPF, and 5 with REF. All patients achieved both satisfactory bone union and functional outcomes, and there was no significant difference in preoperative baseline data or postoperative outcomes among the three groups.

CONCLUSION

IMN, PEPF, and REF were all demonstrated favorable postoperative bone and functional outcomes, suggesting their reliability as treatment options for managing docking site refracture following external fixation removal.

Trifocal versus Pentafocal bone transport in segmental tibial defects: a matched comparative analysis for posttraumatic osteomyelitis treatment

PURPOSE

The objective of this study was to evaluate and compare the effectiveness and clinical results of trifocal bone transport (TBT) and pentafocal bone transport (PBT) in treating distal tibial defects > 6 cm resulting from posttraumatic osteomyelitis, highlighting the potential advantages and challenges of each method.

METHODS

A retrospective assessment was conducted on an overall population of 46 eligible patients with distal tibial defects > 6 cm who received treatment between January 2015 and January 2019. Propensity score analysis was used to pair 10 patients who received TBT with 10 patients who received PBT. The outcomes assessed included demographic information, external fixation time (EFT), external fixation index (EFI), bone and functional outcomes assessed using the Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system, and postoperative complications evaluated using the Paley classification.

RESULTS

The demographic and baseline data of the two groups were comparable. Following radical debridement, the average tibial defect was 7.02 ± 0.68 cm. The mean EFT was significantly shorter in the PBT group (130.9 ± 16.0 days) compared to the TBT group (297.3 ± 14.3 days). Similarly, the EFI was lower in the PBT group (20.67 ± 2.75 days/cm) than in the TBT group (35.86 ± 3.69 days/cm). Both groups exhibited satisfactory postoperative bone and functional results. Pin site infection was the most common complication and the rates were significantly different between the groups, with the PBT group demonstrating a higher incidence.

CONCLUSION

Both TBT and PBT effectively treat posttraumatic tibial defects greater than 6 cm, with PBT offering more efficient bone regeneration. However, PBT is associated with a higher rate of pin site infections, highlighting the importance of careful management in these complex procedures and emphasizing the need for expert surgical execution and tailored treatment approaches in orthopedic reconstructive surgery.

Use of locked plates and mono-rail fixator in segmental tibial defects: A prospective interventional study

Introduction

The management of gap non-union is a major challenge to both the clinician and the patient as it is technically difficult, time-intensive, and physically arduous for the patient along with an unpredictable result. Gap non-union can arise from extrusion of bony fragment at the time of trauma or after debridement of unhealthy bone later. Moreover, Tibia because of its subcutaneous anatomy can easily undergo bone-loss and segmental defect. Among various methods available for managing gap non-union of tibia distraction osteogenesis using either ilizarov fixator or mono-rail fixator is the most popular one. Here we present functional and bony outcomes of combined use of locking plate and Limb Reconstruction System (LRS) in tibial gap non-union and assess whether it decreases fixator time and related complications.

Patients and methods

A prospective intervention study constituting 10 patients with Paley's type B1 tibial gap non-union over a period of 22months. In first stage, debridement was done; tibial locking plate and mono-rail fixator were applied along with corticomy at proximal tibia. Distraction was started 7-14 days later. At the end of distraction phase, fixator was removed and transported segment was fixed with screws with or without bone grafting at docking site. Patients were followed up every 6 weeks for radiological and clinical assessment. Functional assessment using Application for the Study and Application of the Method of Ilizarov (ASAMI) functional score, and Musculoskeletal Tumour Society (MSTS) functional score while bone outcome was assessed with ASAMI bone score. Quality of regenerate was assessed by Fernandez-Esteve grading. Detailed scoring was done at the time of index surgery, at the time of LRS removal and at the time of consolidation phase.

Results

All the 10 patients were male with mean age of 33 years. The mean defect size was 4.94 cm after debridement. Minimum duration of follow up was 30 weeks after removal of LRS. Mean duration between trauma and inclusion in the study was 17.7 months. The median external fixator index was 15.63 days/cm. The complication rate was 1.3/patient. According to Paley's classification, there were eleven problems and two obstacles, and no true complications. Both ASAMI bone score and functional scores were excellent in three and good in six patients. The median MSTS composite score was 76.66%.

Conclusion

The integrated fixation is an effective and satisfactory method enabling early external fixator removal with low rate of complication. So, this technique can be recommended for the management of segmental tibial defects.

Level of evidence

II.

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.

Complex Ankle Fusion With Circular Frames: Factors Influencing Outcomes, Complications, and Patient Satisfaction

BACKGROUND

Circular frames for ankle fusion are reserved for complex clinical scenarios. The literature is heterogenous and conflicting. We aim to present the indications and outcomes of this procedure.

METHODS

A retrospective cohort study based on a prospective database of frame surgeries performed in a tertiary institution. Inclusion criteria were patients undergoing complex ankle fusion with circular frames between 2005 and 2020, with a minimum 12-month follow-up. Data were collected on patient demographics, surgical indications, comorbidities, surgical procedures, external fixator time (EFT), length of stay (LOS), radiologic and clinical outcomes, and adverse events. Factors influencing radiologic and clinical outcomes were analyzed.

RESULTS

47 patients were included, with a median follow-up of 30 months (interquartile range [IQR] 20-40). The median age at time of surgery was 63.5 years (IQR 58-71). Patients had a median of 2 previous surgeries (IQR 1-3). The median LOS was 8.5 days, and median EFT was 237 days (IQR 166-280). Simultaneous limb lengthening (median 3.3 cm, IQR 1.9-3.5) was performed in 11 patients, increasing the EFT by a mean of 4 months. Primary and final union rates were 91.5% and 95.7%, respectively. At last follow-up, ASAMI bone scores were excellent or good in 87.2%. ASAMI functional scores were good in 79.1%. Patient satisfaction was 83.7%. In addition, 97.7% of patients experienced adverse events, most commonly pin-site related, with major complications in 30.2% and reoperations in 60.5%. There were 3 amputations. Adverse events were associated with increased age, poor soft tissue condition, severe deformities, subtalar fusions, peripheral neuropathy, peripheral vascular disease, and prolonged EFT.

CONCLUSION

Complex ankle fusion using circular frames can achieve good outcomes, however time in frame may be prolonged with a high rate of adverse events. Identified risk factors for poorer outcomes should be considered in patient counselling and prognostication.

LEVEL OF EVIDENCE

Level III, prognostic.

[Effectiveness of bone transport with a locking plate versus conventional bone transport for tibial defects]

Objective

To investigate the effectiveness difference between bone transport with a locking plate (BTLP) and conventional bone transport with Ilizarov/Orthofix fixators in treatment of tibial defect.

Methods

The clinical data of 60 patients with tibial fractures who met the selection criteria between January 2016 and September 2020 were retrospectively analyzed, and patients were treated with BTLP (BTLP group, n=20), Ilizarov fixator (Ilizarov group, n=23), or Orthofix fixator (Orthofix group, n=17) for bone transport. There was no significant difference in gender, age, cause of injury, time from injury to admission, length of bone defect, tibial fracture typing, and comorbidities between groups ( P>0.05). The osteotomy time, the retention time of external fixator, the external fixation index, and the occurrence of postoperative complications were recorded and compared between groups. The bone healing and functional recovery were evaluated by the Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria.

Results

All patients of 3 groups were followed up 13-45 months, with a mean of 20.4 months. The osteotomy time was significantly shorter in the BTLP group than in the Ilizarov group, and the retention time of external fixator and the external fixation index were significantly lower in the BTLP group than in the Ilizarov and Orthofix groups ( P<0.05). Twenty-two fractures healed in the Ilizarov group and 1 case of delayed healing; 16 fractures healed in the Orthofix group and 1 case of delayed healing; 18 fractures healed in the BTLP group and 2 cases of delayed healing. There was no significant difference between groups in fracture healing distribution ( P=0.824). After completing bone reconstruction treatment according to ASAMI criteria, the BTLP group had better bone healing than the Orthofix group and better function than the Ilizarov groups, showing significant differences ( P<0.05). Postoperative complications occurred in 4 cases (20%) in the BLTP group, 18 cases (78%) in the Ilizarov group, and 12 cases (70%) in the Orthofix group. The incidence of complication in the BTLP group was significantly lower than that in other groups ( P<0.05).

Conclusion

BTLP is safe and effective in the treatment of tibial defects. BTLP has apparent advantages over the conventional bone transport technique in osteotomy time, external fixation index, and lower limb functional recovery.

Bone Defects in Tibia Managed by the Bifocal vs. Trifocal Bone Transport Technique: A Retrospective Comparative Study

Background

The purpose of this study is to evaluate the clinical effectiveness and determine the differences, if any, between the trifocal bone transport (TFT) technique and the bifocal bone transport (BFT) technique in the reconstruction of long segmental tibial bone defects caused by infection using a monolateral rail external fixator.

Methods

A total of 53 consecutive patients with long segmental tibial bone defects caused by infection and treated by monolateral rail external fixator in our department were retrospectively collected and analyzed from the period January 2013 to April 2019, including 39 males and 14 females with an average age of 38.8 ± 12.4 years (range 19–65 years). Out of these, 32 patients were treated by the BFT technique, and the remaining 21 patients were managed by the TFT technique. The demographic data, operation duration (OD), docking time (DT), external fixation time (EFT), and external fixation index (EFI) were documented and analyzed. Difficulties that occur during the treatment were classified according to Paley. The clinical outcomes were evaluated by following the Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria at the last clinical visit.

Results

All patients achieved an infection-free union finally, and there was no significant difference between the two groups in terms of demographic data and both ASAMI bone and functional scores (p > 0.05). The mean defect size and OD in TFT (9.4 ± 1.5 cm, 161.9 ± 8.9 min) were larger than that in BFT (7.8 ± 1.8 cm, 122.5 ± 11.2 min) (p < 0.05). The mean DT, EFT, and EFI in TFT (65.9 ± 10.8 days, 328.0 ± 57.2 days, 34.8 ± 2.1 days/cm) were all less than those in BFT (96.8 ± 22.6 days, 474.5 ± 103.2 days, 60.8 ± 1.9 days/cm) (p < 0.05). Difficulties and complications were more prevalent in the BFT group than in the TFT group (p < 0.05).

Conclusion

Both the trifocal and BFT techniques achieve satisfactory clinical outcomes in the reconstruction of long segmental tibial bone defects caused by infection using a monolateral rail external fixator. The TFT technique can significantly decrease the DT, EFT, EFI, difficulties, and complications compared with the BFT technique.

Evaluation of complications associated with bifocal bone transport as treatment for either proximal, intermediate or distal femoral defects caused by infection: outcome analysis of 76 patients

BACKGROUND

The purpose of this study was to evaluate the outcomes of bifocal bone transport in the treatment of femoral bone defects caused by infections.

METHODS

Clinical and radiographic data of patients with infected femoral nonunion treated by the bifocal bone transport at our hospital were analyzed retrospectively, from January 2008 to December 2019. Depending on the location of bone defects, the patients were divided into three groups (proximal, intermediate, and distal). The Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria was applied to assess the bone and functional outcomes. Postoperative complications of three groups were documented and compared.

RESULTS

Seventy-six cases of infected femoral bone defects (31 cases of proximal, 19 cases of intermediate, and 26 cases of distal) were managed by bifocal bone transport successfully with a mean follow-up time of 30.8 months (range, 23 to 41 months). There were 58 men (76.3%) and 18 women (23.6%), with a mean age of 38.8 years (range, 23 to 60 years). The bone union was received in 76 cases with a mean of 6.9 months (range, 5 to 8 months). Pin tract infection was observed in twenty-nine cases (38.1%), 7 cases (9.2%) of muscle contractures, 3 cases (7.9%) of joint stiffness, 13 cases (17.1%) of axial deviation, 2 cases (2.6%) of delayed union, one case (1.3%) of nonunion, and none (0%) of transport gap re-fracture. One patient (1.3%) was scheduled for knee arthroplasty when bone transport treatment ended.

CONCLUSIONS

Bone transport using an external rail fixator was a practical method to treat the femoral bone defects, since the satisfactory rate of bone union and limb function recovery. Complications of distal femoral bone transport were more severe than the proximal and intermedia, but the rate of complication was the least of the three groups. Soft-tissue-related complications were more likely to occur in the intermediate bone transport.

Reconstruction of massive tibial defect caused by osteomyelitis using induced membrane followed by trifocal bone transport technique: a retrospective study and our experience

OBJECTIVE

To evaluate clinical outcomes of the application of induced membrane followed by trifocal bone transport technique in the treatment of massive tibial defect caused by osteomyelitis.

METHOD

A total of 18 eligible patients with tibial defect > 6 cm caused by osteomyelitis who were admitted to our institution from January 2010 to January 2016 and treated by induced membrane followed by trifocal bone transport technique. There were 12 male and 6 females with an average age of 40.4 years old. A detailed demographic data (age, sex, etiology, previous operation time, defect size and location, interval from Masquelet technique to trifocal bone transport technique, external fixation index (EFI), duration of regenerate consolidation and docking union) were collected, bone and functional outcomes were evaluated by Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system. Complications during and in the period of follow up were recorded and evaluated by Paley classification at a minimum follow-up of 2 years.

RESULTS

The etiology include posttraumatic osteomyelitis in 13 cases and primary osteomyelitis in 5 cases. An average of previous operation time was 3.4 times. Mean tibial defect after radical debridement was 6.8 cm. An average interval duration from formation of induced membrane to trifocal bone transport was 4.8 weeks. An average of EFI was 37.1 days/cm, the duration of regenerate consolidation and docking union were 124.7 days and 186.4 days, respectively. An average time of follow-up after removal of external fixator was 28.5 month without recurrence of osteomyelitis. The bony outcome was excellent in 6 cases, good in 8 cases, fair in 3 cases and poor in 1 case, and functional outcome was excellent in 4 cases, good in 10 cases, fair in 2 cases and poor in 2 cases. The most common complication was pin tract infection which occurred in 15 cases and there were no major complications such as nerve or vascular injury.

CONCLUSION

Massive tibial defect caused by osteomyelitis can be successfully treated first stage using induced membrane followed by second stage using trifocal bone transport technique, which is an effective method in terms of radical elimination of osteomyelitis with expected clinical outcomes.

Matched Comparison of Bone Transport Using External Fixator Over a Nail Versus External Fixator Over a Plate for Segmental Tibial Bone Defects

OBJECTIVE

To compare the outcomes and complications of bone transport over a nail (BTON) with those of bone transport over a plate (BTOP) for segmental tibial bone defects.

DESIGN

Retrospective matched study design.

SETTING

A major metropolitan tertiary referral trauma center.

PATIENTS

Thirty-six patients with segmental tibial bone defects of >4 cm were included in this study.

INTERVENTION

Either BTON or BTOP was performed on 18 patients.

MAIN OUTCOME MEASUREMENTS

We compared the healing of the distraction process and of the docking site between the techniques. Distraction parameters including external fixator (EF) time, external fixation index, and healing index were compared. Bone and functional results were compared according to the Paley-Maar classification. Complications associated with each procedure were compared.

RESULTS

Both BTON and BTOP achieved similar rates of primary union (83% vs. 89%) at the distraction or docking site. Significantly less time wearing an EF was needed for BTOP than for BTON (2.8 vs. 5.4 months; P < 0.01). The external fixation index was significantly lower for BTOP than for BTON (0.45 vs. 0.94 mo/cm; P < 0.01), whereas the healing indexes were similar. The final outcomes and complication incidences were not significantly different.

CONCLUSIONS

The EF time was significantly shorter for BTOP than for BTON; however, the final outcomes were similar. Therefore, BTOP could be considered an attractive option for bone transport in patients with segmental tibial defects.

LEVEL OF EVIDENCE

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

Ilizarov bone transport using an intramedullary cable transportation system in the treatment of tibial bone defects

INTRODUCTION

Segmental tibia defects remain challenging for orthopedic surgeons to treat. The aim of this study was to demonstrate bone-related and functional outcomes after treatment of complex tibial bone defects using Ilizarov bone transport with a modified intramedullary cable transportation system (CTS).

PATIENTS AND METHODS

We conducted a single-center, retrospective study including all 42 patients treated for tibial bone loss via Ilizarov bone transport with CTS between 2005 and 2018. Bone-related and functional results were evaluated according to the Association for the Study and Application of Methods of Ilizarov (ASAMI) scoring system. Complication and failure rates were determined by the patients' medical files.

RESULTS

Patients had a mean age of 45.5 ± 15.1 years. The mean bone defect size was 7.7 ± 3.4 cm, the average nonunion scoring system (NUSS) score was 59 ± 9.5 points, and the mean follow-up was 40.8 ± 24.4 months (range, 13-139 months). Complete bone and soft tissue healing occurred in 32/42 patients (76.2%). These patients had excellent (10), good (17), fair (2), and poor (3) results based on the ASAMI functional score. Regarding bone stock, 19 patients had excellent, 10 good, and 3 fair results. In total, 37 minor complications and 62 major complications occurred during the study. In 7 patients, bone and soft tissue healing occurred after CTS failure with either an induced membrane technique or classic bone transport; 3 patients underwent lower leg amputation. Patients with treatment failure were significantly older (57.6 vs. 41.8 years; p = 0.003). Charlson score and treatment failure had a positive correlation (Spearman's rho 0.43; p = 0.004).

CONCLUSION

Bone transport using both intramedullary CTS and Ilizarov ring fixation is viable for treating patients with bone loss of the tibia and complex infection or soft tissue conditions. However, a high number of complications and surgical revisions are associated with the treatment of this severe clinical entity and should be taken into account.

Treatment of segmental tibial defects by bone transport with circular external fixation and a locking plate

Objective

To evaluate the effectiveness of bone transport involving circular external fixation and locking plate application for the treatment of segmental tibial defects.

Methods

A retrospective review of 12 patients with segmental tibial defects who underwent bone transport with circular external fixation and locking plate application. We evaluated external fixation time, external fixation index, time to achieve union, and complications. Clinical results were assessed using the Association for the Study and Application of the Methods of Ilizarov (ASAMI) score. Generic health-related outcome was assessed using the 36-Item Short-Form Health Survey questionnaire (SF-36).

Results

The mean follow-up was 25.8 months, and the mean defect size was 6.7 cm. All of the patients achieved union at the distraction callus and docking site. The average external fixation time was 299.5 days. The mean external fixation index was 16.5 days/cm, and the mean healing index was 44.9 days/cm. The functional outcomes were excellent in eight cases and good in four. The average SF-36 score was 92.

Conclusion

Bone transport with external fixation and locking plate application may be a promising method for the treatment of segmental tibial defects.

Bifocal or Trifocal (Double-Level) Bone Transport Using Unilateral Rail System in the Treatment of Large Tibial Defects Caused by Infection: A Retrospective Study

Objective

The aim of this study is to assess the clinical results of bifocal or trifocal bone transport using unilateral rail system in the treatment of large tibial defects caused by infection.

Methods

There were a total of 37 eligible patients with an average age of 40.11 ± 10.32 years (range, 18–57 years; 28 males and nine females) with large tibial defects due to infection who were admitted to our hospital from June 2006 to June 2016. Among the patients, 21 underwent bifocal bone transport (BF group), and the remaining 16 were treated with trifocal bone transport (TF group). The demographic data (age, sex, interval duration before bone transport, previous operation time), intraoperative outcomes (size and location of the defect, size of soft tissue defect), postoperative variables (lengthening speed, external fixation index, duration of regenerate consolidation and docking union), postoperative bone and functional outcomes evaluated by Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system, and postoperative complications evaluated by Paley classification (muscle contraction, axial deviation, delayed consolidation, pin problems, repeated fracture, joint stiffness and others) of the two groups were recorded and compared at a minimum follow‐up of 24 months.

Results

The mean duration of follow‐up after removal of fixator was 29.49 ± 4.34 months (range, 24–38 months). There was no statistically significant difference in the demographic data, intraoperative outcomes including size and location of the defect, size of soft tissue defect, as well as postoperative complications. However, postoperative functional result in the TF group were superior to those in the BF group at a minimum follow‐up of 24 months, and lengthening speed, external fixation index (EFI), duration of regenerate consolidation and docking union were significantly reduced in the TF group when compared with the BF group.

Conclusions

Treatment of large tibial defects caused by infection with trifocal bone transport using unilateral rail system could significantly improve postoperative functional recovery and reduce duration of regenerate consolidation and docking union. The present study provides novel insight for the treatment of large tibial defects caused by infection.

Prospective randomized comparison of quality of regenerate in distraction osteogenesis of ring versus monolateral fixator in patients with infected nonunion of the tibia using digital radiographs and CT

Aims

In this randomized study, we aimed to compare quality of regenerate in monolateral versus circular frame fixation in 30 patients with infected nonunion of tibia.

Patients and Methods

Both groups were comparable in demographic and injury characteristics. A phantom (aluminium step wedge of increasing thickness) was designed to compare the density of regenerate on radiographs. A CT scan was performed at three and six months postoperatively to assess regenerate density. A total of 30 patients (29 male, one female; mean age 32.54 years (18 to 60)) with an infected nonunion of a tibial fracture presenting to our tertiary institute between June 2011 and April 2016 were included in the study.

Results

The regenerate mineralization on radiographs was comparable in both groups at two, four, six, and ten months’ follow-up but the rail fixator group had statistically significant higher grades of mineralization when compared with the circular frame group at eight and 12 months’ follow-up. The regenerate mineralization was also higher in the rail fixator group than in the circular frame group on CT at three and six months, although this difference was not statistically significant.

Conclusion

Overall, the regenerate mineralization was higher in the monolateral than the circular frame group. A monolateral fixator may be preferred in patients with infected nonunion of the tibia with bone defects up to 7 cm. Cite this article: Bone Joint J 2019;101-B:1416–1422.

[Application of bone transport with unilateral external fixator combined with locked plate internal fixation in treatment of infected tibial nonunion]

Objective

To summarize the effectiveness of bone transport with unilateral external fixator combined with locked plate internal fixation in treatment of infected tibial nonunion.

Methods

Between January 2010 and December 2014, 23 patients with infected tibial nonunion were treated with bone transport with unilateral external fixator combined with locked plate internal fixation. There were 19 males and 4 females with an average age of 37.8 years (range, 19-54 years). The mean length of the bone defect was 6.5 cm (range, 5.2-8.1 cm). The number of previous operations ranged from 2 to 4 times, with an average of 2.5 times. The time from injury to this treatment was 7-23 months, with an average of 11.8 months. The time of bone transport, time of the external fixation, fracture healing time, external fixation index, healing index, and complication were recorded; and the Association for the Study and Application of the Methods of Ilizarov (ASAMI) bone healing and function scores were used to evaluate the effectiveness.

Results

All patients were followed up 3-6 years with an average of 4.8 years. Wounds and bone defects healed in all patients. No complication such as infection recurrence, nonunion, re-fracture, malunion, iatrogenic nerve paralysis, or stiffness of knee and ankle joints occurred. Five patients had needle infections which were treated by local care and no deep infection occurred. The time of bone transport was 65-120 days (mean, 75.6 days); the time of the external fixation was 75-145 days (mean, 97.8 days); the fracture healing time was 4-17 months (mean, 8.7 months); the external fixation index was 18-28 days/cm (mean, 22.4 days/cm); and the healing index was 31-52 days/cm (mean, 40.2 days/cm). At last follow-up, according to ASAMI criteria, the result of bone healing was excellent in 15 cases and good in 8 cases, and the result of function was excellent in 18 cases and good in 5 cases, all with the excellent and good rate of 100%.

Conclusion

For infected tibial nonunion, bone transport with unilateral external fixator combined with locked plate internal fixation can reduce the time of external fixation and related complications, with a satisfactory effectiveness.

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

Background

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

Methods

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

Results

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

Conclusions

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