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Wang X, Jia C, Wu H, Luo F, Hou T, Li G, Lin S, Xie Z. Activated allograft combined with induced menbrane technique for the reconstruction of infected segmental bone defects. Sci Rep 2024; 14:12587. [PMID: 38821992 PMCID: PMC11143316 DOI: 10.1038/s41598-024-63202-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 05/27/2024] [Indexed: 06/02/2024] Open
Abstract
This study was desinged to evaluate the efficacy and safety of activated allograft combined with the induced membrane technique for reconstruction of infected segment bone defects of lower limbs. A retrospective analysis was conducted on 19 patients from May 2015 to February 2017. After debridements, the bone defects were filled with antibiotic bone cement to form the induced membrane. Autologous mesenchymal stem cells were seeded onto allografts to construct activated allograft, which was implanted into the induced membrane after infection was controlled. The clinical efficacy and complications were observed. 19 patients with 20 infected segment bone defect were evaluated. The average deficit size was 11.08 (4-17) cm in length. After a mean follow-up of 71.84 (61-82) months, bone union was achieved in 16 patients (17 sites), resulting in a final union rate of 84.21% (16/19 patients). The average bone union time was 10.18 (5-28) months. There were 2 patients with recurrence of infection, 3 patients with graft absorption, and 1 patient with malunion due to implant breakage. There were no graft-related complications. This study provides clinical significance for the treatment of patients with insufficient autologous bone.
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Affiliation(s)
- Xiaohua Wang
- Department of Orthopaedics, First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, People's Republic of China
| | - Chao Jia
- Department of Orthopaedics, First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, People's Republic of China
| | - Hongri Wu
- Department of Orthopaedics, First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, People's Republic of China
- Department of Orthopaedics, Navy 905 Hospital, Navy Medical University, Shanghai, People's Republic of China
| | - Fei Luo
- Department of Orthopaedics, First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, People's Republic of China
| | - Tianyong Hou
- Department of Orthopaedics, First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, People's Republic of China
| | - Gang Li
- Stem Cells and Regenerative Medicine Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, People's Republic of China
- Musculoskeletal Research Laboratory, Department of Orthopaedics & Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, People's Republic of China
| | - Sien Lin
- Stem Cells and Regenerative Medicine Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, People's Republic of China.
- Musculoskeletal Research Laboratory, Department of Orthopaedics & Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, People's Republic of China.
| | - Zhao Xie
- Department of Orthopaedics, First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, People's Republic of China.
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Shen J, Wei Z, Wu H, Wang X, Wang S, Wang G, Luo F, Xie Z. The induced membrane technique for the management of infected segmental bone defects. Bone Joint J 2024; 106-B:613-622. [PMID: 38821512 DOI: 10.1302/0301-620x.106b6.bjj-2023-1443.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2024]
Abstract
Aims The aim of the present study was to assess the outcomes of the induced membrane technique (IMT) for the management of infected segmental bone defects, and to analyze predictive factors associated with unfavourable outcomes. Methods Between May 2012 and December 2020, 203 patients with infected segmental bone defects treated with the IMT were enrolled. The digital medical records of these patients were retrospectively analyzed. Factors associated with unfavourable outcomes were identified through logistic regression analysis. Results Among the 203 enrolled patients, infection recurred in 27 patients (13.3%) after bone grafting. The union rate was 75.9% (154 patients) after second-stage surgery without additional procedures, and final union was achieved in 173 patients (85.2%) after second-stage surgery with or without additional procedures. The mean healing time was 9.3 months (3 to 37). Multivariate logistic regression analysis of 203 patients showed that the number (≥ two) of debridements (first stage) was an independent risk factor for infection recurrence and nonunion. Larger defect sizes were associated with higher odds of nonunion. After excluding 27 patients with infection recurrence, multivariate analysis of the remaining 176 patients suggested that intramedullary nail plus plate internal fixation, smoking, and an allograft-to-autograft ratio exceeding 1:3 adversely affected healing time. Conclusion The IMT is an effective method to achieve infection eradication and union in the management of infected segmental bone defects. Our study identified several risk factors associated with unfavourable outcomes. Some of these factors are modifiable, and the risk of adverse outcomes can be reduced by adopting targeted interventions or strategies. Surgeons can fully inform patients with non-modifiable risk factors preoperatively, and may even use other methods for bone defect reconstruction.
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Affiliation(s)
- Jie Shen
- Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
- Trauma Medical Centre, Department of Orthopaedic Surgery, Orthopaedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Zhiyuan Wei
- Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Hongri Wu
- Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
- Department of Orthopaedics, Navy 905 Hospital, Navy Medical University, Shanghai, China
| | - Xiaohua Wang
- Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Shulin Wang
- Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Guanglin Wang
- Trauma Medical Centre, Department of Orthopaedic Surgery, Orthopaedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Fei Luo
- Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Zhao Xie
- Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
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Wakefield SM, Papakostidis C, Giannoudis VP, Mandía-Martínez A, Giannoudis PV. Distraction osteogenesis versus induced membrane technique for infected tibial non-unions with segmental bone loss: a systematic review of the literature and meta-analysis of available studies. Eur J Trauma Emerg Surg 2024; 50:705-721. [PMID: 37921889 PMCID: PMC11249469 DOI: 10.1007/s00068-023-02375-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 09/29/2023] [Indexed: 11/05/2023]
Abstract
INTRODUCTION Infected tibial non-unions with associated bone loss can be challenging to manage. At present, the two main methods utilized in the management of these fractures include the Ilizarov technique of Distraction Osteogenesis (DO) using external fixator devices, or alternatively, the Induced Membrane Technique (IMT), devised by Masquelet. As there is a paucity of data directly comparing the outcomes of these techniques, there is no universal agreement on which strategy a surgeon should choose to use. AIMS This systematic review and meta-analysis aimed to summarize the outcomes of both DO and IMT, in terms of primary outcomes (bone union and infection elimination), and secondary outcomes (complication rates and functional outcomes). METHODS A PRISMA strategy was used. Medline, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar library databases were interrogated using pre-defined MeSH terms and Boolean operators. Quality of evidence was evaluated using OCEBM and GRADE systems. RESULTS Thirty-two studies with 1136 subjects met the inclusion criteria. With respect to the primary outcomes of interest, union was observed in 94.6% (DO method) and 88.0% (IMT method); this difference, however, was not significant between the two techniques (p = 0.45). In addition, infection elimination rates were also higher in the Ilizarov DO group when compared to Masquelet (Mq) IMT (93.0% vs 80.4% respectively). Again, no significant difference was observed (p = 0.06). For all secondary outcomes assessed (unplanned re-operations, re-fracture rates amputation rate), no statistically significant differences were documented between the treatment options. CONCLUSION This study demonstrated that there is no clinical difference in outcomes for patients treated with Ilizarov DO versus Mq IMT techniques. The evidence base at present is relatively sparse and, therefore, we would recommend for further Level I studies to be conducted, to make more meaningful conclusions.
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Affiliation(s)
- Sophia M Wakefield
- Academic Department of Trauma and Orthopaedics Surgery, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon Wing, Floor D, Great George Street, Leeds, LS1 3EX, UK
| | - Costas Papakostidis
- Academic Department of Trauma and Orthopaedics Surgery, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon Wing, Floor D, Great George Street, Leeds, LS1 3EX, UK
| | - Vasileios P Giannoudis
- Academic Department of Trauma and Orthopaedics Surgery, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon Wing, Floor D, Great George Street, Leeds, LS1 3EX, UK
| | - Alfonso Mandía-Martínez
- Academic Department of Trauma and Orthopaedics Surgery, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon Wing, Floor D, Great George Street, Leeds, LS1 3EX, UK
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics Surgery, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon Wing, Floor D, Great George Street, Leeds, LS1 3EX, UK.
- NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, UK.
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Bas A, Balci HI, Kocaoglu M, Demirel M, Kochai A. Augmentation with a non-vascularized autologous fibular graft for the management of Cierny-Mader type IV chronic femoral osteomyelitis: a salvage procedure. INTERNATIONAL ORTHOPAEDICS 2024; 48:439-447. [PMID: 37696991 DOI: 10.1007/s00264-023-05954-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 08/22/2023] [Indexed: 09/13/2023]
Abstract
PURPOSE The study aimed to evaluate preliminary clinical and radiographic results of patients with Cierny-Mader type IV chronic femoral osteomyelitis and augmented with a non-vascularized fibular autograft as a salvage procedure because of the poorly regenerated new bone after bone transport over an intramedullary nail (BTON). METHODS Patients diagnosed with CM type IV chronic femoral bone infection and treated with BTON procedure between 2003 and 2020 were retrospectively reviewed. Seven patients were included in the study whose distraction gap was poorly regenerated and then augmented with a non-vascularized fibular autograft. A three-stage treatment was administered. First, the infection was eradicated. Second, BTON was performed. Third, the poorly regenerated distraction gap was augmented with a fibular autograft before removing the external fixator (EF). Clinical and radiological results were evaluated based on the criteria described by Paley-Maar and Li classification. RESULTS The mean patient age was 52 years. The mean treatment time was 24.8 months, with a mean femoral lengthening of 12.6 cm. The mean EF and bone healing indexes were 0.57 months/cm and 0.8 months/cm, respectively. The mean length of the fibular graft was 13 cm. The bone healing of new bones was achieved in all patients with good quality after grafting. Functional scores were excellent in four patients. No patients experienced any sequelae. CONCLUSIONS Non-vascularized fibular autograft augmentation may be an effective salvage procedure for poorly regenerated new bone after BTON to manage chronic femoral bone infection.
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Affiliation(s)
- Ali Bas
- Department of Orthopaedics and Traumatology, Koç University Hospital, Maltepe Mahallesi Topkapı Cd. No:4, 34010 Zeytinburnu, İstanbul, Turkey
| | - Halil Ibrahim Balci
- Department of Orthopaedics and Traumatology, İstanbul University, İstanbul Faculty of Medicine, Turgut Özal Millet Cd. 34093, Çapa, Fatih, İstanbul, Turkey
| | - Mehmet Kocaoglu
- Department of Orthopaedics and Traumatology, İstanbul University, İstanbul Faculty of Medicine, Turgut Özal Millet Cd. 34093, Çapa, Fatih, İstanbul, Turkey
| | - Mehmet Demirel
- Department of Orthopaedics and Traumatology, İstanbul University, İstanbul Faculty of Medicine, Turgut Özal Millet Cd. 34093, Çapa, Fatih, İstanbul, Turkey.
| | - Alauddin Kochai
- Department of Orthopaedics and Traumatology, Sakarya University Faculty of Medicine, Korucuk Mahallesi Konuralp Bulvarı No:81/1, 54290, Adapazarı, Sakarya, Turkey
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Liodakis E, Giannoudis VP, Harwood PJ, Giannoudis PV. Docking site interventions following bone transport using external fixation: a systematic review of the literature. INTERNATIONAL ORTHOPAEDICS 2024; 48:365-388. [PMID: 38148379 PMCID: PMC10799803 DOI: 10.1007/s00264-023-06062-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 12/07/2023] [Indexed: 12/28/2023]
Abstract
PURPOSE Although bone transport is a well-recognised technique to address segmental bone defects, optimal management of docking sites is not absolutely determined. Some surgeons routinely intervene in all cases, and others prefer to observe and intervene only if spontaneous union does not occur. Primary aim of the study was to compare rates of docking site union between patients who underwent routine docking site intervention and those who did not. METHODS A systematic literature review using the keywords "bone transport", "docking", "tibia", and "femur" was performed in PubMed using PRISMA guidelines. Studies published in English from January 2000 to August 2022 were included and assessed independently by two reviewers. Pooled analysis was undertaken dividing patients into two groups: those managed by routine intervention and those initially observed. RESULTS Twenty-three clinical studies met the eligibility criteria for pooled analysis, including 1153 patients, 407 in the routine intervention and 746 in the observed group. The rate of union after initial treatment was 90% in the routine intervention group and 66% in the observed group (p < 0.0001). Overall union rates at the end of treatment were similar at 99% in both groups. Patients in the observed group required an average of 2.2 procedures to achieve union overall compared with 3.8 in the routine intervention group. Time in frame was similar between groups. CONCLUSION Based on the current literature, routine docking site interventions cannot be recommended, since this may lead to unnecessary interventions in two thirds of patients. Timely selective intervention in those at high risk or after a defined period of observation would appear to be a logical approach.
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Affiliation(s)
- E Liodakis
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - V P Giannoudis
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Leeds, UK
| | - P J Harwood
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Leeds, UK
| | - P V Giannoudis
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Leeds, UK
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Wang L, Lu S, Luo W, Wang G, Zhu Z, Liu Y, Gao H, Fu C, Ren J, Zhang Y, Zhang Y. Efficacy comparison of antibiotic bone cement-coated implants and external fixations for treating infected bone defects. INTERNATIONAL ORTHOPAEDICS 2023; 47:1171-1179. [PMID: 36862164 PMCID: PMC10079742 DOI: 10.1007/s00264-023-05727-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/30/2023] [Indexed: 03/03/2023]
Abstract
PURPOSE This study aimed to investigate the clinical efficacy of antibiotic bone cement-coated implants compared with external fixations for treating infected bone defects. METHODS We retrospectively enrolled 119 patients with infected bone defects in our hospital from January 2010 to June 2021, of which 56 were treated with antibiotic bone cement-coated implants and 63 were with external fixation. RESULTS The pre-operative and post-operative haematological indexes were tested to assess the infection control; the post-operative CRP level in the internal fixation group was lower than that in the external fixation group. No statistical significance was found in the rate of infection recurrence, loosening and rupture of the fixation, and amputation between the two groups. Twelve patients in the external fixation group had pin tract infection. In the evaluation of the Paley score scale, bone healing aspect revealed no significant difference between the two groups, while in the limb function aspect, antibiotic cement-coated implant group showed a much better score than the external fixation group (P = 0.002). The anxiety evaluation scale result also showed lower score in the antibiotic cement implant group (P < 0.001). CONCLUSIONS Compared with external fixation, antibiotic bone cement-coated implant had the same effect on controlling infection and was more effective in recovering limb function and mental health in the first-stage treatment of infected bone defects after debridement.
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Affiliation(s)
- Linhu Wang
- Department of Orthopaedics, Second Affiliated Hospital, Air Force Medical University, 1 Xinsi Rd, Xi’an, 710038 Shaanxi China
| | - Shuaikun Lu
- Department of Orthopaedics, Second Affiliated Hospital, Air Force Medical University, 1 Xinsi Rd, Xi’an, 710038 Shaanxi China
| | - Wen Luo
- Department of Ultrasound, Xijing Hospital, Air Force Medical University, 169 Changlexi Rd, Xi’an, 710032 Shaanxi China
| | - Guoliang Wang
- Department of Orthopaedics, Second Affiliated Hospital, Air Force Medical University, 1 Xinsi Rd, Xi’an, 710038 Shaanxi China
| | - Zhenfeng Zhu
- Department of Orthopaedics, Second Affiliated Hospital, Air Force Medical University, 1 Xinsi Rd, Xi’an, 710038 Shaanxi China
| | - Yunyan Liu
- Department of Orthopaedics, Second Affiliated Hospital, Air Force Medical University, 1 Xinsi Rd, Xi’an, 710038 Shaanxi China
| | - Hao Gao
- Department of Orthopaedics, Second Affiliated Hospital, Air Force Medical University, 1 Xinsi Rd, Xi’an, 710038 Shaanxi China
| | - Congxiao Fu
- Department of Orthopaedics, Second Affiliated Hospital, Air Force Medical University, 1 Xinsi Rd, Xi’an, 710038 Shaanxi China
| | - Jun Ren
- Department of Orthopaedics, Second Affiliated Hospital, Air Force Medical University, 1 Xinsi Rd, Xi’an, 710038 Shaanxi China
| | - Yunfei Zhang
- Department of Orthopaedics, Second Affiliated Hospital, Air Force Medical University, 1 Xinsi Rd, Xi’an, 710038 Shaanxi China
| | - Yong Zhang
- Department of Orthopaedics, Second Affiliated Hospital, Air Force Medical University, 1 Xinsi Rd, Xi’an, 710038 Shaanxi China
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Papakostidis C, Giannoudis PV. Reconstruction of infected long bone defects: Issues and Challenges. Injury 2023; 54:807-810. [PMID: 36828614 DOI: 10.1016/j.injury.2023.01.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Affiliation(s)
- Costas Papakostidis
- Consultant Orthopaedic and Trauma Surgeon, Assistant Director of the Orthopaedic Department, Limassol General Hospital, Limassol, Cyprus.
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, UK; NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, United Kingdom
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Zhang H, Zhao X, Yang X, Zhang X, Chen X, Zhou T, Xu X, Song M, Luo S, Xie Z, Xu Y, Shi J. Comparison of internal and external fixation after debridement in the Masquelet technique for Cierny-Mader type IV tibial post-traumatic osteomyelitis. Injury 2023; 54:422-428. [PMID: 36414499 DOI: 10.1016/j.injury.2022.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/07/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To compare the effect of internal fixation vs. external fixation after debridement in stage I of the Masquelet technique for Cierny-Mader (C-M) type Ⅳ chronic post-traumatic tibial osteomyelitis. METHODS This retrospective observational study included patients with tibial osteomyelitis who underwent staged treatment with the Masquelet technique between January 2016 and June 2020 at the 920 Hospital of Joint Logistic Support Force of the PLA. The patients were grouped according to the fixation they received after stage I. Infection recurrence, time to radiological bone healing and full weight-bearing, self-rating anxiety scale (SAS) score, Hospital for Special Surgery (HSS) Knee Score, and American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score were compared. RESULTS Sixty-three patients were included (50 males and 13 females). There were 40 and 23 patients with internal and external fixation, respectively. There were no significant differences between the two groups regarding the preoperative and intraoperative data (all P>0.05). After stage I operation, the infection control rates were 85.0% and 82.6% in the internal and external fixation groups (P=0.803), and these rates were 92.5% and 95.7% after stage II (P=0.621). There were no differences in the SAS scores (P=0.278), time to radiological union (P=0.795), time to full weight-bearing (P=0.725), AOFAS scores (P=0.302), HSS scores (P=0.085), and complication rates (P=0.593). There were 27 times complications in 19 patients, with an incidence of 42.9%, without significant differences between groups. CONCLUSION There were no differences between the two fixation methods after debridement in stage I of the Masquelet technique for C-M type Ⅳ chronic post-traumatic tibia osteomyelitis.
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Affiliation(s)
- Hu Zhang
- Department of Orthopaedics, 920 Hospital of the Joint Logistics Support Force of the PLA, 212 Daguan Road, Kunming 650032, China
| | - Xingang Zhao
- Department of Orthopaedics, Taian Municipal Hospital, 1 Yincai Street, Taian 271000, China
| | - Xiaoyong Yang
- Department of Orthopaedics, 920 Hospital of the Joint Logistics Support Force of the PLA, 212 Daguan Road, Kunming 650032, China
| | - Xijiao Zhang
- Department of Orthopaedics, 920 Hospital of the Joint Logistics Support Force of the PLA, 212 Daguan Road, Kunming 650032, China
| | - Xingyu Chen
- Department of Orthopaedics, 920 Hospital of the Joint Logistics Support Force of the PLA, 212 Daguan Road, Kunming 650032, China
| | - Tianhua Zhou
- Department of Orthopaedics, 920 Hospital of the Joint Logistics Support Force of the PLA, 212 Daguan Road, Kunming 650032, China
| | - Xiaoyan Xu
- Department of Orthopaedics, 920 Hospital of the Joint Logistics Support Force of the PLA, 212 Daguan Road, Kunming 650032, China
| | - Muguo Song
- Department of Orthopaedics, 920 Hospital of the Joint Logistics Support Force of the PLA, 212 Daguan Road, Kunming 650032, China
| | - Shunji Luo
- Department of Orthopaedics, 920 Hospital of the Joint Logistics Support Force of the PLA, 212 Daguan Road, Kunming 650032, China
| | - Zhao Xie
- Department of Orthopaedics, First affiliated hospital, Army Medical University, Chongqing 404199, China.
| | - Yongqing Xu
- Department of Orthopaedics, 920 Hospital of the Joint Logistics Support Force of the PLA, 212 Daguan Road, Kunming 650032, China.
| | - Jian Shi
- Department of Orthopaedics, 920 Hospital of the Joint Logistics Support Force of the PLA, 212 Daguan Road, Kunming 650032, China.
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Yalikun A, Ren P, Yushan M, Yusufu A. Clinical outcomes of bone transport using rail fixator in the treatment of femoral nonunion or bone defect caused by infection. Front Surg 2023; 9:970765. [PMID: 36700025 PMCID: PMC9869684 DOI: 10.3389/fsurg.2022.970765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 12/12/2022] [Indexed: 01/11/2023] Open
Abstract
Purpose The rail fixator can improve the treatment outcome and provide good stability in patients with femoral bone transport. The purpose of this study is to investigate the clinical outcomes of bone transport using the Ilizarov technique by rail fixator in the treatment of femoral nonunion or bone defects caused by infection. Methods Clinical feature and treatment outcomes of 32 consecutive adult patients with femoral nonunion or bone defect caused by infection from January 2012 to January 2019 at a minimum of 2 years of follow-ups were retrospectively analyzed. Data were collected on participants' demographic details. All difficulties related to bone transport were documented according to Paley's classification. The clinical outcomes were evaluated using ASAMI criteria at the last clinical visit. Results All 32 patients with an average follow-up of 33.5 months. There were 17 problems, 21 obstacles, and 8 complications, and the complication rate per patient was 1.4. The main complications were pin-site infection (53.1%), axial deviation (21.9%), joint stiffness (18.8%), the delayed union of the docking site (18.8%), soft tissue incarceration(15.6%), delayed consolidation(6.3%), malunion(6.3%), and refracture (3.1%). All the patients achieved bone union, and no recurrence of infection was observed. The excellent and good rates of ASAMI bone and functional results were 87.5% and 81.3%, respectively. Conclusion Bone transport using the Ilizarov technique is an effective method for the treatment of femoral nonunion or bone defect caused by infection, and rail fixators have obtained satisfactory results in terms of bone and functional results.
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Bidolegui F, Codesido M, Pereira S, Abraham A, Pires RE, Giordano V. Antibiotic cement-coated plate is a viable and efficient technique for the definitive management of metaphyseal septic nonunions of the femur and tibia. Rev Col Bras Cir 2023; 49:e20223060. [PMID: 36629717 PMCID: PMC10578849 DOI: 10.1590/0100-6991e-20223060-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 08/25/2022] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE the management of septic metaphyseal nonunions is challenging, with inconsistent outcomes. Antibiotic cement-coated implants have been demonstrated good outcome for diaphyseal infected nonunions, however there is no data in metaphyseal infected nonunions. METHODS fifteen adult patients with septic metaphyseal nonunions of the femur or tibia were treated with antibiotic cement-coated plates. The antibiotic cement-coated plate was prepared with either gentamicin or vancomycin. Outcome measures were infection control, bone healing, return to pre-injury level on daily activities, and quality of life at the last follow-up visit. A p value of <5% was considered significant. RESULTS Methicillin-susceptible S. aureus was isolated in 53.3% cases. Average postoperative follow-up time was 18 months. Local infection control and radiographic bone healing were adequately achieved in 93.3% patients. No patient presented recurrent symptoms of surgical site infection. Fourteen patients reported to be either able, or on the same level as before injury, with 73.3% reporting no problems in all five dimensions of the EQ-5D-3L. Persistent infection was the only variable associated with a reduced long-term quality of life. CONCLUSION antibiotic cement-coated plate is a viable and efficient surgical technique for the definitive management of juxta-articular metaphyseal septic nonunions of the femur and tibia.
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Affiliation(s)
- Fernando Bidolegui
- - Hospital Sirio Libanés, Servicio de Ortopedia y Traumatología - Buenos Aires - Argentina
| | - Mariano Codesido
- - Hospital Universitario Austral, Servicio de Ortopedia y Traumatología - Buenos Aires - Argentina
| | - Sebastián Pereira
- - Hospital Sirio Libanés, Servicio de Ortopedia y Traumatología - Buenos Aires - Argentina
| | - Agustín Abraham
- - Hospital Universitario Austral, Servicio de Ortopedia y Traumatología - Buenos Aires - Argentina
| | - Robinson Esteves Pires
- - Universidade Federal de Minas Gerais, Departamento do Aparelho Locomotor - Belo Horizonte - MG - Brasil
| | - Vincenzo Giordano
- - Hospital Municipal Miguel Couto, Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro - Rio de Janeiro - RJ - Brasil
- - Clínica São Vicente, Rede D'or São Luiz, Ortopedia - Rio de Janeiro - RJ - Brasil
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BIDOLEGUI FERNANDO, CODESIDO MARIANO, PEREIRA SEBASTIÁN, ABRAHAM AGUSTÍN, PIRES ROBINSONESTEVES, GIORDANO VINCENZO. O uso de placas revestidas de cimentado com antibiótico é uma técnica viável e eficiente para o tratamento da pseudoartrose infectada da metáfise do fêmur e da tíbia. Rev Col Bras Cir 2022. [DOI: 10.1590/0100-6991e-20223060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
RESUMO Introdução: implantes revestidos de cimento com antibiótico vêm demonstrando bons resultados no tratamento da pseudoartrose infectada da diáfise, no entanto seu uso na metáfise dos ossos longos ainda é pouco explorado. Neste estudo relatamos uma série de casos de pseudoartrose infectada da metáfise do fêmur e da tíbia tratados com o uso de placas revestidas de cimento com antibiótico. Métodos: Os antibióticos usados foram gentamicina e/ou vancomicina. Os desfechos analisados na última visita ambulatorial foram controle de infecção, consolidação óssea, retorno às atividades diárias e qualidade de vida. Regressão linear bivariada foi usada para avaliar fatores individuais que afetaram a qualidade de vida dos pacientes. Um valor p<5% foi considerado estatisticamente significativo. Resultados: quinze pacientes adultos foram incluídos no estudo. S. aureus suscetível à meticilina foi isolado em 53,3% dos casos. O tempo médio de acompanhamento pós-operatório foi de 18 meses. Controle local da infecção e consolidação óssea radiográfica foram alcançados em 93,3% dos pacientes. Nenhum paciente apresentou sintomas recorrentes de infecção de sítio cirúrgico. Quatorze pacientes relataram ser capazes, mas não no nível pré-lesional ou no mesmo nível de antes da lesão, com 73,3% relatando nenhum problema em todas as cinco dimensões do EQ-5D-3L. Infecção persistente foi a única variável associada à redução da qualidade de vida a longo prazo. Conclusão: A placa revestida de cimento com antibiótico mostrou-se uma técnica cirúrgica viável e eficiente para o tratamento da pseudoartrose infectada da metáfise do fêmur e da tíbia.
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Affiliation(s)
| | - MARIANO CODESIDO
- Hospital Universitario Austral, Servicio de Ortopedia y Traumatología, Argentina
| | | | - AGUSTÍN ABRAHAM
- Hospital Universitario Austral, Servicio de Ortopedia y Traumatología, Argentina
| | | | - VINCENZO GIORDANO
- Hospital Municipal Miguel Couto, Brasil; Clínica São Vicente, Brazil
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12
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Yoon YC, Oh CW, Cho JW, Oh JK. Early definitive internal fixation for infected nonunion of the lower limb. J Orthop Surg Res 2021; 16:632. [PMID: 34670557 PMCID: PMC8529840 DOI: 10.1186/s13018-021-02785-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/11/2021] [Indexed: 01/03/2023] Open
Abstract
Background The management of an infected nonunion of long bones is difficult and challenging. A staged procedure comprising radical debridement followed by definitive internal fixation was favored. However, no standard treatment has been established to determine the appropriate waiting period between initial debridement and definitive internal fixation. We propose a management method that incorporates early definitive internal fixation in infected nonunion of the lower limb. Methods Thirty-four patients (28 men and 6 women; mean age 46.09 years; range 25–74 years) with infected nonunion of the tibia or femur were included. Initial infected bone resection and radical debridement were performed in each patient in accordance with the preoperative plans. Definitive surgery was performed 2–3 weeks after the resection (4 weeks after flap surgery was required), and a third surgery was performed to fill the bone defect through bone grafting or transport (three-stage surgery). In cases of unplanned additional surgery, the reason for the requirement was analyzed, and radiological and functional results were investigated in accordance with the Association for the Study and Application of the Method of Ilizarov criteria. Results Bone union was achieved in all patients, and treatment was conducted as planned preoperatively in 28 patients (28/34, 82.35%). The mean interval between primary debridement and secondary definitive fixation was 2.76 weeks (range 2–4 weeks). Six unplanned additional surgeries were performed, and the infection relapsed in two cases. The radiological and functional outcomes were good or better in 32 and 31 patients, respectively. Conclusions Early definitive surgery can be performed to treat infected nonunion by thorough planning and implementation of radical resection, active response to infection, restoration of defective bones, and soft tissue healing through a systemic approach.
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Affiliation(s)
- Yong-Cheol Yoon
- Orthopedic Trauma Division, Trauma Center, Gachon University College of Medicine, Namdong-gu, Incheon, Republic of Korea
| | - Chang-Wug Oh
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Jung-gu, Daegu, Republic of Korea
| | - Jae-Woo Cho
- Department of Orthopedic Surgery, Korea University Guro Hospital, College of Medicine, Korea University, 148, Gurodong-ro, Guro-gu, 08308, Seoul, Republic of Korea
| | - Jong-Keon Oh
- Department of Orthopedic Surgery, Korea University Guro Hospital, College of Medicine, Korea University, 148, Gurodong-ro, Guro-gu, 08308, Seoul, Republic of Korea.
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13
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Fu R, Feng Y, Liu Y, Yang H. Mechanical regulation of bone regeneration during distraction osteogenesis. MEDICINE IN NOVEL TECHNOLOGY AND DEVICES 2021. [DOI: 10.1016/j.medntd.2021.100077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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14
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Shen J, Sun D, Fu J, Wang S, Wang X, Xie Z. Management of surgical site infection post-open reduction and internal fixation for tibial plateau fractures. Bone Joint Res 2021; 10:380-387. [PMID: 34218687 PMCID: PMC8333030 DOI: 10.1302/2046-3758.107.bjr-2020-0175.r2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
AIMS In contrast to operations performed for other fractures, there is a high incidence rate of surgical site infection (SSI) post-open reduction and internal fixation (ORIF) done for tibial plateau fractures (TPFs). This study investigates the effect of induced membrane technique combined with internal fixation for managing SSI in TPF patients who underwent ORIF. METHODS From April 2013 to May 2017, 46 consecutive patients with SSI post-ORIF for TPFs were managed in our centre with an induced membrane technique. Of these, 35 patients were included for this study, with data analyzed in a retrospective manner. RESULTS All participants were monitored for a mean of 36 months (24 to 62). None were subjected to amputations. A total of 21 patients underwent two-stage surgeries (Group A), with 14 patients who did not receive second-stage surgery (Group B). Group A did not experience infection recurrence, and no implant or cement spacer loosening was noted in Group B for at least 24 months of follow-up. No significant difference was noted in the Lower Extremity Functional Scale (LEFS) and the Hospital for Special Surgery Knee Score (HSS) between the two groups. The clinical healing time was significantly shorter in Group B (p<0.001). Those with longer duration of infection had poorer functional status (p<0.001). CONCLUSION Management of SSI post-ORIF for TPF with induced membrane technique combined with internal fixation represents a feasible mode of treatment with satisfactory outcomes in terms of infection control and functional recovery. Cite this article: Bone Joint Res 2021;10(7):380-387.
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Affiliation(s)
- Jie Shen
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Dong Sun
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Jingshu Fu
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Shulin Wang
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Xiaohua Wang
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Zhao Xie
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
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15
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Valtanen RS, Yang YP, Gurtner GC, Maloney WJ, Lowenberg DW. Synthetic and Bone tissue engineering graft substitutes: What is the future? Injury 2021; 52 Suppl 2:S72-S77. [PMID: 32732118 DOI: 10.1016/j.injury.2020.07.040] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/05/2020] [Accepted: 07/18/2020] [Indexed: 02/02/2023]
Abstract
The management of large segmental bone defects caused by trauma or disease remains clinically challenging within orthopaedics. The major impediment to bone healing with current treatment options is insufficient vascularization and incorporation of graft material. Lack of rapid adequate vascularization leads to cellular necrosis within the inner regions of the implanted material and a failure of bone regeneration. Current treatment options for critical size bone defects include the continued "gold standard" autograft, allograft, synthetic bone graft substitutes, vascularized fibular graft, induced membrane technique, and distraction osteogenesis. Bone tissue engineering (BTE) remains an exciting prospect for the treatment of large segmental bone defects; however, current clinical integration of engineered scaffolds remains low. We believe that the barrier to clinical application of bone tissue engineering constructs lies in the lack of concomitant vascularization of these scaffolds. This mini-review outlines the progress made and the significant limitations remaining in successful clinical incorporation of engineered synthetic bone substitutes for segmental defects.
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Affiliation(s)
- Rosa S Valtanen
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway St., Mailcode 6342, Redwood City, CA 94063 USA
| | - Yunzhi P Yang
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway St., Mailcode 6342, Redwood City, CA 94063 USA
| | - Geoffrey C Gurtner
- Department of Plastic Surgery, Stanford University School of Medicine, Stanford, USA
| | - William J Maloney
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway St., Mailcode 6342, Redwood City, CA 94063 USA
| | - David W Lowenberg
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway St., Mailcode 6342, Redwood City, CA 94063 USA.
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16
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Shen J, Sun D, Yu S, Fu J, Wang X, Wang S, Xie Z. Radiological and clinical outcomes using induced membrane technique combined with bone marrow concentrate in the treatment of chronic osteomyelitis of immature patients. Bone Joint Res 2021; 10:31-40. [PMID: 33380210 PMCID: PMC7845462 DOI: 10.1302/2046-3758.101.bjr-2020-0229.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Aims Treatment of chronic osteomyelitis (COM) for young patients remains a challenge. Large bone deficiencies secondary to COM can be treated using induced membrane technique (IMT). However, it is unclear which type of bone graft is optimal. The goal of the study was to determine the clinical effectiveness of bone marrow concentrator modified allograft (BMCA) versus bone marrow aspirate mixed allograft (BMAA) for children with COM of long bones. Methods Between January 2013 and December 2017, 26 young patients with COM were enrolled. Different bone grafts were applied to repair bone defects secondary to IMT procedure for infection eradication. Group BMCA was administered BMCA while Group BMAA was given BMAA. The results of this case-control study were retrospectively analyzed. Results Patient infection in both groups was eradicated after IMT surgery. As for reconstruction surgery, no substantial changes in the operative period (p = 0.852), intraoperative blood loss (p = 0.573), or length of hospital stay (p = 0.362) were found between the two groups. All patients were monitored for 12 to 60 months. The median time to bone healing was 4.0 months (interquartile range (IQR) 3.0 to 5.0; range 3 to 7) and 5.0 months (IQR 4.0 to 7.0; range 3 to 10) in Groups BMCA and BMAA, respectively. The time to heal in Group BMCA versus Group BMAA was substantially lower (p = 0.024). Conclusion IMT with BMCA or BMAA may attain healing in large bone defects secondary to COM in children. The bone healing time was significantly shorter for BMCA, indicating that this could be considered as a new strategy for bone defect after COM treatment. Cite this article: Bone Joint Res 2021;10(1):31–40.
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Affiliation(s)
- Jie Shen
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Dong Sun
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Shengpeng Yu
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China.,Department of Orthopaedics, Dujiangyan Medical Center, Dujiangyan, Sichuan, China
| | - Jingshu Fu
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Xiaohua Wang
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Shulin Wang
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Zhao Xie
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
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17
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Bachmeier AT, Euler E, Bader R, Böcker W, Thaller PH. Novel method for determining bone dimensions relevant for longitudinal and transverse distraction osteogenesis and application in the human tibia and fibula. Ann Anat 2020; 234:151656. [PMID: 33278581 DOI: 10.1016/j.aanat.2020.151656] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/10/2020] [Accepted: 11/12/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND In distraction osteogenesis (DO) of long bones, new bone tissue is formed and distracted to lengthen limbs or reconstruct bone defects. However, certain anthropometric quantities relevant for biomechanical modelling of DO are unknown, such as areas where new bone tissue is formed. We developed a novel method to facilitate the determination of these distraction areas (DA), which we applied in the tibia and fibula of adults for longitudinal and transverse DO to advance knowledge of anatomical boundary conditions. METHODS CT data sets of 21 adult human tibiae and 24 fibulae were selected for investigation. Volumetric models were created utilizing image segmentation. The DA for longitudinal DO was determined in a CAD environment using the total bone cross section in the proximal, central and distal diaphysis of the tibia and fibula. Additionally, the medullary canal area was determined in the fibula. Furthermore, we measured the total DA and medullary canal DA for transverse distraction using a longitudinally split fibula with an osteotomy length of 8, 12, 16 and 20 cm. The osteotomy plane was oriented in medial and anteromedial direction. Finally, Spearman analyses were conducted to assess the correlation between bone length and DA. RESULTS For longitudinal DO, the mean total DAs were 878, 535 and 482 mm2 in the tibia and 132, 153, 124 mm2 in the fibula for the proximal, central and distal diaphysis, respectively. Regarding transverse distraction, the mean total DAs for a medial and anteromedial osteotomy plane orientation were 962, 1423, 1868 and 2306 mm2 as well as 925, 1387, 1844, 2279 mm2 for an osteotomy length of 8, 12, 16 and 20 cm, respectively. Weak, positive, and non-significant correlations were observed when correlating bone length and DA in the tibia and fibula. CONCLUSIONS Quantification of DAs and hence distracted callus tissue in DO advances anatomical knowledge and improves biomechanical modelling by adding a parameter which cannot be approximated based on bone length.
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Affiliation(s)
- A T Bachmeier
- 3D-Surgery, Department of General, Trauma and Reconstructive Surgery, University Hospital LMU Munich, Munich, Germany; Biomechanics and Implant Technology Research Laboratory, University Medicine Rostock, Rostock, Germany.
| | - E Euler
- Department of General, Trauma and Reconstructive Surgery, University Hospital LMU Munich, Munich, Germany
| | - R Bader
- Biomechanics and Implant Technology Research Laboratory, University Medicine Rostock, Rostock, Germany
| | - W Böcker
- Department of General, Trauma and Reconstructive Surgery, University Hospital LMU Munich, Munich, Germany
| | - P H Thaller
- 3D-Surgery, Department of General, Trauma and Reconstructive Surgery, University Hospital LMU Munich, Munich, Germany
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18
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Lopez de Armentia S, del Real JC, Paz E, Dunne N. Advances in Biodegradable 3D Printed Scaffolds with Carbon-Based Nanomaterials for Bone Regeneration. MATERIALS 2020; 13:ma13225083. [PMID: 33187218 PMCID: PMC7697295 DOI: 10.3390/ma13225083] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 11/05/2020] [Accepted: 11/09/2020] [Indexed: 01/09/2023]
Abstract
Bone possesses an inherent capacity to fix itself. However, when a defect larger than a critical size appears, external solutions must be applied. Traditionally, an autograft has been the most used solution in these situations. However, it presents some issues such as donor-site morbidity. In this context, porous biodegradable scaffolds have emerged as an interesting solution. They act as external support for cell growth and degrade when the defect is repaired. For an adequate performance, these scaffolds must meet specific requirements: biocompatibility, interconnected porosity, mechanical properties and biodegradability. To obtain the required porosity, many methods have conventionally been used (e.g., electrospinning, freeze-drying and salt-leaching). However, from the development of additive manufacturing methods a promising solution for this application has been proposed since such methods allow the complete customisation and control of scaffold geometry and porosity. Furthermore, carbon-based nanomaterials present the potential to impart osteoconductivity and antimicrobial properties and reinforce the matrix from a mechanical perspective. These properties make them ideal for use as nanomaterials to improve the properties and performance of scaffolds for bone tissue engineering. This work explores the potential research opportunities and challenges of 3D printed biodegradable composite-based scaffolds containing carbon-based nanomaterials for bone tissue engineering applications.
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Affiliation(s)
- Sara Lopez de Armentia
- Institute for Research in Technology/Mechanical Engineering Dept., Universidad Pontificia Comillas, Alberto Aguilera 25, 28015 Madrid, Spain; (S.L.d.A.); (J.C.d.R.)
| | - Juan Carlos del Real
- Institute for Research in Technology/Mechanical Engineering Dept., Universidad Pontificia Comillas, Alberto Aguilera 25, 28015 Madrid, Spain; (S.L.d.A.); (J.C.d.R.)
| | - Eva Paz
- Institute for Research in Technology/Mechanical Engineering Dept., Universidad Pontificia Comillas, Alberto Aguilera 25, 28015 Madrid, Spain; (S.L.d.A.); (J.C.d.R.)
- Correspondence: (E.P.); (N.D.)
| | - Nicholas Dunne
- Centre for Medical Engineering Research, School of Mechanical and Manufacturing Engineering, Dublin City University, Stokes Building, Collins Avenue, Dublin 9, Ireland
- School of Mechanical and Manufacturing Engineering, Dublin City University, Dublin 9, Ireland
- School of Pharmacy, Queen’s University of Belfast, 97 Lisburn Road, Belfast BT9 7BL, UK
- Department of Mechanical and Manufacturing Engineering, School of Engineering, Trinity College Dublin, Dublin 2, Ireland
- Advanced Manufacturing Research Centre (I-Form), School of Mechanical and Manufacturing Engineering, Dublin City University, Glasnevin, Dublin 9, Ireland
- Advanced Materials and Bioengineering Research Centre (AMBER), Trinity College Dublin, Dublin 2, Ireland
- Advanced Processing Technology Research Centre, Dublin City University, Dublin 9, Ireland
- Trinity Centre for Biomedical Engineering, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin 2, Ireland
- Correspondence: (E.P.); (N.D.)
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19
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Kapukaya R, Ciloglu O. Two-stage treatment with sliding fibular flap technique for chronic infected nonunion of the tibia. Chin J Traumatol 2020; 23:302-306. [PMID: 32855045 PMCID: PMC7567902 DOI: 10.1016/j.cjtee.2020.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 06/17/2020] [Accepted: 07/20/2020] [Indexed: 02/04/2023] Open
Abstract
PURPOSE To assess the effectiveness of two-stage treatment with the fibular sliding technique in chronic infected nonunion of the tibia. METHODS The study included patients who were diagnosed with long-term chronic infected tibial nonunion following trauma and treated with the two-stage technique between January 2010 and November 2017. Patients with (1) intra-articular fractures of the distal third of the tibia and fibula, (2) pathological fracture resulting in bone loss or (3) neurological and vascular pathologies of the limbs were excluded. The operation consisted of two stages and the main goal in the first stage was to control the infection and in the second stage to control the healing of the bone. Functional & radiographic results and complications were evaluated according to Paley's criteria. RESULTS The patients comprised 14 males and 5 females with a mean age of 37.4 years (range, 21-52 years). Patients were followed up for an average of 27 months (range, 15-38 months). The microorganisms produced from these patients were Staphylococcus aureus in 13 patients, Pseudomonas aeruginosa in 4 patients and no bacteria in 2 patients. After the first stage operation, superficial skin necrosis developed in 1 patient. In another patient, there was a persistent infection, although union was achieved. For the entire patient group, union was observed at the end of 7.44 months (range, 7-11 months). Based on Paley's criteria, there were 16 (84.2%) patients with excellent scores, 2 (10.5%) good scores and 1 (5.3%) fair scores radiologically; while regarding the tibial function, 15 (78.9%) patients had excellent scores, 3 (15.8%) good scores, and 1 (5.3%) fair scores. No patients had poor radiological or functional score. CONCLUSION Two-stage treatment can be considered as an alternative for fractures in regions that are susceptible to many and persistent complications, such as the tibia. This technique has the advantages of short operation time, minimal blood loss, no excessive tissue damage and not very technique-demanding (a short learning curve with no requirement for an experienced team).
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Affiliation(s)
- Rana Kapukaya
- Department of Plastic and Reconstructive Surgery, University of Health Sciences, Adana City Research and Training Hospital, Adana, Turkey
| | - Osman Ciloglu
- Department of Orthopaedic and Traumatology, University of Health Sciences, Adana City Research and Training Hospital, Adana, Turkey,Corresponding author.
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20
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Akdemir M, Biçen Ç, Türken MA, Turan AC, Arıkan A. Treatment of femoral defective osteomyelitis with minimal invasive plates. Trauma Case Rep 2020; 28:100317. [PMID: 32490130 PMCID: PMC7256327 DOI: 10.1016/j.tcr.2020.100317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2020] [Indexed: 12/04/2022] Open
Abstract
Although recent treatment modalities reduced chronic osteomyelitis, it is still a challenging problem for both orthopaedic surgeons and patients. Especially treatment of femoral osteomyelitis with defective nonunion is reasonably difficult. Most accepted treatment option is external fixation. But the duration needed for external fixation may be too long for patient compliance. To reduce external fixation duration several methods were described. In this study we described a method for reconstruction of infected femoral defective nonunions using minimal invasive plates. Minimal invasive plating can reduce external fixator duration in treatment of defective femur osteomyelitis. Minimal invasive plating reduces relapse of infection in treatment of defective femur osteomyelitis. In treatment of defective femur osteomyelitis stepped treatment could be a favourable option.
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21
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Jia C, Wang X, Yu S, Wu H, Shen J, Huang Q, Xie Z. An antibiotic cement-coated locking plate as a temporary fixation for treatment of infected bone defects: a new method of stabilization. J Orthop Surg Res 2020; 15:44. [PMID: 32046768 PMCID: PMC7014650 DOI: 10.1186/s13018-020-1574-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 01/28/2020] [Indexed: 12/20/2022] Open
Abstract
Background The induced membrane technique has achieved good clinical results in the treatment of infected bone defects, and external fixation is the main method, but it causes inconvenience and complications in patients. In this study, our objective was to investigate the outcomes of using an antibiotic cement-coated locking plate as a temporary internal fixation in the first stage of the surgical induced membrane technique for treating extremities with infected bone defects. Methods We retrospectively analysed patients with lower extremity infected bone defects in our department between January 2013 and December 2017. All patients were treated with the induced membrane technique. In the first stage, the defects were stabilized with an antibiotic cement-coated locking plate as a temporary fixation after debridement, and polymethyl methacrylate cement was implanted to induce the formation of a membrane. In the second stage, bone grafting rebuilt the bone defects after infection control, and the temporary fixation was changed to a stronger fixation. Results A total of 183 patients were enrolled, with an average follow-up duration of 32.0 (12–66) months. There were 154 males and 29 females with an average age of 42.8 (10–68) years. The infection sites included 81 femurs, 100 tibias and 2 fibulas. After the first stage of treatment (infection control), 16 (8.7%) patients had recurrence of infection. In terms of the incidence of complications, 4 patients had poor wound healing, 2 patients had fixation failure and 1 patient had femoral fracture due to a fall. After the second stage of treatment (bone reconstruction), there were 24 (13.1%) recurrences of infection, with a mean time of 9.9 months (range 0.5 to 36). Among them, 18 patients underwent bone grafting after re-debridement, 6 received permanent placement of antibiotic bone cement after debridement and 2 patients refused further treatment and chose amputation. Bone healing was achieved in 175 (95.9%) patients at the last follow-up, and the average time to bone union was 5.4 (4–12) months. Conclusions Antibiotic cement-coated locking plates have good clinical effects in the control of bone infection, but attention must be paid to the possible difficulty of skin coverage when applied in calves.
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Affiliation(s)
- Chao Jia
- Department of Orthopedics, First Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400038, People's Republic of China
| | - Xiaohua Wang
- Department of Orthopedics, First Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400038, People's Republic of China
| | - Shengpeng Yu
- Department of Orthopedics, First Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400038, People's Republic of China
| | - Hongri Wu
- Department of Orthopedics, First Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400038, People's Republic of China
| | - Jie Shen
- Department of Orthopedics, First Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400038, People's Republic of China
| | - Qiang Huang
- Department of Orthopaedics, Traditional Chinese Medicine Hospital, Shaping Ba District, Chongqing, 400038, People's Republic of China
| | - Zhao Xie
- Department of Orthopedics, First Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400038, People's Republic of China.
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Affiliation(s)
- Meng Mi
- Department of Orthopaedics and Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | | | - Xinbao Wu
- Department of Orthopaedics and Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedic, School of Medicine, University of Leeds, Leeds General Infirmary, Leeds, UK; NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, UK.
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Simpson AHRW, Robiati L, Jalal MMK, Tsang STJ. Non-union: Indications for external fixation. Injury 2019; 50 Suppl 1:S73-S78. [PMID: 30955871 DOI: 10.1016/j.injury.2019.03.053] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 03/28/2019] [Indexed: 02/02/2023]
Abstract
External fixation is currently used as the definitive mode of fracture stabilisation in the management of ˜50% of long-bone non-unions. Distinction between non-union and delayed union is a diagnostic dilemma especially in fractures healing by primary bone repair. This distinction is important, as non-unions are not necessarily part of the same spectrum as delayed unions. The aetiology of a fracture non-union is usually multifactorial and the factors can be broadly categorized into mechanical factors, biological (local and systemic) factors, and infection. Infection is present in ˜40% of fracture non-unions, often after open fractures or impaired wound healing, but in 5% of all non-unions infection is present without any clinical or serological suspicion. General indications for external fixation include clinical scenarios where; 1) percutaneous correction of alignment, or mechanical stimulation of the non-union site is required; 2) fixation of juxta-articular or 'emmental' bone fragments is necessary; and 3) staged bone or soft tissue reconstruction is anticipated. Specific anatomical indications include infected non-unions of the tibia, humerus, and juxta-articular bone. External fixation is an essential tool in the management of fracture non-unions. However, with greater understanding of the outcomes associated with both external and internal fixation the relative indications are now being refined.
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Affiliation(s)
- A H R W Simpson
- Department of Trauma and Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, United Kingdom.
| | - L Robiati
- Department of Trauma and Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, United Kingdom
| | - M M K Jalal
- Department of Trauma and Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, United Kingdom
| | - S T J Tsang
- Department of Trauma and Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, United Kingdom
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Bhardwaj R, Singh J, Kapila R, Boparai RS. Comparision of Ilizarov Ring Fixator and Rail Fixator in Infected Nonunion of Long Bones: A Retrospective Followup Study. Indian J Orthop 2019; 53:82-88. [PMID: 30905986 PMCID: PMC6394165 DOI: 10.4103/ortho.ijortho_77_17] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND About 70 million trauma injuries that occur annually, around the world. More than 4.5 million open fractures occur per year in India. Long bone fractures nonunion (NU) rate varies from 2% to 7%. The management of open fracture is challenging for the orthopedic surgeon. The conventional protocol of management of compound fracture are debridement, temporary stabilization by external fixators, wound and definitive management. Very few prospective studies have been done comparing Illizarov and RF in infected nonunion. Thus we performed a retrospective study to compare the acceptance, complications, and functional outcome of Ilizarov ring fixator (IRF) and rail fixator (RF) in the treatment of infected NU. MATERIALS AND METHODS A retrospective cohort study of fifty infected long bone NU patients, who consulted Orthopedics Department of a tertiary care hospital of North-India from 2010 to 2014 was undertaken. Patients were divided into two Groups (Gp) of 25 each: one group was treated with IRF, another with RF and both followed for one year. Results were analyzed as per the ASAMI criteria (Association for the Study and Application of Methods of Illizarov) and complications as per Paley's classification. Patient's satisfaction was assessed by Visual Analog Scale (VAS) ranging from 0 to 100 mm. RESULTS Majority of the patients were in age group of 31- 45 years males with right sided involvement with previously treated infected NU of tibia involving distal one-third. According to VAS score, patients had mild to moderate pain in 13 cases in Gp-IRF and in 16 cases in Gp-RF, whereas severe pain was present in 12 cases of Gp-IRF and 9 cases of Gp-RF. Pin tract infection and pain were the commonest complication. Mean bone gap was 7.76 cm and 5.78 cm; average total treatment time was 17.64 and 13.40 months in Gp-IRF and Gp-RF, respectively. Duration of IRF application was more than RF (P < 0.01). Both the limbs were equated in 20 cases (80%) in Gp-IRF and 18 cases (72%) in Gp-RF. Results were found to be excellent in 7 (28%) and 8 (32%), good in 8 (32%) and 13 (52%), and fair in 10 (40%) and 4 (16%) cases in Gp-IRF and Gp-RF, respectively. Bony union achieved in 100% cases. Treatment index was 68.45 days/cm and 64.29 days/cm in Gp-IRF and Gp-RF, respectively. CONCLUSION In view of the patient acceptance, functional outcome and complications, rail fixator shows a better result than Ilizarov.
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Affiliation(s)
- Ravisha Bhardwaj
- Department of Orthopedics, Rajindra Hospital, Government Medical College, Patiala, India,Address for correspondence: Dr. Ravisha Bhardwaj, H. No. 4 A, Dhillon Marg, Model Town, Patiala - 147 001, Punjab, India. E-mail:
| | - Jaspal Singh
- Department of Orthopedics, Guru Nanak Hospital, Government Medical College, Amritsar, Punjab, India
| | - Rajesh Kapila
- Department of Orthopedics, Guru Nanak Hospital, Government Medical College, Amritsar, Punjab, India
| | - Randhir S Boparai
- Department of Orthopedics, Guru Nanak Hospital, Government Medical College, Amritsar, Punjab, India
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Yang H, Zhang Y, Han Q, Peng A, Zheng X, Qin S, Xia H. [Effectiveness of minimally invasive osteotomy Ilizarov technique combined with intramedullary nail for femoral lengthening]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2018; 32:1524-1529. [PMID: 30569677 PMCID: PMC8414221 DOI: 10.7507/1002-1892.201804118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 11/07/2018] [Indexed: 11/03/2022]
Abstract
Objective To explore the effectiveness of minimally invasive osteotomy Ilizarov technique combined with intramedullary nail for femoral lengthening. Methods Seventy-one patients with femoral shortening deformity who met the selection criteria between January 2013 and June 2016 were randomly divided into trial group (36 cases were treated with minimally invasive osteotomy Ilizarov technique combined with intramedullary nail for femoral lengthening) and control group (35 cases were treated with simple Ilizarov technique for femoral lengthening). There was no significant difference in age, gender, causes of femoral shortening, length of femoral shortening, rate of femoral deformity between the two groups ( P>0.05). The operation duration, intraoperative blood loss, lengthening rate, external fixation duration, frequency of pin tract infection, osteotomy healing time, and range of motion (ROM) of knee at 1 year after operation were recorded and compared between the two groups. Results The patients of two groups were followed up 12-60 months (mean, 31 months). Pin tract infection occured in 8 cases (10 pins), including 1 case (1 pin) in the trial group and 7 cases (9 pins) in the control group. There was significant difference in the incidence of pin tract infection between the two groups ( χ2=5.265, P=0.022). All patients were cured by replacing the fixation pins, changing dressing actively, application of antibiotics, and adequate postoperative care. The operation duration, intraoperative blood loss, external fixation duration, osteotomy healing time, and ROM of knee at 1 year after operation of the trial group were superior to those of the control group, showing significant differences ( P<0.05). There was no significant difference in the lengthening rate between the two groups ( t=-1.581, P=0.153). Conclusion The minimally invasive osteotomy Ilizarov technique combined with intramedullary nail in femoral lengthening increases the operation time, but the external fixation duration and incidence of pin tract infection are significantly reduced and the function of knee is significantly improved.
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Affiliation(s)
- Huaqing Yang
- Department of Orthopaedics, Beijing Rehabilitation Hospital of Capital Medical University, Beijing, 100144,
| | - Yaohua Zhang
- Department of Orthopaedics, Beijing Rehabilitation Hospital of Capital Medical University, Beijing, 100144, P.R.China
| | - Qinghai Han
- Department of Orthopaedics, Beijing Rehabilitation Hospital of Capital Medical University, Beijing, 100144, P.R.China
| | - Aimin Peng
- Department of Orthopaedics, Beijing Rehabilitation Hospital of Capital Medical University, Beijing, 100144, P.R.China
| | - Xuejian Zheng
- Department of Orthopaedics, Beijing Rehabilitation Hospital of Capital Medical University, Beijing, 100144, P.R.China
| | - Sihe Qin
- Department of Orthopaedics, Beijing Rehabilitation Hospital of Capital Medical University, Beijing, 100144, P.R.China
| | - Hetao Xia
- Department of Orthopaedics, Beijing Rehabilitation Hospital of Capital Medical University, Beijing, 100144, P.R.China
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Attias N, Thabet AM, Prabhakar G, Dollahite JA, Gehlert RJ, DeCoster TA. Management of extra-articular segmental defects in long bone using a titanium mesh cage as an adjunct to other methods of fixation. Bone Joint J 2018; 100-B:646-651. [DOI: 10.1302/0301-620x.100b5.bjj-2017-0817.r2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Aims This study reviews the use of a titanium mesh cage (TMC) as an adjunct to intramedullary nail or plate reconstruction of an extra-articular segmental long bone defect. Patients and Methods A total of 17 patients (aged 17 to 61 years) treated for a segmental long bone defect by nail or plate fixation and an adjunctive TMC were included. The bone defects treated were in the tibia (nine), femur (six), radius (one), and humerus (one). The mean length of the segmental bone defect was 8.4 cm (2.2 to 13); the mean length of the titanium mesh cage was 8.3 cm (2.6 to 13). The clinical and radiological records of the patients were analyzed retrospectively. Results The mean time to follow-up was 55 months (12 to 126). Overall, 16 (94%) of the patients achieved radiological filling of their bony defect and united to the native bone ends proximally and distally, resulting in a functioning limb. Complications included device failure in two patients (12%), infection in two (12%), and wound dehiscence in one (6%). Four patients (24%) required secondary surgery, four (24%) had a residual limb-length discrepancy, and one (6%) had a residual angular limb deformity. Conclusion A titanium mesh cage is a useful adjunct in the treatment of an extra-articular segmental defect in a long bone. Cite this article: Bone Joint J 2018;100-B:646–51.
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Affiliation(s)
- N. Attias
- St. Joseph’s Hospital, 350
W Thomas Rd, Phoenix, Arizona
85013, USA
| | - A. M. Thabet
- Department of Orthopaedic Surgery and
Rehabilitation, Paul L. Foster School of Medicine,Texas Tech Health
Sciences Center, 4801 Alberta Avenue, El
Paso, Texas 79905, USA
| | - G. Prabhakar
- Paul L. Foster School of Medicine at Texas
Tech Health Sciences Center, 4801 Alberta
Avenue, El Paso, Texas
79905, USA
| | - J. A. Dollahite
- Department of Orthopaedic Surgery, University
of New Mexico, Albuquerque, New
Mexico 87131, USA
| | - R. J. Gehlert
- Department of Orthopaedic Surgery, University
of New Mexico, Albuquerque, New
Mexico 87131, USA
| | - T. A. DeCoster
- Department of Orthopaedic Surgery, University
of New Mexico, Albuquerque, New
Mexico 87131, USA
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Walker JA, Scammell BE, Bayston R. A web-based survey to identify current practice in skeletal pin site management. Int Wound J 2018; 15:250-257. [PMID: 29250909 PMCID: PMC7949627 DOI: 10.1111/iwj.12858] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 10/11/2017] [Indexed: 11/30/2022] Open
Abstract
Infections associated with percutaneous pins and wires are common complications which can have a significant impact on patient outcomes. A survey was undertaken to identify current practice and gain insight into variations of clinical practice. Invitations were sent by email to complete an electronic questionnaire using SurveyMonkey. The survey was left open for 100 days. The single largest group of respondents (37.4%, n = 120) cleansed pin sites daily, with significant differences identified between medical and nursing professions (P = 0.02), and country of practice (P < 0.001). Significant differences were also identified in the use of different cleansing solutions between medical and nursing professions (P < 0.001) and country (P < 0.001). The majority group preferences were saline 30% (n = 96) and alcoholic chlorhexidine 29.6% (n = 95). Pin site crusts were routinely removed by 57.9% (n = 186). Pin sites were left exposed by 50.3% (n = 160). Dry gauze was identified as the most common dressing used to dress pin sites, however, substantial variation was identified in the types of dressings used. Compression was not routinely applied to pin sites by 51.6% (n = 165). There remains considerable diversity of practice when caring for pin sites. Further research is required to identify the most effective methods in preventing pin site infection.
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Affiliation(s)
- Jennie A Walker
- Surgery DivisionNottingham University Hospitals NHS TrustNottinghamUK
| | - Brigitte E Scammell
- Division of Rheumatology, Orthopaedics and DermatologyUniversity of NottinghamNottinghamUK
| | - Roger Bayston
- Division of Rheumatology, Orthopaedics and DermatologyUniversity of NottinghamNottinghamUK
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Abstract
OBJECTIVES To analyze long-term functional outcomes in patients with posttraumatic infected tibial nonunions having undergone bone transport with hexapod external fixator. DESIGN Retrospective cohort study. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS Thirty-eight patients with infected nonunions of the tibia. INTERVENTION Resection of nonunion with application of stacked hexapod external fixator for bone transport. MAIN OUTCOME MEASUREMENTS Functional outcome was measured using the short Musculoskeletal Functional Assessment (sMFA). Parameters measured included age, sex, presence of diabetes, smoking, use of a free flap, bone defect size, length in frame, external fixation index, and direction of lengthening. RESULTS The mean sMFA score for the entire group was 27.1. Average patient age was 46.8 ± 12.7 years, 74% patients were male, 8% were diabetic, and 29% were smokers. Seventeen patients had soft-tissue defects that required a free flap. Smokers had higher degrees of disability compared with nonsmokers (39 ± 16 vs. 22 ± 14, P = 0.011). Patients requiring adjunctive stabilization had worse functional scores compared with those who did not receive adjunctive stabilization (33 ± 17 vs. 22 ± 15, P = 0.049). Sixteen patients returned 2 sMFA surveys at different time points after completion of bone transport. Initial average sMFA score was 26.5 at a mean of 25.3 months; subsequent sMFA scores averaged 19.4 at a mean of 98.8 months. CONCLUSIONS Stacked hexapod external fixator bone transport is a reliable technique for infected nonunion of the tibia with bone loss. Improved sMFA scores can be expected from 2 to 8 years, suggesting full recovery takes longer than previously anticipated. Limb salvage with hexapod bone transport is justified over time. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Zhang Q, Zhang W, Zhang Z, Zhang L, Chen H, Hao M, Deng J, Tang P. Femoral nonunion with segmental bone defect treated by distraction osteogenesis with monolateral external fixation. J Orthop Surg Res 2017; 12:183. [PMID: 29178906 PMCID: PMC5702156 DOI: 10.1186/s13018-017-0684-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 11/09/2017] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Currently, the common treatment for femoral nonunion with large segmental bone defect is difficult and complex. The effective surgical methods are rare, include vascularized bone grafting, Masquelet technique and Ilizarov distraction osteogenesis. The objective of this study is to investigate the outcomes of segmental femoral defects treated with monolateral external fixation using the distraction osteogenesis. METHODS We retrospectively analyzed patients with femoral nonunion with segmental bone defects (> 6 cm) between January 2010 and January 2014 in our single trauma center. All patients were treated by distraction osteogenesis with monolateral external fixation. All surgeries were performed by the same surgeon. Bone union, duration of distraction osteogenesis in days, time to consolidation in months, external fixation index (EFI), complications, and additional surgical interventions were recorded postoperatively. The modified Application of Methods of Illizarov (ASAMI) criteria were used to evaluate the operative effectiveness. RESULTS Forty-one patients were enrolled in this study for analysis. The length of the bone defect ranged from 6 to 17 cm. All patients eventually achieved healing, and no patient experienced recurrence of infection or newly developed infection. The average time needed for healing was 13 months. In terms of the incidence of complications, 3 cases axial deviations, 5 cases docking site nonunion, 23 cases pin-tract infection, 14 cases knee joint stiffness or their joint mobility declined, 2 cases osteogenesis insufficient in the distraction area,1 case refracture, and 2 cases loose external fixation pins. In terms of the evaluations of fracture healing and function, 30 patients excellent, 6 patients good, 5 patients fair, and 0 patient poor. In terms of postoperative function evaluations, 21 patients excellent, 9 patients good, 7 patients fair, and 4 patients poor. CONCLUSION For patients with femoral nonunion with large segmental bone defects, the monolateral external fixation can provide effective stability, improve compliance, and reduce complications.
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Affiliation(s)
- Qun Zhang
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853 People’s Republic of China
| | - Wei Zhang
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853 People’s Republic of China
| | - Zhuo Zhang
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853 People’s Republic of China
| | - Licheng Zhang
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853 People’s Republic of China
| | - Hua Chen
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853 People’s Republic of China
| | - Ming Hao
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853 People’s Republic of China
| | - Junhao Deng
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853 People’s Republic of China
| | - Peifu Tang
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853 People’s Republic of China
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Treatment of critical-sized bone defects: clinical and tissue engineering perspectives. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 28:351-362. [PMID: 29080923 DOI: 10.1007/s00590-017-2063-0] [Citation(s) in RCA: 200] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 10/08/2017] [Indexed: 12/11/2022]
Abstract
Critical-sized bone defects are defined as those that will not heal spontaneously within a patient's lifetime. Current treatment options include vascularized bone grafts, distraction osteogenesis, and the induced membrane technique. The induced membrane technique is an increasingly utilized method with favorable results including high rates of union. Tissue engineering holds promise in the treatment of large bone defects due to advancement of stem cell biology, novel biomaterials, and 3D bioprinting. In this review, we provide an overview of the current operative treatment strategies of critical-sized bone defects as well as the current state of tissue engineering for such defects.
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Abstract
Non-union is a devastating consequence of a fracture. Non-unions cause substantial patient morbidity with patients suffering from loss of function of the affected extremity, increased pain, and a substantial decrease in the quality of life. The management is often associated with repeated, unsuccessful operations resulting in prolonged hospital stays, which has social and economic consequences to both the patient and the healthcare system. The rates of non-union following intramedullary (IM) nailing vary according to anatomical location. There is currently no consensus regarding the treatment of infected non-unions following IM nailing, but the most common procedures reported are; exchange IM nail with antibiotic suppression or excision of the non-union, (stabilisation with external fixation or less commonly plate or IM nail) and then reconstruction of the bone defect with distraction osteogenesis or the Masquelet technique. This article explores the general principles of treatment, fixation modalities and proposes a treatment strategy for the management of infected non-unions following intramedullary nailing.
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Affiliation(s)
- A Hamish Simpson
- Department of Trauma and Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK.
| | - Jerry S T Tsang
- Department of Trauma and Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
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Treatment Options for Nonunion With Segmental Bone Defects: Systematic Review and Quantitative Evidence Synthesis. J Orthop Trauma 2017; 31:111-119. [PMID: 27611666 DOI: 10.1097/bot.0000000000000700] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine which reconstruction treatment of long bones nonunion with segmental bone defects (SBDs) is effective to restore bone length and union with good function. DATA SOURCES PubMed was used to identify published literature on treatment of SBD caused by fracture nonunion regardless of infection between January 1975 and December 2014. STUDY SELECTION We included retrospective cohort studies with a minimum sample size of 10 consecutive patients with minimum follow-up of 18 months and available data on radiographic and functional outcomes. DATA EXTRACTION Literature review revealed 24 publications with a sample size of 504 patients (395 males, 109 females). Data on bone union and functional outcome and complications were collected and analyzed based on validated classification systems. DATA SYNTHESIS Two outcome groups were categorized for bone union and functional outcome, success, and failure. We then performed heterogeneity test to examine the variability or differences in the methods used by these studies and based on that we determined whether the fixed effect or random effect method is appropriate in examining the summary or pool estimate. Pool estimate was examined for bone union and functional outcome in each surgical modality and in each anatomic location when data were available. CONCLUSIONS Treatment of SBD can be challenging. This quantitative evidence synthesis shows that bone union was achieved by different procedures with variable bone union and functional outcomes. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Two stage management of Cierny-Mader type IV chronic osteomyelitis of the long bones. Injury 2017; 48:511-518. [PMID: 28088375 DOI: 10.1016/j.injury.2017.01.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 09/15/2016] [Accepted: 01/01/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Cierny-Mader (C-M) type IV chronic osteomyelitis represents a complex clinical challenge with permeation of extensive bone and soft tissue involvement. Aggressive debridement through viable tissue margin includes en bloc resection improves the odds of eradication of infection, which creates large bone and soft tissue loss in treating this type of osteomyelitis. The potentially large defects increase reconstruction problems with traditional reconstruction technique. The newly staged induced membrane technique presents length-independent, potential as an alternative reconstruction method for segmental bone defects due to type IV chronic osteomyelitis. The purpose of this study was to assess the result and related factors of C-M type IV chronic osteomyelitis treated with staged methods of aggressive debridement and induced membrane technique. METHODS From January 2012 to January 2014, 36 consecutive adult patients of C-M type IV chronic osteomyelitis were treated by this staged method in our clinical center with a minimum of 2-years follow-up. The clinical and imaging results were retrospectively analyzed. RESULTS Five patients had a second debridement and eight needed a local flap transfer to cover the wound in the first stage. Patients formed a mean of 5.5cm (range: 2-10.9) segmental bone defect; Sixteen patients had autograft and twenty had autograft mixed allograft in the second stage. The mean follow-up time was 29.5 months (range: 24-45). No patients required amputation. Bone union was achieved in all patients. Clinical eradication of osteomyelitis was achieved in 35 (97%) patients, 35 (97%) patients were able to walk independently, and 31patients (86%) returned to work. Patients returned to a mean of 82% (46.3%-100%) lower extremity function. Bone union time was not dependent on the length of bone defect, but associated with the infection site (p=0.005) and age (p=0.005). CONCLUSIONS Staged methods of aggressive debridement and induced membrane technique seems to be a simple, reliable and effective for the treatment of C-M type IV chronic osteomyelitis. Advanced age and poor soft tissue envelope may have adverse affects and are relative contraindications. The combined assessment and management of such patients with a plastic surgeon are advocated.
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From prevention of pin-tract infection to treatment of osteomyelitis during paediatric external fixation. J Child Orthop 2016; 10:605-612. [PMID: 27848193 PMCID: PMC5145837 DOI: 10.1007/s11832-016-0787-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 10/19/2016] [Indexed: 02/06/2023] Open
Abstract
Pin-tract infection (PTI) is the most commonly expected problem, or even an almost inevitable complication, when using external fixation. Left unteated, PTI will progress unavoidably, lead to mechanical pin loosening, and ultimately cause instability of the external fixator pin-bone construct. Thus, PTI remains a clinical challenge, specifically in cases of limb lengthening or deformity correction. Standardised pin site protocols which encompass an understanding of external fixator biomechanics and meticulous surgical technique during pin and wire insertion, postoperative pin site care and pin removal could limit the incidence of major infections and treatment failures. Here we discuss concepts regarding the epidemiology, physiopathology and microbiology of PTI in paediatric populations, as well as the clinical presentations, diagnosis, classification and treatment of these infections.
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Clinical evaluation of patients submitted to osteogenic distraction in the lower limb at a university hospital. Rev Bras Ortop 2016; 51:521-526. [PMID: 27818972 PMCID: PMC5090956 DOI: 10.1016/j.rboe.2016.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Accepted: 11/26/2015] [Indexed: 11/29/2022] Open
Abstract
Objective To evaluate the clinical characteristics from patients submitted to osteogenic distraction to correct bone gap at a university hospital. Methods Retrospective transversal study, with a convenience sample, from 2000 to 2012, evaluating clinical aspects of patients treated, submitted to osteogenic distraction (bone transport) with Ilizarov's external fixation device. The chi-squared, Fisher's, and Mann–Whitney's U tests were used with a 5% level of significance (p < 0.05). Results 33 patients were studied, of whom 28 men (84.8%). The more frequent age was from 21 to 40 years. Most patients were from the metropolitan region of the capital (57.6%). The leg was the most affected limb (75.8%), and the left side was the most affected (66.7%). The most common cause was infected pseudoarthrosis (75.8%). The most common bone transportation type was bifocal (75.8%). Mean previous surgery at others institutions were 2.62 (1.93 standard deviation), and mean surgeries after treatment were 1.89 (1.29 standard deviation). Ilizarov's external fixation device was used for 1.94 years (1.34 mean deviation), from one to six years. The most common complications were pin infection (57.6%), equinus (30.3%), deep infection (24.2%), and shortening (21.2%). Conclusion Osteogenic distraction for bone gaps were more frequent in young adults, men, in the leg, with bifocal transportation, after several previous surgeries, treated for a mean of two years, with many complications (infections were the most common).
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Moghaddam A, Thaler B, Bruckner T, Tanner M, Schmidmaier G. Treatment of atrophic femoral non-unions according to the diamond concept: Results of one- and two-step surgical procedure. J Orthop 2016; 14:123-133. [PMID: 27843223 DOI: 10.1016/j.jor.2016.10.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 10/13/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The treatment of non-unions in long bones poses a great challenge, particularly in cases of infection or large osseous defects. This article evaluates the use of the diamond concept in the treatment of femoral non-unions in a one-step or two-step procedure according to the Masquelet technique. PATIENTS AND METHODS Between February 2010 and March 2014, 88 patients with atrophic femoral non-unions were included in our study. The treatment was performed in one step (Group G1) on 41 patients and in two-step Masquelet technique (Group G2) on 47 patients, according to the diamond concept. In 72 cases it was decided to apply the growth factor BMP-7. The mean age of patients was 49.9 ± 15.3. The data were analysed after following up all patients for at least 12 months after surgery. RESULTS 74% of patients achieved consolidation in an average of 9.3 months. Positive bacterial cultures were found in 16 cases (18%). The consolidation rate in G2 was dependent on the non-union localisation and the osteosynthesis method applied. 83% of patients treated by intramedullary reaming achieved consolidation, while this was the case for only 60% of patients with osteosynthesis plates. Smokers in G2 had a larger average osseous defect and a lower consolidation rate. The quality of life as assessed with the SF-12 questionnaire had improved in both groups, with no significant differences between G1 and G2 one year after surgery. CONCLUSIONS One-step therapy is a suitable method of treatment for aseptic femoral non-unions with small osseous defects, using BMP-7 and RIA in the case of primarily failed atrophic non-union treatment. The Masquelet technique is an efficient means of eradicating infections in non-unions. In combination with intramedullary nailing, this technique is the method of choice for the treatment of femoral shaft non-unions with large defects.
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Affiliation(s)
- Arash Moghaddam
- HTRG - Heidelberg Trauma Research Group, Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, D-69118 Heidelberg, Germany
| | - Benjamin Thaler
- HTRG - Heidelberg Trauma Research Group, Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, D-69118 Heidelberg, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Im Neuenheimer Feld 305, D-69120 Heidelberg, Germany
| | - Michael Tanner
- HTRG - Heidelberg Trauma Research Group, Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, D-69118 Heidelberg, Germany
| | - Gerhard Schmidmaier
- HTRG - Heidelberg Trauma Research Group, Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, D-69118 Heidelberg, Germany
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Sampaio FMB, Marçal LP, dos Reis DG, Kasuo AW, Fraga CEC, de Moraes FB. Avaliação clínica de pacientes submetidos à distração osteogênica no membro inferior em hospital universitário. Rev Bras Ortop 2016. [DOI: 10.1016/j.rbo.2015.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Yu X, Wu H, Li J, Xie Z. Antibiotic cement-coated locking plate as a temporary internal fixator for femoral osteomyelitis defects. INTERNATIONAL ORTHOPAEDICS 2016; 41:1851-1857. [PMID: 27520738 DOI: 10.1007/s00264-016-3258-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 07/22/2016] [Indexed: 12/11/2022]
Abstract
PURPOSE Recently we modified the Masquelet technique by using an antibiotic cement-coated locking plate as a temporary internal fixator when treating septic bone defects. This modification is in order to prevent the complications related to external fixator use and provides the involved limb with a greater stability to undergo earlier and more vigorous physical therapy for recovery of joint function. The purpose of this study was to assess the outcomes of large femoral osteomyelitis defects managed by Masquelet technique combined with the antibiotic cement-coated locking plate used as a temporary internal fixator. METHODS Between November 2013 to November 2014, 13 cases of large femoral osteomyelitis defects were treated by Masquelet technique and the antibiotic cement-coated locking plate was used as a temporary internal fixator in the first stage surgery. All the patients' clinical and imaging results were retrospectively analyzed. RESULTS After debridement, there was a femoral bone defect with a mean of 9.8 cm (range, 5-16 cm). The mean follow-up was 17.8 months (range 12 to 24 months). One patient developed infection in nine months after second stage surgery. Radiographic bony union was achieved within a mean 20.3 weeks (range, 18-30 weeks) in all patients. The mean time period to full weight bearing after the second step procedure was 5.8 months (range, 5-8.5 months). The mean knee range of motion for the patients at the last follow up was 122° (range 100-135°). CONCLUSION Based on our experience, we believe that antibiotic cement-coated locking plate is a viable fixation method in the first stage of Masquelet technique for the management of large femoral osteomyelitis defects. It may offer a better chance of infection eradication as well as improved recovery of joint function without increasing the infection recurrence rate and without compromising bone graft union.
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Affiliation(s)
- Xin Yu
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing, 400038, China
| | - Hongri Wu
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing, 400038, China
| | - Jianhua Li
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing, 400038, China
| | - Zhao Xie
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing, 400038, China.
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Hernigou P, Trousselier M, Roubineau F, Bouthors C, Chevallier N, Rouard H, Flouzat-Lachaniette CH. Local transplantation of bone marrow concentrated granulocytes precursors can cure without antibiotics infected nonunion of polytraumatic patients in absence of bone defect. INTERNATIONAL ORTHOPAEDICS 2016; 40:2331-2338. [PMID: 26928724 DOI: 10.1007/s00264-016-3147-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 02/16/2016] [Indexed: 01/03/2023]
Abstract
PURPOSE Infected, long bone non-unions present a significant clinical challenge. New and alternative therapies are needed to address this problem. The purposes of this study were to compare the number of circulating granulocyte-macrophage colony-forming units (CFU-GM) in the peripheral blood of polytraumatic patients with infected tibial non-unions and in the peripheral blood of control patients with the hypothesis that their number was decreased in polytraumatic patients; and to treat their infection without antibiotics and with local transplantation of bone marrow concentrated granulocytes precursors. METHODS Thirty (18 atrophic and 12 hyperthrophic ) infected tibial non-unions (without bone defect) that occurred after open fractures in polytraumatic patients were treated without antibiotics and with percutaneous injection of autologous bone marrow concentrate (BMC) containing granulocytes precursors (CFU-GM). CFU-GM progenitors were assessed in the bone marrow aspirate, peripheral blood, and fracture site of these patients. The number of these progenitors was compared with the CFU-GM progenitors of control patient samples (healthy donors matched for age and gender). Outcome measures were: timing of union, callus formation (radiographs and CT scan), and recurrence of clinical infection. RESULTS As compared to control patients, the number of CFU GM derived colonies was lower at peripheral blood in patients with infected nonunions. The bone marrow graft injected in nonunions contained after concentration 42 621 ± 20 350 CFU-GM-derived colonies/cc. Healing and cure of infection was observed at six months for 25 patients and at one year follow up for 30 patients. At the median ten year follow-up (range: 5 to 15), only one patient had clinical recurrent infection after healing (between 6 months and last follow-up). CONCLUSION The peripheral blood of these polytraumatic patients with infected nonunions had a remarkable decrease in CFU-GM-derived colonies as compared with normal controls. Local transplantation of concentrated CFU-GM-derived colonies aspirated from bone marrow allowed cure of infection and healing without antibiotics.
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Affiliation(s)
- Philippe Hernigou
- Orthopaedic Surgery, University Paris East (UPEC), Hôpital Henri Mondor, 94010, Creteil, France.
| | - Matthieu Trousselier
- Orthopaedic Surgeon, University Paris East (UPEC), Hôpital Henri Mondor, 94010, Creteil, France
| | - François Roubineau
- Orthopaedic Surgery, University Paris East (UPEC), Hôpital Henri Mondor, 94010, Creteil, France
| | - Charlie Bouthors
- Orthopaedic Surgeon, University Paris East (UPEC), Hôpital Henri Mondor, 94010, Creteil, France
| | - Nathalie Chevallier
- EFS Cell Therapy Facility, University Paris East (UPEC), Hôpital Henri Mondor, 94010, Creteil, France
| | - Helene Rouard
- EFS Cell Therapy Facility, University Paris East (UPEC), Hôpital Henri Mondor, 94010, Creteil, France
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Azzam W, El-Sayed M. Ilizarov distraction osteogenesis over the preexisting nail for treatment of nonunited femurs with significant shortening. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 26:319-28. [DOI: 10.1007/s00590-016-1740-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 01/05/2016] [Indexed: 02/08/2023]
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Rodriguez-Collazo ER, Urso ML. Combined use of the Ilizarov method, concentrated bone marrow aspirate (cBMA), and platelet-rich plasma (PRP) to expedite healing of bimalleolar fractures. Strategies Trauma Limb Reconstr 2015; 10:161-6. [PMID: 26602551 PMCID: PMC4666232 DOI: 10.1007/s11751-015-0239-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 11/19/2015] [Indexed: 01/25/2023] Open
Abstract
Distal tibial and fibular fractures, particularly in patients with comorbidities, heal slowly and have a high incidence of postoperative nonunion and infection. Autologous concentrated bone marrow aspirate (cBMA) and platelet-rich plasma (PRP) increase osteogenic potential of demineralized bone matrix (DBM). The purpose of this case series was to evaluate the efficacy of cBMA, PRP, DBM in conjunction with the Ilizarov fixator as compared to DBM and the Ilizarov fixator alone in expediting fracture healing. Ten patients (mean age 52.9 years) were in the cBMA Group, and 10 patients (mean age 54 years) were in the Control Group. Comorbidities included diabetes, obesity, smoking, and renal disease. Radiographs showed a significant difference in the rate of complete healing in the cBMA Group at 16 ± 1.6 weeks post-surgery as compared to 24 ± 1.3 weeks in the Control Group (P < 0.001). No differences were observed between groups in infection rate or nonunions. We conclude that the Ilizarov fixator combined with DBM, cBMA, and PRP expedites fracture healing of the distal tibia and fibula in patients with significant comorbidities.
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Affiliation(s)
| | - Maria L Urso
- Arteriocyte Medical Systems, 45 South St., Suite 3, Hopkinton, MA, 01748, USA.
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A Systematic Review and Meta-Analysis of Ilizarov Methods in the Treatment of Infected Nonunion of Tibia and Femur. PLoS One 2015; 10:e0141973. [PMID: 26529606 PMCID: PMC4631548 DOI: 10.1371/journal.pone.0141973] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 10/15/2015] [Indexed: 01/03/2023] Open
Abstract
Background Infected nonunion of tibia and femur are common in clinical practice, however, the treatment of these diseases has still been a challenge for orthopaedic surgeons. Ilizarov methods can eradicate infection, compensate bone defects and promote the bone union through progressive bone histogenesis. The objective of this systematic review was to review current available studies reporting on Ilizarov methods in the treatment of infected nonunion of tibia and femur, and to perform meta-analysis of bone and functional results and complications to evaluate the efficacy of Ilizarov methods. Methods A comprehensive literature search was performed from the SCI, PubMed, Cochrane Library; and Embase between January 1995 and August 2015. Some major data were statistically analyzed using weighted means based on the sample size in each study by SPSS 13.0, including number of patients, mean age, mean previous surgical procedures, mean bone defects, mean length of follow-up, bone union, complications per patient, external fixation time, and external fixation index(EFI). Bone results (excellent, good, fair and poor rate), functional results (excellent, good, fair and poor rate) and complications were analyzed by Stata 9.0. Findings A total of 590 patients from 24 studies were included in this systematic review. The average of bone union rate was 97.26% in all included studies. The poor rate in bone results and functional results was 8% (95%CI, 0.04–0.12; I2 = 44.1%, P = 0.065) and 10% (95%CI, 0.05–0.14; I2 = 34.7%, P = 0.121) in patients with infected nonunion of tibia and femur treated by Ilizarov methods. The rate of refracture, malunion, infectious recurrence, knee stiffness, amputation, limb edema and peroneal nerve palsy was respectively 4%, 7%, 5%, 12%, 4%, 13% and 13%. Conclusions Our systematic review showed that the patients with infected nonunion of tibia and femur treated by Ilizarov methods had a low rate of poor bone and functional results. Therefore, Ilizarov methods may be a good choice for the treatment of infected nonunion of tibia and femur.
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Abstract
Infected non-union is a devastating complication post fracture fixation. While its incidence is small, its management is lengthy, challenging and costly. Complex reconstruction surgery is often required with unpredictable outcomes despite the significant advances that have been made in diagnostics, surgical techniques and antibiotic protocols. In this article we present recent approaches to the surgical treatment of this condition.
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Pallaro J, Angelliaume A, Dunet B, Lavoinne N, Tournier C, Fabre T. Reconstruction of femoral bone loss with a monoplane external fixator and bone transport. Orthop Traumatol Surg Res 2015; 101:583-7. [PMID: 26045056 DOI: 10.1016/j.otsr.2015.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 03/24/2015] [Accepted: 04/02/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Treatment of femoral bone loss is difficult. Ilizarov described the bone lengthening technique using a circular external fixator, but this technique is uncomfortable on the femur because of the circular fixator. We have therefore opted for use of a monoplane external fixator to treat femoral bone loss with bone lengthening. The objectives of this study were to determine whether (1) bone union can be obtained with a monoplane external fixator; (2) infections can be treated; (3) the lower limb axes and alignment can be controlled; and (4) patient satisfaction is high. HYPOTHESIS A monoplane external fixator provides a high rate of bone union during bone transport with no risk of deformity over the long term. MATERIAL AND METHODS Between 2007 and 2012 seven patients were treated with bone transport using a monoplane external fixator for femoral bone loss measuring a mean 8.1cm (range, 6-10cm). All were infected (osteomyelitis) or contaminated following Gustilo type IIIB fractures. The mean time from initial injury to the beginning of bone loss management was 3.9months (range, 1.5-8 months) for six of them and 108 months for one patient. RESULTS At the mean follow-up of 4.7 years (range, 2-7 years), all of the patients showed union after a mean 11.1months (range, 8-18 months), i.e., 41.2 days/cm of transport, and all infections were resolved. Only one patient had unequal leg length measuring 2cm and another showed 3° varus. Five patients were satisfied despite disappointing functional results. All could fully extend the knee but the mean flexion was 50° (range, 20-90°). DISCUSSION This series confirms that use of the monoplane external fixation with descending bone transport to treat infected femoral bone loss is efficient and provides bone union, treatment of the infection, and control of bone axes and lengths. This technique does not allow recuperation of complete knee flexion. LEVEL OF EVIDENCE IV, retrospective study.
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Affiliation(s)
- J Pallaro
- Service de chirurgie orthopédique et traumatologique, CHU Pellegrin de Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France.
| | - A Angelliaume
- Service de chirurgie orthopédique et traumatologique, CHU Pellegrin de Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - B Dunet
- Service de chirurgie orthopédique et traumatologique, CHU Pellegrin de Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - N Lavoinne
- Service de chirurgie orthopédique et traumatologique, CHU Pellegrin de Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - C Tournier
- Service de chirurgie orthopédique et traumatologique, CHU Pellegrin de Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - T Fabre
- Service de chirurgie orthopédique et traumatologique, CHU Pellegrin de Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
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Yin P, Zhang L, Li T, Zhang L, Wang G, Li J, Liu J, Zhou J, Zhang Q, Tang P. Infected nonunion of tibia and femur treated by bone transport. J Orthop Surg Res 2015; 10:49. [PMID: 25889513 PMCID: PMC4415215 DOI: 10.1186/s13018-015-0189-5] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2014] [Accepted: 01/27/2015] [Indexed: 12/19/2022] Open
Abstract
Objective The objective of this study was to evaluate the effectiveness of the treatment of infected nonunion of tibia and femur by bone transport. Material and methods We retrospectively reviewed 110 patients with infected nonunion of tibia and femur treated by bone transport. Our study included 92 males and 18 females with a mean age of 38.90 years. The site of infected nonunion involved 72 tibias and 38 femurs. The mean length of the bone defects after radical debridement was 6.15 cm (range 3–13 cm). Results The mean follow-up after removal of the apparatus was 23.12 months (14–46 months). Ten patients including seven patients with infected tibia nonunion and three patients with infected femur nonunion were lost to follow-up. All the patients achieved bone union, and no recurrence of infection was observed. The time of bone transport took a mean of 67.50 days (range 33 to 137 days), and the mean external fixation index was 1.48 months/cm (range 1.15–1.71 months/cm). According to Association for the Study and Application of the Method of Ilizarov (ASAMI) classification, bone results were excellent in 68, good in 28, fair in 12, and poor in 2; functional results were excellent in 37, good in 42, fair in 21, and no poor. Conclusions Our study and the current evidence suggested that Ilizarov methods in the treatment of infected nonunion of tibia and femur acquired satisfied results. Radical debridement is the key step to control bone infection.
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Affiliation(s)
- Peng Yin
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853, P.R. China. .,Medical College, Nankai University, No. 94 Weijin Road, Tianjin, 300071, P.R. China.
| | - Lihai Zhang
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853, P.R. China.
| | - Tongtong Li
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853, P.R. China. .,Medical College, Nankai University, No. 94 Weijin Road, Tianjin, 300071, P.R. China.
| | - Licheng Zhang
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853, P.R. China.
| | - Guoqi Wang
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853, P.R. China.
| | - Jiantao Li
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853, P.R. China.
| | - Jianheng Liu
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853, P.R. China.
| | - Jianfeng Zhou
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853, P.R. China.
| | - Qun Zhang
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853, P.R. China.
| | - Peifu Tang
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853, P.R. China.
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Mercado-Pagán ÁE, Stahl AM, Shanjani Y, Yang Y. Vascularization in bone tissue engineering constructs. Ann Biomed Eng 2015; 43:718-29. [PMID: 25616591 PMCID: PMC4979539 DOI: 10.1007/s10439-015-1253-3] [Citation(s) in RCA: 173] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 01/13/2015] [Indexed: 01/04/2023]
Abstract
Vascularization of large bone grafts is one of the main challenges of bone tissue engineering (BTE), and has held back the clinical translation of engineered bone constructs for two decades so far. The ultimate goal of vascularized BTE constructs is to provide a bone environment rich in functional vascular networks to achieve efficient osseointegration and accelerate restoration of function after implantation. To attain both structural and vascular integration of the grafts, a large number of biomaterials, cells, and biological cues have been evaluated. This review will present biological considerations for bone function restoration, contemporary approaches for clinical salvage of large bone defects and their limitations, state-of-the-art research on the development of vascularized bone constructs, and perspectives on evaluating and implementing novel BTE grafts in clinical practice. Success will depend on achieving full graft integration at multiple hierarchical levels, both between the individual graft components as well as between the implanted constructs and their surrounding host tissues. The paradigm of vascularized tissue constructs could not only revolutionize the progress of BTE, but could also be readily applied to other fields in regenerative medicine for the development of new innovative vascularized tissue designs.
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Affiliation(s)
| | - Alexander M. Stahl
- Department of Orthopedic Surgery, Stanford University, Stanford, CA, USA
- Department of Chemistry, Stanford University, Stanford, CA, USA
| | - Yaser Shanjani
- Department of Orthopedic Surgery, Stanford University, Stanford, CA, USA
| | - Yunzhi Yang
- Department of Orthopedic Surgery, Stanford University, Stanford, CA, USA
- Department of Materials Science and Engineering, Stanford University, Stanford, CA, USA
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Efficacy of a compliant semicircular Ilizarov pin fixator module for treating infected nonunion of the femoral diaphysis. Strategies Trauma Limb Reconstr 2014; 9:101-9. [PMID: 25070587 PMCID: PMC4122683 DOI: 10.1007/s11751-014-0199-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Accepted: 07/22/2014] [Indexed: 10/27/2022] Open
Abstract
Percutaneous transosseous Ilizarov wiring, whilst preferred in the tibia because of its unique properties, carries a high risk of complications in the femur. The aim of this work was to evaluate the efficacy of a more patient-friendly semicircular pin external fixator module built up from parts of the Ilizarov fixator components and its use in managing diaphyseal femoral nonunions. A group of 20 patients with infected diaphyseal nonunions of the femur after internal osteosynthesis were included in this study. The mean age of the patients at the time of surgery was 46 years (range 16-60, SD 15.6). The mean morbidity time since the original trauma was 10.2 months (range 6-15, SD 2.5). All the cases were fixed by the described external fixator module. Bony union with resolution of infection occurred in 18 (94.7 %) out of 19 cases after a mean period in the fixator of 11.2 months (range 8-18 SD 2.9). After a mean follow-up period of 3.5 years (range 2-9, SD 2.6), there were 14 excellent, 3 good, 1 fair and 1 poor results from radiological evaluation and 10 excellent, 7 good, 1 fair and 1 poor results from functional assessment. In conclusion, the described semi-circular pin fixator module is patient-friendly and effective in managing infected nonunions of the femoral diaphysis.
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Papakostidis C, Bhandari M, Giannoudis PV. Distraction osteogenesis in the treatment of long bone defects of the lower limbs: effectiveness, complications and clinical results; a systematic review and meta-analysis. Bone Joint J 2014; 95-B:1673-80. [PMID: 24293599 DOI: 10.1302/0301-620x.95b12.32385] [Citation(s) in RCA: 127] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- C Papakostidis
- "G. Hatzikostas" General Hospital, Department of Trauma and Orthopaedics, Makriyianni Av., 45 001, Ioannina, Greece
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