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Schaffler BC, Konda SR. Tibial bone loss. OTA Int 2024; 7:e315. [PMID: 38840708 PMCID: PMC11149745 DOI: 10.1097/oi9.0000000000000315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 06/07/2024]
Abstract
Critical bone loss after open fractures, while relatively uncommon, occurs most frequently in high-energy injuries. Fractures of the tibia account for the majority of open fractures with significant bone loss. A number of different surgical strategies exist for treatment of tibial bone loss, all with different advantages and disadvantages. Care should be taken by the surgeon to review appropriate indications and all relevant evidence before selecting a strategy.
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Affiliation(s)
| | - Sanjit R. Konda
- NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
- Jamaica Hospital Medical Center, Queens, NY
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Akhoundzadeh D, Bloemers FW, Verhofstad MHJ, Schoonmade LJ, Geeraedts LMG. Which surgical technique may yield the best results in large, infected, segmental non-unions of the tibial shaft? A scoping review. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02478-y. [PMID: 38446155 DOI: 10.1007/s00068-024-02478-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 02/19/2024] [Indexed: 03/07/2024]
Abstract
PURPOSE Infected nonunion of the tibia with a large segmental bone defect is a complex and challenging condition for the patient and surgeon. This scoping review was conducted to identify existing evidence and knowledge gaps regarding this clinical scenario. Secondly, the objective of this study was to search for a valid recommendation on the optimal treatment. METHODS A comprehensive search was conducted in the bibliographic databases: PubMed, Embase.com, and Web of Science Core Collection. Studies reporting on bone transport techniques, the Masquelet technique, and vascularized fibular grafts in bone defects greater than 5 cm were included. Bone healing results and functional results were compared according to duration of nonunion, infection recurrence, bone consolidation, complication rate, external fixation time, and time until full weight-bearing. RESULTS Of the 2753 articles retrieved, 37 studies could be included on bone transport techniques (n = 23), the Masquelet technique (n = 7), and vascularized fibular grafts (n = 7). Respective bone union percentages were 94.3%, 89.5%, and 96.5%. The percentages of infection recurrence respectively were 1.6%, 14.4% and 7.0%, followed by respectively 1.58, 0.78, and 0.73 complications per patient. CONCLUSION Bone transport was found to be the most widely studied technique in the literature. Depending on the surgeon's expertise, vascularized fibular grafts may be held as a favourable alternative. This review indicates that further high-quality research on large bone defects ( ≥ 5 cm) in patients with infected tibial nonunions is necessary to gain more insight into the potentially beneficial results of vascularized fibular grafts and the Masquelet technique.
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Affiliation(s)
- Dena Akhoundzadeh
- Department of Surgery, Section Trauma Surgery, Amsterdam UMC, location VUmc, De Boelelaan 1117, P.O. Box 7057, 1007, Amsterdam, MB, Netherlands.
| | - Frank W Bloemers
- Department of Surgery, Section Trauma Surgery, Amsterdam UMC, location VUmc, De Boelelaan 1117, P.O. Box 7057, 1007, Amsterdam, MB, Netherlands
| | | | - Linda J Schoonmade
- University Library, VU University, Amsterdam UMC, Amsterdam, Netherlands
| | - Leo M G Geeraedts
- Department of Surgery, Section Trauma Surgery, Amsterdam UMC, location VUmc, De Boelelaan 1117, P.O. Box 7057, 1007, Amsterdam, MB, Netherlands
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Dheenadhayalan J, Imran A, Devendra A, Venkatramani H, Velmurugesan PS, Rajasekaran S, Sabapathy SR. Can locking plate fixation and free Vascularised fibular transfer with skin island achieve good functional outcome in the treatment of large bone defects of Tibia ? A study of 26 cases. Injury 2024:111465. [PMID: 38508984 DOI: 10.1016/j.injury.2024.111465] [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: 10/16/2023] [Revised: 02/02/2024] [Accepted: 02/25/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Despite the availability of multiple treatment options, management of tibial bone loss continues to be a challenge. Free vascularized fibula graft (FVFG) with a skin paddle offers better advantages over the other methods. We aimed to study the functional outcomes and QALY of patients with large tibial bone defects following FVFG with a locking plate in 26 patients. MATERIALS AND METHODS We analyzed 26 consecutive patients with large tibial bone defects treated by free vascularized fibular graft (FVFG) and stabilization using a long locking plate between 2009 and 2018. All were followed up for a mean period of 42 months (24 months to 120 months). Bony union, graft hypertrophy, and complications such as stress fracture and infections were assessed. Multivariate regression analysis was performed to identify any association between demographic factors, injury characteristics, treatment-related factors, and fibular hypertrophy. Additionally, The EQ-5D quality-of-life (QOL) indices were obtained using the SF-12 score to evaluate the patients' overall quality of life. RESULTS The mean age of the patients at the time of presentation was 36.26 yrs (range, 18-60 years). The cause of bone loss was open injury in 16 patients and infected nonunion in 10 patients. Complete union was achieved in 25 patients (96 %) without any requirement of additional surgical procedures. The mean union time of the graft was 4.04 months (range, 3-6 months). The mean fibular hypertrophy calculated by De Boer index was 0.61 %, 11 %, 28.24 % and 52.52 % at 3,6 months and 1 and 2 years respectively. Patients with metaphyseal bone loss have significant fibular hypertrophy. Participants in our study experienced a quality of life equivalent to 0.88 (range 0.79-0.99) of perfect health. CONCLUSIONS FVFG with skin paddle and LCP fixation for massive tibial bone loss achieved satisfactory outcome and QALY even in the challenging healthcare environment of South India, a developing country.It maintains alignment, promotes graft hypertrophy, and prevents stress fractures. LEVEL OF EVIDENCE Level 4 LEVEL OF CLINICAL CARE: Level I Tertiary trauma centre.
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Affiliation(s)
- Jayaramaraju Dheenadhayalan
- Department of Orthopaedics and Trauma, Ganga Medical Centre and Hospitals Pvt., Coimbatore, Tamil Nadu, India.
| | - Asif Imran
- Department of Orthopaedics and Trauma, Ganga Medical Centre and Hospitals Pvt., Coimbatore, Tamil Nadu, India
| | - Agraharam Devendra
- Department of Orthopaedics and Trauma, Ganga Medical Centre and Hospitals Pvt., Coimbatore, Tamil Nadu, India
| | - Hari Venkatramani
- Department of Plastic, Hand and Reconstructive Surgery, Ganga Medical Centre & Hospitals, Coimbatore, Tamil Nadu, India
| | | | - Shanmuganathan Rajasekaran
- Department of Orthopaedics and Trauma, Ganga Medical Centre and Hospitals Pvt., Coimbatore, Tamil Nadu, India
| | - Shanmuganathan Raja Sabapathy
- Department of Plastic, Hand and Reconstructive Surgery, Ganga Medical Centre & Hospitals, Coimbatore, Tamil Nadu, India
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Zoabi A, Redenski I, Oren D, Kasem A, Zigron A, Daoud S, Moskovich L, Kablan F, Srouji S. 3D Printing and Virtual Surgical Planning in Oral and Maxillofacial Surgery. J Clin Med 2022; 11:jcm11092385. [PMID: 35566511 PMCID: PMC9104292 DOI: 10.3390/jcm11092385] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 04/15/2022] [Accepted: 04/18/2022] [Indexed: 02/01/2023] Open
Abstract
Compared to traditional manufacturing methods, additive manufacturing and 3D printing stand out in their ability to rapidly fabricate complex structures and precise geometries. The growing need for products with different designs, purposes and materials led to the development of 3D printing, serving as a driving force for the 4th industrial revolution and digitization of manufacturing. 3D printing has had a global impact on healthcare, with patient-customized implants now replacing generic implantable medical devices. This revolution has had a particularly significant impact on oral and maxillofacial surgery, where surgeons rely on precision medicine in everyday practice. Trauma, orthognathic surgery and total joint replacement therapy represent several examples of treatments improved by 3D technologies. The widespread and rapid implementation of 3D technologies in clinical settings has led to the development of point-of-care treatment facilities with in-house infrastructure, enabling surgical teams to participate in the 3D design and manufacturing of devices. 3D technologies have had a tremendous impact on clinical outcomes and on the way clinicians approach treatment planning. The current review offers our perspective on the implementation of 3D-based technologies in the field of oral and maxillofacial surgery, while indicating major clinical applications. Moreover, the current report outlines the 3D printing point-of-care concept in the field of oral and maxillofacial surgery.
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Affiliation(s)
- Adeeb Zoabi
- Department of Oral and Maxillofacial Surgery, Galilee College of Dental Sciences, Galilee Medical Center, Nahariya 2210001, Israel; (A.Z.); (I.R.); (D.O.); (A.K.); (A.Z.); (S.D.); (L.M.); (F.K.)
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
| | - Idan Redenski
- Department of Oral and Maxillofacial Surgery, Galilee College of Dental Sciences, Galilee Medical Center, Nahariya 2210001, Israel; (A.Z.); (I.R.); (D.O.); (A.K.); (A.Z.); (S.D.); (L.M.); (F.K.)
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
| | - Daniel Oren
- Department of Oral and Maxillofacial Surgery, Galilee College of Dental Sciences, Galilee Medical Center, Nahariya 2210001, Israel; (A.Z.); (I.R.); (D.O.); (A.K.); (A.Z.); (S.D.); (L.M.); (F.K.)
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
| | - Adi Kasem
- Department of Oral and Maxillofacial Surgery, Galilee College of Dental Sciences, Galilee Medical Center, Nahariya 2210001, Israel; (A.Z.); (I.R.); (D.O.); (A.K.); (A.Z.); (S.D.); (L.M.); (F.K.)
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
| | - Asaf Zigron
- Department of Oral and Maxillofacial Surgery, Galilee College of Dental Sciences, Galilee Medical Center, Nahariya 2210001, Israel; (A.Z.); (I.R.); (D.O.); (A.K.); (A.Z.); (S.D.); (L.M.); (F.K.)
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
| | - Shadi Daoud
- Department of Oral and Maxillofacial Surgery, Galilee College of Dental Sciences, Galilee Medical Center, Nahariya 2210001, Israel; (A.Z.); (I.R.); (D.O.); (A.K.); (A.Z.); (S.D.); (L.M.); (F.K.)
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
| | - Liad Moskovich
- Department of Oral and Maxillofacial Surgery, Galilee College of Dental Sciences, Galilee Medical Center, Nahariya 2210001, Israel; (A.Z.); (I.R.); (D.O.); (A.K.); (A.Z.); (S.D.); (L.M.); (F.K.)
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
| | - Fares Kablan
- Department of Oral and Maxillofacial Surgery, Galilee College of Dental Sciences, Galilee Medical Center, Nahariya 2210001, Israel; (A.Z.); (I.R.); (D.O.); (A.K.); (A.Z.); (S.D.); (L.M.); (F.K.)
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
| | - Samer Srouji
- Department of Oral and Maxillofacial Surgery, Galilee College of Dental Sciences, Galilee Medical Center, Nahariya 2210001, Israel; (A.Z.); (I.R.); (D.O.); (A.K.); (A.Z.); (S.D.); (L.M.); (F.K.)
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
- Correspondence:
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Long-term follow-up of a severely traumatized leg treated with ipsilateral fracture-united fibular transfer in a patient with amputation of the contralateral leg: a case report. Arch Plast Surg 2021; 48:699-702. [PMID: 34818719 PMCID: PMC8627945 DOI: 10.5999/aps.2021.01186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 09/14/2021] [Indexed: 11/08/2022] Open
Abstract
Extensive bone loss associated with severe vascular injury remains a challenge for lower extremity reconstruction. The fibular free flap has been utilized for many decades to reconstruct long-segment tibial defects. We present an unusual scenario of unilateral weight-bearing, wherein we salvaged the sole lower extremity by transfer of the fractured ipsilateral fibula and a bipedicled skin flap. A 38-year-old man sustained a severe crush injury in the right leg with loss of circulation. His left lower leg had a soft tissue defect measuring 20×15 cm with an exposed comminuted fracture and a 17-cm tibial defect, along with a segmental fracture of the fibula. Subsequently, we reconstructed the tibial defect by transferring a 17-cm-long section of the ipsilateral fibula. We covered the soft tissue defect with a bipedicled skin flap. The patient eventually began to ambulate independently after surgery.
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Migliorini F, La Padula G, Torsiello E, Spiezia F, Oliva F, Maffulli N. Strategies for large bone defect reconstruction after trauma, infections or tumour excision: a comprehensive review of the literature. Eur J Med Res 2021; 26:118. [PMID: 34600573 PMCID: PMC8487570 DOI: 10.1186/s40001-021-00593-9] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 09/20/2021] [Indexed: 12/16/2022] Open
Abstract
Large bone defects resulting from musculoskeletal tumours, infections, or trauma are often unable to heal spontaneously. The challenge for surgeons is to avoid amputation, and provide the best functional outcomes. Allograft, vascularized fibular or iliac graft, hybrid graft, extracorporeal devitalized autograft, distraction osteogenesis, induced-membrane technique, and segmental prostheses are the most common surgical strategies to manage large bone defects. Given its optimal osteogenesis, osteoinduction, osteoconduction, and histocompatibility properties, along with the lower the risk of immunological rejection, autologous graft represents the most common used strategy for reconstruction of bone defects. However, the choice of the best surgical technique is still debated, and no consensus has been reached. The present study investigated the current reconstructive strategies for large bone defect after trauma, infections, or tumour excision, discussed advantages and disadvantages of each technique, debated available techniques and materials, and evaluated complications and new perspectives.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Gerardo La Padula
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy
| | - Ernesto Torsiello
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy
| | - Filippo Spiezia
- Ospedale San Carlo Potenza, Via Potito Petrone, 85100, Potenza, Italy
| | - Francesco Oliva
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy.,School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Thornburrow Drive, Stoke on Trent, England.,Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary University of London, 275 Bancroft Road, London, E1 4DG, England
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Othman S, Bricker JT, Azoury SC, Elfanagely O, Weber KL, Kovach SJ. Allograft Alone vs. Allograft with Intramedullary Vascularized Fibular Graft for Lower Extremity Bone Cancer: A Systematic Review and Meta-Analysis. J Plast Reconstr Aesthet Surg 2020; 73:1221-1231. [DOI: 10.1016/j.bjps.2020.02.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/09/2020] [Indexed: 12/30/2022]
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Jiang N, Wang BW, Chai YM, Wu XB, Tang PF, Zhang YZ, Yu B. Chinese expert consensus on diagnosis and treatment of infection after fracture fixation. Injury 2019; 50:1952-1958. [PMID: 31445830 DOI: 10.1016/j.injury.2019.08.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Currently, accurate diagnosis and successful treatment of infection after fracture fixation (IAFF) still impose great challenges. According to the onset of infection symptoms after implantation, IAFF is classified as early infection (<2 weeks), delayed infection (2∼10 weeks) and late infection (>10 weeks). Confirmation of IAFF should be supported by histopathological tests of intraoperative specimens which confirm infection, cultures from at least two suspected infection sites which reveal the same pathogen, a definite sinus or fistula which connects directly the bone or the implant, and purulent drainage from the wound or presence of pus during surgery. Diagnosis of IAFF is built on comprehensive assessment of medical history, clinical signs and symptoms of the patient, and imaging and laboratory tests. The gold standard of diagnosis is histopathological tests. Treatment of IAFF consists of radical debridement, adequate irrigation, implant handling, systematic and local antibiotics, reconstruction of osseous and/or soft tissue defects, and functional rehabilitation of an affected limb. Early accurate diagnosis and appropriate treatment of IAFF play a key role in increasing the cure rate, reducing infection recurrence and disability risk, restoring limb function and improving quality of life of the patient.
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Affiliation(s)
- Nan Jiang
- Department of Orthopaedics & Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Bo-Wei Wang
- Department of Orthopaedics & Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Yi-Min Chai
- Department of Orthopaedics, The Sixth People's Hospital of Shanghai Jiao Tong University, Shanghai, PR China
| | - Xin-Bao Wu
- Department of Orthopaedics & Traumatology, Beijing Jishuitan Hospital, Beijing, PR China.
| | - Pei-Fu Tang
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, PR China.
| | - Ying-Ze Zhang
- Department of Orthopaedics, The Third Hospital of Hebei Medical University, Shijiazhuang, PR China.
| | - Bin Yu
- Department of Orthopaedics & Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China.
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Meselhy MA, Singer MS, Halawa AM, Hosny GA, Adawy AH, Essawy OM. Gradual fibular transfer by ilizarov external fixator in post-traumatic and post-infection large tibial bone defects. Arch Orthop Trauma Surg 2018; 138:653-660. [PMID: 29417207 DOI: 10.1007/s00402-018-2895-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Several reconstructive procedures have been used in management of large tibial bone defects including bone graft, bone transport (distraction osteogenesis) using various external fixators, and vascularized bone graft. Each of these procedures has its limitations and complications. The study describes gradual medial fibular transfer using Ilizarov external fixators in management of patients with large tibial defect, either following infection or trauma. PATIENTS AND METHODS Between May 2011 and June 2013, 14 patients were prospectively included in the current study. The inclusion criteria were large tibial defect due to trauma or infection with severe soft tissue compromise, and small or poor tibial bone remnants making bone lengthening difficult. Exclusion criteria were patients with vascular or nerve injuries. The average age of the patients was 31.64 (± 6.5) years. Medial fibular transfer was done for all patients using Ilizarov at a rate of 0.5 mm twice daily. Iliac bone graft was used in all patients after the transfer. RESULTS The average segmental bone defect of the tibia was (13.2 ± 2.6), ranging between 8 and 18.6 cm. Union was achieved in all patients with average fixator time was 32.42 (± 4.32) weeks. Average follow-up after removal of the fixator was 40.5 (± 6.9) months. CONCLUSION Gradual fibular transfer by Ilizarov external fixator is a reliable technique in management of post-traumatic and post-infection large tibial bone defects with good clinical outcome, and with few complications.
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Affiliation(s)
- Mohammed Anter Meselhy
- Orthopedic Department, Benha University, El-Shaheed Farid Nada Street, Kafer el Gazar, Banha, Qalyubia, 13511, Egypt.
| | - Mohamed Salah Singer
- Orthopedic Department, Benha University, El-Shaheed Farid Nada Street, Kafer el Gazar, Banha, Qalyubia, 13511, Egypt
| | - Abdelsamie M Halawa
- Orthopedic Department, Benha University, El-Shaheed Farid Nada Street, Kafer el Gazar, Banha, Qalyubia, 13511, Egypt
| | - Gamal Ahmed Hosny
- Orthopedic Department, Benha University, El-Shaheed Farid Nada Street, Kafer el Gazar, Banha, Qalyubia, 13511, Egypt
| | - Adel H Adawy
- Orthopedic Department, Benha University, El-Shaheed Farid Nada Street, Kafer el Gazar, Banha, Qalyubia, 13511, Egypt
| | - Osama M Essawy
- Orthopedic Department, Benha University, El-Shaheed Farid Nada Street, Kafer el Gazar, Banha, Qalyubia, 13511, Egypt
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The psychological impact of external fixation using the Ilizarov or Orthofix LRS method to treat tibial osteomyelitis with a bone defect. Injury 2017; 48:2842-2846. [PMID: 29122280 DOI: 10.1016/j.injury.2017.10.036] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 10/21/2017] [Accepted: 10/25/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To examine the psychological impact of external fixation for a tibial bone defect due to osteomyelitis, and to compare the Orthofix limb reconstruction system (LRS) with the Ilizarov external fixator. MATERIALS AND METHODS The SCL-90-R questionnaire was administered at four different time points (before surgery, while patients wore the external fixation device, when the device was removed, and two to three months after). The scores at the four time points were compared, as were the two different methods of external fixation (Orthofix LRS vs. Ilizarov). RESULTS The patients experienced a significant adverse impact on their mental health, with the worst outcomes at Time 2 (while wearing the external fixator), but with some negative effects still present even several months after removal of the fixation device. Although the Orthofix LRS and Ilizarov groups showed similar mental health scores at Time 1 (preoperatively) and Time 3 (upon removal of the fixation device), the Orthofix LRS was associated with better scores, specifically in the Hostility (Time 2), Phobic Anxiety (Time 2), Psychoticism (Times 2 and 4), and Other (Time 2) sub-scores, as well as the total score (Times 2 and 4). CONCLUSIONS Although both Ilizarov and Orthofix LRS fixation resolved the bone defects, external fixation had a negative impact on the patients' mental health, which persisted even after removal of the devices. Although both methods led to negative effects on the patients' mental, the impact of the Orthofix LRS was less severe.
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Abstract
Infected nonunions of tibia pose many challenges to the treating surgeon and the patient. Challenges include recalcitrant infection, complex deformities, sclerotic bone ends, large bone gaps, shortening, and joint stiffness. They are easy to diagnose and difficult to treat. The ASAMI classification helps decide treatment. The nonunion severity score proposed by Calori measures many parameters to give a prognosis. The infection severity score uses simple clinical signs to grade severity of infection. This determines number of surgeries and allows choice of hardware, either external or internal for definitive treatment. Co-morbid factors such as smoking, diabetes, nonsteroidal anti-inflammatory drug use, and hypovitaminosis D influence the choice and duration of treatment. Thorough debridement is the mainstay of treatment. Removal of all necrotic bone and soft tissue is needed. Care is exercised in shaping bone ends. Internal fixation can help achieve union if infection was mild. Severe infections need external fixation use in a second stage. Compression at nonunion site achieves union. It can be combined with a corticotomy lengthening at a distant site for equalization. Soft tissue deficit has to be covered by flaps, either local or microvascular. Bone gaps are best filled with the reliable technique of bone transport. Regenerate bone may be formed proximally, distally, or at both sites. Acute compression can fill bone gaps and may need a fibular resection. Gradual reduction of bone gap happens with bone transport, without need for fibulectomy. When bone ends dock, union may be achieved by vertical or horizontal compression. Biological stimulus from iliac crest bone grafts, bone marrow aspirate injections, and platelet concentrates hasten union. Bone graft substitutes add volume to graft and help fill defects. Addition of rh-BMP-7 may help in healing albeit at a much higher cost. Regeneration may need stimulation and augmentation. Induced membrane technique is an alternative to bone transport to fill gaps. It needs large amounts of bone graft from iliac crest or femoral canal. This is an expensive method physiologically and economically. Infection can resorb the graft and cause failure of treatment. It can be done in select cases after thorough eradication of infection. Patience and perseverance are needed for successful resolution of infection and achieving union.
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Affiliation(s)
- Milind Madhav Chaudhary
- Director, Orthopaedic Surgery, Centre for Ilizarov Techniques, Chaudhary Hospital, Akola, Maharashtra, India,Address for correspondence: Dr. Milind Madhav Chaudhary, Chaudhary Hospital, Akola - 444 001, Maharashtra, India. E-mail:
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Molina CS, Stinner DJ, Obremskey WT. Treatment of Traumatic Segmental Long-Bone Defects: A Critical Analysis Review. JBJS Rev 2016; 2:01874474-201404000-00001. [PMID: 27490871 DOI: 10.2106/jbjs.rvw.m.00062] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Cesar S Molina
- Department of Orthopedics, Orthopedic Trauma Institute, Vanderbilt University Medical Center, 1215 21st Avenue South, Suite 4200 MCE-South Tower, Nashville, TN 37232
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Management of post-traumatic bone defects of the tibia using vascularised fibular graft combined with Ilizarov external fixator. Injury 2016; 47:969-75. [PMID: 26948238 DOI: 10.1016/j.injury.2016.01.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Revised: 01/24/2016] [Accepted: 01/26/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Post-traumatic bone defects of the tibia present a difficult reconstructive challenge. Various methods of reconstruction are available, such as allografts, vascularised fibular graft (either free or pedicled) and bone transport technique. PATIENTS AND METHODS Fourteen patients with an average age of 34.1 years at operation (range, 12-65) with post-traumatic bony defects of the tibia were selected for reconstruction with vascularised fibular graft combined with Ilizarov external fixation. There were 12 male and two female. The size of the bony gap was 10.4 cm (range, 7-13) and the average length of the fibula used was 16.4 cm (range, 14-21). RESULTS The mean follow up period was 20.4 months (range, 10-37). All patients had bony union at both proximal and distal ends of the fibula primarily except one patient that required secondary iliac bone graft at the distal end of the fibula to obtain union. The average time for bone healing was 3.9 months (range, 3-9). The average time spent in Ilizarov frame was 5.9 months (range, 5-11). Unprotected full weight-bearing was achieved within an average of 7.3 months (range, 6-12). CONCLUSION Vascularised fibular bone graft combined with an Ilizarov frame is a successful approach to safely and effectively reconstruct bone defects of the tibia. It has the advantages of vascularised fibular bone grafts together with the biomechanical advantages of Ilizarov frame that allows weight bearing to start almost immediately after surgery. This leads to a good outcome regarding the union and function.
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