Masquelet combined with free-flap technique versus the Ilizarov bone transport technique for severe composite tibial and soft-tissue defects

BACKGROUND

The treatment of bone and soft-tissue defects after open fractures remains challenging. This study aimed to evaluate the clinical efficacy of the Masquelet technique combined with the free-flap technique (MFFT) versus the Ilizarov bone transport technique (IBTT) for the treatment of severe composite tibial and soft-tissue defects.

METHODS

We retrospectively analysed the data of 65 patients with tibial and soft-tissue defects and Gustilo type IIIB/C open fractures treated at our hospital between April 2015 and December 2021. The patients were divided into two groups based on the treatment method: group A (n = 35) was treated with the MFFT and internal fixation, and group B (n = 30) was treated with the IBTT.

RESULTS

The mean follow-up period was 28 months (range 13-133 months). Complete union of both soft-tissue and bone defects was achieved in all cases. The mean bone-union times were 6 months (range 3-12 months) in group A and 11 months (range 6-23 month) in group B, with a significant difference between the two groups (Z = -4.11, P = 0.001). The mean hospital stay was 28 days (range 14-67 d) in group A which was significantly longer than the mean stay of 18 days (range 10-43 d) in group B (Z = -2.608, P = 0.009). There were no significant differences in the infection rate between group A (17.1 %) and group B (26.7%) (χ2 = 0.867, P = 0.352). The Total Physical Health Scores were 81.51 ± 6.86 (range 67-90) in group A and 75.83±16.14 (range 44-98) in group B, with no significant difference between the two groups (t = 1.894, P = 0.063). The Total Mental Health Scores were significantly higher in group A (90.49 ± 6.37; range 78-98) than in group B (84.70 ± 13.72; range 60-98) (t = 2.232, P = 0.029).

CONCLUSION

Compared with IBTT, MFFT is a better choice of treatment for open tibial and soft-tissue defects with Gustilo IIIB/C fractures. IBTT is the preferred option when the tibial bone defect is large or if the surgeon's expertise in microsurgery is limited.

Treatment of Tibial Plateau Fractures with a Circular External Fixator: A Comparative Analysis of Two Assembly Methods

Objective  To compare the functional outcomes of two circular external fixation techniques to treat complex fractures of the proximal end of the tibia. Materials and Methods  The present is a retrospective cohort study with 51 patients who underwent surgical treatment for complex fractures of the tibial plateau with a circular external fixator. There were two groups of patients: 12 subjects underwent treatment with the classic assembly technique, and 39 subjects underwent treatment with the simplified technique. The variables analyzed included age, sex, injury mechanism, trauma energy, associated injuries, fixator type, time of fixator use, and clinical-radiographic outcomes. The classic technique mainly uses transfixing Kirschner wires, while the simplified one replaces the Kirschner wires with Schanz pins in the distal block of the circular external fixator. Result  There were no statistically significant differences ( p  > 0.05) between the two groups concerning the clinical-radiographic outcomes, including fracture consolidation, quality of joint fracture reduction, range of motion, lower limbs residual discrepancy, and postoperative pain. Conclusion  We suggest that the simplified technique, using Schanz pins instead of Kirschner wires, can be a viable and effective alternative to treat complex fractures of the proximal end of the tibia with a circular external fixator. This simplified approach can offer benefits, such as a lower infection rate and greater patient comfort, without compromising clinical and radiographic outcomes, thus justifying its use.

The Outcomes of Distraction Osteogenesis over an Intramedullary Nail for the Treatment of Bone Defects in Infectious Nonunions

Objectives

The concurrent utilization of an external fixator and intramedullary nail (IMN) for segment transportation may potentially decrease the duration of external fixator implementation and reduce associated complications. This study aimed to report the outcomes of bone transport utilizing a combination of IMN and Ilizarov frame in a cohort of individuals who had tibia or femur critical-sized bone deficiency resulting from nonunion.

Methods

The present research used a single-arm clinical trial design to enroll a series of patients presenting with critical-sized bone defects resulting from infectious nonunion of the tibia or femur. The study was conducted during the period of 2017-2020 in a referral Orthopedic Surgery Center located in Tehran, Iran. The management of patients with infectious nonunion was carried out through two main stages, including infection eradication and bone transportation. The process of bone healing and segment transportation was evaluated by radiographic assessment throughout the follow-up period.

Results

A total of 39 patients with bone defects in the tibia (19 cases) or femur (20 cases) with a mean age of 31.44 (±11.95, range=18-60) were included in this study. Twenty-nine (74.3%) patients had open fractures. The bone defect exhibited an average size of 6.31 ± 1.95 cm. The mean of the consolidation index (CI) was 0.97 (range=0.51-1.32) mo/cm, and the mean of the external fixator index was 0.67 (range=0.41-1.10). Although the CI was longer in patients with open fracture compared to those with closed fracture, the difference was not statistically significant (P=0.353). After the end of the two-year follow-up, complete union was observed in 35 patients (89.7%).

Conclusion

Intercalary segmental bone transportation using the Ilizarov technique over an IMN, as well as preserving the advantages of the conventional callotasis method, reduces the complications of long-term use of the Ilizarov frame and increases patient adherence to treatment.

Advances in the Application of Bone Transport Techniques in the Treatment of Bone Nonunion and Bone Defects

Bone nonunion and bone defects frequently occur following high-energy open injuries or debridement surgeries, presenting complex challenges to treatment and significantly affecting patients' quality of life. At present, there are three primary treatment options available for addressing bone nonunion and bone defects: vascularized bone grafts, the Masquelet technique, and the Ilizarov technique. The Ilizarov technique, also known as distraction osteogenesis, is widely favored by orthopedic surgeons because of several advantages, including minimal soft tissue requirements, low infection risk, and short consolidation time. However, in recent years, the application of the Masquelet technique has resulted in novel treatment methods for managing post-traumatic bone infections when bone defects are present. Although these new techniques do not constitute a panacea, they continue to be the most commonly employed options for treating complex large bone nonunion and bone defects. This review evaluates the currently available research on the Ilizarov and Masquelet bone transport techniques applied at various anatomical sites. Additionally, it explores treatment durations and associated complications to establish a theoretical foundation that can guide clinical treatment decisions and surgical procedures for the management of bone nonunion and bone defects.

Docking site complications analysis of Ilizarov bone transport technique in the treatment of tibial bone defects

BACKGROUND

Treating long bone defects of the extremities caused by trauma, infection, tumours, and nonunion has been challenging for clinical orthopaedic surgeons. Bone transport techniques have the potential to treat bone defects. However, inevitable docking site complications related to bone transport techniques have been reported in many studies. The purpose of this study was to investigate the risk factors associated with docking site complications in patients who underwent the Ilizarov bone transport technique for the treatment of tibial bone defects.

METHODS

This retrospective study included 103 patients who underwent bone transport for the treatment of large bone defects in the tibia from October 2012 to October 2019. Patient demographic data, complications and clinical outcomes after a minimum of 2 years of follow-up were collected and retrospectively analysed. Additionally, univariate analysis and logistic regression analysis were used to analyse the factors that may affect the development of docking site complications in patients with tibial bone defects treated with the Ilizarov bone transport technique. The clinical outcomes were evaluated using the Association for the Study and Application of the Ilizarov criteria (ASAMI) at the last clinical follow-up.

RESULTS

All 103 patients with an average follow-up of 27.5 months. The docking site complications rate per patient was 0.53, and delayed union occurred in 22 cases (21.4%), axial deviation occurred in 19 cases (18.4%) and soft tissue incarceration occurred in 10 cases (9.7%). According to the results of the logistic regression analysis, the bone defect length (P = 0.001, OR = 1.976), and bone defect of distal 1/3 (P = 0.01, OR = 1.976) were significantly correlated with delayed union. Bone defect length (P < 0.001, OR = 1.981) and external fixation time (P = 0.012, OR = 1.017) were significantly correlated with axial deviation. Soft tissue defects (P = 0.047, OR = 6.766) and the number of previous operations (P = 0.001, OR = 2.920) were significantly correlated with soft tissue incarceration. The ASAMI bone score at the last follow-up showed a rate of excellent and good bone results of 95.1% and a rate of excellent functional results of 90.3%.

CONCLUSION

The Ilizarov bone transport technique is a practical and effective method for the treatment of tibial bone defects. However, the incidence of complications at the docking site is high, of which bone defect length, external fixation time, the number of previous operations, soft tissue defects and the bone defect of distal 1/3 are statistically significantly associated with the occurrence of docking site complications.

Complications analysis of Ilizarov bone transport technique in the treatment of tibial bone defects-a retrospective study of 199 cases

BACKGROUND

The clinical treatment of long bone defets in the extremities caused by trauma, infection, tumours, and nonunion has been a challenge for orthopaedic surgeons. Bone transport techniques have become the only way to treat such bone defects. However, inevitable difficulties and complications related to bone transport techniques have been reported in many studies.

AIM

The purpose of this study was to investigate the risk factors for complications and the effectiveness of the Ilizarov bone transport technique in the treatment of tibial bone defects.

METHODS

The study was conducted in 199 patients who underwent treatment with the Ilizarov bone transport technique at our institution from May 2012 to September 2019. Patient demographic data, complications and clinical outcomes after a minimum of 2 years of follow-up were collected and retrospectively analysed. Additionally, a risk factor analysis was performed for the top three major complications. The clinical outcomes were evaluated using the Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria at the last clinical follow-up.

RESULTS

A total of 199 patients underwent follow-up for 12-40 months, with an average of 23.5 months, and all achieved bone healing. A total of 310 complications occurred, with an average of 1.04 minor complications and 0.48 major complications per patient. The top three complications were pin tract infection in 48 cases (61.3%), axial deviation in 86 cases (43.2%), and delayed union in 50 cases (25.13%). Multivariate analysis showed that the bone defect length (P = 0.02, OR = 5.489), the number of previous surgeries (P = 0.003, OR = 2.204), and the external fixation index (P = 0.01, OR = 1.202) were significantly correlated with pin tract infection. Bone defects of the middle 1/3 (P < 0.001, OR = 23.769), the bone defect length (P < 0.001, OR = 2.776), and the external fixation index (P < 0.001, OR = 1.154) were significantly correlated with axial deviation. The bone defect length (P = 0.003, OR = 1.242), soft tissue defects (P = 0.013, OR = 0.312) and bone defects of the distal 1/3 (P = 0.023, OR = 4.257) were significantly correlated with delayed healing. The ASAMI bone score at the last follow-up showed a rate of excellent and good bone results of 95.48% and a rate of excellent functional results of 87.94%.

CONCLUSION

The Ilizarov bone transfer technique is an effective method for treating tibial bone defects, and shortening the treatment period can reduce the incidence of complications. Older patients and those with longer bone defects, a higher external fixation index, more previous operations, and defects of the middle and distal 1/3 had a higher incidence of complications.

Ilizarov technique in the treatment of bone defects of the radius and ulna: a systematic review and meta-analysis

PURPOSE

The objective of this systematic review and meta-analysis was to assess the efficacy of the Ilizarov method in the treatment of radius and ulna bone defects.

METHODS

The PubMed, Embase, Web of Science, Cochrane Library, Ovid MEDLINE, and Scopus databases were searched for articles published up to May 2023. The quality of the studies was evaluated using a modified version of the Newcastle-Ottawa scale. The effect size and confidence intervals at 95% for the main results were calculated. The heterogeneity was evaluated. The demographic data, defect size (DS), external fixation time (EFT), external fixation index (EFI), and complications were extracted and analyzed using the Stata version 16.

RESULTS

This meta-analysis identified and included seven studies involving 98 patients. The union rate of 100% was reported in all studies. According to the findings of the single-arm meta-analysis, the pooled DS was 3.42 cm (95% CI [2.64, 4.21], I2 = 53.5%, P = 0.045), EFT was 148.43 days (95% CI [97.49, 199.38], I2 = 91.9%, P = 0.000), and EFI was 41.32 days/cm (95% CI [35.72, 46.91], I2 = 62.2%, P = 0.021). Pin tract infection was the most common complication, as reported in six studies.

CONCLUSION

The findings of the present meta-analysis indicate that the Ilizarov technique is a successful treatment option for bone defects in the radius and ulna. This method has demonstrated efficacy in achieving expected clinical outcomes.

Treatment of Infected Pseudarthrosis of the Tibia Using the Ilizarov Method and the Orr Dressing

Objective  This study aims to analyze outcomes and clinical and epidemiological data of infected tibial pseudarthrosis using the Ilizarov method and the Orr dressing. Methods  Data from n = 43 patients diagnosed with infected tibial pseudarthrosis were analyzed by descriptive and inferential statistical methods. In addition, Paley's assessment criteria evaluated bone and functional outcomes. Qualitative variables were presented as the distribution of absolute and relative frequencies. The presentation of quantitative variables followed the D'Agostino-Pearson test. Results  Thirty-seven (86.04%) subjects were males, and six (13.95%) were females. The most frequent age group among patients was 50 to 59 years old (25.6%), with a p-value = 0.8610. The treatment time was longer for the trifocal treatment (23.8 months) when compared to the bifocal treatment (15.6 months), with a p-value = 0.0010* (highly significant). Excellent bone outcomes represented 72.09% of the sample; 23.25% of outcomes were good. Functional outcomes were excellent in 55.81%, good in 6.97%, and regular in 27.90% of subjects. The Orr dressing (using Vaseline gauze) proved effective, achieving wound healing with soft tissue coverage in all patients evaluated. Conclusions  The Ilizarov method resulted in a substantial change in the treatment of bone infections, especially infected pseudarthrosis. The versatility of this method has turned it into an effective tool, allowing the healing of the infectious process and the correction of potential deformities and shortening.

Treatment of a compound calcaneus fracture Sanders IV with an external circular fixator and calcaneal osteotomy

Compound Gustilo-type III intra-articular calcaneus fractures are challenging to treat. Anatomical reduction of the subtalar joint increases the chances of a better functional outcome and is traditionally achieved by an open reduction and plating. Conversely, ORIF is associated with a high risk of infection and even amputation. In our case study, we present the treatment of a Gustilo-type III intra-articular calcaneus fracture with a circular external fixator and a temporary antibiotic cement spacer for fracture reduction and stabilization. Active bio-glass was implanted to fill bone loss and to prevent infection. A closing-wedge calcaneal tuberosity osteotomy was used to facilitate wound closure. We paid special attention to reducing the posterior facet. The patient returned to work and full ambulation five months post-injury.

[Analysis of the effectiveness of sequential plate internal fixation in correction of Madelung deformity after ulnar osteotomy and shortening]

Objective

To investigate the effectiveness of sequential plate internal fixation in the correction of Madelung deformity after ulnar osteotomy and shortening.

Methods

The clinical data of 13 patients with Madelung deformity admitted between September 2015 and July 2021 were retrospectively analyzed. There were 5 males and 8 females with an average age of 18.3 years ranging from 17 to 23 years. The disease duration ranged from 12 to 24 months, with an average of 17 months. Three cases had a clear history of trauma. All patients had external radial deviation deformity and limited movement of the ulnar deviation, and the ulnar impact pain was significant during ulnar deviation movement; 9 patients had limited wrist joint supination movement, and the supination movement was normal. In the first stage, ulnar osteotomy and shortening combined with external fixator were used to correct wrist deformity in 13 patients. After operation, bone transfer was performed 6 times per day, with adjustments made every 4 hours, which was 1 mm per day. After the osteotomy was in place, the ulnar plate internal fixation was performed to reconstruct the ulnar stability in the second stage. The Cooney wrist joint score was used to assess the pain, function, range of motion, flexion and extension range of motion, and grip strength of the wrist joint before operation and before the removal of internal fixator. The subjective feeling and appearance satisfaction of patients were recorded.

Results

After the second-stage operation, all the 13 patients were followed up 10-22 months, with an average of 15 months. The deformity of wrist joint disappeared after operation, and the flexion, extension, and ulnar deviation were basically normal. There was no complication such as ulnar impingement sign, nonunion or infection. Wrist function, pain, and range of motion were significantly improved after operation, except for 1 patient who had no significant improvement in rotation and pain. The ulnar internal fixator was removed at 10-18 months after the second-stage operation. The scores of pain, function, range of motion, flexion and extension range of motion, and grip strength in the Cooney wrist score before removal of internal fixator significantly improved when compared with those before operation ( P<0.05). Subjective and appearance satisfaction of patients were excellent in 9 cases, good in 3 cases, and fair in 1 case.

Conclusion

Ulnar osteotomy and shortening with sequential plate internal fixation for correction of Madelung deformity, with mild postoperative pain, can effectively avoid bone nonunion, improve wrist joint function, and have significant effectiveness.

Treatment of talipes equinovarus after triceps surae intramuscular hemangioma surgery by Ilizarov technology in adults: A case report

BACKGROUND

Postoperative complications of triceps surae intramuscular hemangioma surgery with talipes equinovarus have rarely been described, and the evidence for treatment is limited. The purpose of this case study was to report the new application of the Ilizarov technique, which successfully treated talipes equinovarus in adults after triceps surae intramuscular hemangioma.

CASE SUMMARY

A 29-year-old woman treated with the Ilizarov technique for talipes equinovarus in the right leg after triceps surae intramuscular hemangioma surgery. The equinus deformity was roughly corrected after 2 years of follow-up, without significant secondary sequelae.

CONCLUSION

Talipes equinovarus caused by postoperative sequelae of intramuscular hemangioma was successfully corrected by the Ilizarov technique. The Ilizarov technique may be used for treating talipes equinovarus caused by various causes.

Metacarpal Lengthening Using a Mini-Ring Ilizarov Device for Thumb Reconstruction

PURPOSE

To explore the results of using the mini-ring Ilizarov external fixator for thumb metacarpal lengthening and its compatibility with a simultaneous groin flap.

METHODS

From May 2016 to June 2019, 17 adult patients with thumb loss were treated with metacarpal lengthening using a mini-ring Ilizarov device. The device was composed of 2 rings, threaded rods, nuts, and K-wires (diameter, 1.5 mm). Of these patients, 6 also underwent simultaneous groin flap transfer. Lengthening was started 3 days after surgery at a rate of 0.66 mm/d. The pedicle of the groin flap was divided 1 month after the surgery. The healing index (days per cm), which denotes the number of days the external fixator is attached to the bone per centimeter of length gained, was used to evaluate the lengthening efficiency.

RESULTS

The patients were observed for 21.9 ± 9.0 months. The lengthening continued for 29.1 ± 4.5 days, resulting in an additional length of 1.9 ± 0.3 cm.

CONCLUSIONS

The mini-ring Ilizarov external fixator is a simple device for primary metacarpal lengthening. This device can be used with a groin flap for single-stage lengthening of injured thumbs with bone exposure.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

[Preliminary study of Ilizarov technique in treatment of lower limb deformity caused by achondroplasia]

Objective

To investigate the surgical method and preliminary effectiveness of Ilizarov technique in the treatment of lower limb deformity caused by achondroplasia.

Methods

The clinical data of 38 patients with lower limb deformity caused by achondroplasia treated by Ilizarov technique between February 2014 and September 2021 were retrospectively analyzed. There were 18 males and 20 females, the age ranged from 7 to 34 years, with an average of 14.8 years. All patients presented with bilateral knee varus deformity. The preoperative varus angles was (15.2±4.2)°, and knee society score (KSS) was 61.8±7.2. Nine of these patients underwent tibia and fibula osteotomy, 29 cases underwent tibia and fibula osteotomy and bone lengthening at the same time. Full-length bearing position X-ray films of bilateral lower limbs were taken to measure the bilateral varus angles, analyze the healing index, and record the occurrence of complications. KSS score was used to evaluate the improvement of knee joint function before and after operation.

Results

All 38 cases were followed up 9-65 months, with an average of 26.3 months. Needle tract infection occurred in 4 cases and needle tract loosening occurred in 2 cases after operation, which were improved after symptomatic treatment such as dressing change, Kirschner wire change, and oral antibiotics, and no neurovascular injury occurred in all patients. The external fixator was worn for 3-11 months after operation, with an average of 7.6 months, and the healing index was 43-59 d/cm, with an average of 50.3 d/cm. At last follow-up, the leg was 3-10 cm longer, with an average of 5.5 cm. The varus angles was (1.5±0.2)° and the KSS score was 93.7±2.6, which significantly improved when compared with those before operation ( P<0.05).

Conclusion

Ilizarov technique is a safe and effective method for the treatment of short limb with genu varus deformity caused by achondroplasia, which can improve the quality of life of patients.

How accurate is computer-assisted mandible gunshot wound management by patient-specific distraction device? Preoperative planning versus postoperative outcomes

Gunshot wounds of the lower face are a challenge for the surgeon. Customized distraction osteogenesis (DO) is a well-established procedure for managing facial gunshot wounds. However, differences between the preoperative planning and postoperative outcomes are often noted. This multi-centre, retrospective study was performed to analyse the differences between the planning and outcomes for the lower third of the face, in patients undergoing the computer-assisted repair of mandible gunshot wounds using patient-specific distraction devices. Different planes and points were defined, and two distances (anteroposterior and intercondylar lengths) and an angle (inter-mandible body angle) were measured on the preoperative planning models and the postoperative models obtained from the computed tomography data. Twelve patient cases that met the study eligibility criteria were included. A significant difference between the planning and postoperative outcome was found for the anteroposterior length (6.6 mm shorter than the preoperative planning; P = 0.003). The differences in intercondylar length (P = 0.116) and inter-mandible body angle (P = 0.121) were not significant. This study revealed a difference between the planning and outcomes. Various factors such as scar tissue and muscle forces limit distraction and therefore lead to under-correction with insufficient projection.

A modified pixel value ratio based on contralateral normal bone: a novel reliable indicator for distraction osteogenesis

BACKGROUND

The traditional pixel value ratio (tPVR) is subject to disuse osteopenia of the adjacent bone in distraction osteogenesis (DO). Therefore, a modified PVR (mPVR) based on the contralateral normal bone was developed and validated to address this issue.

METHODS

A total of 79 bone lengthening subjects were recruited in this retrospective study. The difference between the mPVR and tPVR of early callus was identified in the first three months after osteotomy. Moreover, we further investigated the relationship between mPVR and healing index (HI), lengthening index (LI) and external fixator index (EFI). Finally, the potential influencing factors for mPVR of the early callus were analyzed.

RESULTS

The mPVR was significantly lower than the tPVR in the first three months after osteotomy, and the difference gradually increased. Interestingly, the mPVR of the early callus in the first two months was negatively correlated with the HI, LI and EFI. Moreover, the age, lengthening site, total bilirubin and mean hemoglobin content were associated with the mPVR of early callus during DO.

CONCLUSION

The mPVR based on contralateral normal bone is a novel reliable indicator for DO, which may be helpful for the clinical management of DO. However, the findings of this study need to be confirmed further by larger prospective research.

Plate fixation after lengthening with an external fixator in patients with achondroplasia : A comparative study between two centers

BACKGROUND

This study compared internal fixation with a plate after lengthening (PAL) with an external fixator with the conventional method (CM) in terms of radiologic and clinical outcomes in the lower extremities of patients with achondroplasia.

METHODS

In this study 20 patients (50 lower extremity long bones) who underwent PAL or CM were divided into 2 cohort groups. The amount of lengthening, percentage lengthening, external fixator index (EFI), external fixator time, Li regeneration index, complication rate, and knee range of motion (ROM) were compared between the groups.

RESULTS

The median age was 9.4 years (range 6-16 years) in the PAL group and 12 years (range 9-16 years) in the CM group (p = 0.01). Males comprised 80% of the patients in the PAL group and 47% of the patients in the CM group (p = 0.02). The median amount of lengthening in the PAL and CM groups was 7.5 cm (range 5.5-9.5 cm) and 6.0 cm (range 5.5-9.0 cm), respectively (p < 0.01). The median percentage of lengthening in the PAL and CM groups was 44.6% (range 20.0-70.1%) and 43.0% (range 20.5-57.3%), respectively (p = 0.01). The median external fixator time in the PAL and CM groups was 127 days (range 94-185 days) and 180 days (range 105-355 days), respectively (p < 0.01). The median EFI in the PAL and CM groups was 21 days/cm (range 10-33 days/cm) and 27 days/cm (range 15-59 days/cm), respectively (p < 0.01). The Li regeneration index was 3 (interquartile range, IQR 2-4) in both groups (p = 0.2). The total complication rate was similar between the groups.

CONCLUSION

In patients with achondroplasia, after lengthening with an external fixator, internal fixation with a plate can be a reliable alternative to the conventional method.

LEVEL OF EVIDENCE

Level III therapeutic.

New bone formation using antibiotic-loaded calcium sulfate beads in bone transports for the treatment of long-bone osteomyelitis

PURPOSE

Bone transport is one of the most frequently used techniques for critical-sized bone defects due to trauma or infection. To fill the defect area and avoid the collapse of soft tissues during transport, some authors have described the use of polymethylmethacrylate or absorbable antibiotic carriers in the form of cylindrical blocks.

METHODS

In this article, we present our experience in the treatment of post-traumatic osteomyelitis of the lower and upper limbs, using a bone transport technique with antibiotic-loaded calcium sulfate in the form of beads. Results With the progressive absorption of calcium sulfate, we observed the formation of a bone-like tissue envelope at the periphery of the defect area. Histological analysis and direct visualization during open revision surgery of the docking site in all patients confirmed the presence of newly formed bone tissue with a high presence of osteoblasts and few osteoclasts; no areas of necrosis or signs of infection were observed. This bone envelope maintained the mechanical protective function of the transport path and docking site, and also provided a biological stimulus to avoid the development of necrotic areas and optimize the consolidation phase. Conclusion Bone transport with calcium sulfate beads improves biological and mechanical support and reduces the number of surgeries required.

[NRD assisted Ilizarov technique in the treatment of infected bone and soft tissue defect of tibia]

OBJECTIVE

To investigate the clinical effect of NRD assisted Ilizarov technique in the treatment of infected bone and soft tissue defect of tibia.

METHODS

All 48 patients with infected bone and soft tissue defect of tibia were randomly divided into study group and control group from March 2013 to December 2020. There were 34 males and 14 females, aged from 24 to 55 years old with an average of (40.54±11.64) years old. There were 25 patients in the study group, including 17 males and 8 females, aged from 31 to 55 years old with an average of (41.36±9.69) years old. The study group were treated with NRD assisted with Ilizarov bone transport technique. There were 23 patients in control group, including 17 males and 6 females, aged from 24 to 53 years old with an average of(38.61±8.76) years old. The control group were treated with traditional bone transport technique. The curative rate, recurrence rate, incidence rate of pin track infection, time of using antibiotics, time of wound healing, time of carrying external fixation, time of bone transport, time of bone healing and postoperative function were used to evaluate the therapeutic effect of the two groups.

RESULTS

The follow-up period was from 12 to 62 months with an average of (33.0±7.2) months. At the final follow-up, there was no significant difference in the curative rate between the two groups (P>0.05). The recurrence rate in the study group was lower than that in the control group(P<0.05). The incidence of pin track infection in the study group was lower than that in the control group (P<0.05). The time of using antibiotics and wound healing in the study group was shorter than that in the control group(P<0.05). There was no significant difference in the time of bone transport and carrying of external fixation between the two groups(P>0.05). There was no significant difference in bone healing and postoperative function between the two groups(P>0.05).

CONCLUSION

NRD assisted Ilizarov technique can achieve satisfactory results in the treatment of infected bone and soft tissue defect of tibia and shorten the treatment period and the time of using antibiotics. It is worthy of development in clinic.

[Effect of freshening technique on docking site in tibial bone transport management]

OBJECTIVE

To study the effect of freshening technique on docking site in tibial bone transport management.

METHODS

Retrospective cohort study was conducted about the effect of freshening technique on docking site in 20 cases(15 males and 5 females) treated with tibial bone transport from January of 2014 to December of 2019. The age of patients ranged from 19 to 62 years old, with an average of (42.3±11.5)years old. Seven patients had infectious bone defect and 13 patients had non-infectious. Application of freshening technique immediately after docking included resection of invaginated skin or soft tissue, removal of closed sclerotic bone, re-apposition, increasing the contact, acute compression of freshened docking site and grafting from adjacent medullary or bone debris, followed by post-operative gradual compression.

RESULTS

The amount of segmented bone defect ranged from 5 to 15 cm, with an average of(9.2±2.9) cm. Time required from osteotomy to contact of butt end ranged from 26 to 243 days, with an average of(109.1±51.1) days. The duration needed from 3 to 7 months with an average of(3.7±1.1) months before reaching radiological healing criterion in docking site. Fourteen out of 15 concurrent fibular osteotomy were united. Consolidation time for distracted callus ranged from 5 to 28 months, with an average of (15.0±6.5) months. Bone healing index(BHI) ranged from 0.8 to 2.8 months/cm, with an average of (1.6±0.5) months. One surgical site infection (5%) in tibial was noted. No refractures were found in follow-up ranged from 12 to 73 months, with an average of(37.6±20.3) months after fixator removal.

CONCLUSION

Freshening technique immediately after docking had advantages of the shorter healing time, avoidance of refracture, and independance of necessity for remote autograft harvest.

Risk factors of transport gap bending deformity in the treatment of critical-size bone defect after bone transport

Background

The purpose of this study was to investigate the risk factors of transport gap bending deformity (TGBD) in the treatment of critical-size bone defect (CSBD) after the removal of the external fixator.

Methods

From January 2008 to December 2019, 178 patients with bone defects of the lower extremity caused by infection were treated by bone transport using a unilateral external fixator in our medical institution. TGBD was defined as the bone callus in the distraction area with a deviation to the force line of the femur (> 10°) or tibia (> 12°) after removal of the external fixator. The Association for the Study and Application of the Method of Ilizarov (ASAMI) standard was applied to assess the bone and functional outcomes. After the data were significant by the T-test or Pearson’s Chi-square test was analyzed, odds ratios were calculated using logistic regression tests to describe factors associated with the diagnosis of TGBD.

Results

A total of 178 patients were enrolled in the study, with a mean follow-up time of 28.6 ± 3.82 months. The positive result of the bacteria isolated test was observed in 144 cases (80.9%). The rate of excellent and good in the bone outcomes (excellent/good/fair/poor/failure, 41/108/15/14/0) was 83.7%, and 92.3% in the functional results (excellent/good/fair/poor/failure, 50/98/16/14/0) according to the ASAMI criteria. TGBD after removal of external fixator occurred in twenty-two patients (12.3%), including 6 tibias, and 16 femurs. Age > 45 years, BMI > 25 kg/m², femoral defect, diabetes, osteoporosis, glucocorticoid intake, duration of infection > 24 months, EFT > 9 months, EFI > 1.8 month/cm were associated significantly with a higher incidence of TGBD in the binary logistic regression analysis (P < 0.05). The incidence more than 50% was found in patients with femoral defect (76.1%), osteoporosis (72.7%), BMI > 25 kg/m² (69.0%), diabetes (59.5%), glucocorticoid intake (54.7%). In the multivariate logistic regression analyses, the following factors were associated independently with TGBD, including age > 45 years, BMI > 25 kg/m², femoral defect, diabetes, and osteoporosis.

Conclusions

Bone transport using a unilateral external fixator was a safe and practical method in the treatment of CSBD caused by infection. The top five risk factors of TGBD included femoral defect, BMI > 25 kg/m², duration of bone infection > 24 months, age > 45 years, and diabetes. Age > 45 years, BMI > 25 kg/m², femoral defect, osteoporosis, and diabetes were the independent risk factors. The higher incidence of TGBD may be associated with more risk factors.

Tetrafocal (three osteotomies) and pentafocal (four osteotomies) bone transport using Ilizarov technique in the treatment of distal tibial defect-preliminary outcomes of 12 cases and a description of the surgical technique

OBJECTIVE

To evaluate the preliminary outcomes of tetrafocal (three osteotomies) and pentafocal (four osteotomies) bone transport using Ilizarov technique for the treatment of distal tibial defect and describe the surgical technique.

METHODS

A total of 12 eligible patients with distal tibial defect > 6 cm caused by direct trauma or posttraumatic osteomyelitis who were admitted to our institution from January 2017 to January 2019 were treated by tetrafocal or pentafocal bone transport using Ilizarov technique. Detailed demographic data, including age, sex, etiology, defect size, number of osteotomies (three or four), external fixation time (EFT) and external fixation index (EFI), were collected, and the bone and functional outcomes were evaluated by the Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system. Complications during the surgery and the follow-up period were recorded and evaluated by the Paley classification at a minimum follow-up of two years after removal of the fixator.

RESULTS

There were 9 men and 3 women with an average age of 37.4±7.8 years. The etiology included posttraumatic osteomyelitis in 8 cases and posttraumatic bone loss in 4 cases. The mean bone defect after radical debridement was 7.1±0.6 cm. Tetrafocal bone transport was applied in 9 cases, and pentafocal bone transport was applied in 3 cases. The average EFT and EFI were 5.2±0.8 months and 0.7±0.2 months/cm, respectively. The average time of follow-up after removal of the external fixator was 28.5±3.3 months without recurrence of osteomyelitis. The bone results were good in 7 cases, fair in 4 cases, and poor in 1 case, and the functional results were good in 5 cases, fair in 6 cases, and poor in 1 case. The most common complication was pin tract infection, which occurred in all cases, but there were no major complications, such as nerve or vascular injury.

CONCLUSION

Tetrafocal and pentafocal bone transport using Ilizarov technique could be an alternative treatment option in selected cases with distal tibial defect > 6 cm. It could shorten the distraction period, fasten regeneration, and reduce the associated complications.

Pilot Study of Additive Effect of "Offloading Ilizarov Frame" To Reduce "Reverse Sural Flap" Surgery Complications: A Clinical Trial

Background

A reverse sural flap is an available surgical technique because it provides robust axial blood circulation to flaps with a substantially larger surface area. We aimed to assess Ilizarov frames outcome after reverse sural flaps among patients with traumatic injuries to the distal portion of the leg.

Methods

Patients with traumatic distal injury of leg in Shoha-e Tajrish Hospital in 2022-2021 were recruited and treated with reverse sural flaps. Interventional group was followed by Ilizarov frames application (group A). For the second group, just conventional dressings and proper positioning were done after surgery (group B). Between the two groups, the duration of surgery, the degree of flap swelling, the time from surgery to discharge and flap failure, surgical site infection, deep vein thrombosis (DVT), and other complications were compared using SPSS 25 software.

Results

Of 26 recruited patients, twenty consented to participate in this study. The average time from initial injury to reconstruction surgery, the mean duration of surgery, the mean time from surgery to discharge and the degree of swelling of the flap was compared between these two groups. The results showed better outcome in Ilizarov group, but the flap swelling grade was the only statistically significant factor between groups (P value= 0.03).

Conclusions

The use of "offloading Ilizarov frames" to protect reverse sural flaps resulted in a considerable reduction in the flap swelling. It is a safe, quick, easy, and effective technique.

Bifocal femoral lengthening assisted by preoperative 3-dimensional design in the restoration of posttraumatic limb length discrepancy

Background

To assess the clinical outcomes of preoperative three-dimensional planning followed by bifocal femoral lengthening in the treatment of posttraumatic limb length discrepancy (LLD).

Methods

A total of 8 eligible patients with posttraumatic femoral LLD > 6 cm were admitted to our institution from January 2015 to January 2018 and treated by bifocal femoral lengthening with the assistance of 3-dimensional imaging technology. The following data were collected: detailed demographic information, the amount of lengthening, external fixation time (EFT), external fixation index (EFI), postoperative bone and functional outcomes, and complications in the follow-up period.

Results

All included patients were successfully followed up for in an average of 55.4 ± 6.7 months after removal of the external fixator. There were six males and two females with an average age of 38.4 ± 12.2 years. The mean preoperative LLD was 69.2 ± 6.2 mm. The mean lengthening amount was 67.5 ± 6.9 mm. The mean EFT was 180.1 ± 20.2 days. The EFI was 26.73 ± 1.36 days/cm on average. All patients achieved satisfactory postoperative bone and functional outcomes. No major complications such as nerve or vascular injury were observed.

Conclusions

Bifocal femoral lengthening with preoperative three-dimensional design provided precise surgical guidance and resulted in satisfactory postoperative outcomes, demonstrating that it is an effective treatment for posttraumatic femoral LLD.

Matched comparative study of trifocal bone transport versus induced membrane followed by trifocal bone transport in the treatment of segmental tibial defects caused by posttraumatic osteomyelitis

Objectives

To compare the efficacy and clinical outcomes of trifocal bone transport (TBT) versus induced membrane followed by trifocal bone transport (IM + TBT) in the treatment of tibial defects > 6 cm caused by posttraumatic osteomyelitis.

Methods

A total of 69 eligible patients with tibial defects > 6 cm who were treated between January 2010 and January 2018 were retrospectively reviewed. Overall, 18 patients treated by IM + TBT and 18 treated by TBT were matched by propensity score analysis. The mean tibial defect after radical debridement was 6.97 ± 0.76 cm (range, 6.0 to 8.9 cm). The measurements, including demographic data, external fixation index (EFI), external fixation time (EFT), duration of docking union, bone and functional outcomes evaluated by the Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system, and postoperative complications evaluated by Paley classification during follow-up were recorded.

Results

Age, gender, injury mechanism, affected side, defect size, previous operation time, and follow-up time were not significantly different between the two groups (P > 0.05). The mean EFT was 293.8 ± 12.1 days in the TBT group vs. 287.5 ± 15.3 days in the IM + TBT group. The mean EFI was 36.02 ± 2.76 days/cm vs. 34.69 ± 2.83 days/cm, respectively. The mean duration of docking union was 210.7 ± 33.6 days vs. 179.7 ± 22.9 days, respectively. There was no significant difference in postoperative bone and functional results between the two groups. Delayed union or nonunion and soft tissue incarceration were significantly reduced in the IM + TBT group compared to those in the TBT group.

Conclusion

Both TBT and IM + TBT achieved satisfactory postoperative bone and functional outcomes in patients with segmental tibial defects > 6 cm following posttraumatic osteomyelitis, while IM + TBT had a significantly lower incidence of postoperative complication in delayed union or nonunion and soft tissue incarceration, as well as faster docking union.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05501-8.

Role of Perforating Artery Pedicled Neurotrophic Flap in the Treatment of Compound Tissue Defect of Tibia Using the Ilizarov Technique

OBJECTIVE

To describe our experience with the combined use of pedicled neurotrophic flap and distraction osteogenesis in the management of complex lower extremity injuries with composite bone and soft tissue defects and assess the functional and cosmetic results of this method.

METHODS

A pedicled flap with a marked perforator artery was applied for soft tissue coverage after radical debridement and temporary external fixation. In the second stage, the Ilizarov external fixator was used in place of the temporary external fixator for reconstruction of the segmental bone defect by distraction osteogenesis. Twenty-five patients (16 men and nine women; mean age, 39.2 years) were treated by using this combined technique between 2008 and 2016. All cases were graded initially as Gustilo-Anderson grade IIIB open fractures. The soft tissue defect after radical debridement ranged from 9 cm × 5 cm to 14 cm × 11 cm, and the average size of segmental defect was 5.2 (Range, 2.5-8.5) cm. Seventeen of these patients had a history of local infection. The bone structure and function were evaluated by two independent evaluators using Paley's criteria.

RESULTS

Twenty-five patients were followed up for an average of 28.96 (Range, 15-48) months. The distally based sural neurovascular flap was applied in 13 patients, and the greater saphenous neurocutaneous perforator flap in 12 patients. The flap area ranged from 10 cm × 5 cm to 14 cm × 12 cm. Sufficient coverage of soft tissue defect was achieved in all cases. All flaps survived completely without complications. The bone defects were corrected by a mean lengthening of 6.94 (Range, 4.5-9.5) cm. The residual discrepancy was <1 cm in all cases, which was not clinically significant. The function was evaluated as excellent in 12 patients and good in 13 patients. Bone results were graded as excellent in 18 patients and good in seven patients. Complications during treatment included pain, pin tract infections, ankle midfoot joint stiffness, and docking site nonunion. No recurrence of infection was observed in infected patients. All cases achieved successful limb salvage and satisfactory function recovery without recurrence of infection.

CONCLUSIONS

The combined technique of a perforator artery pedicled neurotrophic flap and distraction osteogenesis is an effective alternative approach in the salvage treatment of massively traumatized and chronically infected lower extremities.

Twenty Years Development of Tibial Cortex Transverse Transport Surgery in PR China

Tibial cortex transverse transport (TTT) surgery is an extension of the Ilizarov technique. Based on the law of tension‐stress, its primary function is to rebuild microcirculation which can relieve ischemic symptoms and promote wound healing. It has received more and more scholars' attention and has experienced a series of changes for 20 years since it entered PR China. The mechanisms involved have gradually become clear, such as the reconstruction of the polarization balance of macrophages, the promotion of vascular tissue regeneration, and the mobilization and regulation of bone marrow‐derived stem cells. TTT technique is mainly used in the treatment of chronic ischemic diseases of the lower extremities. It has recently been successfully used in the treatment of primary lymphedema of the lower extremities. A series of improvements have been made in the external fixator's style, the size of skin incision and osteotomy, and distraction method. For example, the annular external fixator has been redesigned as a unilateral external fixator, and accordion technology has been introduced. For distraction methods after surgery, there was no uniform standard in the past. The technique can also be used in combination with other treatments to achieve better effects, such as interventional therapy, negative pressure sealed drainage, 3D printing technology, traditional Chinese medicine. Nevertheless, the surgery may bring some complications, such as secondary fracture, nail infection, skin necrosis at the surgical site, etc. Reports of complications and doubts about the technique have made the TTT technique controversial. In 2020, the relevant expert consensus was published with treatment and management principles, which might guide the better application and development of this technique.

Evolution and Development of Ilizarov Technique in the Treatment of Infected Long Bone Nonunion with or without Bone Defects

The treatment of infected bone nonunion and bone defects is a considerable challenge in the orthopedics field. The standard clinical therapy methods include local free bone transplantation, vascularized bone graft, and the Ilizarov technique; the first two are controversial due to the iatrogenic self‐injury. The Ilizarov bone transport technique has been widely used to treat infected bone nonunion and bone defects, and good clinical effect has been demonstrated. Yet, it brings many related complications, which exerts additional suffering to the patient. The best treatment is to combine bone defect rehabilitation with infection control, intramedullary nail fixation, appropriate time for bone grafts, beaded type scaffold slippage and new Taylor fixation, reducing the external fixation time and the incidence of complications, thereby reducing the occurrence of patients' physical and psychological problems. This review focuses on the induction, summary and analysis of the Ilizarov bone transport technique in the treatment of infected long bone nonunion with or without bone defects, providing new ideas and methods for orthopedic disease prevention and treatment by the Ilizarov technique, which is following the development direction of digital orthopedics.

Severe hand contracture treated by external fixation after proximal row carpectomy and awake tenolysis after general anesthesia: A case report

Wide-awake local anesthesia has many advantages. We describe a new method to use wide-awake local anesthesia with more flexibility. A 32-year-old man with a severe right-hand contracture after an iatrogenic tourniquet accident during an anterolateral thigh flap for a partial hand amputation underwent contracture release using external fixation after proximal row carpectomy and subsequent tenolysis. We performed most of the tenolysis procedure under general anesthesia and the final stage with an intraoperative assessment of active finger movement and dissection under local anesthesia. He regained his grip strength 2.5 years post-injury. General anesthesia is useful to treat a surgical site with extensive hard scars, whereas local anesthesia is useful for adjusting tension in an awake patient. The indication for wide-awake surgery is yet to be established; our method of combining general and local anesthesia in the tenolysis procedure illustrates the possibilities in expanding this method.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Novel piston technique versus Ilizarov technique for the repair of bone defect after lower limb infection

BACKGROUND

We aimed to compare the effectiveness and complications of a novel piston technique versus the Ilizarov technique for the repair of bone defects after lower limb infection.

PATIENTS AND METHODS

We retrospectively reviewed 41 patients who had been treated at our department for lower extremity bone defects following osteomyelitis. There were 38 men and three women with a mean age of 43.41 (range, 12-69 years). The infected bone defects involved 36 tibias and five femurs. The piston technique (PT, group A) was used in 12 patients and the Ilizarov technique (IT, group B) in 29 patients. The mean follow-up period was 28.50 months (PT) and 29.90 months (IT). The modified Application of Methods of Illizarov (ASAMI) criteria was used to evaluate bone healing and functional recovery.

RESULTS

Complete eradication of the infection and union of docking sites were accomplished in both groups. The mean external fixator index (EFI) was 42.32 days/cm in group A versus 58.85 days/cm in group B (p < 0.001). The bone outcomes were similar between groups A and B (p = 0.558) (excellent [9 vs. 19], good [3 vs.10]); group A showed better functional outcomes than group B (p < 0.05) (excellent [7 vs. 6], good [4 vs. 12], fair [0 vs. 10] and poor [1 vs. 1]). Pain was the most common complaint during follow-up, and group A had fewer cases of pin tract infection (1 vs. 6), adjacent joint stiffness (3 vs. 8), and delayed healing of the joint (0 vs. 3).

CONCLUSIONS

Satisfactory bone healing can be achieved by using both PT and IT, although PT demonstrated better functional results, lower EFI, and allowed early removal of the external fixation. We found that this novel piston technique can improve the comfort of patients, reduce the incidence of complications, and provide rapid and convenient rehabilitation.

[Preliminary analysis of the clinical characteristics of 1 012 patients with secondary lower limb deformity of spina bifida from QIN Sihe Orthopedic Surgery Case Data between October 12, 1986 and December 31, 2020]

Objective

To analyze the characteristics of patients with secondary lower limb deformity of spina bifida based on the QIN Sihe Orthopedic Surgery Case Data, and provide the references for clinical research, diagnosis, and treatment.

Methods

A clinical data of 1 012 patients with secondary lower limb deformity of spina bifida between October 12, 1986 and December 31, 2020 selected from QIN Sihe Orthopedic Surgery Case Data was retrospectively analyzed. Among them, 231 cases (22.83%) had undergone orthopedic surgery for lower extremity deformities in other hospitals. The gender, age at surgery, indicators related to spina bifida (deformity side, comorbidity, sensory disturbance level), and information related to surgery (operating time, surgical site, postoperative fixation method) were analyzed.

Results

Of the 1012 patients, 457 were males and 555 were females. The age was 3-51 years at the time of surgery, with a median of 18.0 years; among them, the 15-30 years old group had the most patients, accounting for 53.16%. Most deformities involved both lower limbs (652 cases, 64.43%). There were 111 cases of ulcers in the weight-bearing area of the foot, 265 cases of gatism, 554 cases of sensory disturbance, and 85 cases of abnormal hair on the waist. From 2010 to 2019, there were significantly more patients undergoing surgery than before 2010, reaching 61.17%. Sensory disturbances mostly occurred in the ankle and foot. A total of 1 149 sites were treated with surgery, of which the most ankle joint deformities were corrected by surgery, accounting for 84.33%. The main fixation methods after orthopedic surgery were external fixation, including Ilizarov external fixation (442 cases), combined external fixation (315 cases), and plaster fixation (189 cases).

Conclusion

Spina bifida can be secondary to severe deformities of the lower limbs, mainly in the ankles. Common complications include ulcers in the weight-bearing area, dysfunction of urine and feces, and sensory disturbances; external fixation is the main method of fixation after surgery.

The Role of the Ilizarov Ring External Fixator in the Management of Tibial Fractures with Impending/Incomplete Compartment Syndrome

Objective  The management of tibia fractures complicated by compartment syndrome affects the treatment and functional outcome of patients due to the complications associated with fasciotomy. The purpose of the present study is to differentiate impending/incomplete compartment syndrome (ICS) from established acute compartment syndrome (ACS) in tibial fractures, and to assess the outcome of the fixation of the Ilizarov apparatus in patients with these fractures presenting with ICS, who were not submitted to fasciotomy.

Methods  After the establishment of the inclusion and exclusion criteria, 19 patients were included in the study from January 2007 to December 2017. All patients were male, with an average age of 42.3 ± 11.38 years. All of these patients were managed with Ilizarov ring fixation as per the medical and surgical protocol established in the present study.

Results  The average follow-up obtained for our 18 patients was of 47 ± 41.5 months, with one patient being lost to follow-up. The average time for ring application was of 3.7 ± 1.7 days. In total, 3 (16.7%) of these patients had nonunion. There were no soft-tissue or neurovascular complications in the immediate postoperative period. All of the patients eventually united and were independently mobile without any sequelae of compartment syndrome.

Conclusion  The Ilizarov ring external fixator can be used in the management of tibial fractures with ICS, avoiding fasciotomy with its various complications of infection and nonunion, resulting in fewer surgeries and faster rehabilitation. Surgeons should carefully differentiate ACS and ICS in these patients, as the clinical and functional results vary significantly. Unnecessary fasciotomies should be avoided.

Risk factors of pin tract infection during bone transport using unilateral external fixator in the treatment of bone defects

Background

The bone transport using the unilateral external fixator, one of the Ilizarov techniques, is widely practiced in lower limb reconstructive surgery. Pin tract infection (PTI), one of most common complication, has become the important postoperative problems which plague clinicians gradually.

Methods

A group of 130 patients who received bone transport surgery for tibia or femur defects using the unilateral external fixation (Orthofix limb reconstruction system, Verona, Italy) and met the inclusion criteria were selected for the study from 2015 to 2019. Regular pin tract care was performed twice a day, and the conditions of the pin tract were evaluated by the same observer using clinical appearance criteria. The Saw’s classification of PTI was used to assess the condition around screws. After the data were significant by the T-test or Pearson’s Chi-square test analyzed, odds ratios were calculated using logistic regression tests to describe factors associated with the diagnosis of PTI.

Results

Ninety-one males and thirty-nine females with a mean age of 43 years (range 28–58 years) were included in this cohort. 7816 observations were documented from 12 to 36 months, and 58 cases (44.6%) of PTI (thirty-nine cases in grade 1, 17 cases in grade 2, and 2 cases in grade 3). The top five risk factors were agricultural work (OR 1.86, CI 0.94–2.39), non-urban living (OR 1.75, CI 1.24–3.26), male (OR 1.71, CI 1.02–2.31), smoking (OR 1.53, CI 0.76–1.89), and diabetes (OR 1.26, CI 1.12–2.64). No long-term sequelae were observed at the latest clinical visit.

Conclusion

Occupation, gender, living environment (non-urban), smoking, and diabetes were the top five significant risk factors for PTI in the period of bone transport using unilateral external fixation. Awareness of predictable risk factors of PTI is beneficial to avoid or early detect the severe complications which can affect the effectiveness.

[Application of double osteotomy and lengthening of proximal phalanx and metacarpal with Ilizarov technique for thumb defect]

Objective

To investigate the effectiveness of double osteotomy and lengthening of proximal phalanx and metacarpal with Ilizarov technique in treatment of thumb defect.

Methods

Between February 2017 and June 2019, 6 patients with traumatic thumb defects were treated with double osteotomy and lengthening of proximal phalanx and metacarpal by Ilizarov technique. There were 5 males and 1 female. The age ranged from 28 to 57 years, with an average of 41.5 years. There were 3 cases on the left side and 3 cases on the right side. All patients were admitted to the hospital in emergency department after injury, and the stump of the thumb was trimmed and sutured. The osteotomy plane was the distal part of the proximal phalanx in 4 cases and the interphalangeal joint in 2 cases. The interval between injury and osteotomy was 20-245 days (median, 34.5 days). After minimally invasive osteotomy and placement of a semi-circular external fixator, the lengthening began on the 5th day. The proximal phalanx and metacarpal were lengthened by 0.5 mm every day, once every 12 hours. The thumb of the affected side was distracted to the middle of the distal phalanx of the healthy thumb, and the fixator was removed after the bone healed.

Results

The distraction time was 14-23 days, with an average of 18.8 days. The osteotomies were healed with healing time of 91-147 days (mean, 120.2 days). The total distraction length of the proximal phalanx and metacarpal was 1.40-2.25 cm, with an average of 1.86 cm; healing index was 51.0-72.2 days/cm, with an average of 64.9 days/cm. All patients were followed up 5-12 months (mean, 8.2 months). At last follow-up, the two-point discrimination was 5.3-8.5 mm with an average of 6.98 mm. According to the evaluation standard of the upper limb part of the Chinese Medical Association, the score was 10-14, with an average of 12.5. Among them, 4 cases were excellent and 2 cases were good, with an excellent and good rate of 100%. All patients were satisfied with the function and appearance of thumb after operation. The Quick Disabilities of Arm, Shoulder, and Hand (Quick-DASH) score was 2.3-9.1, with an average of 6.1.

Conclusion

The double osteotomy and lengthening of proximal phalanx and metacarpal with Ilizarov technique is an effective method for the treatment of thumb defects.

Effectiveness of teriparatide combined with the Ilizarov technique in septic tibial non-union. Med Glas (Zenica). 2021;18:287-292. [PMID: 33269583 DOI: 10.17392/1280-21]

Aim The septic non-union is a common compliance in bone healing due to bone infection. Bone resection, associated with Ilizarov osteo-distraction technique, is commonly used in these cases. The aim of this study was to analyse clinical and radiological results of teriparatide in combination with the Ilizarov technique and to compare this treatment with the standard treatment. Methods Forty adult patients underwent surgery because of type C of the Association for the Study and Application of Methods of Ilizarov (ASAMI) classification non-union were enrolled. The patients were divided in two groups: those treated with Ilizarov technique (Norm group) and those treated with Ilizarov technique combined with teriparatide injection (Teri group). Surgical duration, complication rate, bone healing status, clinical and functional outcomes were assessed according to the A.S.A.M.I. classification in the mean follow-up of 12 months. The subjective quality of life was assessed by the Short Form Survey (SF)-12. Results Teri group showed less time wearing Ilizarov's frame (p <0.05) than the Norm group and a statistical significance in the inter-rater reliability Cohen's k (p>0.05) respect to Norm according the score between the bone healing and clinical outcome results. There was no statistically significant difference between the two groups in other parameters that were assessed. Conclusion A benefit of teriparatide was found as adjuvant in the treatment of septic non-union.

Efficacy of the "Eiffel tower" double titanium elastic nailing in combined management of congenital pseudarthrosis of the tibia: preliminary outcomes of 17 cases with review of literature

Background

Difficulty in obtaining union, recurrent fractures, and residual deformities remain the problems challenging the management of congenital pseudarthrosis of the tibia (CPT). We applied the “Eiffel Tower” double titanium elastic nails (TENs) in the existing combined approach, which takes advantages of TEN’s mechanical stability with the protection against refracture, Ilizarov’s high fusion rate with alignment control and the biologic environment provided by bone grafting for bony union. The results of this procedure are presented and discussed.

Methods

Seventeen patients with CPT treated by combined surgery including pseudarthrosis resection, the “Eiffel Tower” double TENs technique, autogenous iliac bone grafting, and Ilizarov fixation between 2013 and 2019 were retrospectively investigated. Signs of bone union, limb length discrepancy (LLD), rate of refracture, and degree of residual deformities were reviewed. The AOFAS Ankle Hindfoot scale and measurement of ankle motion were used to evaluate ankle function. The mean follow-up time was 40.5 (11 to 91) months.

Results

The mean age at index surgery was 6.2 (2.5 to 15) years. Union of the pseudarthrosis was achieved in 100% of cases. Among them, 15 (88.2%) patients obtained union of the pseudarthrosis on the first attempt (primary union). The average time to primary union was 3.8 (2 to 6) months. The rest 2 cases achieved union after additional surgeries (secondary union). In terms of complications, refracture occurred in 2 patients (11.8%) and 4 patients (23.5%) developed pin infection. The mean limb length discrepancy at the final follow up was 33.4 (6–141) mm. The average AOFAS score improved from 38.2 (27 to 51) pre-operatively to 77 (63 to 87) post-operatively (p < 0.01).

Conclusions

The “Eiffel Tower” double TENs technique is an ideal intramedullary fixation method in the surgical treatment of CPT. The combination of TENs technique with bone grafting and Ilizarov fixation has the advantages of early bone union, less injury on metaphysis, and early functional recovery.

Level of evidence

Level IV.

A Case Report of Proximal Migration of Fibular Head with Intact Peroneal Nerve in a Post-Operative Infected Tibia Gap Non-union Managed by Ilizarov Technique

Introduction:

We hereby present a rare case of proximal fibular head migration associated with Ilizarov technique for infected tibia gap non-union due to follow-up failure in post-operative management during the coronavirus disease (COVID) pandemic.

Case Report:

A 45-year-old male patient had undergone primary external fixation with wound debridement for a compound tibia shaft fracture Grade 3 A Gustilo class which later on with a healed external wound with a discharging sinus at the fracture site was confirmed to be infected non-union and subsequently managed by Ilizarov ring fixation over an antibiotic coated intramedullary nail and local gentamycin beads after a necrotic bone fragment of around 6 cm was excised. Post-operative protocol of compression and distraction was initiated and the patient educated regarding the same before discharge. As the world over was hit by the COVID pandemic and the lockdown limited all possible movements in our country, the patient could not follow up for monitoring the Ilizarov limb lengthening procedure. He presented to us after 4 months after the relaxation of lockdown with radiological union at the docking site but with a shortening of about 3 cm. Vigorous knee range physiotherapy failed to improve range beyond 90° which prompted us to check X-ray the knee joint and revealed the complication of proximal fibular head migration of 4 cm but with no neurodeficit and currently the patient is being managed with full weight mobilization with the help of crutch and shoe raise and an improved knee range till 100° of flexion with no pain tenderness or any other complaints.

Conclusion:

Having knowledge of this possible rare complication and the need for follow-up and monitoring with the importance of patient education makes practicing orthopedic surgeons equipped to handle and anticipate such undesirable complications.

Risk factors of ankle osteoarthritis in the treatment of critical bone defects using ilizarov technique

Background

Distraction osteogenesis using the Ilizarov external circular fixator has been applied in lower limb reconstructive surgery widely. The increasing ankle osteoarthritis (OA) progression and severity are often associated with the period of external fixator and the greater relative instability of the ankle joint, but few studies have quantified risk factors directly during this technique.

Methods

The study was conducted on 236 patients who underwent bone transport surgery for tibias using the Ilizarov external circular fixator from 2008 to 2018. The cumulative incidence of ankle OA diagnoses in patients after the Ilizarov technique treatment was calculated and stratified by risk factors from preoperative and postoperative management. After the data were significant through the Mann-Whitney U test analyzed, odds ratios were calculated using logistic regression to describe factors associated with the OA diagnosis including gender, age, BMI, location of bone defect, diabetes, hypertension, osteoporosis, the history of metal allergy and glucocorticoid intake, the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-HF scale scores, defect size (DS), the type of bone transport, the bone union time, external fixator time (EFT), and external fixator index (EFI).

Results

There were 199 males and 37 females with a mean age of 47 years (range 28–59 years). Out of 236 patients, 49 had an additional treatment for ankle OA after the Ilizarov technique treatment of bone defects (average follow-up time 2.1 years, range 1.6–4.2 years). The incidence of postoperative ankle OA was 20.8 %, with 19 patients classified as K&L grade 3 and seven patients as grade 4. The top five risk factors included double-level bone transport (OR3.79, P = 0.005), EFI > 50days/cm (OR3.17, P = 0.015), age > 45years (OR2.29, P = 0.032), osteoporosis (OR1.58, P < 0.001), BMI > 25 (OR1.34, P < 0.001). Male, BMI > 25, diabetes, osteoporosis, and AOFAS ankle-HF scale scores are the independent risk factors.

Conclusions

Ilizarov external circular fixator is a safe and effective method of treatment for critical bone defects. The double level bone transport, EFI > 50days/cm, age > 45years, osteoporosis, BMI > 25 are the top five relevant risk factors of ankle OA. The probability of developing ankle OA among patients having three or more risk factors is 50–70 %.

Improved Ilizarov method for management of deformity and ulceration on foot and ankle of spina bifida

Objective

To analyze the characteristics of foot and ankle deformity with ulceration in patients with spina bifida, to conclude experiences on management with improved Ilizarov method in one stage.

Methods

77 cases suffering foot and ankle deformity with ulceration of spina bifida were included from January 2008 to June 2019, in which 30 male and 47 female, aged 6–46 years with an average age of 22.86 years. There were 10 cases on left, 14 on right and 53 on both. The improved Ilizarov method combined soft tissue surgery, bone osteotomy and Ilizarov technique in one stage, by which the ulcer was dressed aseptically and avoid weight bearing preoperatively, no special treatment, no debridement, no flap coverage and no bacterial culture. Antibiotics were given for 3 days routinely, and the dressing was removed 5 days later. If there was exudation, gauze could be used to wrap continually, if there was no swelling and exudation, no need further more caring. General appearance and radiological image of ulcer and deformity were observed during the period of evaluation and treatment, surgical method and complications, foot & ankle function and overall function were evaluated using AOFAS scoring system and special table designed by authors.

Results

77 cases were followed up for 6–132 months with an average of 50.5 months. Achilles tendon subcutaneous lengthening was performed in 2 cases, posterior tibial tendon and Achilles tendon simultaneous released for 31cases, subtalar joint arthrodesis 25 cases, calcaneus osteotomy 5 cases, triple osteotomy 28 cases, ankle arthrodesis 19 cases, internal rotation osteotomy of tibia was performed in 1 case and 1 case in external rotation osteotomy. There were 67 cases using Ilizarov fixators and 10 cases using Hybrid fixators for immobilization and correction. Stable feet were obtained and ulcers healed simultaneously when all deformities of foot and ankle had been corrected. The healing time of ulcer was average 26.5 days ranging 7–36 days, and there was no infection or delayed healing occurred in any case. Ankle ankylosis in 25 cases, 3 cases of pin tract infection, 2 wires were broken. The AOFAS score significantly increased from 70.5 ± 4.5 preoperative to 81.6 ± 3.9 postoperative; based special table evaluating, Excellent 28 cases, Good 42 cases, Fair7 cases.

Conclusion

The patients with foot & ankle deformity and ulceration suffered from spinal bifida can be treated by improved Ilizarov method in one stage, and the results are satisfactory with short treatment period and decreased complications.

Translational potential of this article

The characteristics of foot and ankle deformity with ulceration inpatients with spina bifida have been analyzed and the experiences on management with improved Ilizarovmethod in one stage have been summarized in this study, which updated treatment concept of neurogenic deformity with ulceration on foot and ankle joint.

[Simultaneous treatment of traumatic calcaneal osteomyelitis and defect deformity with near-arc bone transport by Ilizarov technique]

Objective

To investigate the effectiveness of simultaneous treatment of traumatic calcaneal osteomyelitis and defect deformity with near-arc bone transport by Ilizarov technique.

Methods

Between January 2014 and August 2020, 6 cases of traumatic calcaneal osteomyelitis with defect deformities were treated by simultaneous treatment of near-arc bone transport by Ilizarov technique. The patients were all male; aged from 40 to 61 years (mean, 49.3 years). The disease duration was 2-72 months, with an average of 16.1 months. All patients were traumatic calcaneal osteomyelitis, including 4 cases of falling from height, 1 case of traffic accident injury, and 1 case of crushing injury. The infection affected the talar-heel joint in 4 cases, and the talar-heel joint was fused or partially fused in 2 cases. After the external fixator was removed, the Maryland foot scoring system was used to evaluate the foot function, and the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot function scoring system was used to evaluate the ankle-hindfoot function, and were compared with the preoperative scores.

Results

All patients were followed up 1.5-26.0 months, with an average of 16.3 months. All incisions healed by first intention, no recurrence of infection occurred, and no surgical intervention such as second-stage bone grafting and fusion was performed. Five cases of calcaneal osteomyelitis with defect deformity underwent one-stage osteotomy and slipped, 1 case of the original bone mass after debridement after infection of calcaneal fractures slipped directly. The bone sliding time was 28-62 days, with an average of 38.7 days; the sliding distance was 3.1-5.2 cm, with an average of 3.6 cm. In 1 patient, due to the short follow-up time, the calcaneal slip bone had not healed, the external fixator had not been removed (not involved in clinical scoring), but the foot shape, reexamination of X-ray films and with frame walking were satisfactory. The time with external fixator was 6-8 months, with an average of 6.5 months in the other 5 cases. After removing the external fixator, the foot returned to three-point weight-bearing, and the longitudinal arch was recovered to varying degrees, and there was no obvious varus valgus. The Maryland score after removal of the external fixator was 80.8±4.7, which was significantly higher than that before operation (33.6±4.3) ( t=-35.782, P=0.000), 3 cases were excellent and 2 cases were good; the median AOFAS ankle-hindfoot score was 84, the interquartile range was (79, 86), which was significantly improved when compared with the preoperative score [the median score was 33.5, the interquartile range was (21.3, 37.5)] ( Z=-2.023, P=0.043), 4 cases were excellent and 1 case was good. Among them, pain, walking distance, getting rid of walking aids, going up and down stairs, deformity, etc. were significantly improved when compared with preoperative ones. Mobility such as subtalar and hock joints were poor or disappeared.

Conclusion

Simultaneous treatment of traumatic calcaneal osteomyelitis and defect deformity with near-arc bone transport by Ilizarov technique can optimize the operation method, reduce the number of operations, and try to simulate the original shape of the calcaneus. It is an effective, economical, and novel treatment method.

[Clinical observation of accordion technique in promoting bone transport and prolonging newborn bone mineralization]

OBJECTIVE

To analyze effect of accordion technique on bone mineralization of extended bone segment in treating tibial bone defect with bone transport.

METHODS

From May 2017 to October 2019, 22 patients with tibial bone defects were treated with Ilizarov bone-transport technique, and divided into two groups after bone-transport was completed, 11 patients in each group. In observation group, there were 9 males and 2 females aged from 20 to 60 years old with an average of (42.6± 13.3) years old;the length of bone defect ranged from 3 to 13 cm with an average of(6.4±2.6) cm;2 patients were suffered from upper tibial bone defects, 3 patients were middle and 6 patients were lower;patients were treated with accordion technique for 35 days. In control group, there were 10 males and 1 female aged from 41 to 60 years old with an average of (51.6±6.4) years old;the length of bone defect ranged from 3 to 10.7 cm with an average of (6.6±2.5) cm;1 patient was suffered from upper tibial bone defects, 3 patients were middle and 7 patients were lower;patients were treated with lock external fixator to waiting bone mineralization. The content of hydroxyapatite (HAP) extended bone segment was measured after bone-transport completed immediately, 35, 65 and 95 days after bone-transport was completed, respectively, then the mineralization time and healing time were compared between two groups, and the therapeutic effect of bone defect was evaluated by using Paley scoring criteria.

RESULTS

Twenty-two patients were followed up from 18 to 36 months with an average of (27.0±6.3) months. The wounds on the bone defects healed spontaneously during bone transport, and there were no wound complications such as skin infection or skin necrosis occurred. There were statisticaldifference in the content of HAP of the extended bone segments at 35, 65 and 95 days after bone-transport between two groups (P<0.05). There were difference in mineralization time and healing time between two groups (P<0.05). According to Paley standard evaluation, 10 patients got excellent results, and 1 good in observation group; while 9 patients got excellent results, 2 good in control group;and there was no differences between two groups (Z=-0.607, P= 0.544).

CONCLUSION

Accordion technique and locking external fixator mineralization in prolonging bone segment healing after bone-transport have the equal clinical effect, while the accordion technique could significantly accelerate the growth rate of HAP and shorten the mineralization time and healing time.

[Clinical application of nose ring drain technique combined with Ilizarov circular external fixation for Gustilo ⅢA Pilon fractures]

Objective

To investigate the effectiveness of the nose ring drain (NRD) technique combined with Ilizarov circular external fixation in treatment of Gustilo ⅢA Pilon fracture.

Methods

Between March 2017 and December 2019, 17 patients with Gustilo ⅢA Pilon fractures were admitted and treated with NRD technique combined with Ilizarov circular external fixation. Among them, there were 11 males and 6 females; the age ranged from 24 to 63 years, with an average of 38.2 years. There were 3 cases of traffic accident injury, 13 cases of falling injury, and 1 case of penetrating injury. There were 13 cases of emergency admittance and 4 cases of wound infection after surgical treatment. Furthermore, there were 2 cases of fibula fractures and 3 cases of lateral malleolus fractures.

Results

All patients were followed up 8-12 months, with an average of 9.9 months. All wounds healed by first intention, and 4 patients with preoperative infection had no recurrence during the follow-up. The external fixator was removed after fracture healing in 17 patients at 3-7 months after operation (mean, 4.5 months). At last follow-up, the pain score of the ankle joint Kofoe score was 40-50, with an average of 44; the functional score was 17-27, with an average of 25; the mobility score was 8-18, with an average of 14; and the effectiveness was rated as excellent in 8 cases, good in 7 cases, and poor in 1 case.

Conclusion

For Gustilo ⅢA Pilon fractures, the NRD technique combined with Ilizarov circular external fixation has advantages of good fracture fixation and drainage effects, which greatly reduces the complications of traditional treatment options and the number of operations.

Current trends in craniofacial distraction: A literature review

The techniques and procedures involved in craniofacial distraction are constantly evolving. The understanding of histological and biochemical response at the distraction site is now improved. The cascade of events in distraction osteogenesis (DO) differs significantly from the typical fracture healing, and a better knowledge about these events has helped us identify suitable candidates for DO, make appropriate modifications to the distraction protocols and minimize the risk of complications. Recent advances in the manufacturing techniques have also facilitated the availability of distractors of various shapes and designs, which are now changing the way different craniofacial defects are being treated. Small but rigid intraoral distractors now enable easy placement, are well tolerated by patients and allow for a long consolidation period. The introduction of newer approaches toward treatment, together with the simultaneous management of different craniofacial defects at multiple osteotomy sites and enhanced surgical accuracy with the help of digital imaging, have made treatment outcomes more predictable.

Unprecedented tibial bone lengthening of 33.5 cm by distraction osteogenesis for the reconstruction of a subtotal tibial bone defect. A case report and literature review

Background

We present a case of an immense unprecedented tibial bone lengthening of 33.5 cm. The management of chronic osteomyelitis of the right tibia with subtotal tibial bone defect, talus defect and equinus ankle deformity. We demonstrate limb reconstruction by distraction osteogenesis and correction of ankle deformity with the Ilizarov technique. Limb salvage was preferred as an alternative to amputation to restore basic limb function.

Case presentation

A 16-year-old male patient fell and injured his right lower leg. He attempted to treat the symptoms with traditional home remedies. During 15 months of self-treating, he developed osteomyelitis of the right tibia and had lost function in his foot. Radiology revealed immense bone defect of the right tibia, including talus bone defect and equinus deformity of the calcaneus. The patient’s right tibia was non weight-bearing, had drainage sinus just below his knee and a large scar anteriorly along the entire length of the tibia.

Conclusion

Upon completion of treatment, the patient was able to avoid amputation of his leg with partially restored function for weight-bearing. He carried himself without assistance after 3 years of lost function in his right leg. Tibial bone distraction osteogenesis of 33.5 cm was done after 90% of the tibial length was defected. To the best of our best knowledge, this case is one of a kind to achieve distraction of tibial bone to such length.

Ilizarov Method for Acute Paediatric Tibial Fractures

AIM AND BACKGROUND

A systemic method for the application of Ilizarov fixators and on-table fracture reduction is described in this instructional article. This technique has been developed from the unit's practice in adult patients. The indications, underlying principles and rationale for the method are also discussed.

TECHNIQUE

The basic concept involves the construction of a series of concentric, colinear rings aligned with the mechanical axis of the limb. An orthogonal ring block is initially placed on the proximal segment and extended distally. Wire to ring reduction techniques are used resulting in the contact, alignment and stability required for early full weight-bearing, free movement of knee and ankle, and subsequent healing.

CONCLUSION AND CLINICAL SIGNIFICANCE

Our step-by-step guide takes the reader through a systematic approach to surgery along with tips and tricks on how to achieve reduction and avoid the common pitfalls. With this method, it is possible to achieve an on-table reduction and correction of a multiplanar deformity without the use of expensive hexapod technology. This may allow less experienced users reproduce the technique with a shorter learning curve.

HOW TO CITE THIS ARTICLE

Messner J, Prior CP, Pincher B et al. Ilizarov Method for Acute Paediatric Tibial Fractures. Strategies Trauma Limb Reconstr 2021;16(1):46-52.

Influence of Different Connecting Rod Configurations on the Stability of the Ilizarov/TSF Frame: A Biomechanical Study

Aim

The Ilizarov external fixator (IEF) is frequently used in trauma and elective orthopaedics. Many of its biomechanical variables (ring size, wire diameter, wire number, half pins vs wires, etc.) and their influence on stability and stiffness have been investigated. There is, however, a paucity in the literature regarding the influence of the connecting rod numbers and configurations between the rings on IEF stability. The primary aim of this biomechanical study was to compare the stability between four- and three-rod IEF configurations. Secondarily to assess the difference in stability between symmetrical and asymmetrical spacing of the IEF rods.

Materials and methods

A custom jig was designed to facilitate mounting of a basic two-ring IEF in a hydraulic press. Controlled centre and off-centre (thus simulated bending) axial loading was then applied across the frame. The configurations were loaded up to 4,000 N. The frame deformation was plotted and the data were then analysed and interpreted.

Results

Negligible differences were observed between different four- and three-rod configurations as long as the applied force at the loading point (LP) was within the area of support (AOS) created by the rods. The different four-rod constructs were always more stable than the three-rod constructs during bending.

Conclusion

There is comparable stiffness between a four-rod and a three-rod IEF construct as long as the LP is within the AOS created by the rods. A four-rod IEF is stiffer than a three-rod IEF in bending.

Clinical significance

This study will possibly change some paradigms regarding the planning and application of IEFs by Orthopaedics Traumatologists and Reconstruction Surgeons.

How to cite this article

Thiart G, Herbert C, Sivarasu S, et al. Influence of Different Connecting Rod Configurations on the Stability of the Ilizarov/TSF Frame: A Biomechanical Study. Strategies Trauma Limb Reconstr 2020;15(1):23–27.

Presentation and outcome of femoral infected non-unions in children and adolescents

Objectives

To document the presentation of infected non-unions of femur in pediatric and adolescent population and evaluate the outcome of segmental bone transport with the Ilizarov method.

Methods

This prospective case series study was carried out over a period of five years, from January 01, 2015 to December 31, 2019. The study included all children and adolescent patients who presented with femoral infected non unions. The study excluded patients above the age of 16 years and those who had pathological fractures secondary to bone pathologies such as cysts, tumors or metabolic bone diseases.

Results

Out of 31 patients, 27(87.09%) were males and 4(12.90%) were females. The mean age was 13.48±1.98 years. The underlying mechanisms that lead to the causation of fractures included road traffic accidents (n=23;74.19%), fall from height (n=7;22.58%) and firearm injuries (n=1;3.22%). The bone gaps ranged from 3-5 cm with a mean of 4.00± 0.856 cm. Bone union was achieved among 28(90.32%) patients. Infection was eradicated among 27(87.09%) patients whereas the remaining patients continued to suffer persistent infection. The most common complications included pin tract inflammation/ infection among (n=31;100%) patients and stiffness of knee joint among (n=19;61.29%) patients.

Conclusion

Majority of the patients were males, aged 9-16 years. Road traffic accidents were the commonest cause of the fractures. The Ilizarov method of segmental bone transport was effective in treating the majority of infected non-unions.

[Application of simple Ilizarov ring external fixation technique in treatment of tibial plateau fracture complicated with osteofascial compartment syndrome]

OBJECTIVE

To explore the effectiveness of simple Ilizarov ring external fixation technique in treatment of tibial plateau fractures complicated with osteofascial compartment syndrome.

METHODS

Between September 2013 and March 2017, 30 patients with tibial plateau fractures complicated with osteofascial compartment syndrome were treated with simple Ilizarov ring external fixation technique. There were 23 males and 7 females, with an average age of 34.4 years (range, 23-43 years). The injuries were caused by traffic accident in 12 cases, by falling from height in 4 cases, by falling in 8 cases, and by a crashing object in 6 cases. The time from injury to admission was 1-12 hours (mean, 4.8 hours). According to the Schatzker classification, there was 1 case of type Ⅱ, 3 cases of type Ⅲ, 10 cases of type Ⅳ, 7 cases of type Ⅴ, and 9 cases of type Ⅵ. All patients underwent fasciotomy due to osteofascial compartment syndrome; the interval between fasciotomy and operation was 10-15 days (mean, 12.5 days). Knee Society Score (KSS) and Ilizarov Method Research and Application Association (ASAMI) protocol were used to evaluate knee function.

RESULTS

The operation time was 110-155 minutes (mean, 123.1 minutes); the intraoperative blood loss was 100-500 mL (mean, 245 mL); the postoperative hospital stay was 3-5 days (mean, 3.8 days). All patients were followed up 20-24 weeks (mean, 22.7 weeks). Except for 2 patients with signs of needle tract infection, no other complication occurred. X-ray films showed that the fractures healed, and the healing time was 10-20 weeks (mean, 14.6 weeks). At last follow-up, the KSS clinical score was 70- 95 with an average of 87.5; the functional score was 70-90 with an average of 79.0. According to ASAMI protocol evaluation, the effectiveness was rated as excellent in 24 cases, good in 3 cases, fair in 2 cases, and poor in 1 case.

CONCLUSION

For tibial plateau fractures complicated with osteofascial compartment syndrome, simple Ilizarov ring external fixation technique can basically restore joint function and has fewer complications. It is a relatively safe and effective treatment method.