Reconstruction of bony defects using the Ilizarov “bone transport” technique

Summary Ilizarov's method of percutaneous transosseous osteosynthesis allows management of complex skeletal deformities using elastic external fixation, atraumatic corticotomy and gradual adaptations between bony fragments. One particular application, useful in the reconstruction of bony defects, is the lift or bone transport technique, in which in fact internal lengthening is carried out. Using some of their first cases as illustrations, the authors describe the technique and its potential problems.     

Eurocer® in the filling of bone defects, especially in addition osteotomies of the knee: a preliminary study

Summary After one year, Eurocer® appears to satisfy all requirements in the case of addition osteotomies of the anterior tibial crest (ATT) and its use continues in the department. We have used Eurocer® in other applications: an addition varisation osteotomy of the lower end of the femur, the packing of traumatic losses of bone substance (10 cases), packing for bone defects of tumoral origin (1 case), revisions for loosened total hip prostheses (3 aseptic cases, 1 septic case) and for pseudarthroses of the tibia (Figs. a and 3), etc. Strictly speaking, there is no longer a problem in the use of this biomaterial; no image of sequestration has appeared in our series and no evidence of poor tolerance. In each case careful radiologic study for about one year has shown sharp lines of junction between the surrounding bone and the Eurocer®. There was no image of a demarcating sclerotic marg-in and it seems, subject to reservations, that progressive disappearance of the Eurocer® is in process of taking place. Fig. 1 shows the Eurocer® six months after insertion in a tibia and- this radiograph shows complete absence of sequestration of the product, as well the progressive lysis and smoothing-off of the contours of the Eurocer® fragments. Thus it seems that the findings are varied and multiple. Currently, no factor suggests any doubt as to the value of the use of this product.Paper presented at the 1998 meeting of GECO (Arc 1800, Bourg-Sant-Maurice, France)     

Use of Masquelet’s technique for treating the first metatarsophalangeal joint in cases of gout combined with a massive bone defect

Background

To examine the safety and efficacy of Masquelet’s technique as a surgical method for treating the first metatarsophalangeal joint in cases of gout accompanied by a massive bone defect.

Reverse and pseudoreverse cortical sign in thoracolumbar burst fracture: radiologic description and distinction—a propos of three cases

In thoracolumbar burst fracture the “reverse cortical sign” is a known entity that corresponds to a fragment of the posterior wall that has been flipped 180° with the cancellous surface of the fragment facing posteriorly in the canal and the cortical surface (posterior wall) facing anteriorly. The identification of such reverse cortical fragment is crucial as ligamentotaxis is classically contraindicated as the posterior longitudinal ligament is ruptured. Recognition of such a flipped cortical fragment has relied so far on the axial CT. The advent of CT scans with sagittal reconstruction has allowed us to better describe such entities that have received little attention in the literature. The goal of this report was therefore to describe the appearance of the reverse cortical sign and its likes as they can appear on axial CT scans, sagittal reconstructions and MRI. During 1-year practice at our institution we had to treat three patients with thoracolumbar burst fracture associated with what looked like a reverse cortical sign on the axial CT scans. Further analysis of the sagittal reconstruction CT could differentiate the true reverse cortical sign from a new entity that we coined “the pseudoreverse cortical sign” as observed in two out of the three cases. In the pseudo reverse cortical sign what appears to be a flipped piece of posterior vertebral body is actually part of the superior or inferior endplate that is depressed into the comminuted vertebral body. In such cases the posterior longitudinal ligament appears to be in continuity and therefore such fracture can theoretically be treated with posterior ligamentotaxis as evidenced in one of our case. Careful analysis of the CT scan and specifically the sagittal reconstruction and MRI can differentiate two separate entities that may correspond to a different severity injury.     

“Sandwich technique” in the surgical treatment of primary complex fractures of the femur and humerus

In this prospective study, our aim was to determine the clinical and radiographic outcomes of the surgical treatment of primary complex problem femoral and humeral shaft fractures treated by a new technique called “sandwich technique.” A total of 45 patients with comminuted, complex and/or osteopoenic fractures of the femur or humerus (30 femoral and 15 humeral fractures) were treated using this technique. The patients were followed up for a mean of 25 months. In 24 (85.7%) of 28 patients with femoral fractures and in 14 (93.3%) of 15 patients with humeral fractures, union was achieved within 3–6 months of the operation (mean: 4.5 months). The total union rate was 88.4%. The pseudoarthrosis rate was 12%. There was no infection or implant failure seen during the follow-up period. The cortical allograft struts can be used to provide collateral support to weakened osteopoenic/osteoporotic bone. This technique provides a union rate of about 88% in osteoporotic and/or complex primary humerus or femur fractures.

---

Résumé Etude prospective de l’évolution clinique et radiographique des fractures complexes de l’humérus et du fémur avec une technique appelée “sandwich technique”. 30 fractures du fémur et 15 de l’humérus avaient été traitées avec un suivi moyen de 25 mois. Pour 24 des 28 patients opérés du fémur et 14 des 15 opérés de l’humérus, la consolidation était obtenue en 3 à 6 mois après l’opération, en moyenne 4,5 mois. Le taux total de consolidation était de 88,4% et celui des pseudarthroses de 12%. Il n’y a pas eu d’infection ni d’échec d’implant durant ce suivi. Les baguettes d’allogreffes corticales peuvent être utilisés pour renforcer les os ostéopéniques ou ostéoporotiques. Cette technique permet 88% de consolidation pour les fractures primaires mais complexes de l’humérus et du fémur.

     

Arthrodesis of the distal interphalangeal joint: description of a new technique and clinical follow-up at 2 years

INTRODUCTION: Arthrodesis of the distal interphalangeal joint (DIPJ) is an accepted operative procedure to treat osteoarthritis, instability and joint deformity. There is a wide spectrum of recommended operative techniques including cerclage wires, headless screws, bio-resorbable pins and lag screws. Lag screw fixation remains one of the most accepted methods of fixation; however, problems can occur in particular subsidence of the screw head leading to loss of compression and prominence of the screw head in the finger tip necessitating removal. We describe here a new technique of DIPJ arthrodesis that avoids these problems. METHODS AND PATIENTS: The technique is described here in detail, and clinical results are given for 18 joints (17 patients) followed-up at a mean 24 months (range 6-44). RESULTS: Mean post-operative DASH score was 15. There were no cases of non-union; only four complications were seen, one case of nail growth disturbance and one of early screw breakage necessitating revision. Two infections necessitated early hardware removal although both arthodesis were united. CONCLUSION: The technique is simple and reliable giving consistent clinical results.     

Totally extraperitoneal (TEP) bilateral hernioplasty using the Single Site® robotic da Vinci platform (DV-SS TEP): description of the technique and preliminary results

Purpose

Laparoendoscopic single site totally extraperitoneal (TEP) hernia repair showed to be a feasible alternative to conventional laparoscopic hernia repair; nevertheless single site surgery, with the loss of instruments triangulation can be a demanding procedure. To overcome those hurdles, the Single Site® (SS) platform of the da Vinci (DV) Si robotic system enables to perform surgical procedures through a 25-mm skin incision, with a stable 3D vision and restoring an adequate triangulation of the surgical instruments. We present in details the technique and the preliminary results of DV-SS TEP, to our knowledge the first cases reported in literature.

Methods

In March 2016, three consecutive male patients (mean age 46.6 years–mean BMI 25.3) with bilateral symptomatic inguinal hernia were submitted to DV-SS TEP in our institutions. Feasibility, codification of the technique, operative time and perioperative outcomes were recorded.

Results

All the procedures were completed as scheduled, with no conversion to other techniques. Mean operative time was 98.6 min, ranging between 155 and 55 min, reflecting the learning curve of the operating room team on this new procedure. No intraoperative or postoperative complications were experienced and all the patients were discharged within 24 h after surgery. Patients reported satisfactory postoperative course, with no recurrence of inguinal hernia and satisfaction in cosmetic result at 6-month follow-up.

Conclusions

DV-SS TEP inguinal hernia repair showed to be feasible and effective surgical option for bilateral groin hernia repair. Patients’ outcome was uneventful, with optimal cosmetic results. Further studies comparing this innovative technique to TEP or LESS TEP should be promoted.

     

Experience in surgical treatment of typeⅡodontoid fractures:A report of two cases and review of the literature

Two cases of typeⅡodontoid fractures were reported to share our experience in surgery treatment of such cases.A 33-year-old woman with comminuted typeⅡodontoid fracture and a 42-year-old man with fracture end hardened typeⅡodontoid fracture received surgical treatment in our hospital.Though imaging examination suggested that these two patients were suitable for anterior screw fixation,we encountered difficulties during the operation.The two patients eventually underwent posterior C1–C2 fusion surgery and recovered well.According to the experience of these two cases,we found that the fracture line angle and the degree of comminution are two important factors affecting surgical decision-making.Although anterior screw fixation is the ideal choice for typeⅡodontoid fractures with anterior superior to posterior inferior fracture line,it may not be the best choice for comminuted or fracture end hardened typeⅡodontoid fractures.     

Treatment strategies for the surgical complications of thoracic spinal stenosis： of two hundred and a retrospective analysis eighty three cases

Objective： To investigate the causes of and treatment strategies for surgical complications of thoracic spinal stenosis. Methods： Between May 1990 and May 2010, 283 patients with thoracic spinal stenosis were treated in our department. Three physicians were assigned to patient follow-up. Patient medical records and radiographs were reviewed. Complications were categorised as perioperative, mid- to long-term and donor-site. Results： Follow-up was completed for 254 patients; 249 patients survived. Follow-up time ranged from 1 to 19 years, with a mean of six years and two months. There were 107 cases had complications with an incidence rate of 42.1%. Eleven cases had pulmonary infection, seven transient nerve-root injury, three pulmonary injury and one vertebral canal haematoma, all of which resolved. Thirteen cases of spinal cord injury postoperatively were treated using dehydration and corticosteroid therapy; eight recovered to the preop- eration level, and five deteriorated. Eleven cases resulted in dural injury, and four led to cerebrospinal fluid leakage. There were five cases of wound-fat liquefaction and one of wound infection. Seven cases with deep venous thrombosis of the lower limbs resolved by elevating the affected limb and administration of low- molecular-weight dextran. Seven cases of delayed wound healing recovered following change of dressings and antibiotic administration. Four cases of delayed bone-graft fusion recovered by extending the external fixation time. One case of bone-graft absorption was treated by iliac bone grafting and bracing. Two cases of inter- nal fixation breakage were treated by removing the internal fixation. Conclusion： Thoracic spinal stenosis surgery may result in various complications but has a good prognosis with proper treatment. The key points in reducing complications are the surgeon＇s familiarity with operative imperatives and the appropriate surgi cal approach.     

Surgical treatment of Scheuermann’s kyphosis using a combined antero-posterior strategy and pedicle screw constructs: efficacy,radiographic and clinical outcomes in 111 cases

Introduction

There is sparse literature on how best to correct Scheuermann’s kyphosis (SK). The efficacy of a combined strategy with anterior release and posterior fusion (AR/PSF) with regard to correction rate and outcome is yet to be determined.

Materials and methods

A review of a consecutive series of SK patients treated with AR/PSF using pedicle screw–rod systems was performed. Assessment of demographics, complications, surgical parameters and radiographs including flexibility and correction measures, proximal junctional kyphosis angle (JKA + 1) and spino-pelvic parameters was performed, focusing on the impact of curve flexibility on correction and clinical outcomes.

Results

111 patients were eligible with a mean age of 23 years, follow-up of 24 months and an average of eight levels fused. Cobb angle at fusion level was 68° preoperatively and 37° postoperatively. Flexibility on traction films was 34 % and correction rate 47 %. Postoperative and follow-up Cobb angles were highly correlated with preoperative bending films (r = 0.7, p < 0.05). Screw density rate was 87 %, with increased correction with higher screw density (p < 0.001, r = 0.4). Patients with an increased junctional kyphosis angle (JKA + 1) were at higher risk of revision surgery (p = 0.049). 22 patients sustained complication, and 21 patients had revision surgery. 42 patients with ≥24 months follow-up were assessed for clinical outcomes (follow-up rate for clinical measures was 38 %). This subgroup showed no significant differences regarding baseline parameters as compared to the whole group. Median approach-related morbidity (ArM) was 8.0 %, SRS-sum score was 4.0, and ODI was 4 %. There was a significant negative correlation between the SRS-24 self-image scores and the number of segments fused (r = −0.5, p < 0.05). Patients with additional surgery had decreased clinical outcomes (SRS-24 scores, p = 0.004, ArM, p = 0.0008, and ODI, p = 0.0004).

Conclusion

The study highlighted that AR/PSF is an efficient strategy providing reliable results in a large single-center series. Results confirmed that flexibility was the decisive measure when comparing surgical outcomes with different treatment strategies. Findings indicated that changes at the proximal junctional level were impacted by individual spino-pelvic morphology and determined by the individually predetermined thoracolumbar curvature and sagittal balance. Results stressed that in SK correction, reconstruction of a physiologic alignment is decisive to achieving good clinical outcomes and avoiding complications.     

Use of double-layer autologous dermal flap in the treatment of recurrent and/or infected incisional hernias: presentation of the surgical technique and the results of 1-year follow-up—a prospective,consecutive cohort study

Introduction

The difficulties of treating recurrent and/or infected incisional hernias are well known in surgical practice. Several surgical techniques and various types of grafts are available for surgeons. This study presents a new surgical technique option together with the results of the 1-year follow-up.

Purpose

The primary aim of the study is to present the surgical technique of the procedure suitable for the treatment of recurrent and/or infected incisional hernias. The secondary aim is to determine the recurrence rate and analyse the surgical complications. The tertiary aim is to present the quality of life test results performed 3, 6 and 12 months after the surgery.

Patients and method

The authors evaluated the results of 36 recurrent and/or infected incisional hernia surgeries (11 men, average age 60.6 years; 25 women, average age 58.9 years) performed with their own surgical method in the framework of a tightly controlled, prospective, interventional and observational consecutive cohort study conducted between 1 January 2011 and 31 December 2013 at a university surgical department. The study evaluates the results of the 1-year follow-up period. All 36 patients had at least one recurrence of abdominal wall hernia; 12 of them also had concurrent infection of the synthetic graft and a complicating fistula. The mean BMI was 31.82 kg/m² (25.2–43.5 kg/m²). The average size of the abdominal wall defect was 145.9 cm² (59–275 cm²). The abdominal wall reconstruction was performed using an autologous, double-layer dermal flap. The grafts, which had been inserted during previous surgeries, were removed completely. The autologous dermal tissue was prepared using the flap harvested during dermolipectomy. The reconstruction was achieved using a tension-free technique. The essence of the abdominal wall reconstruction is the completion of the abdominal wall defect by a double-layer autologous dermal flap. The original abdominal wall defect was not closed by direct sutures. The quality of the prepared dermal flap was histologically evaluated. IAPMS (intra-abdominal pressure monitoring set) was applied to verify intra-abdominal pressure in the post-operative period. The result of the surgeries was assessed using a quality of life questionnaire.

Results

No recurrence of the abdominal wall hernia was registered during the 1-year follow-up period. Abdominal bulking was observed in case of three patients (8.3 %). Wound infection occurred in one patient (2.77 %) and skin dehiscence in two patients (5.55 %). Haematoma was registered in case of one patient (2.77 %) on the fifth post-operative day. Seroma formation occurred in case of eight patients (22.22 %), which required percutaneous tapping. A fistula formation was observed in one patient (2.77 %) 45 days after the surgery. The intra-abdominal pressure remained moderately elevated during the early post-operative period (9.65–5.76 mmHg on post-operative days 1 and 5). Reoperation was performed in one case due to haematoma. No fatality occurred.

Conclusions

The 1-year recurrence rate in case of the abdominal wall reconstruction using double-layer autologous dermal flap is favourable. Being compliant with the surgical technique developed, the procedure is safe to perform. The number of surgical site infections and fistula formations is low. Based on the questionnaires evaluated, all patients would choose this method instead of the previous reconstruction(s). The method is cost-effective. Based on the results, this procedure is feasible for the treatment of recurrent and/or infected abdominal wall, incisional ventral hernias in obese “high risk” patients.

     

Asymptomatic Paget’s bone disease in ethnic Thais: a series of four case reports and a review of the literature

Paget's bone disease is quite common in some parts of Europe and countries inhabited by European emigrants, but it is rare in Asia. There have been only 13 reported cases in Southeast Asia, including one reported case from Thailand. Half of the previously reported cases had bone symptoms and the other half were asymptomatic, but were incidentally discovered when patients were being investigated for other medical problems. Here are reported cases of four asymptomatic patients who presented elevation of serum alkaline phosphatase during routine annual medical checkups. All patients were of Chinese descent and all cases were proven by biopsy. Based on this experience, we are of the opinion that a substantial number of unrecognized cases of Paget's disease exist among ethnic Thais. We feel that they would be revealed if clinicians were alerted of its presence and if they included it as a possible diagnosis together with metastasis and osteoporosis when examining bone lesions or when results for elevated serum alkaline phosphatase are detected during routine checkups. We also anticipate that a higher prevalence of this disease may occur in future Thai generations due to the addition of offspring from Asian-European intermarriages to offspring of Chinese descent in the ethnic Thai population.     

Percutaneous laparoscopic assisted gastrostomy (PLAG)—a new technique for cases of pharyngoesophageal obstruction

Purpose  

Percutaneous endoscopic gastrostomy (PEG) is the preferable method to provide enteral nutrition for a longer time period. Safe placement of a PEG tube requires passage of the esophagus and transillumination of the stomach through the abdominal wall. Surgical placement of a PEG tube has been shown to be feasible although the local complication rate ranges above the endoscopic procedure. We are presenting a new technique (percutaneous laparoscopically assisted gastrostomy, PLAG) to provide enteral access for patients with pharyngoesophageal obstruction not suitable for PEG placement.     

Influence of the induced membrane filled with syngeneic bone and regenerative cells on bone healing in a critical size defect model of the rat’s femur

IntroductionThe induced membrane technique for the treatment of large bone defects consists of a 2-stage procedure. In the first stage, a polymethylmethacrylate (PMMA) cement spacer is inserted into the bony defect of a rat’s femur and over a period of 2–4 weeks a membrane forms that encapsulates the defect/spacer. In a second operation the membrane is opened, the PMMA spacer is removed and the resulting cavity is filled with autologous bone.Since little effort has been made to replace the need for autologous bone this study was performed to elucidate the influence of different stem cells and the membrane itself on bone healing in a critical size femur defect model in rats.Especially the question should be addressed whether the use of stem cells seeded on a β-TCP scaffold is equivalent to syngeneic bone as defect filling in combination with the induced membrane technique.Materials and MethodsA total of 96 male Sprague-Dawley (SD) rats received a 10 mm critical size defect of the femur, which was stabilized by a plate osteosynthesis and filled with PMMA cement. In a second step the spacer was extracted and the defects were filled with syngeneic bone, β-TCP with MSC + EPC or BM-MNC. In order to elucidate the influence of the induced membrane on bone defect healing the induced membrane was removed in half of the operated femurs. The defect area was analysed 8 weeks later for bone formation (osteocalcin staining), bone mineral density (BMD) and bone strength (3-point bending test).ResultsNew bone formation, bone mineral density and bone stiffness increased significantly, if the membrane was kept. The transplantation of biologically active material (syngeneic bone, stem cells on b-TCP) into the bone defect mostly led to a further increase of bone healing. Syngeneic bone had the greatest impact on bone healing however defects treated with stem cells were oftentimes comparable.ConclusionFor the first time we demonstrated the effect of the induced membrane itself and different stem cells on critical size defect healing. This could be a promising approach to reduce the need for autologous bone transplantation with its’ limited availability and donor site morbidity.     

Distal forearm fracture in the adult: is ORIF of the radius and closed reduction of the ulna a treatment option in distal forearm fracture?

INTRODUCTION: Distal forearm fractures in younger adults are rare injuries resulting from high energy trauma. Treatment options vary from cast fixation, external fixator, percutaneus pinning and open reduction and internal fixation. METHOD: We retrospectively reviewed 13 patients aged 18-59 from 1996 to 2005 with a distal unstable forearm fracture. All were treated with open reduction and internal fixation of the radius. The ulna was stabilized either by an open reduction and internal fixation or by a closed reduction with or without pin fixation and cast fixation in all cases. At follow-up, we evaluated the radiologic results in terms of forearm fracture retention and functional outcome according to the wrist score by Krimmer. RESULT: Radial inclination amounted to 24 degrees at the injured side when compared to 27 degrees at the non-injured side, palmar tilt was 3 degrees versus 7 degrees and ulna variance was -2 versus -1 mm. According to the modified wrist score by Krimmer, seven excellent, two good and four fair results were achieved. The range of motion of the injured wrist joint was 149 degrees of rotation, in the sagittal plane 106 degrees , frontal plane 61 degrees and on the non-injured side rotation was 171 degrees , and movement in the sagittal plane was 146 degrees and 79 degrees in the frontal plane. Decreased forearm rotation (107 degrees vs. 162 degrees ) and decreased range of motion in the sagittal plane (77 degrees vs. 114 degrees ) were measured in patient following open reduction and internal fixation of radius and ulna compared to the outcome in patients with open reduction and internal fixation of the radius and closed reduction of the ulna. Grip strength of the injured side averaged 350 N versus 440 N which is 76% of that of the opposite side. All patients stated no pain at rest and some experienced slight pain at work. Three patients had an excellent performance at daily activities, nine patients presented problems with certain activities, and one patient showed severe limitations. CONCLUSIONS: Open reduction and internal fixation of the radius is the keystone in treating distal forearm fracture. In case of stable retention of the ulnar head after closed reduction, cast fixation with or without percutaneus pin fixation is a sufficient method to treat unstable distal forearm fractures. In patients with remaining instability of the distal ulna fracture, ORIF is indicated.     

Repair of bone defect in caprine tibia using a laminated scaffold with bone marrow stromal cells loaded poly (L-lactic acid)/β-tricalcium phosphate

Repair of bone defects of a critical size encounters many problems, and many efforts aim to build a porous scaffold loading bone marrow stromal cells (BMSCs) or bone morphogenetic protein (BMP2) to quickly repair bone defects. In this paper, a laminated scaffold was designed and tested for the repair of bone defects in a caprine tibia. Beta-tricalcium phosphate (β-TCP) and poly (L-lactic acid) (PLLA) were fabricated to a sandwich structured composite that was then rolled up to form a cylindrical shaped, porous scaffold. The porosity and bending strength of the PLLA/β-TCP laminated scaffold were around 70% and 1.7 MPa, respectively. Results from in vitro experiments showed that the pH value of the scaffold in water fluctuated between 4.9 and 7.0 during its degradation. When exposed to the simulated body fluid, the scaffold lost its strength after 11 weeks of degradation. After implantation in Chinese caprines' diaphyseal defects with loaded allogeneic BMSCs, the scaffold sped up the bone repair without collapse of the scaffold and the unwanted inflammatory response, and then rapidly degraded and finally disappeared at 12 weeks. Gross examinations and pullout tests showed that the experimental caprines walked normally and the implanted leg could be heavily loaded. X-ray examinations and histological analyses showed new bone tissues formed with similar structures to normal ones. It is suggested that the novel PLLA/β-TCP laminated scaffold with BMSCs loading can regenerate new bones quickly.     

Congenital pseudarthrosis of the tibia treated with a combination of Ilizarov��s technique and intramedullary rodding: 15 cases followed for mean 4.5 years

Background and purpose

Ilizarov’s technique and intramedullary rodding have often been used individually in congenital pseudarthrosis of the tibia. In this series, we attempted to combine the advantages of both methods while minimizing the complications.

Methods

We reviewed 15 cases of congenital pseudoarthrosis of the tibia (CPT) who were treated with a combination of Ilizarov’s apparatus and antegrade intramedullary nailing between 2003 and 2008. The mean age at surgery was 7.5 (3–12) years and the mean limb length discrepancy was 2.5 (1.5–5) cm. At a mean follow-up time of 4.5 (1.6–7.2) years after the index surgery, the patients were evaluated clinically and radiographically for ankle function (AOFAS score) and for malalignment, signs of union, limb length discrepancy, and complications.

Results

14 patients achieved union, in 6 patients primary union and in 8 patients after secondary procedures. The AOFAS score improved from a preoperative mean of 40 (20–57) to 64 (47–75). The main complication was refracture in 1 patient, and non-union in 1 patient.

Interpretation

The combination of the Ilizarov technique and conventional antegrade intramedullary nailing was successful in achieving union with few complications, though this should be shown in long-term studies lasting until skeletal maturity.Congenital pseudarthrosis of the tibia (CPT), also called congenital tibial dysplasia, is difficult to treat with a substantial risk of non-union, refractures, leg length discrepancy (LLD), and malalignment of the tibia and the ankle (Plawecki et al. 1990, Paley et al. 1992). Treatment procedures can be broadly classified into 3 groups: (1) Intramedullary rodding (usually trans-ankle) with bone grafting (Johnston 2002, Dobbs et al. 2004), (2) microvascular fibular transfer (Ohnishi et al. 2005), and (3) the Ilizarov technique with its various modifications (Paley et al. 1992, Boero et al. 1997, Johnston and Birch 2008). However, no single treatment has been shown to be uniformly effective.Intramedullary rodding, usually retrograde through the calcaneum to the tibia, has been used relatively widely with success in achieving union and protection against refracture (Johnston 2002, Shah et al. 2011). However, concerns still exist about ankle stiffness and arthritic changes in the ankle following the nailing (Dobbs et al. 2005). On the other hand, various series using the Ilizarov technique have shown high union rates with good ankle function (Paley et al. 1992, Boero et al. 1997). However, there is a risk of refracture with this technique. We therefore wanted to make use of the advantages of both techniques. We have found only 1 report on this combined method (Mathieu et al. 2008) involving 10 cases.We report the clinico-radiographical outcomes of 15 patients with CPT who were treated with a combination of the Ilizarov technique and intramedullary rodding.     

Non-union and use of proton pump inhibitors in the treatment of femoral and tibial shaft fractures: a nested case–control study

European Journal of Orthopaedic Surgery & Traumatology - Proton pump inhibitors (PPIs) are one of the most frequently used drugs worldwide. Previous research has shown that they could increase...