Ilizarov bone transport for massive tibial bone defects

This article reports the treatment of massive tibial bone defects by bone transport using the Ilizarov external fixator. Fifteen patients were treated using this technique (3 females and 12 males). The defect size ranged between 7 and 22 cm (average: 10.6 cm). Etiology was infected nonunion in 9 patients, nonunion in 5 patients, and recurrent giant-cell tumor in 1 patient. The affected site was the tibial diaphysis in 10 patients, the lower tibial metaphysis in 4, and the upper tibial epiphysis in 1 patient. The external fixation time ranged from 9 months to 17 months (average: 12.27 months). External fixation index ranged from 21.8 to 42.5 day/cm (average: 35.7 day/cm). There was no recurrence of infection, no recurrence of the tumor, nor fractures after frame removal. We had to graft the docking site in 2 patients for delayed union and 2 patients developed equinus deformity and had tenoplasty for the Achilles tendon at the time of frame removal. Four patients had pin tract infection at > or =1 of the wires and this was successfully treated by antibiotic injection at the wire site. This study suggests that Ilizarov bone transport is a reliable method to fill massive bone defects.     

Ilizarov bone transport treatment for tibial defects

OBJECTIVES: To evaluate the results and complications of Ilizarov bone transport in the treatment of tibial bone defects. DESIGN: Retrospectively reviewed consecutive series. METHODS: Nineteen patients with tibial bone defects were treated by the Ilizarov bone transport method. The mean bone defect was ten centimeters, and there were eight soft-tissue defects. The mean external fixation time was sixteen months. Ten patients required debridement of the bone ends and/or bone grafting of the docking site at the end of transport. RESULTS: Union was achieved in all cases. One refracture of the docking site required retreatment with the Ilizarov apparatus to achieve union. There was one residual leg length discrepancy greater than 2.5 centimeters and two angular deformities greater than 5 degrees. There were no recurrent or residual infections. Seven of the eight soft-tissue defects were closed by soft-tissue transport; the eighth required a free-vascularized flap. The bone results were graded as fifteen excellent, three good, and one fair. The functional results were graded as twelve excellent, six good, and one poor. There were twenty-two minor complications, sixteen major complications without residual sequelae, and three major complications with residual sequelae. To treat the bone defect and the complications, a mean of 2.9 operations per patient was required. CONCLUSIONS: Our results compare favorably with those for other methods of bone grafting as well as with those from other published accounts of the Ilizarov method, especially considering the large defect size in this series. The main disadvantage of the Ilizarov method is the lengthy external fixation time.     

Tibial bone defects treated by internal bone transport using the Ilizarov method

We reviewed 27 cases of tibial bone defects treated by internal bone transport using the Ilizarov method. The causes of the bone defects were open fractures in 14 segments and infected non-unions in 13. The average length of the defects was 8.3 cm (range, 3–20 cm). There were 21 one-level tibial transports, 3 two-level tibial transports, 1 one-level tibial transport with fibular transport, and 2 fibular transports. At the docking site, 25 segments underwent bone grafting. Eleven of the 25 were Papineau-type open cancellous bone grafts. Acute shortening or docking was performed in 10 segments. Bone union was obtained in every instance. The average time of external fixation was 8 months and the average time to union was 7.1 months. Bone grafting at the docking site is recommended in order to shorten the duration of treatment and to prevent refracture and non-union.

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Résumé. Nous avons passé en revue 27 cas de perte de substance du tibia traités par ?transport osseux interne? conformément à la méthode Ilizarov. Ces anormalies provenaient de fractures ouvertes dans 13. La longeur moyenne des defect osseux était de 8,3 cm (entre 3 et 20 cm). On a effectué 21 ?transports tibiaux? de niveau 1, 3 ?transports tibiaux? de niveau 2, 1 ?transport tibial? avec ?transport du péroné?, ainsi que 2 ?transport du péroné?. Dans 25 cas une greffe osseuse a été pratiquée sur le site de réduction. 11 cas des 25 greffes pratiquées étaitent du type Papinau. D’importances réduction ont d?étre effectuées dans 10 cas. Des fusions ont été obtenues dans tous les cas. Le temps moyen de fixation externe était de 8 mois et celui de fusion de 7,1 mois. La greffe osseuse est recommandée sur le site de réduction afin de raccourcir la durée du traitement et de prévenir toute récidive de fracture ou de non-consolidation.

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Accepted: 7 November 1997     

Ilizarov技术同期治疗感染性胫骨大段缺损并小腿软组织缺损

目的探讨Ilizarov技术同期治疗感染性胫骨大段骨缺损并小腿软组织缺损的疗效。方法回顾性分析2012-01—2014-05应用Ilizarov技术同期治疗8例感染性胫骨骨缺损并软组织缺损。均为胫骨骨折术后感染,清创后小腿软组织缺损位于胫前内外侧,面积平均为30.4(24~91)cm2,胫骨缺损长度平均为9.5(6~13)cm。7例胫骨中远段缺损采用胫骨结节下方截骨向远端骨搬运修复,1例胫骨近段缺损采用胫骨远端截骨向近端骨搬运修复,软组织缺损修剪成椭圆形后直接拉拢缝合。术后10 d开始骨段搬运,速度为1 mm/d,分4次完成。结果术后延长段切口及创面均一期愈合。所有患者均获随访17~36个月,平均23个月。延长段骨自然愈合,愈合时间为210~496 d,平均271 d;愈合指数3.4~4.0 d/mm,平均3.7 d/mm。对接点2例行二期植骨后愈合,其余6例均自然愈合,愈合时间170~308 d,平均236 d。去除外固定架后5个月疗效根据ASAMI评价标准评定:优6例,良2例。结论Ilizarov技术简便、疗效良好,是同期修复感染后大段胫骨缺损并软组织缺损的可靠方法。     

Ilizarov technique: Bone transport versus bone shortening-lengthening for tibial bone and soft-tissue defects

Objective

To compare the outcomes of bone transport and bone shortening-lengthening by Ilizarov technique for treatment of tibial bone and soft-tissue defects.

Ten year experience with use of Ilizarov bone transport for tibial defects

Tibial defects greater than 4 cm and secondary to high-energy trauma or debridement for infected nonunion pose a significant challenge to the treating orthopaedic surgeon. Twelve patients who had been treated with Ilizarov bone transport for tibial defects over the past ten years were retrospectively reviewed. All patients were male with an average age of thirty-two. Ten of the twelve limbs were categorized as Grade IIIB fractures initially. The average tibial defect at initiation of bone transport was 9.45 cm (range 4 to 20 cm). The mean external fixator time (EFT) was 16.7 months with a mean external fixator index (EFI) of 2.0 months per centimeter. There were a total of 36 complications. Twenty were minor, fourteen were major without sequelae and two were major with sequelae. Overall bone results were good or excellent in nine patients. Overall functional results were good or excellent in eight patients. Ten patients achieved union after Ilizarov bone transport. Use of Ilizarov bone transport can be an effective tool for treating large tibial defects. However, the treatment time is lengthy with a considerable risk of complications.     

Ilizarov技术自体骨段延长治疗胫骨感染性骨折不愈合伴骨缺损

目的 探讨Ilizarov技术自体骨段延长治疗胫骨感染性骨折不愈合的疗效.方法 2000年9月至2006年6月共收治胫骨感染性骨折不愈合伴骨缺损患者14例,男11例,女3例;年龄19～49岁,平均31.9岁;胫骨近端3例,中段8例,远端3例.原始损伤:5例为开放骨折钢板内固定,3例为开放骨折髓内钉内固定,4例为开放骨折外固定架固定,2例为闭合骨折钢板内固定术后所致.患者自受伤至此次治疗时间为2～24个月,平均7.54个月;手术次数平均6次(3～14次).根据Jain骨缺损和感染程度分型:A2型5例,B1型2例,B2型7例.窦道形成10例,骨外露4例;骨外露面积最大7 cm×5 cm,最小2 cm×1 cm;清创后骨缺损长度3～12 cm,平均6.71 cm.14例患者均采用清创联合Ilizarov技术自体骨段延长治疗.结果 14例患者均获8个月～6年(平均20个月)随访,均获稳定骨折愈合.住院时间1～7个月,平均3个月;骨折愈合时间6～12个月,平均7.79个月;骨外固定时间8～14个月,平均9.64个月.并发症:针道感染1例,皮肤过敏1例,骨折畸形愈合再截骨1例,提前矿化再截骨1例,断针1例,无深部感染、骨折不愈合和膝关节僵直发生.根据Paley骨折愈合评分标准:优13例,良1例.结论 Ilizarov骨段延长是治疗胫骨感染性骨折不愈合伴大段骨缺损的一种有效方法.     

Acute compression and lengthening by the Ilizarov technique for infected nonunion of the tibia with large bone defects

PURPOSE. To assess the Ilizarov technique in treating large infected tibial defects by resection of the infected focus, its acute compression, and gradual distant site lengthening. METHODS. 27 men (mean age, 39 years) with infected nonunion and large bone defects of the tibia underwent complete resection of the nonunion site, debridement, sequestrectomy, lavage, and Ilizarov ring fixator application. Patients underwent acute compression of the defect site, followed by distant site metaphyseal corticotomy for simultaneous lengthening. The mean length of resection was 10 (range, 6-17) cm. The mean follow-up was 27 (range, 25-39) months. RESULTS. The mean lengthening achieved was 10 cm, mean union time 6.3 months, and mean duration of consolidation 10.2 months. Functional results were excellent in 19 patients and good in 5. The union time was longer in older patients. CONCLUSION. Acute compression and simultaneous lengthening can be used safely for treatment of large bone defects in the tibia. This avoids secondary operations at the docking site and reduces the duration of treatment.     

Management of segmental defects by the Ilizarov intercalary bone transport method.

Seventeen patients with segmental skeletal defects were managed with the Ilizarov intercalary bone transport method, whereby an osseous defect is eliminated by elongating one fragment. On average, the regenerate new bone length measured 5.14 cm, corresponding to the creation of new osseous tissue equaling 13.7% of the bone's original length (range, 4.2%-35%). The average time in fixation was 9.6 months, including 4.8 months to transport the bone fragment throughout the limb. Numerous complications were encountered, most commonly wire-site sepsis and fixator instability. No serous nerve or vessel complications occurred. All but one patient eventually healed, although six patients required bone grafts, five at the target site and one at the level of the regenerate. Most of the difficulties encountered were due to a lack of technical knowledge with the method.     

Masquelet technique versus Ilizarov bone transport for reconstruction of lower extremity bone defects following posttraumatic osteomyelitis

ObjectiveThis study was to compare the effectiveness of Masquelet technique versus Ilizarov bone transport in the treatment of lower extremity bone defects following posttraumatic osteomyelitis.Patients and methodsWe retrospectively reviewed 39 patients who had been treated at our department for lower extremity bone defects following posttraumatic osteomyelitis. They were 30 males and 9 females with a mean age of 39.18 (range, 12–63 years). The infected bone defects involved 26 tibias and 13 femurs. The mean length of the bone defects after radical debridement was 6.76 cm (range, 2.7–15.7 cm). Masquelet technique (MT, group A) was used in 20 patients and Ilizarov bone transport (IBT, group B) in 19 ones. The measurements were bone outcomes (union, deformity, infection and leg-length discrepancy) and functional outcomes (significant limping, joint contracture, soft tissue dystrophy, pain and inactivity).ResultsThe mean follow-up after removal of the apparatus was 25.26 months (range, 14–51 months). The mean finite fixator time was 10.15 months (range, 8–14 months) in group A versus 17.21 months (range, 11–24 months) in group B. The bone outcomes were similar between groups A and B [excellent (5 vs. 7), good (10 vs.9), fair (4 vs. 2) and poor (1 vs. 1)]; group A showed better functional outcomes than group B [excellent (8 vs. 3), good (9 vs. 6), fair (3 vs. 8) and poor (0 vs. 2)].ConclusionsIn the treatment of segmental lower extremity bone defects following posttraumatic osteomyelitis, both IBT and MT can lead to satisfactory bone results while MT had better functional results, especially in femoral cases. IBT should be preferred in cases of limb deformity and MT may be a better choice in cases of periarticular bone defects.     

Ilizarov bone transport combined with the Masquelet technique for bone defects of various etiologies (preliminary results)

BACKGROUNDThe Ilizarov bone transport (IBT) and the Masquelet induced membrane technique (IMT) have specific merits and shortcomings, but numerous studies have shown their efficacy in the management of extensive long-bone defects of various etiologies, including congenital deficiencies. Combining their strong benefits seems a promising strategy to enhance bone regeneration and reduce the risk of refractures in the management of post-traumatic and congenital defects and nonunion that failed to respond to other treatments.AIMTo combine IBT and IMT for the management of severe tibial defects and pseudarthrosis, and present preliminary results of this technological solution. METHODSSeven adults with post-traumatic tibial defects (subgroup A) and nine children (subgroup B) with congenital pseudarthrosis of the tibia (CPT) were treated with the combination of IMT and IBT after the failure of previous treatments. The mean number of previous surgeries was 2.0 ± 0.2 in subgroup A and 3.3 ± 0.7 in subgroup B. Step 1 included Ilizarov frame placement and spacer introduction into the defect to generate the induced membrane which remained in the interfragmental gap after spacer removal. Step 2 was an osteotomy and bone transport of the fragment through the tunnel in the induced membrane, its compression and docking for consolidation without grafting. The outcomes were retrospectively studied after a mean follow-up of 20.8 ± 2.7 mo in subgroup A and 25.3 ± 2.3 mo in subgroup B. RESULTSThe “true defect” after resection was 13.3 ± 1.7% in subgroup A and 31.0 ± 3.0% in subgroup B relative to the contralateral limb. Upon completion of treatment, defects were filled by 75.4 ± 10.6% and 34.6 ± 4.2%, respectively. Total duration of external fixation was 397 ± 9.2 and 270.1 ± 16.3 d, including spacer retention time of 42.4 ± 4.5 and 55.8 ± 6.6 d, in subgroups A and B, respectively. Bone infection was not observed. Postoperative complications were several cases of pin-tract infection and regenerate deformity in both subgroups. Ischemic regeneration was observed in two cases of subgroup B. Complications were corrected during the course of treatment. Bone union was achieved in all patients of subgroup A and in seven patients of subgroup B. One non-united CPT case was further treated with the Ilizarov compression method only and achieved union. After a follow-up period of two to three years, refractures occurred in four cases of united CPT. CONCLUSIONThe combination of IMT and IBT provides good outcomes in post-traumatic tibial defects after previous treatment failure but external fixation is longer due to spacer retention. Refractures may occur in severe CPT.     

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

IntroductionSegmental tibia defects remain challenging for orthopedic surgeons to treat. The aim of this study was to demonstrate bone-related and functional outcomes after treatment of complex tibial bone defects using Ilizarov bone transport with a modified intramedullary cable transportation system (CTS).Patients and MethodsWe conducted a single-center, retrospective study including all 42 patients treated for tibial bone loss via Ilizarov bone transport with CTS between 2005 and 2018. Bone-related and functional results were evaluated according to the Association for the Study and Application of Methods of Ilizarov (ASAMI) scoring system. Complication and failure rates were determined by the patients’ medical files.ResultsPatients had a mean age of 45.5 ± 15.1 years. The mean bone defect size was 7.7 ± 3.4 cm, the average nonunion scoring system (NUSS) score was 59 ± 9.5 points, and the mean follow-up was 40.8 ± 24.4 months (range, 13-139 months). Complete bone and soft tissue healing occurred in 32/42 patients (76.2%). These patients had excellent (10), good (17), fair (2), and poor (3) results based on the ASAMI functional score. Regarding bone stock, 19 patients had excellent, 10 good, and 3 fair results. In total, 37 minor complications and 62 major complications occurred during the study. In 7 patients, bone and soft tissue healing occurred after CTS failure with either an induced membrane technique or classic bone transport; 3 patients underwent lower leg amputation. Patients with treatment failure were significantly older (57.6 vs. 41.8 years; p = 0.003). Charlson score and treatment failure had a positive correlation (Spearman's rho 0.43; p = 0.004).ConclusionBone transport using both intramedullary CTS and Ilizarov ring fixation is viable for treating patients with bone loss of the tibia and complex infection or soft tissue conditions. However, a high number of complications and surgical revisions are associated with the treatment of this severe clinical entity and should be taken into account.     

Management of post-traumatic bone defects of the tibia using vascularised fibular graft combined with Ilizarov external fixator

IntroductionPost-traumatic bone defects of the tibia present a difficult reconstructive challenge. Various methods of reconstruction are available, such as allografts, vascularised fibular graft (either free or pedicled) and bone transport technique.Patients and methodsFourteen patients with an average age of 34.1 years at operation (range, 12–65) with post-traumatic bony defects of the tibia were selected for reconstruction with vascularised fibular graft combined with Ilizarov external fixation. There were 12 male and two female. The size of the bony gap was 10.4 cm (range, 7–13) and the average length of the fibula used was 16.4 cm (range, 14–21).ResultsThe mean follow up period was 20.4 months (range, 10–37). All patients had bony union at both proximal and distal ends of the fibula primarily except one patient that required secondary iliac bone graft at the distal end of the fibula to obtain union. The average time for bone healing was 3.9 months (range, 3–9). The average time spent in Ilizarov frame was 5.9 months (range, 5–11). Unprotected full weight-bearing was achieved within an average of 7.3 months (range, 6–12).ConclusionVascularised fibular bone graft combined with an Ilizarov frame is a successful approach to safely and effectively reconstruct bone defects of the tibia. It has the advantages of vascularised fibular bone grafts together with the biomechanical advantages of Ilizarov frame that allows weight bearing to start almost immediately after surgery. This leads to a good outcome regarding the union and function.     

Ilizarov non-free bone plasty for extensive tibial defects

Purpose

The purpose of this study was to present a retrospective comparative overview of the Ilizarov non-free bone plasty techniques of one-stage multilevel fragment lengthening and gradual tibilisation of the fibula used for extensive tibial defect management.

Methods

Extensive tibial defects in 83 patients were managed either by multilevel fragment lengthening (group I, n = 41, mean defect size 13.1 ± 0.9 cm) or gradual tibilisation of the fibula (group II, n = 42, mean defect size 12.5 ± 1.2 cm) using the Ilizarov apparatus. The initial findings, treatment protocols and outcomes of those patients treated within the period 1972–2011 were studied retrospectively by medical records and radiographs, and statistically assessed with Microsoft Excel and Attestat software.

Results

Group I had multilevel fragment lengthening over one stage that averaged 288.0 ± 14.4 days. The mean total period of gradual tibilisation of the fibula in group II was 316.0 ± 29.7 days. The patient’s age in the latter group had an effect on the completeness of leg-length equalisation.

Conclusions

The techniques can be used to manage extensive tibial defects as all the defects bridged, leg-length discrepancy and deformity were corrected and patients were able to load their limbs.     

Ilizarov bone transport as a treatment of congenital pseudarthrosis of the tibia: a long-term follow-up study

Purpose

Most studies on congenital pseudarthrosis of the tibia (CPT) report on the short-term union rate and refracture rate but do not take into account the long-term outcome. This review includes patients treated with an Ilizarov bone transport, who all reached skeletal maturity. It describes long-term results and highlights any prognostic factors that could predict the final outcome.

Methods

The records of patients with CPT treated with an Ilizarov bone transport in our institution were retrospectively evaluated.

Results

A total of 12 consecutive patients were studied. The mean follow-up was 24.5 years (range 6–39 years). Primary consolidation was seen in ten patients (83 %). Half of these patients had a refracture. At final follow-up, eight patients experienced union and four remained un-united, of whom one had an amputation.

Conclusions

The present data confirm a good primary healing rate. However, tibial union at final follow-up was only seen in 67 %, indicating that refracture is the main issue. United bone is often of inferior biological and mechanical quality, so lifetime protection with intramedullary devices, braces or a combination of both is recommended.     

Bone transport over an intramedullary nail for reconstruction of long bone defects in tibia

BACKGROUND: Although long bone defects may be treated by callus distraction, frequent complications arise from the long duration of external fixation. To reduce such complications, bone transport over an intramedullary nail (BTON) has been done for tibial bone defect. METHODS: In 12 patients (mean age, 46.1 years) of chronic osteomyelitis or bone defect, segmental transport was done using external fixator over an intramedullary nail. Prior to the index procedure, all patients had had serial debridements and five required myocutaneous or free flaps for covering of soft tissue defects. Using Mekhail's criteria, functional results were evaluated. RESULTS: The mean transported amount was 5.9 (range, 3.5-12) cm. The mean external fixation index was 26 days/cm, and healing index was 62.6 days/cm. The primary union of distraction and docking site was achieved in all, except for one failure in union at the docking site, which required another bone graft. Except for one patient with associated ankle injury, all had excellent or good functions. There was one recurrence of osteomyelitis and one procurvatum of the proximal tibia of 10 degrees . CONCLUSION: BTON may be a successful method in tibial reconstruction and allows patients to return to daily life earlier with relatively few complications.