Ilizarov treatment of tibial nonunions with bone loss

Twenty-five patients aged 19-62 years were treated for tibial nonunions (22 atrophic, three hypertrophic) with bone loss (1-23 cm, mean 6.2 cm) by the Ilizarov technique and fixator. Thirteen had chronic osteomyelitis, 19 had a limb-length discrepancy (2-11 cm), 12 had a bony defect (1-16 cm), and 13 had a deformity. Six had a bone defect with no shortening, 13 had shortening with no defect, and six had both a bone defect and shortening. Nonunion, bone defects, limb shortening, and deformity can all be addressed simultaneously with the Ilizarov apparatus. Bone defects were closed from within without bone grafts by the Ilizarov bone transport technique of sliding a bone fragment internally, producing distraction osteogenesis behind it until the defect is bridged (internal lengthening). Length was reestablished by distraction of a percutaneous corticotomy or through compression and subsequent distraction of the pseudarthrosis site (external lengthening). Distraction osteogenesis resulting from both processes obviated the need for a bone graft in every case. Deformity was corrected by means of hinges on the apparatus. Infection was treated by radical resection of the necrotic bone and internal lengthening to regenerate the excised bone. Union was achieved in all cases. The mean time to union was 13.6 months, but it was only 10.6 months if the time taken for unsuccessful compression-distraction of the nonunion is eliminated from the calculation. The bone results were excellent in 18 cases, good in five, and fair in two based on union in all cases, persistent infection in three, deformity in four, and limb shortening in one. The functional results were excellent in 16 cases, good in seven, fair in one, and poor in one based on return to work and daily activities in all cases, limp in four cases, equinus deformity in five cases, dystrophy in four cases, pain in four cases, and voluntary amputation for neurogenic pain in one case.     

应用牵拉成骨技术治疗股骨、胫骨肥大型骨不愈合合并畸形患者的疗效

目的探讨应用牵拉成骨技术治疗股骨、胫骨肥大型骨不愈合合并畸形患者的疗效。方法回顾性分析2016年11月至2019年11月在北京积水潭医院创伤骨科应用牵拉成骨技术治疗的3例股骨、胫骨肥大型骨不愈合合并畸形患者的病历资料。3例均为男性。所有骨折不愈合端均不切开。胫骨不愈合者均需经皮截断腓骨,使用Taylor Spatial Frame(施乐辉公司)固定,将13个参数输入计算机,设定牵开速度1 mm/d,生成电子处方。股骨不愈合者使用Orthofix外固定架固定。术后第2天按照1 mm/d的速度牵拉,在牵开恢复长度的过程中逐渐纠正畸形。随访期间,观察患者畸形纠正情况和骨愈合情况。结果病例A术后20 d畸形完全纠正,术后15个月获得骨性愈合。病例B术后25 d畸形完全纠正,术后15个月获得骨性愈合。病例C术后29 d成角畸形纠正,术后19个月获得骨性愈合。结论牵拉成骨技术可纠正肥大型骨不愈合的成角畸形及短缩,可作为肥大型骨不愈合的一种微创治疗方法。     

Callus distraction for humeral nonunion with bone loss and limb shortening caused by chronic osteomyelitis

Nonunion of the humerus with bone loss and shortening due to osteomyelitis is rare but difficult to treat. We describe our experience with a callus distraction technique using a monolateral external fixator for the treatment of this condition. Between October 1994 and January 2004, 11 patients were treated. There were seven males and four females, with a mean age of 14 years (10 to 17). The mean bone loss was 1.9 cm (1 to 2.7) and the mean length discrepancy in the upper limb was 5.6 cm (3.5 to 8.0). The mean follow-up was for 106 months (54 to 166). The mean external fixation index was 34.8 days/cm (29.8 to 40.5). The mean lengthening was 9.5 cm (5.5 to 13.4). There were seven excellent results, three good and one poor. There were nine excellent functional results and two good. The treatment of humeral nonunion with bone loss and shortening due to osteomyelitis by callus distraction is a safe and effective means of improving function and cosmesis.     

Management of combined bone defect and limb-length discrepancy after tibial chronic osteomyelitis

Bone defects and leg shortening due to chronic osteomyelitis are rare yet challenging problems to treat. The aim of this study was to summarize our experience with a distraction osteogenesis technique performed with an external fixator for these conditions. Twenty-three consecutive patients with tibial bone defects and limb-length discrepancy caused by osteomyelitis were treated from January 1994 to January 2009. Thirteen boys and 10 girls had a mean age of 12.2 years (range, 8-16 years). Twenty of the 23 patients (87.0%) had undergone an unsuccessful bone grafting procedure. Mean amount of bone defect was 3.6 cm (range, 1.5-6.2 cm) as measured on plain radiographs. Mean leg-length discrepancy was 4.0 cm (range, 0-8.0 cm). All patients were followed for a mean of 116 months (range, 31-182 months). Mean external fixation index was 48.0 days/cm (range, 40.7-66.5 days/cm). Mean lengthening was 9.3 cm (range, 5.8-12.1 cm). Based on the criteria recommended by Paley et al, 16 bone results were excellent, 6 good, and 1 fair. Fifteen functional results were excellent, 7 good, 1 fair, and 0 poor. This study shows that distraction osteogenesis with an external fixator is an effective treatment for massive postosteomyelitis bone defects and leg shortening.     

Bifocal compression-distraction in the acute treatment of grade III open tibia fractures with bone and soft-tissue loss: a report of 24 cases

OBJECTIVE: To evaluate the results of bifocal compression-distraction method for the acute treatment of open tibia fractures with bone and soft-tissue loss. DESIGN: Patients were selected for bifocal compression-distraction (shortening and lengthening) who had open tibia fractures with bone and soft-tissue loss and a Mangled Extremity Severe Score of 6 and below indicating good leg viability. PATIENTS: Bifocal compression-distraction osteogenesis using the Ilizarov type circular external fixator was applied to 24 patients with 14 grade IIIA and 10 grade IIIB open tibia fractures with bone and soft-tissue loss. Mean age of the patients was 30.6 years (range 18-53). The mean bone defect was 5 cm (range 3-8.5). The mean soft tissue defect was 2.5 x 3.5 (1 x 2-10 x 5) cm. INTERVENTIONS: Acute shortening at the fracture site was done for patients with bone defects up to 3 cm to achieve apposition of bone ends. Gradual shortening at a rate of 2 mm/d was done for patients who had bone defects more than 3 cm. Leg length discrepancy was overcome by lengthening at the same time through a corticotomy at a proximal or distal level depending on fracture localization, until there was equalization of leg lengths. RESULTS: Mean follow-up period was 30 months (range 18-60). Mean bone healing time was 7.5 months (range 4-11). The mean time in external fixation was 7.1 months (range 3-10), and the average external fixator index was 1.4 months/cm. Results were evaluated using the Paley bone and functional assessment scores. The bone assessment results were excellent in 21 and good in 3 patients. Functional assessment scores were excellent in 19, good in 4, and fair in 1 patient. Pin site infections were present in 10.7% of the pin sites. There were 52 complications in 24 patients, for a complication rate per patient of 2.08. Of the complications, 48.1% were problems (minor complications), 38.5% obstacles (major complications requiring a surgical solution), and 13.4% sequelae (true complications). Minor complications included soft tissue inflammation and infection, translation/angulation, and delayed maturation during distraction and transient knee contracture and loss of motion. All grade 1 and 2 soft tissue inflammations and infections healed with nonoperative therapy. Major complications included pin tract infection and reinfection, equinus deformity, frame failure, and premature consolidation, all of which required additional surgery to correct the problem. Sequelae included leg length discrepancy, loss of knee/ankle range of motion, knee flexion contracture, malalignment, and chronic osteomyelitis. CONCLUSION: Bifocal compression-distraction osteogenesis is a safe, reliable, and largely successful method for the acute treatment of open tibia fractures with bone and soft-tissue loss. Further nonoperative or operative treatment can correct most complications.     

Reconstruction with distraction osteogenesis for juxta-articular nonunions with bone loss

BACKGROUND: Nonunions of a juxta-articular lesion with bone loss, which represent a challenging therapeutic problem, were treated using external fixation and distraction osteogenesis. METHODS: Seven juxta-articular nonunions (five septic and two aseptic) were treated. The location of the nonunion was the distal femur in four patients, the proximal tibia in one patient, and the distal tibia in two patients. All of them were located within 5 cm from the affected joints. Preoperative limb shortening was present in six cases, averaging 2.9 cm (range, 1-7 cm). The reconstructive procedure consisted of refreshment of the nonunion site, deformity correction, stabilization by external fixation, and lengthening to eliminate leg length discrepancy or to fill the defect. Shortening-distraction was applied to six patients and bone transport to one patient for reconstruction. Intramedullary nailing to reduce the duration of external fixation was simultaneously performed in two cases. All the patients had at least 1 year of follow-up evaluation. RESULTS: Osseous union without angular deformity or leg length discrepancy greater than 1 cm was achieved in all patients. The mean amount of lengthening was 5.8 cm (range, 2.2-10.0 cm). The mean external fixation period was 219 days (range, 98-317 days), and the mean external fixation index was 34.4 days/cm (range, 24.5-47.6 days/cm). All patients reported excellent pain reduction. There were no recurrences of infection in five patients with prior history of osteomyelitis. The functional results were categorized as excellent in two, good in three, and fair in two. CONCLUSION: Despite the length of postoperative external fixation, distraction osteogenesis can be a valuable alternative for the treatment of juxta-articular nonunions.     

Reconstruction with callus distraction for nonunion with bone loss and leg shortening caused by suppurative osteomyelitis of the femur

We present a retrospective study of 27 patients treated by callus distraction using a unilateral external fixator of our own design for nonunion with bone loss and shortening of the femur caused by suppurative osteomyelitis. The unilateral external fixator was used either alone or in combination with an intramedullary nail. The mean age of the patients was 13.6 years (8 to 18). The fixator was used alone in 13 patients and with an intramedullary nail in 14. The bone results at a mean follow-up of 88 months (37 to 144) were excellent in 16 patients and good in 11. The functional results were excellent in 18 patients and good in nine. However, four patients still had draining sinuses at the latest follow-up. A residual deformity greater than 7 degrees was present in seven femora, but this did not adversely affect function or require further treatment.     

Reconstruction of segmental bone defects due to chronic osteomyelitis with use of an external fixator and an intramedullary nail

BACKGROUND: Callus distraction over an intramedullary nail is a rarely used technique for the reconstruction of intercalary defects of the femur and tibia after radical débridement of chronic osteomyelitic foci. The aim of this study was to summarize our experience with distraction osteogenesis performed with an external fixator combined with an intramedullary nail for the treatment of bone defects and limb-shortening resulting from radical débridement of chronic osteomyelitis. METHODS: Thirteen patients who ranged in age from eighteen to sixty-three years underwent radical débridement to treat a nonunion associated with chronic osteomyelitis of the tibia (seven patients) and femur (six patients). The lesions were classified, according to the Cierny-Mader classification system, as type IVA (nine) and type IVB (four). The resulting segmental defects and any limb-length discrepancy were then reconstructed with use of distraction osteogenesis over an intramedullary nail. Two patients required a local gastrocnemius flap. Free nonvascularized fibular grafts were added to the distraction site for augmentation of a femoral defect at the time of external fixator removal and locking of the nail in two patients. At the time of the latest follow-up, functional and radiographic results were evaluated with use of the criteria of Paley et al. RESULTS: The mean size of the defect was 10 cm (range, 6 to 13 cm) in the femur and 7 cm (range, 5 to 10 cm) in the tibia. The mean external fixator index was 13.5 days per centimeter, the consolidation index was 31.7 days/cm, and the mean time to union at the docking site was nine months (range, five to sixteen months). At a mean follow-up of 47.3 months, eleven of the thirteen patients had an excellent result in terms of both bone and functional assessment. There were two recurrences of infection necessitating nail removal. These patients underwent revision with an Ilizarov fixator. Subsequently, the infection was controlled and the nonunions healed. CONCLUSIONS: This combined method may prove to be an improvement on the classic techniques for the treatment of a nonunion of a long bone associated with chronic osteomyelitis, in terms of external fixation period and consolidation index. The earlier removal of the external fixator is associated with increased patient comfort, a decreased complication rate, and a convenient and rapid rehabilitation.     

混合式单臂外固定架骨延长术治疗感染性骨不连

目的评价混合式单臂外固定架骨延长术治疗长骨干骺端感染性骨不连的初步临床结果。方法2003年1月至2006年2月采用混合式单臂外固定架固定、局部清创和截骨延长法治疗感染性骨不连21例,男17例,女4例;年龄18～48岁,平均31.5岁。16例为开放骨折内固定术后感染,5例为闭合骨折内固定术后感染。胫骨近端12例,胫骨远端6例,股骨远端3例。12例行骨折端植骨,其中2例二次植骨。结果21例术后随访10～36个月,平均18个月。18例骨折获得初期愈合,3例骨折愈合时仍有局部窦道和渗液,2例骨折尚未完全愈合,1例行截肢术,20例感染得到控制。改良ASAMI骨评定结果为优良13例,中4例,差4例;功能评定结果为优良11例,中6例,差4例。平均骨延长5.6cm,平均愈合时间为11个月。15例发生钉道感染。结论对长骨干骺端感染性骨不连可使用混合式单臂外固定架骨延长术、骨折端开放换药的方法。该方法控制感染好,可自体修复骨缺损,供区畸形发生率低。但固定需采用HA涂层螺钉,严格控制延长速度,一般在1mm/d以内,分次进行延长,手术风险小。     

Treatment of Gustilo-Anderson type III open fractures with segmental long bone loss secondary to gunshot and war ınjurıes in paediatric patients with bone segment transport by the limb reconstructıon system (LRS)

ObjectiveThe information on firearm- or explosive-related extremity injuries in children is very limited. Reports of segmental bone loss due to these types of fractures are even rarer and the treatment remains a problem. There has been no report of distraction osteogenesis with limb reconstruction system (LRS) specifically in children. We evaluated the treatment results of Gustilo–Anderson type 3 open fractures with segmental bone loss due to firearm injuries by distraction osteogenesis performed with LRS in skeletally immature patients.MethodsNine patients with Gustilo–Anderson (GA) type 3 open fractures with segmental bone loss due to firearm injuries who had not completed their skeletal development were included. Two of the patients had GA type 3a, four had type 3b, and the remaining three had type 3c. Bony and functional assessment was conducted using Association for the Study and Application of the Methods of Illizarov (ASAMI) criteria.ResultsMean follow-up period was 20.1 months (range 5.5–35 months). The mean bone loss was 45.5 mm (range 15–80 mm) before the treatment started. The mean time of external fixation (day) was 180.6. The mean distraction index (distraction period per cm) was 11.3 day/cm. The mean time for bone union index (duration of bony union per cm) was 33.7 days/cm. Bony union was achieved in all patients at the end of the treatment. Bony results as per ASAMI score were excellent in seven fractures and good in three. Functional results were excellent in five patients, good in two, and fair in two. We had no fair or poor results with respect to bony results but had two fair functional results.ConclusionsLRS provides a good treatment choice for children with fractures with segmental bone loss due to firearm injuries. It also provides easy access to the wound with its monolateral construction.     

Inferior subluxation of the fibular head following tibial lengthening with a unilateral external fixator

BACKGROUND: Inferior subluxation of the proximal part of the fibula has been reported to occur with distraction osteogenesis of the tibia; however, the clinical sequelae of this subluxation are unknown. The purpose of this study was to evaluate inferior subluxation of the proximal part of the fibula and its possible clinical implications in patients who had undergone tibial lengthening by distraction osteogenesis with use of a unilateral external fixator. METHODS: Thirty tibiae in seventeen patients with a variety of conditions underwent tibial lengthening by distraction osteogenesis with use of a unilateral external fixator and were followed clinically and radiographically for a mean of two years and ten months (range, two to four years). Ten patients were female and seven were male. Their mean age at the time of the surgery was seventeen years (range, eight to twenty-five years). The mean tibial lengthening was 8.1 cm (range, 3.5 to 13 cm). RESULTS: An inferior shift of the fibular head in relation to the tibia was evident in all cases. The shift, which ranged from 0.4 to 3.3 cm, was proportionally related to the amount of tibial lengthening. This type of subluxation is probably attributable to the tension that is exerted by the intact interosseous membrane during the distraction as well as to the tension of the regenerated bone of the fibula and the fact that the fibula itself is not fixed or directly lengthened by the external fixator. CONCLUSIONS: It appears that inferior subluxation of the fibula is a common phenomenon in patients undergoing tibial lengthening by distraction osteogenesis with use of a unilateral external fixator. However, no clinical symptoms or findings related to the inferior subluxation of the fibula were found in our series.     

Distraction osteogenesis for the treatment of post traumatic complications using a conventional external fixator. A novel technique

PURPOSE: To evaluate the clinical results of post traumatic complications treated by the author's own technique using an AO/ASIF conventional external fixator (without special distraction device). MATERIALS AND METHODS: There were 70 patients (77 limbs) with an average of 26.8 years (range, 4-54). There were 33 femurs, 43 tibias and one ulna. The following post traumatic complications were treated: 14 limb shortening, 20 nonunion, 28 malunion 14 infected open fractures with bone loss and 1 chronic osteomyelitis. Linear lengthening was performed in 29 limbs, acute de-rotation and subsequent lengthening in two limbs, gradual angular correction in six limbs, combined gradual angular correction and subsequent lengthening in 10 limbs, combined acute angular correction and subsequent lengthening in eight limbs and 22 limbs with bony defects were treated with the technique so-called "bone transportation". All of the limbs were treated with an AO/ASIF conventional external fixator, using the author's own technique with distraction rate of 1 mm in one step on alternate day (1 mm/48 h). RESULTS: A new bone formation in the distraction gap was achieved in 73 of the 77 limbs. Four cases without consolidation were successfully treated with an iliac bone graft combined with plating or reapplication of the external fixator. Average new bone formation was 5.6 cm (range, 1-17 cm). The average follow-up period was 10.8 months (range, 1-71 months) after removal of the fixator. The average healing time was 244.7 days (range, 60-836 days) and the healing index was 50 days/cm (range, 17-100 days). In the group with associated angular deformity the mean correction was 18.5 degrees (range, 10-40). CONCLUSIONS: The author's technique of distraction osteogenesis, using a conventional external fixator combined with a distraction rate of 1 mm/48 h (1 mm/step) adequately treated the post traumatic complications. No extra equipment was needed other than readily available AO/ASIF fixation systems. The described technique, using an AO/ASIF fixator as a lengthening apparatus was simple and cost-effective.     

牵拉成骨技术治疗下肢大段骨缺损

目的 探讨应用牵拉成骨技术治疗下肢大段骨缺损的临床疗效.方法 回顾性分析2002年8月至2010年8月收治的11例下肢大段骨缺损患者临床资料,男10例,女1例;年龄14～53岁,平均34.5岁.均行牵拉成骨治疗,右侧胫骨7例,左侧胫骨3例,右侧股骨1例;骨缺损长度5～15cm,平均8.6 cm;9例治疗已结束,2例仍处于矿化阶段.结果 所有患者术后获7～48个月(平均27.3个月)随访.9例治疗结束患者,平均骨愈合指数为1.99个月/cm;根据Paley评价系统评价骨性结果:优6例,良3例,优良率为100%;功能结果:优4例,良4例,一般1例.结论应用牵拉成骨技术治疗大段骨缺损,手术操作简单,尤其是对于单纯骨干缺损患者,采用单边外固定支架治疗,且其手术操作更为简洁.

Abstract：

Objective To discuss the therapeutic effect of distraction osteogenesis for large bone defect of the lower extremity. Methods From August 2002 to August 2010, 11 patients with large bone defect at the lower extremity were treated with distraction osteogenesis. They were 10 men and one woman, aged from 14 to 53 years (average, 34. S years). The defect was at the right tibia in 7 cases, left tibia in 3 cases and right femur in one case. The lengths of bone defect ranged from 5 to 15 cm (average, 8. 6 cm). Results The patients were followed up for 7 to 48 months, with a mean period of 27. 3 months. The treatment of 9 cases was over, with a mean healing index of 1. 99 months/cm. According to the Paley evaluation system, the bony results were excellent in 6 and good in 3 patients; the functional results were excellent in 4, good in 4, and fair in one patient. Two cases were still in the mineralization period. Conclusion Treatment of large bone defects with distraction osteogenesis is simple and can obtain satisfactory therapeutic effects, especially when a monolateral external fixator is used for the simple shaft bone defect.     

Treatment of tibial defect and bone nonunion with limb shortening with external fixator and reconstituted bone xenograft

Objective: To explore the effect of external fixator and reconstituted bone xenograft (RBX) in the treatment of tibial bone defect, tibial bone nonunion and congenital pseudarthrosis of the tibia with limb shortening. Methods : Twenty patients ( 13 males and 7 females)with tibial bone defect, tibial bone nonunion or congenital pseudarthrosis of the tibia with limb shortening were treated with external fixation, Two kinds of external fixators were used: a half ring sulcated external fixator used in 13 patients and a combined external fixator in 7 patients.Foot-drop was corrected at the same time with external fixation in 4 patients. The shortened length of the tibia was in the range of 2-9 cm, with an average of 4.8 cm. For bone grafting, RBX was used in 12 patients, autogenous ilium was used in 3 patients and autogenous fibula was implanted as a bone plug into the medullary canal in 1 case,and no bone graft was used in 4 patients. Results: All the 20 patients were followed-up for 8 months to 7 years, averaging 51 months. Satisfactory function of the affected extremities was obtained. All the shortened extremities were lengthened to the expected length. For all the lengthening area and the fracture sites,bone union was obtained at the last. The average healing time of 12 patients treated with RBX was 4.8 months. Conclusions: Both the half ring sulcated external fixator and the combined external fixator have the advantages of small trauma, simple operation, elastic fixation without stress shielding and non-limitation from local soft tissue conditions, and there is satisfactory functional recovery of affected extremities in the treatment of tibial bone defects, tibial bone nonunion and congenital pseudarthrosis of the tibia combined with limb shortening.RBX has good biocompatibility and does not cause immunological rejections. It can also be safely used in treatment of bone nonunion and has reliable effect to promote bone healing.     

Outcome of limb reconstruction system in open tibial diaphyseal fractures

Background:Management of open tibial diaphyseal fractures with bone loss is a matter of debate. The treatment options range from external fixators, nailing, ring fixators or grafting with or without plastic reconstruction. All the procedures have their own set of complications, like acute docking problems, shortening, difficulty in soft tissue management, chronic infection, increased morbidity, multiple surgeries, longer hospital stay, mal union, nonunion and higher patient dissatisfaction. We evaluated the outcome of the limb reconstruction system (LRS) in the treatment of open fractures of tibial diaphysis with bone loss as a definative mode of treatment to achieve union, as well as limb lengthening, simultaneously.Results:Mean followup period was 15 months. The mean bone loss was 5.5 cm (range 4-9 cm). The mean duration of bone transport was 13 weeks (range 8-30 weeks) with a mean time for LRS in place was 44 weeks (range 24-51 weeks). The mean implant index was 56.4 days/cm. Mean union time was 52 weeks (range 31-60 weeks) with mean union index of 74.5 days/cm. Bony results as per the ASAMI scoring were excellent in 76% (19/25), good in 12% (3/25) and fair in 4% (1/25) with union in all except 2 patients, which showed poor results (8%) with only 2 patients having leg length discrepancy more than 2.5 cm. Functional results were excellent in 84% (21/25), good in 8% (2/25), fair in 8% (2/25). Pin tract infection was seen in 5 cases, out of which 4 being superficial, which healed to dressings and antibiotics. One patient had a deep infection which required frame removal.Conclusion:Limb reconstruction system proved to be an effective modality of treatment in cases of open fractures of the tibia with bone loss as definite modality of treatment for damage control as well as for achieving union and lengthening, simultaneously, with the advantage of early union with attainment of limb length, simple surgical technique, minimal invasive, high patient compliance, easy wound management, lesser hospitalization and the lower rate of complications like infection, deformity or shortening.     

Bone transport versus acute shortening for the management of infected tibial non-unions with bone defects

IntroductionThis study compared bone transport to acute shortening/lengthening in a series of infected tibial segmental defects from 3 to 10 cm in length.MethodsIn a retrospective comparative study 42 patients treated for infected tibial non-union with segmental bone loss measuring between 3 and 10 cm were included. Group A was treated with bone transport and Group B with acute shortening/lengthening. All patients were treated by Ilizarov methods for gradual correction as bi-focal or tri-focal treatment; the treating surgeon selected either transport or acute shortening based on clinical considerations. The principle outcome measure was the external fixation index (EFI); secondary outcome measures included functional and bone results, and complication rates.ResultsThe mean size of the bone defect was 7 cm in Group A, and 5.8 cm in Group B. The mean time in external fixation in Group A was 12.5 months, and in Group B was 10.1 months. The external fixation index (EFI) measured 1.8 months/cm in Group A and 1.7 months/cm in Group B (P = 0.09). Minor complications were 1.2 per patient in the transport group and 0.5 per patient in the acute shortening group (P = 0.00002). Major complications were 1.0 per patient in the transport group versus 0.4 per patient in the acute shortening group (P = 0.0003). Complications with permanent residual effects (sequelae) were 0.5 per patient in the transport group versus 0.3 per patient in the acute shortening group (P = 0.28).ConclusionsWhile both techniques demonstrated excellent results, acute shortening/lengthening demonstrated a lower rate of complications and a slightly better radiographic outcome. Bone grafting of the docking site was often required with both procedures.Level of evidence: Level III; Retrospective comparative study     

Distraction osteogenesis for nonunion after high tibial osteotomy.

The purpose of this study was to determine whether distraction osteogenesis can be used to treat hypertrophic nonunion associated with angular deformity and shortening after Coventry style high tibial osteotomy. Five consecutive patients were retrospectively reviewed. In all patients the alignment had collapsed into excessive varus or valgus and leg length discrepancy was present. The leg length discrepancy, malalignment, and nonunion were treated simultaneously with distraction. Union was achieved by the time of fixator removal, which averaged 4.4 months. The Hospital for Special Surgery knee score significantly improved from 42 to 89. The mechanical axis deviation significantly improved by 5 cm. The coronal plane deformity significantly improved by 13 degrees, and leg length discrepancy improved significantly from 2.3 to 0.5 cm. Metaphyseal bone stock increased by 43%, and the Insall-Salvati ratio increased from 1.1 to 1.2 and remained within normal limits. All patients were satisfied with the procedure, and none have had or need a total knee replacement at an average followup of 4 years. Distraction osteogenesis of nonunion after high tibial osteotomy is a minimally invasive and successful procedure. It leads to bony union with correction of deformity and leg length discrepancy and prevents the need for total knee replacement at intermediate-term followup. The increase in metaphyseal bone stock may make total knee replacement technically easier.     

Tetrafocal leg reconstruction using combined Ilizarov/TSF technique

Treatment of segmental tibial bone defects after high-energy trauma or atrophic nonunion resection is challenging. In the last two decades, distraction osteogenesis Ilizarov bone transport has become a gold standard for the treatment of segmental tibial bone defects and lengthening in spite of the fact that frequent frame modifications and the need for sequential correction of deformities during bone transport are the main limitations of the device itself. The Taylor Spatial Frame applies the concept of the Stewart platform to the standard Ilizarov frame while applying the same principles of distraction osteogenesis postulated by Ilizarov. We report the case of a patient with two problems we could treat simultaneously: an ankle equinus contracture (a consequence of limb leg discrepancy) and infected tibial nonunion and soft-tissue damage complication after plating in a 41A3 type II Gustilo fracture of the left leg.     

External fixation reconstruction of the residual problems of benign bone tumours

The mechanical features of and biologic response to using distraction osteogenesis with the circular external fixator are the unique aspects of Ilizarov’s contribution that allows deformity correction and reconstruction of bone defects. We present a retrospective study of 20 patients who suffered from a variety of benign tumours for which external fixators (EF) were used to treat deformity, bone loss, and limb-length discrepancy. A total of 26 bony segments in twenty patients (10 males, 10 females; mean age 17 years; range 7–58 years) were treated with EF for residual problems from the tumour itself (primary treatment) in 8 patients and for complications related to the primary surgery (secondary treatment) in 12 patients. Histological diagnoses were Ollier’s disease (n = 4), Fibrous Dysplasia (n = 5), Congenital multiple exostosis (n = 5), giant cell tumour (n = 2) and one case for chondromyxoid fibroma, desmoid fibroma, chondroma and unicameral bone cyst. Various types of external fixators used to treat these problems. These were Ilizarov, unilateral fixator, multiaxial correction frame (Biomet, Parsippany, NJ), Taylor spatial frame (Memphis, TN) and smart correction multiaxial frame. The mean follow-up time was 69.5 months (range 35–108 months). The mean external fixation time was 159.5 days (range 27–300 days). The mean external fixation index was 67.4 days/cm (12–610) in 26 limbs who underwent distraction osteogenesis. The mean length of distraction was 4.9 cm (range 0.2–14 cm). At final follow-up, all patients had returned to normal activities. Complications were in the form of knee arthrodesis in one patient, pin tract infection in six and residual shortening in eight patients. The use of EF and the principles of distraction osteogenesis, in the management of problems associated with benign bone tumours and related surgery yields successful results especially in young patients. With this approach, the risk for recurrence of shortening and deformity may be minimized with overcorrection or over-lengthening as dictated by preoperative planning.