Comparison between lengthening over nail and conventional Ilizarov lengthening: a prospective randomized clinical study

The aim of this study is to compare lengthening over an intramedullary nail to the conventional Ilizarov method with regard to percentage length increase, external fixation index, consolidation index and incidence of complications. This is a prospective randomized controlled study. Thirty-one limbs in 28 patients were included in the study; 15 were lengthened over an intramedullary nail, and 16 limbs were lengthened conventionally. The mean duration of external fixation in the lengthening over nail group was 52.2 days compared to 180.4 days in the conventional group. There was higher incidence of complications in the conventional method group. In comparison with conventional Ilizarov lengthening, lengthening over an intramedullary nail offers a shorter period of external fixation and fewer complications overall, but there is a high incidence of deep intramedullary infection which is serious.     

International recognition of the Ilizarov bone reconstruction techniques: Current practice and research(dedicated to 100~(th) birthday of G. A. Ilizarov)

The Ilizarov method is one of the current methods used in bone reconstruction. It originated in the middle of the past century and comprises a number of bone reconstruction techniques executed with a ring external fixator developed by Ilizarov GA. Its main merits are viable new bone formation through distraction osteogenesis, high union rates and functional use of the limb throughout the course of treatment. The study of the phenomenon of distraction osteogenesis induced by tension stress with the Ilizarov apparatus was the impetus for advancement in bone reconstruction surgery. Since then, the original method has been used along with a number of its modifications developed due to emergence of new fixation devices and techniques of their application such as hexapod external fixators and motorized intramedullary lengthening nails. They gave rise to a relatively new orthopedic subspecialty termed "limb lengthening and reconstruction surgery". Based on a comprehensive literature search, we summarized the recent clinical practice and research in bone reconstruction by the Ilizarov method with a special focus on its modification and recognition by the world orthopedic community. The international influence of the Ilizarov method was reviewed in regard to the origin country of the authors and journal's rating. The Ilizarov method and other techniques based on distraction osteogenesis have been used in many countries and on all populated continents. It proves its international significance and confirms the greatest contribution of Ilizarov GA to bone reconstruction surgery.     

Ilizarov技术骨短缩-延长治疗无血管损伤的胫骨与软组织缺损

目的探讨Ilizarov技术骨短缩-延长治疗无血管损伤的胫骨与软组织缺损的疗效。方法回顾性分析2007年1月至2017年10月无锡市第九人民医院骨科采用Ilizarov技术骨短缩-延长治疗的28例无血管损伤的胫骨与软组织缺损患者资料。男20例,女8例;年龄18~69岁,平均36.4岁。均为创伤性骨折,GustiloⅡ型5例,ⅢA型6例,ⅢB型17例。17例合并感染。清创或扩创后创面皮缺损范围4 cm×3 cm^16 cm×5 cm,骨缺损长度4.5~11.0 cm(平均6.9 cm)。急性短缩3~7 cm后直接缝合或局部皮瓣转移或游离植皮,或术后逐渐短缩创口延迟闭合。术后观察创口愈合、骨愈合、下肢功能恢复和并发症等情况。骨愈合和下肢功能恢复分级按照Ilizarov技术研究与应用学会(ASAMI)标准分别评定。Ilizarov手术相关并发症按照Paley标准分为主要和次要并发症。结果创口愈合时间13~35 d(平均21.9 d),缺损端靠拢时间为0~75 d(平均21.8 d)。所有患者术后获12~45个月(平均20.5个月)随访。延长段骨愈合时间6~12个月(平均8.9个月);缺损端1例骨不连,骨愈合时间6~11个月(平均8.3个月)。ASAMI骨愈合分级优良率为100%(28/28),ASAMI下肢功能恢复优良率为89.3%(25/28)。Ilizarov术后主要并发症发生率为14.3%(4/28),次要并发症发生率为57.1%(16/28),总体并发症发生率为60.7%(17/28),并发症人次平均为1.7个/例。结论Ilizarov技术骨短缩-延长治疗无血管损伤的胫骨与软组织缺损,可以解决皮肤等软组织缺损修复困难难题,具有简化创口闭合、骨缺损端骨愈合较快、愈合率较高、并发症相对较少和肢体功能恢复满意等特点。     

胫骨骨运输术中对接端新鲜化技术的临床观察

目的:研究胫骨骨运输术中对接端应用骨面新鲜化处理技术的效果。方法:对2014年1月至2019年12月胫骨骨运输术中对接端骨面新鲜化处理手术的20例患者进行分析。其中男15例,女5例;年龄19~62(42.3±11.5)岁;感染性7例,非感染性13例。对接端达到接触后即刻通过使骨面新鲜化处理的手术技术,清除卡入断端的皮肤和软组织,切除硬化封闭的骨端,改善对位,增加接触面积,术中即刻对对接端进行加压,并就近取骨植骨。术后继续逐渐加压。结果:缺损长度5~15(9.2±2.9) cm,从截骨到对接端接触需要26~243(109.1±51.1) d。所有患者对接端达到骨性愈合。达到影像学愈合标准需要3~7(3.7±1.1)个月,20例中15例需要腓骨截骨,其中14例腓骨的截骨端达到骨性愈合。胫骨牵开端的骨痂达到影像学坚实化的时间需要5~28(15.0±6.5)个月,骨愈合指数(bone healing index,BHI)为每厘米需0.8~2.8(1.6±0.5)个月。20例中1例胫骨切口出现感染。拆除外固定架后随访时间为12~73(37.6±20.3)个月,所有患者对接端未发生骨折。结论:胫骨骨运输术中,当对接端接触后尽早进行骨面新鲜化处理能缩短对接端的愈合时间,避免对接端再骨折,术中收集的松质骨和钻孔产生的骨屑能消除缺损和间隙,避免在其他部位取自体骨植骨。     

Ilizarov骨搬移技术在胫骨骨折术后骨感染骨缺损中的应用

目的探讨Ilizarov骨搬移技术治疗胫骨骨折术后骨感染骨缺损的临床疗效。方法回顾性分析自2010-06—2013-06应用Ilizarov骨搬移技术治疗27例胫骨骨折术后骨感染。结果 27例术后均获得平均28(16~50)个月随访。骨搬移长度平均7.9(5~12)cm,搬移时间平均78(55~160)d,骨搬移停止至拆除外固定架时间平均180(95~220)d。出现针道感染2例,停止搬移,静点抗生素、对症处理后感染控制;出现牵张成骨区成骨不全1例,植骨后愈合;拆除外架后发生牵张成骨区骨折1例,经内固定后骨愈合;骨搬移停止后,对15例断端进行去除嵌压组织、新鲜化处理后断端骨性愈合,9例无需进一步手术,通过断端加压后骨愈合,3例加压固定3个月后无明显愈合表现,按照骨不连处理方案,应用手风琴技术处理后顺利愈合。结论应用Ilizarov骨搬移技术治疗胫骨骨折术后骨感染骨缺损可以取得满意的疗效,骨搬移过程中的环形固定器有利于畸形矫正,但患者对单边固定器有更好的耐受性。严谨的术前设计、精细的术中操作、耐心细致的术后随访是治疗成功的必要保证。     

Ilizarov外固定架在胫骨截骨延长治疗中的应用

目的：探讨Ilizarov外固定架在胫骨截骨延长治疗中的应用。方法：1990年1月～2002年12月对66例应用Ilizarov外固定架进行胫骨截骨延长的患者手术疗效进行分析。结果：延长长度最长9．3cm，最短5．7cm，平均7．3cm；延长时间24～128d，平均62d；拆架时间2．5～10个月，平均6．0个月；愈合指数27～56d／cm，平均34d／cm。无严重并发症发生，其中1例术后出现腓总神经损伤症状；4例出现不同程度的针道感染；6例出现膝关节屈曲受限；4例出现跟腱挛缩致足呈马蹄畸形。给予对症处理后好转。结论：应用Ilizarov外固定架技术对于胫骨截骨延长是一种有效的方法。     

Outcome of oscillating saw open osteotomy in two-stage lower extremity bone transport with monolateral frame

IntroductionBone transport techniques have been widely used to solve massive bone defects due to trauma, osteomyelitis or bone tumors. The technique of bone interruption to achieve better new bone formation is a subject of debate. Low-energy osteotomy (LEO) techniques have been proposed as the gold standard. Some authors reject open osteotomy with an oscillating saw (OOS osteotomy), based on the danger of bone tissue thermal necrosis and periosteal damage. To date, however, there is no strong clinical evidence to discourage this high-energy (HEO) bone interruption technique.MethodsThe aim of this study was to determine outcomes in using OOS osteotomy in a series of patients, where monolateral-frame bone transport has been used to resolve segmental bone defects of the lower extremity. The minimum accepted follow-up was 1 year. The primary endpoints were radiographic evidence of regenerated bone quality (Li classification) and final outcome (Cattaneo clinical system assessment). Further, we analyzed associated complications, and compared results with other published series. We hypothesized that OOS osteotomy produces results no less favorable than those achieved with other, low-energy techniques.ResultsA total of 54 patients, with an average bone defect of 8.58 cm (CI95% 7.01–10.16), were enrolled in the study. In terms of regeneration quality, 84% of the regenerated segment shapes were associated with good outcomes; only 16% exhibited a shape (hypotrophic) predictive of a poor outcome. Regarding functional assessment, following the Cattaneo system, we found a total of 90% good or excellent results. Finally, the Bone Healing Index (BHI) in our series averaged 21.09 days per cm. The main complication observed was pin-track infection, occurring in 45% of the cases.ConclusionAccording our data, the superiority of an LEO technique over HEO techniques is yet to be confirmed; it appears that any open osteotomy is effective, performed well and in a proper clinical setting, and that many factors other than choice of osteotomy technique must play important roles.     

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     

应用Ilizarov技术治疗下肢复杂畸形

目的：总结应用Ilizarov技术治疗下肢短缩，大段骨缺损合并其他病变的复杂畸形的体会。方法：应用骨段皮质截骨延长输送或楔形骨压缩迟延延长等方法治疗开放性骨缺损伴骨髓炎4例；股骨或胫骨肿瘤瘤段切除3例；肢体短缩伴成角畸形3例。结果：10例均恢复了支体长度和持重功能。2例股骨延长者发生膝关节屈曲受限，1年后恢复。1例儿童出现胫骨过生长。结论：Ilizarov技术是治疗短肢，修复创伤，炎症，肿瘤等所致骨缺损的简单而有效的新方法。     

Ilizarov骨搬移技术轴向偏移的临床观察

目的 :探讨Iliazrov骨搬移技术治疗骨不连出现轴向偏移的角度、发生率、原因及对策。方法 :自2007年1月至2012年12月,对10例骨不连患者行Ilizarov骨搬移技术治疗,其中男8例,女2例;年龄18~49岁,平均(30.3±10.6)岁。骨缺损部位:胫骨上段2例,胫骨中段2例,胫骨下段5例,股骨上段1例。根据Paley骨缺损分型:B1型6例,B3型4例。观察术后患者发生轴向偏移角度、发生率,并采用Paley评价标准对其骨性结果进行评价。结果 :10例患者术后均获得随访,时间19~32个月,平均(22.0±5.6)个月。3例患者对合端自然愈合,其余7例经植骨相应处理后愈合。佩戴外固定架时间16~28个月,末次随访时发生冠状位成角3例,成角度数5°~11°,平均(8.7±3.2)°;矢状位成角4例,成角6°~9°,平均(8.5±2.1)°。发生轴向偏移共4例。末次随访时Paley评价标准,骨性结果:优7例,良3例;功能结果:优6例,良4例。结论:轴向偏移在Ilizarov骨搬移术后较常见,造成骨愈合延迟及患肢力线不良,术中术后应采取相应措施避免或减少其发生以提高骨愈合率。     

手风琴技术用于骨搬移治疗胫骨骨缺损

目的 :分析Ilizarov技术治疗胫骨大段骨缺损时加用"手风琴技术"的临床治疗效果。方法 :2014年1月至2016年6月采用Ilizarov骨搬移技术治疗胫骨大段骨缺损患者22例,男19例,女3例;年龄23~60岁,平均44.04岁;骨搬移前骨缺损长度5~11 cm,平均7.68 cm;14例交通事故,3例摔伤,4例砸伤,1例高处跌落;左侧6例、右侧16例。分成两组,手风琴组搬移结束后实施手风琴技术11例,对照组搬移结束后外架锁定等待矿化11例。两组患者均获得随访,随访时间18~36个月,平均27.9个月。两组患者性别、年龄、骨缺损的长度比较,差异均无统计学意义(P0.05)。分析愈合时间、愈合指数等指标,并采用Paley等方法评价骨愈合和患肢功能恢复的治疗效果。结果:两组X线评价均达到骨性愈合;手风琴组:骨愈合时间(365±91)d,愈合指数(46.2±3.5)d/cm;对照组:愈合时间(435±108)d,愈合指数(57.8±3.5)d/cm;两组骨愈合时间比较,差异无统计学意义(t=1.648:P=0.115);两组骨愈合指数比较,差异有统计学意义(t=7.754,P=0.000)。末次随访时依据Paley评价标准评价疗效:实验组优9例,良2例;对照组优8例,良3例;两组比较差异无统计学意义(Z=-0.479,P=0.619)。并发症:钉道感染:手风琴组9例,对照组10例;局部牵拉痛:手风琴组2例,对照组1例;轴向偏移10°:手风琴组4例,对照组3例;骨缺损汇合端对位差:手风琴组3例;对照组2例;两组并发症比较差异无统计学意义(P0.05)。结论 :Ilizarov骨搬移技术治疗胫骨骨缺损时加用"手风琴技术"操作后可缩短治疗时间和矿化时间,提高愈合指数。     

The ultrasound scan in monitoring regenerated bone

The aim of this work was to delimit the diagnostic possibilities of the ultrasound scan in the evaluation of regenerated bone produced in bone lengthenings and transports. The study is based on 56 ultrasound scans of regenerated bone regarding 4 lengthenings and 18 bone transports. X-ray examinations were taken in 13 patients contemporarily with the ultrasound scans and a comparative and qualitative evaluation between the radiographic gap and the ultrasound one was made. The ultrasound scans allowed us to distinguish 3 kinds of regenerated bone: normal, cystic and hypertrophic. In 7 cases, at the proximal third of the tibia, a cyst in the regenerated bone was noticed on ultrasonography. The evaluation of these cysts after the slowing down of the distraction speed was satisfactory in the sense that they disappeared in the following examinations, their volume did not change and they did not interact with the following maturation and corticalization of the regenerated bone. In one case, at the proximal third of the tibia, we noticed two cysts that disappeared after regenerated bone compression while, after a new distraction made at a lower speed, a cyst appeared again maintaining its unchanged volume. The presence of one or more cysts indicates an initial crisis of the regenerated bone which could develop into a dangerous hypotrophy if the distraction speed remained unchanged. In 5 cases with a hypertrophic regenerated bone, a gap less than 10 mm was noticed. It was treated by accelerating the distraction speed. The ultrasound examination can offer a precise monitoring of distractional osteogenesis. Received: 27 November 2001, Accepted: 4 April 2002 Correspondence to: C. Iacobellis     

Preliminary experience with motorized distraction for tibial lengthening

Limb lengthening by callus distraction is commonly performed with the use of external fixation. Lengthening is routinely performed by the patient through small increments throughout the course of a day. Ilizarov has shown that both the rate and frequency of distraction are important factors in the quality of osteogenesis. We report the effect of motorized high frequency distraction for tibial lengthening in comparison with manual low-frequency distraction at the same rate. Manual distraction (0.25 mm four times a day) in a group containing 43 tibiae was compared with motorized distraction (1/1,440 mm 1,400 times a day) in a group containing 27 tibiae. There was no significant difference in time to union or in the incidence of complications.     

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.     

Bone transport using the Ilizarov method: a review of complications in 100 consecutive cases

We present the results of treatment of 100 patients (72 men, 28 women) by the Ilizarov method of bone transport using circular (55) and monolateral external fixators (45). A total of 26 femurs (18 monolateral, 8 circular) and 74 tibias (49 circular, 25 monolateral) was examined. There were no significant differences between the circular fixator and the monolateral fixator with regard to treatment time, complications in the treated bone segments or compliance with the presence of the fixator. The main complications (pseudoarthrosis at bone contact points after transport, insufficient ossification of lengthened bone, knee stiffness) were resolved with further treatment for all patients with the exception of one case which continued with repeated infections. The circular fixator allows for deformity corrections during bone transport but the monolateral fixator is tolerated better by patients, especially in those with femoral defects.     

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.     

CT evaluation of regenerated osseous segments following bone transport

Abstract A morphological analysis using radiography and computed tomography was performed in a total of 17 bone segments following single or double bone transport in 11 and 3 patients, respectively. All bone transports involved the tibia, with the exception of 2 single bone transports, which were femoral. The following parameters were measured: cortical wall thickness, sectional area of the medullary canal, and density of the cortical bone and medullary canal in Hounsfield units (HU). The regenerated segments showed a cortical thickness and density that were less than the contralateral portion, with an enlargement of the medullary canal and an increase in density due to the presence of cancellous bone in the medullary area. Successive controls showed an increase in thickness and density of the cortical bone and a small reduction in the diameter of the medullary canal and its cancellous bone. The variations in the cortical and the medullary canal appeared to be independent of the length of the regenerated segment. In the 3 tibia treated by double bone transport, the anatomical variations in the distal regenerated portion varied less from normal values than the proximal portion of the same segment. In the 2 femurs examined, enlargement of the regenerated section was smaller with respect to cases involving regeneration of the proximal tibia. These differences are presumably dependent on the fact that in the latter case, a more vascularized segment is produced after osteotomy in spongy bone, with respect to those involving the distal tibia or femur. Double transport is preferable due to the reduced treatment times.     

骨搬运技术治疗胫骨骨缺损疗效及影响因素分析

目的探讨骨搬运技术治疗胫骨骨缺损的临床疗效及影响因素。方法回顾性分析自2006-03—2014-10诊治的46例胫骨骨缺损,按照手术方式不同分为观察组(采用骨搬运技术治疗)和对照组(采用单臂外固定架手术治疗)。比较2组骨愈合指数、AKS膝关节、Baird踝关节功能、Fernandez-Esteve骨痂评分,观察组疗效采用多因素Logistic回归分析。结果所有患者均获得11~25(18.7±7.2)个月随访。观察组骨愈合指数低于对照组,但AKS膝关节、Baird踝关节功能、Fernandez-Esteve骨痂评分高于对照组,差异均有统计学意义(P0.05)。观察组的疗效回归分析显示,肢体负重开始时间(OR=1.10,P=0.002)、骨搬运速度(OR=1.07,P=0.010)、骨搬运频率(OR=1.17,P=0.021)评分是骨愈合指数评分的保护性因素,吸烟(OR=0.89,P=0.006)、骨缺损长度(OR=0.96,P=0.000)、年龄(OR=0.87,P=0.000)评分是骨愈合指数评分的危险性因素,差异有统计学意义(P0.05);对合端接触面积(OR=1.21,P=0.001)、肢体负重开始时间(OR=1.19,P=0.001)、负重持续总计时间(OR=1.06,P=0.005)评分是骨痂评分保护性因素,差异有统计学意义(P0.05)。结论骨搬运技术治疗胫骨骨缺损在骨愈合、骨延长速度、重建下肢肢体长度和功能方面有更好的评价。