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     

Ilizarov external fixator: acute shortening and lengthening versus bone transport in the management of tibial non-unions

Eighteen patients with tibial shaft non-unions were treated by the Ilizarov method between March 1995 and September 2001 by the senior author. Three subgroups of six patients each were treated by either acute shortening and lengthening, bone transport or simple stabilisation with a frame. All aspects of non-union, infection, shortening, deformity and bone loss were addressed by using Ilizarov principles. There were 10 cases of infected non-unions in the entire series. Bone resection in the shortening group was between 3 and 6 cm (median 4.6) compared to 3-7.5 cm (median 5.9) in the bone transport group. Union was achieved in all the patients with the average time to union at 12.1 months, 17.2 months and 8.0 months, respectively. The bone transport group required additional bone grafting in five patients (83.3%) prior to union compared to one (16.7%) in the acute shortening group.     

Acute shortening versus bone transport for the treatment of infected femur non-unions with bone defects

BackgroundThe bone transport technique has been a well-known method in the treatment of osteomyelitis of the long bones with large segmental bone defects. However, one of the major drawbacks with this traditional technique is the long-lasting consolidation period, which may entail infectious and non-infectious complications. To overcome this drawback, several techniques were developed, one of which is acute shortening and re-lengthening. The aims of this study were: 1) to present our experience with a new modified technique of acute shortening and re-lengthening using a monolateral external fixator combined with a retrograde intramedullary nail, and 2) to compare its results with the classic Ilizarov bone transport method in the management of infected non-unions of the distal femur with bone loss.MethodsThis retrospective study compared these two techniques. 17 patients were treated using our modified technique of acute shortening and re-lengthening (Group A); 15 patients were treated using segmental bone transport (Group B). The average follow-up was 66 months (range: 24–180) in Group A and 70 months (range: 24–240) in Group B. The mean bone loss was 5.5 cm (range: 3–10) in Group A and 5.9 cm (range: 3–10) in Group B. The primary outcome of the present study was to compare the external fixator time (EFT) and external fixation index (EFI) between the two groups. The bone and functional status were also assessed.ResultsThe mean EFI was lower in Group A (mean: 31.8 days/cm; range: 24–50) than in Group B (mean 48.7 days/cm; range: 40–100) (p = 0.02). The mean EFT was shorter in Group A (mean: 120 days; range: 100–150) than in Group B (mean: 290 days; range: 100–400) (p = 0.0003). With respect to the bone and functional results, no difference was observed.ConclusionsAlthough both techniques could be employed safely in the treatment of infected non-union of the distal femur with size defects ranging between 3 cm and 10 cm, our modified technique of acute shortening and re-lengthening may confer greater patient satisfaction because of shorter EFI.     

急性骨短缩-延长加骨髓移植治疗胫骨骨折并骨缺损

随着高能量损伤的增多，胫骨开放性骨折并骨缺损病例逐年增多，由于胫骨解剖的特殊性，其治疗颇为棘手。2000年3月-2004年3月，应用半环槽外固定架采用急性骨短缩-延长加骨髓移植方法治疗胫骨骨折并骨缺损14例，取得了较满意的效果，现报告如下。     

Segment transport employing intramedullary devices in tibial bone defects following trauma and infection

OBJECTIVES: To compare two different methods of segment transport in posttraumatic and postseptic tibial defects by employing intramedullary tibial nails as the fixation system and to evaluate differences in the complication rate between external fixation and wire towropes as the transport system. DESIGN: Randomized, prospective, nonblinded study. SETTING: Level 1 trauma center. PATIENTS: Thirty patients with posttraumatic or postseptic defects of the tibial shaft were admitted at our center between January 1994 and December 1995. For study purposes, they were divided into two groups with fifteen patients in each. METHODS: All thirty patients underwent a standardized therapy protocol consisting of three phases: (a) eradication of infection, (b) restoration of soft tissue defects, and (c) bone segment transport. The first two phases were identical for both groups. The third phase was different: in Group A transport of the segment was performed with a combination of intramedullary nail and wire towrope; in Group B the intramedullary nail was combined with an external fixation device. We then evaluated both subjective data (patient comfort, restrictions in physiotherapy) and objective data (mobility of knee and ankle joint, transport time, reoperations, complications) to determine treatment success. RESULTS: Both methods are useful for segment transport in patients with tibial shaft defects following trauma and infection. The relative transport time was shorter in Group A than in Group B (12.2 versus 13.7 days/centimeter; p = 0.002). Group B also recorded a significantly higher complication rate than did Group A (septic complications, twenty-six versus six events; necessary recorticotomies, four versus zero events). CONCLUSIONS: An intramedullary nail and wire towrope proves to be a reliable combination for segment transport in tibial defects following trauma and infection and provides a relatively high patient comfort rate and a low complication rate.     

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.

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.     

Ilizarov bone transport after massive tibial trauma: Case report

IntroductionThis is a case report of extreme lengthening of the tibia of about 14.5 cm using bone transport technique following road traffic accident trauma to the lower limbs. The management of the subsequent massive skeletal defects was challenging to orthopedic surgeons. Based on reported cases, the highest tibial lengthening was 22 cm using bifocal transport, while the highest unifocal tibial lengthening reached 14.5 cm.Case presentationA 20-year-old male driver was brought to the emergency department after a road traffic accident. The patient had a right Gustilo IIIA segmental open tibia fracture with bone loss and other severe injuries. The tibial defect was 14.5 cm and the patient was then admitted for Ilizarov application six months after the accident. Although this case was particularly complicated, full limb length was restored.DiscussionThe management of this case was directed to correct the deformities and achieve equal length of both limbs to restore the normal function. Several new techniques have been developed recently to fill large bone defects. Limb lengthening using bone transport technique by application of Ilizarov ring fixator has been suggested as the leading option in filling massive bone gaps.ConclusionThe use of bone transport technique using Ilizarov external rings has proved to be a minimally invasive and reliable method in managing massive bone defects. Accurate application of the Ilizarov frame and proper transport of the middle segment are important factors alleviating the risk for deviation of the transported segment. However, due to the need for regular follow-ups and monitoring, it demands high compliance from the patient to achieve optimal results.     

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.     

The management of bone defects of the forearm after trauma.

In summary, the authors believe that traumatic bone defects of the diaphyseal forearm, fewer than 6 cm in length, can be well managed with corticocancellous bone grafting, provided the patient has an adequate soft-tissue envelope. In cases of soft-tissue compromise, primary bone grafting is still the treatment of choice, combined with simultaneous soft-tissue coverage. This does not exclude the use of immediate primary shortening. Traumatic bone defects larger than 6 cm can best be managed with osteoseptocutaneous free fibular graft with excellent functional and cosmetic results. The creation of a one-bone forearm is rarely necessary, but remains a treatment option for an otherwise unsalvageable extremity. Osteo-articular defects can be more difficult to manage. Proximal osteo-articular defects of the radial head can be treated with excision or placement of a titanium radial head prosthesis. Distal osteo-articular defects may be better addressed in the case of radial bone loss by primary wrist fusion and, in the ulna, by a primary Darrach or Suave-Kapandji procedure.     

胫骨截骨骨延长治疗小腿骨缺损感染

目的介绍胫骨截骨骨延长方法修复小腿骨与软组织同时缺损的临床经验。方法2002年6月～2003年12月采用Ilizarov型组合外固定架固定治疗18例小腿骨与软组织缺损感染患者,骨坏死缺损长度为4～12mm,平均5．6mm。对骨缺损处彻底清创,尽最大限度覆盖创面,在小腿近侧干骺端处行水平截骨,骨段牵移直到与远骨折端接触并加压固定。结果所有患者术后获5～24个月(平均14．5个月)随访,全部患者创面均得到良好的软组织覆盖,骨延长与缺损处骨性愈合,膝关节功能正常,踝关节维持术前状态,未发生神经、血管损伤。结论小腿截骨骨延长修复术治疗创伤后小腿骨、皮缺损感染疗效良好。     

应用胫骨Ⅰ期短缩加Ⅱ期延长治疗严重胫骨开放性骨折

目的 评价应用胫骨Ⅰ期短缩加Ⅱ期延长的方法治疗严重胫骨开放性骨折的临床效果.方法 自2006年5月至2009年8月应用胫骨Ⅰ期短缩加Ⅱ期延长治疗5例严重胫骨开放骨折患者,均为男性;年龄23～41岁,平均35岁.清创和胫骨短缩后用单边外固定支架临时固定,血管损伤者行动脉吻合.1例伤口Ⅰ期闭合,2例经植皮后愈合,2例分别通过腓肠神经营养支筋膜瓣和交腿皮瓣闭合伤口.伤口愈合后从胫骨近端做截骨,应用Ilizarov架行胫骨延长,恢复小腿的长度.胫骨短缩3～5 cm,平均4.2 cm.结果 所有患者术后获18～24个月(平均20个月)随访.患者骨折短缩处伤口均获愈合,无一例发生感染.全部患者骨折均获愈合,愈合时间为6～12.5个月,平均9.6个月,平均愈合指数1.7个月/cm,患肢长度均恢复,与健侧无差别.按Paley功能评价标准:优3例,良1例,可1例.结论 应用胫骨Ⅰ期短缩加Ⅱ期延长治疗严重胫骨开放性骨折,具有安全可靠、简化治疗过程及减少皮瓣应用等优点,是一种较好的方法.

Abstract：

Objective To evaluate clinical results of primary shortening plus secondary lengthening of the tibia for sever tibial fractures. Methods From May 2006 to August 2009, 5 men with severe open tibial fracture were treated with primary shortening plus secondary lengthening of the tibia in our center. They were aged from 23 to 41 years (average, 35 years) . Four cases were Gustilo type MB and one was Gustilo type M C. The primary procedure included debridement, shortening of the tibia and temporary fixation with a unilateral external fixator, and arterial anastomosis in cases of vessel injury. The wounds healed primarily in one case, after skin graft in 2 cases, and after flap transplantation in 2 cases. After wound healing, secondary lengthening of the tibia was performed following osteotomy of the proximal tibia with an Ilizarov fixator to restore the length of the injured leg. The average shortening was 4. 2 cm (range, 3 to 5 cm). Results The average follow-up period was 20 months (range, 18 to 24 months). All the wounds were healed without signs of osteomyelitis. All the fractures united. The mean bone healing time was 9. 6 months (range, 6 to 12. 5 months) . The average healing index was 1. 7 months/cm. A normal length was restored in all the affected lower limbs. By Paley functional assessment system, 3 cases were excellent, one was good and one was fair. Conclusion Primary shortening plus secondary lengthening of the tibia is a reliable and successful method for sever tibial fractures, because it can simplify management and minimize the need for flap coverage.     

骨搬移术治疗胫骨骨折术后感染性大段骨缺损的疗效分析

背景：胫骨骨折术后感染性大段骨缺损的发生率高,治疗困难,效果不理想。目前,骨缺损修复方法包括皮瓣覆盖＋自体骨移植术、异体骨或异种骨移植、带血供腓骨移植、骨延长和骨搬移术。目的：探讨骨搬移术治疗胫骨骨折术后感染性大段骨缺损的疗效。方法：选取2010年9月至2014年9月收治的胫骨骨折术后感染性大段骨缺损患者40例,男24例,女16例;年龄18~64岁,平均（42.8±12.1）岁。将患者随机分成两组各20例,一组采用Orthofix单臂外固定延长架截骨延长,另一组采用Ilizarov环形外固定延长架截骨延长,术后随访对比两组患者的手术时间、手术出血量、HHS膝关节功能评分、Baird-Jackson踝关节功能评分。结果：Orthofix单臂外固定延长架的手术时间较短、手术出血量较少,与Ilizarov环形外固定延长架比较均有统计学差异（P〈0.05）。两组患者的术后HHS膝关节功能评分、Baird-Jackson踝关节功能评分均较术前有明显提高（P〈0.01）。结论：骨搬移术治疗胫骨骨折术后感染性大段骨缺损的疗效佳,可较好地改善患者的膝关节和踝关节功能。其中Orthofix单臂外固定延长架能减少手术创伤,安全性较高,但骨搬运过程中容易发生延长骨成角和偏移;Ilizarov环形外固定延长架的术中应用置入较多钢针,移动时可造成部分皮瓣坏死和血管损伤,应避免在皮瓣覆盖创面的胫骨大段骨缺损患者中使用。     

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。     

胫骨近端与远端截骨搬运在胫骨骨髓炎治疗中的效果比较

目的比较胫骨近端截骨搬运与胫骨远端截骨搬运在治疗胫骨骨髓炎清创所致大段骨缺损时对搬运区骨生长矿化情况及足踝功能的影响。方法回顾性分析2012年7月至2017年7月南方医科大学南方医院骨科采用骨髓炎清创及骨搬运手术治疗的42例慢性胫骨骨髓炎患者资料。根据慢性骨髓炎Cierny-Mader分型:42例患者均为弥散型(Ⅳ型)胫骨骨髓炎。根据搬运部位不同分为2组:32例采用胫骨近端截骨搬运(近端组),男27例,女5例;年龄为17~65岁;左20例,右12例。10例采用胫骨远端截骨搬运(远端组),均为男性;年龄25~63岁;左6例,右4例。比较两组患者术后对合端手术干预数、外固定指数(EFI)和美国足踝外科协会(AOFAS)踝-后足功能评分。结果两组患者性别、年龄、骨髓炎部位等一般资料差异均无统计学意义(P>0.05)。两组患者均获完整随访,近端组与远端组随访时间为(590.1±287.3)、(615.6±130.6)d,差异无统计学意义(P>0.05)。搬运后近端组与远端组分别有3例、2例出现足部马蹄内翻畸形,均需手术干预;术后近端组与远端组分别16、3例对合端需手术干预19例;近端组与远端组EFI分别为(76.2±50.0)、(84.3±59.9)d/cm,以上项目两组间比较差异均无统计学意义(P>0.05)。近端组与远端组AOFAS踝-后足功能评分分别为(81.4±10.1)、(60.0±5.9)分,差异有统计学意义(P<0.05)。结论运用骨搬运治疗胫骨骨髓炎清创所致的骨缺损时,胫骨近端骨搬运与胫骨远端骨搬运对搬运区骨生长及对合端骨愈合无明显影响,但胫骨近端骨搬运对足踝功能的不利影响较小。     

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.     

Functional outcome following bone transport reconstruction of distal tibial defects

BACKGROUND: Little has been written about the functional outcome of patients treated with bone transport to reconstruct a distal tibial defect. The aim of this study was to investigate the functional capabilities of patients who had undergone reconstruction with distraction osteogenesis for the treatment of a distal tibial defect in one lower limb. METHODS: At least eighteen months after completion of treatment, eight patients who had no pain and were able to walk and climb stairs without difficulty performed isometric ankle plantar flexion maximum voluntary contractions while the electromyographic activity of the tibialis anterior and triceps surae muscles was simultaneously recorded. Seven of the patients also underwent gait analysis. Data for the involved limb were compared with those collected for the contralateral limb. RESULTS: During gait, stance time (p = 0.01), the plantar flexion angular displacement and peak moment developed during the second half of stance (p < 0.046), and the amount of ankle power generated (p = 0.02) were significantly decreased in the involved limb compared with the contralateral limb. Similar decreases were observed in the plantar flexion (p = 0.01) and dorsiflexion (p = 0.01) maximum voluntary contractions and the corresponding electromyographic activity (p = 0.01). CONCLUSIONS: These results suggest that adaptive changes had occurred at the level of the transported muscles, which affected both routine and maximal effort capabilities. These findings contribute to our understanding of the functional limitations of patients who have undergone bone transport with its obligatory shortening of muscle length.