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.     

Distraction osteogenesis for tibial nonunion with bone loss using combined Ilizarov and Taylor spatial frames versus a conventional circular frame

This retrospective review assesses 55 tibial nonunions with bone loss to compare union achieved with combined Ilizarov and Taylor spatial frames (I–TSF) versus a conventional circular frame with the standard Ilizarov procedure. Seventeen (31 %) of the 55 nonunions were infected. Thirty patients treated with I–TSF were compared with 25 patients treated with a conventional circular frame. In the I–TSF group, an average of 7.6 cm of bone was resected and the lengthening index (treatment time in months divided by lengthening amount in centimeters) was 1.97. In the conventional circular frame group, a mean of 6.5 cm was resected and the lengthening index was 2.1. Consolidation at the docking site and at the regenerate bone occurred in 49 (89 %) of 55 cases after the first procedure. No statistically significant difference was shown between the two groups. Superiority of one modality of treatment over the other cannot be concluded from our data. Application of combined Ilizarov and Taylor spatial frames for bone transport is useful for treatment of tibial nonunion with bone loss. Level of evidence Case series, Level III.     

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.     

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.     

Knee Joint Bone Defects: Reconstruction With Bone Transport and Arthrodesis

BackgroundThe increasing in primary total knee arthroplasty has led to an increase in infectious complications, revision surgery, and bone loss. Knee joint bone defects (KJBD) may be managed using bone transport and arthrodesis with Ilizarov or bone transport over nail (BTON) techniques. The aim of this study is to compare both techniques in the reconstruction of KJBDs.MethodsThis was a retrospective cohort study of 29 patients with extensive KJBD. All patients underwent reconstruction of the KJBD using bone transport (either Ilizarov or BTON techniques). The primary outcome variables for comparison between the two groups included time in frame (days), external fixation index (EFI, days/cm), residual limb length discrepancy (cm), and complications (Caton classification).ResultsGender and age profiles were comparable. Mean time spent in frame for bone transport was 566 days (σ = 236, 95% CI 429-702) for the Ilizarov cohort and 191 days (σ = 162, 95% CI 101-280) for BTON (P < .0001). EFI for the period of bone transport was 75.1 d/cm (σ = 41.5, 95% CI 51.1- 99.1) for the Ilizarov cohort and 24.7 d/cm (σ = 24.0, 95% CI 11.4-38) for BTON (P = .0004). Union, limb length discrepancy and complication rates were comparable between both groups.ConclusionFor the management of KJBD after failed total knee arthroplasty, BTON is preferred due to significantly less time spent in frame, lower EFI, and higher rates of normal mechanical alignment. The Ilizarov method may be useful when there is a contraindication to BTON.     

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     

A comparative evaluation of the time to frame removal for tibia fractures treated with hexapod and Ilizarov circular frames

IntroductionTraditional Ilizarov and hexapod frames have different biomechanical properties and there is limited literature regarding their effect on time to fracture union or time to frame removal.MethodsTibial fractures managed with a circular frame at a tertiary limb reconstruction referral centre between 2011 and 2018 were retrospectively identified from a prospectively maintained database. They were classified into three treatment groups; Ilizarov style, Taylor Spatial Frame (TSF) and TrueLok Hex (TL-Hex). Data were extracted from electronic patient records and digital radiographs. The primary outcome was time to frame removal, which was seen as an indicator of clinical and radiological fracture union. Odds ratios were calculated with the clinical significance set at 30 days.Results274 patients (median age 49 years, 36% female) were included in the analysis. 8.4% Ilizarov, 10.5% TSF and 13.5% TL-Hex frames required further surgery to aid fracture healing (p = 0.38). 30% of patients had open fractures. Median time to removal for Ilizarov, TSF & TL Hex frames was 167, 198 and 185 days respectively. There was a significant difference between Ilizarov and hexapod frames. Both TSF (OR 2.2, p<0.003) and TL-Hex (OR 1.8, p<0.04) had a significantly increased time to removal of 30 days or more compared with Ilizarov frames.The time to frame removal in metaphyseal fractures was significantly shorter for Ilizarov frame fixation than hexapod frames (p = 0.04). Open fractures were significantly more likely to require at least 30 days extra time to removal than closed fractures (OR 3.3, p<0.001). There was no significant difference in the time to frame removal between fracture location, age or sex.ConclusionIlizarov frames have demonstrated a reduced time to frame removal in the management of tibial fractures than hexapod frames. Differences in the time to frame removal, an indicator of time to fracture union, may be due to the different mechanical properties of the frame, or early disruption of the fracture haematoma through secondary frame manipulation and fracture reduction, increased proportion of metaphyseal fractures treated with Ilizarov, or patient selection. The healing time was comparable across the tibia. Pooled meta-analyses may be able to further quantify these associations.     

Resorbable polylactide membrane for the treatment of segmental bone defects

IntroductionSegmental bone defects are a challenging clinical problem. In animal studies and craniomaxillofacial surgery, resorbable polylactide membrane (OrthoMesh; DePuy Synthes, West Chester, PA) shows promise for treatment of bone defects. This study presents the results of the treatment of segmental bone defects with resorbable polylactide membrane, bone morphogenic protein-2 (BMP-2), and autograft.MethodsThis study was approved by the institutional review board. All patients with a segmental bone defect treated with a resorbable polylactide membrane by a single surgeon from 2010 to 2019 were retrospectively reviewed. Data related to demographic variables, surgical details, and union were collected.ResultsEleven patients with median age of 37 years (range 22–62 years) were included in the study with segmental bone defects in the tibia (n = 3), femur (n = 4), or forearm (n = 4). Median bone defect size was 6 cm (range 3–12 cm). Etiology of bone defects included osteomyelitis (n = 7), oncologic resection (n = 3), and post-traumatic aseptic nonunion (n = 1). Flap coverage was performed in two patients. Median radiographic follow-up was 24 months (range 5–75 months). Ten patients (10/11) achieved union at a median of 17 months (range 5–46 months). Seven patients required reoperation for any reason with six patients requiring repeat grafting.ConclusionsTo our knowledge, this study is the largest series of patients with segmental bone defects treated with resorbable polylactide membrane. Resorbable polylactide membrane in combination with BMP-2 and autograft represents a safe and effective method of bone graft containment in segmental bone defects measuring up to 12 cm in this series. Ten of 11 patients achieved union at a median time of 16 months with 6 patients requiring repeat grafting. These results compare favorably with the induced membrane technique. This study is limited by its retrospective design, absence of control and comparison groups, and low patient numbers. Future prospective randomized study of the induced membrane technique and resorbable polylactide membrane should be undertaken to determine preferred approaches for treatment of segmental bone defects.     

Reconstruction of intercalary bone defects following bone tumor resection with segmental bone transport using an Ilizarov circular external fixator

Aim The purpose of this retrospective study was to report the long-term follow-up results of the reconstruction of bony defects with Ilizarov distraction osteogenesis using the bone transport method following en bloc resection of bone tumors.Materials and methods En bloc resection was performed in 13 patients with bone tumors between October 1991 and December 2010 in our clinic. The mean age of the patients was 19.46 years (range 7–42 years) at the time of surgery. Histological diagnosis was osteosarcoma in seven cases, Ewing's sarcoma in three cases, giant cell tumor in one case, osteoblastoma in one case and fibrous dysplasia in one case. In all cases either the femur or tibia was involved.Results The average follow-up period was 157.23 months (range 32–288 months), and the bone defect after resection was 14.61 cm ± (9–24 cm). The mean Musculoskeletal Tumor Society score of the patients was 89.46 (83–96) at the final follow-up. The mean Knee Society Scale scores of patients in whom reconstruction was performed around the knee joint were 74.3 (51–84). The mean foot and ankle disability index of patients with a tumor around the ankle joint was 81 (73–95). Quality of life of the patients according to the SF-36 and BQUILI indexes was scored as 104 (88–150) and 4 (0–13), respectively.Conclusion From the long-term follow-up results, reconstruction with distraction osteogenesis seems to be an efficient method in patients with long life expectancies. However, a long external fixation time is a disadvantage of this technique. Problems in patient compliance and possible complications such as nonunion should be managed promptly.     

Recombinant human bone morphogenetic protein is a valid alternative to autologous bone graft for long bone non-unions: a systematic review and meta-analysis

ObjectiveTo compare the efficacy of recombinant human bone morphogenetic proteins (rhBMPs) and autologous bone graft (ABG) on the healing of long bone non-union.MethodsA systematic literature search was conducted on PubMed, Web of Science, Cochrane Library, and CNKI up to December 2021. Two authors independently screened the studies, extracted data, and assessed the quality of the trials. A Meta-analysis was performed using state software (version 12.0).ResultsA total of 14 studies were included in this meta-analysis. Overall, there was no significant difference between the rhBMPs group and the ABG group in terms of healing rate (RR = 1.04, 95% CI = 0.96–1.12, p = 0.365) and healing time (SMD = −0.31, 95% CI = −0.76–0.14, p = 0.175). Subgroup analysis showed rhBMPs lead to higher healing rates (RR = 1.35, 95% CI = 1.17–1.56, p < 0.001), and shorter healing time (SMD = −0.65, 95% CI = −1.08 to −0.22, p = 0.003) in the subgroup of moderate-quality studies. Sensitivity analysis proved that our conclusions were relatively robust. No significant publication bias was recognized in all studies (Begg’s test, p = 0.193; Egger's test, p = 0.307).ConclusionsRhBMPs or combined with allografts bone, inorganic bone was a valid alternative to ABG for the treatment of long bone non-union.     

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.     

Tetrafocal (three osteotomies) and pentafocal (four osteotomies) bone transport using Ilizarov technique in the treatment of distal tibial defect—preliminary outcomes of 12 cases and a description of the surgical technique

ObjectiveTo evaluate the preliminary outcomes of tetrafocal (three osteotomies) and pentafocal (four osteotomies) bone transport using Ilizarov technique for the treatment of distal tibial defect and describe the surgical technique.MethodsA total of 12 eligible patients with distal tibial defect > 6 cm caused by direct trauma or posttraumatic osteomyelitis who were admitted to our institution from January 2017 to January 2019 were treated by tetrafocal or pentafocal bone transport using Ilizarov technique. Detailed demographic data, including age, sex, etiology, defect size, number of osteotomies (three or four), external fixation time (EFT) and external fixation index (EFI), were collected, and the bone and functional outcomes were evaluated by the Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system. Complications during the surgery and the follow-up period were recorded and evaluated by the Paley classification at a minimum follow-up of two years after removal of the fixator.ResultsThere were 9 men and 3 women with an average age of 37.4±7.8 years. The etiology included posttraumatic osteomyelitis in 8 cases and posttraumatic bone loss in 4 cases. The mean bone defect after radical debridement was 7.1±0.6 cm. Tetrafocal bone transport was applied in 9 cases, and pentafocal bone transport was applied in 3 cases. The average EFT and EFI were 5.2±0.8 months and 0.7±0.2 months/cm, respectively. The average time of follow-up after removal of the external fixator was 28.5±3.3 months without recurrence of osteomyelitis. The bone results were good in 7 cases, fair in 4 cases, and poor in 1 case, and the functional results were good in 5 cases, fair in 6 cases, and poor in 1 case. The most common complication was pin tract infection, which occurred in all cases, but there were no major complications, such as nerve or vascular injury.ConclusionTetrafocal and pentafocal bone transport using Ilizarov technique could be an alternative treatment option in selected cases with distal tibial defect > 6 cm. It could shorten the distraction period, fasten regeneration, and reduce the associated complications.     

A Novel technique of three-ring Ilizarov fixator frame in gap non-union of tibia

IntroductionGap non-union of tibia occurring mostly after trauma and many times complicated by infection, is a difficult problem to treat. The study aimed to assess the outcome of the three-ring construct of the Ilizarov fixator frame in the management of gap non-union of the tibia.MethodsThis retrospective study included 30 patients of gap non-union of tibia operated from April 2016 to March 2019 with a three-ring Ilizarov fixator frame and follow-up done till March 2021. The mean age was 39.27 (range 10–66) years. The results were assessed by the Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria. MPTA, PPTA, and LDTA after removal of the frame were also measured.ResultsOut of the total 30 cases, all the patients showed complete union. The Ilizarov fixator was kept for an average period of 11.43 months and the mean defect size was 7.17 (range 2–12) cm. All patients were followed up for an average period of 39.36 (range 24–54) months. According to the ASAMI score bone/radiological results, 27 were classified as excellent, 2 as good, and 1 as poor. Functionally 28 were graded as excellent and the remainder as good. The normal ranges of MPTA, LDTA & PPTA were also achieved in a majority (80%) of patients.ConclusionOur results after using only a three-ring Ilizarov fixator frame are almost equivalent to earlier studies and have advantages such as less weight, better patient compliance, superior radiographic visualization, easy mobilization, and reduced costs. Ilizarov ring fixator remains an excellent treatment modality for tibial non-union with a defect, regarding bone union, deformity correction, infection eradication, limb-length achievement, and limb function.     

Knee arthrodesis with simultaneous lengthening using the Ilizarov method

OBJECTIVE: To determine whether knee arthrodesis with simultaneous lengthening using the Ilizarov method for a nonreconstructable knee joint with bone loss and infection is a successful salvage procedure. DESIGN: Retrospective review of patients. SETTING: University hospital-based orthopaedic practice. PATIENTS: From 1999 to 2001, 4 consecutive patients with a nonreconstructable knee joint, bone loss, and infection after trauma underwent knee arthrodesis with simultaneous lengthening. INTERVENTION: Arthrodesis of the knee with simultaneous limb lengthening through an osteotomy of the tibia and/or femur and the use of an Ilizarov frame. External bone stimulation was used at the knee arthrodesis site and the lengthening sites. Application of this device began during the early distraction phase and continued until frame removal. MAIN OUTCOME MEASURES: Bony union at the arthrodesis and bone lengthening sites, alignment of the lower extremity, limb length discrepancy, infection, pain, and outcome scales (SF-36 scores and American Academy of Orthopaedic Surgeons lower limb modules). RESULTS: Bony union of the knee arthrodesis and lengthening sites and good alignment were achieved in all 4 patients. Mean amount of lengthening was 5.4 cm (range 2.5-11.5 cm). Average time in frame was 11 months (range 6-17 months). Limb length discrepancy after treatment averaged 1.8 cm (range 0.6-3.7 cm). Mean duration of follow-up after frame removal was 35 months (range 28-48 months). At follow-up, infection had not recurred, pain was not present, and assistive devices were not needed for ambulation. Average SF-36 scores improved in all 8 categories, and the average American Academy of Orthopaedic Surgeons lower limb modules improved from a mean of 33 (range 11-37) to a mean of 68 (range 51-76). CONCLUSION: Knee arthrodesis with simultaneous lengthening can be performed successfully using the Ilizarov method. It enables surgeons to optimize limb length during knee arthrodesis. The use of external fixation and the avoidance of internal implants may be advantageous in the presence of or history of infection. The Ilizarov frame provides stability that allows weight bearing during treatment.     

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。     

Ilizarov segmental bone transport of infected tibial nonunions requiring extensive debridement with an average distraction length of 9,5 centimetres. Is it safe?

ObjectivesTo evaluate the results of one stage radical debridement and segmental bone transport with circular fixator in the treatment of infected tibial non-union requiring extensive debridement with an average defect size of 8 cm and distraction length of 9,5 cm.DesignRetrospective study.SettingLevel I trauma centre at an academic university hospital.PatientsThirty patients with infected tibial non-union with an average of 2,9 previous failed operations after a mean 12,5 months post-injury were treated consecutively. The mean age was 39,5 years (R:16–68). After radical debridement and irrigation, all patients were treated with segmental bone transport using Ilizarov circular fixator. All patients except 3, managed with an open docking protocol without bone grafting. In 2 patients a planned ankle arthrodesis with transport was done.Main outcome measurementsBone union, resolution of infection, external fixation index (EFI), external fixation time (EFT), bone and functional results for this big defect size.ResultsUnion and eradication of infection was achieved in all patients. Mean follow-up was 32,5 months (R: 12–72 mo.) The average bone defect after debridement was measured 8.1 cm (R, 6–15). The total distraction length to restore the debridement defect and previous LLD was 9,5 cm (R, 6–15). The mean external fixation time was 13,7 months; the mean external fixation index was 1,49 mo./cm. One non-union, one refracture and one late valgus deformity was managed successfully with plating or nailing and all were healed uneventfully at the completion of the treatment. According to Paley & Maar and Katsenis criteria, the bone results were excellent in 24 and good in 6, functional scores were excellent in 21, good in 7, and fair in 2 patients. Minor complications were 1,36 per patient, major complications were 0,4 per patient and permanent complications were 0,2 per patient in the study group.ConclusionIn the management of large post-infectious bone defects requiring an average 9,5 cm distraction; segmental bone transport is safe in terms of union and eradication of infection. The EFI, EFT, complications, bone and functional results do not differ from the other published studies with smaller defect size.     

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.     

Reoperation rate and implant survivorship compared between cementless and cemented bipolar hemiarthroplasty in femoral neck fracture patients with chronic kidney disease

BackgroundChronic kidney disease (CKD) is commonly associated with aging and disorders of mineral and bone metabolism. Femoral neck fracture (FNF) is one of the most common fractures among older adults with coexisting CKD, and bipolar hemiarthroplasty (BHA) is a preferred treatment. However, the optimal method of stem fixation has not been conclusively determined. Accordingly, this study aimed to investigate the reoperation rate and implant survivorship compared between cementless and cemented BHA in FNF patients with CKD.MethodsA total of 183 FNF patients with moderate to severe CKD who underwent BHA during 2003 to 2019 were recruited and divided into either the cemented (CT group, n = 56) or cementless (CL group, 127) groups. Demographic data, preoperative laboratory investigations, preoperative radiographic outcomes, perioperative outcomes, and 90-day morbidity, mortality, and reoperation rates for any reason were recorded and compared between groups. Kaplan-Meier survival analysis was used to compare implant survivorship between the CT and CL groups. Cox proportional hazards regression model was used to identify independent risk factors for implant survivorship.ResultsThere were no significant differences in patient characteristics or preoperative data between groups, except for Dorr's classification of proximal femoral geometry. The CT group had a significantly lower proportion of Dorr type A (p = 0.020), and a higher proportion of Dorr type C (p<0.001). The CT group also had significantly more intraoperative blood loss (p<0.01). No significant differences in morbidity or mortality were observed. The median follow-up time in the CT group and CL group was 22.6 months (range: 0–151) and 22.6 months (range 0–154), respectively (p = 0.607). The reoperation rate was 5.4% and 4.7% among CT and CL patients, respectively (p = 1.000). There was no significant difference in the mean survival time between the CT (139.5 ± 6.3 months, 95%CI: 127.1–151.8) and CL (142.5 ± 4.7 months, 95%CI: 133.2–151.7) groups (p = 0.880). Univariate and multivariate analyses revealed no independent risk factors for implant survivorship.ConclusionThe results of this study showed no significant differences in the reoperation rate or implant survivorship between cemented and cementless BHA for treating FNF in moderate to severe CKD patients. A well-designed larger and longer-term study is needed to confirm these results.     

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.     

Forearm lengthening

Abstract Eleven cases of forearm shortening underwent lengthening using Ilizarov principles. The aetiology was hereditary multiple exostosis in 6 cases, radial club hand in 2 cases, and trauma in 3 cases. Average age at operation was 15.5 years (range, 9–40 years). At an average follow-up of 3.5 years (range, 2–6 years), there were 8 good, 2 fair and one poor results. Achieved lengthening ranged from 2 cm (10% of the original bone length) to 11 cm (110%). The average healing index was 40 days/cm. There were no neurovascular problems. Complications included pin tract infections in all cases, fracture of the regenerated bone in one case, breakage of a half pin in one case and increased carpal subluxation in another case. Combination of Ilizarov method and hybrid fixation provides a relatively safe method of forearm lengthening with possibility of deformity correction and gradual reduction of chronic dislocations.