Comparison of bone transport and acute shortening methods in the treatment of gunshot defects of the tibial diaphysis

Acute shortening and double-level lengthening versus bone transport for the management of large tibial bone defects after trauma and infection.

This prospective study compared bifocal acute shortening and relengthening (ASR) with bone transport (BT) in a consecutive series of complex tibial infected non-unions and osteomyelitis, for the reconstruction of segmental defects created at the surgical resection of the infection. Patients with an infected tibial segmental defect (>2 cm) were eligible for inclusion. Patients were allocated to ASR or BT, using a standardized protocol, depending on defect size, the condition of soft tissues and the state of the fibula (intact or divided). We recorded the Weber–Cech classification, previous operations, external fixation time, external fixation index (EFI), follow-up duration, time to union, ASAMI bone and functional scores and complications. A total of 47 patients (ASR: 20 patients, BT: 27 patients) with a median follow-up of 37.9 months (range 16–128) were included. In the ASR group, the mean bone defect size measured 4.0 cm, and the mean frame time was 8.8 months. In the BT group, the mean bone defect size measured 5.9cm, and the mean frame time was 10.3 months. There was no statistically significant difference in the EFI between ASR and BT (2.0 and 1.8 months/cm, respectively) (p = 0.223). A total of 3/20 patients of the ASR and 15/27 of the BT group needed further unplanned surgery during Ilizarov treatment (p = 0.006). Docking site surgery was significantly more frequent in BT; 66.7%, versus ASL; 5.0% (p < 0.0001). The infection eradication rate was 100% in both groups at final follow-up. Final ASAMI functional rating scores and bone scores were similar in both groups. Segmental resection with the Ilizarov method is effective and safe for reconstruction of infected tibial defects, allowing the eradication of infection and high union rates. However, BT demonstrated a higher rate of unplanned surgeries, especially docking site revisions. Acute shortening and relengthening does not reduce the fixator index. Both techniques deliver good functional outcome after completion of treatment.

To compare 2 distraction osteogenesis techniques in post-traumatic tibial nonunion patients with composite bone and soft-tissue defects. Nonrandomized prospective, case series, single-center study. Department of Orthopaedics and Traumatology, Limb Reconstruction Unit, El-Helal hospital, Cairo, Egypt. Fifty post-traumatic tibial nonunion patients with composite bone and soft-tissue defects. Twenty-five patients were treated using bone transport (BT) technique, and 25 patients were treated using acute shortening (AS) and distraction technique. The external fixation index (EFI); functional and bone results; and complication rates. All patients were followed for a minimum of 18 months after removal of their Ilizarov frame. AS and BT groups were followed up for a mean of 19.7 and 20.3 months, respectively. The mean bone gap after resection and debridement was 4 cm in AS group and 5.9 cm in BT group (P = 0.06). The mean EFI was statistically significant and lower in the AS group compared with BT group (P = 0.03). There were no other statistically significant differences between either intervention groups. Both techniques achieved comparable good to excellent results, and the differences in number of complications and ASAMI scores for bone or function were not statistically significant. Yet, it appears that the AS technique may be superior because it has a significantly lower EFI. This may not be feasible in all cases, however, because the AS technique is limited by the defect size and the condition of the surrounding soft tissues. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

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

Objective To explore the feasibility and clinical value of Ilizarov bone transport technique combined with bone graft and internal fixation at the docking site in the treatment of large segmental bone defect of the lower limbs. Methods Thirty patients with large lower limbs bone defects were prospectively divided into two groups according to the random number table: pure bone transport group (Ilizarov bone transport technique alone, n=15, 10 males and 5 females, average age 34.4±4.6 years old, 2 cases bone defect of femur, 13 cases tibia, and the length of bone defect 6.2±2.4 cm), and combined bone transport group (Ilizarov bone transport technique with bone graft and internal fixation at the docking site, n=15, 12 males and 3 females with the average age of 33.8±5.2 years, 1 case of bone defect and 14 tibia, and the length of bone defect 6.5±2.2 cm). The preoperative hospital for special surgery (HSS) knee functional scores, Baird-Jackson ankle function scores, external fixation time, external fixation index, bone union time, bone union index, postoperative ASAMI scores and incidence of complications were compared between the two groups. Results All patients were followed up for 9 to 24 months (mean 16.2 months). Pure bone transport group was followed up for 9 to 24 months (mean 16.2 months), and combined bone transport group was 10 to 24 months (mean 16.4 months). In pure bone transport group, the external fixation time was 17.6±5.4 months, and the bone union time was 11.2±3.1 months with the average bone union index 42.4±4.6 d/cm. While in combined bone transport group, the external fixation time of group B was 8.4±2.1 months, and the bone union time was 7.2±2.1 months with the average bone union index 21.1±2.7 d/cm. The external fixation index of pure bone transport group was 32.4±2.1 d/cm, while in combined bone transport group it was 32.1±2.5 d/cm, and there was no significant difference between these two groups (t=0.812, P=0.884) . According to the bone and function score of the ASAMI, in pure bone transport group, bone healing: excellent 6 cases, good 6 cases, fair 2 cases, poor 1 case, excellent rate was 80%. While in combined bone transport group: excellent in 8 cases, good 6 cases, fair 1 case, excellent rate was 93.3%. The difference between the two groups was statistically significant (χ2=10.6, P=0.032). The lower limb function in pure bone transport group: excellent in 5 cases, good in 5, fair in 4, poor in 1, excellent rate was 66.7%; while in combined bone transport group: excellent in 6 cases, good in 7, fair in 2, excellent rate was 86.7%. There was also a significant difference in the incidence of complications between the two groups. Conclusion Both the pure Ilizarov bone transport technique and the Ilizarov technique with bone graft and internal fixation at the docking site could satisfactorily treat the large bone defect and shortening of the lower limb. But the latter technique had shorter healing time, higher healing rates, better limb function and fewer complications. Key words: Ilizarov technique; Femur; Tibia; Internal fixators

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

Segmental femoral bone defects are a severe challenge for orthopedic trauma surgeons. The objective of this study was to compare the efficacy of the shortening/re-lengthening and nailing (SRN) technique with the traditional bone transport (BT) technique in treating patients with such defects. A retrospective study was conducted involving 46 patients with segmental femoral bone defects, with 21 cases treated using the SRN technique (SRN group) and 25 cases managed with the traditional BT technique (BT group). The mean length of the bone defect was 5.8 ± 1.1 cm in the SRN group and 6.1 ± 1.6 cm in the BT group. Various parameters including time in frame, external fixation index, self-rating anxiety scale (SAS) scores, bone healing scores, limb function scores, and complications were recorded. The mean time in frame for the SRN group was 3.7 ± 1.4 months, significantly shorter than the 9.4 ± 3.7 months observed in the BT group (p < 0.05). Furthermore, the mean external fixation index for the SRN group was 0.62 ± 0.12 months/cm, significantly lower than the 1.50 ± 0.19 months/cm observed in the BT group (p < 0.05). There were no significant differences in bone healing scores between the SRN and BT groups (p = 0.237). The SAS scores and incidence of complications were significantly lower in the SRN group compared to the BT group (p < 0.05). Overall, the SRN technique demonstrated superior clinical efficacy compared to the traditional BT technique for the management of segmental femoral bone defects, with shorter time in frame, lower external fixation index, and reduced complications. Therefore, the SRN technique may be considered an optimal choice for treating patients with such conditions.

To explore the therapeutic methods for the prevention and treatment of tibial bone defect and bone transport related complications. From January 2012 to June 2015, 38 cases of bone defect of tibia were treated by bone transport technique treatment, including 26 males and 12 females, with an average age of 49.0 years old ranging from 36 to 66 years old. All patients were open fractures. The length of bone defect of 38 patients was 4 to 9.6 cm with an average of 5.2 cm. The force line and bone carrying rate were adjusted in time after operation. Patients insisted on loading. All patients were followed up for 17 to 36 months with an average of 24 months. Among them, 19 patients got natural healing in involution end;the other 18 cases respectively got healing after accordion technology in 10 cases, auxiliary internal fixation of bone graft after corresponding processing in 8 cases, 1 patient for dottiness, pneumonia, the knee joint dislocation, diabetes, cerebral palsy sequela was difficult to care, patients' families urged amputation surgery, so the amputation processing. The time of moving the bone transport was 4 to 10 months with an average of 7.1 months. Move length was 5 to 11.6 cm with an average of 8.0 cm. According to tibial stem diagnostic criteria of Johner-Wruhs score, 11 cases were excellent, 18 cases were good, 6 cases were moderate and 3 cases were poor. In addition to 1 case of amputation, the remaining cases were cured, no infection recurrence, re fracture and so on. Bone transport method is an effective method for the treatment of bone defect of tibia, but the existence of many complications is to limit the clinical application of the main factors, including shifting when the distance is too long the long reprojected line offset (bone exposure), nail tract infection, pin loosening, subsidence of soft tissue, loss of function of knee and ankle joint, pull a callus is not long, the contact ends were nonunion.

Aims The Ilizarov bone transport (BT) technique is a common surgical method for treating segmental bone defects. However, major issues with the BT technique are prolonged external fixation period and docking site problems. This study aims to introduce a new modification of the Ilizarov technique – shortening and in situ relengthening (SISRL) – specifically for treating bone defects in the metaphyseal long bones in the lower limbs, and to compare its effectiveness with that of BT technique. Methods This retrospective comparative study included 70 patients with segmental bone defects in the lower limbs following direct trauma or osteomyelitis debridement, treated between January 2019 and January 2021. Patients were divided into two groups based on the Ilizarov technique used: the SISRL group (n = 32) and the BT group (n = 38). Data on bone lengthening time, external fixation time (EFT), and external fixation index (EFI) were collected. Pain from pin-track skin damage during the distraction period was assessed using a visual analogue scale (VAS). Bone and functional outcomes, the function of adjacent joints, and complications were all collected and evaluated. Results SISRL was associated with a significant reduction in mean EFT (220.8 days (SD 71.8) vs 278.4 days (SD 79.4); p &lt; 0.001) and mean EFI (39.0 days/cm (SD 6.2) vs 46.5 days/cm (SD 6.6); p &lt; 0.001). The SISRL group required fewer interventions. During the distraction phase, SISRL patients experienced less median pain (VAS 5.6 (IQR 5.2 to 6.5) vs 7.3 (IQR 6.9 to 8.1); p &lt; 0.001) . SISRL patients had better functional results (p = 0.011) and joint functional scores (p &lt; 0.001) compared to the BT group. Conclusion Compared with BT, SISRL was associated with reduced EFT, EFI, and patients’ pain during the distraction phase. Due to lengthening occurring at the location of the bone defect, SISRL was associated with better preservation of the adjacent joint function and avoidance of problems at the docking site. It showed superior clinical results with metaphyseal segmental defect of lower limb long bones after trauma and infection. Cite this article: Bone Joint J 2025;107-B(12):1343–1351.

BackgroundTrifocal bone transport (TF) rather than bifocal bone transport (BF) can shorten the treatment time when treating of large bone defect in tibia. However, few studies have reported efficacy and complications among different bone transport.AimTo evaluate the effectiveness and complications of bone transport technique for the treatment of large bone defect in tibia.MethodsThe retrospective study including 48 patients who underwent bone transport for the treatment of large bone defect in tibia from May 2015 to September 2019. A total of 30 were treated by bifocal bone transport (BF group) and 18 by trifocal bone transport (TF group). Patient demographic data, intraoperative outcomes, postoperative variables, complications and clinical outcomes of the two groups were recorded and compared at a minimum follow-up of 24 months. Postoperative complications were also evaluated according to Paley classification. Based on the Association for the Study and Application of Methods of Ilizarov (ASAMI) standard, the bone and functional results were evaluated at the last clinical follow-up.ResultsAll patients with an average follow-up of 27.5 months. All patients achieved complete union in the docking site and consolidation in the regenerate bone. Compared to the BF group, the TF group had a longer bone defect length(9.08 ± 1.74 > 6.33 ± 3.15, P < 0.01) but a shorter external fixation index (42.22 ± 2.41 < 65.82 ± 6.98, P < 0.001). The mean number of complications per patient was 1.6 and 1.7 for BF and TF patients (P > 0.05). At the postoperative follow-up, there were no significant differences between the 2 groups in the bone and functional results (P > 0.05).ConclusionFor tibial bone defects, both bifocal and trifocal bone transport can achieve good clinical results. Compared to the bifocal bone transport, The trifocal bone transport can significantly shorten the external fixation index without increasing the incidence of associated complications.

To determine whether bone transport or Masquelet results in higher rates of major unplanned reoperations for the treatment of segmental tibial bone defects ≥4 cm in length. Retrospective cohort. Level I trauma center. Adult patients with segmental tibial defects (OTA/AO 41, 42, 43) ≥4 cm who underwent surgical treatment with ring fixator bone transport or Masquelet between 2011 and 2022 with a minimum 1-year follow-up were included. The primary outcome was a major unplanned reoperation after corticotomy (bone transport) or autografting (Masquelet), including below knee amputation, surgical debridement for deep infection, or surgical intervention for nonunion. Ring fixator bone transport and Masquelet were compared using multivariable logistic regression, adjusting for defect size as a potential confounder. Twenty-four patients treated with bone transport [mean age 40 years (18-66), 100% men] and 22 patients treated with Masquelet [mean age 42 years (22-71), 91% men] were included. Defect etiology was identified as acute traumatic in 25 patients (54%) and postinfectious in 21 patients (46%) ( P = 0.23). The median defect size was 7.2 cm (interquartile range 6.1-10.1) for transport and 5.8 cm for Masquelet (interquartile range 4.7-8.0) ( P = 0.08). Bone transport was associated with an 85% reduction in the odds of a major unplanned reoperation compared to treatment with the Masquelet technique (odds ratio, 0.15; 95% confidence interval, 0.03-0.58; P = 0.01). Bone transport patients underwent a mean of 0.38 major unplanned reoperations compared to 0.91 in the Masquelet group. Reoperation for deep infection occurred significantly less in the bone transport group (21%) compared to the Masquelet group (46%) (odds ratio, 0.18; 95% confidence interval, 0.03-0.76; P = 0.03). Bone transport was associated with a reduction in major reoperations compared to Masquelet for segmental tibial bone defects. This finding may have been driven by fewer surgeries for infection in the bone transport group. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Bone resection and subsequent bone transport and bone lengthening is a well-established treatment for a tibial non-union with shortening (Rozbruch et al. 2008). To our knowledge, this is the first description in the literature of bone transport and subsequent bone lengthening of the tibia only by use of a motorized intramedullary nail. A 53-year-old male twisted his leg while downhill skiing and sustained an OTA classification 43-A2.3 (4) closed fracture of the distal tibia and fibula (Marsh et al. 2007). Both fractures were treated with open reduction and locking plates in January 2009. A non-union developed with loosening of the osteosynthesis, and 7 months after the initial operation the patient was reoperated with bone allograft and exchange of the plates and screws. The non-union did not heal. The patient was referred to our institution 20 months after the first reoperation. At this time, the tibial plate was loose, with broken screws (Figure 1). The tibia had a varus deformity of 16 degrees and was 2.2 cm shortened (Figure 1). The non-union site was tested clinically and found to be loose. Figure 1. Frontal plane varus deformity without sagittal plane deformity of the tibia, with leg-length discrepancy of 2.2 cm in patient with tibial non-union. We operated the patient 24 months after the first reoperation. After removal of all previously inserted implants and screws, except a distal AP screw, the non-union site was found at surgery to be atrophic. The non-union site (3.1 cm bone segment) was resected to vital bone. The fibula was osteotomized at the level of the tibial resection. A proximal percutaneous tibial osteotomy was performed 9 cm from the knee joint line. A custom-made motorized tibial lengthening nail (Fitbone TSA (Tibial Segment Actuator) was inserted. The nail had a length of 35 cm and was capable of 4 cm of bone transport initially and 2 cm of bone lengthening subsequently. The nail had 8 degrees of anterior bending, starting 40 mm from the proximal tip of the nail. The nail was locked with 2 proximal and 2 distal locking screws to the tibia. In addition, a screw was inserted into a sliding hole in the middle part of the tibia, allowing bone transport of the middle tibial segment (Figure 2). A tibio-fibular screw was inserted distally to protect the distal tibio-fibular joint. Acute shortening of the bone defect was not performed. A radiograph taken immediately after surgery showed that 3.1 cm of bone had been resected. Bone transport was initiated 10 days postoperatively at a rate of 1 mm daily (Figure 3). There were no clinical signs of infection and the white blood cell and C-reactive protein levels were normal before surgery. However, biopsies of the resected bone were cultured and showed growth of coagulase-negative staphylococci, which were sensitive to dicloxacillin. Dicloxacillin was therefore administered orally for 3 months. Figure 2. Immediately postoperatively, showing tibial bone gap after bone resection. The bone transport and lengthening nail is inserted in the tibia after proximal tibial osteotomy and distal fibula osteotomy. Figure 3. A. 1 month after surgery. 4 weeks postoperatively, 3.3 mg of recombinant BMP-7 (eptotermin alfa, Osigraft; Stryker) was administered percutaneously to the docking site. A loose proximal locking screw was exchanged at the same surgery and intraoperative fluoroscopy showed that the fibula osteotomy was still loose, allowing lengthening of the fibula. Partial weight bearing was allowed from 2 months postoperatively when the proximal tibia had been lengthened 5 cm (3 cm of bone transport plus 2 cm of leg lengthening). The docking site was united 5 months postoperatively, and full weight bearing was allowed at this time. Healing time for the regenerate was 45 days/cm of bone lengthening. The distal tibio-fibular screw bothered the patient and was removed at 6 months postoperatively. The nail was removed 15 months postoperatively. At the latest follow-up, 18 months after nail insertion and 3 months after nail removal, the patient had no pain or restrictions in daily activities. Motion of the knee and the ankle on the operated side was equal to that on the healthy side. Motion of the knee was from full extension to 140 degrees of flexion and motion of the ankle was from 15 degrees of dorsal flexion to 30 degrees of plantar flexion. An AP radiograph showed no mechanical axis deviation in the operated leg compared to the healthy leg. There was equal leg length. There was a 3-degree varus deformity in the frontal plane. There was no deformity in the sagittal plane on the lateral radiograph. The posterior proximal tibial angle (PPTA) and the anterior distal tibial angle (ADTA) equalled the preoperative values of 78 degrees (PPTA) and 83 degrees (ADTA). There have not been any clinical signs of infection.

Periarticular large bone defects treatment with ring external fixator

BackgroundThe treatment for infected tibial bone defects can be a great challenge for the orthopaedic surgeon. This meta-analysis was conducted to compare the safety and efficacy between bone transport (BT) and the acute shortening technique (AST) in the treatment of infected tibial bone defects.MethodsA literature survey was conducted by searching the PubMed, Web of Science, Cochrane Library, and Embase databases together with the China National Knowledge Infrastructure (CNKI) and the Wanfang database for articles published up to 9 August 2019. The modified Newcastle-Ottawa scale (NOS) was adapted to evaluate the bias and risks in each eligible study. The data of the external fixation index (EFI), bone grafting, bone and functional results, complications, bone union time and characteristics of participants were extracted. RevMan v.5.3 was used to perform relevant statistical analyses. Standard mean difference (SMD) was used for continuous variables and relative risk (RR) for the binary variables. All of the variables included its 95% confidence interval (CI).ResultsFive studies, including a total of 199 patients, were included in the study. Statistical significance was observed in the EFI (SMD = 0.63, 95% CI: 0.25, 1.01, P = 0.001) and bone grafting (RR = 0.26, 95%CI: 0.15, 0.46, P < 0.00001); however, no significance was observed in bone union time (SMD = − 0.02, 95% CI: − 0.39, 0.35, P = 0.92), bone results (RR = 0.97, 95% CI: 0.91, 1.04, P = 0.41), functional results (RR = 0.96, 95% CI: 0.86, 1.08, P = 0.50) and complications (RR = 0.76, 95% CI: 0.41, 1.39, P = 0.37).ConclusionsAST is preferred from the aspect of minimising the treatment period, whereas BT is superior to AST for reducing bone grafting. Due to the limited number of trials, the meaning of this conclusion should be taken with caution for infected tibial bone defects.