Comparison of Ilizarov Bifocal, Acute Shortening and Relengthening with Bone Transport in the Treatment of Infected, Segmental Defects of the Tibia.

Irene K Sigmund,David Stubbs,Martin A Mcnally,Geertje A M Govaert,Jamie Ferguson

doi:10.3390/jcm9020279

Abstract

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.

Highlights

Infected segmental defects are common after tibial injury [1,2,3]
This prospective study was conducted in a tertiary healthcare centre, providing advanced specialty care to patients with musculoskeletal infections
20 (43%) patients were treated with acute shortening with bifocal relengthening (ASR) and 27 (57%) with bone transport (BT)

Summary

Introduction

Infected segmental defects are common after tibial injury [1,2,3]. They are problematic for patients, due to the prolonged treatment time, permanent functional deficits and high reinfection and non-union rates [4]. To manage the resulting bone defects, distraction osteogenesis techniques such as Ilizarov acute shortening with bifocal relengthening (ASR) and bone transport (BT) have been shown to be effective treatment options to achieve union and infection clearance [1,12,15,16,18]. This technique permits the gradual restoration of the bone, and deformity correction, correction of joint contractures, and rehabilitation, with early weight bearing to avoid muscle wasting and disuse osteopenia

Methods

Discussion

Conclusion