Bone Transport Group Research Articles

Bone Transport through Induced Membrane Technique versus Conventional Bone Transport Technique in Management of Bone Defects of Lower Limbs

Abstract Objectives To assess whether Bone transport through induced membrane (BTM) has better outcomes regarding docking site union and infection recurrence than conventional bone transport (BT) or not in the treatment of infected lower limb long bones defects. Methods A prospective randomized controlled study in a single institution was conducted. A total of 30 patients with infected non united fractures of long bones of lower limbs were divided into 15 patients (10 femurs, 5 tibias) treated by BTM and 15 patients (3 femurs,12 tibias) treated by BT. The outcome measures includes external fixation time (EFT), external fixation index (EFI), docking time (DT), bone and functional outcomes evaluated by the Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system, postoperative complications evaluated by Paley classification and number of additional operations. Results The mean docking time (DT) was significantly lower in BTM group in comparison to BT group (3.67 ± 0.82 months vs 4.80 ± 0.86 months respectively) (p value 0.001). Docking site nonunion and infection recurrence were significantly lower in BTM group in comparison to BT group (0% vs 40% respectively) (p value 0.02) and (0% vs 33.3% respectively) (p value 0.04). Mean number of additional operations per patient was significantly lower in BTM group in comparison to BT group (0 vs 0.80 ± 1.08 operations respectively) (p value 0.01) Conclusion Both BTM and BT achieved satisfactory postoperative bone and functional outcomes in patients with infected long bones defects of lower limbs, while BTM had significantly faster docking site union, lower incidence of postoperative complications including docking site nonunion and infection recurrence rates and lower number of additional operations needed at the expense of 2 staged procedure in comparison to BT.

Surgical treatment of critical size bone defects with Masquelet technique versus bone transport: a systematic review and meta-analysis of comparative studies.

To date, the management of critical-sized bone defects lacks a universally accepted approach among orthopedic surgeons. Currently, the main options to treat severe bone loss include autologous grafting, free vascularized bone transfer, bone transport and induced-membrane technique. The purpose of this study is to critically compare the outcomes of Masquelet technique and bone transport to provide a higher level of evidence regarding the indexed techniques. The authors conducted a systematic search on several databases according to the PRISMA guidelines. English-written reports comparing outcomes of the Masquelet technique versus the bone transport technique in patients with critical-sized defects in lower extremities were included. Six observational studies involving 364 patients were included. The systematic review and meta-analysis of pooled data showed no significant difference in most outcomes, except for ASAMI bone outcomes and residual deformity, which showed better results in the bone transport group. The 64% of patients treated with Masquelet technique obtained excellent/good bone ASAMI results compared to 82.8% with bone transport (p = 0.01). Post-operative residual deformity was 1.9% with the bone transport method versus 9.7% with the Masquelet technique (p = 0.02). Both the Masquelet technique and bone transport showed comparable results for the management of critical-sized bone defects of the lower limb. However, these findings must be carefully interpreted due to the high risk of bias. Further prospective randomized controlled trials are necessary to better clarify the strengths and limitations of these two techniques and to identify the variables affecting the outcomes.

Bone Transport through Induced Membrane versus Conventional Bone Transport in Management of Infected long bone defects of Lower Limbs: a randomized controlled trial.

To compare bone transport through induced membrane (BTM) and conventional bone transport (BT) regarding docking site union and infection recurrence in management of infected long bone defects. prospective randomized controlled study. tertiary level center. 30 patients with infected non-united long bone fractures of lower limbs. 15 patients treated by BTM in group (A) and 15 patients treated by BT in group (B). External fixation time (EFT), External fixation index (EFI), Docking time (DT). Bone and functional outcomes evaluated by the Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system. Postoperative complications evaluated according to Paley's classification. The mean docking time (DT) was significantly lower in BTM group in comparison to BT group (3.6 ± 0.82 months vs 4.8 ± 0.86 months respectively; P value 0.001). Docking site non-union and infection recurrence were significantly lower in BTM group in comparison to BT group (0% vs 40%; P value 0.02 and 0% vs 33.3%; P value 0.04 respectively) with no significant difference in EFI (P value 0.08). This is the first prospective randomized controlled study comparing BTM and BT techniques showing that BTM had significantly faster docking site union, lower incidence of postoperative complications including docking site non-union and infection recurrence rates and lower number of additional procedures needed at the expense of two staged operation in comparison to BT.

Shortening/re-lengthening and nailing versus bone transport for the treatment of segmental femoral 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.

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

The aim of this study was to present our experience with a new modified Ilizarov technique of acute shortening and double-level lengthening (ASDL) for the management of large tibial bone defects after trauma and infection and compare it with bone transport (BT). A retrospective comparative study was performed on 47 patients with large tibial defects after trauma and infection from June 2014 to June 2018. Depending on different Ilizarov methods, these patients were divided into ASDL group (n=21) and BT group (n=26). The difference in bone lengthening time, time in frame, external fixation index, docking site healing time were recorded and compared between the two groups. Bone and functional results were evaluated according to the Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria. Complications encountered in both groups were categorized according to the classification of Paley, including problems (treated nonoperatively), obstacles (treated operatively), and sequelae (unresolved at last). All patients were followed for at least two years since the lengthening frame was removed. All cases achieved complete union at the docking site and consolidation of the regenerate callus. The mean bone loss was 8.9cm (range 6.5-16.0cm) in ASDL group vs. 10.3cm (range 5.2-18.5cm) in BT group. The mean bone lengthening time was 2.4±0.7 months in ASDL group vs. 4.1±1.4 months in BT group (p<0.001); time in frame was 9.1 months (range 7.0-14.5 months) in ASDL group vs. 17.7 months (range 13.5-23.0 months) in BT group (p<0.001); and external fixation index was 1.04 months/cm (range 0.83-1.38 months/cm) in ASDL group vs. 1.91 months/cm (range 1.28-2.70 months/cm) in BT group (p<0.001). The incidence of obstacles occurred in ASDL group was significantly lower than that in BT group (p<0.001). There was no significant difference in the bone (p=0.635) and functional results (p=0.293) between the two groups. Compared with bone transport, our modified technique of acute shortening and double-level lengthening could reduce bone lengthening time, time in frame, external fixation index and postoperative complications. It showed better clinical effects in patients with large tibial bone defects after trauma and infection.

Comparison of Iliac Bone Transplantation with Bone Transport in the Treatment of Femur Fracture and Bone Defect.

Objective To compare the curative effect of iliac bone transplantation with the bone transport in the treatment of femur fracture complicated with a bone defect. Methods Patients with femur fractures and defects who were admitted to our hospital from January 1, 2020, to January 31, 2022, and met the inclusion criteria were retrospectively selected and allocated into an iliac bone transplantation group or a bone transport group. The treatment effect and quality of life of the two groups were compared. Results A total of 98 patients who met the inclusion standards were enrolled, including 50 cases in the iliac bone transplantation group and 48 cases in the bone transport group. There were no significant differences in IL-6, IL-8, TNF-α, visual analog scale (VAS) score, or Japanese Orthopedic Association (JOA) score between the two groups on postsurgical day 1 (p=0.051, 0.150, 0.102, 0.564, and 0.826 respectively), but there were significant differences in the above index on postsurgical day 7 (all p < 0.01). There were no significant differences in social function, physical function, role function, and cognitive function between the two groups one week after the operation (p=0.245, 0.051, 0.102, and 0.067, respectively), but there were significant differences in the above parameters at one month after operation (p=0.001, 0.005, 0.005, and 0.001, respectively). The total effective rate of the bone transplantation group was significantly better than that of the iliac bone transplantation group (p=0.026). The number of postoperative complications in the bone removal group was significantly fewer than that of the iliac bone graft group (p=0.001). Conclusion Bone transport is effective in treating femur fractures complicated with bone defects, with fewer postoperative complications.

Pedicled Double-Barrel Fibular Transplantation Versus Bone Transport in the Treatment of Upper Tibial Osteomyelitis with Bone Defects: A Retrospective Study.

This study aimed to compare the clinical effects of using pedicled double-barrel fibular transplantation (PDBFT) and bone transport (BT) for the treatment of upper tibial osteomyelitis with bone defects. A total of 83 patients with upper tibial osteomyelitis and bone defects were selected and retrospectively studied in Xi'an Hong Hui Hospital from January 2009 to January 2019. There were 52 males and 31 females, aged 19-72 years. The tibial defect range was 5-12 cm. Patients were divided into two groups, including the PDBFT (40 cases) and the BT group (43 cases). All patients were classified according to Cierny-Mader classification, including 48 cases of type III and 35 cases of type IV. Operation time, blood loss and cure time were compared. Ennecking score was used to evaluate limb functions, including pain, activity function, self-perception, brace use, walking ability, and gait change, while self-rating anxiety scale (SAS) was used for postoperative mental and psychological status. In addition, complications were recorded. All patients were followed for at least 2 years. SPSS 23.0 software was used to process data. There was no significant difference in demographic data between the two groups (p > 0.05). Operation time was 182.5 ± 22.7min in PDBFT group vs, 124.2 ± 15.6min in BT group, respectively (p < 0.05); intra-operative blood loss was 286 ± 34 ml vs 45 ± 18 ml (p < 0.05); cure time was 7.3 ± 1.8 months vs 11.6 ± 3.7 months (p < 0.05); and Ennecking score was 87.3% and 76.0%, respectively (p < 0.05). So, the PDBFT group showed longer operation time, more blood loss, shorter cure time, and better Ennecking score than the BT group. Importantly, limb functions of the PDBFT group were better than that of the BT group. Moreover, the PDBFT group presented better postoperative mental status and fewer complications than that in BT group (p < 0.05). Patients were successfully cured by both the PDBFT and BT techniques. Compared with the BT group, the PDBFT group brought better clinical effects and fewer complications which could be the first operative choice for the treatment of upper tibial osteomyelitis with bone defects.

Union, complication, reintervention and failure rates of surgical techniques for large diaphyseal defects: a systematic review and meta-analysis

To understand the potential and limitations of the different available surgical techniques used to treat large, long-bone diaphyseal defects by focusing on union, complication, re-intervention, and failure rates, summarizing the pros and cons of each technique. A literature search was performed on PubMed, Web of Science, and Cochrane databases up to March 16th, 2022; Inclusion criteria were clinical studies written in English, of any level of evidence, with more than five patients, describing the treatment of diaphyseal bone defects. The primary outcome was the analysis of results in terms of primary union, complication, reintervention, and failure rate of the four major groups of techniques: bone allograft and autograft, bone transport, vascularized and non-vascularized fibular graft, and endoprosthesis. The statistical analysis was carried out according to Neyeloff et al., and the Mantel–Haenszel method was used to provide pooled rates across the studies. The influence of the various techniques on union rates, complication rates, and reintervention rates was assessed by a z test on the pooled rates with their corresponding 95% CIs. Assessment of risk of bias and quality of evidence was based on Downs and Black’s “Checklist for Measuring Quality” and Rob 2.0 tool. Certainty of yielded evidence was evaluated with the GRADE system. Seventy-four articles were included on 1781 patients treated for the reconstruction of diaphyseal bone defects, 1496 cases in the inferior limb, and 285 in the upper limb, with trauma being the main cause of bone defect. The meta-analysis identified different outcomes in terms of results and risks. Primary union, complications, and reinterventions were 75%, 26% and 23% for bone allografts and autografts, 91%, 62% and 19% for the bone transport group, and 78%, 38% and 23% for fibular grafts; mean time to union was between 7.8 and 8.9 months in all these groups. Results varied according to the different aetiologies, endoprosthesis was the best solution for tumour, although with a 22% failure rate, while trauma presented a more composite outcome, with fibular grafts providing a faster time to union (6.9 months), while cancellous and cortical-cancellous grafts caused less complications, reinterventions, and failures. The literature about this topic has overall limited quality. However, important conclusions can be made: Many options are available to treat critical-size defects of the diaphysis, but no one appears to be an optimal solution in terms of a safe, satisfactory, and long-lasting outcome. Regardless of the bone defect cause, bone transport techniques showed a better primary union rate, but bone allograft and autograft had fewer complication, reintervention, and failure rates than the other techniques. The specific lesion aetiology represents a critical aspect influencing potential and limitations and therefore the choice of the most suitable technique to address the challenging large diaphyseal defects.

MEMBRANE INDUCED OSTEOGENESIS (MASQUELET TECHNIQUE) VERSUS BONE TRANSPORT IN MANAGEMENT OF LARGE BONE DEFECTS OF THE LOWER LIMB

Background: Management of bone defects is controversial, between grafting, acute shortening, and up to amputation anddisarticulation in extensive defects. This study is a comparative study between 2 modalities for management of bone defects to reveal advantages and disadvantages of each modality. Aim of the work: The aim of this work is to assess and compare results of membrane induced osteogenesis and bone transport in extensive bone defects of the lower limb .Patients and methods: We prospectively studied 40 patients (29 males and 11 females) with lower limb bony defects. They were divided into two groups according to the method of reconstruction using either Masquelet technique in 20 patients (group A) or bone transport in the other 20 patients (group B). The mean age of the patients was 35.٢ years in group A and was 35.2 years in group B. diagnosis was infected non union (20 cases: 10 in group A &10 in group B) and posttraumatic and non infective defects (20 cases: 10 in group A &10 in group B) .The most common anatomical site was the tibia (24 cases:9 in group A &15 in group B).. Patients were reviewed every 3 monthly for a minimum period of 1 year. Regular outpatient follow-up was done with a mean period of 18.35±5.58 months in group A and 18.25±3.95 months in group B. Results: In cases of group A (Masquelet group) 12 cases showed complete union, and the other 8 cases showed no evidence of union (all from infected group). While in case of group B (bone transport group) all cases showed complete union Conclusion: bone transport technique is more reliable method with more expectable results for healing and infection eradication. Up to our study, Masquelet technique can be used in the following indications: small, metaphyseal and posttraumatic or non infective defects

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

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.

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.

PO585 Update On Critical Congenital Heart Disease Screening Using Pulse Oximetry Following Systematic Implementation In the United States

The 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.This 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.The 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.Although 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.

Clinical study of bone transport combined with bone graft and internal fixation at the docking site in the treatment of large segmental bone defect in lower limb

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

Bone transport technique versus induced membrane technique for treatment of infected bone nonunion

Objective To compare the clinical outcomes of bone transport technique versus induced membrane technique for treatment of infected bone nonunion. Methods A retrospective study was made on 46 cases of infected bone nonunion admitted from April 2011 to December 2014. They were 33 males and 13 females, aged from 12 to 68 years (mean, 45.3 years), involving 40 tibial and 6 femoral fractures. Bone transport technique was used in 37 cases while 9 cases were treated with induced membrane technique. Fracture union and complications were recorded. The function of the affected limb was evaluated at the final follow-up using Johner-Wruhs criteria. Results The 46 cases were followed up for 9 to 18 months (mean, 14 months). In the bone transport group, bone union was achieved after a mean duration of 6.5 months (range, from 4 to 11 months) without complications like wound infection or neurovascular lesions. In the induced membrane group, bone union was achieved after a mean duration of 5.8 months (range, from 4 to 11 months) and there was one case of reinfection. According to the Johner-Wruhs score system, 34 cases were rated as excellent, 9 as good and 3 as fair, with a total excellent and good rate of 93.5%. Bone transport technique led to 28 excellent, 4 good and one fair cases in the patients with tibial nonunion,and one excellent, 2 good and one fair cases in the patients with femoral nonunion. Induced membrane technique led to 3 excellent, 3 good and one fair cases in the patients with tibial nonunion,and 2 excellent cases in the patients with femoral nonunion. Conclusions Both bone transport technique and induced membrane technique are effective for infected bone nonunion. Bone transport technique may be preferred for tibial infected nonunion while induced membrane technique preferred for femoral infected nonunion. Key words: Tibia; Femur; Fractures, nonuion; Bone grafting

Ilizarov bone transport versus vascularized fibular graft in reconstruction of post-traumatic tibial bone defects

Background Traumatic bone defects may be primary, following open fractures, or secondary to an aseptic or septic nonunion. The traditional procedures to bridge segmental bone defects include autogenous bone grafting, the open bone grafting (Papineau) technique, posterolateral bone grafting of the tibia, transplantation of allograft bone, and fibula protibia procedures. However, these procedures usually require multiple surgical procedures, no weight bearing during treatment, and have limited extent of bone defect reconstruction. Vascularized bone grafts and bone transport according to the Ilizarov technique show much better results. However, each has its advantages and disadvantages. Patients and methods Between April 2001 and September 2008, we treated 32 patients with post-traumatic tibial bone defects at the El-Hadra University Hospital. The patents were divided into two groups: group 1 consisted of 17 patients who were treated using the Ilizarov bone transport technique; group 2 consisted of 15 patients who were treated by vascularized fibular grafting. The average age of the patients at the time of the surgery was 39.9 years in group 1 and 29.7 years in group 2. The mean length of the bone defect was 4.1 cm in group 1 and 7.6 cm in group 2. The site of the bone defect was proximal in six and two patients and middle in eight and 13 patients of group 1 and group 2, respectively. The distal tibia was affected in six patients of group 1. All patients had undergone surgeries previously (one to four operations). The results were divided into bone and functional results. The bone results were based on five criteria: union, infection, deformity, lower limb deformities, and the cross-sectional area of union of the regenerated bone and docking site. The functional results were based on five criteria: pain, need for walking aids or braces, ankle or knee deformity or contracture, loss of range of ankle and knee motion compared with the preoperative range, and ability to return to normal activities of daily living and/or work. Results The mean amount of the filled defect was 4.1 cm with Ilizarov bone transport and 7.6 cm with vascularized fibular grafting. The external fixator time in group 1 was 6.9±1.39 months. The average time to achieve union in group 2 was shorter than that in group 1 (4.8 months, range 3–9 months), whereas the average time to full weight bearing is 8.7 months (range 5–15 months). The average follow-up period was 10.9 months (range 6–24 months) in the bone transport group and 17.6 months (8–24 months) in the vascularized fibular graft group. The bone results and functional results of Ilizarov bone transport were excellent in 64.7 and 29.4%, good in 17.6 and 41.2%, fair in 5.9 and 17.6%, and poor in 11.8 and 11.8% of the patients in groups 1 and 2, respectively, whereas those of vascularized fibular grafting were excellent in 73.3 and 6.7%, good in 13.3 and 73.3%, fair in 6.7 and 13.3%, and poor in 6.7 and 6.7%, respectively. The main problems in Ilizarov bone transport were patient compliance, pin tract infection (all patients), residual deformity in seven patients, and skin sloughing in one patient who was treated using a skin flap. Stress fracture of the transported fibula (eight patients) and need for secondary procedures (10 procedures) were the main problems in the vascularized fibular graft group. Conclusion Ilizarov bone transport is a good method for management of post-traumatic tibial defects, especially short bone defects; in addition, bone grafting of the docking site is necessary in all cases to achieve union and to shorten the time of external fixator application. Although the vascularized fibular graft yielded better results in longer bone defects with shorter time for union, non-weight-bearing is mandatory until graft hypertrophy to avoid stress fractures, which were the main problem in our series.

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.

Circular External Fixation in Tibial Nonunions

The Ilizarov method based on compression-distraction and subperiostic corticotomy was used in 82 lower extremities. There were 45 tibial nonunions without a significant bone defect and 37 tibial nonunions with a bone defect that required radical removal of the necrotic bone and bone lengthening or bone transport. Bone healing was obtained in 39 of the 45 tibial nonunions without bone defect (mean bone healing, 5.4 months) and in all patients with bone defect (mean bone healing, 15 months for patients treated with bone transport) although secondary surgeries (autografting and tibial nails) were frequent (23 patients). Infection was eradicated in all patients after necrotic bone removal and bone transport. The final mean limb length discrepancy was 0.7 cm for the patients without a bone defect and 2.03 cm for the patients with a bone defect. In the patients in the bone transport group, residual axial deviation and residual limb shortening were common. Circular external fixation is a useful method to solve complex tibial nonunions in patients in whom internal devices and autografting have failed. Patients must be cooperative, and must understand the length of time the frame needs to be worn, and that complications are a probability.

Ankle arthrodesis combined with tibial lengthening using the Ilizarov apparatus

AbstractWe report our experience using the Ilizarov method to perform combined ankle arthrodesis and tibial lengthening in six patients (mean age 47 years; range 25–66 years). The average distraction length was 4.1cm (range 1.1–6.8cm), and the mean period of follow-up was 36 months (range 26–44 months). Three patients had active infection of the ankle. Four patients had undergone previous surgery, two of which were primary ankle arthrodeses. We performed compressiondistraction in three patients and bone transport in three. In the compression-distraction group, the mean length gained was 1.9cm, the mean external fixation index (EFI) was 144 days/ cm, and the mean external fixation time was 246 days. In the bone transport group, the mean length gained was 6.2cm, the mean EFI was 35.4 days/cm, and the mean external fixation time was 233 days. All cases achieved a good clinical result with a solid ankle arthrodesis and no infection, deformity, or need for additional support. The Ilizarov method may be practically applied for ankle arthrodesis, especially in complicated cases. The EFI and external fixation time tended to increase for patients with a length gain of 3cm or less.

Chronic Infected Tibia1 Nonunions With Bone Loss Conventional Techniques Versus Bone Transport

Twenty-five patients with infected nonunions of the tibia and segmental bone loss were treated by one of two methods: resection and bone transport, or conventional treatment using less extensive debridement, external fixation, bone grafting, and soft-tissue coverage. The two groups were comparable except for gender distribution. Each group experienced similar rates of healing; eradication of infection; treatment time; final angulation; number of complications; and total number of surgical procedures. However, the final limb-length discrepancy was significantly less in the bone transport group.

Skeletal Defects A Comparison of Bone Grafting and Bone Transport for Segmental Skeletal Defects

To evaluate two different methods of managing segmental skeletal defects, 15 patients treated with the open bone graft (Papineau) technique were compared with 17 patients who had intercalary bone transport (Ilizarov) management. The treatment time was identical for both groups: 1.9 months in fixation for each centimeter of defect reconstructed. Both techniques shared several fixator-associated problems such as implant site sepsis and patient discomfort. Each method of treatment, however, had its own unique problems. For the bone grafted group, limited graft availability, donor site morbidity (three patients), and graft fractures (two patients) occurred. For the bone transport group, the main problems were failure of the docking site to unite without a supplementary graft (seven patients) and joint contractures (seven patients). A new synthesis of both techniques is described.