External Fixation Index Research Articles

Gradual ulnar lengthening by an Ilizarov ring fixator for correction of Masada IIb forearm deformity without tumor excision in hereditary multiple exostosis: preliminary results.

Bony exostoses are benign osteocartilaginous growths that start close to growth plates. Approximately 30-60% of patients have forearm deformities. The commonly encountered forearm deformities in these patients are bowing of the radius, with or without ulnar drift of the carpus, radial head dislocation, shortening of the ulna, and radial head dislocation. The current study reported on the results of management of radial head dislocation for type IIb Masada and Oho classification of forearm deformities by Ilizarov ulnar lengthening and without tumor excision. A series of 12 patients with Masada type IIb deformity were treated by Ilizarov lengthening at AlHadra University Hospital, Alexandria, Egypt, during the period from January 2008 to June 2014. There were eight males and four females; the right forearm was affected in seven patients. The mean age of the patients was 8.7 years (range: 7.5-10 years). All cases showed ulnar shortening with distal ulnar exostosis and radial head dislocation (Masada type IIb). All patients were operated on under general anesthesia, with application of the Ilizarov frame to the forearm. The frame used was assembled of two complete rings; the proximal one was fixed to the proximal ulna and the distal ring was fixed to both radius and ulna. Ulnar osteotomy was performed between the two rings, followed by ulnar lengthening 10 days postoperatively to lengthen the ulna and pull down the radius. Over a follow-up period of 33.2 months (24-48 months), all patients showed spontaneous reduction of the radial head and correction of the forearm deformity. The range of motion improved: flexion increased from 117.5° (110-130°) to 145° (130-160°) and extension increased to 4.6° (0-10°), whereas it was 13.8° (10-20°) preoperatively and the supination increased from 46.3° (40-50°) preoperatively to 73.6° (65-80°) postoperatively. Pronation improved from a preoperative average of 37.9° (30-40°) to 70.8° (60-80°) at the end of follow-up. The average amount of ulnar length was 27.9 mm (25-35) and the duration of external fixation was 103.3 days on average, with a range of 90-130. Thus, the average external fixation index was 3.7 days/mm (range: 3.6-4.0). Gradual lengthening of the ulna and pulling down the radius with an Ilizarov frame is an excellent method for correction of forearm deformity in patients with multiple hereditary exostosis (Masada IIb). Early intervention is the key to achieving spontaneous reduction of the radial head in all patients without the need for corrective osteotomy or tumor excision. Level of evidence: level IV.

Management of open tibial fractures type IIIB by segment transfer using limb reconstruction system fixator

Purpose To evaluate the effectiveness of bone transport using limb reconstruction system (LRS) fixator and early coverage in open-type IIIB tibial fractures with massive bone and soft tissue loss. Patients and methods In this study, eight patients with type IIIB open tibial fractures were managed by initial debridement and fixation by LRS uniplanar external fixator. A second-stage rotational myocutaneous flap coverage and osteotomy for segment transfer was done within 14 days. All patients were followed up till full union. Results Full union was achieved in all patients. A total of five patients needed iliac bone graft at the docking site. Union occurred in an average external fixator index of 45.3 days/cm. No flap coverage infection occurred, and there was no significant limb malalignment. Significant limb shortening occurred only in one patient. Conclusion LRS fixator is an effective definitive method for management of open tibial fractures with massive bone loss and soft tissue defects. It is easy to apply, allows early intervention by plastic surgeons to obtain soft tissue coverage, and also allows early patient rehabilitation and joint mobilization.

Treatment of deformities in patients with healed congenital pseudarthrosis of the tibia

Background. Correction of deformities and lengthening of the lower extremities in patients with healed congenital pseudarthrosis of tibia (cCPT) is associated with certain characteristics, difficulties, and complications. But even the restoration of the anatomy and length of the tibia does not solve the problem of further recurrence of the deformity.
 Aim. This study aimed to evaluate the results of the correction of deformities of the tibia in patients with congenital pseudarthrosis of the tibia after achieving union by using external fixation and guided growth.
 Materials and methods. The results of treatment of 19 patients with cCPT, aged 4–15 years, which were observed in the Department of the Turner Scientific Research Institute from 2013 to 2018 years, were analyzed. We analyzed the types of deformities before the stage of correction deformities, evaluated the accuracy of the correction deformities after two-level osteotomies of the tibia, and used ortho-SUv passive computer navigation. External fixation index and number of complications were also determined. The type and number of recurrence of deformities and the timing of their detection were analyzed.
 Results. On the basis of clinical classification, patients with cCPT had complex deformities of the affected lower limb. The accuracy of the correction of deformities was 84% at the end of the correction period. The amount of elongation was 4.5 ± 1.5 cm. The IEF was 64.3 ± 40.6 days/cm. After the end of the external fixation period, deformities recurred in 100% of cases. In 17 patients, temporary hemiepiphysiodesis of the tibial bones, the second stage, was performed. The accuracy of the correction was 100%. The period of correction ranged from 12 to 14 months.
 Discussion. In the literature, we found no studies investigating the accuracy of the deformity correction, the choice of the level of osteotomies in patients with cCPT. Considering these data and the experience of the senior author of the publication, we performed two osteotomies of the tibia, outside the consolidation zone of the pseudarthrosis. High accuracy of the correction deformities was achieved in conjunction with the use of the ortho-SUv frame.
 Conclusion. The analysis showed that the deformity relapsed in 100% of children as the child grows, regardless of the accuracy of the deformity correction in children after achieving union CPT. Hemiepiphysiodesis is an effective treatment for this complication.

Management of Osteomyelitis-Induced Massive Tibial Bone Defect by Monolateral External Fixator Combined with Antibiotics-Impregnated Calcium Sulphate: A Retrospective Study.

Aim The present study is aimed at evaluating the effect of combined treatment on massive bone defect using radical debridement, antibiotic calcium sulphate, and monolateral external fixator. Methods 35 patients with tibial osteomyelitis received radical debridement, and during surgery antibiotics-impregnated calcium sulphate was used for filling the bone defect. Monolateral external fixator was used to manage the bone defect of average 95 (61-185) cm. Results Bone union was achieved in 34 patients (97.1%) with no reinfection. One case was presented with reinfection and further debridement was conducted. The average time for the utility of external fixation was 17 (7-32) months, and external fixation index (EFI) was 1.79 mon/cm. The mean follow-up duration after surgery was 33.7 (21-41) months. 19, 13, and 3 patients got excellent, good, and fair bone results, respectively. Meanwhile, functional results were excellent, good, fair, and poor in 13, 15, 6, and 1 patient. The most common complication was pain (100%) and superficial pin-tract infection (22.8%). Delayed maturation was incurred in 2 patients. Conclusion Our study reveals that radical debridement combined with antibiotics-impregnated calcium sulphate can suppress infection, and distraction osteogenesis using monolateral external fixators plays an effective role in managing osteomyelitis-induced massive tibial bone defect.

Surgical technique and outcomes for bilateral humeral lengthening for achondroplasia: 26-year experience.

Elongation in patients with achondroplasia provides better overall skeletal proportionality and significantly improves such individuals' access to their perineal region to self-manage personal hygiene. This paper describes our surgical technique and outcomes for bilateral humeral lengthening in achondroplasia patients over 26years. Ours was a retrospective study of 55 patients with achondroplasia-related short stature, in whom bilateral humeral lengthening was performed from 1990 to 2016. We describe the surgical technique and analyze mean gain in humeral length, days using an external fixator, mean percentage of lengthening, external fixation index, type of callus, and complications. Pre- and postoperative radiographic measurements were obtained. Patients also were contacted by telephone and asked about their ability to perform peri-anal self-hygiene and about their overall satisfaction. In total, 110 humeri were lengthened (28 males and 27 females) with medium elongation of 9.5cm on the right and 9.6cm on the left, while averaging 220days in an external fixator. We observed 14 minor complications. There was no significant association between pin position and type of callus, and elongation most often external and in the presence of a straight callus. Before elongation, 77.1% of patients reported difficulties with perineal hygiene and 85.4% could not put their hands in their pockets. Upon completion of lengthening, 100% could perform both tasks and 94.5% were very satisfied. Bilateral humeral elongation yields significant improvements in patient autonomy, with a relatively low complication rate and very high patient satisfaction.

Clinical efficacy of bone transport technique in treatment of large segment infective nonunion of femoral shaft

Objective To investigate the clinical effect of bone transport technique in the treatment of large segment infective nonunion of femoral shaft. Methods A retrospective case series study was conducted to analyze the clinical data of 33 patients with large segment infective nonunion of femoral shaft admitted to Chinese PLA General Hospital from June 2012 to October 2015. There were 25 males and eight females, aged 19-58 years (mean, 34.6 years). In terms of the initial injury, 23 patients were with open fracture and 10 with closed fracture. All patients previously received 1-9 times of operation, with an average of 2.3 times. The duration from injury to operation ranged from 7-60 months, with an average of 34 months. All patients underwent treatment with bone transport technique. After thorough debridement, the length of femoral defect ranged from 6 cm to 18 cm, with an average of 10.5 cm. The single arm limb reconstruction external fixator was placed on the lateral side of the femur under C-arm X-ray fluoroscopy. The wound healing, bone healing time, external fixation index (EFI), and complications were recorded. The function of the affected limb was evaluated using the modified criteria of Association for the Study and Application of the Method of Ilizarov (ASAMI). Results All patients were followed up for 21-53 months (average, 38.5 months). Femoral defects were completely repaired, with no recurrent infection reported. Bone healing time ranged from 8 months to 25 months (average, 13 months). The external fixation index (EFI) ranged from 1.13 months/cm to 1.83 months/cm, with an average of 1.26 months/cm. The infection rate of the nail tract was 55% (18/33). There were 12 patients with Type A, five with Type B, and one with Type C. The function of the affected limb was graded as excellent in 18 patients, good in six, fair in five, and poor in four, with an excellent and good rate of 73% (24/33). Conclusions In the treatment of large segment infective nonunion of femoral shaft, bone transport technique can control the infection, promote defect repair, and restore the function of affected limbs. Key words: Femur fractures; Infection; Ilizarov technique; Fracture, ununited

Comparison of the use of antibiotic-loaded calcium sulphate and wound irrigation-suction in the treatment of lower limb chronic osteomyelitis

AimsWe sought to compare the efficacy of antibiotic-loaded calcium sulphate with wound irrigation-suction in patients with lower limb chronic osteomyelitis. Patients and methodsAdult patients with lower limb chronic osteomyelitis treated at our hospital by means of segmental bone resection, antibiotic-loaded calcium sulphate implantation or wound irrigation-suction, followed by bone transport with external fixator from January 2011 to July 2015 were retrospectively evaluated. The clinical presentation, laboratory results, complications, docking obstruction, infection recurrence were compared. ResultsThere were totally 74 patients met the inclusion criteria. Docking obstruction rate and infection recurrence were higher in the irrigation group with significant difference. The success rate of the first operation was 90.74% in the calcium sulphate group compared with 45% in the irrigation group. Postoperaton leakage of the incision happened more in the calcium sulphate group, but it wasn’t a risk factor for docking obstruction and infection recurrence. Patients in the calcium sulphate group had shorter hospital stay and systemic antibiotic treatment, also with less external fixator index. ConclusionsThe findings of our study suggest that antibiotic-loaded calcium sulphate implantation for lower chronic limb osteomyelitis was a more successful method than wound irrigation-suction, it greatly decreased infection recurrence and docking obstruction. Postoperative leakage after implantation didn’t worsen patient’s outcome.

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.

Ilizarov technique for treatment of distal radius deformity and bone defect after trauma

To investigate the effectiveness on the distal radius deformity and bone defect after trauma by using Ilizarov external fixator. The clinical data of 9 patients of post-traumatic distal radius deformity with bone defect treated by Ilizarov technique between January 2012 and December 2016 were retrospectively analyzed. There were 7 males and 2 females with an average age of 25.6 years (range, 11-46 years). Of the 9 cases, 4 were radial baseball hand deformity with large bone defect, 4 were short deformity of distal radius, 1 was distal radius deformity with radial deflection and pronation deformity, all with distal dislocation of the distant radial-ulnar joint. The time from injury to operation was 6 months to 6.2 years (mean, 1.5 years). The bone defect was 1.4-6.8 cm (mean, 3.6 cm). After complete debridement, the forearm was fixed with Ilizarov external fixator. At 7 days after operation, bone transport or bone lengthening was performed at the rate of 0.8-1 mm/d, 4 times a day, the deformity was slowly corrected and the bone defect was repaired. According to the loss of palmar tilt angle and ulnar tilt angle measured before operation, the position of distal radial articular surface was gradually adjusted in the course of moving or prolonging, so as to restore palmar tilt angle and ulnar tilt angle as far as possible. All wounds healed by first intention and no leakage or rupture occurred. All the 9 patients were followed up 15-36 months (mean, 23 months). All the radius defects healed and the distal deformity was corrected, the healing time was 92.4-138.6 days (mean, 104.7 days); the external fixation index was 32.6-51.1 days/cm (mean, 40.2 days/cm). After 2 months of external fixator removal, the wrist joint flexion was (42.6±3.1)°, the wrist dorsum extension was (48.5±4.7)°, the palm inclination angle was (11.5±1.3)°, and the ulnar deviation angle was (21.2±3.7)°; the elbow flexion was (128.2±6.4)°, the elbow extension was (3.2±2.1)°, the forearm pronation was (71.5±4.3)°, and the forearm rotation was (38.2±6.5)°; the wrist and elbow joint extension and forearm rotation were significantly improved when compared with preoperative values ( P<0.05). At last follow-up, wrist function was assessed according to Gartland-Werley standard, the results were excellent in 3 cases, good in 5 cases, and fair in 1 case. Four cases had pinhole infection, and were cured after anti inflammatory dressing change or replacement of needles; 3 cases did not heal at the bone junction, and were healed after bone grafting; 4 cases deviated from the radial force line, and the deformity was corrected after adjusting the needle. Ilizarov technique can correct deformity and reconstruct bone defect of the post-traumatic distal radius simultaneously, so it is a good method to treat this kind of disease.

The management of infected nonunion of tibia with a segmental defect using simultaneous fixation with a monorail fixator and a locked plate.

The aims of this study were to establish whether composite fixation (rail-plate) decreases fixator time and related problems in the management of patients with infected nonunion of tibia with a segmental defect, without compromising the anatomical and functional outcomes achieved using the classical Ilizarov technique. We also wished to study the acceptability of this technique using patient-based objective criteria. Between January 2012 and January 2015, 14 consecutive patients were treated for an infected nonunion of the tibia with a gap and were included in the study. During stage one, a radical debridement of bone and soft tissue was undertaken with the introduction of an antibiotic-loaded cement spacer. At the second stage, the tibia was stabilized using a long lateral locked plate and a six-pin monorail fixator on its anteromedial surface. A corticotomy was performed at the appropriate level. During the third stage, i.e. at the end of the distraction phase, the transported fragment was aligned and fixed to the plate with two to four screws. An iliac crest autograft was added to the docking site and the fixator was removed. Functional outcome was assessed using the Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria. Patient-reported outcomes were assessed using the Musculoskeletal Tumor Society (MSTS) score. The mean age of patients was 38.1 years (sd 12.7). There were 13 men and one woman. The mean size of the defect was 6.4 cm (sd 1.3). the mean follow-up was 33.2 months (24 to 50). The mean external fixator index was 21.2 days/cm (sd 1.5). The complication rate was 0.5 (7/14) per patient. According to the classification of Paley, there were five problems and two obstacles but no true complications. The ASAMI bone score was excellent in all patients. The functional ASAMI scores were excellent in eight and good in six patients. The mean MSTS composite score was 83.9% (sd 7.1), with an MSTS emotional acceptance score of 4.9 (sd 0.5; maximum possible 5). Composite fixation (rail-plate) decreases fixator time and the associated complications, in the treatment of patients of infected nonunion tibia with a segmental defect. It also provides good anatomical and functional results with high emotional acceptance. Cite this article: Bone Joint J 2018;100-B:1094-9.

Staged distraction osteogenesis followed by arthrodesis using internal fixation as a form of surgical treatment for complex conditions of the ankle.

The aim of this study was to describe the technique of distraction osteogenesis followed by arthrodesis using internal fixation to manage complex conditions of the ankle, and to present the results of this technique. Between 2008 and 2014, distraction osteogenesis followed by arthrodesis using internal fixation was performed in 12 patients with complex conditions of the ankle due to trauma or infection. There were eight men and four women: their mean age was 35 years (23 to 51) at the time of surgery. Bone healing and functional recovery were evaluated according to the criteria described by Paley. Function was assessed using the ankle-hindfoot scale of the American Orthopedic Foot and Ankle Society (AOFAS). A solid fusion of the ankle and eradication of infection was achieved in all patients. A mean lengthening of 6.1 cm (2.5 to 14) was achieved at a mean follow-up of 25.2 months (14 to 37). The mean external fixation index (EFI) was 42 days/cm (33.3 to 58). The function was judged to be excellent in six patients and good in six patients. Bone results were graded as excellent in ten patients and good in two patients. The mean AOFAS score was 37.3 (5 to 77) preoperatively and 75.3 (61 to 82) at the final follow-up. Minor complications, which were treated conservatively, included pain, pin-tract infection, loosening of wires, and midfoot stiffness. Major complications, which were treated surgically included grade V pin-tract infection with inflammation and osteolysis, poor consolidation of the regenerate bone, and soft-tissue invagination. The reoperations required to treat the major complications included the exchange of pins and wires, bone grafting and invagination split surgery. The technique of distraction osteogenesis followed by arthrodesis using internal fixation is an effective form of treatment for the management of complex conditions of the ankle. It offers a high rate of union, an opportunity to remove the frame early, and a reduced EFI without infection or wound dehiscence. Cite this article: Bone Joint J 2018;100-B:755-60.

'Rail and Nail' bifocal management of atrophic femoral nonunion.

The management of a significant bony defect following excision of a diaphyseal atrophic femoral nonunion remains a challenge. We present the outcomes using a combined technique of acute femoral shortening, stabilized with a long retrograde intramedullary nail, accompanied by bifocal osteotomy compression and distraction osteogenesis with a temporary monolateral fixator. Eight men and two women underwent the 'rail and nail' technique between 2008 and 2016. Proximal locking of the nail and removal of the external fixator was undertaken once the length of the femur had been restored and prior to full consolidation of the regenerate. The mean lengthening was 7 cm (3 to 11). The external fixator was removed at a mean of 127 days (57 to 220). The mean bone healing index was 28 days/cm and the mean external fixation index was 20 days/cm (11 to 18). There were no superficial or deep infections. This small retrospective study shows encouraging results for a combined technique, enabling compression of the femoral osteotomy, alignment, and controlled lengthening. Removal of the fixator and proximal locking of the nail reduces the risk of complications and stabilizes the femur with the maximum working length of the nail. Cite this article: Bone Joint J 2018;100-B:634-9.

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

Resection arthrodesis using distraction osteogenesis then plating as a hybrid surgical technique for the management of bone sarcomas of the distal tibia.

We report the oncological and functional results of limb salvage for bone sarcomas involving the distal tibia using hybrid surgical technique of resection arthrodesis by bone transport then plating. Five patients (mean age 18.6years) with primary distal tibial sarcomas (two Ewing's sarcomas and three osteosarcomas) were treated by this method. The average duration of follow-up is 53months. All patients accepted distraction osteogenesis with a standard technique using external fixator after wide (four cases) or marginal (one case) resection in the first operation. They were re-admitted for the second surgical treatment (plate insertion and removal of the external fixator) one to two months after they achieved the necessary limb length and desired alignment. Solid union of the lengthening site and sound fusion of the ankle were achieved in all five patients with full and unassisted weight bearing. The mean lengthening was 11.8cm (range 8-14cm) and the external fixation index (EFI) was 29.3days/cm (range 22.8-36.3days/cm). The mean functional score according to the rating system of the Musculoskeletal Tumour Society was 88% (83-90%). One patient showed poor response to chemotherapy, had local recurrence of sarcoma one year after plating, and was treated with above-knee amputation. In carefully selected patients with primary distal tibial sarcomas, this hybrid method can effectively eliminate tumor lesion, reconstruct function, and shorten the length of wearing an external fixator by a meticulous conversion to internal fixator.

Tibial bone lengthening via external fixation: Comparative study of the traditional technique and a technique with intramedullary nail assistance

ObjectiveTo compare outcomes and complications when performing bone lengthening with two different techniques: isolated external fixation versus external fixation combined with intramedullary nail. Material and methodComparative retrospective study of 30 cases of tibial lengthening divided in two symmetrical groups. Cases were matched based on several variables to maximise homogeneity between the groups.Variables used for comparison were external fixation time, external fixation index, rate of consolidation, clinical outcomes, complications and range of joint motion. ResultsMean external fixation time was 2.08 months in the group lengthened with nail while the standard group showed 5.85 months (p<0.0001). Mean external fixation index was 0.42 months per centimetre in the nail group compared with 1.15 in the group without nail (p<0.0001). There were no significant differences in the rate of consolidation (1.23 months per centimetre against 1.15) or in terms of clinical outcomes. We found differences in the rate of complications (1.2 per patient to 2.6) in favour of the technique with nail. There were no differences in the range of motion of ankle joint. Discussion and conclusionsLengthening over an intramedullary nail is more effective than using external fixation alone for tibial lengthening with regard to time of external fixation, index of external fixation and complication rate. We found no advantages in terms of consolidation and joint mobility.

Hexapod Stacked Transport for Tibial Infected Nonunions With Bone Loss: Long-Term Functional Outcomes.

To analyze long-term functional outcomes in patients with posttraumatic infected tibial nonunions having undergone bone transport with hexapod external fixator. Retrospective cohort study. Level 1 trauma center. Thirty-eight patients with infected nonunions of the tibia. Resection of nonunion with application of stacked hexapod external fixator for bone transport. Functional outcome was measured using the short Musculoskeletal Functional Assessment (sMFA). Parameters measured included age, sex, presence of diabetes, smoking, use of a free flap, bone defect size, length in frame, external fixation index, and direction of lengthening. The mean sMFA score for the entire group was 27.1. Average patient age was 46.8 ± 12.7 years, 74% patients were male, 8% were diabetic, and 29% were smokers. Seventeen patients had soft-tissue defects that required a free flap. Smokers had higher degrees of disability compared with nonsmokers (39 ± 16 vs. 22 ± 14, P = 0.011). Patients requiring adjunctive stabilization had worse functional scores compared with those who did not receive adjunctive stabilization (33 ± 17 vs. 22 ± 15, P = 0.049). Sixteen patients returned 2 sMFA surveys at different time points after completion of bone transport. Initial average sMFA score was 26.5 at a mean of 25.3 months; subsequent sMFA scores averaged 19.4 at a mean of 98.8 months. Stacked hexapod external fixator bone transport is a reliable technique for infected nonunion of the tibia with bone loss. Improved sMFA scores can be expected from 2 to 8 years, suggesting full recovery takes longer than previously anticipated. Limb salvage with hexapod bone transport is justified over time. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Femoral nonunion with segmental bone defect treated by distraction osteogenesis with monolateral external fixation

BackgroundCurrently, the common treatment for femoral nonunion with large segmental bone defect is difficult and complex. The effective surgical methods are rare, include vascularized bone grafting, Masquelet technique and Ilizarov distraction osteogenesis. The objective of this study is to investigate the outcomes of segmental femoral defects treated with monolateral external fixation using the distraction osteogenesis.MethodsWe retrospectively analyzed patients with femoral nonunion with segmental bone defects (> 6 cm) between January 2010 and January 2014 in our single trauma center. All patients were treated by distraction osteogenesis with monolateral external fixation. All surgeries were performed by the same surgeon. Bone union, duration of distraction osteogenesis in days, time to consolidation in months, external fixation index (EFI), complications, and additional surgical interventions were recorded postoperatively. The modified Application of Methods of Illizarov (ASAMI) criteria were used to evaluate the operative effectiveness.ResultsForty-one patients were enrolled in this study for analysis. The length of the bone defect ranged from 6 to 17 cm. All patients eventually achieved healing, and no patient experienced recurrence of infection or newly developed infection. The average time needed for healing was 13 months. In terms of the incidence of complications, 3 cases axial deviations, 5 cases docking site nonunion, 23 cases pin-tract infection, 14 cases knee joint stiffness or their joint mobility declined, 2 cases osteogenesis insufficient in the distraction area,1 case refracture, and 2 cases loose external fixation pins. In terms of the evaluations of fracture healing and function, 30 patients excellent, 6 patients good, 5 patients fair, and 0 patient poor. In terms of postoperative function evaluations, 21 patients excellent, 9 patients good, 7 patients fair, and 4 patients poor.ConclusionFor patients with femoral nonunion with large segmental bone defects, the monolateral external fixation can provide effective stability, improve compliance, and reduce complications.

Alargamiento óseo tibial mediante fijación externa. Estudio comparativo entre la técnica tradicional y la asistida por clavo intramedular

ObjectiveTo compare outcomes and complications when performing bone lengthening with two different techniques: isolated external fixation versus external fixation combined with intramedullary nail. Material and methodComparative retrospective study of thirty cases of tibial lengthening divided in two symmetrical groups. Cases were matched based on several variables to maximise homogeneity between the groups.Variables used for comparison were external fixation time, external fixation index, rate of consolidation, clinical outcomes, complications and range of joint motion. ResultsMean external fixation time was 2.08 months in the group lengthened with nail while the standard group showed 5.85 months (P<.0001). Mean external fixation index was 0.42 months per centimetre in the nail group compared with 1.15 in the group without nail (P<.0001). There were no significant differences in the rate of consolidation (1.23 months per centimetre against 1.15) or in terms of clinical outcomes. We found differences in the rate of complications (1.2 per patient to 2.6) in favour of the technique with nail. There were no differences in the range of motion of ankle joint. Discussion and conclusionsLengthening over an intramedullary nail is more effective than using external fixation alone for tibial lengthening with regard to time of external fixation, index of external fixation and complication rate. We found no advantages in terms of consolidation and joint mobility.

Double-level bone transport for large post-traumatic tibial bone defects: a single centre experience of sixteen cases.

The aim of this study was to evaluate the clinical and functional outcomes of patients with large post-traumatic tibial bone defects managed by double-level bone transport using the Ilizarov technique. We retrospectively reviewed 16 patients of 39.1years (range, 16.0-65.0years). The bone defects averaged 10.9±3.8cm (range: 6.0cm-20.0cm) after radical resection and were managed by double-level bone transport. Bone and functional results were evaluated according to the ASAMI criteria. The mean duration of follow-up after frame removal was 29.5±1.8months (range, 12.0-36.0months). All patients achieved complete union in both the regenerates and the docking site and eradication of infection. The mean bone transport time was 55.6±23.7days (range, 30.0-125.0days). The mean external fixation time was 12.0±3.9months (range, 5.0-18.0months), and the mean external fixation index was 1.1±0.3months/cm (rang, 0.8-2.0months/cm). The bone results were excellent in ten patients and poor in six patients. The functional results were excellent in 12 patients and good in four patients. Double-level bone transport is a safe, reliable, and successful method for large post-traumatic tibial bone defects. Furthermore, this technique can reduce bone transport time, time in frame, and total treatment time in one stage.

Metacarpal Lengthening in Adults With Brachymetacarpia.

Metacarpal lengthening by distraction osteogenesis has been well documented in pediatric patients but limited in older patients. Fewer studies have assessed the success of the procedure through outcome measure scores. The purpose of this study is to assess the outcomes of distraction osteogenesis in skeletally mature adults with brachymetacarpia and patients' perspectives on their satisfaction through outcome measure scores. Retrospective chart review of a consecutive series of metacarpal lengthenings for the treatment of brachymetacarpia was performed. Key parameters collected include starting metacarpal length, amount lengthened, range of motion of metacarpophalangeal joint, type of fixator used, distraction time, and total time in fixator. Relevant comorbidities and complications encountered were recorded as well. The Body Image Quality of Life Inventory (BIQLI) and Limb Deformity Modified Scoliosis Research Society (LD-SRS) score were given to evaluate patients' perspectives on their satisfaction of surgery. Seven metacarpal lengthenings were performed in 4 adult females (average age: 22.8 years) between 2005 and 2016. The average amount lengthened was 1.5 cm (range, 1.2-2.1 cm), corresponding to a mean percent lengthening of 44.4% (range, 33.3%-57.1%). The mean distraction rate was 0.432 mm/day (range, 0.286-0.724 mm/day). The mean distraction time was 38 days (range, 28-55 days). External fixation index was 71.8 days/cm (range, 53.5-99.2 days/cm). No functional loss was observed. Progressive distraction osteogenesis can obtain functionally successful results and improvement in aesthetics and body image without severe complications in skeletally mature adults with brachymetacarpia.