External Fixation Time Research Articles

Outcome analysis of ilizarov and monorail fixators in the treatment of nonunion of long bones: A systematic review and proportion meta-analysis

IntroductionNonunion of long bones is a major complication following fractures that requires a substantial amount of investment both monetary and time from patients and surgeons. The need to comprehensively understand the complications, outcomes and distraction capability is profound, which necessitates a review of current evidence on special fixators used for distraction. The current systematic review aims to study the available literature on distraction osteogenesis using special fixators (Ilizarov and Limb Reconstruction System) in the management of nonunion (infected and non-infected). MethodsCochrane Library, PubMed, Scopus were searched until January 2022. The review included all original studies which used Ilizarov or Monorail Fixators/LRS in the treatment of nonunion of long bones. The quality of studies was assessed using the Modified Coleman Methodology Score. ResultsA total of 35 original studies with Ilizarov (n = 29) and LRS (n = 8) were selected including two comparative studies. The pooled data meta-analysis and the subgroup analysis of these studies found both Ilizarov and LRS fixator yield similar functional outcomes for the treatment of long bones nonunion. ConclusionThe review was conducted to understand the scenario of nonunion in long bones. Pin tract infection is found to be the most common complication followed by adjacent joint stiffness and deformity. In our review we observed that both external fixator time and index were lower in LRS compared to Ilizarov group. Further RCT are required comparing Ilizarov and LRS fixators to effectively comment upon the superiority of the implants.

Treatment of fifth metacarpal neck fracture in adolescents with minimally invasive surgery: percutaneous Kirschner wire fixation versus elastic stable intramedullary nailing.

This retrospective study compared two minimally invasive surgical methods for fifth metacarpal neck fractures in adolescents: percutaneous Kirschner wire (K-wire) fixation and elastic stable intramedullary nailing (ESIN). This study involved 42 adolescents aged 11 to 16 years with fifth metacarpal neck fractures treated by either K-wire fixation (n = 20) or ESIN (n = 22). The palmar tilt angle and shortening were compared on radiographs preoperatively and 6 months postoperatively. Total active range of motion (TAM), the visual analogue scale score for pain, and the Disabilities of the Arm, Shoulder and Hand score for upper limb function were recorded at 5 weeks, 3 months, and 6 months postoperatively. The mean TAM was significantly greater in the ESIN than K-wire group at all postoperative time points. The mean external fixation time was 2 weeks longer in the K-wire than ESIN group. One patient in the K-wire group developed infection. There was no statistically significant difference between the two groups in other postoperative outcomes. ESIN fixation has the advantages of greater stability, better activity, a shorter external fixation time, and a lower infection rate than K-wire fixation in the treatment of fifth metacarpal neck fractures in adolescents.

Complex Ankle Fusion With Circular Frames: Factors Influencing Outcomes, Complications, and Patient Satisfaction

Circular frames for ankle fusion are reserved for complex clinical scenarios. The literature is heterogenous and conflicting. We aim to present the indications and outcomes of this procedure. A retrospective cohort study based on a prospective database of frame surgeries performed in a tertiary institution. Inclusion criteria were patients undergoing complex ankle fusion with circular frames between 2005 and 2020, with a minimum 12-month follow-up. Data were collected on patient demographics, surgical indications, comorbidities, surgical procedures, external fixator time (EFT), length of stay (LOS), radiologic and clinical outcomes, and adverse events. Factors influencing radiologic and clinical outcomes were analyzed. 47 patients were included, with a median follow-up of 30 months (interquartile range [IQR] 20-40). The median age at time of surgery was 63.5 years (IQR 58-71). Patients had a median of 2 previous surgeries (IQR 1-3). The median LOS was 8.5 days, and median EFT was 237 days (IQR 166-280). Simultaneous limb lengthening (median 3.3 cm, IQR 1.9-3.5) was performed in 11 patients, increasing the EFT by a mean of 4 months. Primary and final union rates were 91.5% and 95.7%, respectively. At last follow-up, ASAMI bone scores were excellent or good in 87.2%. ASAMI functional scores were good in 79.1%. Patient satisfaction was 83.7%. In addition, 97.7% of patients experienced adverse events, most commonly pin-site related, with major complications in 30.2% and reoperations in 60.5%. There were 3 amputations. Adverse events were associated with increased age, poor soft tissue condition, severe deformities, subtalar fusions, peripheral neuropathy, peripheral vascular disease, and prolonged EFT. Complex ankle fusion using circular frames can achieve good outcomes, however time in frame may be prolonged with a high rate of adverse events. Identified risk factors for poorer outcomes should be considered in patient counselling and prognostication. Level III, prognostic.

Bifocal versus trifocal bone transport for the management of tibial bone defects caused by fracture-related infection: a meta-analysis

BackgroundThe purpose of this meta-analysis was to compare the efficacy and outcomes of bifocal bone transport (BFT) and trifocal bone transport (TFT) for the treatment of tibial bone defects caused by fracture-related infection (FRI).MethodsThe literature searches of Cochrane Library, Embase, Google Scholar databases, PubMed/Medline, and Web of Science for literature published up to September 20, 2022, were performed. The quality of the included studies was evaluated according to the MINORS scale. Patients were divided into the BFT group and the TFT group, depending on the site of the osteotomy. The demographic data, defect size (DS), external fixation time (EFT), external fixation index (EFI), bone and functional results, complications, and autologous bone grafting (ABG) were extracted and analyzed using the Review Manager software (version 5.3).ResultsFive studies included 484 patients with tibial bone defects treated by bone transport investigated in this meta-analysis, with a mean bone defect of 9.3 cm. There were statistical differences in DS (MD = − 2.38, 95% CI − 3.45 to − 1.32, P < 0.0001), EFT (MD = 103.44, 95% CI 60.11 to 146.77, P < 0.00001), and EFI (MD = 26.02, 95% CI 14.38 to 37.65, P < 0.00001) between BFT group and TFT group. There was no statistical difference in bone results (RR = 0.98, 95% CI 0.91 to 1.06, P = 0.67), functional results (RR = 0.94, 95% CI 0.82 to 1.07, P = 0.37), complications (OR = 1.57, 95% CI 0.59 to 4.14, P = 0.36), and ABG (RR = 1.2, 95% CI 0.78 to 1.84, P = 0.42) between two groups.ConclusionsTFT was a feasible and practical method in the treatment of massive tibial bone defects caused by FRI to receive shorter EFT and satisfactory bone and functional results.

Treatment of Gustilo-Anderson type III open fractures with segmental long bone loss secondary to gunshot and war ınjurıes in paediatric patients with bone segment transport by the limb reconstructıon system (LRS)

ObjectiveThe information on firearm- or explosive-related extremity injuries in children is very limited. Reports of segmental bone loss due to these types of fractures are even rarer and the treatment remains a problem. There has been no report of distraction osteogenesis with limb reconstruction system (LRS) specifically in children. We evaluated the treatment results of Gustilo–Anderson type 3 open fractures with segmental bone loss due to firearm injuries by distraction osteogenesis performed with LRS in skeletally immature patients. MethodsNine patients with Gustilo–Anderson (GA) type 3 open fractures with segmental bone loss due to firearm injuries who had not completed their skeletal development were included. Two of the patients had GA type 3a, four had type 3b, and the remaining three had type 3c. Bony and functional assessment was conducted using Association for the Study and Application of the Methods of Illizarov (ASAMI) criteria. ResultsMean follow-up period was 20.1 months (range 5.5–35 months). The mean bone loss was 45.5 mm (range 15–80 mm) before the treatment started. The mean time of external fixation (day) was 180.6. The mean distraction index (distraction period per cm) was 11.3 day/cm. The mean time for bone union index (duration of bony union per cm) was 33.7 days/cm. Bony union was achieved in all patients at the end of the treatment. Bony results as per ASAMI score were excellent in seven fractures and good in three. Functional results were excellent in five patients, good in two, and fair in two. We had no fair or poor results with respect to bony results but had two fair functional results. ConclusionsLRS provides a good treatment choice for children with fractures with segmental bone loss due to firearm injuries. It also provides easy access to the wound with its monolateral construction.

Research progress in etiology and clinical diagnosis and treatment of scaphotrapeziotrapezoid osteoarthritis

To summarize the research progress of scaphotrapeziotrapezoid osteoarthritis (STT OA) and its etiology and clinical treatment. The domestic and foreign literature on STT OA in recent years was reviewed and the research progress was summarized. STT OA is a common OA, which is highly prevalent in postmenopausal women and diagnosed by wrist X-ray films. The current treatment methods include conservative treatment and surgery. Among them, the conservative treatment can relieve clinical symptoms, but the long-term effectiveness is not ideal. In surgical treatment, scaphoid arthrodesis can effectively relieve wrist pain, but it sacrifices part of the range of motion and grip strength of the wrist, and there is a risk of fusion failure. Distal scaphoid resection and trapezium resection have the advantages of short operation time, simple operation, less damage to the joint capsule and ligament, and shorter postoperative external fixation time, but they lead to changes in carpal bone alignment and dorsal intercalated segmental instability. Arthroplasty can provide pain relief while restoring grip strength and preserving wrist motion, but there is a risk of dislocation of the prosthesis. At present, there is no gold standard for the STT OA treatment. The short-term effectiveness of arthroplasty and arthroscopic distal scaphoid resection are satisfactory, but the long-term effectiveness needs further study.

The Gradual Correction of Adult Severe Rigid Equinus Deformity Using Minimal Invasive U-Osteotomy With Taylor Spatial Frame.

U-osteotomy with Taylor Spatial Frame correction is a rarely reported treatment method particularly well-suited for severe rigid equinus deformity in adults. The purpose of this study was to evaluate the effectiveness and efficacy of deformity correction and clinical outcome using this technique. We present a retrospective review of 30 feet in 26 patients who received U-osteotomy with Taylor Spatial Frame. Radiologic outcomes were measured using the anterior tibiotalar angle (TTA) with conventional weightbearing radiographs. Functional assessments included American Orthopaedic Foot & Ankle Society (AOFAS) ankle and hindfoot scores and patient satisfaction using Likert scale. The etiology included trauma (9), neglected or relapsed clubfoot (6), spina bifida (5), poliomyelitis (4), Charcot-Marie-Tooth disease (4), and iatrogenic (2). All patients had equinus deformity with TTA more than 140 degrees (median 157.5, 141-177). There were varus deformity in 19 feet, limb length discrepancy in 6 legs, and genu procurvatum deformity in 2 legs. The duration of gradual correction was 53.6±13.5 days (33-73 days), and the external fixation time was 147.8±25.2 days (98-203 days). At last follow-up, TTA in all patients improved significantly (P < .001) to 113.5 degrees (111.8-116.0). All patients had plantigrade feet, except for 2 cases of residual mild equinovarus deformity, 2 cases of residual mild hindfoot varus deformity, 1 case of moderate hindfoot varus recurrence. The AOFAS scores significantly improved (P < .001) from 51.0 points (29.0-66.0) to 76.0 points (69.5-88.0). Eighteen patients were very satisfied, 6 patients were somewhat satisfied, and 2 patients were somewhat dissatisfied. Using minimally invasive U-osteotomy with Taylor Spatial Frame to gradually correct the adult severe rigid equinus deformity proved to be an effective and relatively safe method associated with high patient satisfaction rates. Level IV, case series.

Direct versus indirect posterior malleolar fixation in the treatment of trimalleolar ankle fractures: Is there a difference in outcomes?

The purpose of this study was to examine the differences in functional outcomes between direct and indirect surgical fixation methods of the posterior malleolus in the setting of trimalleolar fractures and identify any variables affecting patient outcomes. Primary outcomes were evaluated by PROMIS scores for short-term outcomes regarding total pain (TP) and total function (TF) comparing 40 patients with direct fixation with 77 with indirect fixation. Continuous variables were analyzed using t tests for parametric variables and the Mann-Whitney U test for nonparametric variables. Categorical variables were analyzed using a χ2 test. Univariate and multivariate linear regression models were performed to analyze factors that affect outcomes of TP and TF. There was no difference in TP or TF between groups (P = 0.65 vs. P = 0.19). On univariate linear regression for TP, BMI, incidence of complication, tobacco use, and open injury showed significance in increasing pain levels with open injuries providing the greatest effect (coef = 11.8). On multivariate analysis, BMI, incidence of complication, open injury, and tourniquet time all significantly increased pain. For TF, univariate analysis showed age, BMI, incidence of complication, and diabetes to decrease function, and use of external fixator and tourniquet time increased function. In the multivariate model, increased BMI, open injuries, and increasing tourniquet time all decreased TF while use of an external fixator increased TF. This study showed no difference in TP and TF using the PROMIS outcome scores when comparing direct fixation versus indirect fixation under univariate and multivariate models. Therapeutic III.

Bone Transport to Arthrodesis for Ankle and Hindfoot Osseous Defects

Category: Trauma; Ankle; Hindfoot Introduction/Purpose: Distal tibia and hindfoot bone defects represent a challenging scenario for the foot and ankle surgeon. Recovering bone stock whilst achieving fusion in an infection-free environment with no soft tissue defects are the main objectives to obtain limb salvage. Bone transport to arthrodesis using distraction osteogenesis is a two-staged procedure for the management of intercalary defects. The initial stage consists of resection of non-vital osseous tissue and installation of a cement spacer. The second stage is performed after the infection process and soft tissue cover is completed and consists of a proximal tibial corticotomy with the installation of a circular external fixation. There are few reports in the literature of the salvage rate, functional/quality of life outcomes and satisfaction results of this technique. Methods: Retrospective IRB-approved study including patients with distal tibial and hindfoot bone defect treated in a trauma level I center between January 2015 and February 2020. We included patients treated with bone transport to tibiotalar o tibiocalcaneal arthrodesis using a circular external fixator with a minimum 12 months follow-up after frame removal. Demographic and clinical data were obtained. In addition, union rates, external fixator times and complications were noted. SMFA and SF-12 scores were obtained for assessing functional results and quality of life respectively. Residual pain was evaluated using a visual analog scale and patient's satisfaction was assessed with a likert-type categorical scale. Results: Eighteen patients with a mean age of 50.9 years (R:24-72) were included in this study. The mean defect size was 7.3 cm (R:3-12) with osteomyielitis of the distal tibia secondary to trauma as the most common etiology. Fifteen cases were transported to tibiotalar artrhodesis and in three cases to tibiocalcaneal artrhodesis. Free flaps were used to cover soft tissue defects in 10 patients (56%). Union rate was 94% (17/18 patients) with one patient requiring a below knee amputation for persistant infection during bone transport. The mean fixator time was 12 months (R:5-20). Conversion to internal fixation was performed in 12 patients. The mean SMFA dysfunction score was 37.9 and bother score 45.3. SF-12 results were 30.5 in the physical score and 45.5 regarding mental health. The mean VAS was 4 and sixteen patients were completely satisfied or satisfied with minor remarks with the procedure (89%). Conclusion: Bone transport to arthrodesis obtained a high rate of limb salvage in this series as a treatment for segmental osseous deficits of the hindfoot and ankle. Nevertheless is a technique that requires a long recovery and external fixation time. Patients at one-year follow-up after frame removal have lower functionality and quality of life scores than the general population but with a high rate of satisfaction.

Can Laser-Assisted Indocyanine Green Angiography Be Used to Quantify Perfusion Changes During Staged Fixation of Pilon Fractures? A Pilot Study.

To quantify soft tissue perfusion changes in pilon fractures during staged treatment using laser-assisted indocyanine green angiography (LA-ICGA). Level 1 trauma center. Prospective cohort study. Twelve patients with 12 pilon fractures participated in the study. Seven patients had OTA/AO classification of 43-C3, 3 had 43-C2, and 2 had 43-B2. LA-ICGA was performed with the SPY fluorescence imaging platform. Analysis via ImageJ was used to generate a fractional area of perfusion (FAP) based on fluorescent intensity to objectively quantify soft tissue perfusion. Anterior, medial, and lateral measurements were performed at the time of initial external fixation (EF) application and then at the time of definitive fixation. FAP within the region of interest was on average 64% medially, 61% laterally, and 62% anteriorly immediately before EF placement. Immediately before definitive open reduction internal fixation, fractional region of interest perfusion was on average 86% medially, 87% laterally, and 86% anteriorly. FAP increased on average 24% medially ( P = 0.0004), 26% laterally ( P = 0.001), and 19% anteriorly ( P = 0.002) from the time of initial EF to the time of definitive open reduction and internal fixation. Quantitative improvement in soft tissue perfusion was identified through the course of staged surgical management in pilon fractures. LA-ICGA potentially may be used to determine appropriate timing for definitive surgical intervention based on the readiness of the soft tissue envelope. Ultimately, these findings may influence clinical outcomes with respect to choice of surgical approach, soft tissue management, surgical timing, and wound healing. Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Shortening and re-lengthening versus bone transport for the treatment of distal tibial periarticular post-traumatic defects

In the present study, we presented our experience with a new modified technique of shortening and re-lengthening using a monolateral external frame combined with a calcaneal intramedullary nail and compared it with the bone transport technique for the treatment of distal tibial periarticular post-traumatic defects. Forty-one patients were retrospectively analyzed. Among them 19 were treated using our modified shortening and re-lengthening technique (MSR group) and 22 by bone transport (BT group). The difference in external fixation time (EFT), external fixation index (EFI), self-rating anxiety scale (SAS), and complications were compared between the two groups. The mean EFT was 3.4 ± 0.6 months in the MSR group and 7.5 ± 1.4 months in the BT group; the EFI was 0.57 ± 0.06 month/cm and 1.32 ± 0.23 month/cm, respectively. The EFT, EFI, and SAS scores were significantly lower in the MSR group than in the BT Group (p < 0.05). The mean number of complications per patient in the BT group was nearly 2.4 times that of the MSR group (p < 0.05). Our modified shortening and re-lengthening technique reduced the EFI and complication incidence compared to the bone transport technique. Therefore, patients with distal tibial periarticular post-traumatic defects can achieve great satisfaction with this new technique.

Treatment of tibial large bone defects: A comparative study of bone transport over an intramedullary nail in combination with antibiotic-impregnated calcium sulphate versus bone transport alone with antibiotic-impregnated calcium sulphate

PurposeTo compare the bone transport over an intramedullary nail in combination with antibiotic-impregnated calcium sulphate versus bone transport alone with antibiotic-impregnated calcium sulphate for the treatment of tibial large bone defects. MethodsA retrospective analysis was conducted by enroling 33 surgically treated patients with tibial large bone defects after the debridement for tibial infection or osteomyelitis who were admitted in Lower Limb Surgery Ward of Traumatic orthopaedic Department, Xi'an Honghui Hospital from January 2018 to January 2021. All the patients were categorized in Group A (transport over intramedullary nail, 12 cases) and Group B (transport alone, 21 cases) based on the surgery strategy. The collected clinical materials and data included gender, age, injury mechanism, smoking habits, comorbidity diseases, initial fracture type (open or close), bone defect size, surgical duration, intraoperative bleeding loss, resorption time of calcium sulphate, bone transport time, external fixation time, external fixation index, weight bearing time, complications and Paley bone and functional criteria. ResultsThirty-three patients were enroled and successfully followed up with an average time of 15.25±4.31 months ranged from 8 to 21 months in Group A and an average time of 17.09±5.64 months ranged from 9 to 31 months in Group B. No significantly statistical differences of the demographic data were discovered between the two groups. There were no significantly statistical differences of the average bone defect size, intraoperative bleeding loss, resorption time of calcium sulphate and bone transport time between the two groups. However, the average surgical duration (P = 0.002) was significantly longer in Group A than Group B and the average external fixation time (P<0.001), external fixation index(P = 0.002) and weight bearing time (P = 0.030) were significantly shorter in Group A than Group B. No significantly statistical difference of excellent and good rate of bone outcomes and complication rate was observed, however, the excellent and good rate of functional outcomes (P = 0.041) was significantly higher in Group A than Group B. ConclusionCompared with the conventional Ilizarov technique combining with antibiotic-impregnated calcium sulphate for large tibial bone defects, bone transport over an intramedullary nail in combination with antibiotic-impregnated calcium sulphate had favourable external fixation time, external fixation index, weight bearing time and clinical functional outcomes which effectively suppressed the infection and allowed patients earlier removal of the external fixator and weight bearing for rehabilitation.

114 Bone Transport Using the Monorail External Fixator Over an Intramedullary Nail for Post-Traumatic Femoral Defects

Abstract Aim The management of limb-length discrepancy secondary to traumatic bone loss poses a unique challenge for surgeons. The Ilizarov technique is popular but is associated with long external fixator time and many complications. This retrospective study assessed outcomes of post-traumatic femoral defects managed by monorail external fixation over an intramedullary nail. Method Eight patients were included from over a four-year period with post-traumatic femoral defects, that underwent treatment with monorail fixator-assisted intramedullary nailing. Mean follow-up time was 232.83 weeks. Five were open fractures (Gustilo-Anderson type 3A:n=4, 3B:n=1), one had closed fracture. Average bone defect size was 8cm. Primary outcomes were lengthening index, consolidation time and index, external fixator index. Secondary outcomes were time to full weight bearing(FWB), time to union, complications. Patient reported outcome measures including EQ-5D-5L, SF-36, Oxford knee scores(OKS), Oxford hip scores(OHS) were recorded after recovery. Results Average consolidation time and index were 11.35months and 1.24months/cm, respectively. Mean lengthening and external fixator index were 20.2days/cm and 23.88days/cm, respectively. On average, patients achieved FWB and bone union 56.25 weeks and 68.83 weeks after bone transport initiation, respectively. Two patients had docking site non-union, treated by reamed intramedullary exchange nailing. Two patients had osteomyelitis. EQ-5D-5L and EQ-VAS scores were compared to UK population norms (p=0.104, p=0.238, respectively). Average OKS was 32.17 and OHS was 34.00. Conclusions Monorail external fixation over an intramedullary nail is an effective option for post-traumatic femoral defects, reducing external fixator time, lowering complication rate, returning patients’ quality of life to a level comparable with the normal population.

Effectiveness of bone transport with a locking plate versus conventional bone transport for tibial defects

To investigate the effectiveness difference between bone transport with a locking plate (BTLP) and conventional bone transport with Ilizarov/Orthofix fixators in treatment of tibial defect. The clinical data of 60 patients with tibial fractures who met the selection criteria between January 2016 and September 2020 were retrospectively analyzed, and patients were treated with BTLP (BTLP group, n=20), Ilizarov fixator (Ilizarov group, n=23), or Orthofix fixator (Orthofix group, n=17) for bone transport. There was no significant difference in gender, age, cause of injury, time from injury to admission, length of bone defect, tibial fracture typing, and comorbidities between groups ( P>0.05). The osteotomy time, the retention time of external fixator, the external fixation index, and the occurrence of postoperative complications were recorded and compared between groups. The bone healing and functional recovery were evaluated by the Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria. All patients of 3 groups were followed up 13-45 months, with a mean of 20.4 months. The osteotomy time was significantly shorter in the BTLP group than in the Ilizarov group, and the retention time of external fixator and the external fixation index were significantly lower in the BTLP group than in the Ilizarov and Orthofix groups ( P<0.05). Twenty-two fractures healed in the Ilizarov group and 1 case of delayed healing; 16 fractures healed in the Orthofix group and 1 case of delayed healing; 18 fractures healed in the BTLP group and 2 cases of delayed healing. There was no significant difference between groups in fracture healing distribution ( P=0.824). After completing bone reconstruction treatment according to ASAMI criteria, the BTLP group had better bone healing than the Orthofix group and better function than the Ilizarov groups, showing significant differences ( P<0.05). Postoperative complications occurred in 4 cases (20%) in the BLTP group, 18 cases (78%) in the Ilizarov group, and 12 cases (70%) in the Orthofix group. The incidence of complication in the BTLP group was significantly lower than that in other groups ( P<0.05). BTLP is safe and effective in the treatment of tibial defects. BTLP has apparent advantages over the conventional bone transport technique in osteotomy time, external fixation index, and lower limb functional recovery.

WE7.7 Bone transport using the Monorail External Fixator over an Intramedullary Nail for Post-Traumatic Femoral Defects

Abstract Aim The management of limb-length discrepancy secondary to traumatic bone loss poses an unique challenge for surgeons. The Ilizarov technique is popular, but is associated with long external fixator time and many complications. This retrospective study assessed outcomes of post-traumatic femoral defects managed by monorail external fixation over an intramedullary nail. Method Eight patients were included from over a four-year period with post-traumatic femoral defects, that underwent treatment with monorail fixator-assisted intramedullary nailing. Mean follow-up time was 232.83 weeks. Five were open fractures (Gustilo-Anderson type 3A:n=4, 3B:n=1), one had closed fracture. Average bone defect size was 8cm. Primary outcomes were lengthening index, consolidation time and index, external fixator index. Secondary outcomes were time to full weight bearing (FWB), time to union, complications. Patient reported outcome measures including EQ-5D-5L, SF-36, Oxford knee scores (OKS), Oxford hip scores (OHS) were recorded after recovery. Results Average consolidation time and index were 11.35months and 1.24months/cm, respectively. Mean lengthening and external fixator index were 20.2days/cm and 23.88days/cm, respectively. On average, patients achieved FWB and bone union 56.25 weeks and 68.83 weeks after bone transport initiation, respectively. Two patients had docking site non-union, treated by reamed intramedullary exchange nailing. Two patients had osteomyelitis. EQ-5D-5L and EQ-VAS scores were compared to UK population norms (p=0.104, p=0.238, respectively). Average OKS was 32.17 and OHS was 34.00. Conclusions Monorail external fixation over an intramedullary nail is an effective option for post-traumatic femoral defects, reducing external fixator time, lowering complication rate, returning patients’ quality of life to a level comparable with the normal population.

Bifocal femoral lengthening assisted by preoperative 3-dimensional design in the restoration of posttraumatic limb length discrepancy

BackgroundTo assess the clinical outcomes of preoperative three-dimensional planning followed by bifocal femoral lengthening in the treatment of posttraumatic limb length discrepancy (LLD).MethodsA total of 8 eligible patients with posttraumatic femoral LLD > 6 cm were admitted to our institution from January 2015 to January 2018 and treated by bifocal femoral lengthening with the assistance of 3-dimensional imaging technology. The following data were collected: detailed demographic information, the amount of lengthening, external fixation time (EFT), external fixation index (EFI), postoperative bone and functional outcomes, and complications in the follow-up period.ResultsAll included patients were successfully followed up for in an average of 55.4 ± 6.7 months after removal of the external fixator. There were six males and two females with an average age of 38.4 ± 12.2 years. The mean preoperative LLD was 69.2 ± 6.2 mm. The mean lengthening amount was 67.5 ± 6.9 mm. The mean EFT was 180.1 ± 20.2 days. The EFI was 26.73 ± 1.36 days/cm on average. All patients achieved satisfactory postoperative bone and functional outcomes. No major complications such as nerve or vascular injury were observed.ConclusionsBifocal femoral lengthening with preoperative three-dimensional design provided precise surgical guidance and resulted in satisfactory postoperative outcomes, demonstrating that it is an effective treatment for posttraumatic femoral LLD.

Use of LRS mono-lateral external fixator for the treatment of comminuted femoral fracture with bone loss

Background: Comminuted fracture femur with bone loss is a high energy injury with variable clinical and radiological scenarios; therefore, management has been a challenge to Orthopaedic surgeons because of associated complications and absence of standard guidelines to organize the different treatment options. The aim of the work is to assess radiological and functional results of managing comminuted fracture femur with bone loss by mono lateral external fixator, study the technique of application and related complication. Methods: This retrospective case series study was done in May 2010 to December 2016 with mean follow up period 1.5 years and included 21 patients who were divided into two main groups, group (I) included 11 patients managed by acute shortening and distraction, and the group (II) included 10 patients managed by bone transport technique. Outcome in both groups was compared regarding time to union (external fixator time), length gained, healing index (external fixator time/length gained), bone results and functional results according to Paley. Complications in both groups have been compared and classified according to Paley into 3 categories: problems, obstacles, and sequelae.

An update on the intramedullary implant in limb lengthening: A quinquennial review Part 1: The further influence of the intramedullary nail in limb lengthening

The goal of limb lengthening is to restore length to bone, safely stretch soft tissues and improve quality of life with minimal complications. Traditionally this was achieved with the use of external fixators, associated with complications related to pin site tethering and infections, joint stiffness and regenerate deformity and fracture following frame removal. The duration of treatment also impacts on patient mental health and well-being. In order to reduce external fixator time, intramedullary nails have been introduced as an adjunct, either at the initial surgery or after completion of lengthening. Complications related to the external fixator still remained and innovation has led to the popularisation of the intramedullary lengthening nail.The lengthening mechanism of the nail can be divided into those with ratchet systems and those driven by motors. In the ratchet group, patients are required to manually rotate their limb, with movement at the osteotomy site, in order to create forward movement. This was often associated with pain, and in some cases led to the requirement of general anaesthesia to enable rotation and continuation of lengthening. Further issues were reported related to lengthening rate control. Once the nail had lengthened sufficiently for the osteotomy to disengage, rapid lengthening termed a ‘runaway’ nail could occur. The nails were limited to forward movement, and once length was gained it could not be retracted, leading to poor regenerate formation and soft tissue contractures.The introduction of the Fitbone implant utilised a transcutaneous electrical conduit, powered by a high frequency electrical signal, enabling more control over the lengthening. The Precice intramedullary lengthening system is controlled by the use of an external device with two rotating neodymium magnets, which produce rotation of a third magnet in the nail. By altering the direction of the magnet rotation, the lengthening can be controlled both forwards and backwards with sub-millimetre precision.Following initial excellent outcomes published, the use of the lengthening intramedullary nail has become accepted by many as the implant of choice in limb lengthening. The aim of this article comes in two parts. The first to highlight the latest research and clinical results in the last five years using an intramedullary implant during limb lengthening, and the second to report the outcome in extended surgical indications and further implant innovation.

Matched comparative study of trifocal bone transport versus induced membrane followed by trifocal bone transport in the treatment of segmental tibial defects caused by posttraumatic osteomyelitis

ObjectivesTo compare the efficacy and clinical outcomes of trifocal bone transport (TBT) versus induced membrane followed by trifocal bone transport (IM + TBT) in the treatment of tibial defects > 6 cm caused by posttraumatic osteomyelitis.MethodsA total of 69 eligible patients with tibial defects > 6 cm who were treated between January 2010 and January 2018 were retrospectively reviewed. Overall, 18 patients treated by IM + TBT and 18 treated by TBT were matched by propensity score analysis. The mean tibial defect after radical debridement was 6.97 ± 0.76 cm (range, 6.0 to 8.9 cm). The measurements, including demographic data, external fixation index (EFI), external fixation time (EFT), duration of docking union, bone and functional outcomes evaluated by the Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system, and postoperative complications evaluated by Paley classification during follow-up were recorded.ResultsAge, gender, injury mechanism, affected side, defect size, previous operation time, and follow-up time were not significantly different between the two groups (P > 0.05). The mean EFT was 293.8 ± 12.1 days in the TBT group vs. 287.5 ± 15.3 days in the IM + TBT group. The mean EFI was 36.02 ± 2.76 days/cm vs. 34.69 ± 2.83 days/cm, respectively. The mean duration of docking union was 210.7 ± 33.6 days vs. 179.7 ± 22.9 days, respectively. There was no significant difference in postoperative bone and functional results between the two groups. Delayed union or nonunion and soft tissue incarceration were significantly reduced in the IM + TBT group compared to those in the TBT group.ConclusionBoth TBT and IM + TBT achieved satisfactory postoperative bone and functional outcomes in patients with segmental tibial defects > 6 cm following posttraumatic osteomyelitis, while IM + TBT had a significantly lower incidence of postoperative complication in delayed union or nonunion and soft tissue incarceration, as well as faster docking union.

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

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