Internal Bone Transport Research Articles

Development and principles of intramedullary and extramedullary segmental bone transport: overview and clinical results

Segmental bone transport using intramedullary or extramedullary techniques is one of the most commonly used procedures for bone defect management in the diaphyseal region of long bones. The purpose of this work is to provide an overview of the historical development and general principles as well as the current status of extramedullary and intramedullary techniques of bone segment transport. In addition, own results on internal segmental bone transport are presented. Aretrospective database analysis included all patients between May 2019 and January 2021 who underwent segmental bone transport via afully implantable intramedullary segment transport nail system. In addition to the radiological outcome, the clinical outcome was assessed using the lower extremity functional scale (LEFS). A total of 9 patients (8male, 1female; age 41.7 ± 3.9years) could be included. The cause of the segmental bone defect was chronic fracture-related infection in all cases. The segmental defect size was 62 ± 10 mm. Sufficient bridging of the bone defect was achieved in all patients, with amean distraction rate of 0.9 ± 0.1 mm per day. Bony consolidation of the regeneration was achieved after 292 ± 57days, and final bony consolidation of the docking zone was achieved after 469 ± 116 days. At 22 ± 3months after implantation of the segmental transport nail, the LEFS demonstrated aresult of 59 ± 4points. No recurrence of infection or regeneration failure occurred. The aim of treating segmental bone defects, in addition to reconstructing aload-bearing bone, is to restore correct joint angles, leg length, and leg axis without torsional deviation and can be achieved via classical external segmental bone transport. In recent years, internal segmental bone transport has been developed as an alternative. It remains to be seen whether the preliminary and reproducibly good clinical and radiological results of segmental transport nails can be confirmed for widespread use in the future.

Bone transport in the management of post-osteomyelitis femoral defects in children: A case series with a minimum of 10-year follow-up in Uganda.

Purpose:The aim of this study was to evaluate the long-term outcomes of the bone transport technique in the management of post-infectious segmental femoral bone defects in children in a low-income country.Methods:Eleven children were included in this case series. All had a femoral defect secondary to osteomyelitis managed with the internal bone transport technique using an external fixator alone. Bone and functional results were evaluated and complications recorded after a minimum follow-up period of 10 years (range: 10–16).Results:The mean age of the patients was 7.8 years, and the average size of the bone defect was 10.8 cm. At the latest follow-up, bone results were excellent in three, good in five, and fair in three, while the functional results were excellent in three, good in four, fair in three, and poor in one. Limb length discrepancy was observed in 10 cases while hip and/or knee joint disorder was recorded in six cases. At the last follow-up, only one patient had a recurrence of infection.Conclusion:The bone transport technique has proven to be a valid option for eradicating infection and filling large bone defects in children. However, it is a technically difficult and lengthy procedure that is prone to unique complications.Level of Evidence:IV-Case series

Technical considerations for the management of segmental osseous defects with an internal bone transport nail

ABSTRACT Introduction Traditionally, distraction osteogenesis has been accomplished with an external fixator. All internal transport utilizing magnetic intramedullary nails is a newer technique for bone reconstruction. The Precice Bone Transport Nail is a new implant that allows for noninvasive transport via a magnetically driven motor. Areas covered This report describes the function of the Bone Transport Nail along with the technical considerations on how to successfully manage bone defects with this new technology. Appropriate use of the nail, preoperative planning, intraoperative considerations, and postoperative management are discussed in detail. Expert opinion The Precice Bone Transport Nail utilizes the technology of the original Precice nail to provide an all-internal option for reconstruction of intercalary defects. This obviates the need for an additional plate with a standard Precice nail when performing bone transport and allows for a less invasive option that decreases operating room time. It provides a more cosmetic result than external fixation and avoids the risks of pin tract infection. Preoperative planning is essential to appropriate execution of the operative procedure and to perform a successful transport. A thorough understanding of the nail design and limitations are a prerequisite as this implant is significantly different from a standard intramedullary nail.

Bone transport combined with bone graft and internal fixation versus simple bone transport in the treatment of large bone defects of lower limbs after trauma

BackgroundBone transport has been successfully applied for the management of large segmental bone defects. However, its main shortcoming is the long-lasting consolidation period, which may cause lots of related complications. To overcome this shortcoming, we developed bone transport combined with bone graft and internal fixation technique. The purpose of this study was to compare the clinical effects of this modified technique with simple bone transport in the treatment of large segmental bone defects of lower limbs after trauma.MethodsEighty-four patients with large segmental bone defects treated in our institution from January 2014 to January 2017 were selected for retrospective study. A total of 77 cases were completely followed. Among them, 35 patients were treated by bone transport combined with bone graft and internal fixation technique (Group A), and 42 by simple bone transport technique (Group B). Patients with open injuries were classified according to Gustilo-Anderson (GA) classification. The general data of Group A and B were compared. The time in external fixator, total cure time and operation times of two groups were recorded. Ennecking score was used to evaluate the recovery of limb functions while self-rating anxiety scale (SAS) for the postoperative anxiety evaluation. In addition, the total complication incidence was compared between Group A and B.ResultsThere was no significant difference in demographic data between Group A and B (p > 0.05). The time in external fixator of Group A and B was (4.8 ± 1.6) and (18.2 ± 3.9) months, respectively (p < 0.05). The total cure time was (17.6 ± 2.2) and (20.4 ± 2.8) months in Group A and B (p < 0.05). The number of operations in Group A and B was (4.9 ± 1.2) and (4.8 ± 1.0) (p > 0.05). Ennecking score of Group A and B was 84.7 and 75.7% (p < 0.05). SAS score and total complication incidence in Group A were significantly lower than those in Group B (p < 0.05).ConclusionsThe clinical effects of bone transport combined with bone graft and internal fixation technique were better than that of simple bone transport technique, including shorter time in external fixator, shorter total cure time, lower anxiety score and better limb functions.

Treatment of Infected Nonunion of the Tibia and Femur Shaft Fractures with Classical Internal Bone Transport

Treatment of Infected Nonunion of the Tibia and Femur Shaft Fractures with Classical Internal Bone Transport

Acute Shortening and Re-Lengthening (ASRL) in Infected Non-union of Tibia - Advantages Revisited.

Introduction:A gap non-union in various conditions has been treated successfully by the Ilizarov method. The gap can be filled up either by an acute shortening and re-lengthening (ASRL) procedure or by an internal bone transport (IBT). We compared the functional and clinical outcome of ASRL and IBT in gap non-unions of the infected tibia.Material and Methods:A retrospective study was conducted in our department from the data collected in the period between 1997 and 2010. There were 86 cases of infected non-union of the tibia, in patients of the age group 18 to 65 years, with a minimum two-year follow-up. Group A consisted of cases treated by ASRL (n=46), and Group B, of cases by IBT (n=40). The non-union following both open and closed fractures had been treated by plate osteosynthesis, intra-medullary nails and primary Ilizarov fixators. Radical debridement was done and fragments stabilised with ring fixators. The actual bone gap and limb length discrepancy were measured on the operating table after debridement. In ASRL acute docking was done for defects up to 3cm, and subacute docking for bigger gaps. Corticotomy was done once there was no infection and distraction started after a latency of seven days. Dynamisation was followed by the application of a patellar tendon bearing cast for one month after removal of the ring with the clinico-radiological union.Results:The bone loss was 3 to 8cm (4.77±1.43) in Group A and 3 to 9cm (5.31± 1.28) in Group B after thorough debridement. Bony union, eradication of infection and primary soft- tissue healing was 100%, 85% and 78% in Group A and 95%, 60%, 36% in Group B respectively. Nonunion at docking site, equinus deformity, false aneurysm, interposition of soft-tissue, transient nerve palsies were seen only in cases treated by IBT.Conclusion:IBT is an established method to manage gap non-union of the tibia. In our study, complications were significantly higher in cases where IBT was employed. We, therefore, recommend ASRL with an established protocol for better results in terms of significantly less lengthening index, eradication of infection, and primary soft tissue healing. ASRL is a useful method to bridge the bone gap by making soft tissue and bone reconstruction easier, eliminating the disadvantages of IBT.

Distraction osteogenesis: A review of the literature

Distraction osteogenesis has been one of the most remarkable achievements in musculoskeletal surgery. It is the sheet anchor for the process of limb lengthening and internal bone transport as well as gradual deformity correction. It has revolutionised the management of limb deficiencies and bone loss. Since its conception over a 100 years ago, it has gone through several stages of evolution brought on by an increasing understanding of the underlying principles that govern the successful application of the concept as well as technological advancements in the field of limb reconstruction surgery. The result of this has been a significantly changing outlook for many musculoskeletal conditions. This review looks at the historical perspectives of this concept, noting the contributions of the pioneers in this field of surgery. Its evolution and the principles governing the various aspects of distraction osteogenesis are discussed in detail. The various methods in use today and its application in modern-day orthopaedics are also critically reviewed.

A Modification of Internal Bone Transport Method for Reconstruction of Nonunion of Forearm.

Background:Defects of bone and soft tissue occur frequently after high-energy trauma, infections, and tumor resection. Treatment options are limited and outcomes are controversial in nonunion. Classical reconstruction methods are challenging. We describe a method of internal bone transport for treatment of complicated nonunion of the forearm. This method permits axial and internal bone transport without harming the distorted and complex neurovascular anatomy or soft-tissue envelope.Materials and Methods:Five patients (mean age, 27 years) with defect nonunion (3 ulna, 2 radius) were treated. Mean preoperative defect size was 36 mm, mean shortening was 14 (0–30) mm, and the extent of surgical resection was 24 (20–40) mm. Total bone loss due to defect, resection, or shortening was 74 mm. According to Paley classification, two of the patients had B1, and three had B3 defect nonunion. This study treats defect nonunion of the forearm using an internal bone-transport method. Our method involved cannulated screws, a cerclage wire, and a circular fixator being used in combination. When transportation was completed, internal fixation of the docking site with a plate and screws was done, with bone grafting after fixator removal. Bone healing and functional outcomes were assessed with radiographs and disabilities of the arm, shoulder, and hand (DASH) scores, respectively.Results:Mean followup was 67.6 months. Solid osseous union and functional improvement were achieved in all cases. Mean bone loss was 66 mm, mean fixator time was 131.8 days, the lengthening index was 1.3 days/mm, and the fixator index was 2.1 days/mm. DASH score was 82.2 before treatment and 15.36 after treatment.Conclusions:Using our method, internal bone transport and progressive axial docking of defects can be done with minimal effects on surrounding neurovascular arrangements and soft tissues. Size of fixators can be decreased and formation of painful scar tissue can be avoided.

MagicTube: new possibilities for completely internal bone segmental transport and optional lengthening : New additional module for motorized lengthening nails for treatment of large bone defects

Segmental bone transport is an effective method of treatment for segmental defects but the previous need for external fixation constructs during the transport phase is agreat disadvantage, especially in the femur. In order to avoid external fixation, anew cylindrical combitube segmental transport (CKTST, MagicTube) module for combination with a commercially available motorized lengthening nail was developed by the author. This MagicTube module enables completely internal segmental bone transport and also enables optional lengthening if needed. The concept and surgical technique of MagicTube are described, illustrated, discussed and exemplified by clinical cases involving the tibia and femur.

Internal bone transport using a cannulated screw as a mounting device in the treatment of a post-infective ulnar defect.

Bone transport techniques can be used to address the segmental bone loss occurring after debridement for infection. Secure fixation of the bone transport construct to the bone transport segment can be challenging, particularly if the bone is small and osteopenic. We report a case of a segmental ulnar bone defect in a young child treated with internal bone transport using a cannulated screw as the mounting device. We found this technique particularly useful in the treatment of bone loss secondary to infection, where previous treatment and prolonged immobilisation had led to osteopenia. This technique has not been previously reported.

Treatment of Post Traumatic Femoral Bone Loss Using Ilizarov External Fixator; Technical difficulties and complications analysing approach.

Purpose Internal bone transport using Ilizarov external fixator for management of post traumatic femoral bone loss is a technically demanding procedure that entails many surgical difficulties. Many complications were encountered either intra or post operative. Proper and early management of these complications markedly improves the overall results. Methods In the period from January 2011to June 2013, 17 cases of post traumatic femoral bone loss were treated with bone transport using Ilizarov external fixator. All fractures were open, 15 cases were grade IIIb and two cases were grade IIIc according to Gustillo – Anderson classification. The cases included in this study had bone defect more than four cm. The defect was diaphyseal in five cases and metaphyseal diaphyseal in 12 cases with distal intra articular extension in two cases. This procedure was lengthy; to reduce the time of the procedure, all cases were managed either by acute collapse at the fracture site and subsequent limb lengthening or partial collapse of the defect and limb lengthening to achieve limb length equality. Results In all cases the bone continuity was restored with complete union of the fracture. The complication rate was high but all of them could be dealt with successfully. According to ASAMI scoring system the bone results were higher than functional results in all cases. Conclusion This method was proved to be effective in restoring the skeletal integrity inspite of many complications recorded.

Treatment Of Post Traumatic Femoral Bone Loss Using Ilizarov External Fixator; Technical Difficulties and Complications Analysing Approach

Purpose Internal bone transport using Ilizarov external fixator for management of post traumatic femoral bone loss is a technically demanding procedure that entails many surgical difficulties. Many complications were encountered either intra or post operative. Proper and early management of these complications markedly improves the overall results. Methods In the period from January 2011to June 2013, 17 cases of post traumatic femoral bone loss were treated with bone transport using Ilizarov external fixator. All fractures were open, 15 cases were grade IIIb and two cases were grade IIIc according to Gustillo – Anderson classification. The cases included in this study had bone defect more than four cm. The defect was diaphyseal in five cases and metaphyseal diaphyseal in 12 cases with distal intra articular extension in two cases. This procedure was lengthy; to reduce the time of the procedure, all cases were managed either by acute collapse at the fracture site and subsequent limb lengthening or partial collapse of the defect and limb lengthening to achieve limb length equality. Results In all cases the bone continuity was restored with complete union of the fracture. The complication rate was high but all of them could be dealt with successfully. According to ASAMI scoring system the bone results were higher than functional results in all cases. Conclusion This method was proved to be effective in restoring the skeletal integrity inspite of many complications recorded.

Femoral Lengthening Over an Intramedullary Nail: A Case of Failed Distraction: A Case Report.

Internal bone transport has been used to successfully lengthen diaphyseal bone1. In 1997, Paley et al. described femoral lengthening over a nail (LON), specifically an intramedullary nail, with the use of a unilateral external fixator2. Although this technique is often successful, several complications have been reported, including nonunion of the docking site, infection, pin loosening, fracture, subluxation of the posterior part of the knee or of the patella, and deformation of bone2-8. We report a case of failed femoral LON with a unilateral external fixator related to an oversized intramedullary nail. The patient was informed that data concerning the case would be submitted for publication, and he provided consent. A forty-eight-year-old man presented on crutches with the chief symptom of pain in the left hip. He had fallen four months prior and had sustained a femoral neck fracture that had been treated with percutaneous screws at an outside hospital. Radiographs of the left hip revealed a femoral neck nonunion with accompanying posterior and varus collapse. The patient underwent hardware removal, followed by an intertrochanteric valgus osteotomy with a blade plate. The femoral neck nonunion and osteotomy site healed, and the patient was walking independently three months postoperatively. He reported resolution of the left hip pain; however, he had developed pain in the lower back and contralateral hip, which was exacerbated by walking and prolonged standing. Physical examination revealed a shortened left lower extremity. The gait was mildly antalgic with a slight Trendelenburg component. A computed tomography (CT) scanogram demonstrated an overall leg-length discrepancy of 2.9 cm. Because of the symptomatic limb-length discrepancy, the patient elected to pursue femoral LON with a unilateral external fixator. The patient was brought to the operating room and placed in the supine position. The four screws securing …

Treatment of excessive bone loss from both crus bones with internal bone transport using an intramedullary nail – case report.

We present a case report of a 16-year-old patient who suffered multisite and multiorgan injuries following a road accident. The most prominent musculoskeletal problem was a bilateral crush injury of the crus in combination with open fractures. The aim of this study is to present the possibilities and available methods of treatment of patients with extensive posttraumatic and postinflammatory bone loss of the lower limbs that make it possible to avoid amputation. We used intramedullary nailing and internal bone transport to reconstruct continuity and leg length of both crus bones. The treatment was complicated by poor vascularity and emerging complications. After several months and multi-stage treatment the patient was able to walk with full weight-bearing without crutches. Importantly, the patient is satisfied with the outcome of the treatment and does not consider herself disabled. The study presents our approach to the dilemma of choosing between prolonged reconstruction surgery and amputation as a final method.

A Novel Device for Long Bone Osteodistraction

The purpose of this study was to present a novel intramedullary device (M-Bone; Phenix, Paris, France) that contains a mechanism for internal osteodistraction and bone transport in patients with segmental bone defects or limb length discrepancy after limb salvage operations. A total of five patients with primary bone tumors were enrolled in the study. After implantation, daily lengthening was performed in an outpatient setting either by the patient or with the help of a therapist, without the use of anesthesia. This unique device offers a totally new approach for the treatment of segmental bone defects or limb length discrepancy. It is designed to expand the remaining native bone by a magnetically activated drive system and induces new bone formation using osteodistraction and bone transport.

All Internal Bone Transport: Use of a Lengthening Nail and Double Plating for Management of Femoral Bone Loss.

ABSTRACTBackgroundVariety of techniques for management of segmental femoral bone loss have been described, each with different advantages and challenges during treatment. The development of motorized lengthening nails has provided a potential for all internal bone transport, avoiding some of the difficulties with external fixation in the femur. At present, there is limited published literature on experiences in this technique.AimThe development of this technique aimed to overcome the difficulties previously reported for internal bone transport in the femur, particularly varus deformity and joint stiffness.TechniqueWe describe the technique of double plating with bone transport utilizing a magnetic lengthening nail to manage segmental femoral bone loss. The benefits of the technique are discussed, along with specific challenges and lessons that have been learned through experience of internal bone transport.ConclusionUse of a magnetic lengthening nail and double plating as a method of all internal bone transport provides an option for the management of massive femoral bone loss, while avoiding some of the challenges that have been reported with the existing techniques.Clinical significanceThis technique provides an additional method in the armamentarium of the trauma or limb reconstruction surgeon treating massive femoral bone loss.How to cite this articleWright J, Bates P, Heidari N, et al. All Internal Bone Transport: Use of a Lengthening Nail and Double Plating for Management of Femoral Bone Loss. Strategies Trauma Limb Reconstr 2019;14(2):94–101.

Outcomes of Ilizarov ring fixation in recalcitrant infected tibial non-unions – a prospective study

BackgroundInfected non-union of long bones is a problem in the developing countries. Persistent infection, deformity, shortening, bone loss, joint stiffness and disability complicate the non-union. Secondary procedures are often required for correction of bone defects and deformity. Ilizarov method addresses all the above problems simultaneously and offers a panacea for infected non-unions. The stability of the fixation and provision for bone transport allows bridging of bone defects, limb lengthening, early weight bearing ambulation and joint mobilisation.Aim of the studyTo know the suitability of this procedure in recalcitrant infected tibial non-unions in the Indian population and the influence of socio-economic factors in the functional outcome.Method of studyThis was a 3-year prospective study in 22 consecutive patients with an average follow up of 13 months following fracture union. The results were analysed using the ASAMI scoring system.ResultsOf 22 patients in the study, 13 patients who underwent external bone transport, had an average bone gap of 4 cms [2–11 cms] with an average duration of fixation of 9.3 months [6.5–13 months]. There were 4 excellent, 3 good, 4 fair and 2 poor bony results and 1 excellent, 3 good, 6 fair and 2 poor results. 1 patient was lost for follow up at final functional analysis. 9 patients who underwent internal bone transport had an average bone gap of 5.4 cms [1.5–9 cms] with an average duration of fixation of 8.5 months [4–11 months]. There were 3 good 4 fair and 2 poor bony results and 1 good, 3 fair, and 2 poor functional results. Good to excellent results were witnessed in well-motivated patients with adequate social and financial support. Patients with fair to poor results preferred amputation to limb salvage despite the fact that they retained their limbs.ConclusionTreatment of infected non-unions of Tibia with Ilizarov ring fixation is effective but for optimal results the treatment needs to be individualised by the treating surgeon with due consideration of the socio-economic factors.

Distraction Osteogenesis

The treatment of bone loss resulting from acute trauma has traditionally been a complex surgical problem. Numerous procedures have been devised to reconstitute bone stock, obtain fracture union, and provide a stable functional limb. Traditional internal bone transport has been used successfully for bony reconstruction for both acute and reconstructive bone loss. Potential complications are primarily related to the complexity of the external device, prolonged time in the frame, and nonunion of the docking and regenerate segments. Recent advances in fixator and pin design have reduced the complexity of these devices as well as the incidence of pin- and frame-related complications. Gradual shortening, rapid distraction using autodistractors, transporting over intramedullary devices, and using orthobiologic and adjuvant techniques to assist in the consolidation of regenerate and docking sites are now being combined to decrease the morbidity and excessive frame time required to complete these reconstructions.

Tibial infected nonunion treated by internal bone transport using the mono-lateral external fixation

To evaluate the clinical and functional outcomes of infected nonunion of the tibia by internal bone transport using the LRS mono-lateral external fixation. From June 2003 to October 2005, twenty-eight patients who underwent internal bone transport for infected nonunion in the tibia were reviewed. Twenty-three cases were open fractures: grade IIIA, 5 cases; grade IIIB, 11 cases; grade IIIC, 7 cases. The other five cases were infected nonunion after internal fixation. The results were evaluated by the classification of the Association for the Study and Application of the Method of Ilizarove (ASAMI) which divided into bone and functional categories. Mean follow-up was 16 months. All the cases got primary bone union, and infection was controlled. Bone results were 14 excellent, 9 good, 2 fair and 3 poor. And functional results were 10 excellent, 13 good, 2 fair and 3 poor. The mean length of time in healing for all patients were 9 months. The mean length of regenerate bone were 6.6 cm. The most common complication was pin infection, and 2 cases refractured at the docking site. Tibial infected nonunion can be successfully treated using the internal bone transport technique.

Internal Bone Transport in the Management of Tibial Bone Defects

목 적: 일리자로프 방법을 이용하여 경골의 골 결손에 대하여 내측 골 이동술을 실시하고, 임상적, 기능적 결과를 후향적으로 평가 하였다. 대상 및 방법: 경골의 외상성 (16례) 또는 골수염 (23례) 후에 발생한 골 결손이 있는 39명의 대하여 일리자로프 내측 골 이동술을 실시하였 으며, 수술시의 평균 나이는 33.8세 (범위, 13~66세)이었고, 평균 추시는 3.5년 (범위, 1.6년~8년)이었다. 이동된 골의 거리는 평균 6.3 cm (범위, 2.7~20 cm)이었으며, 외고정 장치는 술 후 평균 345일 (범위, 120~700일)에 제거하였고, 외고정 장치의 장착율은 평균 60.3일/cm (범위, 13.1~121.3일/cm)이었다. 결 과: 대부분의 환자에서 신연부와 재결합부의 1차적 골 유합을 얻을 수 있었으나, 2환자에서는 재결합부의 골 유합의 실패가 있었다. 기능 적 결과에서 우수 6례, 양호 19례, 보통 10례, 불량 4례가 있었고, 20세 미만의 군의 환자들이 더 좋은 결과를 나타냈다. 합병증은 73례가 발 생하였으며 (발생율, 1.87례/명), 그 중 치유되지 못한 후유증은 20명에서 27례가 발생하였고, 동측 하지에 동반된 손상이 많을수록 그 후유증 의 발생빈도는 증가 하였다. 결 론: 내측 골 이동술은 경골의 큰 골 결손을 해결할 수 있는 방법이나, 합병증의 발생이 적지 않으며, 이는 동반된 동측 하지의 손상과 중요 한 관계가 있는 것으로 생각한다.