Large Tibial Defects Research Articles

Huntington's procedure revisited

BackgroundManagement of gap nonunion of tibia is difficult for the surgeons, and time consuming for patients with unpredictable results. There are various methods to treat gap nonunion, but each one has its own limitations. We report the outcomes of ipsilateral fibular transposition (Huntington's procedure) for reconstruction of major tibial defects. MethodsIt is a retrospective study including 4 patients who underwent ipsilateral vascularized transposition of fibula for gap nonunion of tibia. Fibula was transferred to tibia as vascularized pedicle graft in one-staged procedure. ResultsSingle stage fibular transposition was performed in four patients. The transferred fibula united in all patients. Mean follow-up after fibular transposition was 1.2 years. Partial weight bearing started after an average of 5.25 months till hypertrophy of fibula is seen on radiographs than full weight bearing started. The mean time to healing was 7.5 months (range: 5–10 months). Tibialization of fibula occurred in all patients as evident on radiographs. ConclusionsHuntington procedure is a simple and technically easy for large tibial defects. It does not require microsurgical skill and implants. The union of transferred fibula is faster than conventional graft as it is a vascularized graft. It is a rational choice for the treatment of large tibial defects in selected cases.

Evaluation of a genicular axial pattern flap to repair large cutaneous tibial defects in two dogs

BackgroundClinical outcome after cutaneous reconstruction using genicular artery flaps has not been reported. Major cutaneous defects of the pelvic limb between the stifle and hock are frequent in dogs and closure is difficult due to lack of available skin from immediately adjacent areas.Case presentationHere we report the first two clinical cases successfully managed by genicular axial pattern flap closure. A 2-year-old 38 kg (83.77-lb) intact male Labrador Retriever and a 14-year-old 42 kg (92.59-lb) spayed mixed breed female dog were admitted for the management of large skin defects in the lateral tibiotarsal joint. One defect was the result of a fibrosarcoma removal in the Labrador dog and the other defect was a chronic large wound caused by a car accident in the mixed breed female dog. Both defects were reconstructed by using genicular flaps. The bed of the wound in mixed breed dog was surgically debrided and underwent open wound management until a proper granulation tissue bed was formed before reconstruction. The skin defect in the Labrador dog was covered immediately after tumor removal. After surgery both dogs were bearing weight on the limbs normally. Small area of dehiscence occurred in both dogs 2 weeks after surgery. At follow-up examination one month after surgery, the surgical wound of the Labrador retriever still had a small area of dehiscence. Two months after surgery, the wound of the mixed breed dog was completely healed, covered with hair and no lameness was observed.ConclusionFindings suggested that genicular axial pattern flap is a good option for reconstruction of large cutaneous defects of the lateral aspects of the tibia in dogs.

The Management of Problems in Lower Extremity Salvage Using Shortening-Lengthening Technique and Free Flaps: A Case Report

High-energy trauma leads to the increasing number of patients with severe leg injuries, often resulting in severe comminuted bone fractures with large area of soft tissue defects and vascular, nerve and muscle injuries. In the 1950s, Ilizarov technique was applied to the treatment of large tibial defect with bone transplantation and bone lengthening techniques. In recent years, shortening-lengthening technique was also used in the second stage. One case of complex lower extremity injury was also treated by shortening-lengthening technique combined with free flap transplantation. The problems in the process were managed properly. The clinical effect was good and the patients were satisfied. The report is as follows.

Immediate Soft-Tissue Reconstruction for Chronic Infected Tibia Nonunions Treated with an Ilizarov Frame.

Summary:There are multiple options available for the management of large tibial defects. The Ilizarov frame is one of the most widely used techniques due to the physiological bone growth and the symmetrical distribution of axial forces permitting adequate bone distribution. However, disadvantages still remain including obtaining additional soft-tissue access for defect coverage. We present our experience with soft-tissue reconstruction for chronic infected tibial nonunions using free tissue transfers simultaneously with Ilizarov device placement. A retrospective review was performed from 2014 to 2016 of patients presenting with a chronically infected tibia nonunion and treated by our senior orthopedic and plastic surgeons. Demographic data, comorbidities, intraoperative details and postoperative outcomes were collected. A total of 6 patients were identified with a mean age of 46.2 ± 11.6 years. Complete flap survival and resolved active infection were achieved in 5 of our patients, 4 demonstrated body union on imaging, and all of them reached complete ambulance. Flap revisions with allografting for partial flap loss were performed in 1 patient. Preoperative planning is critical for immediate lower extremity reconstruction in the setting of an Ilizarov frame. From our institutional experience, free tissue transfer can safely be placed after frame placement.

Addressing large tibial osseous defects in primary total knee arthroplasty using porous tantalum cones

BackgroundTibial osseous defects can present a serious challenge in primary total knee arthroplasty. We describe a technique of using porous tantalum cones along with primary arthroplasty implants to address large tibial osseous defects in primary total knee arthroplasty and present the short-term results. MethodsWe present 17 cases (15 patients) in which primary total knee implants and porous tantalum cones were used to address large tibial bony defects. Clinical results were evaluated using Knee Society Scores, pre- and postoperative knee range of motion, and serial radiographs. ResultsAt an average of 3.5 years of follow-up, all 17 knees had functioning implants with stable metaphyseal cones demonstrating radiographic evidence of osteointegration. At a minimum follow-up of two years, no patient had signs of osteolysis, instability, infection, or systemic complications. All 15 patients had excellent results with an average post-operative Knee Society Score of 94.6. Knee flexion improved by an average of 12.0° and knee extension improved to neutral in all patients. ConclusionPrimary total knee arthroplasty with porous tantalum cone augmentation produced excellent short-term results and should be considered an effective method for addressing large tibial osseous defects in primary total knee arthroplasty.

Intercalary allograft reconstruction in a patient with large tibial defect: Case report

A fit 26 year-old-man presented to our Department with an open fracture of the left tibial shaft (AO 42-C3). The fracture was initially treated with an External Fixator, which was replaced by an intramedullary Grosse Kempf nail after 4 months. In the following year he developed an atrophic non-union and we witnessed the increasing bone resorption at the fracture site which led to the nail breakage. An accurate CT pre-operative planning was made and a revision surgery was successfully performed: the broken nail was removed and intercalary allograft reconstruction was made, using a compressible intramedullary nail. Whereas in literature it is well described how intercalary allografts can be used to fill the massive diaphyseal defects after tumor resections, we assumed it could also be an adequate technique to treat a large bone defect at a non-union site.

Restoration of long bone defects of infected tibia with induced membrane technique

Objective To evaluate the induced membrane technique (Masquelet technique) used for restoration of long bone defects of infected tibia. Methods This retrospective study evaluated 44 patients with long bone defect of infected tibia who had been treated at Department of Orthopedics, The Second Affiliated Hospital by the induced membrane technique between January 2004 and January 2017. They were 31 males and 13 females, aged from 18 to 71 years (mean, 43.7 years). Of them, 17 were complicated with diabetes, 13 with primary hypertension, and 12 with more than two basic diseases. Their bone defects ranged from 6 to 17 cm (average, 11 cm). Their postoperative fracture healing and complications were observed. Results This cohort received from 2 to 5 operations on average (average, 3.7 operations). All the patents obtained bony union after 9 to 13 months (average, 11.3 months). Their follow-ups ranged from 16 months to 11 years (average, 3.1 years). Nineteen complications related to the surgery occurred in 15 cases. Skin healing problem after implantation of bone cement was found in 5 cases which called for operative intervention, infection relapsed in 8 patients after the first phase of cement implantation which necessitated further surgical debridement for successful management, local haematoma appeared after bone grafting in one case of 17 cm bone defect, implant failure occurred in one case, leg length discrepancy larger than 2 cm was observed in 3 cases, and a discharging sinus developed in one case 2 years after successful healing of a tibial defect. Conclusions The induced membrane technique appears to be a good alternative management for large tibial defects secondary to infection. The technique should be considered in the surgeon's armamentarium and patients conditions as it is effective and associated with a low rate of complications. Key words: Tibia; Infection; Bone reconstruction; Bone defects; Induced membrane

Biological reconstruction of varus deformity in primary total knee replacement using bone graft and description of a new technique

Peripheral bony defects of the tibia can be seen in patients with osteoarthritis of the knee. These defects must be corrected at the time of total knee replacement to ensure correct placement and alignment of the components.We describe a new technique for correcting large tibial defect by using bone graft, where the uncontained defects were converted to contained defects using bone graft and the contained defect was impacted with cancellous bone. Between 2006 and 2010, 48 cases of primary total knee arthroplasty were reconstructed using autologous bone graft. Of 48 cases, five cases had large tibial defect and were treated with the new technique. Collapse was seen in one knee at 5 months postoperative. The rest of the patients showed improvement in total knee score and limb alignment.We now use this technique to treat large tibial defect during total knee replacement.

A case of bilateral revision total knee arthroplasty using distal femoral allograft\u2013prosthesis composite and femoral head allografting at the tibial site with a varus-valgus constrained prosthesis: ten-year follow up

BackgroundWe report the successful use of allograft–prosthesis composite (APC) and structural femoral head allografting in the bilateral reconstruction of large femoral and tibial uncontained defects during revision total knee arthroplasty (RTKA).Case presentationA 67-year-old female with degenerative arthritis underwent bilateral total knee arthroplasty (TKA) using the Press Fit Condylar (PFC) modular knee system at our clinic in March, 1996. At 8 years postoperatively, the patient presented with painful, bilateral varus knees, with swelling, limited passive range of motion (ROM), and severe instability. We treated to reconstruct both knee using a femoral head allograft at the tibial site, a structural distal femoral allograft at the femoral site, and a varus-valgus constrained (VVC) prosthesis with cement. At the 10-year follow up, we found no infection, graft failure, loosening of implants, in spite of using massive bilateral structural femoral head allografts in RTKA.ConclusionThe use of APC enabled a stable and durable reconstruction in this uncommon presentation with large femoral bone deficiencies encountered during a RTKA.

Gradual fibular transfer by ilizarov external fixator in post-traumatic and post-infection large tibial bone defects.

Several reconstructive procedures have been used in management of large tibial bone defects including bone graft, bone transport (distraction osteogenesis) using various external fixators, and vascularized bone graft. Each of these procedures has its limitations and complications. The study describes gradual medial fibular transfer using Ilizarov external fixators in management of patients with large tibial defect, either following infection or trauma. Between May 2011 and June 2013, 14 patients were prospectively included in the current study. The inclusion criteria were large tibial defect due to trauma or infection with severe soft tissue compromise, and small or poor tibial bone remnants making bone lengthening difficult. Exclusion criteria were patients with vascular or nerve injuries. The average age of the patients was 31.64 (± 6.5) years. Medial fibular transfer was done for all patients using Ilizarov at a rate of 0.5mm twice daily. Iliac bone graft was used in all patients after the transfer. The average segmental bone defect of the tibia was (13.2 ± 2.6), ranging between 8 and 18.6cm. Union was achieved in all patients with average fixator time was 32.42(± 4.32) weeks. Average follow-up after removal of the fixator was 40.5 (± 6.9) months. Gradual fibular transfer by Ilizarov external fixator is a reliable technique in management of post-traumatic and post-infection large tibial bone defects with good clinical outcome, and with few complications.

Intercalary diaphyseal endoprosthetic reconstruction for tibial septic non-union in an elderly patient: A case report

The surgical treatment of septic non-union is challenging and carries a high failure rate. Bone defect management and fracture site stabilisation are key treatment objectives. We report the case of a 75-year-old woman who underwent intercalary endoprosthetic reconstruction of a large tibial defect due to septic non-union after two previous treatment failures. The two-stage procedure involved extensive excision of infected tissues and implantation of an antibiotic-loaded cement spacer followed by insertion of an intercalary endoprosthesis. Within only 2 months after the procedure, the patient was able to walk with no assistive device and no limp. After 12 months and 6 months after antibiotic discontinuation, the laboratory tests and imaging studies showed no evidence of infection. Intercalary endoprosthetic reconstruction may be a valid treatment option to avoid amputation for recurrent septic non-union, particularly in elderly patients.

Metaphyseal sleeves implant used for large tibial defects in re-revision TKA: A case report

Metaphyseal sleeves implant used for large tibial defects in re-revision TKA: A case report

Reconstruction of large tibial bone defects following osteosarcoma resection using bone transport distraction: A report of two cases.

The clinical efficiency of bone transport distraction osteogenesis in the reconstruction of large tibial defects following resection of osteosarcoma remains unclear. The current study presents two cases of large tibial defects treated with bone transport distraction using an Orthofix external fixator. Case 1 was a 29-year-old man with a tibial defect 11 cm in length, while case 2 was a 16-year-old girl with a 15-cm-long defect. Bone transport distraction osteogenesis was initiated for the both cases on day 14 following resection of the tibial osteosarcoma. Bone transport distraction in case 1 and 2 was continued for 16 and 28 months, respectively, and the patients were followed up for 51 and 56 months, respectively. The two patients did not exhibit any signs of tumor recurrence or tumor metastasis during the follow-up period. The Musculoskeletal Tumor Society functional scores at final follow-up visits were 22 and 18 for case 1 and 2, respectively. Based on the experience gained in these 2 cases, a bone transport is a viable option for the reconstruction of large tibial defects following osteosarcoma resection.

Outcome of distraction osteogenesis by ring fixator in infected, large bone defects of tibia

Salvage of large, infected bone defects in tibia poses a formidable problem. The present prospective study aimed to evaluate radiologic and functional outcome of ring fixator in infected, large (≥6cm) bone defects of tibia treated with distraction osteogenesis. The study included 35 patients (30 males and 5 females) who had minimum of 6cm gap after radical resection of necrotic bone and presence or history of active infection. Mean age was 36.1 years. Mean bone gap was 7.27cm. Mean follow-up period was 25.4 months. Fracture united primarily in 17 cases and after fixator adjustment with freshening of fracture margins in 15 cases. Fixator adjustment with bone grafting was done in one patient to achieve union. One patient had nonunion and another had amputation. The bone result was excellent, good, and poor in 19, 13, and 3 patients, respectively. The functional results were excellent, good, fair and failure in 14, 19, 1, and one patient, respectively. 24 patients had superficial pin tract infection and 18 patients had ankle stiffness. Ring fixator systems reliably achieve union in infected, large bone defects of tibia and help in treating infection, shortening, bone and soft tissue loss simultaneously. We advocate early freshening of fracture ends and removal of interposed soft tissue at docking sites to achieve union. Superficial pin tract infection and ankle stiffness are common problems in managing large tibial defects. But good to excellent functional outcomes can be achieved in majority of patients.

Ipsilateral medial fibular transport using a circular external fixator for reconstruction of massive tibial bone defects in children and adolescents

BackgroundIpsilateral fibular transport is a novel option in limb salvage surgery for patients with large tibial defects. A less common application of the Ilizarov technique is transverse bone transport. The frame allows for gradual transport of the fibula into the adjacent tibial defect site, with precise proximal and distal alignment of the fibula, and compression at tibial contact sites. Here, we outline a method of limb salvage for large tibial bone loss using ipsilateral medial fibular transport using the Ilizarov apparatus in a group of children and adolescents.Patients and methodsWe retrospectively reviewed six consecutive patients, average age 8 years (range 3-18 years), with infection or trauma-related large tibial bone loss. All patients were treated using gradual medial transport of the ipsilateral fibula using the Ilizarov technique. The follow-up of the patients averaged 4 years, with a range of 4-7 years after removal of the circular external fixator. We reviewed patients' medical records and radiographs. We recorded the fracture type in trauma cases, length of the tibial segment replaced, time to union, additional procedures, knee and ankle range of motion, limb length, satisfaction with the reconstructive surgery compared with amputation, and possible complications.ResultThe Ilizarov ring fixation time to achieve fibular transport and bone union averaged 11 months (range from 7-17 months). The amount of tibial bone loss replaced using the Ilizarov frame with fibular transport averaged 9.8 cm, with a range of 8-11 cm. Hypertrophy of the transported fibula accompanied full weight bearing and satisfactory lower extremity joints motion occurred in all patients. Four of the six patients had a superficial pin-site infection. All patients and or parents were satisfied with the results, and none of them reported that amputation would have been a better option.ConclusionThe Ilizarov technique of ipsilateral medial fibular transport to address massive tibial bone loss led to limb salvage for our six patients, with satisfactory functional results. Adolescent patients may require iliac crest bone grafting at the docking sites if the healing response is poor. Our work shows that ipsilateral fibular gradual transport in children and adolescents provides a reasonable alternative for surgeons addressing limb salvage in patients with large tibial bone loss. Patients should be treated by surgeons familiar and experienced with the Ilizarov method.

The Huntington procedure: still a reasonable option for large tibial defects in paediatric patients.

BackgroundManagement of gap nonunion of tibia is technically difficult, time consuming, physically and psychologically demanding for the patient with unpredictable results. Various techniques have been described in literature for the treatment of gap nonunions, but each one has its own limitations.PurposeThis study reports the outcomes of ipsilateral fibular transposition for reconstruction of tibial defects in paediatric age group.MethodsWe retrospectively reviewed records of 14 patients who underwent surgery for gap nonunion tibia with ipsilateral tibialization of fibula. Fibula is transferred to tibia as pedicle graft in two-staged procedure. Due to retained blood supply to one end of the transplant, the graft easily takes up and hypertrophies upon weight bearing over a period of time.ResultsAverage time of radiographic union was 13.35 weeks. Guarded partial weight bearing was started at an average of 16.5 weeks with gradual progression to full weight bearing. The leg length discrepancy at final follow-up ranged from 0 to 7 cms with an average of 2.60 cms. Hypertrophy of tibialized fibula was observed in all patients, with 8 patients showed grafted fibula reaching the diameter of opposite tibia. On subjective assessment, 9 patients were highly satisfied, 4 patients were satisfied and one patient was dissatisfied with the procedure.ConclusionsHuntington procedure is a simple, cost-effective and easy procedure for large tibial defects in paediatric patients which does not require any specialized team and implants, and can be performed in moderately equipped hospital. Leg length discrepancy may be addressed, after the transferred fibula is well developed.

Reconstruction of a Tibial Defect With a Previously Fractured Fibula Including the Fractured Segment as a Free Osteoseptocutaneous Flap

Reconstruction of major bone defects using free fibular transfer provides a good biological option in unsound situations. Most authors recommend selection of the recipient blood vessels outside the zone of injury to achieve successful free fibular transfer. Occasionally, in polytraumatized patients, the surgeon has to use a previously fractured fibula as a graft, with increased risk of inclusion of the injury zone that may lead to failure. We report a rare case of successful reconstruction of a large tibial defect using a previously fractured fibula as a free osteoseptocutaneous flap. The innovative point in our case is the inclusion of the fracture site within the utilized segment, which to our knowledge has never been reported. As long as the microsurgical principles are adhered to, the effect of the zone of injury on the graft viability should not be overwhelming.

Use of Screws and Cement in Primary TKA with Up to 20 Years Follow-Up

The purpose of this study was to investigate screws and cement for large tibial bone defects during primary TKA. Of 14,686 consecutive primary TKAs performed between December 1988 and February 2010, 256 received screws and cement for tibial defects. Cox regression was used for the analysis. 20-year survival probability was 0.9897 (screws) and 0.9339 (no screws) (P=.4225 log-rank). Tibial bone condition was significantly worse in knees receiving screws (P<.0001) with 73.0% having defects in the screws group and 3.4% (P<.0001) for non-screws. Radiolucency appeared in 13.7% (screws) and 6.4% (no screws) postoperatively. Screws were $137 each, wedges $910 to $2240. Knees with tibial defects and screws performed similarly if not better than knees without defects at substantially lower cost than alternatives.

Bone Transport Combined With Locking Bridge Plate Fixation for the Treatment of Tibial Segmental Defects

Segmental tibial bone loss, specifically in the setting of high-energy trauma, presents a challenging problem to the treating orthopaedic surgeon. These injuries are often complicated by tissue loss, poor wound healing, and infection. Many techniques of reconstruction have been advocated from bone grafting to bone transport. Transport can accomplished using Ilizarov frames, monolateral external fixators, and intramedullary devices. Although transport over an intramedullary device offers the advantage of rigidity and controlled alignment, many authors consider prolonged external fixation and history of pin tract infection to be contraindications to this technique. To our knowledge, bone segment transport used in combination with locking plate fixation has not been described for the treatment of tibial bone defects. We describe two cases of bone transport using a combination of locked plate fixation and a monolateral external fixation frame for large tibial bone defects. This technique allows for easy correction of length and alignment, stable fixation, facilitates quicker, and easier frame removal and also allows for compression of transported segment at the time of docking.

Use of Porous Tantalum Cones in Revision Total Knee Arthroplasty

Porous tantalum cones show promise as a tool to allow for reconstruction of large tibial and femoral bone defects during revision total knee arthroplasty (TKA). They function as a metallic substitute for structural bone graft during revision surgery. They are designed for ingrowth into the metaphyseal or metadiaphyseal regions of host bone, and serve as a platform for the tibial or femoral prosthetic components that are united to the inner surface of the cones using bone cement. Porous tantalum cones come in various sizes and shapes and can be used with various knee revision arthroplasty systems, providing the surgeon with flexibility in reconstructive options. Small series with short-term follow-up have reported encouraging results using porous tantalum cones during revision TKA, which are summarized in this manuscript. In addition, we provide a comprehensive description for the technique of using various types of cones to address large tibial and femoral bone defects during revision TKA.