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To understand the potential and limitations of the different available surgical techniques used to treat large, long-bone diaphyseal defects by focusing on union, complication, re-intervention, and failure rates, summarizing the pros and cons of each technique. A literature search was performed on PubMed, Web of Science, and Cochrane databases up t...
Contexts in source publication
Context 1
... aetiology of the defects included trauma in 751 cases (42.2%), tumour in 554 cases (31.1%), non-union after previous treatment in 289 cases (16.2%), infection in 177 cases (9.9%), and congenital defect in ten cases (0.6%). Aetiology of the defects are shown in Table 2. Gender was represented by 70.4% men and 29.6% women, and age presented a range of 2-86 years. ...Context 2
... techniques are applied for the treatment of different types of patients and lesions, which could influence the results in terms of outcomes and complications. Among the four groups of techniques retrieved, the bone defect causes that led to the surgical intervention were different: bone allograft and autograft and bone transport were used mainly for traumatized patients (53.7% and 55.6%), almost all patients with a diaphyseal bone defect caused by infection were treated with bone transport techniques, while tumor resection was the indication of 73.1% of the fibular graft and 100% of the endoprosthesis (Table 2). ...Similar publications
The study was carried out to determine lecturers' perception on tasks and operations expected for the assessment of agricultural practical in Colleges of Education in Adamawa and Taraba States, Nigeria. Three research questions and two null hypotheses were formulated to guide the study; the hypotheses were tested at 0.05 level of significance. The...
Citations
... Bone defects of the lower extremities are among the most challenging pathologies to treat in orthopaedic surgery and represent a significant burden of disease for patients and the health care system. [1][2][3][4] There is a plethora of underlying causes of bone defects including primary bone loss following trauma and secondary bone loss following debridement after trauma or infection, nonunion, or oncologic resection. 1,3,4 The aim of bone defect treatment was to achieve consolidation and preserve or restore alignment to allow for weight-bearing in a timely manner. ...
... [1][2][3][4] There is a plethora of underlying causes of bone defects including primary bone loss following trauma and secondary bone loss following debridement after trauma or infection, nonunion, or oncologic resection. 1,3,4 The aim of bone defect treatment was to achieve consolidation and preserve or restore alignment to allow for weight-bearing in a timely manner. Besides eradication of any associated bone infection, 5 treatment options include primary shortening of the bone, 6,7 autologous spongiosa, 8,9 induced membrane procedure (Masquelet technique), 2,10-12 vascularized autograft of the fibula, 6,13,14 the use of bone graft substitutes, 15,16 and bone transport. ...
OBJECTIVES
The purposes of this study were to assess clinical and radiographic outcomes following Plate-assisted Bone Segment Transport (PABST) in large bone defects of the lower extremities.
METHODS
Design
Retrospective study of prospectively collected data.
Setting
Level-1 trauma center located in Germany.
Patient Selection Criteria
Patients who underwent PABST and were at least one year postoperatively were included.
Outcome Measures and Comparisons
Demographic data were collected. Radiographic apparent bone gap (RABG), time to consolidation, as well as time to full weight bearing and consolidation index were calculated. Numeric Rating Scale (NRS), Lower Extremity Functional Scale (LEFS), and complications were assessed.
RESULTS
Fifteen patients (13 male; mean age 51 years [range, 20-75]) underwent PABST and had follow-up at a mean of 29.1 months. The tibia was affected in 8 and the femur in 7 patients. Preoperative RABG was 60 mm (IQR: 40-125) and bone defects were caused by septic non-unions in 73%. Fourteen patients (93%) demonstrated consolidated transport callus at 7.3 months (95%CI: 6-8.5) and nine patients (60%) demonstrated complete consolidation of both docking site and transport callus at 11.5 months (95%CI: 7.3-15.3). Postoperative RABG was 0.1mm (IQR: 0-0.8), consolidation index was 1.9 months/cm (95%CI: 1.3-2.5). All patients achieved full weight-bearing at 8.7 months (IQR:6.5-10.3). LEFS was 42 (95%CI: 34-50) and NRS was 3 (95%CI: 2-4). Patients treated for tibial defects had a significantly higher consolidation rate compared to patients treated for femoral defects (p=.040).
CONCLUSIONS
PABST demonstrated high consolidation of transport callus with few complications. Although full weight-bearing was achieved in all patients, complete consolidation of the docking site was only present in 60% of cases.
Level of Evidence
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
... Проблема постала гостріше в Україні через активні військові дії, коли застосування високоенергетичної зброї серед постраждалих збільшило кількість осіб із переломами довгих кісток, ускладнених утворенням значних дефектів [1]. Саме сегментарні діафізарні дефекти довгих кісток критичного розміру, за визначенням, є нездатними до спонтанного загоєння й, отже, є показанням до хірургічного втручання [2]. ...
Polylactide (PLA) frameworks printed on a 3D printer are used for filling the bone defects. The osteotropic properties of 3D-PLA can be improved by combining with tricalcium phosphate (TCP) and mesenchymal stromal cells (MSCs). Objective. Study the reconstruction in the rat femurs after implanting 3D-printed implants based on PLA and TCP (3D-I) in combination with cultured allogeneic MSCs into defects in the distal metaphysis. Methods. 48 white laboratory rats (age 5–6 months) were used, which were randomly divided into groups: Control — 3D-I; Experiment-I — 3D-I, saturated MSCs; Experiment II — 3D-I, with injection of 0.1‒0.2 ml of medium with MSCs into the area of surgical intervention 7 days after implantation. 15, 30 and 90 days after the operation, histological (with histomorphometry) studies were conducted. Results. The area of 3D-I decreased with time in all groups and connective and bone tissues formed in different ratios. 15 days after the surgery, in the Experiment-I group, the area of the connective tissue was 1.9 and 1.6 times greater (p<0.001) in comparison to the Control and Experiment II; 30 days it was greater 1.6 times (p < 0.001) and 1.4 times (p=0.001), respectively. 30 days after the surgery, the area of newly formed bone in the Experiment-I group was 2.2 times (p < 0.001) less than in the Control. On the contrary, in the Experiment-II, the area of newly formed bone was 1.5 and 3.3 times greater (p < 0.001) compared to Experiment-I and Control, respectively. Conclusions. The studied 3D-I with time after their implantation into the metaphyseal defects of the rats’ femurs are replaced by connective and bone tissues. The use of 3D-I, saturated MSCs, 15 and 30 days after the surgery, caused excessive formation of connective tissue and slower bone formation. Local injection of MSCs 7 days after the implantation of 3D-I caused to the formation of a larger area of newly bone 30th day after surgery compared to 3D-I alone and 3D-I with MSCs.
... Крім того, алотрансплантати більш легкодоступні порівняно з аутотрансплантатами. У разі їх застосування скорочується термін перебування пацієнта в лікарні та знижується вартість оперативного втручання [7]. ...
The aim of the study: to evaluate the course of metabolic processes after replacing femoral metaphysis defects with allogeneic bone implants saturated with allogeneic mesenchymal stem cells (MSCs) based on the analysis of serum biochemical indicators of connective tissue metabolism in laboratory rats. Material and methods. A critical-sized transcortical femoral defect model in the femur metaphysis of white rats was used. Blood serum concentrations of glycoproteins, total chondroitin sulfates, total protein and calcium, alkaline and acid phosphatase activity were measured. Results. On the 28th day, in 3-month-old animals with MSC, in comparison with the data of rats without MSC, clear signs of connective tissue formation and bone resorption activity were observed, as evidenced by an increase in serum chondroitin sulfates and acid phosphatase activity. On the 90th day, this group of rats under the influence of MSCs showed signs of decreased bone tissue formation with lower serum activity of alkaline phosphatase. In 3-month-old rats with MSC, signs of the inflammatory process chronization with higher serum concentrations of glycoproteins were detected on the 90th day of the experiment in comparison with data from animals without MSC. In 12-month-old rats with MSCs, signs of bone resorption were documented on the 14th day, which were manifested by a higher serum activity of acid phosphatase with less formation of connective tissue and lower concentrations of chondroitin sulfates. On the 28th day, the effect of MSCs in 12-month-old animals was manifested in the form of a slowdown in bone formation with a decrease in alkaline phosphatase activity. On the 90th day, the connective tissue formation was activated with higher concentrations of chondroitin sulfates in these animals. Conclusions. The studied biochemical indicators in 3-month-old animals showed greater lability. The regeneration phases were faster in 3-month-old animals as well as in animals with alloimplants without MSCs. Injections of allogeneic MSCs together with an allograft immediately after a bone damage, regardless of age, caused signs of bone formation slowing and excessive formation of connective tissue, therefore, the combination of allogeneic MSCs with an allogeneic bone implant is not advisable to use in fresh fractures.
... Half of all orthopedic operations require bone grafting for the successful treatment of bone defects resulting from trauma, tumor, infection or congenital deformity [2]. Large diaphyseal defects of long bones of critical size are by definition considered incapable of spontaneous healing and, therefore, require surgical intervention [7]. Violation of consolidation is often associated with an imbalance of the Changes in markers of collagen metabolism in the blood serum of white rats during the filling of femur defects with implants based on polylactide and tricalcium phosphate with allogeneous mesenchymal stem cells ...
The use of synthetic materials in combination with osteogenesis stimulators is one of the advanced directions of the development of traumatology. The purpose of the study: based on the analysis of biochemical markers of collagen metabolism in the blood serum of laboratory rats with a femur defect, to evaluate the course of bone remodeling after filling the defect with implants based on polylactide and tricalcium phosphate with simultaneous and delayed administration of allogeneic mesenchymal stem cells (MSCs). On the model of a defect in the metaphysis of the femur in white rats, the indicators of collagen exchange in blood serum were studied: the content of protein-bound, free fractions, the amount of hydroxyproline (HOP), the ratio of the content of protein-bound HOP to free PB/F was calculated. Comparison of the results of different groups was performed using the Student-Fisher method. The difference was considered statistically significant if p<0.05. Filling the defect with implants led to a decrease in the content of protein-bound HOP by 16.69 % and 14.34 % on the 15th and 90th days (p<0.05), an increase in the content of free HOP by 74.96 %; 67.31 % and 56.74 % (p<0.001), the content of the amount of HOP by 25.37 %; 23.66 % and 18.28 % (p<0.05), and reduction of PB/F by 52.20 %; 49.90 % and 45.30 % (p<0.001) relative to intact on the 15th; 30th and 90th days. Addition of MSCs to the implants at the same time as the installation caused a decrease in the content of free HOP by 63.90 %; 54.63 % and 42.76 % on the 15th; on the 30th and 90th days (p<0.001), the total metabolite by 21.87 % and 18.58 % on the 15th and 30th days (p<0.05) and a decrease in PB/F by 47, 50 %; 43.20 %; 37.60 % on the 15th; on the 30th and 90th days (p<0.001) relative to the intact. Postponing the introduction of MSCs increased the content of free HOP by 40.48 % (p<0.001); 20.49 % and 16.58 % (p<0.05) with a lower PB/F by 38.20 %; 25.80 % and 23.40 % (p<0.05) on the 15th; 30th and 90th days relatively intact. When the defect was filled with implants without MSCs, a moderate inhibition of anabolism and rapid activation of collagen destruction was observed. With the simultaneous use of implants and MSCs, the rate of formation and intense destruction of collagen was observed. When the introduction of MSCs was delayed, a moderate rate of destruction was recorded, which most contributed to collagen metabolism.
... Since its introduction in the mid-1970s, the free fibula flap has been an extensively used flap for lower and upper extremity reconstruction when the bridging of long bone defects is required [3,4]. It is particularly useful for the reconstruction of weight-bearing bone due to its ability to remodel and hypertrophy in response to mechanical stress, and it shows comparable results in regards to primary union, complication, and reintervention rates when compared to alternative techniques, such as bone allo-and autografting, bone transport, and endoprosthesis, in a wide patient population [5][6][7]. While subjective donor site morbidity remains low following free fibula transfers, reautomatization and restoration of gait can still be incomplete [8][9][10][11]. ...
This case report focuses on a 17-year-old polytrauma patient who suffered a septic wound infection after an open reduction and internal fixation (ORIF) and soft tissue reconstruction with a pedicled flap, which led to a substantial bone and soft tissue defect of the lower leg. After thorough antibiotic treatment and after ensuring a non-septic wound, the defect was reconstructed using a contralateral free fibula flap designed as a flow through flap in a double loop manner to accommodate two fibular fragments and an ipsilateral ALT flap. Early weight bearing was initiated 11 days after the free flap transfer under external fixation, with full weight bearing achieved in 36 days with external fixation. After the removal of external fixation, full weight bearing was able to be reinitiated after 13 days, leading to the patient’s return to normal activity 6 months after the bony reconstruction. This case presents an innovative approach to treating a complex defect, with the final decision on using two separate free flaps instead of a single osteofasciocutaneous free flap resulting in a good bony reconstruction and soft tissue coverage, and with the use of external fixation enabling early rehabilitation.
... These patients presented with non-union, infected bone and soft tissue defects. The Illizarov technique effectively provides stability, smooth tissue coverage and bone transport (Feltri et al., 2022). In the current study, the cases with a history of unsuccessful flap operations or severe soft tissue injury radical resection were done to eradicate infection and create space to enable primary closure. ...
... Radical debridement resulted in primary closure in all patients. This study's results align with a previous study in which Illizarov method resulted in the infection-free union in cases with poor soft tissue coverage and long defect (Feltri et al., 2022). Another study shows that fractures of the femur and tibia Illizarov methods results in good functional outcome (Feltri et al., 2022). ...
... This study's results align with a previous study in which Illizarov method resulted in the infection-free union in cases with poor soft tissue coverage and long defect (Feltri et al., 2022). Another study shows that fractures of the femur and tibia Illizarov methods results in good functional outcome (Feltri et al., 2022). The mean bone defect in patients in our study was 13.07 ± 4.4 cm, and docking time was longer for the longer bone gap. ...
This study was designed to assess the outcome of the illizarov method for treating patients with dead bone segments or open fractures along with severe soft tissue injury. This retrospective study was conducted at Bakhtawar Ameen Trust Hospital, Multan, from September 2019 to September 2022. A total of 35 patients having non-union tibial fractures and dead bone segments were included in the study. These patients had tibia grade 3 open fractures and had undergone bone grafting and soft tissue closure. The defective bone segment was debrided, and radical resection was done. Illizarov technique was performed on all subjects. All patients reported good smooth tissue coverage and bone transport. The mean docking period of bone transport in all subjects was 3.87 ± 0.45 months. A leg length discrepancy of 1 cm occurred in 4 subjects. No subject complained of pain at follow-up. The Illizarov method is effective for the management of bone and soft tissue injuries.
The aim of this narrative review is to describe the various surgical management strategies employed in fracture-related infection (FRI), to explore how they are selected and discuss the rationale for early surgical intervention. Surgical treatment options in patients with FRI include debridement, antibiotics and implant retention (DAIR), revision (exchange) or removal. In selecting a treatment strategy, a variety of factors need to be considered, including the condition of the bone, soft tissues, host and causative microorganism. Irrespective of the selected treatment strategy, prompt surgical intervention should be considered in order to confirm the diagnosis of an FRI, to identify the causative organism, remove necrotic or non-viable tissue that can serve as a nidus for ongoing infection, ensure a healthy soft tissue envelope and to prevent the vicious cycle of infection associated with skeletal and/or implant instability. Ultimately, the objective is to prevent the establishment of a persistent infection. Urgent surgery may be indicated in case of active, progressive disease with systemic deterioration, local progression of infection, deterioration of soft tissues, or progressive fracture instability. In case of static disease, the patient should be monitored closely and surgery can be performed on an elective basis, allowing adequate time for optimisation of the host through risk factor modification, optimisation of the soft tissues and careful planning of the surgery.
Introduction
Bone is considered a tissue with good healing properties, and many bone defects can heal spontaneously under appropriate conditions. Extreme bone loss can hinder remodeling and regenerative processes, leading to bone nonunion. This condition negatively impacts the patient's quality of life with a severe socioeconomic burden. Many treatment options have been proposed, but none can be defined as a gold standard, mainly due to the variety of clinical presentation, bone loss, and quality.
Presentation of case
We present a 15-year-old case of tibial nonunion following multiple traumas. The patient was treated non-surgically at the beginning, but the external fixator positioning was required due to a delay in the healing process. Following further trauma, the patient showed progressive anterolateral angulation, severe lateral procurvation, and a progressive worsening of the pseudoarthrosis. The severe bone loss and poor quality of the bone surrounding the defect required a special technique called Huntington procedure that consists in a vascularized bone autograft from the ipsilateral fibula to achieve mechanical and biological healing of the pseudoarthrosis. The patient recovered well and returned to full weight bearing without a mobility aid.
Discussion
We report this case of complex tibial nonunion and malalignment, developed after subsequent traumas. Due to the multiple complications, and the poor biology a Huntington procedure was required to provide mechanical stability and a biological boost to the bone defect.
Conclusion
This case report shows a complicated case requiring several surgeries and treatment options and confirms the potential benefit of the Huntington procedure for treating a tibial severe bone loss.
Introduction
The management of gap non-union is a major challenge to both the clinician and the patient as it is technically difficult, time-intensive, and physically arduous for the patient along with an unpredictable result. Gap non-union can arise from extrusion of bony fragment at the time of trauma or after debridement of unhealthy bone later. Moreover, Tibia because of its subcutaneous anatomy can easily undergo bone-loss and segmental defect. Among various methods available for managing gap non-union of tibia distraction osteogenesis using either ilizarov fixator or mono-rail fixator is the most popular one. Here we present functional and bony outcomes of combined use of locking plate and Limb Reconstruction System (LRS) in tibial gap non-union and assess whether it decreases fixator time and related complications.
Patients and methods
A prospective intervention study constituting 10 patients with Paley's type B1 tibial gap non-union over a period of 22months. In first stage, debridement was done; tibial locking plate and mono-rail fixator were applied along with corticomy at proximal tibia. Distraction was started 7–14 days later. At the end of distraction phase, fixator was removed and transported segment was fixed with screws with or without bone grafting at docking site. Patients were followed up every 6 weeks for radiological and clinical assessment. Functional assessment using Application for the Study and Application of the Method of Ilizarov (ASAMI) functional score, and Musculoskeletal Tumour Society (MSTS) functional score while bone outcome was assessed with ASAMI bone score. Quality of regenerate was assessed by Fernandez-Esteve grading. Detailed scoring was done at the time of index surgery, at the time of LRS removal and at the time of consolidation phase.
Results
All the 10 patients were male with mean age of 33 years. The mean defect size was 4.94 cm after debridement. Minimum duration of follow up was 30 weeks after removal of LRS. Mean duration between trauma and inclusion in the study was 17.7 months. The median external fixator index was 15.63 days/cm. The complication rate was 1.3/patient. According to Paley's classification, there were eleven problems and two obstacles, and no true complications. Both ASAMI bone score and functional scores were excellent in three and good in six patients. The median MSTS composite score was 76.66%.
Conclusion
The integrated fixation is an effective and satisfactory method enabling early external fixator removal with low rate of complication. So, this technique can be recommended for the management of segmental tibial defects.
Level of evidence
II.
