учреждение «Российский научный центр "Восстановительная травматология и ортопедия" им. акад. Г.А. Илизарова» Министерства здравоохранения Российской Федерации, г. Курган, Россия; 2 Федеральное государственное бюджетное образовательное учреждение высшего образования «Тюменский государственный медицинский университет» Министерства здравоохранения Российской Федерации, г. Тюмень, Россия Combined bone plasty interventions for rehabilitation of patients with congenital pseudarthrosis of the tibia

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BACKGROUND The Ilizarov bone transport (IBT) and the Masquelet induced membrane technique (IMT) have specific merits and shortcomings, but numerous studies have shown their efficacy in the management of extensive long-bone defects of various etiologies, including congenital deficiencies. Combining their strong benefits seems a promising strategy to enhance bone regeneration and reduce the risk of refractures in the management of post-traumatic and congenital defects and nonunion that failed to respond to other treatments. AIM To combine IBT and IMT for the management of severe tibial defects and pseudarthrosis, and present preliminary results of this technological solution. METHODS Seven adults with post-traumatic tibial defects (subgroup A) and nine children (subgroup B) with congenital pseudarthrosis of the tibia (CPT) were treated with the combination of IMT and IBT after the failure of previous treatments. The mean number of previous surgeries was 2.0 ± 0.2 in subgroup A and 3.3 ± 0.7 in subgroup B. Step 1 included Ilizarov frame placement and spacer introduction into the defect to generate the induced membrane which remained in the interfragmental gap after spacer removal. Step 2 was an osteotomy and bone transport of the fragment through the tunnel in the induced membrane, its compression and docking for consolidation without grafting. The outcomes were retrospectively studied after a mean follow-up of 20.8 ± 2.7 mo in subgroup A and 25.3 ± 2.3 mo in subgroup B. RESULTS The “true defect” after resection was 13.3 ± 1.7% in subgroup A and 31.0 ± 3.0% in subgroup B relative to the contralateral limb. Upon completion of treatment, defects were filled by 75.4 ± 10.6% and 34.6 ± 4.2%, respectively. Total duration of external fixation was 397 ± 9.2 and 270.1 ± 16.3 d, including spacer retention time of 42.4 ± 4.5 and 55.8 ± 6.6 d, in subgroups A and B, respectively. Bone infection was not observed. Postoperative complications were several cases of pin-tract infection and regenerate deformity in both subgroups. Ischemic regeneration was observed in two cases of subgroup B. Complications were corrected during the course of treatment. Bone union was achieved in all patients of subgroup A and in seven patients of subgroup B. One non-united CPT case was further treated with the Ilizarov compression method only and achieved union. After a follow-up period of two to three years, refractures occurred in four cases of united CPT. CONCLUSION The combination of IMT and IBT provides good outcomes in post-traumatic tibial defects after previous treatment failure but external fixation is longer due to spacer retention. Refractures may occur in severe CPT.

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Introduction The Masquelet induced membrane technique is effective in the management of acquired heterogeneous long bone defects and pseudarthrosis. The combination of the Masquelet technology and Ilizarov non-free bone grafting seems promising and reduces the risks of recurrence at long-term in patients with congenital pseudarthrosis. Purpose Presentation of new technological solutions that allow combining the advantages of the Ilizarov bone transport and Masquelet bone grafting in patients with acquired bone defects. Materials and methods Retrospective assessment of the results of bone reconstruction in 10 patients who were treated by a combination of Ilizarov and Masquelet bone grafting technologies to repair long bone defects after failures of previous treatment. Fragments of the biomembrane formed around the cement spacer temporarily replacing the tibial gap after resection bone defect or pseudarthrosis were examined in all patients. The studies were carried out using a Reichard sledge microtome, an AxioScope stereomicroscope and an AxioCam ICc 5 digital camera, a JSM- 840 scanning electron microscope and an INCA-200 Energy X-ray electron probe microanalyzer. Results and discussion The combined Masquelet technique and Ilizarov non-free bone plasty provide the conditions that are favorable for reparative processes of the transported fragments. After removal of the spacer, there is a tunnel formed in the interfragmental gap, the walls of which are made of the induced membrane. Bone transport is carried out without technical problems through the compromised tissues which are debrided at the time of distraction initiation, outside the scars. At the same time, there are low risks of inflammation around the transosseous elements; there is no danger of cutting and perforation of soft tissues by transported fragments. Conclusions Complete organotypic rearrangement of the distraction regenerate with the use of Ilizarov non-free bone plasty and the Masquelet technique excludes the possibility of deformities or fractures at the level of newly formed bone areas. Active distraction histogenesis ensures the closure of soft tissue defects without additional reconstructive plastic interventions. The revealed dependence of the induced membrane blood supply on the method of treatment previously used might be a criterion for predicting the treatment outcome in patients with acquired bone defects and pseudarthrosis.