Management of post-traumatic bone defects of the tibia using vascularised fibular graft combined with Ilizarov external fixator

Semaya, Ahmad El-Sayed; Badawy, Ehab; Hasan, Mohammad; El-Nakeeb, Ramy Mohammad

doi:10.1016/j.injury.2016.01.033

Cited by 19 publications

(8 citation statements)

References 27 publications

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“…Bone transport technique345678 with its variations of technique and hardware is the established method. The alternative is to use the induced membrane technique described by Masquelet et al .,3738394041 and fill up the gap with the help of vascularized bone grafts4243 and/or substitutes 4445…”

Section: Reconstruction Of Bony Defect and Gapmentioning

confidence: 99%

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Infected nonunion of tibia

Chaudhary¹

2017

IJOO

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Infected nonunions of tibia pose many challenges to the treating surgeon and the patient. Challenges include recalcitrant infection, complex deformities, sclerotic bone ends, large bone gaps, shortening, and joint stiffness. They are easy to diagnose and difficult to treat. The ASAMI classification helps decide treatment. The nonunion severity score proposed by Calori measures many parameters to give a prognosis. The infection severity score uses simple clinical signs to grade severity of infection. This determines number of surgeries and allows choice of hardware, either external or internal for definitive treatment. Co-morbid factors such as smoking, diabetes, nonsteroidal anti-inflammatory drug use, and hypovitaminosis D influence the choice and duration of treatment. Thorough debridement is the mainstay of treatment. Removal of all necrotic bone and soft tissue is needed. Care is exercised in shaping bone ends. Internal fixation can help achieve union if infection was mild. Severe infections need external fixation use in a second stage. Compression at nonunion site achieves union. It can be combined with a corticotomy lengthening at a distant site for equalization. Soft tissue deficit has to be covered by flaps, either local or microvascular. Bone gaps are best filled with the reliable technique of bone transport. Regenerate bone may be formed proximally, distally, or at both sites. Acute compression can fill bone gaps and may need a fibular resection. Gradual reduction of bone gap happens with bone transport, without need for fibulectomy. When bone ends dock, union may be achieved by vertical or horizontal compression. Biological stimulus from iliac crest bone grafts, bone marrow aspirate injections, and platelet concentrates hasten union. Bone graft substitutes add volume to graft and help fill defects. Addition of rh-BMP-7 may help in healing albeit at a much higher cost. Regeneration may need stimulation and augmentation. Induced membrane technique is an alternative to bone transport to fill gaps. It needs large amounts of bone graft from iliac crest or femoral canal. This is an expensive method physiologically and economically. Infection can resorb the graft and cause failure of treatment. It can be done in select cases after thorough eradication of infection. Patience and perseverance are needed for successful resolution of infection and achieving union.

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Section: Reconstruction Of Bony Defect and Gapmentioning

confidence: 99%

“…Infection and anastomotic failure could result in significant morbidity. Combining the free vascularized fibula with the Ilizarov fixator combines benefits of both methods to fill up gaps in infected nonunions 4243…”

Section: Free Vascularized Fibular Graftmentioning

confidence: 99%

Infected nonunion of tibia

Chaudhary¹

2017

IJOO

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“…Nonetheless, great progress has been achieved in the treatment of severe composite tibial bone and soft tissue defects. e following methods can be combined or adopted alone in clinical practice: flap surgery, free vascularized bone graft (fibula [5,6], ilium [7]), bone transport (Ilizarov technique) [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22], Masquelet technique [11], simple bone graft after wound closure [23], and Papineau technique for open bone graft [24]. Among them, bone transport has become the primary method to treat large bone defects owing its success to improved external fixators, more precise surgical procedures, and new insights into "autologous bone tissue engineering technology" and "regenerative medicine.…”

Section: Introductionmentioning

confidence: 99%

Bone Transport for Treatment of Traumatic Composite Tibial Bone and Soft Tissue Defects: Any Specific Needs besides the Ilizarov Technique?

Zhu

Chen

et al. 2020

BioMed Research International

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Objective. To evaluate the surgical efficacy of bone transport (Ilizarov technique) plus “shortening-lengthening,” “flap surgery,” and “open bone transport” as individualized treatments for traumatic composite tibial bone and soft tissue defects. Methods. We retrospectively analyzed sixty-eight cases (mean age: 35.69 years, (range, 16–65)) treated from July 2014 to June 2017, including 29 middle, 18 distal, and 21 proximal tibial bone defects (4–18 cm, mean: 7.97 cm) with soft tissue defects (2.5 cm × 4.0 cm to 30.0 cm × 35.0 cm after debridement). We adopted the bone transport external fixator to fix the fracture after debriding the defect parts. In the meantime, we adopted the “shortening-lengthening technique,” “flap surgery,” and “open bone transport” as individualized treatment based on the location, range, and severity of the composite tibial bone and soft tissue defects. Postoperative follow-up was carried out. Surgical efficacy was assessed based on (1) wound healing; (2) bone defect healing rate; (3) external fixation time and index; (4) incidence/recurrence of deep infection; (5) postoperative complications; and (6) Association for the Study and Application of the Methods of Ilizarov (ASAMI) score. Results. The mean duration from injury to reconstruction was 22 days (4–80 d), and the mean postoperative follow-up period was 30.8 months (18–54 m). After the repair and reconstruction, 2 open bone transport patients required infected bone removal first before continuing the bone transport treatment. No deep infection (osteomyelitis) occurred or recurred in the remaining patients, and no secondary debridement was required. Some patients had complications after surgery. All the postoperative complications, including flap venous crisis, nail channel reaction, bone nonunion, mechanical axis deviation, and refracture, were improved or alleviated. External fixation time was 12.5 ± 3.41 months, and the index was 1.63 ± 0.44. According to the ASAMI score, 76.47% of the outcomes were good/excellent. Conclusion. The Ilizarov technique yields satisfactory efficacy for composite tibial bone and soft tissue defects when combined with “shortening-lengthening technique,” “flap surgery,” and “open bone transport” with appropriate individualized treatment strategies.

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“…Indeed, multiple techniques are often required in combination for specific cases. For example, Semaya et al [28] treated 40 patients with tibial bone defects using combined FVFG and IBT to achieve high clinical efficacy as indicated by the average recovery time of 7.3 months (range, 6-12 months) until unprotected full weight-bearing. fractures of the right tibia and fibula (Gustilo grade II) due to a traffic accident underwent emergency debridement and internal fixation in a local hospital for half a year.…”

Section: Discussionmentioning

confidence: 99%

Treatment options for infected bone defects in the lower extremities: free vascularized fibular graft or Ilizarov bone transport?

Ren

et al. 2020

J Orthop Surg Res

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Objective The objective was to explore the relative indications of free vascularized fibular graft (FVFG) and Ilizarov bone transport (IBT) in the treatment of infected bone defects of lower extremities via comparative analysis on the clinical characteristics and efficacies. Methods The clinical data of 66 cases with post-traumatic infected bone defects of the lower extremities who underwent FVFG (n = 23) or IBT (n = 43) from July 2014 to June 2018 were retrieved and retrospectively analyzed. Clinical characteristics, operation time, and intraoperative blood loss were statistically compared between two groups. Specifically, the clinical efficacies of two methods were statistically evaluated according to the external fixation time/index, recurrence rate of deep infection, incidence of complications, the times of reoperation, and final functional score of the affected extremities. Results Gender, age, cause of injury, Gustilo grade of initial injury, proportion of complicated injuries in other parts of the affected extremities, and numbers of femoral/tibial defect cases did not differ significantly between treatment groups, while infection site distribution after debridement (shaft/metaphysis) differed moderately, with metaphysis infection little more frequent in the FVFG group (P = 0.068). Femoral/tibial defect length was longer in the FVFG group (9.96 ± 2.27 vs. 8.74 ± 2.52 cm, P = 0.014). More patients in the FVFG group presented with moderate or complex wounds with soft-tissue defects. FVFG treatment required a longer surgical time (6.60 ± 1.34 vs. 3.12 ± 0.99 h) and resulted in greater intraoperative blood loss (873.91 ± 183.94 vs. 386.08 ± 131.98 ml; both P < 0.05) than the IBT group, while average follow-up time, recurrence rate of postoperative osteomyelitis, degree of bony union, and final functional scores did not differ between treatment groups. However, FVFG required a shorter external fixation time (7.04 ± 1.72 vs. 13.16 ± 2.92 months), yielded a lower external fixation index (0.73 ± 0.28 vs. 1.55 ± 0.28), and resulted in a lower incidence of postoperative complications (0.87 ± 0.76 vs. 2.21±1.78, times/case, P < 0.05). The times of reoperation in the two groups did not differ (0.78 ± 0.60 vs. 0.98 ± 0.99 times/case, P = 0.615). Conclusion Both FVFG and IBT are effective methods for repairing and reconstructing infected bone defects of the lower extremities, with unique advantages and limitations. Generally, FVFG is recommended for patients with soft tissue defects, bone defects adjacent to joints, large bone defects (particularly monocortical defects), and those who can tolerate microsurgery.

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Management of post-traumatic bone defects of the tibia using vascularised fibular graft combined with Ilizarov external fixator

Cited by 19 publications

References 27 publications

Infected nonunion of tibia

Infected nonunion of tibia

Bone Transport for Treatment of Traumatic Composite Tibial Bone and Soft Tissue Defects: Any Specific Needs besides the Ilizarov Technique?

Treatment options for infected bone defects in the lower extremities: free vascularized fibular graft or Ilizarov bone transport?

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