Reconstruction of Long Segmental Tibial Bone Defect Using the Bone Transport Compared to Acute Shortening and Re-lengthening : A Retrospective Study

Background: Ilizarov technique has been widely used to salvage bone defects. However, treating large bone defects remains a challenge for surgeons. The aim of this study was to compare bone transport with acute shortening/re-lengthening in a series of large tibial segmental defects.Method: A total of 39 patients (29 males, 10 females) with large tibial segmental defects were treated with the Ilizarov technique (Group A: bone transport in 23 cases; Group B: acute shortening/re-lengthening 16 in cases) from March 2010 to December 2018. The mean age was 38.7 years (range24 years to 55 years). The average bone defect size was 8.82 cm (range from 6 cm to 12 cm). The demographic data, operation duration, docking time, external fixation time, and external fixation index were retrospectively documented and analyzed. Complications that occur during the treatment were classified. The clinical outcomes were evaluated by the Association for the Study and Application of the Method of Ilizarov criteria (ASAMI) at the last clinical visit.Result: There were no statistically significant differences (P>0.05) in the demographic data of the two groups. There was no significant difference in operation duration between the two groups. The docking time in group A was longer than that in group B (93.26±19.52 days, 58.44±14.23 days, P<0.001). No statistical significance was obversed for the external fixation time in the two groups (330.87±88.52 days in group A, 321.25±56.67 days in group B,P=0.704). A higher external fixation index was presented in group A (38.32±5.39 days/cm) than group B (35.17±2.14 days/cm) (P=0.033). There was no significant difference between the two groups in ASAMI bone results and functional results (Table 4). Complications were more prevalent in group A (28 complications of 23 patients), while less in group B (7 complications of 16 patients) (P<0.05).Conclusion: Both bone transport and acute shortening/re-lengthening technique can achieve satisfactory clinical outcomes in the reconstruction of long segmental tibial bone defect caused by infection using a monolateral rail external fixator. The acute shortening/re-lengthening can significantly decrease the docking time, external fixation index, and complications compared with bone transport.

GUNSHOT INDUCED HUMERUS FRACTURE TREATED USING THE MASQUELET TECHNIQUE

Humerus fractures secondary to gunshot injury are slow to unite and may require multiple surgeries to obtain union. 1We report a gunshot induced humerus fracture treated via the Masquelet technique. Report: A 27-year old gentleman had a shotgun injury to his left arm exposing the humerus bone. He underwent debridement and external fixator and a 4cm segmental bone loss was noted. The following debridement, a humeral nail and 3cm acute shortening was done, as well as the 1st stage Masquelet (Figure 1). After 6 weeks, the 2nd stage Masquelet was performed (Figure 2). At 1 year follow up, radiographical union was noted (Figure 3). [Figure: see text][Figure: see text][Figure: see text] Discussion: Masquelet technique consists of cement spacer insertion which is then exchanged with autologous cancellous bone graft packed into an induced membrane. 2To our knowledge, there have not been reported cases of Masquelet technique used to treat shotgun induced open humerus fractures. The use of an external fixator is proposed by many authors1. The key to success is a thorough debridement of the fracture3. Conclusion: The Masquelet technique is a reliable tool in the surgeon’s armamentarium in the management of humeral segmental bone defects2. Reference: Management of shotgun induced open fractures of the humerus with Ilizarov fixator;2015 The Masquelet Technique for Thumb Metacarpal Reconstruction Following Trauma ; JBJS; 2018 Muscle reconstruction in reconstructive surgery: soft tissue repair and long bone reconstruction; 2003

Bone transport versus acute shortening for the management of infected tibial bone defects: a meta-analysis

Background: The treatment for infected tibial bone defects can be a great challenge for the orthopaedic surgeon. This meta-analysis was conducted to compare the safety and efficacy between bone transport (BT) and the acute shortening technique (AST) in the treatment of infected tibial bone defects. Methods: A literature survey was conducted by searching the PubMed, Web of Science, Cochrane Library, and Embase databases together with the China National Knowledge Infrastructure (CNKI) and the Wanfang database for articles published up to 9 August 2019. The modified Newcastle-Ottawa scale (NOS) was adapted to evaluate the bias and risks in each eligible study. The data of the external fixation index (EFI), bone grafting, bone and functional results, complications, bone union time and characteristics of participants were extracted. RevMan v.5.3 was used to perform relevant statistical analyses. Standard mean difference (SMD) was used for continuous variables and relative risk (RR) for the binary variables. All of the variables included its 95% confidence interval (CI). Results: Five studies, including a total of 199 patients, were included in the study. Statistical significance was observed in the EFI (SMD = 0.63, 95% CI: 0.25, 1.01, P = 0.001) and bone grafting (RR = 0.26, 95%CI: 0.15, 0.46, P <0.00001); however, no significance was observed in bone union time (SMD = –0.02, 95% CI: –0.39, 0.35, P = 0.92), bone results (RR = 0.97, 95% CI: 0.91, 1.04, P = 0.41), functional results (RR = 0.96, 95% CI: 0.86, 1.08, P = 0.50) and complications (RR = 0.76, 95% CI: 0.41, 1.39, P = 0.37). Conclusions: AST is preferred from the aspect of minimising the treatment period, whereas BT is superior to AST for reducing bone grafting. Due to the limited number of trials, the meaning of this conclusion should be taken with caution for infected tibial bone defects.

Bone transport versus acute shortening for the management of infected tibial bone defects: A meta-analysis

Background: The treatment for infected tibial bone defects can be a great challenge for the orthopaedic surgeon. This meta-analysis was conducted to compare the efficacy and safety between bone transport (BT) and the acute shortening technique (AST) in the treatment of infected tibial bone defects.Methods: A literature survey was conducted by searching the PubMed, Web of Science, Cochrane Library, and Embase databases together with the China National Knowledge Infrastructure (CNKI) and the Wanfang database for articles published up to 9 August 2019. The Newcastle-Ottawa scale (NOS) was adapted to evaluate the bias and risks in each eligible study. The data of the external fixation index (EFI), bone grafting, bone and functional results, complications, bone union time and characteristics of participants were extracted. RevMan v.5.3 was used to perform relevant statistical analyses. Relative risk (RR) was used for the binary variables and standard mean difference (SMD) for continuous variables. Each variable included its 95% confidence interval (CI).Results: Five studies, including a total of 199 patients, were included in the meta-analysis. Statistical significance was observed in the EFI (SMD = 0.63, 95% CI: 0.25, 1.01, P = 0.001) and bone grafting (RR = 0.26, 95%CI: 0.15, 0.46, P <0.00001); however, no significance was observed in bone union time (SMD = –0.02, 95% CI: –0.39, 0.35, P = 0.92), bone results (RR = 0.97, 95% CI: 0.91, 1.04, P = 0.41), functional results (RR = 0.96, 95% CI: 0.86, 1.08, P = 0.50) and complications (RR = 0.76, 95% CI: 0.41, 1.39, P = 0.37).Conclusions: AST is preferred from the aspect of minimising the treatment period, whereas BT is superior to AST for reducing bone grafting. Due to the limited number of trials, the meaning of this conclusion should be taken with caution for infected tibial bone defects.Trial registration: PROSPERO CRD42019133659

Comparison of Ilizarov Bifocal, Acute Shortening and Relengthening with Bone Transport in the Treatment of Infected, Segmental Defects of the Tibia

This prospective study compared bifocal acute shortening and relengthening (ASR) with bone transport (BT) in a consecutive series of complex tibial infected non-unions and osteomyelitis, for the reconstruction of segmental defects created at the surgical resection of the infection. Patients with an infected tibial segmental defect (>2 cm) were eligible for inclusion. Patients were allocated to ASR or BT, using a standardized protocol, depending on defect size, the condition of soft tissues and the state of the fibula (intact or divided). We recorded the Weber–Cech classification, previous operations, external fixation time, external fixation index (EFI), follow-up duration, time to union, ASAMI bone and functional scores and complications. A total of 47 patients (ASR: 20 patients, BT: 27 patients) with a median follow-up of 37.9 months (range 16–128) were included. In the ASR group, the mean bone defect size measured 4.0 cm, and the mean frame time was 8.8 months. In the BT group, the mean bone defect size measured 5.9cm, and the mean frame time was 10.3 months. There was no statistically significant difference in the EFI between ASR and BT (2.0 and 1.8 months/cm, respectively) (p = 0.223). A total of 3/20 patients of the ASR and 15/27 of the BT group needed further unplanned surgery during Ilizarov treatment (p = 0.006). Docking site surgery was significantly more frequent in BT; 66.7%, versus ASL; 5.0% (p < 0.0001). The infection eradication rate was 100% in both groups at final follow-up. Final ASAMI functional rating scores and bone scores were similar in both groups. Segmental resection with the Ilizarov method is effective and safe for reconstruction of infected tibial defects, allowing the eradication of infection and high union rates. However, BT demonstrated a higher rate of unplanned surgeries, especially docking site revisions. Acute shortening and relengthening does not reduce the fixator index. Both techniques deliver good functional outcome after completion of treatment.

Bone transport versus acute shortening for the management of infected tibial bone defects: a meta-analysis

Background The treatment for infected tibial bone defects can be a great challenge for the orthopaedic surgeon. This meta-analysis was conducted to compare the efficacy and safety between bone transport (BT) and acute shortening technique (AST) in the treatment of infected tibial bone defects.Materials and Methods A literature survey was conducted by searching the PubMed, Web of Science, Cochrane Library, Embase together with China National Knowledge Infrastructure (CNKI), and Wanfang database for articles published as of August 9, 2019. NOS (Newcastle-Ottawa scale) and Cochrane's risk of bias tool were adapted to evaluated the bias and risk of each eligible study. The data of external fixation index (EFI), bone grafting, bone and functional results, complications, bone union time and characteristics of participants were extracted. RevMan V.5.3 was used to perform relevant statistical analyses. Relative risk (RR) were used for the binary variables and standard mean difference (SMD) for continuous variable. Each variable included its 95% confidence interval (CI).Results 5 studies, including a total of 199 patients, were included in the meta-analysis. Statistical significance was observed in EFI (SMD = 0.63,95% CI:0.25,1.01,P=0.001) and Bone grafting (RR = 0.26,95%CI:0.15,0.46,P<0.00001), however, no significance was observed in bone union time (SMD = -0.02, 95% CI: -0.39, 0.35, P=0.92), bone results (RR = 0.97,95%CI:0.91,1.04,P=0.41),functional results (RR = 0.96,95%CI:0.86,1.08,P=0.50) and complication (RR = 0.76,95%CI:0.41,1.39,P=0.37).Conclusions AST is preferred on the aspect of minimizing treatment period, while BT is superior to AST for reducing bone grafting. Due to the limited number of trials, The meaning of this conclusion should be taken with caution for infected tibial bone defects.