A NEW 2 STAGE PROCEDURE FOR SEVERE BONE TIBIAL DEFECT USING INTRAMEDULLARY NAILING

Abstract

Introduction: diaphyseal bone defect is one of the most difficult challenge in Orthopaedic and Traumatologic Surgery. One of the techniques for reconstruction of bone defect described by Masquelet is a two-stage procedure: induction of a membrane around a ciment spacer and autologous cancellous bone graft with external fixator. The aim of the study is to evaluate a modified technique with intramedullary nailing for tibial bone defect.

Materials and Methods: between 2001 and 2006, 13 patients presented important tibial bone defect. On radiological examination, the mean size was 18,5 cm³ (12–30 cm³). Initially, there were 12 opened fractures (1 Gustilo 1, 2 Gustilo II, 9 fractures Gustilo III), and one osteomyelitis following a compartment syndrome. The mean age of the patients at the procedure was 41 years old (18–74). Our modified technique was as follows:

1. several debridment and stabilization of bone fragments with a temporary external fixator

2. first stage: removal of external fixator, intramedullary nailing, and filling of the bone defect with gentamycin cement spacer

3. Local or free muscular fiap to cover the soft tissue defect

4. second stage: removal of the spacer and placing autologous cancellous bone graft inside the induced membrane at 3 months.

10 patients had hyperbare oxygenotherapy. All patients were evaluated radiographically and by physical examination. using SF-36 questionnary.

Results: There was no amputation but 4 complications. There were 3 deep infections: one just between the 2 stages and one 2 years after the second stage: both were treated by nail exchange and adapted intra-venous anti-biotherapy. The third one was the complete bone graft resorption because of an infection just after the second stage (the only failure of the method). The fourth complication is the nonunion 13 months after the second stage: nails has broken and has been changed. Bone healing was obtained in 12 patients at mean follow-up was 32 months (12–69). They were able to walk 4,3 months after bone grafting. 8 patients answered to the SF-36 questionnary: overall function was limited with a mean score of 99.8.

Discussion: and conclusion: Our modified technique gave satisfactory results at medium term. Nailing, comparing to external fixator, offers a better stabilization of bone fragments, better control of axis and length of lower limb, and an easier access for plastic surgery and nurse care. Others bone reconstruction treatment like ilizarov bone transport, free vascularized fibula fiap or allograft are still possible if failure. However, the rate of deep infections are quite high (4/13) may be questionable. Sacrifice of intramedullary blood supply and the difficulties to confirm union on radiological exams are still problematics.