Aims. Many authors have reported a shorter treatment time when using trifocal bone transport (TFT) rather than bifocal bone transport (BFT) in the management of long segmental tibial bone defects. However, the difference in the incidence of additional procedures, the true complications, and the final results have not been investigated. Patients and Methods. A total of 86 consecutive patients with a long tibial bone defect (≥ 8 cm), who were treated between January 2008 and January 2015, were retrospectively reviewed. A total of 45 were treated by BFT and 41 by TFT. The median age of the 45 patients in the BFT group was 43 years (interquartile range (IQR) 23 to 54). Results. The size of the bone defect was significantly longer (p = 0.005), the number of previous operations was significantly higher (p < 0.001), the operating time was significantly longer (p < 0.001), and the bone transport distance was significantly increased (p = 0.017) in the TFT group. However, the external fixation time (p < 0.001), the healing index (p < 0.001), the number of additional procedures (p = 0.013), and the number of true complications (p < 0.001) were significantly reduced in this group. Both groups achieved highly satisfactory bone and functional results. Conclusion. TFT can significantly reduce the treatment time, the number of additional surgical procedures, and true complications compared with BFT in the treatment of long segmental tibial bone defects

Introduction. We demonstrate the preliminary results with a novel technique to solve large bone defects using two lengthening nails, working together and aligned in a custom made device. An illustrative case that successfully produced 17 cm bone in 3.5 months, is presented. Materials and Methods. A 28 year old healthy male presented with a slowly growing mass in the left femur. No general symptoms were reported, no weight loss, no previous illness. Histopathology, CT and MRI scans revealed a malignant diaphyseal bone tumor. A three-stage trifocal bone transport was projected and conducted based on a 3D model test. Results. Trifocal bone transport using two lengthening nails in a custom made device, reduced the 17 cm bone defect in 3.5 months. Follow up was 9 months. Conclusions. The presented technique successfully solved the clinical problem and is a showcase for further developments of internal devices for complex and large bone losses and lengthenings

Background. Acute anterior dislocation of the glenohumeral joint may be complicated by injury to neighboring structures. These injuries are best considered a spectrum of injury ranging from an isolated dislocation (unifocal injury), through injuries associated with either nerve or osteoligamentous injury (bifocal injury), to injuries where there is evidence of both nerve and osteoligamentous injury. The latter combination has previously been described as the “terrible triad,” although we prefer the term “trifocal,” recognizing that this is the more severe end of an injury spectrum and avoiding confusion with the terrible triad of the elbow. We evaluated the prevalence and risk factors for nerve and osteoligamentous injuries associated with an acute anterior glenohumeral dislocation in a large consecutive series of patients treated in our Unit. Materials and Methods. 3626 consecutive adults (mean age 48yrs) with primary traumatic anterior shoulder dislocation treated at our unit were included. All patients were interviewed and examined by an orthopaedic trauma surgeon and underwent radiological assessment within a week of injury. Where rotator cuff injury or radiologically-occult greater tuberosity fracture was suspected, urgent ultrasonography was used. Deficits in neurovascular function were assessed clinically, with electrophysiological testing reserved for equivocal cases. Results. Unifocal injuries occurred in 2228 (61.4%) of patients. There was a bimodal distribution in the prevalence of these injuries, with peaks in the 20–29 age cohort (34.4% patients) and after the age of 60 years (23.0% patients). Of the 1120 (30.9%) patients with bifocal dislocations, 920 (82.1%) patients had an associated osteotendinous injury and 200 (17.9%) patients had an associated nerve injury. Trifocal injuries occurred in 278 (7.7%) of cases. In bifocal and trifocal injuries, rotator cuff tears and fractures of the greater tuberosity or glenoid were the most frequent osteotendinous injuries. The axillary nerve was most frequently injured neurological structure. We were unable to elicit any significant statistical differences between bifocal and trifocal injuries with regards to patient demographics. However, when compared with unifocal injuries, bifocal or trifocal injuries were more likely to occur in older, female patients resulting from low energy falls (p<0.05). Conclusions. We present the largest series reporting the epidemiology of injury patterns related to traumatic anterior shoulder dislocation. Increased understanding and awareness of these injuries among clinicians will improve diagnosis and facilitate appropriate treatment

Introduction. Hallux valgus deformity is a common potentially painful condition. Over 150 orthopaedic procedures have been described to treat hallux valgus and the indication for surgery is pain intractable to nonoperative management. Methods. A retrospective analysis of the treatment of complex hallux valgus with bifocal metatarsal and Akin osteotomies of the first ray performed by the senior author (CC). 22 patients were treated over a three year period from 2008 to 2011, 24 trifocal osteotomies were undertaken. Hallux valgus angle (HVA), intermetatarsal angle (IMA) and distal metatarsal articular angle (DMAA) were all measured from pre- and postoperative radiographs. The patients were also clinically reviewed. Results. The study group consisted of 21 women and 1 man with a mean age of 53 years. The average time to follow up was 19 months. Four cases had undergone previous surgery. Average HVA correction was 26.9 degrees (p < 0.0001), average IMA correction was 12.65 degrees (p < 0.0001). No patients had postoperative infection and all osteotomies went on to union. All patients reported resolution of pain. Two patients required removal of metalwork and the distal osteotomy angulated slightly in one patient not requiring reoperation. Conclusion. We demonstrate that bifocal metatarsal and akin osteotomies of the first ray are a safe and effective method of correcting complex hallux valgus

Introduction: External fixation has evolved from a mean to hold a bone in position to one that allows a gradual correction and lengthening. Platelet gel has been reported to be effective in enhancing osteogenesis. The association of these techniques could be effective in the treatment of pottraumatic bone loss fracture. Materials and methods: Platelet gel has been obtained mixing 50 mL of autologous platelet concentrate to 2.5 mL of fibrin glue, produced from autologous FFP through CS-1 Cryoseal Thermogenesis. Patient 1: Male, 39 years old, smoker, bearing tibial non-union with 17 cm bone loss has been treated by trifocal technique with platelet gel in the docking site procedure with autologous bone graft. Patient 2: Male, 43 years old, smoker, suffering from exposed femoral fracture with sovracondilar bone loss, treated by acute shortening and proximal osteotomy in order to improve distractional ostogenesis according to Ilizarov method. Platelet gel had been positioned in the non-union sovracondilar site. Results. Patient 1 has reached a good bone repair in the platelet gel application site within 4 months. Patient 2 has healed within 3 months

Distal tibial bone loss involving the ankle is a devastating injury with few options for reconstruction. The purpose of our study was to look at the long term results of ilizarov technique used to achieve lengthening of tibia and fusion at the ankle. 17 cases (16 post traumatic and one post tumor resection) admitted to one institution between 1994 and 2003. 13 cases were done in bifocal and four in trifocal mode. The duration of follow up was 12 to 84 months The average age was 33 years (Range 7-71). The mean length of the defect was 4.5 cm (Range 1-12). Union of the fusion site occurred in 88 % (15/17) of the patients with mean duration to docking and union being 8 months. The mean time in fixator was 13 months (Range 5 to 29). Average number of surgeries per patient was 3.2. Five patients required free vascularised grafts before the index procedure and 4 patients required realignment at the docking site. Functional results – Fourteen (77.5%) of the patients could walk without support or bracing and twelve patients (71%) returned to same or modified occupation. Complications – Two non-union. Deformity – Fusion site equinus deformity occurred with non union after re-fracture in one case. There were 2 cases of residual fore-foot equinus. Residual low grade infection with discharging sinus was present in two patients. One patient needed change of wires for Pin tract infection. Our study showed 76% good and excellent scores on functional scoring but also demonstrates the high morbidity associated with this procedure. In spite of the steep learning curve and high complication rates the procedure can be undertaken in specialised centres for highly motivated patients to achieve good functional results

Distal tibial bone loss involving the ankle is a devastating injury with few options for reconstruction. The purpose of our study was to look at the long term results of ilizarov technique used to achieve lengthening of tibia and fusion at the ankle. 17 cases (16 post traumatic and one post tumor resection) admitted to one institution between 1994 and 2003. 13 cases were done in bifocal and four in trifocal mode. The duration of follow up was 12 to 84 months The average age was 33 years (Range 7–71). The mean length of the defect was 4.5 cm (Range 1–12). Union of the fusion site occurred in 88% (15/17) of the patients with mean duration to docking and union being 8 months. The mean time in fixator was 13 months (Range 5 to 29). Average number of surgeries per patient was 3.2. Five patients required free vascularised grafts before the index procedure and 4 patients required realignment at the docking site. Functional results – Fourteen (77.5%) of the patients could walk without support or bracing and twelve patients (71%) returned to same or modified occupation. Complications – Two non-union. Deformity – Fusion site equinus deformity occurred with non union after re-fracture in one case. There were 2 cases of residual fore-foot equinus. Residual low grade infection with discharging sinus was present in two patients. One patient needed change of wires for Pin tract infection. Our study showed 76% good and excellent scores on functional scoring but also demonstrates the high morbidity associated with this procedure. In spite of the steep learning curve and high complication rates the procedure can be undertaken in specialised centers for highly motivated patients to achieve good functional results

Post – traumatic nonunion is unusual in children. The presence of more than one site for nonunion in a single bone, infection, shortening, osteoporosis and deformity makes the treatment more complicated. Case Report: A 10-y old boy presented to us with a post-traumatic 12 cm Rt. tibial shortening, unstable knee and a discharging sinus over the upper tibia. Roentgenograms revealed 3 sites of nonunion: in the upper middle and lower 1/3 of the tibia. The deformity of the upper tibia was varus 20° and recurvatum 25° while there was varus of the lower part 15°. The fibular head was over hanging the tibia. Treatment: Ilizarov Ext. fixator was applied concomitant with freshening of the upper site, sinus excision and osteotomy of the fibula. The lower fibula was fixed to the tibia leaving the upper part free. Then, gradual correction of deformities by distraction using properly positioned hinges was applied through the upper and lower sites for nonunion. Compression – Distraction was applied alternatively to stimulate the regenerate till we reached the sum of 12 cm lengthening from the 3 sites. The fixator was removed after 9 months where there was union and consolidation from all sites for non-union. The patient was followed up for 4 years. Complications: Included wire tract infection, mild bowing of the regenerate after fixator removal and refracture. Conclusion: Using the nonunion sites to correct complicated deformities and lengthen the bone is an effective method in children. Up to our knowledge, this is the first time to report the results of trifocal lengthening

Purpose of the Study: To study the results of resection of giant cell tumour around the knee and limb salvage by distraction osteogenesis using Ilizarov construction over intramedullary nail. Summary: The treatment of GCT has ranged from curettage and en-bloc resection. It has always been a challenge to reconstruct the resected gap especially across the joints. We have done juxta articular resection of the tumour followed by interlocking nailing across the resected gap as first stage. In the second stage simple Ilizarov construct was used for transportation of bone across the resected gap. Results and Discussion: There were 6 male and 2 females. The mean age at presentation was 27 years. 3 lesions were in proximal tibia and 5 in the distal femur. The mean length of bone defect was 13.9 cm. With trifocal distraction the mean duration of Ilizarov external fixation was 90 days. We used colour doppler to asses the quality of regenerate during follow-ups. Mean duration of follow up was 44 months. A good quality of regenerate was seen at last follow up and all patients were fully weight bearing. Allografts are an alternative to endoprosthetic reconstruction but high incidence of complications such as fracture, deformity and infection makes the outcome unpredictable. The treatment option of reconstructing the resected gap with endoprosthesis is limited in our Indian subcontinent set up because of limited resource and availibility. The advantage include, the method we used has given us best alternative which allowed us to fill the large resected gap without the need of massive bone grafts. The distraction from both sides of resected gap has reduced the transportation time and use of DCP plate across the docked bone has allowed us to remove the fixator earlier. The regenerate had sufficient biological strength and durability. The disadvantages include the long duration of external fixation and related problems such as pin tract infections and frustration of patients due to the long period of treatment. Conclusion: Resection of tumour across the joint especially around the knee and recostruction by distraction osteogenesis using Ilizarov construct over the nail to fill the large gaps without using grafts is very encouraging

What was the question? The treatment of multi-injured patients requires initial stabilization of general conditions and vital parameters. The first stage in orthopedic management of the fractures in trauma involves stabilization of the bone segments to reduce blood loss and allow nursing. External fixators are fast, versatile and essential in the emergency situation in cases of multiple fractures, especially with soft tissue loss. According to damage control orthopedics (DCO) concepts, it is possible to replace an external fixator (EF) with internal synthesis (ORIF) after a period of time to reduce the risks of ORIF. However, surgery can be difficult to perform and pin sites can be the source of bone infection, in which the EF as a definitive treatment option may be considered. How did you answer the question? In trauma surgery, instability of the hardware, fractures near the joint, frame extending across the knee and the ankle, initial fixation was converted to definitive treatment with circular frames according to the Ilizarov method. Fourteen patients (2 female and 12 males; age 24 to 80 yrs, average age 43,4 y/o) were treated with various circular framses as definitive treatment: Ilizarov (2), Sheffield (7), Taylor Spatial Frame (TSF) (4) and TrueLok (1) between November 2002 and December 2007 in multiply injured patients with ISS > 20. Seven cases were femoral and seven tibial. The femoral group had four knee spanning fixator configurations and three unilateral external fixators. The tibial group had 4 unilateral frames, 1 hybrid EF, 1 across the knee EF and 1 across the ankle EF. Five patients had temporary femoral and tibial hardwares in the same side. Three patients had unilateral tibial and femoral fractures. What are the results? All patients achieved consolidation. The mean duration of femoral EF was 7.6 months (5–9 months). One bone loss in a distal femoral shaft treated with Sheffield EF had lengthening (5 cm) after acute short-hening. Two patients had a gradual distal femoral fracture reduction and a mechanical axis correction by TSF. Three patients with tibial bone loss had 2 trifocal bone transport (17,5 and 9 cm) and 1 bifocal bone transport 5 cm. The TSF had no additional pre-operative planning and major post-operative frame adjustments. The intra-operative devices was easier for the TSF. What are your conclusions? Circular frame osteosynthesis following initial EF, is a reliable and effective strategy for treatment in severe open femur and tibia fractures and post traumatic reconstruction

We present two children with massive defects of the tibia and an associated active infection who were treated by medial transport of the fibula using the Ilizarov device. The first child had chronic discharging osteomyelitis which affected the whole tibial shaft. The second had sustained bilateral grade-IIIB open tibial fractures in a motor-car accident. The first child was followed up for three years and the second for two years. Both achieved solid union between the proximal and distal stumps of the tibia and the fibula, with hypertrophy of the fibula. The first child had a normal range of movement at the knee, ankle and foot but there was shortening of 1.5 cm. The second had persistent anterior angulation at the proximal tibiofibular junction and the ankle was stiff in equinus.

Although gradual bone transport may permit the restoration of large-diameter bones, complications are common owing to the long duration of external fixation. In order to reduce such complications, a new technique of bone transport involving the use of an external fixator and a locking plate was devised for segmental tibial bone defects.

A total of ten patients (nine men, one woman) with a mean age at operation of 40.4 years (16 to 64) underwent distraction osteogenesis with a locking plate to treat previously infected post-traumatic segmental tibial defects. The locking plate was fixed percutaneously to bridge proximal and distal segments, and was followed by external fixation. After docking, percutaneous screws were fixed at the transported segment through plate holes. At the same time, bone grafting was performed at the docking site with the external fixator removed.

The mean defect size was 5.9 cm (3.8 to 9.3) and mean external fixation index was 13.4 days/cm (11.8 to 19.5). In all cases, primary union of the docking site and distraction callus was achieved, with an excellent bony result. There was no recurrence of deep infection or osteomyelitis, and with the exception of one patient with a pre-existing peroneal nerve injury, all achieved an excellent or good functional result.

With short external fixation times and low complication rates, bone transport with a locking plate could be recommended for patients with segmental tibial defects.

Cite this article: Bone Joint J 2013;95-B:1667–72.

We carried out a systematic review of the literature to evaluate the evidence regarding the clinical results of the Ilizarov method in the treatment of long bone defects of the lower limbs.

Only 37 reports (three non-randomised comparative studies, one prospective study and 33 case-series) met our inclusion criteria. Although several studies were unsatisfactory in terms of statistical heterogeneity, our analysis appears to show that the Ilizarov method of distraction osteogenesis significantly reduced the risk of deep infection in infected osseous lesions (risk ratio 0.14 (95% confidence interval (CI) 0.10 to 0.20), p < 0.001). However, there was a rate of re-fracture of 5% (95% CI 3 to 7), with a rate of neurovascular complications of 2.2% (95% CI 0.3 to 4) and an amputation rate of 2.9% (95% CI 1.4 to 4.4).The data was generally not statistically heterogeneous. Where tibial defects were > 8 cm, the risk of re-fracture increased (odds ratio 3.7 (95% CI 1.1 to 12.5), p = 0.036).

The technique is demanding for patients, illustrated by the voluntary amputation rate of 1.6% (95% CI 0 to 3.1), which underlines the need for careful patient selection.

Cite this article: Bone Joint J 2013;95-B:1673–80.