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

Abstract. Distraction Osteogenesis (DO) for the management of bone defects in long bones is an established technique. Problems with bone regeneration are a common occurrence and literature is full of different modalities to enhance regenerate formation and quality. Strontium Ranelate (SR) has a dual mode of action and enhances bone formation in addition to decreasing osteoclastic activity. Due to this dual mode of action as well as ease of administration in a suspension form, it makes an ideal drug in scenarios where realignment of bone homeostasis towards positive bone balance is desirable. We studied the relationship of administration of SR with rate of regenerate progression, docking site union and complications associated with bone transport in 48 patients undergoing bone transport for management of bone defects. The findings of our retrospective observation study indicated that compliant use of SR was associated with good regenerate progression, decreased problems with docking site union and decreased the need for additional interventions

Background. Although gradual bone transport may provide a large-diameter bone, complications are common with the long duration of external fixation. To reduce such complications, a new technique of bone transport with a locking plate has been done for tibial bone defect. Methods. In 13 patients (mean age, 38.9 years) of chronic osteomyelitis or traumatic bone defect, segmental transport was done using external fixator with a locking plate. In surgical technique, a locking plate was fixed submuscularly, holding the proximal and distal segments. Then, the external fixator for transport was fixed without contact of the locking plate. After docking, 2 or 3 screws were fixed at the transported segment through the plate holes. At the same time, the external fixator was removed. Results. The mean transported amount was 5.8cm, and the mean external fixation index was 13.3 days/cm. The primary union at the docking site was achieved in all cases. No patients showed angular deformity over 5 degrees. There were 2 patients of leg length discrepancy with less than 1.5cm. Deep infection or recurrence of osteomyelitis was not developed. Except for two patients with pre-existed peroneal nerve injury, all had excellent or good functions according to the criteria of Mekhail. Conclusion. In tibial reconstruction, transport with a locking plate may be a successful method with reducing external fixation time. It may allow patients to return to daily life earlier with relatively few complications

Introduction. Segmental bone defect is a challenging problem. We report our experience of bone transport by hexapod external fixator in patients with segmental defects if the tibia. Method. We report herein 15 patients with segmental bone defect of tibia who completed their treatment protocol. All patients were treated had bone transport with Taylor Spatial Frame from 2012 to 2017. All were treated by the senior author NH. Parameters measured included age, sex, diabetes, smoking, diagnosis, method of fixation prior to treatment use of a free flap, bone defect size, frame-time, external fixation index. Results. Mean age at the time of frame application was 42.7 years. Mean follow-up after frame removal was 23.7 months. Three were diabetic, one smoked and one quit smoking during treatment. Seven had Gustilo-Anderson 3B (47%) and 5 Gustilo-Anderson 3A (33%) open fractures. Three (20%) had closed fractures. Nine (60%) had internal fixation with plate in eight and IM nail in one. Ten patients (67%) had soft tissue defect that required a free flap in seven, local flap in two and skin graft in one. Mean transport was 62 mm. Mean external fixator time and latency were 350.1 and 12 days, respectively. Mean External fixator, distraction and maturation indices were 2.1, 0.52 and 1.43 month per centimeter, respectively. Ten Extra- procedures were required in 7 patients. There were no docking site procedures, non-union of regenerate, adjunctive stabilization after frame removal, recurrence of bone infection and recurrence of deformity. Conclusions. Segmental resection and transport by TSF is an effective method to achieve length, alignment and eradicate infection. Although our cohort had longer external fixator indices than similar studies, the complication rate was low

Aims. To investigate a treatment algorithm of various Ilizarov methods in managing infected tibial non-union. Patients and Methods. A consecutive series of 76 patients with infected tibial non-union were treated with one of four Ilizarov protocols, consisting of; monofocal distraction (25 cases), monofocal compression (18), bifocal compression/distraction (16) and bone transport (17). Median duration of non-union was 10.5 months (range 2–546 months). All patients underwent at least one previous operation, 36 had associated limb deformity and 49 had non-viable non-unions. Twenty-six cases had a new muscle flap at the time of Ilizarov surgery and 24 others had pre-existing flaps. Results. Infection was eradicated in 74 cases (96.1%) at a mean follow-up of 42 months (range 8–131). Both infection recurrences were in the monofocal compression group. Union was achieved in 66 cases (86.8%) with the initial Ilizarov method alone. Union was highest amongst the monofocal distraction and bifocal compression/distraction groups, 96% and 93.8% respectively. Monofocal compression was successful in only 77.8% of mobile non-unions. Bone transport secured initial union in 76.5% with a 47% unplanned reoperation rate. However, following further treatment union was 100% in the bone transport group compared to 88.9% in the monofocal compression group. Six cases sustained a refracture, with 5/6 occurring in the monofocal compression group, representing a 27.7% refracture rate. ASAMI scores were also significantly lower for the monofocal compression group. Conclusion. We do not recommend monofocal compression in the treatment of infected, mobile non-unions. Distraction (monofocal or bifocal) was more effective achieving higher rates of infection clearance, lower refracture rates and better ASAMI scores

Aim. Simultaneous application of Ilizarov frames and free muscle flaps to treat osteomyelitis or infected non-unions is currently not standard practice in the UK, in part related to logistical issues, surgical duration and challenging access for microvascular anastomosis. We present the outcomes for 56 such patients. Methods. Retrospective single centre consecutive series between 2005–2017. We recorded comorbidities, Cierny-Mader and Weber-Cech classification, the Ilizarov method used, flap and anastomosis used, follow-up duration, time to union and complications. Results. 56 patients (55 tibiae and 1 forearm) were included (mean age 48 years). Thirty-four cases had osteomyelitis (20/34 Cierny-Mader Stage IV) and 22 had an infected non-union (14/22 Weber-Cech Type E or F). Forty-six patients had a segmental defect after resection. Monofocal compression was used in 14, monofocal distraction in 15, bifocal compression/distraction in 8, bone transport in 9 and a protective frame in 10. 8/56 had an ankle fusion, 7/56 had an angular deformity corrected at the same time and 32 also had local antibiotic carrier inserted. Forty-six gracilis, 9 latissimus dorsi and 1 rectus abdominus flaps were used. Six cases required urgent flap re-exploration (5 anastomotic revisions and 1 haematoma washout) with 4/6 successfully salvaged. Two cases suffered total flap failure (3.6%). Both had successful revision free muscle flaps with the frame in situ at 10 and 16 days respectively. There were no partial flap failures and no failures in bone transport frames. Mean follow-up was 22 months (4–89). Excluding three cases that still have a frame on, 42/43 (97.7%) achieved bony union. Recurrence of infection occurred in 8.9%. All were infection free at final follow-up after further surgery. Conclusions. With the right expertise, simultaneous Ilizarov frame and free muscle flap is safe and effective in treating complex limb infection, and is not associated with an increased flap failure rate. Level of evidence. III

Aims

The aim of the present study was to assess the outcomes of the induced membrane technique (IMT) for the management of infected segmental bone defects, and to analyze predictive factors associated with unfavourable outcomes.

AIM. To present our experience in patients treated under primary diagnosis giant cell tumor of bone at Department Orthopaedic Surgery Zagreb University School of Medicine in a 15-year period from 1995 to 2009. METHODS. We performed a retrospective study of all patients treated in our Department because of giant cell tumor of bone (GCT) from 1995 to 2009. The mean age of our patients was 29,9 years (range: 14 to 70 years). Sex distribution showed prevalence in female (F:M=23:12=66%:34%). All together, 39 patients were operated under primary diagnosis of GCT. Four patients were lost in follow-up. In total, 35 patients were included in study. Diagnosis of GCT was made according to clinical, imaging and histological findings, and distributed by Campanacci's classification. RESULTS. Not including diagnostic biopsy, 84 operations were performed on 35 patients. Fourteen patients (40%) had GCT grade 1, fourteen (40%) had GCT grade 2, and seven (20%) had GCT grade 3. From the first symptoms to diagnosis there was an average duration of 7 months (range: 0 to 24 months), where the main symptoms were pain and swelling of affected bone and/or joint. GCT was localized in distal femur (n=12, 34%), proximal tibia (n=10, 29%), distal tibia (n=4, 11%), distal radius (n=3, 9%), and other locations (n=6, 17%). Patients with less aggressive GCT (grades 1 and 2) were treated with marginal excision: excochleation and reconstruction with bone transplant (n=12, 34%). In patients with locally more aggressive tumor (grades 2 and 3), “en bloc” resection and reconstruction with tumor endoprosthesis or bone transplant was performed (n=22, 63%). Due to localization of tumor, one patient was treated with radiation (3%). Complications were recorded in 12 patients (34%), and are shown as total number and percentage of all complications. Complications were the most common in knee region, proximal tibia (n=4, 33%) and distal femur (n=3, 25%). Also, the complications occured more frequently after “en bloc” resection (n=7, 58%). GCT classified as gradus 2 had most complications (n=5, 42%) till GCT classified as gradus 3 had least (n=3, 25% of complications, 9% of all). We recorded and treated local recurrence of tumor (n=6, 50%), infection (n=2, 17%), and mehanical complications of endoprosthesis (n=2, 17%). Due to local recurrences, in 2 patients underlying osteosarcoma was revealed, and they were treated with amputation. CONCLUSION. Each patient with GCT should be treated individually. Regardless non-malignant attribute, local behaviour of tumor determines treatment approach according to treatment principles of malignant tumor of bone. Number of complications in our patients is relatively high, recorded in one third of our patients, which matches the literature in announced studies

Introduction. The management of a significant bone defect following excision of a diaphyseal atrophic femoral non-union remains a challenge. Traditional bone transport techniques require prolonged use of an external fixator with associated complications. We present our clinical outcomes using a combined technique of acute femoral shortening, stabilised with a deliberately long retrograde intramedullary nail, accompanied by bifocal osteotomy compression and distraction osteogenesis to restore segment length utilising a temporary monolateral fixator. Method. 9 patients underwent the ‘rail and nail’ technique for the management of femoral non-union. Distraction osteogenesis was commenced on the 6. th. post-operative day. Proximal locking of the nail and removal of the external fixator was performed approximately one month after length had been restored. Full weight bearing and joint rehabilitation was encouraged throughout. Consolidation was defined by the appearance of 3 from 4 cortices of regenerate on radiographs. Results. 7 males and 2 females of adult age underwent treatment between 2009 and 2016. The mean lengthening was 6.6cm (3–10cm). The external fixator was removed at a mean 123 days (57–220), with an external fixation index of 20 days/cm. The regenerate healing index was 28 days/cm. There were no deep infections. Significant complications were seen in 4 patients including knee stiffness, a foot drop, delayed union of the non-union osteotomy (requiring exchange nailing and bone grafting) and revision nailing due to a prominent proximal tip. Conclusion. The combined over-sized intramedullary nail and external fixator enables compression of the femoral osteotomy, alignment of the bone and controlled lengthening. Once the length has been restored, removal of the external fixator and proximal locking of the nail reduces the risk of complications associated with the fixator and stabilises the femur with the maximum working length of the nail. This small retrospective study demonstrates encouraging results for this complex clinical scenario

We analysed the functional and psychological outcomes in children and adolescents with complex tibial fractures treated with the Ilizarov method at our frame unit. An observational study with prospective data collection and retrospective analysis of clinical data was undertaken. Patients younger than 18 years and an open physis were included. The Ilizarov method (combined with percutaneous screw fixation in physeal injuries) was applied and immediate weightbearing recommended. Sixty four patients (50 male, 14 female) aged between 4 and 17 years were admitted to our Major Trauma Centre from 2013 until 2016 (25 tertiary referrals). Thirty one (48%) patients were involved in road traffic accidents, 12 (19%) sustained injuries in full contact sports. The average weight was 51 kg (range 16–105 kg). Twenty three open tibial fractures (14 Gustilo 3A and 9 Gustilo 3B) and 15 associated physeal injuries were treated among a cohort of closed tibial fractures with significant displacement (10 failed conservative treatment prior to frame treatment). We report a 100% union rate with a median hospital stay of 4 days (range 2–19) and a median frame time of 105 days (range 62–205 days). Malunions (> 5 degrees in any plane) were not observed. Three patients required bone transport. At the time of submission, 70% of patients and their parents reported functional outcomes using the Paediatric Quality of Life Inventory (PedsQL) at minimum six months post frame. The PedsQLTM 4.0 Generic Core Scales are comprised of parallel child self-report and parent proxy-report formats. Children's physical average scores were 79 out of 100 and average psychosocial scores were 80 out of 100 and for parent average physical scores were 78 out of 100 and the same for parent average psychosocial scores. These results suggest high levels of quality of life on the PedsQL. The median visual analogue health score (0–100) was 81 out of 100 (71–100), median Lysholm knee scores 98 (range 49–100) and median Olerud & Molander ankle scores 75 (range 40 – 100). Regardless of age, weight and soft tissue damage and complexity of fracture pattern, the Ilizarov method has shown to be safe and effective treating tibial fractures in the paediatric and adolescent population admitted to our Major Trauma Centre. Furthermore, patients reported high physical and psychosocial functioning following treatment. Level of evidence: IV (case series)

Several low energy osteotomy techniques are described in the literature but there is limited evidence comparing healing indices. We present a retrospective review of two techniques to evaluate an optimum method. Method:. Two cohorts of patients underwent osteotomy of the tibia using a Gigli saw (n=15) or DeBastiani corticotomy (n=12) technique. Indications for surgery included limb lengthening and bone transport for defect reconstruction with a minimal distraction of 2 cm. The patient radiographs were anonymised and the regenerate assessed by the two senior authors who were blinded to the osteotomy type. Bone quality was recorded along the anterior, posterior, medial and lateral cortices, graded 1–5 from absent to full consolidation over time in frame. The time to 3 cortices healed/regenerate length was calculated. The time to consolidation of the anterior, posterior, medial and lateral cortices were compared. Results:. The mean 3 cortices index in the Gigli group was 2.0 months/cm and in the DeBastiani group 1.8 months/cm, This was not a significant difference. In both groups anterior bone formation was slower, and in 50% and 33% of the Gigli and DeBastiani groups respectively the anterior cortex did not fully heal by the time of frame removal. Discussion:. Both Gigli saw and DeBastiani corticotomy techniques result in good bone formation following distraction osteogenesis. The anterior tibial cortex consolidates more slowly than the other cortices in both groups. This is likely due to deficient soft tissue cover and direct periosteal damage at time of osteotomy

A systematic literature review of distraction osteogenesis (DO) for the primary reconstruction of bone defects following resection of primary malignant tumours of long bones (PMTLB) is presented. Fewer than 50 cases were identified. Most reports relate to benign tumours or secondary reconstructive procedures. The outcomes of our own series of 7 patients is also presented (4 tibiae, 3 femora). All patients had isolated bone lesions without metastases and were assessed through the hospital sarcoma board. Mean follow-up was 59 months (17–144). Mean age was 42 years. Final histologic diagnoses were 3 chondrosarcoma, 2 malignant fibrous histiocytoma, 1 adamantinoma and 1 malignant intraosseous nerve sheath tumour. Mean bone defect after resection was 13.1cm (10–17) and bone transport was the reconstruction method in all. There was one local recurrence of tumour six months post-resection, necessitating amputation. Mean frame index for remaining cases was 30.9 days/cm (15.7–41.6). Complications included pin infection, docking site non-union, premature corticotomy union, soft-tissue infection and minor varus deformity. Six cases remain tumour-free with united, well-aligned bones and good long-term function. We conclude DO provides an effective biologic reconstruction option in select cases of PMTLB

Introduction. Tunnelwidening in failed anterior cruciate ligament reconstruction (ACLR) can result in the staged revision procedures with a need for bone transplantation prior to revision reconstruction. Limited knowledge exist regarding to quality of different transplantation methods. The present study used CT-scanning to evaluate tunnel bone density after allogenic bone chips and bone cylinder transplantation. We hypothesized that bone chips transplantation resulted in higher bone density than bone cylinder transplantation due to possible voids between individual cylinders in the tunnels. Methods. The records of 24 patients operated for 1st stage revision ACLR from April 2003 to march 2010 were included in the study. twelve patients had their tunnels transplanted with bone chips and twelve patients with bone cylinders from allogenic femoral heads. Bone chips were created by fine bone milling and cylinders were extracted by 7–8 mm core drilling. Bone density 3–4 months after transplantation were evaluated by CT scanning reconstruction slides with 5 mm intervals throughout the tunnel length using histomorphometry. Results. There were 15 females and 9 males with an average age of 32 yrs. Using bone chips the bone density in the tibial tunnels was 55% and the femoral tunnels the bone density was 68% Using bone cylinders bone density was 60% in the tibial tunnels and 53% in the femoral tunnels. The femoral bone density in the bone chip group was significantly higher than the bone cylinders (p < 0.05). Conclusion. Transplantation with bone chips results in superior bone quality in the femoral tunnels where as no difference where demonstrated in the tibial tunnels

We studied the outcome and functional status of 33 patients with 34 severe open tibial fractures (Gustilo grade IIIb and IIIc). The treatment regime consisted of radical debridement, immediate bony stabilisation and early soft-tissue cover using a muscle flap (free or rotational). The review included standardised assessments of health-related quality of life (SF-36 and Euroqol) and measurement of the following parameters: gait, the use of walking aids, limb-length discrepancy, knee and ankle joint function, muscle wasting and the cosmetic appearance of the limb. Personal comments and overall patient satisfaction were also recorded. The mean follow-up was 46 months (15 to 80). There were 30 Gustilo grade IIIb fractures and and four grade IIIc fractures. Of the 33 patients, 29 had primary internal fixation and four, external fixation; 11 (34%) later required further surgery to achieve union and two needed bone transport procedures to reconstruct large segmental defects. The mean time to union was 41 weeks (12 to 104). Two patients (6.1%) developed deep infection; both resolved with treatment. The mean SF-36 physical and mental scores were 49 and 62 respectively. The mean state of health score for the Euroqol was 68. Patients with isolated tibial fractures had a better outcome than those with other associated injuries on both scoring systems. Knee stiffness was noted in seven patients (21%) and ankle stiffness in 19 (56%); 12 patients (41%) returned to work. Our results compare favourably with previous outcome measurements published for both limb salvage and amputation. All patients were pleased to have retained their limbs

Aims

To clarify the effectiveness of the induced membrane technique (IMT) using beta-tricalcium phosphate (β-TCP) for reconstruction of segmental bone defects by evaluating clinical and radiological outcomes, and the effect of defect size and operated site on surgical outcomes.

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In this randomized study, we aimed to compare quality of regenerate in monolateral versus circular frame fixation in 30 patients with infected nonunion of tibia.

Aims

Type IIIB open tibial fractures are devastating high-energy injuries. At initial debridement, the surgeon will often be faced with large bone fragments with tenuous, if any, soft-tissue attachments. Conventionally these are discarded to avoid infection. We aimed to determine if orthoplastic reconstruction using mechanically relevant devitalized bone (ORDB) was associated with an increased infection rate in type IIIB open tibial shaft fractures.

Aims

Open fractures of the tibia are a heterogeneous group of injuries that can present a number of challenges to the treating surgeon. Consequently, few surgeons can reliably advise patients and relatives about the expected outcomes. The aim of this study was to determine whether these outcomes are predictable by using the Ganga Hospital Score (GHS). This has been shown to be a useful method of scoring open injuries to inform wound management and decide between limb salvage and amputation.

Aims

The aims of this study were to establish whether composite fixation (rail-plate) decreases fixator time and related problems in the management of patients with infected nonunion of tibia with a segmental defect, without compromising the anatomical and functional outcomes achieved using the classical Ilizarov technique. We also wished to study the acceptability of this technique using patient-based objective criteria.

Aims

The management of a significant bony defect following excision of a diaphyseal atrophic femoral nonunion remains a challenge. We present the outcomes using a combined technique of acute femoral shortening, stabilized with a long retrograde intramedullary nail, accompanied by bifocal osteotomy compression and distraction osteogenesis with a temporary monolateral fixator.