Post-traumatic Tibial Defects Treated by the Ilizarov Method

Comparison of Classic Versus Integrated Technique

Mitchell Bernstein, MD, FRCSC

Fellow, Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery

Samir Sabharwal, BA

Research Assistant, Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery

Jonathan Barclay, BA

Medical Student, Weill Cornell Medical College

S. Robert Rozbruch, MD
S. Robert Rozbruch, MD

Chief, Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery
Director, Limb Salvage and Amputation Reconstruction Center (LSARC), Hospital for Special Surgery
Attending Orthopaedic Surgeon, Hospital for Special Surgery
Professor of Clinical Orthopaedic Surgery, Weill Cornell Medical College
President Emeritus, Limb Lengthening & Reconstruction Society

Austin T. Fragomen, MD
Austin T. Fragomen, MD

Associate Attending of Orthopaedic Surgery, Hospital for Special Surgery
Fellowship Director, Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery
Director, Limb Lengthening Clinic, Hospital for Special Surgery
Associate Professor of Clinical Orthopaedic Surgery, Weill Cornell Medical College

Abstract:

Limb salvage for posttraumatic tibial bone defects can be successfully performed with distraction osteogenesis with the classic or integrated fixation method. The integrated fixation method allows for earlier removal of the external fixator. while the frequency of adverse events and ability to restore limb lengths are similar in both groups. Adverse events did occur in 53% of patients; however good/excellent results can be expected in all patients with proper management.

Introduction

Limb salvage in the presence of posttraumatic tibial bone loss can be accomplished using the Ilizarov method. Internal fixation at the beginning of the consolidation phase stabilizes the regenerate and allows for early removal of the external fixator

We compared patients with posttraumatic tibial bone loss treated with either a circular external fixator exclusively, termed the “classic technique” or a combination of a circular external fixator and plating or insertion of an intramedullary nail during the consolidation phase, termed “integrated technique”. We asked: (1) Does integrated fixation decrease the time in the external fixator? (2) Is there a difference in the rate of complications between the two groups, and (3) are the results obtained at final follow-up comparable?

Methods

58 consecutive patients (58 tibiae) with posttraumatic tibial bone loss were retrospectively identified. Patients were divided into two groups, “classic technique” (30 patients) and “integrated technique” (28 patients). The mean follow-up was 33 months (range, 6 to 90 months). Institutional review board approval was obtained prior to initiation of the study. Baseline demographics, surgical variables, and outcomes were compared. Adverse events were reported as problems, obstacles, or complications as described by Paley.  Functional and radiographic outcomes were reported using the Association for the Study and Application of Methods of Ilizarov (ASAMI) scoring system.

Results

Baseline demographics were similar in both groups. Mean tibial bone loss was 5.3 cm (range, 1.6 to 13 cm) and 50% of patients were actively infected. Patients treated with integrated fixation, had significantly less time (p < 0.001) in the external fixator, 7 months (range 1.3 to 15 months) compared with 11 months (range 4.5 to 15 months). There were 49 adverse events in 31 patients (17 problems, 31 obstacles, 1 minor complication). There was no difference in the severity (p = 0.8703) or number (p = 0.359) of complications between both groups. Overall, patients required a mean of 4.05 surgical procedures (2 to 5) for limb salvage. There was no difference (p = 0.2194) in the incidence of unplanned surgical procedures (obstacles) between groups. All patients had no recurrence of infection and all had bony union at final follow-up. Good to excellent ASAMI function, and bone scores were obtained in 100%, and 98% of patients, respectively.

Conclusion

Limb salvage with distraction osteogenesis in the presence of posttraumatic tibial bone loss is a challenging surgical entity. The integrated fixation method allows for earlier removal of the external fixator while the frequency of adverse events and ability to restore limb lengths are similar in both groups. A mean of 4.05 surgical procedures were required for tibial reconstruction. Adverse events did occur in 53% of patients; however good/excellent results can be expected in all patients with proper management.

This abstract was presented in the 2014 American Academy of Orthopaedic Surgeons Annual Meeting.

 

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