Published online Mar 18, 2022. doi: 10.5312/wjo.v13.i3.278
Peer-review started: April 28, 2021
First decision: September 29, 2021
Revised: October 11, 2021
Accepted: February 19, 2022
Article in press: February 19, 2022
Published online: March 18, 2022
The challenges of long-bone defect management have increased in contemporary orthopedic practice due to the severity of high-energy trauma and its complications. They lead to a multi-stage, long and costly treatment. The Ilizarov method of bone transport (IBT) and the Masquelet induced membrane technique (IMT) have been used in a great variety of challenging clinical situations including post-traumatic bone loss, infected nonunion, tumor resection, and congenital pseudarthrosis of the tibia (CPT).
The importance of improving bone regeneration in the management of large bone defects and CPT is a very relevant issue due to treatment failures that diminish bone potential for regeneration. Therefore, a combination of the biological merits of IBT and IMT seemed a promising strategy for the management of cases with a history of failed attempts and impaired regeneration potential.
We aimed to conduct clinical studies on the use of a new technological solution that integrates the IMT and IBT techniques for treating non-viable tibial defects of post-traumatic (PTD) etiology and CPT to improve bone regeneration at the docking site, bone consolidation and reduce refracture rate.
We retrospectively studied the treatment course and outcomes in a case series that included seven PTD patients (subgroup A) and nine CPT cases (subgroup B) managed by the combined technology of IMT and IBT. Adult patients in subgroup A had bone defects of post-traumatic origin after several previous treatments failed and non-viable types of nonunion (hypotrophic, torsion-wedge, defect-pseudarthrosis). Subgroup B included nine children with a mean age of 6.1 ± 0.9 years with severe CPT types who had numerous failed interventions to unite pseudarthrosis. Step 1 included Ilizarov frame placement and spacer introduction into the resected defect to generate the induced membrane which remained in the interfragmental gap after spacer removal. Step 2 was an osteotomy and bone transport of the fragment through the tunnel in the induced membrane, its compression and closed docking for consolidation without grafting. Upon docking, supportive compression of 1 mm was provided once every two weeks in the consolidation phase. Postoperative care and radiographic checks followed the standards of the Ilizarov method. Radiographic evidence of bony union, external fixation time, defect filling rate and complications were assessed. The primary outcome measure was radiographic bone union. Secondary outcomes were correction of limb length discrepancy and deformities. The outcomes were retrospectively studied after a mean follow-up period of 20.8 ± 2.7 mo in subgroup A and 25.3 ± 2.3 mo in subgroup B.
Upon completion of treatment, defects were filled by 75.4 ± 10.6% and 34.6 ± 4.2%, in subgroups A and B, respectively. Total duration of external fixation was 397 ± 9.2 and 270.1 ± 16.3 d, including spacer retention time of 42.4 ± 4.5 and 55.8 ± 6.6 d, respectively. Bone infection was not observed. Postoperative complications included several cases of pin-tract infection and regenerate deformity in both subgroups. Ischemic regeneration was observed in two cases of subgroup B. Complications were corrected during the course of treatment. Bone union was achieved in all patients of subgroup A and in seven patients of subgroup B. One non-united CPT case was further treated with the Ilizarov compression method only and achieved union. After a follow-up period of two to three years, refractures occurred in four cases of united CPT.
The combination of IMT and IBT may provide good outcomes in post-traumatic tibial defects after previous treatment failures, although the external fixation is longer due to spacer retention time. This combination might also be used for severe types of CPT, despite the fact that refractures may occur.
There are ways to further investigate the adjuncts to our protocol such as grafting at the docking site and intramedullary nailing, especially in severe CPT.