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World J Orthop. Sep 18, 2011; 2(9): 85-92
Published online Sep 18, 2011. doi: 10.5312/wjo.v2.i9.85
Methods to shorten the duration of an external fixator in the management of tibial infections
Khaled M Emara, Khaled Abd Al Ghafar, Mohamed Ahmed Al Kersh
Khaled M Emara, Orthopaedic Surgery, Ain Shams University Hospitals, Cairo 0020, Egypt
Khaled Abd Al Ghafar, Lecturer in Orthopaedic Surgery, Ain Shams University, Cairo 0020, Egypt
Mohamed Ahmed Al Kersh, Assistant Lecturer of Orthopaedic Surgery, Ain Shams University, Cairo 0020, Egypt
Author contributions: Emara KM designed and wrote up the research; Ghafar K collected the data; Al Kersh MA wrote up the research.
Correspondence to: Khaled M Emara, Professor, Orthopaedic Surgery, Ain Shams University Hospitals, 13 B Kornish el Nile, Agha Khan, Cairo 0020, Egypt.
Telephone: +20-2-22055661 Fax: +20-2-22055662
Received: July 1, 2011
Revised: August 25, 2011
Accepted: August 31, 2011
Published online: September 18, 2011

Massive segmental bone loss due to chronic osteomyelitis represents a considerable challenge to orthopedic surgeons and is a limb threatening condition. The only option available in such a clinical situation is segment transport using the Ilizarov technique of distraction osteogenesis; yet the most common problem in cases of bone transport with the Ilizarov technique in massive bone loss, is the long duration of the fixator. In addition to autologous bone grafting, several mechanical, biologic, and external physical treatment modalities may be employed to promote bone formation and maturation during segment transport in osteomyelitis patients. Mechanical approaches include compressive loading of the distraction regenerate, increased frequency of small increments of distraction, and compression-distraction. Intramedullary nailing and hemicorticotomy can reduce the time in external fixation; however, these techniques are associated with technical difficulties and complications. Exogenous application of low-intensity pulsed ultrasound or pulsed electromagnetic fields may shorten the duration of external fixation. Other promising modalities include diphosphonates, physician-directed use (off-label use) of bone morphogenetic proteins, and local injection of bone marrow aspirate and platelet gel at the osteotomy site. Well-designed clinical studies are needed to establish safe and effective guidelines for various modalities to enhance new bone formation during distraction osteogenesis after segment transfer.

Keywords: Ilizarov, Bone infection, Intramedullary nail, Hemicorticotomy, Tibiofibular synostosis, Fibular transport