Be alert to insidious fracture-related infections secondary to severe open fractures / 中华创伤骨科杂志

Objective:To report our experience in using the Ilizarov technique to treat bone defects secondary to Gustilo Ⅲb open tibial fractures with negative clinical signs and serological inflammatory markers.Methods:A retrospective study was performed to analyze the 19 patients with bone defects secondary to Gustilo Ⅲb open tibial fracture who had been treated at Department of Orthopaedics and Traumatology, Beijing Jishuitan Hospital between January of 2010 and June of 2021. They were 15 males and 4 females with an age of (41±11) years. Their inclusion criteria: undergoing treatment with Ilizarov technique (consecutive compression-distraction or bone transport), soft tissue coverage procedures resulting in wound closure and negative clinical infection signs for at least 3 months and normal serological inflammatory markers, and follow-up for more than 3 months after frame removal. Three-phase bone scan was performed for the patients before the present surgery. Debridement, sampling of deep tissues for bacterial culture, and external stabilization with a fixator were performed in the present surgery. Osteotomy for compression-distraction or bone transport technique was carried out at 1 stage or 2 stages. Systemic antibiotic therapy for 6 weeks was continued for those with positive microbiological analysis guided by antibiogram. Recorded were results of intra-operative pus detection around defects, microbiological findings, length of bone defect reconstructed, rate and time of infection recurrence during treatment, fracture union rate, bone healing index, bony and functional results.Results:The interval between primary injury to the present surgery was (10±8) months. The preoperative three-phase bone scan showed infection free in 8 cases, chronic osteomyelitis in 7 cases, and suspicious infection in 4 cases. No pus was found during intra-operative debridement in all. The intra-operative microbiological detection was positive in 1 sample in 1 patient (infection free indicated by bone scan), and in ≥2 samples in 3 patients (bone scan indicating non-infection, infection not excluded and osteomyelitis in 1 case each). The length of bone defect reconstructed was (8±3) cm. The follow-up after the present surgery was (37±15) months. Fracture union was achieved in all cases, with a bone healing index of (1.7±0.5) months/cm. Clinical infection signs were observed 1 (1, 1) month after the present surgery in 6 patients whose microbiological results were all negative. All the 6 patients ended up with no clinical recurrence after empirical use of systemic antibiotics in 5 and radical debridement in one. The bony results showed 16 excellent and 3 good cases while the functional results showed 10 excellent and 9 good cases.Conclusions:In treatment of bone defects secondary to Gustilo Ⅲb open tibial fractures with negative clinical signs and serological inflammatory markers, constant vigilance is needed against low-grade infection. Intra-operative multiple sampling of deep tissues with a standardized protocol and microbiological testing are extremely valuable for diagnosis of fracture-related infections.

Effect of Systemic Administration of Granulocyte-Colony Stimulating Factor on Rate of Fracture Healing of Bone Defect in Goats as Animal Model

@#Granulocyte-colony stimulating factor (G-CSF) serves as an important cytokine in haematopoiesis; released at both physiological and pathological conditions by a range of cells. We hypothesized that the systemic administration of G-CSF would produce an accelerated fracture-healing rate in non-union bone defects; thus, potentially leading to useful clinical applications. Ten male adult Katjang goats, weighing about 15-26 kilograms were randomly chosen and a tibial bone defect was induced in each animal. The defect was maintained by internal fixation with a titanium plate and reinforced by an external fiberglass cast. Post-operative radiographs were performed twice weekly and radiographic assessments were performed by evaluating the bridging and union measurements through a validated method. In the treatment group, the time for bridging and union exhibited statistically significant differences when compared with a control group. The outcomes of the present study establishing a notion that administration of G-CSF besides inducing haematopoiesis, promotes healing of fractures and non-union bone defects as well.

Relationship between Tibial Bone Defect and Extent of Medial Release in Total Knee Arthroplasty

PURPOSE: To understand the relationship between tibial bone defect and extent of medial release in total knee arthroplasty. MATERIALS AND METHODS: We evaluated 32 knees in 22 patients with variable degrees of tibial bone defect on medial plateau has undergone total knee arthroplasty. In this study, 31 cases had been diagnosed as degenerative osteoarthritis and 1 case was osteonecrosis. We excluded cases with infection, traumatic arthritis, or neuropathic joints. With regard to gender, 29 cases were female and 3 cases were male. The following relationships were analyzed: preoperative degrees of tibial bone defect and varus deformity; the femorotibial angle of both weight-bearing whole extremity radiogram, distractive stress radiogram, and the extent of medial release. RESULTS: Average tibial bone defect was 9.8+/-4.1 mm. Average femorotibial angle on weight-bearing whole extremity radiograph was varus 10.0degrees+/-6.2degrees. Average femorotibial angle on distractive stress radiograph was varus 0.7degrees+/-4.6degrees. Statistically the extent of medial release showed no significant relationship with the degree of tibial bone defect and femoro-tibial angle of whole extremity radiogram. However, it revealed a statistically significant relationship with the femorotibial angle on distractive radiogram (r=0.465, p=0.007). CONCLUSIONS: Preoperative distractive stress radiograph might be a useful method to predict the extent of intraoperative medial release during total knee arthroplasty.

Early Full Weight Bearing after an Autogenous Structural Bone Graft for Treating a Medial Tibial Bone Defect in Total Knee Arthroplasty: Minimum 5 Years Follow up Results

PURPOSE: We evaluated the results of early full weight bearing after an autogenous bone graft and metal screw fixation of severe varus deformity with a medial tibial bone defect in total knee arthroplasty. MATERIALS AND METHODS: From August 1996 to March 2004, 34 patients (43 cases) were selected for the analysis. The average age was 68 and the mean follow up period was 72 month. The clinical results were evaluated using the knee range of motion and the Hospital for Special Surgery (HSS) score. The radiological results were evaluated using the tibiofemoral angle, the presence of loosening, radiolucent lines and osteolysis and the component's location. RESULTS: The mean HSS score increased from 46 to 87 points on the final follow up. The mean range of motion was increased from 71degrees to 118degrees on the final follow up. The mean femorotibial angle showed varus deformity angulation (23.5degrees) at pre-operative surgery, 6.2degrees valgus deformity for the first 7 postoperative days and 6.1 valgus at the last follow up. CONCLUSION: These findings suggest that an autogenous structural bone graft and metal screw fixation has fine results and makes early ambulation possible for the patient who has severe varus deformity with a medial tibial bone defect.

Autogenous Bone Graft with Bone peg for the Medial Tibial Bone Defect in Total Knee Arthroplasty

PURPOSE: The aim of this study is to report the usability of autogenous bone graft with bone peg in total knee arthroplasty in the patients with tibial medial bone defect from osteoarthritis due to severe varus deformity. MATERIALS AND METHODS: From July 1998 to December 2000, fifteen total knee arthroplasties with autogenous bone graft were performed for the medial tibial bone defects. The proximal tibia was resected and then bone pegs which were prepared from resected portion of distal femur and proximal tibia were inserted into the defect site with the shape of peg in the anterior posterior view using press fitting method. Instead of applying screw or K-wire, we performed press-fitting method for early stability. For attaining the stability, we preserved the sclerotic rim and designed precisely the bony defect site. We reviewed the result using the HSS Knee Rating Scale and observed the radiologic change. RESULTS: In HSS Knee Rating Scale review, 52.4 of preoperative score was improved to 84.7 at postoperative 1 year. Tibio-femoral angle , the average 17.8 degrees of varus was improved to the average 5.8 degrees of valgus at 1 year postoperatively. The average union period was 5 months, and there was no evidence of the displacement of grafted bone and loosening of the inserted implants. CONCLUSION: The method of autogenous bone graft applied with bone peg could be supposed as the stable fixation method without using screws or K-wires.

Autogenous Bone Graft with Perpendicular Screw Fixation of the Medial Tibial Bone Defect in Total Knee Arthroplasty / 대한정형외과학회잡지

PURPOSE: We modified the Scuderi bone graft method for severely varus deformed patients, and then analyzed the clinical and radiological results and the changes of BMD at bone graft site. MATERIALS AND METHODS: Twenty-three total knee arthroplasties were performed in severely deformed varus knees. The proximal tibia was resected less than 10 mm thickness. In anteroposterior and tibial plateau view, defects was converted into a trapezoidal wedge shape for the self locking, and preserved anterior and posterior cortex. The defect was filled with an autogenous bone graft and fixed with two screws perpendicularly for early ambulation. RESULTS: The graft was completely united in 21 cases (90%) and the average of the union was 4 months postoperatively. The results were classified as excellent in 16 knees (70%) , good in 6 knees (26%) , and fair 1 knee (4%) using HSS knee rating scale. The average arc of motion was 115. and the tibio-femoral angle was 6.3. valgus. The BMD of bone graft site was checked 1.03 +/- 0.033 g/cm2 postoperatively and converted to 0.82 +/- 0.075 g/cm2 at follow-up 1 year. CONCLUSION: Modified autogenous bone graft could be preserved the subchondral bone essential for optimal thickness of cement and fixation of the tibial component.

Screw and Cement Fixation of Tibial Bone Defects in Total Knee Replacement

PURPOSE: To evaluate clinical and radiographic results for screw and cement fixation of tibial bone defect in total knee replacement arthroplasty(TKRA) retrospectively. MATERIALS AND METHODS: From march 1995 to May 1998, 23 total knee replacement arthroplasties were performed in 19 adults with screw and cement fixation for tibial bone defect. They were followed retrospectively for at least 12 months at mean 28 months(12~50). The average age of the patients at the time of operation was 64 years. The American Knee Society clinical rating system was used for the assessment of the results. We also used Knee Society roentgenographic evaluation and scoring system in all cases for assessment of radiolu-cent line between bone and cement interface, prothesis and cement, and around the threads of the screw within the bone. RESULTS: The average 37.6 preoperative knee rating score and 41 functional score were improved to 94.9 and 95 retrospectively at the last follow-up. Roentgenographic evalua- tion revealed that no radiolu-cent line was detected between prothesis and cement, around the threads of the screws within the bone. Between bone and cement interface, we observed radiolucent line in 8 of 23 cases(34.8%) and they had no progression during follow-up. CONCLUSIONS: Screw and cement fixation may be tried when tibial bone defect are small and situated peripherally. But, we considered that more long-term follow-up evaluation must be needed.

Treatment of Tibial Bone Defect by Internal Bone Transport Using Ilizarov Method / 대한정형외과학회잡지

We reviewed twenty-six tibial bone defects which had been treated by internal bone transport to evaluate the results and complications and of the Ilizarov method. The causes of defects were open fracture(13 cases) and infected non-union(13 cases) The mean bone defect was 8.2 cm, ranging from 2 cm to 20 cm, in open fracture and 6.5 cm, ranging from 2 cm to 17 cm, in infected nonunion. All cases attained bone union. The mean radiologic consolidation index was 1.3 month/cm. The mean external fixation time was 18.5 months, ranging from 4 months to 33 months. Complications were pin-tract infection(20 cases), equines contracture of ankle(4 cases), knee flexion contracture(1 case), axial deviation(5 cases), valgus deformity of ankle(1 case), leg length discrepancy(7 cases), stress fracture at corticotomy site(2 cases), delayed union(1 case), infection recurrence(1 case), soft tissue invagination(3 cases) and refracture(2 case). The Ilizarov method is a useful treatment for tibial bone defects. Bone grafting at the docking site is recommended in order to shorten the treatment time and to avoid refracture and nonunion.

Autogenous bone Graft of the tibial Bone Defect in Total Knee Replacement / 대한정형외과학회잡지

In case of the large bone defect due to severe varus or valgus deformity in total knee replacement, there are many different methods for reconstruction of the bone defect for insertion of the tibial component after resection of the proximal tibia. Total knee replacement using the autogenous bone graft were performed in 27 knees (18 patients) with tibial bone defect. Authors report the methods and results with an average 23 months follow-up. We used the bone removed from distal femur and calculated the size of the proximal tibia. We used the screws, if necessary, for rigid fixation of the grafted bone. l. According to the type of bone defect, central defect type were 3 knees, peripheral defect type were 13 knees and combined type were 11 knees. 2. In A-P view of x-ray, the size of bone defect of the tibial plateau ranged 5mm to 25mm (average 11.1mm) in height. 3. Screws were used for fixation of grafted bone in 14 knees and the average size of the screws was 27.8mm. 4. Bony union of the grafted bone achieved from 3 months to 12 months (average 5.7months). 5. Average knee ROM was 105 degrees and improved post-operatively 121 degrees, and average flexion contracture was 22.4 degrees and improved post-operatively 7.5 degrees. 6. Post-operative tibiofemoral angle was average 7.5 degrees valgus. 7. Average knee rating score was 54.5 and improved post-operatively 89.2. 8. The comlication of bone graft was partial resorption in 1 case and the loosening or displacement due to screw were abscent.