Treatment of Infected Pseudarthrosis of the Tibia Using the Ilizarov Method and the Orr Dressing / Tratamento das pseudoartroses infectadas da tÍbia pelo mÉtodo de Ilizarov associado ao curativo de Orr

Abstract Objective This study aims to analyze outcomes and clinical and epidemiological data of infected tibial pseudarthrosis using the Ilizarov method and the Orr dressing. Methods Data from n = 43 patients diagnosed with infected tibial pseudarthrosis were analyzed by descriptive and inferential statistical methods. In addition, Paley's assessment criteria evaluated bone and functional outcomes. Qualitative variables were presented as the distribution of absolute and relative frequencies. The presentation of quantitative variables followed the D'Agostino-Pearson test. Results Thirty-seven (86.04%) subjects were males, and six (13.95%) were females. The most frequent age group among patients was 50 to 59 years old (25.6%), with a p-value = 0.8610. The treatment time was longer for the trifocal treatment (23.8 months) when compared to the bifocal treatment (15.6 months), with a p-value = 0.0010* (highly significant). Excellent bone outcomes represented 72.09% of the sample; 23.25% of outcomes were good. Functional outcomes were excellent in 55.81%, good in 6.97%, and regular in 27.90% of subjects. The Orr dressing (using Vaseline gauze) proved effective, achieving wound healing with soft tissue coverage in all patients evaluated. Conclusions The Ilizarov method resulted in a substantial change in the treatment of bone infections, especially infected pseudarthrosis. The versatility of this method has turned it into an effective tool, allowing the healing of the infectious process and the correction of potential deformities and shortening.

Resumo Objetivo Analisar os resultados e os dados clínicos e epidemiológicos do tratamento das pseudoartroses infectadas da tíbia pelo método de Ilizarov associado ao curativo de Orr. Métodos Para analisar os dados de n = 43 pacientes com diagnóstico de pseudoartrose infectada da tíbia foram aplicados métodos estatísticos descritivos e inferenciais e os resultados ósseos e funcionais foram avaliados de acordo com os critérios de avaliação de Paley. As variáveis qualitativas foram apresentadas por distribuição de frequências absolutas e relativas. As variáveis quantitativas foram apresentadas pelo teste de DAgostino-Pearson. Resultados Foi encontrado que 37 (86,04%) eram do sexo masculino, 6 (13,95%) femininos. A faixa etária mais frequente entre os pacientes foi de 50 a 59 anos (25.6%), p-valor = 0.8610. O tempo de tratamento é maior no tratamento trifocal (23.8 meses) quando comparado com o Bifocal (15.6 meses), p-valor =0.0010* (altamente significante). Os resultados ósseos excelentes representaram 72,09%, 23,25% foram de resultados considerados bons. Os resultados funcionais considerados excelentes foram 55,81%, os resultados bons foram 6,97%, resultados regulares foram 27,90. O curativo com gaze vaselinada (curativo de Orr) mostrou-se eficaz, alcançando assim a cicatrização das feridas com cobertura de partes moles em todos os pacientes avaliados. Conclusões O método de Ilizarov proporcionou uma mudança substancial no tratamentos das infecções ósseas, especialmente das pseudoartroses infectadas. A versatilidade deste método se transformou em uma ferramenta eficaz, permitindo a cura do processo infeccioso, bem como correção das possíveis deformidades e do encurtamento.

Comparison of acute shortening-lengthening and antibiotic calcium sulfate-loaded bone transport for the treatment of segmental tibial defects after trauma / 国际外科学杂志

Objective:To compare the clinical effects of acute shortening-lengthening technique with antibiotic calcium sulfate-loaded bone transport technique for the treatment of segmental tibial defects after trauma.Methods:The clinical data of 58 patients with large tibial defects treated by Ilizarov technique in Xi′an Honghui Hospital Affiliated to Xi′an Jiaotong University from May 2014 to December 2019 were retrospectively analyzed. Thirty patients were treated by acute shortening-lengthening (group A), and they were divided into those who were successful in one-time shortening during operation (group A1) and those who needed gradual shortening after operation (group A2) according to different shortening conditions. And 28 patients by antibiotic calcium sulfate-loaded bone transport (group B). The external fixation time (EFT) and external fixation index (EFI) of the two groups were compared. Bone defect healing and limb functions were evaluated according to the Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria. Complications were compared by Paley classification. The measurement data of normal distribution were expressed as ± s, and t-test was used for comparison between groups; the count data were expressed as n(%), and the chi-square test, Fisher exact probability method or Mann-Whitney U test were used for comparison between groups. Results:Patients were followed for(27.5±5.1)months. There was no significant difference in EFT, EFI, bone defect healing and limb functions between the two groups( P>0.05). The incidence of Grade-Ⅱ[41.2% (7/17)], Grade-Ⅲ [47.1% (8/17)] pin-tract infection in group A1 and Grade-Ⅱ[46.2% (6/13)], Grade-Ⅲ pin-tract [53.8% (7/13)] in group A2 was significantly higher than those in group B[14.3% (4/28)], [17.9% (5/28)] ( P<0.05). The number of complications per capita in group A1 [(1.4±0.3) times/case] and in group A2 [(1.5±0.3) times/case]was significantly higher than that in group B [(1.1±0.5) times/case]. Conclusions:Patients can be cured successfully by both acute shortening-lengthening and bone transport techniques. Compared with acute shortening-lengthening group, the complication incidence in antibiotic calcium sulfate-loaded bone transport group was lower, especially, the infection-related complications. Therefore, antibiotic calcium sulfate-loaded bone transport technique has a greater application prospect in patients with large segmental bone defects caused by infection or osteomyelitis.

Analysis of the effectiveness of sequential plate internal fixation in correction of Madelung deformity after ulnar osteotomy and shortening / 中国修复重建外科杂志

OBJECTIVE@#To investigate the effectiveness of sequential plate internal fixation in the correction of Madelung deformity after ulnar osteotomy and shortening.@*METHODS@#The clinical data of 13 patients with Madelung deformity admitted between September 2015 and July 2021 were retrospectively analyzed. There were 5 males and 8 females with an average age of 18.3 years ranging from 17 to 23 years. The disease duration ranged from 12 to 24 months, with an average of 17 months. Three cases had a clear history of trauma. All patients had external radial deviation deformity and limited movement of the ulnar deviation, and the ulnar impact pain was significant during ulnar deviation movement; 9 patients had limited wrist joint supination movement, and the supination movement was normal. In the first stage, ulnar osteotomy and shortening combined with external fixator were used to correct wrist deformity in 13 patients. After operation, bone transfer was performed 6 times per day, with adjustments made every 4 hours, which was 1 mm per day. After the osteotomy was in place, the ulnar plate internal fixation was performed to reconstruct the ulnar stability in the second stage. The Cooney wrist joint score was used to assess the pain, function, range of motion, flexion and extension range of motion, and grip strength of the wrist joint before operation and before the removal of internal fixator. The subjective feeling and appearance satisfaction of patients were recorded.@*RESULTS@#After the second-stage operation, all the 13 patients were followed up 10-22 months, with an average of 15 months. The deformity of wrist joint disappeared after operation, and the flexion, extension, and ulnar deviation were basically normal. There was no complication such as ulnar impingement sign, nonunion or infection. Wrist function, pain, and range of motion were significantly improved after operation, except for 1 patient who had no significant improvement in rotation and pain. The ulnar internal fixator was removed at 10-18 months after the second-stage operation. The scores of pain, function, range of motion, flexion and extension range of motion, and grip strength in the Cooney wrist score before removal of internal fixator significantly improved when compared with those before operation ( P<0.05). Subjective and appearance satisfaction of patients were excellent in 9 cases, good in 3 cases, and fair in 1 case.@*CONCLUSION@#Ulnar osteotomy and shortening with sequential plate internal fixation for correction of Madelung deformity, with mild postoperative pain, can effectively avoid bone nonunion, improve wrist joint function, and have significant effectiveness.

Study on characteristics of microvascular perfusion with superb micro-vascular imaging after tibia transverse bone transport for diabetic foot / 中华骨科杂志

Objective:To explore the clinical value of super micro vascular imaging (SMI) in evaluating the microvascular perfusion of diabetes foot treated by tibial transverse bone transport.Methods:A retrospective study of 18 diabetic foot patients who underwent tibial transverse bone transport in the Second Hospital of Shanxi Medical University from May 2019 to December 2021 were analysed, including 12 males and 6 females, with an average age of 64.89±14.34 years (range, 30-90 years). All patients had varying degrees of foot ulcer. Before and after the operation, the blood vessels of the patient's lower leg and foot were examined. The display rate of low-velocity blood flow was compared between color Doppler flow imaging (CDFI) and SMI; the blood flow and vascular index at the beginning of the first dorsal metatarsal artery before and after operation under SMI were compared; the number and length of new blood vessels were also compared before and after operation.Results:All patients were followed up for at least 2 months. CDFI blood flow display rate was 73.6% (106/144), and SMI blood flow display rate was 80.6% (116/144), the difference was statistically significant (χ 2=4.68, P=0.031). Under SMI, the blood flow at the beginning of the first dorsal metatarsal artery on the affected side was measured before operation 3.38 (1.33, 7.56) ml/min, 1 week after operation 4.19(2.84, 11.48) ml/min and 1 month after operation 3.72 (2.52, 11.40) ml/min, with statistically significant difference (χ 2=9.46, P=0.009). There were statistically significant differences in blood flow at 1 week and 1 month after operation compared with that before operation ( P=0.033, P=0.003). The vascular index at the beginning of the first dorsal metatarsal artery on the affected side was 3.84±3.60, 6.51±4.92 and 6.82±5.36 before operation, 1 week and 1 month after operation, respectively, and the differences were statistically significant( F=4.35, P=0.031). The vascular index in the first week after operation was significantly higher than that before operation ( P=0.026). Up to the last follow-up, the number of new collaterals in 18 patients was 4.5 (2, 8), which was significantly different from 1 (0, 2) before operation ( Z=-3.57, P=0.001). In total, the length of 18 new blood vessels in 9 patients was longer than that before operation, and the establishment of grade 2 and grade 3 branches were observed in 5 patients. The superficial subcutaneous vessels were showed more clarity than that before surgery, and there was collateral circulation on the opposite side. Conclusion:SMI objectively reflects the changes of hemodynamics and microcirculation of patients after tibial transverse bone transport, and helps clinical preliminary predict the prognosis of patients and adjust individual treatment plan according to blood perfusion in time.

Treatment of infected tibial nonunion plus soft tissue defects with an Ilizarov external fixator combined with pedicle flap transfer / 中华创伤骨科杂志

Objective:To investigate the clinical effects of Ilizarov external fixation combined pedicle flap transfer in the treatment of infected tibial nonunion plus soft tissue defects.Methods:A retrospective study was performed to analyze the data of 35 patients with infected tibial nonunion plus soft tissue defects who had been admitted to Department of Orthopedic Trauma, Tianjin Hospital Affiliated to Tianjin University from July 2005 to July 2020. There were 25 males and 10 females with an age of (37.5±6.0) years. Their original traumas were 27 open and 8 closed fractures, with a disease course ranging from 8 to 42 months. Three patients had undergone 1 operation, 7 patients 2 operations, and 25 patients 3 or more operations. All patients presented with different degrees of skin and soft tissue defects or bone exposure, wound sinus formation and bone scaring. The size of pedicle flaps transferred ranged from 6 cm×5 cm to 15 cm×10 cm. Surgical transfer of skin flap and external fixation were performed at one stage in 25 patients while staged surgery was performed in 10 patients. The first stage consisted of local debridement, vacuum sealing drainage, and delayed flap operation while the second stage consisted of delayed flap transfer and Ilizarov external fixation. The survival of skin flap, limb shortening, bony union and complications were observed after operation. The limb function was evaluated according to the criteria of The Association for the Study and Application of Methods of Ilizarov (ASAMI) for bone and functional results.Results:All patients were followed up for (23.8±7.4) months. Fracture union was achieved in all. The flaps survived postoperatively, the wounds were repaired by the first intention, infection did not recur, and bony union was achieved in 32 patients. Partial necrosis of the flap edge occurred in 3 cases, but responded to dressing change. In the 10 patients undergoing delayed flap operation, 100% of the flaps survived. In all patients, the limbs were shortened by (0.8±0.1) cm, and the tibial fractures got united after (7.2±1.2) months. By the ASAMI criteria for bone results, 29 cases were excellent and 6 cases good; by the ASAMI criteria for functional results, 25 cases were excellent, 8 cases good, and 2 cases fair.Conclusion:As Ilizarov external fixation combined pedicle flap transfer can repair bone and soft-tissue defects at the same time, this surgical scheme facilitates infection control and leads to reliable outcomes.

"Accordion" technique to promote bony union at the docking site in the treatment of tibial bone defects by Ilizarov technique / 中华创伤骨科杂志

Objective:To evaluate the effect of "accordion" technique on promoting bony union at the docking site in the treatment of tibial bone defects by bone transport.Methods:A retrospective study was conducted to analyze the data of 11 patients with tibial bone infection who had been admitted to Department of Orthopedics, The Second Hospital of Shanxi Medical University from November 2017 to February 2019. There were 10 males and 1 female with an age of (47.0±9.7) years. Seven patients were infected after internal/external fixation for open fractures and 4 cases after internal fixation for closed fractures. After surgical debridement, sensitive antibiotic bone cement was implanted, and dead or infected bone segments were radically resected. In all patients, the resulting bone defects of (6.6±2.9) cm were fixated by an Ilizarov ring external fixator and filled by bone transport. The "accordion" technique was used after the bone segments touched the docking site. The closure time, "accordion" time, bony union time and complications during bone transport were recorded.Results:None of the patients underwent bone grafting. This case series was followed up for (2.7±0.5) years. The closure time was (30.8±6.8) weeks, the "accordion" time (43.1±8.4) days, and the bony union time (31.6±9.0) weeks. None of the patients had obvious pain. Ankle stiffness was observed in 3 patients and traumatic equinus deformity in 1 patient.Conclusions:The "accordion" technique based on the Illizarov technique can accelerate mineralization of the bone segments transported, promote the bony union at the docking site, and effectively solve the problem of tibial bone defects without surgical bone grafting.

Tibial transverse bone transport assisted by nose ring drainage for treatment of foot and ankle chronic osteomyelitis / 中华创伤骨科杂志

Objective:To investigate the clinical effects of tibial transverse bone transport assisted by nose ring drainage (NRD) in the treatment of foot and ankle chronic osteomyelitis.Methods:A retrospective study was conducted to analyze the data of 32 patients with foot and ankle chronic osteomyelitis who had been treated at Department of Orthopedics, Beijing Rehabilitation Hospital from March 2013 to February 2022. The patients were assigned into a study group and a control group. In the control group, there were 12 males and 3 females, aged (39.5±8.8) years. The osteomyelitis was located at the distal tibia in 4 cases, at the talus in 1 case, at the calcaneus in 2 cases, at the midfoot in 4 cases and at the forefoot in 4 cases. According to the Crerny-Mader classification, there were 5 cases of type Ⅰ and 10 cases of type Ⅱ. The control group was treated with Ilizarov transverse tibial bone transport in combination with thorough debridement and anti-infection therapy. In the study group, there were 12 males and 5 females, aged (42.3±13.4) years. The osteomyelitis was located at the distal tibia in 4 cases, at the talus in 1 case, at the calcaneus in 3 cases, at the midfoot in 5 cases and at the forefoot in 4 cases. According to the Crerny-Mader classification, there were 7 cases of type Ⅰ and 10 cases of type Ⅱ. The study group was treated with NRD drainage in addition to the procedures in the control group. The curative effects were evaluated by comparing the cure, recurrence, amputation (toe amputation), antibiotic use time, wound healing time, relevant inflammatory indicators [WBC, neutrophil percentage (NEU), erythrocyte sedimentation rate (ESR), procalcitonin, interleukin-6 (IL-6), C-reactive protein (CRP)], and postoperative functional recovery between the 2 groups.Results:The 2 groups were comparable because there was no statistically significant difference in the general data between them ( P>0.05). The follow-up period was (36.0±9.8) months. There was no significant difference between the 2 groups in the cure or amputation (toe amputation) ( P>0.05), but the recurrence rate in the study group was significantly lower than that in the control group ( P<0.05). The antibiotic use time [(20.7±3.6) d] and wound healing time [(88.3±17.1) d] in the study group were significantly shorter than those [(37.9±6.5) d and (102.2±22.6) d] in the control group ( P<0.05). The ESR, IL-6 and CRP at 1 week after operation in the study group were significantly lower than those in the control group ( P<0.05), but there was no significant difference between the 2 groups in the WBC, NEU or PCT at 1 week after operation ( P>0.05). There was no significant difference either in the inflammatory indicators between the 2 groups at 1 month after operation ( P>0.05). In all patients, the inflammatory indicators like WBC, NEU, ESR, PCT, IL-6 and CRP at 1 week and 1 month after operation were significantly better than those before operation, and the Maryland foot functional score at 12 months after operation was significantly higher than the preoperative one ( P<0.05). There was no significant difference between the 2 groups in the Maryland foot functional score at 12 months after operation ( P>0.05). Conclusion:In the treatment of foot and ankle chronic osteomyelitis, compared with the Ilizarov transverse tibial bone transport, our tibial transverse bone transport assisted by NRD can achieve satisfactory therapeutic effects, shorten antibiotic use time and treatment cycle, and reduce recurrence rate.

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.

Establishment of a rat model of transverse tibial bone transfer on the diabetic foot / 中华创伤骨科杂志

Objective:To establish a rat model of transverse tibial bone transfer on the diabetic foot.Methods:A diabetic model was created by intraperitoneal injection of streptozotocin into 40 SD rats after 5 weeks of high-fat feeding, taking random blood glucose ≥16.7 mmol/L as the criterion for successful modeling. Changes in body weight, food intake, water intake, faecal output and blood glucose were monitored every week after the acclimatization period until random blood glucose ≥16.7 mmol/L was observed for 3 running weeks. After the blood glucose was stabilized, 34 surviving diabetic rats were divided into 2 groups using a random number table. In the experimental group, a transverse transfer outer frame was installed and transverse tibial bone transfer performed after removal of the skin over the dorsal foot; in the control group, a transverse transfer outer frame was installed and the skin over the dorsal foot removed but no transverse tibial bone transfer performed. The wound changes were recorded on the 1, 5, 10, 15 and 20 days after installation of the transverse transfer outer frame. After completion of transverse tibial bone transfer (24 days after modeling of transverse tibial bone transfer), one rat was randomly chosen from each of the 2 groups for angiography while the rest rats were sacrificed for observation of the skin changes on the lower limbs. The densitometric values of CD31 immunohistochemical staining were compared between the 2 groups.Results:The random blood glucose increased from (6.89±1.03) mmol/L before modeling to (25.91±6.42) mmol/L at the last test, keeping at ≥16.7 mmol/L for 3 running weeks. The percentages of ulcer healing of the foot dorsal wound in the experimental group on days 5, 10, and 20 were significantly higher than those in the control group ( P<0.05). Gross observation and angiography found more abundant vessels in the lower extremity on the side of transverse transfer in the experimental group. The immunohistochemical staining of the lower limb skin tissue for CD31 found an AOD value of 0.60±0.23 in the experimental group, significantly higher than that in the control group (0.37±0.13) ( t=3.722, P=0.001). Conclusion:A rat model of transverse tibial bone transfer has been successfully established through installation of a self-designed transverse transfer outer frame on the basis of a successful rat model of diabetic foot, characterized by improved microcirculation in the lower limbs.

Application progress of Ilizarov technique in orthopedics / 中国基层医药

Ilizarov technique is designed based on the "tension-stress principle". Application of the Ilizarov technique can help form a stable mechanical structure through external fixation. It only creates small wounds, without peeling off the surrounding tissue and periosteum. It connects different types of fixation pins and bone or soft tissue to form a traction force, which continuously stimulates the regeneration of bone and tissue and improves the local blood supply and early functional rehabilitation exercises, forming a complete set of minimally invasive orthopedic treatment systems. Ilizarov technique has achieved good results in fracture healing, deformity correction, tissue repair, osteomyelitis, bone nonunion, bone defect, and bone tumor. This paper will summarize the clinical application and research of the Ilizarov technique in orthopedics and explore the key problems of the Ilizarov technique that need to be solved at present.

Ilizarov Ring External Fixation for Complex Tibial Plateau Fractures / Fixação externa do anel de Ilizarov para fraturas complexas do platô tibial

Abstract Objective To analyze the results of clinical, radiological, and functional outcomes of tibial plateau fracture (Schatzker Type V, VI) treated with Illizarov ring external fixator with or without minimum opening. Methods A total of 52 tibial plateau fractures of type V, VI were treated with Ilizarov ring external fixator with or without mininum internal fixation were studied. Functional outcome assessment was done using the American Knee Society (AKS) score with clinical, radiological union, and complications were analyzed. Results There were 37 (71.15%) male and 15 (28.84%) female patients, with a mean age of 39.07 ± 12.58 years old. Road traffic accidents (RTAs) were the major cause of fracture, accounting for 32 cases (61.53%) followed by fall injury, with 16 cases (30.76%), and direct impact, with 4 cases (7.69%). Twenty-one (40.38%) cases were type V and 31 (59.61%) cases were type VI fractures, and there were 24 (46.15%) cases of open fracture. The mean AKS score of Type V and Type VI fractures were 82.8 and 80.70, respectively, but this was statistically not significant at p<0.05. The mean AKS score of closed and open fractures were also statistically not significant at p<0.05. Conclusions For Schatzker Types V and VI complex tibial plateau fractures, Ilizarov external fixation is a safe, cost-effective and efficient treatment method that presents a satisfactory outcome.

Resumo Objetivo Analisar os resultados clínicos, radiológicos e funcionais da fratura do planalto tibial (Schatzker Tipo V, VI) tratada com fixador externo do anel Illizarov com ou sem abertura mínima. Métodos Um total de 52 fraturas do planalto tibial dos tipos V e VI foram tratadas com fixador externo do anel Ilizarov com ou sem fixação interna mínima. A avaliação do desfecho funcional foi feita utilizando-se o escore da American Knee Society (AKS, na sigla em inglês) com consolidação clínica, radiológica e complicações encontradas. Resultados Foram 37 (71,15%) pacientes do sexo masculino e 15 (28,84%) do sexo feminino, com idade média de 39,07 ± 12,58 anos. Acidentes de trânsito (ATs) foram a principal causa das fraturas, contabilizando 32 casos (61,53%), seguidos por lesão por queda, com 16 casos (30,76%), e impacto direto, com 4 casos (7,69%). Foram 21 (40,38%) casos de fraturas tipo V, 31 (59,61%) casos do tipo VI e 24 (46,15%) casos de fratura exposta. Os escores médios da AKS para as fraturas tipo V e VI foram de 82,8 e 80,70, respectivamente, mas não foi estatisticamente significativo em p <0,05. O escore médio da AKS para fraturas fechadas e abertas também não foi estatisticamente significativo em p <0,05. Conclusões Para a fratura do planalto tibial complexa dos tipos V e VI de Schatzker, a fixação externa de Ilizarov é um método de tratamento seguro, econômico e eficiente que resulta em resultados satisfatórios.

Evaluation of the Quality of Life of Patients Using Circular External Fixator in a Trauma Hospital / Avaliação da qualidade de vida dos pacientes em uso de fixador externo circular em um hospital de trauma

Abstract Objective To evaluate the quality of life of patients using an Ilizarov type external fixator for the treatment of complicated fractures and their sequelae. Method This is an observational and cross-sectional study, in which the 36-item short form survey (SF-36) questionnaire (translated into Portuguese) was applied during outpatient consultations in 2 periods, in the months of July 2018 and January 2019. The patients who participated in the study underwent their surgical procedures between January and June 2018. Results We evaluated 36 patients using an external Ilizarov fixator. We observed a predominance of male patients, with a mean age of 37.9 years. Fractures of leg bones and their complications represented half of the sample. Improvement in functional capacity and emotional aspects of the patients was observed throughout the treatment. Conclusion The use of the circular external fixator is an important and effective method for the surgical treatment of complex fractures and their sequelae. This study allowed us to conclude that, after treatment, patients achieved functional return to daily activities with adequate quality of life.

Resumo Objetivo Avaliar a qualidade de vida dos pacientes em uso do fixador externo do tipo Ilizarov para tratamento de fraturas complexas e de suas sequelas Método Trata-se de um estudo observacional e transversal, em que foi aplicado o questionário 36-item short form survey (SF-36) (traduzido para a língua portuguesa) durante as consultas ambulatoriais em 2 períodos, nos meses de julho de 2018 e janeiro de 2019. Os pacientes que participaram do estudo realizaram seus procedimentos cirúrgicos no período de janeiro a junho de 2018. Resultados Foram avaliados 36 pacientes em uso de fixador externo do tipo Ilizarov. Foi observado predomínio do sexo masculino e idade média de 37,9 anos. As fraturas de ossos da perna e suas complicações representaram metade da amostra. Foi observada melhora na capacidade funcional e nos aspectos emocionais dos pacientes ao longo do tratamento. Conclusão O uso do fixador externo circular constitui um método importante e eficaz para o tratamento cirúrgico de fraturas complexas e de suas sequelas. Este trabalho permitiu concluir que, após o tratamento, os pacientes alcançaram retorno funcional às atividades diárias com adequada qualidade de vida.

Biplane osteotomy and bone transport combined external locking plating for sequential treatment of massive tibial bone defects / 中华创伤骨科杂志

Objective:To evaluate biplane osteotomy and bone transport combined external locking plating for sequential treatment of massive tibial bone defects.Methods:Twenty-eight patients with massive tibial bone defects were reviewed who had been treated at Department of Repair and Reconstruction, Wuhan Puai Hospital from October 2013 to October 2019. They were divided into a bone transport group and a combined bone transport group (bone transport combined external locking plating) according to their surgical methods. In the bone transport group of 14 cases, there were 10 males and 4 females with an age of (38.6±3.2) years and a bone defect of (8.0±0.5) cm; in the combined bone transport group of 14 cases, there were 9 males and 5 females with an age of (39.1±3.9) years and a bone defect of (8.3±0.3) cm. The time for wearing external fixator, fracture healing time, dock-in-site healing time, postoperative function assessment and complications were observed and compared between the 2 groups.Results:There was no significant difference between the 2 groups in their preoperative general data, showing they were comparable ( P>0.05). The bone transport group were followed up for 12 to 28 months (average, 18.4 months) and the combined bone transport group for 12 to 26 months (average, 16.8 months). The time for wearing external fixator in the combined bone transport group [(8.4±0.7) months] was significantly shorter than that [(13.3±1.4) months] in the bone transport group ( P<0.05). No significant difference was observed between the 2 groups in either the fracture healing time [(8.4±1.3) months versus (7.4±1.2) months] or the dock-in-site healing time [(210.2±9.1) months versus (206.2±9.8) months] ( P>0.05). By the Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring, the bone healing was excellent in 6, good in 5 and fair in 3 cases in the bone transport group while excellent in 8, good in 4 and fair in 2 cases in the combined bone transport group, showing no significant difference between the 2 groups in the excellent to good rate ( P>0.05). By the postoperative functional assessment of the lower extremity, there were 7 excellent, 3 good, 3 fair and one poor cases in the bone transport group while 8 excellent, 5 good and one poor cases in the combined bone transport group, showing no significant difference between the 2 groups in the excellent to good rate ( P>0.05). In the bone transport group, there were 3 cases of pin track infection, one case of dock-in-site nonunion, 2 cases of poor alignment of lower extremities, 2 cases of skin depression, one case of nail loosening, 5 cases of joint stiffness and 3 cases of delayed union of the distracted bone; in the combined bone transport group, there were one case of pin track infection, 2 cases of poor alignment of lower extremities, 3 cases of skin depression, 3 cases of joint stiffness, 2 cases of delayed union of the distracted bone and one case of refracture. Conclusion:In the sequential treatment of massive tibial bone defects, biplane osteotomy and bone transport combined external locking plating can reduce the time for wearing external fixator and increase the satisfaction of patients.

Research progress concerning the signaling pathway mechanisms related to mechanical stress-induced bone regeneration / 中华创伤骨科杂志

Elucidation of the signaling pathway mechanisms related to the mechanical stress-mediated bone regeneration is of great significance for improvement of bone regeneration and clinical treatment of bone-related diseases such as bone defects and bone elongation. Mechanical stress transmits mechanical stimuli into cells through the piezo channels and integrins, causing a variety of signaling pathway responses, which in turn changes transcription factor translocation, gene expression, and osteoblast differentiation to promote bone regeneration ultimately. This article reviews the research progress concerning the mechanisms related to mechanical stress-mediated bone tissue regeneration.

Tibial cortex transverse transport for long-term chronic wounds after serious lower limb trauma / 中华创伤骨科杂志

Objective:To explore the effects of tibial cortex transverse transport for long-term chronic wounds after serious lower limb trauma.Methods:From January 2016 to July 2021, 11 patients with long-term chronic wounds after lower limb trauma were treated at Department of Orthopedic Surgery, 920 Hospital of Joint Logistics Support Force of PLA. They were 7 males and 4 females, aged from 19 to 57 years (average, 32.3 years). There were 7 lesions of the popliteal artery and 4 ones of the anterior and posterior tibial arteries. The wound was located at the distal leg in 5 cases and at the foot and ankle in 6 ones. The wound size ranged from 3.2 cm × 2.8 cm to 9.5 cm × 7.3 cm. An external fixator for transverse transport was installed after the cortical bone fenestration was performed on the medial tibia more than 10 cm away from the wound surface, with a fenestration area of 5.0 cm × 1.8 cm. The wound was limitedly debrided, irrigated thoroughly and bandaged. Transverse transport began on the postoperative day 7, with the wounds opened for care and dressing change. The transverse transport lasted 25 days and the external fixators were dismantled 2 months after surgery. The healing of the wounds and incisions for transverse transport was observed.Results:The 11 patients were followed up for 3 to 20 months (average, 5.6 months). The wounds healed after 35 to 277 days. By the last follow-up, all the wounds healed without recurrence. Incision infection occurred in 2 patients, whose transverse transport was continued and wounds healed after local debridement; another patient suffered from poor incision healing, which responded gradually to decreased speed of transverse transport.Conclusion:Tibial cortex transverse transport can significantly improve the local blood supply and promote granulation and healing of long-term chronic wounds after serious trauma at the lower leg, foot and ankle.

Ilizarov external fixation combined with bone surface roughening technique for tibial dystrophic nonunion / 中华创伤骨科杂志

Objective:To investigate the clinical effects of Ilizarov external fixation combined with bone surface roughening technique in the treatment of tibial dystrophic nonunion.Methods:The data were retrospectively studied of the 11 patients with tibial dystrophic nonunion who had been treated at Department of Orthopedics, 920 Hospital of the Joint Logistic Support Force of PLA from April 2018 to January 2021. They were 7 males and 4 females, aged from 32 to 61 years (average, 44.6 years). Their last surgical fixation before admission was Hoffman Ⅱ external fixation in 6 cases and locking plate internal fixation in 5 cases. The time from their last operation to the present operation ranged from 9 to 26 months (average, 14.2 months). After treatment by Ilizarov external fixation combined with bone surface roughening technique, the 11 patients started weight-bearing walking with double crutches from the second day after operation, gradually progressed to walking with a single crutch 2 months after operation, and resumed normal weight-bearing walking without any crutch 3 months after operation.Results:All the 11 patients were followed up for 12 to 30 months (average, 20.0 months). The time for bearing Ilizarov external fixation ranged from 6 to 10 months (average, 8.6 months). Mild pin track infection occurred in 4 cases but was healed by pin track rinse with normal saline; moderate pin track infection happened in another 2 cases but responded to oral amoxicillin capsules for one week in addition to pin track rinse with normal saline. All the bone dystrophic nonunion was cured after 6 to 10 months (average, 8.6 months). By the bone criteria of Association for Study and Application of Method of Ilizarov (ASAMI), the efficacy was excellent in 8 cases, good in 2 and fair in one at the last follow-up; by the limb function criteria of ASAMI, the efficacy was excellent in 9 cases and good in 2 at the last follow-up.Conclusion:Ilizarov external fixation combined with bone surface roughening technique is an effective treatment of tibial dystrophic nonunion.

Risk factors for axial deviation in treatment of tibial bone defects by bone transport with Orthofix unilateral external fixator / 中华创伤骨科杂志

Objective:To investigate the risk factors for axial deviation in the treatment of tibial defect susing Orthofix unilateral external fixator and proximal tibial osteotomy for bone transport.Methods:A retrospective study was performed to analyze the clinical data of 90 patients who had been treated for tibial bone defects by the Orthofix unilateral external fixator at Department of Microrepair and Reconstruction, The First Hospital Affiliated to Xinjiang Medical University from May 2012 to June 2019. There were 77 males and 13 females with a mean age of 41.2 years (from 17 to 63 years).The bone defects ranged from 4 to 13 cm in length. According to the Paley criteria for axial deviation, the 90 patients were divided into 2 groups: a deviation-free group with no axial deviation or an axial deviation ≤5° and a deviation group with an axial deviation>5°. The 2 groups were compared in terms of age, number of prior surgery, defect length, placement angle of Schanz screws, external fixation time, external fixation index and bending degree of Schanz screws at the last follow-up.The factors with P<0.05 were analyzed by multivariate logistic regression to find the risk factors for coronal axial deviation. Results:The 90 patients were followed up for an average of 23 months (from 12 to 40 months). The incidence of axial deviation in this cohort was 36.7% (33/90).The deviation group had a significantly larger number of prior surgery [5 (3, 6) times], a significantly longer defect length [8 (8, 9) cm], a significantly longer external fixation time [400.0 (341.8, 426.3) d], and a significantly greater bending degree of Schanz screws at the last follow-up [1.2° (0.4°, 3.5°)] than the deviation-free group [3 (2, 3) times, 6 (5, 8) cm, 340.8 (226.5, 422.8) d, and 0.8° (0.2°, 3.7°)] (all P<0.05). Multivariate logistic regression analysis showed that the number of prior surgery ( OR=2.581, 95% CI: 1.496-4.450, P=0.001) and the defect length ( OR=5.310, 95% CI: 1.952-14.442, P=0.001) were the risk factors for the axial deviation. Conclusion:In the treatment of tibial defect susing Orthofix unilateral external fixator and proximal tibial osteotomy for bone transport, the more prior surgeries and the longer a bone defect, the higher the risk for axial deviation.

Treatment of traumatic fibrous stiffness of the knee with a combination of arthrolysis and Ilizarov tech-nique / 中华创伤骨科杂志

Objective:To investigate the clinical efficacy and indications of arthrolysis plus Ilizarov technique in the treatment of traumatic fibrous stiffness of the knee.Methods:The clinical data were analyzed retrospectively of the 9 patients (10 knees) with traumatic fibrous stiffness who had been treated by arthrolysis plus Ilizarov technique from January 2012 to December 2020 at Department of Orthopaedics, Rehabilitation Hospital of National Research Center for Rehabilitation Technique Aids. There were 8 males and one female, aged from 15 to 42 years (average, 30.2 years). The left side was affected in 2 cases, the right side in 6 ones and bilateral sides in one. Their knee stiffness was all caused by injury around the knee. The time from injury to treatment ranged from 12 months to 38 years (average, 16.5 years). The admission examination revealed that the knee extension ranged from -40° to 0° and the knee flexion from -10° to 40°. Wearing time for the external fixator and incidence of complications were recorded; the ranges of knee motion were compared before and after treatment; the Qin Sihe criteria for postoperative limb deformity correction were used at the last follow-up to evaluate the curative efficacy.Results:The 9 patients were followed up for 20 to 78 months with an average of 35 months. The external fixators were worn for 14 to 200 days with an average of 78.4 days. During the traction period, pin tract reaction (3 holes) occurred in 2 patients with 3 knees, pin tract infection (2 holes) in 2 patients with 2 knees, the incision healed poorly in one patient, and no other complications occurred. The functional recovery of the knee was good at the last follow-up. The knee extension was 0°, insignificantly different from the preoperative value (-6.5°±12.9°) ( t=-1.591, P=0.146); the flexion angle was 70.0°±17.6°, significantly better than the preoperative value (15.0°±17.2°) ( t=-6.822, P< 0.001). According to the Qin Sihe postoperative criteria, the curative efficacy at the last follow-up was excellent in 7 knees and good in 3. Conclusion:In the treatment of traumatic fibrous stiffness of the knee, when the efficacy of simple arthrolysis is not good enough, a combination with Ilizarov technique can help improve the postoperative knee function and prevent severe complications.

Sciatic nerve injury and its effect on bone regeneration in distraction osteogenesis zone in rat / 中华显微外科杂志

Objective:To evaluate the effect and mechanism of bone regeneration in distraction osteogenesis zone after the repair of sciatic nerve in rats.Methods:Between January 2021 and August 2021, 60 healthy adult male Sprague-Dawley rats were divided randomly into 3 groups: Group A, B, and C. In groups B and C, right sciatic nerve transection and anastomosis were performed. Then after 8 and 12 weeks, the 3 groups were treated with extension external fixation (Ilizarov technique) of right femur osteotomy to make distraction osteogenesis model. Electrophysiological changes of peripheral nerves were monitored by electromyography (EMG) pre-and postoperatively in all the femoral lengthening rats. The formation of callus was examined by X-ray every week after operation. The rats were sacrificed on 2nd, 4th, 6th weeks after the bone transport operation. Four-point bending test and histological staining examination were carried out to determine the osteogenesis in the distracted area. SPSS 21.0 was used for statistical analysis. Data of measurement were expressed as (Mean±SD). A non-parametric test was used to assess the statistical difference between groups. Graphs were plotted by GraphPad Prism 8.0 and considered statistically significant when P<0.05. Results:The results of Sciatic nerve function index (SFI), Compound muscle action potential (CMAP) and Motor nerve conduction velocity (MNCV) in group A were better than the group B and group C in both of before and after the surgery. At the 2nd and 4th weeks of the consolidation stage, X-ray showed that bone formation in group B was superior to groups A and C; HE and Safranin O staining showed that local capillary and cartilage formation in group B was significantly more than in groups A and C; Immunohistochemical staining showed that the expression levels of Osteopontin(Opn) and Osteocalcin(Ocn) in the distraction area of group B were higher than that of groups A and C. At the 6th week of the consolidation stage, the four-point bending test showed that the bone quality of group B was better than groups A and C. The differences of the results between groups shown above had statistical significance ( P<0.05). Conclusion:Bone regeneration in the distraction area of the bone lengthening group with sciatic nerve injury was better than that of the bone lengthening group without a never injury. This might be in relation to the fact that a distractive osteogenesis caused the secondary injury to the repaired nerve. The electrophysiological results showed that periodic changes took place in the repaired sciatic nerve caused by the stretch of femoral lengthening, and the injurious changes of sciatic nerve would be gradually relieved in 6th week after surgery.

Three osteotomy methods and bone healing in Ilizarov tibial bone transport / 中华创伤骨科杂志

Objective:To explore the effects of 3 osteotomy methods on the bone healing in Ilizarov tibial bone transport.Methods:The data of 93 patients were retrospectively reviewed who had been treated by Ilizarov single-segment tibial bone transport at Department of Hand Surgery, The Second Hospital of Tangshan from December 2003 to April 2019. Minimally invasive osteotomy was performed in 16 patients [group A: 16 males with an age of (37.1±8.3) years; 5 cases of type Ⅱ and 11 ones of type Ⅲ by Gustilo classification], subperiosteal saw osteotomy in 57 patients [group B: 47 males and 10 females with an age of (39.1±11.8) years; 17 cases of type Ⅱ and 40 ones of type Ⅲ by Gustilo classification] and extraperiosteal wire saw osteotomy in 20 patients [group C: 19 males and one female with an age of (37.7±11.2) years; 18 cases of type Ⅱ and 2 cases of type Ⅲ by Gustilo classification]. The 3 groups were compared in terms of the bone healing index and the Association for the Study and Application of the Method of Ilizarov (ASAMI) functional scores.Results:The 3 groups were comparable because there was no significant difference in the preoperative general data between them ( P>0.05). All the patients were followed up for 19 to 50 months (average, 27.4 months). All patients achieved bony healing, and their associated complications were cured after corresponding treatments. There were no significant differences in the bone healing index between the 3 groups [(53.09±21.88) d/cm for group A, (59.97±33.29) d/cm for group B and (46.20±14.11) d/cm for group C] ( P>0.05). There were no significant differences either in the good to excellent rate by the ASAMI functional scores between the 3 groups (87.5% for group A, 89.5% for group B and 90.0% for group C) ( P> 0.05). Conclusion:All the 3 osteotomy methods may achieve good bony union, leading to similar bone healing indexes and postoperative functional scores.