Role of the Ilizarov non-free bone plasty in the management of long bone defects and nonunion: Problems solved and unsolved

Table 5 Comparative studies of the methods in the period 2015-2019

Ref.	Number of patients	Method, segments, fixator	Complications and problems requiring operations after frame removal or failures	Recommendations to solve the problems (conclusions)
Wen et al[3], 2019, China	317	IMT (106), DO (132), FVFG (79), post-traumatic long bones, monolateal, ring fixators, nails, plates	Major complications: (1) IMT: Hardware failure (3 cases), joint ankylosis or fusion (6 cases), > 3 cm LLD (5 cases), clubfoot or dropping foot (3 cases), and residual deformity requiring secondary procedures (4 cases); (2) DO: Deep infection (1 case), joint ankylosis or fusion (8 cases), > 3 cm LLD (3 cases), clubfoot or dropping foot (6 cases), and residual deformity requiring secondary procedures (2 cases); (3) FVFG: Hardware failure and/or refracture (7 cases), nonunion (5 cases), joint ankylosis or fusion (6 cases), > 3 cm LLD (3 cases), and residual deformity requiring secondary procedures (3 cases); and (4) Complication rates were 22.6%, 25.8%, and 26.6% (P > 0.05), respectively	The methods compared resulted in equivalent long-term outcomes. Overall complication rates were analogous among the three methods. A circular external fixator and intramedullary nail provide better stability than a monolateral external fixator and locking plates, which may benefit early partial weight bearing, thus stimulating consolidation. An approach worth exploring is to cross over from external to internal fixation in step 2 in patients treated with IMT. Special attention should be paid to alignment, external fixator stability, and care of all foot and ankle joints
Tong et al[75], 2017, China	39	IMT (20), IBT (19), posttraumatic osteomyelitis, tibia, femur	The bone outcomes were similar between groups [excellent (5 vs 7), good (10 vs 9), fair (4 vs 2) and poor (1 vs 1)]. IMT group showed better functional outcomes than IBT group	Both IBT and IMT lead to satisfactory bone results following posttraumatic osteomyelitis. IMT had better functional results, especially in femoral cases. IBT should be preferred in cases of limb deformity. IMT may be a better choice in cases of periarticular bone defects
Abdelkhalek et al[82], 2016, Egypt	24	IBT (13), FG (free grafting, 11), tibial defects	1 refracture at the regenerate site in IBM group after removal of the external fixator, 1 stress fracture in FG group. Rates of poor results: 7.6%, 9.1% respectively	Segmental tibial defects can be effectively treated with both methods. The FG method provides satisfactory results and early removal of the external fixator, but its limitation is severe infection and LLD. Also, it requires a long duration of limb bracing until adequate hypertrophy of the graft. IBT has the advantages of early weight bearing, treatment of postinfection bone defect and LLD in a one-stage surgery but a long external fixation time
Borzunov et al[78], 2019, Russia	13	IMT + DO (6) vs DO (7), congenital pseudarthrosis of the tibia	1 nonunion in IMT + DO but no refractures within a year, 29% after-frame refractures in DO group	The combined use of non-free Ilizarov bone grafting according to Ilizarov and Masquelet technology achieves bone fusion of congenital pseudoarthrosis and disease-free course of the condition within a year follow-up

LLD: Leg length discrepancy; IMT: Induced membrane technique; DO: Distraction osteogenesis; IBT: Ilizarov bone transport; FVFG: Free vascularized fibular graft; FG: Fibular graft.