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
Processing time: 323 Days and 2.2 Hours
The Ilizarov bone transport (IBT) and the Masquelet induced membrane technique (IMT) have specific merits and shortcomings, but numerous studies have shown their efficacy in the management of extensive long-bone defects of various etiologies, including congenital deficiencies. Combining their strong benefits seems a promising strategy to enhance bone regeneration and reduce the risk of refractures in the management of post-traumatic and congenital defects and nonunion that failed to respond to other treatments.
To combine IBT and IMT for the management of severe tibial defects and pseudarthrosis, and present preliminary results of this technological solution.
Seven adults with post-traumatic tibial defects (subgroup A) and nine children (subgroup B) with congenital pseudarthrosis of the tibia (CPT) were treated with the combination of IMT and IBT after the failure of previous treatments. The mean number of previous surgeries was 2.0 ± 0.2 in subgroup A and 3.3 ± 0.7 in subgroup B. Step 1 included Ilizarov frame placement and spacer introduction into the 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 docking for consolidation without grafting. The outcomes were retrospectively studied after a mean follow-up of 20.8 ± 2.7 mo in subgroup A and 25.3 ± 2.3 mo in subgroup B.
The “true defect” after resection was 13.3 ± 1.7% in subgroup A and 31.0 ± 3.0% in subgroup B relative to the contralateral limb. Upon completion of treatment, defects were filled by 75.4 ± 10.6% and 34.6 ± 4.2%, 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, in subgroups A and B, respectively. Bone infection was not observed. Postoperative complications were 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 provides good outcomes in post-traumatic tibial defects after previous treatment failure but external fixation is longer due to spacer retention. Refractures may occur in severe CPT.
Core Tip: This study presents preliminary outcomes and the protocol of a developed technology that includes phase 1 of the Masquelet technique for induced membrane generation and Ilizarov bone transport. The technology did not comprise bone grafting or skin flaps. It was used in 16 patients with post-traumatic tibial defects and congenital pseudarthrosis of the tibia (CPT), after multiple failed treatments. The results were rated as good in patients with post-traumatic tibial defects. Congenital cases showed similar rates of pseudarthrosis union as other means currently used for CPT. Refractures may be expected in severe types of CPT after multiple previous treatments