Bone Transport For Large Bone Defects Of Tibial Infection

Background and Objective:Since the trigonous transverse section of tibial shaft prismatic and the quadrilateral in the lower1/3of the junction,tibia subcutaneous tissue and muscles are relatively weak.Open fracture of the junction caused by violence with a higher incidence.Because the lower2/3of tibial shaft without nourish holes,only at the middle1/3of junction has a small hole on the side, the tibial artery,one branch of the posterior nutrient artery into the bone from here,supplying the entire bone blood.Once open fractures in the junction of lower1/3tibia, nutrient artery continuity destroyed,the distal1/3of tibia will ischemic and breed bacteria.Intravenous antibiotics are difficult to reach the lesion site to remove bacteria,.The formation of sinus caused by the fracture avascular necrosis and nonunion.Eventually developed into the chronic osteomyelitis. Whose symptoms are difficult to cure and easy recurrent.Debridement surgery can completely remove the necrosis of soft tissue and sequestrum.However, it is likely to cause varying degrees of bone defects.This contradiction makes the treatment of tibial chronic osteomyelitis become a clinical difficulty.Our study retrospectively analysis and summary of "Ortherfix monolateral external fixator and Ilizarov circular fixator for the bone defects range of3to10cm, which removed the bone segment infected after tibial fracture surgery".Our study will discuss the therapeutic effects of two bone transport method for the tibia infected bone defects range of3to10cm,and reparation for the soft tissue defects at the same time.Methods:Our study retrospectively analyzed32cases of tibial fracture surgery in patients with chronic infection,from January2008to September2012.The diagnosis of chronic infection after tibial fracture surgery mainly based on patient history and clinical symptoms, X ray,CT imaging,blood tests,lesions stratified puncture and secretions bacteriology,intraoperative bacterial culture results.Patients get an active anti-infection treatment,implant removal+replacement of external fixator(or external fixation extender)+VSD debridement and negative pressure drainage.Review the X-ray film.Give the tibial osteotomy lengthening surgery who without recurrence infection of3to6months.Our study has14patients with Ortherfix monolateral external fixator and18patients with Ilizarov circular fixator(2patients with open wounds application of Ilizarov circular fixator to extend the shelf for bone movement, repaired soft tissue defects after fixation).14patients use Orthofix external fixator,8males and6females,aged17to63years old,duration of1month to3years,1to3times of surgical treatment before the study,4cases with compression plate in first fixed,7cases with Interlocking Nails,3cases with external fixation,9cases with soft tissue injury sinus before the study,5cases with wound,Hhs function score of knee with60.29±12.18,Baird-Jackson function score of ankle with62.21±7.59.18patients use Ilizarov circular fixator,10males and8females,aged19to65years old,duration of1month to3years,1to3times of surgical treatment before the study,6cases with compression plate in first fixed,8cases with Interlocking Nails,4cases with external fixation,11cases with soft tissue injury sinus before the study,7cases with wound,Hhs function score of knee with60.32±12.22,Baird-Jackson function score of ankle with62.19±7.61.32patients were no significant differences in age, sex, soft tissue necrosis and bone defect length.Results:32finished the trail,the average follow-up time is13months.The length of tibial defects range of was3.0to10cm, the length time was45-130days,the dismantling time was5-15months,the mean healing index was34-40days per centimeter.All fractures healing,the healing time was5-15months.14patients with Ortherfix monolateral external fixator,the average point is2.85according to the the Fernadez-esteve radiology evaluation of bone callus standard (see appendix).According to the Paley evaluation criteria of bone healing and functional recovery after treatment ends.The bone outcome evaluation:excellent in12cases, good in2cases.Functional outcome assessment:excellent in12cases, good in1, fair in1case.Limbs after osteotomy length achieve a relatively balanced with the normal leg length(shortening<2cm).Flexion and extension activity of Knee and ankle joint function get an effective recovery.The function score of after knee and ankle has a significant difference with before(P<0.01).18patients with Ilizarov circular fixator,the average point is2.86according to the the Fernadez-esteve radiology evaluation of bone callus standard.The bone outcome evaluation: excellent in14cases, good in4cases.Functional outcome assessment:excellent in14cases, good in4.Limbs after osteotomy length achieve a relatively balanced with the normal leg length(shortening<2cm).Flexion and extension activity of Knee and ankle joint function get an effective recovery.The function score of after knee and ankle has a significant difference with before(P<0.01).It has no significant differences in bone healing knee and ankle joint function between Ortherfix monolateral external fixator and Ilizarov circular fixator.14patients with Ortherfix monolateral external fixator,1case got tibial axial offset of postoperative,adjusted by the bedside external fixator correction.2cases got skin caused pain needle pulling.1case got needle tract infections.1case got the small contact area of bone lengthening end,then removed the extender+external fixation+bone graft,bone fracture got healing through review X ray after operative.18patients with Ilizarov circular fixator,1case got necrosis because of extender needle move to cover the wound flap.2cases of pin tract infection,one aseptic needle tract infection.1case with Achilles tendon adhesions and tibia nonunion,get healed after Achilles tendon lengthening surgery and post-tibial pin fixation.4cases of needle pulling causes skin pain.9in10flaps survived.Pin tract infection got9.38%incidence rate(3/32),could be controlled by local dressing and antibiotic treatment.No neurovascular injury cases.One necrosis caused by a needle pulling, and healed after skin grafting after debridement.Conclusions:1. Bone transport have a obvious effect in treatment of tibal infectious large bone defects. 2.There are obvious effects in bone healing,knee and ankle joint function, between Ortherfix monolateral external fixator and Ilizarov circular fixator. BUT it has no significant differences.3.The Ortherfix monolateral external fixator needs conditions of the soft tissue requirements are relatively lower than Ilizarov circular fixator.4. Ilizarov circular fixator needs more needles,which easy to damage the flap or its nutrient vessels.Flap to repair soft tissue defects were carefully chosen.5. Ortherfix monolateral external fixator prone to tibia handling bone segment offset into a corner after operative.6. Ortherfix monolateral external fixator got a shorter operative time and less blood loss.7. Resistant Staphylococcus aureus is the most common pathogens of chronic infection after tibial fracture surgery.