| Background:With a large number of high energy limbs open injury occurrence in the modern society, skin and soft tissue defect, infectious nonunion and bone defect ha ve gradually increased. The relevant treatment in clinic is still very difficult. The previous treatment of infectious nonunion and bone defect is through repeated surgical debridement first and bone grafting or bone flap after infection control. However the process is complicated and duration of treatment is long. Patients will experience chronic pain, the treatment cost is high, and the treatment effect is often unsatisfactory, many patients with severe cases are eventually difficult to escape from amputation. Since 2006, our department have cured the large number of patients in danger of amputation due to severe bone nonunion and bone defect with the bone transport and bone lengthening technology. The curative effect is remarkable. With the in-depth study of basic theory for callus lengthening technology and the continuous development in clinical application, new breakthroughs have been achieved in each operation steps currently. While optimizing all the treatment steps, We also invent a new surgery by combining callus lengthening and ankle arthrodesis: ankle extension fusion for the treatment of old ankle joint disease. The curative effect is remarkable. Hereby clinical cases for these two pats will be analyzed and summarized to guide future clinical work and achieve continuous improvementObjective:1. to discuss the clinical effect of Bone Lengthening or Bone Transport Technology in the Treatment of refractory Bone Defect for lower limbs2. to discuss the clinical effect of new technology: ankle extend fusion in treatment of chronic ankle diseaseMethods:The first part,49 cases that were treated with bone transport and bone lengthening technique for infected bone defects and bone nonunion from December 2006 to February 2014 will be analyzed retrospectively, to evaluate its clinical effect. Among them,15 cases were treated with limb shortening lengthening combined with debridement, skin flap or skin transplantation;34 cases were treated with bone transport technique combined with debridement, skin flap or skin transplantation. Contrast and analysis including the general clinical data, the length of the defect, soft tissue defect area, operation time, bone healing results, postoperative limb function recovery and other information of the recorded cases before and after the surgery will be made.The second part,7 cases of patients with old ankle joint diseases from July 2012 to August 2014 will be retrospectively analyzed. The group consist of 6 male and 1 female; aging from 32 to 60 years, average age 48.00±11.40 years old. All of them were treated with ankle osteotomy and lengthening combined with the new technology. In surgery, ankle joint surface cartilage were complete resected without bone grafting in the joint, Orthofix external fixation.Slow distraction lengthening started around 7 days after the surgery.The extending length will be decided by the shortened length measured from the X ray of the both length of lower limbs taken before and after the surgery, ensuring the same length of the lower limbs. The external fixation was removed after the ankle joint finished complete bone fusion. Foot function improvement was evaluated by the AOFAS score before and after the surgery.Results:Of the 49 cases the complete removal of the external fixator in 33 cases in the 1st part, while 16 cases due to lack of follow-up time, when the end of the date of this issue has not been a complete removal of the external fixator, continue to be the follow-up study,All cases of infection were under control, without recurrence after surgery. including 15 cases with limb shortening lengthening combined with debridement, skin flap or skin transplantation,34 cases with bone transport technique combined with debridement, skin flap or skin transplantation( 3 cases were treated with bilateral osteotomy transport technology). The age ranged from 6 to 59 years old, an average of 32.27±14.13 years old, the hospitalization time was 11 to 314 days, an average of 71.09±74.21 days, the previous operation number was 1 ~ 10 times, an average of 2.52±1.97 times; shortening length of 2 ~ 14 cm, an average of 5.00±3.08 cm, following up duration was 14 ~ 100 months, an average of 56.82±26.33 months; external fixation time was 6 ~ 26 months, an average of 13.40±5.53 months. 37 cases were found for Preoperative soft tissue infection and the formation of sinus or defect. 34 cases were found positive in the taking infection lesions for bacterial culture and drug susceptibility test;3 case was negative; Including 17 cases of Staphylococcus aureus, 4 cases of Bauman Acinetobacter, 2 case of hemolytic staphylococci, 3 cases of Enterobacter cloacae, 3 cases of Proteus, 2 cases o f serratia marcescens and 1 case of Burkholderia cepacia and 2 cases of Mixed infection. Complications: 7 cases of external fixation nail crossing infection, the infection was controlled after antibiotic therapy, 5 cases of Prolonged traction nerve pain, p ain symptoms disappeared for 3 cases after decreasing the distraction lengthening rate, pain suspended for 2 cases and disappeared after 3 ~ 5 days since stopping distraction lengthening, no pain occurred when resuming the previous distraction lengthening speed;Finally the new bone and the bone defect end forming from distraction lengthening after osteotomy were growing well and reached bone healing for 28 cases; bone healing did not occur after 6 month of bone defect transfer connecting for 4 cases, of which 3 cases were treated with autologous iliac bone graft, 1 case with external fixation removal and plate screw internal fixation, and all achieved bony healing 5 ~ 7 months later. 1 case after the removal of the external fixator new bone fractures occur again, to be re-placed orthofix external fixator six months after the fracture healing, be dismantled external fixator.The results were evaluated according to Paley standard: excellent for 23 cases, good for 9 cases, poor for 1 case.7 patients received 5 to 33 months’ follow-up in the 2nd part, an average of 15.00±11.06 months. The wound healed in I stage after operation for all 7 cases, no deep infection, wound dehiscence, no obvious nerve and blood vessel injury. Extend the length of 0.7 to 3.8(mean 1.39 ± 1.11) cm,The ankle joint achieved bony fusion in 5 ~ 11 months(average 6.86 + 2.26 months);both lower limbs were basically equal in length; foot shape was improved; general working and living requirements could be satisfied. 7 patients were very satisfied in pain improvement, fusion joint stability and function recovery. According to AOFAS Standard, preoperative score for the 7 cases was 19 ~ 35(average 25.71±5.79), score at last follow-up was 74 ~ 79 minutes(average 77.14±1.86), which was of significant difference(P<0.01).Conclusion:1. bone lengthening or bone transport technique is very effective surgical method in the treatment of refractory Bone Defect for lower limbs2. bone lengthening or bone transport technique combined with infective bone d efect debridement can effectively control infection with few postoperative recurrence.3. The new operation: ankle extend fusion combines the callus lengthening technique with the ankle joint fusion. The operation is simple with small trauma and definite e ffect. |
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