Management of acute bone loss following high grade open tibia fractures
Review of evidence on distraction osteogenesis and induced membrane techniques
Keywords:
tibia, bone loss, infection, union, distraction osteogenesis, induced membraneAbstract
Introduction: Optimal treatment for acute post-traumatic bone loss in the tibia remains unclear. Distraction osteogenesis (DO) and induced membrane technique (IM) have been established as the mainstays of treatment. Aim of this article is to review the current evidence regarding the use of these two methods. Methods: A review of the MEDLINE database was performed with strict inclusion and exclusion criteria focusing on treatment of the acute bone loss after open tibia fractures with DO and IM. Bone union rate was taken as the primary outcome and infection rate as secondary outcome. Results: Four studies out of 78 on the use of the DO and three studies out of 18 on the use of the IM technique matched the inclusion criteria. Union rate in the DO group ranged between 92% and 100%, with infection rates between 0 and 4%. In the IM group, union was reached in 42% to 100% of cases, with septic complications occurring in 12% to 43%. Differences in union rate and infection rate reached statistical significance. Discussion: We found a considerable evidence gap regarding treatment of bone loss in high grade open tibia fractures. The limitations of our study prevented us from drawing clear causative conclusions on the results. Although our study points to higher union rates and lower infection rate with the use of the DO technique, the results remain preliminary and further high-level evidence is needed to establish the roles of DO and IM in treatment of acute bone loss in open tibia fractures.
References
Keating JF, Robinson CM. The management of fractures with bone loss. J Bone Jt Surg. 2005;
Gustilo R, Mendoza R, Williams D. Problems in Managment of Type III (Severe) Open Fractures: A New Classification of Type III Open Fractures.pdf. J Trauma. 1984;
Giannoudis P V, Papakostidis C, Roberts C. REVIEW ARTICLE A review of the management of open fractures of the tibia and femur. J Bone Jt Surg. 2006;
Court-Brown CM, Cross AT, Marsh DR, Willet K, Quaba AAWF, Small J, et al. British Orthopaedic Association and British Association of Plastic Surgeons The Management of Open Tibial Fractures September 1997 A Report by the BOA / BAPS Working Party on The Management of Open Tibial Fractures. 1997.
BOA, BAPRAS. Open Fractures. 2017.
Lasanianos NG, Kanakaris NK, Giannoudis P V. Current management of long bone large segmental defects. Orthop Trauma [Internet]. 2009;24(2):149–63. Available from: http://dx.doi.org/10.1016/j.mporth.2009.10.003
Nauth A, Schemitsch E, Norris B, Nollin Z, Watson JT. Critical-Size Bone Defects : Is There a Consensus for Diagnosis and Treatment ? J Orthop Trauma. 2018;32(3):7–11.
Blokhuis TJ. Management of traumatic bone defects : Metaphyseal versus diaphyseal defects. Injury [Internet]. 2017;9–11. Available from: http://dx.doi.org/10.1016/j.injury.2017.04.021
Giannoudis P V, Einhorn TA, Marsh D. Fracture healing : The diamond concept. Injury. 2007;3–6.
Giannoudis P V, Gudipati S, Harwood P, Kanakaris NK. Long bone non-unions treated with the diamond concept : a case series of 64 patients. Injury [Internet]. 2015;46(January 2008):S48–54. Available from: http://dx.doi.org/10.1016/S0020-1383(15)30055-3
Decoster TA, Gehlert RJ, Mikola EA, Pirela-cruz MA. Management of Posttraumatic Segmental Bone Defects. J Am Acad Orthop Surg. 2004;12(No. 1):28–38.
Polyzois VD, Stathopoulos IP. Strategies for Managing Bone Defects in the Lower Extremity. Clin Podiatr Med Surg. 2014;31:577–84.
Ilizarov G. The tension-stress effect on the genesis and growth of tissues. Part I: the influence of stability of fixation and soft-tissue preservation. Clin Orthop Relat Res. 1989;
Ilizarov G. The tension-stress effect on the genesis and growth of tissues: Part II: the influence of the rate and frequency of distraction. Clin Orthop Relat Res. 1989;
Bhandari M, Giannoudis P V. Distraction osteogenesis in the treatment of long bone defects of the lower limbs SYSTEMATIC REVIEW AND META-ANALYSIS. Bone Joint J. 2013;95(12):1673–80.
Sella EJ. 〈 Review 〉 Prevention and Management of Complications of the Ilizarov Treatment Method. Foot Ankle Spec. 2008;1(2):105–7.
Masquelet AC, Fitoussi F, Begue T MG. Reconstruction of the long bones by the induced membrane and spongy autograft. Ann Chir Plast Esthet. 2000;
Krappinger D, Lindtner RA, Zegg M, Dal Pont A, Huber B. Die Masquelet-Technik zur Behandlung großer dia- und metaphysärer Knochendefekte. Oper Orthop Traumatol. 2015;4:357–68.
Morelli I, Drago L, George DA, Gallazzi E, Scarponi S, Romanò CL. Masquelet technique : myth or reality ? A systematic review and meta-analysis. Injury [Internet]. 2016;47:S68–76. Available from: http://dx.doi.org/10.1016/S0020-1383(16)30842-7
Morris R, Hossain M, Evans A, Pallister I. Induced membrane technique for treating tibial defects gives mixed results. Bone Joint J. 2015;680–5.
Giotikas D, Tarazi N, Spalding L, Nabergoj M, Krkovic M. Results of the Induced Membrane Technique in the Management of Traumatic Bone Loss in the Lower Limb : A Cohort Study. J Orthop Tra. 2019;33(3):131–6.
Sen C, Kocaoglu M, Cinar M. Bifocal Compression-Distraction in the Acute Treatment of Grade III Open Tibia Fractures With Bone and Soft-Tissue Loss. J Orthop Trauma. 2004;18(3):150–7.
Koettestorfer J, Hofbauer M, Wozasek G. Successful limb salvage using the two-staged technique with internal fixation after osteodistraction in an effort to treat large segmental bone defects in the lower extremity. 2012;1399–405.
Niekerk AH Van, Birkholtz FF, Lange P De. Circular external fixation and cemented PMMA spacers for the treatment of complex tibial fractures and infected nonunions with segmental bone loss. J Orthop Surg. 2017;25(2):1–8.
Hutson JJ, Dayicioglu D. The Treatment of Gustilo Grade IIIB Tibia Fractures with Application of Antibiotic Spacer , Flap and Sequential Distraction Osteogenesis. Vol. 64, Southestern Society of Plastic and Reconstractive Surgeons. 2010.
Christian EP, Bosse MJ, Robb G. Reconstruction of large diaphyseal defects, without free fibular transfer, in grade-IIIB tibial fractures. J Bone Jt Surg - Ser A. 1989;71(7):994–1004.
Morris R, Hossain M, Evans A, Pallister I. Induced membrane technique for treating tibial defects gives mixed results. 2015;680–5.
Schenker M, Yannascoli S, Baldwin K. Does Timing to Operative Debridement Affect Infectious Complications in Open Long-Bone Fractures ? A Systematic Review. J Bone Jt Surg. 2012;1057–64.
Pollak A, Jones A, Castillo R. The Relationship Between Time to Surgical Debridement and Incidence of Infection After Open High-Energy Lower Extremity Trauma. J Bone Jt Surg. 2010;7–15.
Singh S, Lo S, Soldin M. Adherence to national guidelines on the management of open tibial fractures : a decade on. J Eval Clin Pract. 2009;15:1097–100.
Papakostidis C, Bhandari M, Giannoudis P V. Distraction osteogenesis in the treatment of long bone defects of the lower limbs SYSTEMATIC REVIEW AND META-ANALYSIS. 2013;95(12):1673–80.
Pierrie SN, Hsu JR. Shortening and Angulation Strategies to Address Composite Bone and Soft Tissue Defects. J Orthop Trauma. 2017;31(10):32–5.
Masquelet AC, Begue T. The Concept of Induced Membrane for Reconstruction of Long Bone Defects. Orthop Clin NA [Internet]. 41(1):27–37. Available from: http://dx.doi.org/10.1016/j.ocl.2009.07.011
Stafford PR NB. Reamer- irrigator-aspirator bone graft and bi Masquelet technique for segmental bone defect nonunions: A review of 25 cases. Injury. 2010;41(Supp 2)(28):72–7.
Karger C, Kishi T, Schneider L, Fitoussi F, Masquelet A. Treatment of posttraumatic bone defects by the induced membrane technique. Orthop Traumatol Surg Res [Internet]. 2012;98(1):97–102. Available from: http://dx.doi.org/10.1016/j.otsr.2011.11.001
Apard T, Bigorre N, Cronier P, Duteille F, Bizot P, Massin P. Two-stage reconstruction of post-traumatic segmental tibia bone loss with nailing. Orthop Traumatol Surg Res [Internet]. 2010;96(5):549–53. Available from: http://dx.doi.org/10.1016/j.otsr.2010.02.010
Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg. 1986;3(78):285.92
Rhinelander FW. Tibial blood supply in relation to fracture healing. Vol. No. 105, Clin.Orthop. 1974. p. 34–81.
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