Infected Tibial Nonunion: Assessment of compression distraction Ilizarov technique without debridement

Meselhy, Mohammed Anter; Kandeel, Mahmoud; Halawa, Abdelsamie; Siger, Mohamed Salah

doi:10.1016/j.otsr.2021.102881

Cited by 7 publications

(9 citation statements)

References 12 publications

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“…Bright and colleagues 7 also found no difference in time to union between a distraction frequency of 4 times per day and a frequency of 1,400 times per day at a distraction rate of 1 mm/day. The use of an alternating compression-distraction technique to enhance regenerate bone formation has produced the best outcomes 36,37 ; however, other studies have reported that the optimum timing for its application is still unknown 38 . Overdistraction followed by compression was reported to increase the expression of osteogenic factors that lead to osteoblast proliferation 15,39 .…”

Section: Discussionmentioning

confidence: 99%

“…These findings are expected considering that this method resembles the RD regimen, in which active compression increased the rigidity of fixation, resulting in more advanced remodeling 15,39 . Unfortunately, these existing methods demonstrated only limited success in improving the quality of the regenerate 1,9,11,15,[34][35][36][37][38][39] , so future studies are required to identify optimal conditions for regenerate bone. Nevertheless, it appears that perhaps the ideal mechanical manipulation for distraction osteogenesis is one that encourages the initial formation of a larger regenerate column during the distraction period followed by increased stability of the construct to prevent disruption of neovascularization during the consolidation period.…”

Section: Discussionmentioning

confidence: 99%

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Reverse Dynamization Accelerates Regenerate Bone Formation and Remodeling in a Goat Distraction Osteogenesis Model

Bafor,

Iobst,

Samchukov

et al. 2023

Journal of Bone and Joint Surgery

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Background: The concept of reverse dynamization involves modifying the mechanical environment surrounding a fracture to influence the healing response. Initially, less rigid stabilization is performed to allow micromotion, encouraging cartilaginous callus formation. This is followed by a conversion to more rigid fixation to prevent the disruption of neovascularization, thereby accelerating bone healing and remodeling. The effect of reverse dynamization in distraction osteogenesis has not been studied, to our knowledge. The aim of this study was to determine whether reverse dynamization can accelerate the formation and maturation of regenerate bone in a goat distraction osteogenesis model. Methods: Midshaft tibial osteotomies were created in 18 goats and stabilized using circular external fixation. After a 5-day latency period, 4 weeks of limb distraction began to obtain a 2-cm gap; this was followed by 8 weeks of regenerate consolidation. The goats were divided into 3 groups: static (rigid) fixation (SF, n = 6); dynamic fixation (DF, n = 6), consisting of continuous micromotion using dynamizers; and reverse dynamization (RD, n = 6), consisting of initial micromotion during the distraction period using dynamizers followed by rigid fixation during the consolidation period. Healing was assessed using radiographs, micro-computed tomography, histological analysis, and mechanical testing. Results: Radiographic evaluation showed earlier regenerate formation in the DF and RD groups compared with the SF group. After the distraction and consolidation periods were completed, the regenerate formed under the conditions of RD had less trabeculation, higher bone mineral density, and smaller total and bone volumes, and were stronger in torsion compared with the SF and DF groups. This appearance is characteristic of advanced remodeling, returning closest to the values of intact bone. The DF group also had evidence of an interzone (radiolucent fibrous zone) at the end of the consolidation period. Conclusions: Application of the reverse dynamization regimen during distraction osteogenesis accelerated formation, maturation, and remodeling of regenerate bone. Clinical Relevance: The findings of this study have important implications in the clinical setting, as reverse dynamization may lead to shorter treatment times and potentially lower prevalence of complications for patients needing distraction osteogenesis.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Reverse Dynamization Accelerates Regenerate Bone Formation and Remodeling in a Goat Distraction Osteogenesis Model

Bafor,

Iobst,

Samchukov

et al. 2023

Journal of Bone and Joint Surgery

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“…The primary principle was that distraction transforms the newly weak callus into the fibrovascular tissue and repeated distraction stimulates the collagen fiber and osteoblastic cell production followed by bone formation via intramembranous ossification ( Neidlinger-Wilke et al, 1994 ). Although several clinical studies reported positive outcomes regarding the application of the accordion maneuver in cases with poor bone formation during DO, the details of when and how this technique is applied were poorly described ( Inan et al, 2005 ; Madhusudhan et al, 2008 ; Makhdom et al, 2015 ; Zhang et al, 2017 ; Liu et al, 2020 ; Meselhy et al, 2021 ). In the present study, we investigated the effectiveness and potential mechanism of different amplitudes and rates of CDC technique on bone regeneration in a rat femur DO model.…”

Section: Discussionmentioning

confidence: 99%

“…The CDC dynamization technique, which is named as an accordion maneuver, is originally described by Ilizarov ( 1990 ) to accelerate bone formation in DO. Although lots of clinical success of CDC in the treatment of poor regenerate have been reported, they are mostly anecdotal with a poor description, and the optimal pattern of CDC stays uncertain ( Inan et al, 2005 ; Madhusudhan et al, 2008 ; Makhdom et al, 2015 ; Zhang et al, 2017 ; Liu et al, 2020 ; Meselhy et al, 2021 ). Several experimental studies performed on animals have provided some limited details.…”

Section: Introductionmentioning

confidence: 99%

Cyclic Distraction–Compression Dynamization Technique Enhances the Bone Formation During Distraction Osteogenesis

Liu

Cai

et al. 2022

Front. Bioeng. Biotechnol.

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Background: Interfragmentary movements have benefits in the improvement of bone formation during distraction osteogenesis (DO). Although several clinical studies reported positive outcomes regarding the application of the cyclic distraction–compression (CDC) dynamization technique in cases with poor bone formation during DO, they are mostly anecdotal without a detailed description. The purpose of this study was to investigate the effectiveness and potential mechanism of different amplitudes and rates of the CDC technique on bone regeneration in a rat femur DO model.Methods: A total of 60 adult male Sprague-Dawley rats underwent right femoral mid-diaphysis transverse osteotomy and were randomly and evenly divided into Control (no manipulation), Group1 (CDC therapy), Group2 (CDC therapy with larger amplitude), and Group3 (CDC therapy with a slower rate) after distraction. The CDC technique was performed during the middle phase of the consolidation period according to different protocols. Animals were sacrificed after 4 and 6 weeks of consolidation. The process of bone formation was monitored by digital radiographs, and the regenerate bone was evaluated by micro-computed tomography (micro-CT), biomechanical test, and histological analysis. The serum contents of hypoxia-inducible factor (HIF)-1α and vascular endothelial growth factor (VEGF) were measured by enzyme-linked immunosorbent assay (ELISA).Results: Bone regeneration after the CDC technique was improved significantly during DO. The digital radiograph, micro-CT, histomorphological analysis, and biomechanical evaluation showed better effects regarding volume, continuity, and mechanical properties of the regenerate bone in Group2 and Group3 when compared to Group1. The angiogenic and osteogenic markers were more highly expressed in Group2 and Group3 than in Group1 according to the immunohistochemical analysis. As for ELISA, the serum contents of HIF-1α and VEGF were also increased after the CDC technique, especially in Group2 and Group3.Conclusion: The CDC dynamization technique has benefits on the improvement of bone formation during DO, and the mechanism may be due to tissue hypoxia activating the HIF pathway followed by the augmentation of osteogenic–angiogenic coupling. Better outcomes may be achieved by moderately increasing the amplitude and slowing down the rate of the CDC technique.

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“…The external fixation acts a crucial role in the management of infected bone nonunion, complex extremity deformity, bone defects caused by various injuries, and high-energy fractures where internal fixation is impossible [1][2][3][4][5]. For fractures treated by external fixation, the timing of fixator removal is a problem worth considering.…”

Section: Introductionmentioning

confidence: 99%

Bony callus stiffness indirectly evaluated by the axial load-share ratio in vivo as a guide to removing a monolateral external fixator safely

Liu

Cai

et al. 2021

International Orthopaedics (SICOT)

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Purpose As the monolateral external fixator is increasingly used in trauma-control and definitive management for high-energy long bone fractures, timing the fixator removal remains a challenge for surgeons. The purpose of this study was to determine the feasibility and effectiveness of the bony callus stiffness indirectly evaluated by the axial load-share ratio in vivo as a guide to removing a monolateral external fixator safely. Methods A total of 131 patients with tibial shaft fractures treated by the monolateral external fixator in our institution were collected from January 2013 to July 2019. In group I, the fixators were removed based on the clinical and radiological assessment only by the treating surgeon. As for group II, the axial load-share (LS) ratio test was accomplished by another medical team without the knowledge of the clinical results. The external fixator was removed when the mechanical test outcome (LS ratio < 10%) was consistent with the conclusion drawn from the clinical and radiological assessment (bone union achieved) by the treating surgeon. Results There was no statistical significance in demographic data between the two groups (P > 0.05). In group I, four patients suffered refracture (the refracture rate was 7.7%) after fixator removal and were successfully treated by an intramedullary nail. In group II, 71 patients underwent fixator removal after the first mechanical test, and another eight patients terminated the external fixation after the second test. None of the 79 patients in group II suffered refracture (the refracture rate was 0%). There was statistical significance in the refracture rate between the two groups (P < 0.05). Conclusion The bony callus stiffness indirectly evaluated by the axial load-share ratio in vivo using the additional circular frame components is an effectively quantitative indicator to complement the clinical assessment of fracture healing in a monolateral external fixation treatment. Removal of the monolateral external fixator is safe when the axial load-share ratio dropped below 10%.

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Infected Tibial Nonunion: Assessment of compression distraction Ilizarov technique without debridement

Cited by 7 publications

References 12 publications

Reverse Dynamization Accelerates Regenerate Bone Formation and Remodeling in a Goat Distraction Osteogenesis Model

Reverse Dynamization Accelerates Regenerate Bone Formation and Remodeling in a Goat Distraction Osteogenesis Model

Cyclic Distraction–Compression Dynamization Technique Enhances the Bone Formation During Distraction Osteogenesis

Bony callus stiffness indirectly evaluated by the axial load-share ratio in vivo as a guide to removing a monolateral external fixator safely

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