Methods to shorten the duration of an external fixator in the management of tibial infections

Abstract

Massive segmental bone loss due to chronic osteomyelitis represents a considerable challenge to orthopedic surgeons and is a limb threatening condition. The only option available in such a clinical situation is segment transport using the Ilizarov technique of distraction osteogenesis; yet the most common problem in cases of bone transport with the Ilizarov technique in massive bone loss, is the long duration of the fixator. In addition to autologous bone grafting, several mechanical, biologic, and external physical treatment modalities may be employed to promote bone formation and maturation during segment transport in osteomyelitis patients. Mechanical approaches include compressive loading of the distraction regenerate, increased frequency of small increments of distraction, and compression-distraction. Intramedullary nailing and hemicorticotomy can reduce the time in external fixation; however, these techniques are associated with technical difficulties and complications. Exogenous application of low-intensity pulsed ultrasound or pulsed electromagnetic fields may shorten the duration of external fixation. Other promising modalities include diphosphonates, physician-directed use (off-label use) of bone morphogenetic proteins, and local injection of bone marrow aspirate and platelet gel at the osteotomy site. Well-designed clinical studies are needed to establish safe and effective guidelines for various modalities to enhance new bone formation during distraction osteogenesis after segment transfer.

Effects of caffeic acid phenethyl ester and melatonin on distraction osteogenesis: an experimental study

“…There are three phases to distraction osteogenesis (Emara et al 2011 ). The first stage as the latent phase starts with an osteotomy and lasts for mean 7–10 days.…”

“…Several authors have proposed various methods to reduce external fixator duration at this stage of the procedure and have reported successful results. Compression-distraction on the fixator, grafting with autogenous bone graft, the use of bone morphogenic protein, PRP, biphosphanate and calcitonin are the most prominent methods (Alam et al 2009 ; Emara et al 2011 ; Lovisetti and Sala 2013 ).…”

“…In this stage, the lengthy duration of the fixator restricts movement of the joint and increases the risk of pin site infection. Various methods have been recommended to reduce the external fixator time (EFT) and the external fixator index (EFI) and these have been reported with success in literature (Alam et al 2009 ; Catagni et al 2011 ; Emara et al 2011 ; Lovisetti and Sala 2013 ). These may be listed as the use of autogenous bone graft, the application of ultrasonography (USG), electromagnetic waves, bone morphogenic protein, compression-distraction of the regenerative area, biphosphanate, calcitonin and platelet-rich plasma (PRP).…”

Infekt bei intramedullärem Implantat

“…5 cm können relativ zuverlässig mit dem Segmenttransport über Marknagel oder Fixateur externe behandelt werden. [20][21][22] Nach anfänglichen Erfolgen der Defektrekonstruktion mit der Masquelet-Technik scheint dieses Verfahren für größere Defekte (> 5 cm) nur bedingt geeignet [23,24].…”

Cost of external fixationvsexternal fixation then nailing in bone infection

“…Both techniques involve segment transfer by Ilizarov external fixation. In one technique the external fixation is removed early after eradication of infection and finishing segment transfer, and replaced by intramedullary nail [18][19][20] . The other technique is to continue with external fixation till full healing of the fracture, docking site, and distraction callus [21][22][23] .…”