Three-stage limb salvage in tibial fracture related infection with composite bone and soft-tissue defect

Abstract

Introduction Managing critical-sized tibial defects is one of the most complex challenges orthopedic surgeons face. This is even more problematic in the presence of infection and soft-tissue loss. The purpose of this study is to describe a comprehensive three-stage surgical protocol for the reconstruction of infected tibial injuries with combined bone defects and soft-tissue loss, and report the clinical outcomes. Materials and methods A retrospective study at a specialized limb reconstruction center identified all patients with infected tibial injuries with bone and soft-tissue loss from 2010 through 2018. Thirty-one patients were included. All cases were treated using a three-stage protocol: (1) infected limb damage control; (2) soft-tissue coverage with a vascularized or local flap; (3) definitive bone reconstruction using distraction osteogenesis principles with external fixation. Primary outcomes: limb salvage rate and infection eradication. Secondary outcomes: patient functional outcomes and satisfaction. Results Patients in this series of chronically infected tibias had been operated upon 3.4 times on average before starting our limb salvage protocol. The mean soft-tissue and bone defect sizes were 124 cm2 (6–600) and 5.4 cm (1–23), respectively. A free flap was performed in 67.7% (21/31) of the cases; bone transport was the selected bone-reconstructive option in 51.7% (15/31). Local flap failure rate was 30% (3/10), with 9.5% for free flaps (2/21). Limb salvage rate was 93.5% (29/31), with infection eradicated in all salvaged limbs. ASAMI bone score: 100% good/excellent. Mean VAS score was 1.0, and ASAMI functional score was good/excellent in 86% of cases. Return-to-work rate was 83%; 86% were “very satisfied” with the treatment outcome. Conclusion A three-stage surgical approach to treat chronically infected tibial injuries with combined bone and soft-tissue defects yields high rates of infection eradication and successful limb salvage, with favorable functional outcomes and patient satisfaction.

Distraction osteogenesis versus induced membrane technique for infected tibial non-unions with segmental bone loss: a systematic review of the literature and meta-analysis of available studies

“…The only available data pertaining to tibial NUs were used in the pooled analysis [ 39 ]. The remaining articles included single-intervention cohorts of either the Ilizarov method ( n = 22) [ 30 – 38 , 40 , 42 – 51 , 53 , 56 ] or the Mq technique ( n = 8) [ 17 – 20 , 41 , 52 , 55 , 57 ].…”

“…crest: 12 ± Allog 31 Ozpolat [ 55 ] 24.6 (13–40) 2.8 (1–6) Free flaps: 3, Local flaps: 4 2–4 wks IV, + 2 wks PO nr Il. crest: 11 Allog: 10 32 Corona [ 56 ] 48 (15–110) 3.4 (0–15) Free flap: 21, Local flap: 10, VAC: 28 IV: 10d, Oral: 4–6 wks 17.8 (9–32) 11 AB antibiotic; AS acute shortening, Allog. supplementary allograft, BG bone graft, BMP bone morphogenetic protein, Br-sp.…”

“…Studies reporting exclusively on either the Ilizarov or Mq method for the management of septic tibial NUs, as well as single treatment arms in retrospective comparative studies, were processed separately in a proportion meta-analysis. There were 22 studies reporting on the DO method [ 30 – 38 , 40 , 42 – 51 , 53 , 56 ] and 9 on the Mq IMT method [ 17 – 20 , 39 , 41 , 52 , 55 , 57 ].…”

Orthoplastic management of distal tibia bone infection using Masquelet technique and PRECICE nail: A case report

“…To the best of our knowledge, this is the first report describing an orthoplastic approach combining MIMT and PRECICE nail in the management of septic non-union of tibial pilon fractures. Other proposals have combined the orthoplastic approach with definitive bone reconstruction using principles of distraction osteogenesis with external fixation, such as Corona et al, who reported 31 patients with a limb salvage rate of 93.5 % (29/31) and return to work rate of 83 % [8] . Similarly, Bauer et al, in a cohort of 50 patients reported that in 95 % of the cases the limb was not amputated [9] .…”

Pedicled Double‐Barrel Fibular Transplantation Versus Bone Transport in the Treatment of Upper Tibial Osteomyelitis with Bone Defects: A Retrospective Study

“…In practice, such patients have a strong demand for limb salvage treatment. The treatment principle is staged surgeries, including controlling infection, soft tissue and bone reconstruction, and limb function recovery 4 . Although the treatment principle is clear, the treatment course is long.…”