Reconstruction of massive tibial bone and soft tissue defects by trifocal bone transport combined with soft tissue distraction: experience from 31 cases

Abstract

Background: Large post-traumatic tibial bone defects combined with soft tissue defects are a common orthopedic clinical problem associated with poor outcomes when treated using traditional surgical methods. The study was designed to investigate the safety and efficacy of trifocal bone transport (TFT) and soft-tissue transport with the Ilizarov technique for large posttraumatic tibial bone and soft tissue defects.

Methods: We retrospectively reviewed 31 patients with massive posttraumatic tibial bone and soft tissue defects from May 2009 to May 2016. All of the eligible patients were managed by TFT and soft-tissue transport. The median age was 33.4 years (range, 2-58 years). The mean defect of bone was 11.87 cm ± 2.78 cm (range, 8.2-18.2 cm) after radical resection performed by TFT. The soft tissue defects ranged from 7 cm × 8 cm to 24 cm × 12 cm. The observed results included bone union time, wound close time and true complications. The Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system was used to assess bone and functional results and postoperative complications were evaluated by Paley classification.

Results: The mean duration of follow-up after frame removal was 32 months (range, 12-96 months). All cases achieved complete union in both the elongation sites and the docking sites, and eradication of infection. The mean bone transport time was 94.04 ± 23.33 days (range, 63.7-147 days). The mean external fixation time was 22.74 ± 6.82 months (range, 14-37 months), and the mean external fixation index (EFI) was 1.91 ± 0.3 months/cm (range, 1.2-2.5 months/cm). The bone results were excellent in 6 patients, good in 14 patients, fair in 8 patients and poor in 3 patients. The functional results were excellent in 8 patients, good in 15 patients, fair in 5 patients and poor in 3 patients.

Conclusion: TFT, in conjunction with soft tissue transport technique, can give good results in most patients (in this article, good and excellent results were observed in 64% of patients). Soft tissue transport is a feasible method in providing good soft tissue coverage on the bone ends. Although it has no advantages over microvascular techniques, it might be an good alternative in the absence of an experienced flap surgeon. Nonetheless, high-quality controlled studies are needed to assess its long-term safety and efficacy.

Keywords: Bone transport; Defects; Ilizarov techniques; Soft-tissue transport; Tibia.

Fig. 1

Illustration showing the modes of trifocal bone transport: a-b the same direction bone transport c-d the converged bone transport

Fig. 2

a Appearance of the injured right lower leg, open fracture and Gustilo IIIB. b After debridement and external fixation in local hospital, the patient was transferred to our center, with long bone exposure and large soft tissue defect. c-d 15 days after the injury, the patient underwent the first debridement in our hospital, and the previous external fixator was replaced with Ilizarov fixation. The necrotic soft tissue and bone was thoroughly debrided, and skin grafts were performed on partial wound. e Two weeks after the operation, skin graft survived, and most of the soft tissue wound was closed

Fig. 3

a Radiograph of case no. 31 who was involved in a traffic accident resulting in right tibia open fracture and Gustilo IIIB. b-e After three previous debridement operations, there was a defect of 18.2 cm on the tibia, and the proximal and distal osteotomy was performed. The osteotomy sites were obviously shown on the X-rays. f Radiograph of transport bone segment reaching docking site 30 months after osteotomy. g Union was achieved both in docking site and elongation area 35 months post-operatively. h Soft tissue defect was closed during the process of bone transport 5.8 months after osteotomy. i-j Complete bone and soft tissue union was achieved and frame was removed 35 months after osteotomy

Fig. 4

a Radiograph of case no. 27 who was involved in a traffic accident resulting in right tibia open fracture and Gustilo IIIB. b Three weeks later, the patient was transferred to our center and there was lager soft tissue defects associated with facture. c-d The patient underwent the first debridement in our hospital 23 days after injury, and the previous external fixator was replaced with Ilizarov fixation. The wound was open after the necrotic soft tissue and bone was completely debrided, and treated with soft tissue distraction

Fig. 5

a Radiographs of distal and proximal osteotomy after meticulous debridement. The converged bone transport was performed on first day postoperative, and the proximal bone segment was transported at the rate of 1 mm/d, while the distal segment was transported at the speed of 0.6 mm/d, which was manipulated once in the morning and once in the evening. Two weeks later, the transport speed slowed down to 0.5 mm/d to 0.6 mm/d. b The docking site union and consolidation of regenerates were achieved 32 months after the operation. c Frame was removed with good bone result on 33 months after osteotomy. d-e Photographs of standing position with excellent functional result

Fig. 6

Illustration showing the healing process of wound by open bone transport technique. This picture was provided by Hongjie Wen, who was the corresponding author