There are numerous treatment options for large segmental defects in long bones including bone grafting with autologous or allogenic bone graft, vascularized bone graft, distraction osteogenesis, cement spacers, various hardware applications, and the option to add various biologic stimulators like bone morphogenetic protein (BMP)-2 and BMP-7.3-6,12,13,15,18,20,21,23,25,29,32 The clinical results using these techniques have varied.7,8,14,15,22,26 Cobos et al7 reported a novel method of restoring bony continuity in two tibial fractures with segmental bone loss using a titanium mesh cage packed with cancellous bone allograft and stabilized with intramedullary (IM) nails. We present a series of patients successfully treated using a titanium mesh cage for large segmental tibial defects.
A 23-year-old man presented to the emergency department of a Level I trauma center in stable condition after a motorcycle accident. He sustained an open Gustilo-Anderson Type IIIB tibia fracture with extensive segmental bone and soft tissue loss.
Initial treatment at arrival to the emergency department consisted of intravenous administration of broad-spectrum antibiotics and a tetanus shot. The patient was treated with irrigation and débridement of the soft tissues and bone. After excising devitalized tissues, there was a segmental tibial bone defect of approximately 12 to 13 cm (Fig 1). The fracture initially was stabilized with a unilateral external fixator (Synthes, Paoli, PA). We performed a skin graft and the soft tissue healed uneventfully by 6 weeks. We removed the external fixator and then applied a long posterior splint. The pin tract wounds healed 2 weeks later, and the tibia was reconstructed.
Definitive bone reconstruction options were discussed with the patient 1 month after injury. Treatment choices included autologous or allogenic bone graft augmented with BMP-2 and BMP-7, vascularized bone graft, and distraction osteogenesis. We reconstructed the tibia using a technique previously described by Cobos et al7 for a similar large bony segmental defect.
The defect was exposed through an anteromedial approach. Aerobic and anaerobic cultures were taken from the surgical site and scar tissue was removed. The proximal and distal irregular ends of the tibia defect were revised to a smooth transverse edge with adequate bleeding, resulting in a segmental defect length of approximately 12.5 cm. We used a cylindrical titanium mesh cage (oval, 22 × 28 × 130 mm) (DePuy Spine, Warsaw, IN) reinforced with standard rings proximally and distally. The cage length clinically restored the tibial length without excessive tension on the soft tissue envelope and with approximately 0.5-cm cage overlap on the distal tibia. The implant's overlap on the tibia was to assure the bone graft inside the cage would be under compression. The cage was removed and packed with a composite consisting of approximately 10 cc demineralized bone matrix putty (Grafton®, Osteotech, Eatontown, NJ), 90 cc morselized cancellous bone allograft, and 60 cc iliac crest autologous bone graft. Its center was cannulated with a 4.5-mm drill to facilitate passage of a guide wire (Fig 2). The wound was irrigated, and the cage was refitted between the proximal and distal ends of the tibia. Using standard intramedullary (IM) nailing techniques, we passed a guide wire into the proximal medullary canal of the tibia, the center of the predrilled cage, and the distal medullary canal of the tibia. The skin was temporarily closed with loose sutures, and a cannulated reamer was used to sequentially ream the tibia and the center of the grafted cage up to 11 mm. A 10-mm IM nail (DePuy-Ace) was implanted into the tibia and cage, and locked proximally and distally. The final construct was stable enough to permit immediate active mobilization of the lower extremity postoperatively and full weightbearing by 6 weeks. At 1-year followup the cage construct healed clinically and radiographically and alignment was adequately maintained (Fig 3). Computed tomography (CT) scans showed bony ingrowth inside and outside the cage, bridging the proximal and distal ends of the tibia (Fig 4). The patient had full range of motion (ROM) of the ipsilateral knee, hip, and ankle (Fig 5). Although radiographs showed a 1-cm overlap in the fibula fracture, there was not a substantial leg-length discrepancy.
The two other patients were similar in presentation and treatment, except for requiring a longer time for soft tissue healing, and an initial presentation with peroneal nerve injury. These two patients also achieved clinical and radiographic healing, and were full weightbearing by 6 weeks (Figs 6, 7). Patient 2 had partial resolution of his drop foot, and did not require an ankle-foot orthosis. He had a leg-length discrepancy of approximately 2 cm. Patient 3 had a persistent drop foot requiring an ankle-foot orthosis and had a clinical leg-length discrepancy of approximately 1 to 1.5 cm (Table 1). All culture specimens taken at the time of surgery showed no bacterial growth.
Management of large segmental bony defects in long bones can be challenging. Although numerous treatment options have been proposed,15,20-22,26 they all have inherent risks and limitations. Treatment options include: (1) structural autograft (ie, fibular graft with or without vascular pedicles), (2) structural allograft, or (3) distraction osteogenesis.
The limitations of vascularized bone grafts include the technically demanding nature of the procedure and complications such as graft fracture, nonunion, malunion, and donor-site morbidity.3,14,18,21,22,25,26 Its principle advantage is a shorter healing time compared with nonvascularized grafts.24 Many vascularized grafts require repeat procedures before achieving a satisfactory outcome.3,14,18,21,22,25,26
Structural allografts require a sufficient supply of appropriate allografts, and complications include a high incidence of infection contrasted by a low incorporation rate. Its principle advantage is greater initial stability.24 Many patients treated with this technique also require repeat procedures before obtaining a satisfactory outcome.1,5 Mankin et al24 reviewed the long-term results of 870 implanted allografts for management of bone tumors, reporting a 75% success rate, 10% infection rate (mainly during the first year), 19% allograft fracture rate (mainly during the first 3 years), and 17% nonunion rate.
Cierny et al6 compared the results of 23 patients treated with massive cancellous grafts and tissue transfers (Group I) and 21 patients treated using Ilizarov methods (Group II). Although both groups had a 95% success rate, the major complication rates for Groups I and II were 33% and 60%, respectively.6 The period of disability for patients in Group I was 17 months versus 22 months for Group II.6 The authors reported that the Ilizarov method was more cost-effective.6 Dahl et al8 reviewed the results of limb lengthening of 110 patients using the Wagner method, the DeBastiani method, and the Ilizarov method, reporting a 72% major complication rate that decreased to 25% with surgeon experience. Green15 reviewed the results of 17 patients with segmental skeletal defects treated with the Ilizarov bone transport method, and found a high complication rate, most commonly wire-site sepsis and fixator instability. The average fixation time was 9.6 months, and six patients required bone grafts.15 Although distraction osteogenesis is compromised by an extended length of treatment, a myriad of complications,, and the need for repeat procedures before obtaining a satisfactory result, it is considered the standard of care.6,8,15,20,29
Autologous cancellous bone graft is an excellent material for grafting bony defects less than 5 cm because of its inductive and conductive properties. Cancellous bone graft alone is not mechanically stable enough for defects greater than 5 cm.7,8,14,15,22,26
Titanium mesh cages have been used effectively to restore bone continuity in various anatomic regions.2,10,28,31
They were developed in 1986, and since then have been used extensively in spine surgery.16 Robertson et al30 reported on 31 patients treated with titanium mesh cages for anterior spinal reconstruction after thoracolumbar corpectomy, reporting the cages were sound reconstruction alternatives for one-level corpectomy and may prevent complications associated with the harvest and use of large structural autografts. Dvorak et al9 reported similar findings on 43 patients treated with cylindrical titanium mesh cages after vertebrectomy as 93% of the patients achieved osseous union. Titanium mesh cages have been used even in the presence of active infection. Fayazi et al11 reviewed the results of 11 patients with thoracolumbar vertebral osteomyelitis treated with staged anterior débridement and reconstruction, using cylindrical titanium mesh cages followed by delayed posterior spinal fusion and instrumentation. One patient died during revision surgery for hardware failure, one patient had pseudarthrosis, seven patients achieved healing, and three patients were maintained on chronic suppressive therapy as a precaution.11 Fayazi et al reported that mesh cages can be used with consistently good results for large anterior column defect reconstructions, even in the face of active pyogenic infection, as reported by Hee et al.17
Cobos et al7 were successful in using this technique for treatment of two tibial fractures with a mean bony defect of 9 cm. A cylindrical titanium cage packed with cancellous bone allograft and demineralized bone matrix putty (Grafton®) was used to reconstruct the tibial bony defects with stabilization provided by a statically locked IM nail. These patients were permitted immediate full weightbearing, and at 1-year followup, their tibias healed and they regained full function. Cobos et al7 stated that this technique may be a reasonable alternative to the other methods of treating selected long-bone segmental defects. Ostermann et al28 reported on an open tibial fracture with a 15-cm segmental defect at the proximal metadiaphyseal junction that was successfully reconstructed with a cage filled with autologous bone graft, an IM nail, and soft tissue flap coverage of the soft tissue defect in a one-stage procedure.
There is not a uniformly accepted treatment for open fractures with long segmental bony defects. Complex treatment challenges associated with this condition include: (1) serial surgical irrigation and débridements to decontaminate the wound; (2) provisional and definitive fracture stabilization to maintain limb alignment and facilitate bone healing; (3) appropriate soft tissue coverage to prevent contamination and provide the blood supply necessary for bone healing; (4) bony restoration of the defect for definitive limb stability; (5) early joint mobilization to regain limb function; and (6) progressively increasing weightbearing during the prolonged healing phase to facilitate bone healing and functional recovery.7,19 In our patients, repeat wound débridements, immediate external fixator application, and early soft tissue coverage were performed as expeditiously as possible. In two of the patients, the soft tissue wound required an extended time to heal or required a second muscle flap. The cage reconstruction procedure should be restricted to patients with fully healed soft tissues, no evidence of active infection, and meet the published guidelines for exchanging external fixation with internal fixation.27 Our choice of implants to stabilize the bone-cage construct was based on the basic principles of fracture fixation, and influenced by factors including bone size, bone quality, and the segmental defect location.
The titanium mesh cage technique is appealing because of: (1) its success rate2,7,28 despite the theoretical disadvantage of hardware placement in a previously opened fracture27; (2) the construct's ability to accommodate immediate limb mobility, and rapid return to full weightbearing; (3) the biologic advantage of cancellous allograft combined with demineralized bone matrix putty (Grafton®), without the disadvantage of donor site morbidity; and (4) the major inherent limitations of other treatment alternatives.
Although the results of our series are encouraging, more clinical and basic science data are needed to better establish its indications, understand the biologic mechanisms responsible for its success, and establish guidelines for management of complications such as infection, nonunion, or hardware failure.
The basic advantages of our technique are: (1) it uses readily available implants; (2) it is a relatively easy technique; (3) it can use cancellous allograft and demineralized bone matrix; (4) it achieves immediate limb stability; (5) it restores limb length and alignment; and (6) it permits early limb and joint mobilization. Its theoretical disadvantage is a higher risk of infection when treating an open fracture.
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