Union of the docking site required repeat bone grafting in two (trauma) cases. One patient with severe laceration of the quadriceps muscle, poor healing of docking site, comminution of the femoral condyles, and joint surface destruction was referred to a second stage joint arthroplasty below the transported diaphysis (case 5). Two patients with persistently reduced knee flexion (<80°) underwent successful quadriceps release (femur case 3, 4). At final follow-up, three in five patients had normal knee ROM, case 4 had 0° to 130°, and case 5 had 0° to 110° of motion.
Three men and one woman were operated between 2016 and 2018. Average age was 38 (15 to 77 years), LLD and MAD remained roughly unchanged; one patient is healing in mild varus. Three have achieved full consolidation; two await union of the docking site.
Consolidation index (1.26 mo/cm) was higher and consolidation time longer compared with femur cases. One tumor case required a three-stage transport procedure (8 + 3 + 4 cm) because of the large defect (15 cm) and acute shortening of 3 cm. All three tibial trauma patients needed plastic surgery to obtain soft-tissue cover (split skin and rotational flap or free flap) (Table 2).
The average number of procedures required to obtain normal alignment in both bones was five (plating, nailing, docking), not including soft-tissue reconstruction in trauma cases and not including supplementary lengthening. Reduced knee or ankle ROM, superficial infection, delayed healing of docking sites, and heterotopic ossification were the main complications. No deep infections occurred in this series of patients (Figure 4).
We developed the plate-assisted bone segment transport technique (PABST) to eliminate the need for prolonged external fixation and to reduce treatment time, in particular, time to full weight bearing and free joint movement in patients with moderate sized bone defects.
A number of techniques exist to address bone loss: the induced-membrane technique of Masquelet and Begue,13 external bone transport (with or without intramedullary nailing), and vascularized fibular grafts being the most common.14 In tumor cases, specific diaphyseal prostheses are available. Bone transport is the most physiological and durable method with an average treatment time of 1 month per cm. Our consolidation index of 0.9 mo/cm in the femur and 1.26 mo/cm in the tibia compares well with that reported for Ilizarov bone transport after infected nonunion of the tibia by McNally, Tetsworth, and colleagues in 201715,16 and bone transport after resection of malignant tumors in the tibia and femur.17 The consolidation index is approximately half of what has been reported for external fixator lengthening at 1.8 to 1.9 mo/cm.4,18 The consolidation time after lengthening can befurther reduced using the LON/LATP/LATN (Lengthening Over Nail, Lengthening And Then Plating, Lengthening And Then Nailing) techniques, where a plate or a nail is used to protect the regenerate during maturation against collapse, deviation or fracture, as described by a number of authors: Fragomen,18 Simpson,19 and Nayagam.20 In comparison, Masquelet and Begué13 reported an average consolidation time of 14 months for bone defects in a larger series. In another series using the Masquelet technique, eight patients with defect sizes of 3 to 9 cm demonstrated an average time to full weight bearing of 8 months, whereas consolidation time was unpredictable and failed to occur in three cases.21
PABST is particularly suitable for the femur. Thigh external fixation is difficult for the patient, although deep infection risk is likely lower compared with the lower leg due to the larger soft-tissue envelope and robust vascularity.21 We found good to excellent results in our 9 cases and believe that this technique deserves a place in future treatments of bone loss in the femur and tibia. The internal lengthening nail is markedly more patient-friendly than external fixator lengthening, as demonstrated by Horn, Herzenberg, and others and has particularly shorter treatment time than, for example, the Masquelet technique.13
We have not clinically used this technique outside the femur and tibia, but, with a little imagination, it could be applied to the humerus.23
Limitations of Current Implants
In our series, we had limitations with regard to the available nail sizes and the distance over which the nails can lengthen. Currently, PRECICE nail lengths of 150 to 420 mm are available with a lengthening potential of 30 to 80 mm (nail stroke). This allows most cases to be treated by combinations of acute shortening followed by gradual distraction and subsequent repeated lengthening, which may be required in tall patients or in those with very long segment defects.
When the nail stroke is too short to cover the defect, extra length can be obtained by reshortening or relengthening the nail, while temporarily fixing the transport segment to the plate and removing the screw at the tip of the nail. We did this intraoperatively using the rapid distractor device; see Figure 6. In two cases (before the rapid distractor was available), we lengthened the nail by applying the external remote controller to the leg. This procedure takes several hours and was done outside the operating room.
Sufficient bone is required to accommodate both nail and plate fixation above and below the defect. We advocate a minimum of 3 to 4 screws in each end of the plate. Careful preoperative planning is critical to assess the plate construct, the nail size, and the potential need for acute shortening.
A specific custom built transport nail (Fitbone TAA nail) is commercially available8 and others are under development24 but cannot address acute shortenings, concomitant fractures, or lesions in the metaphyseal region and cannot stabilize the transport segment after docking or when more length is needed. Such custom built nails are not readily available and so may not be possible in the acute setting. In cases of comminuted femoral trauma, some advocate stabilizing small defects with an IM nail to await spontaneous healing, particularly where vascularized fragments remain. However, this approach may take up to two years for healing and is not reliable in larger defects.25 Our series only included patients with major bone loss (4.8 to 15 cm).
Assessment of consolidation of the regenerate can be difficult when a large metal plate obscures the lateral radiographic view. The recent development of radiolucent carbon plates may resolve this issue26 (Figure 5).
Acute Shortening Versus Bone Transport
Acute shortening is forgiving, and relatively safer than transport,27 in the femur for defects up to 4 to 5 cm and for defects up to 3 cm in the tibia and should be considered in such cases because it will spare the patient a docking procedure. In 1994, Steen's group reported notable and permanent loss of muscle power in shortenings exceeding 5 cm.16 An Oxford study found that up to 35 mm could be shortened without any permanent loss of muscle power after 2 years.28 In certain clinical situations, (severe trauma, contamination, soft-tissue defects, bilateral injuries, lack of compliance etc.) we recommend acute shortening and docking while carefully monitoring the circulation and then subsequent gradual lengthening. In larger defects, normal length and alignment should be maintained whenever possible.
Infection is a concern in open fractures because contamination is inevitable, with infection rates reported up to 25% to 40%.7 With internal fixation, the risk of biofilm formation is increased, underscoring the need for prevention of infection. We elected to wait up to 6 weeks from soft-tissue closure and obtain normal blood inflammatory biomarkers (CRP, WBC) before insertion of the nail. In trauma patients, we instilled local absorbable antibiotic carriers in the bone void as dead-space management: We used calcium sulfate pellets with gentamicin (Herafill; Heraeus), Cerament V/G paste (Bonesupport AB), or antibiotic-containing cement spacers. Such a spacer will not only help in infection prevention,29-32 it will also create a fibrous chamber with a Masquelet-like bioactive lining, in which the bone transport can take place and prevent potential soft-tissue invagination. Oral antibiotics were continued for 6 weeks after surgery. Continuous soft-tissue assessment is essential and the use of free flaps is often relevant in the tibia to achieve soft-tissue cover over exposed bone and to prevent deep infection.
Concomitant chemo- and radiation therapy and radiation therapy are traditionally considered relative contraindications for distraction osteogenesis because bone formation may be delayed.9,10 However, recent studies have demonstrated that distraction osteogenesis is a safe treatment for larger bone defects in primary osteosarcomas.17,33 Tsuchiya et al have shown excellent, durable function after 10 years, which is particularly attractive as an alternative to endoprosthetic replacement in the younger patient population affected by primary bone sarcomas.34,35 A study by McCoy et al36 and colleagues in 2012 also found excellent results in 20 patients treated with the Ilizarov method for an osseous defect resulting from a primary bone lesion. For selected tumor patients, distraction osteogenesis is a reliable way to substitute resected bone (Figure 6).
All trauma patients experienced a degree of heterotopic ossification, fibrosis, superficial infection, delayed healing of docking sites, or reduced joint movement. Such complications are common in open fractures—where bone disrupts the muscle and penetrates the skin—and do not relate specifically to internal bone transport by a lengthening nail and a plate. However, it is essential to address soft-tissue issues with plastic surgeons (particularly in the tibia) and to address potential contracture (particularly in the femur) with vigorous physiotherapy throughout the treatment. Ultimately, a free flap, surgical débridement, quadricepsplasty, arthrolysis, and removal of ectopic bone may be necessary to maximize functional recovery. In addition, with double osteotomies in the femur (transport plus lengthening), or complex injuries in the tibia, alignment can be difficult to control, as seen with mild varus or valgus deviations in select cases. This may be corrected by secondary insertion of a trauma nail or by relocking of the plate to the bone (tibia cases 1, 3, 4, femur case 4).
This study is limited by the small number of cases and the heterogeneity of the patients. We present it as a description of a combined technique, which will no doubt be modified and improved in the future. Larger scale studies should explore this technique further to draw firm conclusions about its indications and feasibility.
The plate-assisted bone segment transport (PABST) with a lengthening nail and a locking plate technique, is a valuable addition to the arsenal for treating bone defects in the femur and tibia, improving patient comfort during treatment, avoiding the adverse effects of external fixation. Full weight bearing can be allowed shortly after docking due to the stability of the construct. Meticulous surgical planning, careful soft-tissue management, and infection control in open fractures is mandatory.
The present work was initiated during the LLRS travelling fellowship in 2016. The authors thank their colleagues M Kahn, A Hede, AW Paulsen, and M Mørk Petersen for feedback and assistance.
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Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.
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