Reconstruction of segmental bone defects of the tibia requires technical expertise, careful operative planning, and a detailed understanding of the problem at hand. However, reconstructive efforts can easily be derailed by factors outside of the surgeon's direct control. Dedication to maximizing patient factors in the preoperative period is of paramount importance; once the reconstructive effort has begun, the risks inherent to reconstruction cannot be undone—failure to optimize may lead to failure to achieve a good outcome. Potential hazards may be encountered due to previous infection, host comorbidities, poor social support, and financial considerations. A patient's health, willingness to comply with surgical protocols, and ability to withstand the mental stresses are critical factors in the reconstructive process.
Before considering reconstructive efforts for segmental bone loss, a determination must first be made as to whether reconstruction or salvage is a viable option. Multiple decision support tools and classification schemes are available to assist in this process, and a thorough review of them is beyond the scope of this setting.1–6 For the following discussion, the assumption has been made that local host factors intrinsic to the limb have been evaluated carefully and a decision to reconstruct has been made. Reconsideration for reconstruction versus amputation may be needed in light of other systemic factors, both internal and external to the patient. Cierny described a classification system of osteomyelitis based on systemic factors of the host (see Table 1, Supplemental Digital Content 1, http://links.lww.com/JOT/A76). Additionally, the MSIS classification system has been established for use in periprosthetic infection (see Table 2, Supplemental Digital Content 2, http://links.lww.com/JOT/A77). We assume a familiarity with these classifications and explore detailed data of various comorbid conditions.
Reconstruction of segmental bone defects generally requires multiple surgical interventions, and each surgical procedure is associated with risk of perioperative complications. Both the induced membrane technique and distraction osteogenesis have been noted to require 5 to 6 operations to achieve the desired outcome.7,8 As such, patients require detailed optimization of comorbid conditions to limit the rate of complications and attain an optimal outcome.
The use of nicotine has been known to be a risk factor for a myriad of complications associated with orthopaedic surgery. Elevated complication rates have been reported with distraction osteogenesis, particularly focused on delayed consolidation and regenerate deformity.9 This finding has been corroborated in multiple other studies, with a suggested mechanism of uncoupled angiogenesis and osteogenesis due to nicotine exposure.10–12 The presence of this modifiable risk factor in the preoperative period should prompt careful evaluation, assistance to the patient in smoking cessation, and consideration for delaying surgery until successful cessation has been achieved.
Peripheral vascular disease implies a lack of healing potential. This has been demonstrated in a large cohort of ankle fractures, in which patients with peripheral vascular disease carried an increased rate of complications, particularly infection and amputation.13 Unfortunately, peripheral vascular disease is also a risk factor for failed prosthetic fitting and poor function after amputation and thus must be considered carefully.14 Interestingly, distraction osteogenesis has been used as a treatment for peripheral vascular disease, most notably critical ischemia of the digits.15–17 Distraction osteogenesis has been shown to increase vascularity of the treated limb both clinically and histologically.15,18–20 These data would suggest that distraction-osteogenesis-mediated techniques may be more effective in patients affected by peripheral vascular disease, though comparative data do not exist.
Endocrinopathy and metabolic bone disease are recognized as risk factors for nonunions. Brinker et al21 reviewed a series of 683 patients treated at a tertiary referral center for fracture nonunion and evaluated the prevalence of undiagnosed endocrinopathy and other metabolic conditions. Thirty-seven patients were referred for evaluation by an endocrinologist after they were determined to have an “unexplained” nonunion (good surgical technique, absence of infection, or sustained multiple low-energy fractures). Thirty-one of the 37 patients were found to have significant previously undiagnosed metabolic or endocrine disease, with the most common being vitamin D deficiency.21 For the surgeon considering reconstruction, these data indicate that careful screening and evaluation may prevent future complications. We recommend particular attention to Vitamin D, total protein, and albumin/prealbumin levels.
Vitamin D has been the subject of a large volume of research relating to fracture incidence and fracture healing. The general understanding is that low vitamin D levels will increase fracture healing–related complications.21,22 Recent evidence, however, indicates that although vitamin D deficiency is very common in patients affected by both fracture and fracture nonunion, serum levels of vitamin D did not correlate with increased fracture complications.23 Given the low risk of testing and replacement for vitamin D deficiency, we continue to recommend evaluation and treatment for vitamin D deficiency in the perioperative period for segmental bone defects. Further research is required to validate or refute this practice.
The prevalence of protein malnutrition in limb reconstruction patients is currently undefined. However, a cross-sectional study of trauma patients requiring intensive care revealed very high rates of protein malnutrition, significantly elevated when compared with nontrauma patients.24 Extrapolation of these data to patients with segmental bone defects, either from chronic infection or trauma, is not unreasonable. Protein malnutrition has been demonstrated to be associated with poor outcomes and delayed wound healing in patients with hip fractures.25,26 In animal models, protein malnutrition has been shown to reduce fracture healing potential, and supplementation and reversion of the pathology improve anabolic soft-tissue response and fracture healing.27,28 We test all reconstruction patients for protein malnutrition and supplement accordingly.
Detailed data regarding the impact of solid organ dysfunction on limb salvage procedures are not available. However, solid organ dysfunction has been shown to be an increased morbidity in the perioperative period. Elevated rates of postoperative complications and postoperative pain have been reported in patients on hemodialysis, and similar but less severe increases have been reported with chronic kidney disease.29,30 Liver failure is similarly associated with elevated perioperative risk after joint arthroplasty.31,32 Adequate medical management must be assured during the treatment period to mitigate these risk factors.
The role for evaluating immunologic function in patients presenting with infection and segmental bone defects is evolving. No clear guidelines have been established. At our institution, patients who present with no apparent cause of persistent infection (A Hosts) undergo extensive immunologic testing. We have identified a number of patients with immunologic deficiencies that are amenable to treatment, indicating an additional area of potential optimization that has previously been underestimated. Although testing comes with significant expense, it is our position that the potential for avoiding further complications in this difficult setting is warranted. Further data are required to determine the effect of this evaluation.
The presence or absence of infection is of critical importance in host optimization. In the presence of infection, it has been documented that the healing index is increased, thus requiring longer immobilization and protected weight bearing.33 Distraction-osteogenesis-mediated techniques have been shown to have better outcomes for segmental tibial defects in compromised hosts; however, these data predate advances in the induced membrane technique.34 Although series have varied greatly regarding infection recurrence rates, several papers have reported a recurrence rate of 5%–30% with the Masquelet technique.35–37 A large systematic review35 reported a failure rate of approximately 10% of infected cases, largely in the presence of persistent infection (8.9%). Amputation was required in 4%.35 Although pin tract infections are common in bone transport techniques, overall infection rates have been reported to be lower in bone transport series (though no direct comparison studies are available).38
It has been suggested that all complex nonunions and malunions should have consideration for reconstruction.39 Careful consideration of mental function and willingness to undergo complex treatment are required. Interestingly, functional outcomes for immediate amputation versus attempted salvage and delayed amputation have been shown to be similar.40,41 Hence, in cases where a successful salvage is not assured, the surgeon can proceed with the knowledge that the long-term outcome is not significantly worsened for the attempt.
It is clear that patient factors regarding personality and internal drive are important in any reconstructive effort that requires significant rehabilitation. Data in this area are lacking for bone defect reconstruction. However, data are plentiful in sports medicine for ligamentous reconstruction. Parallels can be drawn due to the large amount of therapy required, though the interventions are by no means equal in the demands on the patient. In anterior cruciate ligament reconstruction, highly motivated patients with an internal locus of control have been repeatedly demonstrated to have better outcomes, both emotionally and physically.42–44
Interestingly, the mental health component of the SF-36 for patients undergoing segmental bone defect reconstruction has been shown to be similar to the general population.33 In patients with no previous mental health diagnoses, improvement in mental health fields has been demonstrated after bone reconstruction with the Ilizarov technique and is comparable to patients undergoing joint replacement.45 Although there was a decline in physical function during treatment with external fixation, mental and social function areas improved during fixator wear and continued to improve after completion of reconstruction.45
Reconstruction with external fixation is well known to be stressful for patients and caretakers.46 Given the prolonged periods of limited weight bearing during bone graft incorporation, it is not unreasonable to extend this finding to induced membrane and free fibula reconstructions. It is generally assumed that fixator-free reconstructions would be better tolerated in patients with poor social support or mental health problems, though data to support this assertion are lacking.
The importance of social support cannot be overstated; however, data are again lacking in bone reconstruction. Turning to the arthroplasty literature, it has been shown that higher complications are reported in patients with “difficult” social situations, and rehabilitation and home discharge are dependent on a strong social support system.47,48 Similarly, it has been shown that patients with poor social support and low self-efficacy have worse outcomes after either bone reconstruction or amputation.49 Patients with these traits benefit from additional counseling and care; surgeons and caretakers must be willing to provide this to optimize outcomes.
IMPORTANCE OF SOCIAL SUPPORT AND MENTAL HEALTH
The above discussion should not be taken as a moratorium on caring for patients with compromised social structure or mental health problems. In fact, in the senior author's practice, there is an apparent skewing of the patient population affected by segmental bone defects toward these patients. The surgeon must be aware of these complicating factors and pursue methods to mitigate the risk, such as intramedullary stabilization, additional fixation points in external fixators, and more modest lengthening goals. As reconstructive surgeons, we have an obligation to care for each patient we encounter to the best of our ability. An understanding of likely noncompliance with treatment regimens can aid in averting disaster through preparedness.
Careful consideration of local and systemic factors is critical for successful outcome in the treatment of segmental bone defects of the tibia. Comorbid conditions, nutritional status, immunologic function, peripheral vascular disease, and vitamin D deficiency require particular attention to ensure optimal outcomes. Mental health and social support structure must not be neglected at the risk of unsatisfactory patient participation, rehabilitation, and outcome. Certainly, as in other settings, it can be said that an ounce of prevention is worth a pound of cure.
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