A forty-two-year-old man was in a motorcycle accident and presented to the emergency department of a nearby hospital with a Gustilo type-IIIB open fracture of the left tibia with bone loss. The wound was irrigated and débrided, and a Hoffmann-II external fixator (Stryker, Mahwah, New Jersey) was applied. Ischemia of the left foot was suspected, and the patient was transferred to the vascular surgery unit in another hospital. He was kept under observation for five days and then was transferred back to the original hospital, where repeated wound débridements were done.
Forty days after the time of injury, the patient was referred to our Ilizarov Unit for further treatment. On admission, radiographs of the fracture revealed an unusual defect of the tibia, involving the proximal and distal metadiaphyseal regions with an intact mid-diaphyseal segment. There was skin loss, measuring approximately 3 × 4 cm, on the anteromedial portion of the distal third of the left leg, overlying the bone defect (Fig. 1, A and B).
We removed the external fixator and applied a preassembled Ilizarov frame for tetrafocal bone transport. The frame was formed of one half-ring connected to a complete ring for fixation of the proximal part of the tibia (perpendicular to the bone axis) and another complete ring for fixation of the distal part of the tibia (perpendicular to the bone axis), augmented with two posts for fixation of the calcaneus with two half-pins. A central complete ring was applied perpendicular to the middle of the diaphyseal segment, and one transport ring was placed on each side of the central ring for bone transport in the proximal and distal directions (Fig. 2, A through D).
The patient was discharged with instructions to return for regular follow-up visits at the outpatient clinic, but he needed to be readmitted after one month. The patient was brought back to the operating room, where débridement of the proximal and distal wounds was performed. All loose, exposed, and devitalized bone fragments were removed from the wound, after which two separate osteotomies were performed (percutaneously with a Gigli saw) in the middle fragment. Thus, two transport segments were created on both sides of a central fragment (which was fixed to the central Ilizarov ring) for subsequent bone transport in proximal and distal directions to close the proximal and distal bone defects, respectively.
Early knee and forefoot motion was encouraged as tolerated, and pin-site care with hydrogen peroxide and povidone iodine was started on the first postoperative day. After a latency period of fourteen days, bone transport was started. The proximal segment was transported upward at a rate of 0.25 mm twice daily, and the distal segment was transported downward at a rate of 0.25 mm twice daily. Clinical and radiographic evaluations were done every month until the end of the follow-up period (Fig. 3). The rate of bone transport was modified according to the quality of the regenerated bone.
The patient underwent some additional procedures throughout the course of treatment. To aid in the treatment of a persistent soft-tissue infection, the substitution of a proximal half-pin was performed at the time of resection of some interposed soft tissue and invaginated skin at the planned distal docking site. After bone contact at the distal docking site was achieved, débridement and iliac crest bone-grafting was performed to promote healing. The same procedure was repeated at the proximal docking site three months later.
Union of the proximal docking site was delayed, even after bone-grafting; hence, we decided to remove the frame and repeat the bone-grafting of this docking site. After removal of the Ilizarov frame, the proximal docking site was verified as being stable and bone graft was applied. The patient was then placed in a walking cast. Figure 4 shows radiographs of the leg after healing of the proximal and distal docking sites. The total time in the fixator was fifteen months.
At the time of the two-year follow-up visit, the fracture sites were completely united and the patient had no clinical infection, skin defect, deformity, or limb-length discrepancy. There was good range of motion of the knee and ankle, and the patient was bearing full weight without pain and had returned to work. The range of motion of the left knee was 0° to 130°. The left ankle had 10° of dorsiflexion and 30° of plantar flexion. Dorsiflexion strength of the left ankle was grade four of five with use of the manual muscle testing method (in which a grade of five indicates normal strength), and plantar-flexion strength was grade five of five (Fig. 5).
Aggressive débridement of bone fragments in comminuted fractures helps to reduce the risk of infection, but doing so may create a posttraumatic segmental bone defect. Most authors recommend removal of bone fragments that are contaminated and devoid of soft-tissue attachments. Inadequate resection of contaminated tissue, specifically bone, increases the risk of chronic infection4,6-8.
The Ilizarov technique of external fixation is widely used in the treatment of fractures, nonunions, bone defects, limb-length discrepancy, deformity, and osteomyelitis. Although the Ilizarov method of treatment has in some cases revolutionized the treatment of these problems, several difficulties may be encountered during the course of treatment. However, with a surgeon trained in this technique and with a motivated patient, the results can be very satisfactory9-11.
Ilizarov used the terms monofocal treatment for compression and/or distraction with lengthening all at one level (the level of the pseudarthrosis), bifocal treatment for distraction at one level (osteotomy) and compression at a second level (the level of the pseudarthrosis), and trifocal treatment for distraction at two osteotomy sites and compression at the level of the pseudarthrosis12. In the present article we used tetrafocal treatment of the tibial bone defects; that is, we performed distraction at two osteotomy sites and compression at two levels.
The injury pattern was a challenge; a large bone defect was affecting two separate tibial sites, and a soft-tissue defect was present over the distal third of the tibia, which is a challenging location for soft-tissue reconstructive procedures13.
The options available for treatment were limited. Grafting with autologous nonvascularized cancellous bone was not appropriate for these large defects, especially in the presence of soft-tissue loss, which is associated with an increased risk of infection. In addition, the transfer of the ipsilateral fibula was an unsuitable option in this patient because of the comminution of the fibula and the presence of two separate defects in the tibia.
We used the tetrafocal bone transport method to shorten the treatment time for this injury. The presence of two osteotomies and two levels of bone regeneration accelerated the closure of the bone defect and relatively shortened the treatment time, which reduced the risk of the development of complications that are associated with prolonged transport time, such as pin-track infection, loosening of the pin, and joint stiffness.
During the course of treatment, substitution of a proximal half-pin was needed to treat persistent soft-tissue infection about the pin track. According to Paley14, this was considered an obstacle and not a complication, because the infection fully resolved shortly after removal of the pin. Pin-track infection can be minimized by adequate pin-site care with hydrogen peroxide and povidone iodine and by the prevention of tissue motion at the pin site through the application of pressure to the skin surrounding the pin with gauze compressed by rubber stoppers or foam sponges pushed down with plastic clips14.
At the time of docking, the soft-tissue defect was completely closed and we revised the docking site to refresh the bone edges and remove the excessive soft tissue that had become invaginated between the bone ends.
Although the classic Ilizarov method called for healing of the docking site by gradual and prolonged compression15, we preferred to perform operative débridement of the docking sites and supplementation with autogenous bone graft to accelerate bone healing, as has been recommended by several surgeons9,16,17. In the case of our patient, delayed union at the proximal docking site, which required a second revision and bone-grafting, was the only true complication14; however, this complication can be explained by inadequate resection of the atrophic bone ends during the first revision.
Rozbruch et al.18 reported on the simultaneous treatment of tibial bone and soft-tissue defects with the Ilizarov method. They used the Ilizarov and Taylor Spatial Frames to gradually close the bone and soft-tissue defects simultaneously with use of monofocal shortening or bifocal or trifocal bone transport. Gradual closure of the defect resulted in both osseous union and soft-tissue closure, and the authors recommended the use of this limb-salvage method for patients who are not believed to be candidates for coverage with a soft-tissue flap18.
El-Rosasy19 reported the results of acute shortening and re-lengthening in twenty-one patients who were being treated for tibial fracture complicated by bone and soft-tissue loss. He considered the acute shortening to be analogous to the advancement of a large vascularized osteocutaneous flap to close the defect, and he performed re-lengthening through a metaphyseal osteotomy to restore limb length. He advised that this technique should be used as a definitive treatment immediately after injury but said that, to ensure the best functional results, the technique should not be used as a salvage procedure. Bone transport can also be considered for use during gradual advancement of a vascularized osteocutaneous flap to close bone and soft-tissue defects, which may avoid the need for free-flap coverage.
Finally, it should be remembered that the Ilizarov technique is a specialized surgical technique that is associated with a very steep learning curve and frequent complications14,15,20,21. The results of this technique can be disastrous in an untrained surgeon's hands; hence, someone who has inadequate experience should not attempt a complicated procedure such as the one described in this report.