Strategies in Trauma and Limb Reconstruction

Register      Login

VOLUME 10 , ISSUE 1 ( April, 2015 ) > List of Articles

Original Article

Bone transport through an induced membrane in the management of tibial bone defects resulting from chronic osteomyelitis

Leonard Charles Marais

Keywords : Chronic osteomyelitis, Bone transport, Distraction osteogenesis, Induced membrane, Masquelet technique, Circular external fixation

Citation Information : Marais LC. Bone transport through an induced membrane in the management of tibial bone defects resulting from chronic osteomyelitis. 2015; 10 (1):27-33.

DOI: 10.1007/s11751-015-0221-7

License: CC BY-NC-SA 4.0

Published Online: 30-04-2015

Copyright Statement:  Copyright © 2015; Jaypee Brothers Medical Publishers (P) Ltd.


Abstract

Wide resection of infected bone improves the odds of achieving remission of infection in patients with chronic osteomyelitis. Aggressive debridement is followed by the creation of large bone defects. The use of antibiotic-impregnated PMMA spacers, as a customized dead space management tool, has grown in popularity. In addition to certain biological advantages, the spacer offers a therapeutic benefit by serving as a vehicle for delivery of local adjuvant antibiotics. In this study, we investigate the efficacy of physician-directed antibiotic-impregnated PMMA spacers in achieving remission of chronic tibial osteomyelitis. This retrospective case series involves eight patients with chronic osteomyelitis of the tibial diaphysis managed with bone transport through an induced membrane using circular external fixation. All patients were treated according to a standardized treatment protocol. A review of the anatomical nature of the disease, the physiological status of the host and the outcome of treatment in terms of remission of infection, time to union and the complications that occurred was carried out. Seven patients, with a mean bone defect of 7 cm (range 5–8 cm), were included in the study. At a mean follow-up of 28 months (range 18–45 months), clinical eradication of osteomyelitis was achieved in all patients without the need for further reoperation. The mean total external fixation time was 77 weeks (range 52–104 weeks), which equated to a mean external fixation index of 81 days/cm (range 45–107). Failure of the skeletal reconstruction occurred in one patient who was not prepared to continue with further reconstructive surgery and requested amputation. Four major and four minor complications occurred. The temporary insertion of antibiotic-impregnated PMMA appears to be a useful dead space management technique in the treatment of post-infective tibial bone defects. Although the technique does not appear to offer an advantage in terms of the external fixation index, it may serve as a useful adjunct in order to achieve resolution of infection.


PDF Share
  1. Lasanianos NG, Kanakaris NK, Giannoudis PV (2009) Current management of long bone large segmental defects. Orthop Trauma 24(2):149-163
  2. Tiemann AH, Schmidt HGK, Braunschweig R, Hofmann GO (2009) Strategies for the analysis of osteitic bone defects at the diaphysis of long bones. Strateg Trauma Limb Reconstr 4:13-18
  3. Masquelet AC, Begue T (2010) The concept of induced membrane for reconstruction of long bone defects. Orthop Clin N Am 41:27-37
  4. Viateau V, Bensidhoum M, Guillemin G et al (2010) Use of the induced membrane technique for bone tissue engineering purposes: animal studies. Orthop Clin N Am 41:49-56
  5. Masquelet AC, Fitoussi F, Begue T, Muller GP (2000) Reconstruction of the long bones by the induced membrane and spongy autograft. Ann Chir Plast Esthet 45(3):346-353
  6. Rodner CM, Browner BD, Pestani E (2002) Chronic osteomyelitis. In: Browner B (ed) Skeletal trauma, 1st edn. Saunders, Philadelphia, pp 483-506
  7. El-Gammal TA, Shiha AE, El-Deen MA, El-Sayed A, Kotb MM, Addosooki AI et al (2008) Management of traumatic tibial defects using free vascularized fibula or Ilizarov bone transport: a comparative study. Microsurgery 28:339-346
  8. Aronson J (1994) Temporal increases in blood flow during distraction osteogenesis. Clin Orthop 301:124-131
  9. Spiegl U, Pätzold R, Friederichs J, Hungerer S, Militz M, Bühren V (2013) Clinical course, complication rate and outcome of segmental resection and distraction osteogenesis after chronic tibial osteitis. Injury 44:1049-1056
  10. Uzel A-P, Lemonne F, Casoli V (2010) Tibial segmental bone defect reconstruction by Ilizarov type bone transport in an induced membrane. Orthop Traumatol Surg Res 96:194-198
  11. Anagnostakos K, Kelm J, Regitz T et al (2005) In vitro evaluation of antibiotic release from and bacteria growth inhibition by antibiotic- loaded acrylic bone cement spacers. J Biomed Mater Res B Appl Biomater 72(2):373-378
  12. Anagnostakos K, Fürst O, Kelm J (2006) Antibiotic-impregnated PMMA hip spacers. Acta Orthop 77(4):628-637
  13. Cierny G, Mader JT, Penninck JJ (1985) A clinical staging system for adult Osteomyelitis. Contemp Orthop 10:17-37
  14. De Bastiani G, Aldegheri R, Renzi-Brivio L, Trivella G (1987) Limb lengthening by callus distraction (callotasis). J Pediatr Orthop 7:129-134
  15. Shortt N, Keenan GF (2006) Ilizarov and trauma reconstruction. Curr Orthop 20:59-71
  16. Phemister D (1947) Treatment of ununited fractures by onlay bone grafts without screw or tie fixation and without breaking down the fibrous union. J Bone Joint Surg Am 29(4):946-960
  17. Ferreira N, Marais LC (2012) Prevention and management of external fixator pin tract sepsis. Strateg Trauma Limb Reconstr 7:67-72
  18. Checketts RG, MacEachern AG, Otterburn M (2000) Pin track infection and the principles of pin site care. In: Goldberg A, De Bastiani A, Graham Apley A (eds) Orthofix external fixation in trauma and orthopaedics. Springer, Berlin, pp 97-103
  19. Ferreira N, Marais LC (2012) Pin tract sepsis: incidence with the use of circular fixators in a limb reconstruction unit. SA Orthop J 11(1):10-18
  20. Spellberg B, Lipsky BA (2012) Systemic antibiotic therapy for chronic osteomyelitis in adults. Clin Infect Dis 54(3):393-407
  21. Simpson AH, Deakin M, Latham JM (2001) Chronic osteomyelitis. The effect of the extent of surgical resection on infection- free survival. J Bone Joint Surg Br 83:403-407
  22. Atway S, Nerone VS, Springer KD, Woodruff DM (2012) Rate of residual osteomyelitis after partial foot amputation in diabetic patients: a standardized method for evaluating bone margins with intraoperative culture. J Foot Ankle Surg 51:749-752
  23. Cierny G (2011) Surgical treatment of osteomyelitis. Plast Reconstr Surg 127(Suppl 1):190S-204S
  24. Roa N, Ziran BH, Lipsky BA (2011) Treating osteomyelitis: antibiotics and surgery. Plast Reconstr Surg 127(Suppl):177S- 187S
  25. Tiemann AH, Hofmann GO (2009) Principles of the therapy of bone infection in adult extremities. Strateg Trauma Limb Reconstr 4:57-64
  26. Masquelet AC (2003) Muscle reconstruction in reconstructive surgery: soft tissue repair and long bone reconstruction. Langenbecks Arch Surg 388:344-346
  27. Stafford PR, Norris BL (2010) Reamer-irrigator-aspirator bone graft and bi Masquelet technique for segmental bone defect nonunions: a review of 25 cases. Injury 41(Suppl 2):S72-S77
  28. Richard MJ, Creevy WR, Tornetta P (2012) The use of solid form-fitting antibiotic cement spacers in bone loss of the lower extremity. Curr Orthop Prac 23(5):453-457
  29. Viateau V, Guillemin G, Yang YC et al (2004) A technique for creating critical-size defects in the metatarsus of sheep for use in investigation of healing of long-bone defects. Am J Vet Res 65:1653-1657
  30. Cunningham JL (2001) The biomechanics of fracture fixation. Curr Orthop 15:457-464
  31. Roberts CS, Antoci V, Antovi V Jr, Voor MJ (2005) The effect of transfixion wire crossing angle on the stiffness of fine wire external fixation: a biomechanical study. Injury 36:1107-1112
  32. Papakostidis C, Bhandari M, Giannoudis PV (2013) Distraction osteogenesis in the treatment of long bone defects of the lower limbs. Effectiveness, complications and clinical results; a systematic review and meta-analysis. Bone Joint J 95-B:1673-1680
  33. Paley D (1990) Problems, obstacles and complications of limb lengthening by Ilizarov technique. Clin Orthop 250:81-104
  34. Kristiansen LP, Steen H (2001) Reduced lengthening index by use of bifocal osteotomy in the tibia. Acta Orthop Scan 73(1):92-97
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.