Strategies in Trauma and Limb Reconstruction

Register      Login

SEARCH WITHIN CONTENT

FIND ARTICLE

Volume / Issue

Online First

Archive
Volume  18 (2023)
Volume  17 (2022)
Volume  16 (2021)
Volume  15 (2020)
Volume  14 (2019)
Volume  13 (2018)
Volume  12 (2017)
Volume  11 (2016)
Volume  10 (2015)
Volume  9 (2014)
Volume  8 (2013)
Volume  7 (2012)
Volume  6 (2011)
Volume  5 (2010)
Volume  4 (2009)
Volume  3 (2008)
Volume  2 (2007)
Volume  1 (2006)
Related articles

VOLUME 17 , ISSUE 3 ( September-December, 2022 ) > List of Articles

REVIEW ARTICLE

Hexapod Circular Frame Fixation for Tibial Non-union: A Systematic Review of Clinical and Radiological Outcomes

Khalis Boksh, Senthooran Kanthasamy, Pip Divall, Alwyn Abraham

Keywords : Deformity Correction, Functional outcomes hexapod, Non-union, Union

Citation Information : Boksh K, Kanthasamy S, Divall P, Abraham A. Hexapod Circular Frame Fixation for Tibial Non-union: A Systematic Review of Clinical and Radiological Outcomes. 2022; 17 (3):172-183.

DOI: 10.5005/jp-journals-10080-1570

License: CC BY-NC-SA 4.0

Published Online: 30-12-2022

Copyright Statement:  Copyright © 2022; The Author(s).


Abstract

Introduction: Tibial non-unions present with complex deformities, bone loss, infection, leg length discrepancy (LLD), and other features which influence function. Circular frame-based treatment is popular with the hexapod system used increasingly. This systematic review aims to determine the clinical and radiological outcomes of hexapod fixation when used for tibial non-unions. Materials and methods: The review was performed in accordance with preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. The search strategy was applied to MEDLINE and Embase databases on 15 December 2021. Studies reporting either clinical or radiological outcomes following hexapod fixation on tibial non-unions were included. Primary outcomes were radiological union and patient-reported outcome measures (PROMs). Secondary outcomes included LLD, tibial alignment deformity (TAD), return to pre-injury activity and post-operative complications. Results: After the abstract and full-text screening, 9 studies were included; there were 283 hexapod frame fixations for tibial non-unions. Infection (46.6%) and stiff hypertrophic non-union (39.2%) accounted for most non-unions treated. The average age and mean follow-up were 42.2 years and 33.1 months, respectively. The average time to union was 8.7 months with a union rate of 84.8%. A total of 90.3% of patients had TAD below 5° in all planes, with an LLD ≤1.5 cm of the contralateral leg in 90.5%. Bony and functional results were at least good in over 90% of patients when using the Association for the Study of the Method of Ilizarov (ASAMI) criteria. A total of 84% of patients returned to pre-injury activities. There were complications as follows: a total of 34% developed pin-site infection, almost 9% experienced half-pin breakage and 14% developed an equinus ankle contracture. Conclusion: Hexapod frames for the treatment of tibial non-unions produce favourable functional outcomes. Complication rates are present and need to be discussed when this modality of treatment is proposed. Further comparative studies will allow for this option to be evaluated against that of the traditional Ilizarov frame and other methods of non-union surgery.

HTML PDF Share
  1. Phieffer LS, Goulet JA. Delayed unions of the tibia. J Bone Joint Surg Am 2006;88(1):206–216. DOI: 10.2106/00004623-200601000-00026.
  2. Tzioupis C, Giannoudis PV. Prevalence of long-bone non-unions. Injury 2007;38(Suppl. 2):S3–S9. DOI: 10.1016/s0020-1383(07)80003-9.
  3. Weber B, Cech O. Pseudoarthrosis: Pathology, Biomechanics, Therapy, Results. Bern, Switzerland: Hans Huber Medical Publisher, 1976.
  4. Wu CC, Chen WJ. A revised protocol for more clearly classifying a nonunion. J Orthop Surg 2000;8(1):45–52. DOI: 10.1177/230949900000800109.
  5. Akhtar A, Shami A, Sarfraz M. Functional outcome of tibial nonunion treatment by Ilizarov Fixator. Ann Pak Inst Med Sci 2012;8(3):188–191. Corpus ID: 74404660.
  6. Jones CB, Mayo KA. Nonunion treatment: Iliac crest bone graft techniques. J Orthop Trauma 2005;19(Suppl. 10):S11–S13. DOI: 10.1097/00005131-200511101-00004.
  7. Ferreira N, Marais LC. Management of tibial non-unions according to a novel treatment algorithm. Injury 2015;46(12):2422–2427. DOI: 10.1016/j.injury.2015.09.040.
  8. Catagni MA, Guerreschi F, Holman JA, et al. Distraction osteogenesis in the treatment of stiff hypertrophic nonunions using the Ilizarov apparatus. Clin Orthop Relat Res 1994;301:159–163. PMID: 8156667.
  9. Ilizarov GA. Clinical application of the tension–stress effect for limb lengthening. Clin Orthop Relat Res 1990;250:8–26. PMID: 2403497.
  10. Kocaoglu M, Eralp L, Sen C, et al. Management of stiff hypertrophic nonunions by distraction osteogenesis: A report of 26 cases. J Orthop Traum 2003;17(8):543–548. DOI: 10.1097/00005131-200309000-00001.
  11. Saleh M, Royston S. Management of nonunion of fractures by distraction with correction of angulation and shortening. J Bone Joint Surg 1996;78(1):105–109. PMID: 8898138.
  12. Cattaneo R, Catagni M, Johnston EE. The treatment of infected nonunions and segmental defects of the tibia by the methods of the Ilizarov. Clin Orthop Relat Res 1992;280:143–152. PMID: 1611734.
  13. Paley D, Maar DC. Ilizarov bone transport treatment for tibial defects. J Orthop Trauma 2000;14:76–85. DOI: 10.1097/00005131-200002000-00002.
  14. Paley D, Catagni MA, Argnani F, et al. Ilizarov treatment of tibial nonunions with bone loss. Clin Orthop Relat Res 1989;241:146–165. PMID: 2924458.
  15. Dendrinos GK, Kontos S, Lyritsis E. Use of Ilizarov technique for treatment of non-union of the tibia associated with infection. J Bone Joint Surg 1995;77(6):835–846. DOI: 10.2106/00004623-199506000-00004.
  16. Marsh DR, Shah S, Elliott J, et al. The Ilizarov method in nonunion, malunion and infection of fractures. J Bone Joint Surg 1997;79(2):273–279. DOI: 10.1302/0301-620x.79b2.6636.
  17. Elbatray Y, Fayed M. Deformity correction with an external fixator: Easy of use and accuracy? Orthopaedics 2009;32:82. PMID: 19301808.
  18. Feldman DS, Shin SS, Madan S, et al. Correction of tibial malunion and nonunion with six-axis analysis deformity correction using the Taylor spatial frame. J Orthop Trauma 2003;17(8):549–554. DOI: 10.1097/00005131-200309000-00002.
  19. Shtarker H, Volpin G, Stolero J, et al. Correction of combined angular and rotational deformities by the Ilizarov method. Clin Orthop Relat Res 2002;402:184–195. DOI: 10.1097/00003086-200209000-00017.
  20. Garcia-Cimbrelo E, Marti-Gonzalez JC. Circular external fixation in tibial non-unions. Clin Orthop Relat Res 2004;419:65–70. PMID: 15021133.
  21. Maini L, Chadha M, Vishwanath J, et al. The Ilizarov method in infected nonunion of fractures. Injury 2000:31(7):509–517. DOI: 10.1016/s0020-1383(00)00036-x.
  22. Patil S, Montgomery R. Management of complex tibial and femoral nonunion using the Ilizarov technique, and its cost implications. J Bone Joint Surg Br 2006;88(7):928–932. DOI: 10.1302/0301-620X.88B7.17639.
  23. Williams MO. Long-term cost comparison of major limb salvage using the Ilizarov method versus amputation. Clin Orthop Relat Res 1994;301:156–158. PMID: 8156666.
  24. Fadel M, Hosny G. The Taylor spatial frame for deformity correction in the lower limbs. Int Orthop 2005;29(2):125–129. DOI: 10.1007/s00264-004-0611-9.
  25. Rozbruch SR, Pugsley JS, Fragomen T. Repair of tibial nonunions and bone defects with the Taylor spatial frame. J Orthop Trauma 2008:22(2):88–95. DOI: 10.1097/BOT.0b013e318162ab49.
  26. Rozbruch SR, Fragomen AT, Ilizarov S. Correction of tibial deformity with use of the Ilizarov–Taylor spatial frame. J Bone Joint Surg 2006;88(Suppl. 4):156–174. DOI: 10.2106/JBJS.F.00745.
  27. Manner HM, Huebl M, Radler C, et al. Accuracy of complex lower-limb deformity correction with external fixation: A comparison of the Taylor spatial frame with the Ilizarov ring fixator. J Child Ortho 2007;1:55–61. DOI: 10.1007/s11832-006-0005-1.
  28. Docquier PL, Rodriguez D, Mousny M. Three-dimensional correction of complex leg deformities using a software assisted external fixator. Acta Orthop Belg 2008;74(6):816–822. PMID: 19205330.
  29. Rozbruch SR, Segal K, Ilizarov S, et al. Does the Taylor spatial frame accurately correct tibial deformities? Clin Orthop Relat Res 2010;46(5)8:1352–1361. DOI: 10.1007/s11999-009-1161-7.
  30. Schartsman V, Choi SH, Schwartsman R. Tibial nonunions. Treatment tactics with the Ilizarov method. Orthop Clin North Am 1990;21(4):639–653. PMID: 2216399.
  31. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol 2009;6(7):e10000100. DOI: 10.1371/journal.pmed.1000100.
  32. Coleman BD, Khan KM, Maffuli N, et al. Studies of surgical outcome after patellar tendinopathy: Clinical significant of methodological deficiencies and guidelines for future studies. Victoria Institute of Sport Tendon Study Group. Scan J Med Sci Sports 2000;10(1):2–11. DOI: 10.1034/j.1600-0838.2000.010001002.x.
  33. Napora JK, Weinberg DS, Eagle BA, et al. Hexapod stacked transport for tibial infected nonunions with bone loss: Long-term functional uutcomes. J Orthop Trauma 2018;32(1):e12–e18. DOI: 10.1097/BOT.0000000000001005.
  34. Sala F, Thabet AM, Castelli F, et al. Bone transport for postinfectious segmental tibial bone defects with a combined Ilizarov/Taylor spatial frame technique. J Orthop Trauma 2011;25(3):162–168. DOI: 10.1097/BOT.0b013e3181e5e160.
  35. Ferreira N, Marais LC, Aldous C. Hexapod external fixator closed distraction in the management of stiff hypertrophic tibial nonunions. Bone Joint J 2015;97-B(10):1417–1422. DOI: 10.1302/0301-620X.97B10.35504.
  36. Arvesen JE, Watson JT, Israel H. Effectiveness of treatment for distal tibial nonunions with associated complex deformities using a hexapod external fixator: J Orthop Trauma 2017;31(2):e43–e48. DOI: 10.1097/BOT.0000000000000726.
  37. Mahomed N, O’Farrell P, Barnard AC, et al. Monofocal distraction treatment of stiff aseptic tibial nonunions with hexapod circular external fixation. J Limb Lengthen Reconstr 2017;3(2):101–106. DOI: 10.4103/jllr.jllr_31_16.
  38. Khunda A, Al-Maiyah M, Earldey WGP, et al. The management of tibial fracture non-union using the Taylor spatial frame. J Orthop 2016;13(4):360–363. DOI: 10.1016/j.jor.2016.07.002.
  39. Aboumira IEA, Sala F, Elbatrawy Y, et al. Distraction osteogenesis for tibial nonunion with bone loss using combined Iliarov and Taylor spatial frames versus a conventional circular frame. Strategies Trauma Limb Reconstr 2016;11(3):153–159. DOI: 10.1007/s11751-016-0264-4.
  40. Molepo M, Barnard AC, Birkholtz F, et al. Functional outcomes of the failed plate fixation in distal tibial fractures salvaged by hexapod external fixator. Eur J Orthop Surg Traumatol 2018;28(8):1617–1624. DOI: 10.1007/s00590-018-2231-x.
  41. Perren SM. Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: Choosing a new balance between stability and biology. J Bone Joint Surg 2002;84(8):1093–1110. DOI: 10.1302/0301-620x.84b8.13752.
  42. Feldman DS, Madan SS, Ruchelsman DE, et al. Accuracy of correction of tibia vara: acute vs gradual correction. J Pediatr Orthop 2006;26(6):794–798. DOI: 10.1097/01.bpo.0000242375.64854.3d.
  43. Graehl PM, Hersh MR, Heckman JD. Supramalleolar osteotomy for the treatment of symptomatic tibial malunion. J Orthop Trauma 1987;1(4):281–292. DOI: 10.1097/00005131-198701040-00003.
  44. Hernigou J, Schuind F. Smoking as a predictor of negative outcome in diaphyseal fracture healing. Int Orthop 2013;37:883–887. DOI: 10.1007/s00264-013-1809-5.
  45. Christiano AV, Pean CA, Konda SR, et al. Predictors of patient reported pain after lower extremity non-union surgery: The nicotine effect. Iowa Orthop J 2016;36:53–58. PMCID: PMC4910799.
  46. Eldridge JC. Problems with substantial limb lengthening. Orthop Clin North AM 1991;22(4):625–631. PMID: 1945340.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.