Gulabi Deniz, Erdem Mehmet, Cecen Gultekin Sıtkı, Avci Cem Coskun, Saglam Necdet, Saglam Fevzi
Dr Lutfi Kırdar Kartal Training and Research Hospital, Semsi Denizer Cad. E5, Yanyol Cevizli Kavsagı Kartal, 34890, Istanbul, Turkey,
Clin Orthop Relat Res. 2014 Dec;472(12):3892-901. doi: 10.1007/s11999-014-3640-8.
Treatment of tibial nonunion with bone loss is extremely difficult. A variety of techniques have been described, but each has shortcomings, in particular prolonged external fixation time as well as serious complications such as nonunion and infection. Accordingly, we developed a technique that seeks to reduce these complications by using a circular external fixator in addition to an intramedullary nail to achieve union, limb lengthening, and stability of the regenerated segment.
First, the pseudoarthrosis area is resected, and acute compression is continued until bone contact at the docking site was achieved. Then primary grafting is applied to the docking site using a graft harvested from the patient's iliac bone, and the predrilled nail holes localized on the middle segment of the tibia are locked with a free-hand technique. Finally, lengthening is performed to overcome the leg-length discrepancy with an external fixator.
Between 2008 and 2011, this technique was used to treat five patients with tibial nonunion with bone loss. All patients were available for a minimum of a 14-month followup (mean, 30 months; range, 14-58 months). General indications for the procedure were age older than 16 years, tibial nonunion with bone loss, and the absence of any psychiatric disorder. We evaluated external fixation time, external fixation index (defined as the duration of external fixation in months divided by the total amount of bone transported and/or the amount of lengthening in centimeters), and time to union on plain radiographs, clinical results using the Paley bone and functional assessment scores, and postoperative complications from chart review.
The external fixation time was 4 months (range, 3-5 months), and the average external fixation index was 0.4 months/cm. The mean time to bone union was 4.6 months (range, 3.5-5.5 months). All angles were determined to be in the normal range. No patients developed refracture or malalignment either on the docking site or the osteotomy site. Paley bone evaluation results were excellent in all five patients, and Paley functional results were excellent in four and good in one. We observed 10 pin-site infections as minor complications, and one patient was left with a residual equinus deformity of 5° as a major complication according to the Paley classification.
Our technique combining acute shortening and distraction osteogenesis had promising results for the treatment of tibial nonunion with bone loss in a small group of patients. However, future studies directly comparing available approaches to this difficult problem are required. Because this problem is uncommon, these studies will almost certainly require the cooperation of multiple large participating centers.
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
治疗伴有骨缺损的胫骨骨不连极具挑战性。已描述了多种技术，但每种技术都有缺点，特别是外固定时间延长以及诸如骨不连和感染等严重并发症。因此，我们开发了一种技术，该技术通过使用环形外固定器以及髓内钉来实现骨愈合、肢体延长和再生节段的稳定性，以试图减少这些并发症。
首先，切除假关节区域，并持续进行急性加压直至对接部位实现骨接触。然后，使用从患者髂骨获取的移植物对对接部位进行初次植骨，并采用徒手技术锁定位于胫骨中段的预钻孔钉孔。最后，使用外固定器进行延长以克服腿长差异。
2008年至2011年期间，该技术用于治疗5例伴有骨缺损的胫骨骨不连患者。所有患者均至少随访14个月（平均30个月；范围14 - 58个月）。该手术的一般适应证为年龄大于16岁、伴有骨缺损的胫骨骨不连以及无任何精神疾病。我们评估了外固定时间、外固定指数（定义为外固定持续时间（月）除以骨搬运总量和/或延长量（厘米））、X线平片上的骨愈合时间、使用帕利（Paley）骨和功能评估评分的临床结果以及通过病历审查得出的术后并发症。
外固定时间为4个月（范围3 - 5个月），平均外固定指数为0.4个月/厘米。骨愈合的平均时间为4.6个月（范围3.5 - 5.5个月）。所有角度均确定在正常范围内。对接部位或截骨部位均未发生再骨折或畸形愈合。5例患者的帕利骨评估结果均为优秀，帕利功能结果4例优秀，1例良好。我们观察到10例针道感染为轻微并发症，根据帕利分类，1例患者遗留5°的马蹄足畸形为主要并发症。
我们的急性缩短和牵张成骨相结合的技术在一小群伴有骨缺损的胫骨骨不连患者的治疗中取得了有前景的结果。然而，需要未来的研究直接比较针对这个难题的现有方法。由于这个问题不常见，这些研究几乎肯定需要多个大型参与中心的合作。
IV级，治疗性研究。有关证据水平的完整描述，请参阅作者指南。
