Docking site augmentation followed by Ilizarov's distraction osteogenesis

Mohammad Ruhullah; Dipak Shrestha; Bigyan Bhandari; Prem Shahi

doi:10.4103/0975-7341.118751

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CASE REPORT

Year : 2013 | Volume : 6 | Issue : 1 | Page : 87-91

Docking site augmentation followed by Ilizarov's distraction osteogenesis

Mohammad Ruhullah¹, Dipak Shrestha², Bigyan Bhandari², Prem Shahi²
¹ Department of Orthopedics, National Medical College Teaching Hospital, Birgunj, Nepal
² Department of Orthopedics, Dhulikhel Hospital, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal

Date of Web Publication

23-Sep-2013

Correspondence Address:
Mohammad Ruhullah
Department of Orthopaedics, National Medical College Teaching Hospital, Birgunj
Nepal

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/0975-7341.118751

Abstract

Open fractures of the tibia/fibula are common in renal tubular acidosis patients and may be fraught with complications such as malunion, delayed union, non-union, infection, deformity, bone loss and dead and necrotic bones. The Ilizarov method, as originally described for lengthening, treatment of non-union and bone transport, does not involve the use of bone-grafting at the docking site to aid rapid healing. The most common complication is non-union of the docking site. In this report, we present a case of 18-year-old man with open fracture tibia/fibula treated initially with unilateral external fixation and followed by Ilizarov's distraction osteogenesis technique for skeletal defect created after adequate debridement and resection of the necrotic bone as a result of open fracture. We aimed to demonstrate the success of docking site augmentation of iliac crest cancellous bone graft has been shown to rapid consolidation, decrease the rate of non-union and decrease the time of prolonged fixator use with respect to patient compliance managing complex frame adjustments.

Keywords: Bone defect, bone graft, dead bone, Ilizarov′s technique, open fracture tibia

How to cite this article:
Ruhullah M, Shrestha D, Bhandari B, Shahi P. Docking site augmentation followed by Ilizarov's distraction osteogenesis. J Orthop Traumatol Rehabil 2013;6:87-91

How to cite this URL:
Ruhullah M, Shrestha D, Bhandari B, Shahi P. Docking site augmentation followed by Ilizarov's distraction osteogenesis. J Orthop Traumatol Rehabil [serial online] 2013 [cited 2023 Mar 27];6:87-91. Available from: https://www.jotr.in/text.asp?2013/6/1/87/118751

Introduction

Road traffic accidents are daily occurrences on our roads that often produce crushed limbs with open fractures of the tibia/fibula and may be fraught with complications. Malunion, delayed union, non-union, infection, dead or necrotic bone, with or without bone defect and deformity are all seen regularly after open tibia fractures. ^[1] Dead and necrotic bone is one of these complications and it forms a great clinical problem that make conventional management methods ineffective and requires several operations and long-term treatment. The Ilizarov technique Illizarov remain an important treatment method for surgeons performing post-traumatic reconstructive surgery, particularly in situations with no good alternatives, such as bone defect, non-union, infection, dead or necrotic bone as a result of open fracture. ^[2] The Ilizarov technique entails a segmental bone transport in which corticotomy is performed in the metaphysis and the bone is gradually distracted and the defect calling docking site gradually closed. The Ilizarov method, as originally described for lengthening, treatment of non-union and bone transport, does not involve the use of bone-grafting at the docking site. The most common complication is non-union of the docking site. Many investigators had found that it was supposed that union at the docking site was achieved by the process of transformation osteogenesis, but this technique might take longer time, the difficulties of prolonged fixator use and the potential of major and minor complications than with the use of augmentation of bone graft. The leading edge of the transported segment is relatively avascular. This can delay union, unless the sclerotic end is trimmed and 50% of patients reportedly undergo debridement of the leading edge of the transported segment. ^[2],[3] Numerous authors have demonstrated many successful secondary procedures to manage docking site failure. In this report, we present a case of 18-year-old man with open fracture tibia fibula treated initially with debridement, unilateral external fixation and followed by Ilizarov's distraction osteogenesis technique for skeletal defect created after debridement with supplementation of cancellous bone graft at docking site to allow rapid consolidation and decrease the overall rate of non-union and decrease the time of prolonged fixator use with respect to patient compliance managing complex frame adjustments. ^{[3],[4],[5],[6],[7],[8],[9]}

Materials and Methods

Patient is an 18-year-old man who was struck by a bus while riding a motorcycle. He was hospitalized in the emergency of Dhulikhel Hospital 2 h after the injury. At the time of the presentation there was the open wound size 5 cm × 8 cm anteromedial aspect of middle third of the right leg with exposed bone that had been stripped of its periosteum. Neurovascular status distal to the fracture was intact. After radiographs, fracture was diagnosed by Gustillo and Anderson classification as Grade IIIB open comminuted fractures middle-third shaft tibia/fibula of the right leg with associated lacerated injury heel of left foot.

Patient was brought to the operating room within 6 h from the time of injury. Irrigation of the wound area was performed followed by debridement as removal of the devitalized bone fragments and soft-tissue. After wound irrigation and debridement, stabilization of open tibia fracture was performed by placing the unilateral external fixation [Figure 1]a-c.

Figure 1: (a, b) Anteroposterior and lateral radiograph showing initial status of an 18-year-old man who sustained open comminuted fractures of middle-third tibia/fibula (Grade IIIB) (c) post op unilateral External Fixation.

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Post-surgery X-ray shows fracture site was alignment. The patient continuously received intravenous antibiotics as cefazolin for 2 weeks, gentamycin and metronidazole for 7 days to prevent infection. After daily twice dressing and good granulation formation, open wound site was grafted with split skin taken from the right thigh.

At follow-up after 3 months of post-operative, patient was clinically evaluated there was wound healed, no discharge, external fixator was stable, radiographs of the fracture site evaluated and founded dead and necrotic bone at the fracture site of the right tibia [Figure 2]a and b.

Figure 2: (a, b) One month follow-up anteroposterior and lateral radiograph showing dead and necrotic bone at the fracture site of right tibia

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Different treatment options were considered to achieve bony union and a novel approach was selected as debridement by resection of the necrotic focus of the fracture site and bone transport by Ilizarov is distraction osteogenesis technique to fill skeletal defect created after debridement. After counseling and educating to the patient regarding the importance of distraction process at a proper rate and care of the Ilizarov's frame and pin site, the patient was brought to the operating room. Under spinal anesthesia, at first removed unilateral external fixator and the fracture site was exposed through anterio-lateral approach of the right leg. Dead and necrotic bones was covered with fibrous tissues were seen during operation. Resection and removal of all non-viable bone pieces as well as fibrous tissues were performed. After freshening proximal and distal bone edges of the tibia and fibula with Gigli saw created bone defect as 9 cm of the tibia and 10 cm of the fibula to facilitate the process of compression of the tibia during the distraction osteogenesis process.

A four ring Ilizarov's apparatus were used: one ring with pairs of 1.8 mm tension wires were placed in the proximal tibia with adequate tensioning, a second ring was placed below the level of proximal corticotomy site with a pair of tensioned wires, a pair of wires connected to an intermediate ring was placed to the distal third of the tibia. One of half fourth ring was applied to the calcaneus and the second half ring placed on foot dorsally by passing tension wire through metatarsals and connected to the distal tibial ring to maintain ankle in physiological position.

After application of Ilizarov's ring, percuteneus corticotomy to the proximal metaphysis of the tibia was performed by Gigli saw preserving periosteum and medullary canal to create a middle segment of bone, which was gradually transported within the surrounding soft-tissue envelope to the other side of the bone defect called docking site. The approximation between the segments and checking the alignment of the bone were verified under image intensifier. On the 5 ^th day of post corticotomy, gradual compression and distraction osteogenesis process were started at a rate of 1 mm/day dividing 0.25 mm 4 times a day. After 3 weeks of distraction osteogenesis process, Ultrasonography was performed to confirm regeneration process at the site of corticotomy [Figure 3]a-b.

Figure 3

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At 17 weeks of distraction osteogenesis process, discontinue bone transport and distraction osteogenesis process and grafted iliac crest cancellous bone at docking site and continue lengthening process only up to 5 weeks more to maintain limb length.

At 49 weeks (12 months) of distraction osteogenesis process, the Ilizarov ring fixator was removed after complete consolidation of the regeneration at coticotomy site and union at docking site [Figure 4]a and c. After removal ring advised to patient for continue physiotherapy and non-weight bearing with the axillary's crutch.

Figure 4(a-c): At 12 months of the distraction osteogenesis process anteroposterior and lateral radiograph shows good consolidation of the regeneration at distraction site and union at the docking site and removal of Ilizarov ring

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The time taken to accomplish radiographic and clinical union was recorded and all complications as pin track infections, ankle stiffness were noted. Patient was followed-up to every 2 weeks until full weight bearing allowed.

Results

Bone healing and functional results were evaluated according to a modified Association for the Study and Application of the Method of Ilizarov classification. For bone healing, 4 criteria (union, infection and deformity and leg length discrepancy) were evaluated. An excellent result was defined of this case as bony union at docking site and consolidation at corticotomy site. Functional results were evaluated as significant limp on the right side due to 2 cm shortening occurred as a result of the debridement and resection of necrotic bone fragments and compression at docking site, which was corrected by using 2 cm heel lift shoe to account for his leg length discrepancy. Equinus rigidity of the ankle joint, which was treated with manipulation under general anesthesia and achilles tendon tenotomy at 16 months post distraction osteogenesis process and advise to the patient for full weight bearing. One of the pin track infection and cellulites of dorsal aspect of the right foot were treated with antibiotics.

At 19 months follow-up post-injury, the patient had right knee range of motion of 0-135°. He had 10° of dorsiflexion and 30° of plantar flexion of his right ankle. His right ankle dorsiflexion strength was four out of five and plantar flexion strength was five out of five. At 20 months post-injury follow-up with full weight bearing without pain, full mobility of his knee and ankle [Figure 5]a-d.

Figure 5(a-d): A good clinical appearance and functional outcome of the patient after 20 months of treatment

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Regardless of the outcome, the patient expressed pleasure at having retained his leg. He has returned to work after 20 months of injury.

Discussion

Open fractures of the tibia/fibula are common in renal tubular acidosis patients and may be fraught with complications as malunion, delayed union, non-union, infection, deformity, with or without bone loss and dead and necrotic bones. It is due to severe destruction of soft-tissue, periosteal layer, endosteal vasculature, comminution of underlying bone, elimination of local and cellular defense mechanisms.

Dead and necrotic bones are one of complications that make conventional management methods ineffective and require several operations and long-term treatment. Debridement, sequestrectomy and removal of dead and necrotic bones results in large gaps, which are difficult to treat with conventional methods as internal fixation with dynamic compression plate or interlocking nail.

In these conditions, biological methods of treatment are preferred like segmental bone transport by Ilizarov's distraction osteogenesis techniques that increase the injured site circulation and fill the secondary skeletal defects due to debridement of dead and necrotic bones. The Ilizarov method, as originally described for lengthening, treatment of non-union and bone transport, does not involve the use of bone-grafting. Most studies of bone transport for large bone defects of the tibia have demonstrated a high complication rate, because of a delay in contact and compression and the gradual closure of the defect. Soft- tissue interposition also prevents compression and new bone formation at the docking site. This can delay union, unless the sclerotic end is trimmed and 50% of patients reportedly undergo debridement of the leading edge of the transported segment. The most common complication is non-union of the docking site because the leading edge of the transported segment is relatively avascular. Many investigators had found that Ilizarov method was supposed that union at the docking site was achieved by the process of transformation osteogenesis, but this technique might take longer time, the difficulties of prolonged fixator use and the potential of major and minor complications than with the use of augmentation of bone graft. ^{[2],[5],[6],[7]} Numerous authors have demonstrated many successful secondary procedures to manage docking site failure. More recent experience has demonstrated that 30-50% of cases have required autogenous bone grafting at the docking site has been shown to decrease the overall rate of non-union and decrease the time of prolonged fixator use with respect to patient compliance managing complex frame adjustments. Delay in the formation of the regenerate at the distracted gap may prolong the duration of the fixator application. Healing at the target site does not begin until intercalary fragment lengthening is finished. Treatment becomes unnecessarily prolonged if the regenerate bone forms slowly. Pin-tract infection increases the risk of wire loosening, due to the weight borne by the external fixator, causing frame instability. ^{[2],[4],[8],[9]}

Ilizarov's distraction osteogenesis a technique produces earlier shared stability between the bone ends and the fixator, which offloads the fixator and reduces the likelihood of fixation failure. We recorded a low rate of severe pin tract infection and there was no wire loosening. No re-fracture was encountered at the docking site.

Our experiences with docking site augmentation of iliac crest cancellous bone graft followed by Ilizarov's distraction osteogenesis methods for skeletal defect created after debridement and resection of the necrotic bone of the tibia as a result of open fracture showed to allow rapid consolidation at docking site without any leg length discrepancy and stiffness.

Conclusion

This study sought to highlight the complications of open tibia/fibula fracture and suggest ways of improving result of treatment with docking site augmentation of bone graft followed by Ilizarov's distraction osteogenesis technique for skeletal defect created after debridement and resection of the necrotic bone.

Acknowledgment

The Author would like to thank the patient for providing consent to use her photograph in this article.

References

1.	Rockwood ,C.A. Jr., Green, D.P., Bucholz, R.W. Fractures in Adults. 4th ed. Philadelphia: Lippincott- Raven; 1996 pp. 305-52.
2.	Paley D, Catagni MA, Argnani F, Villa A, Benedetti GB, Cattaneo R. Ilizarov treatment of tibial nonunions with bone loss. Clin Orthop Relat Res 1989;241:146-65. [PUBMED]
3.	Paley D, Maar DC. Ilizarov bone transport treatment for tibial defects. J Orthop Trauma 2000;14:76-85. [PUBMED]
4.	Watson JT, Anders M, Moed BR. Management strategies for bone loss in tibial shaft fractures. Clin Orthop Relat Res 1995;315:138-52. [PUBMED]
5.	Bobroff GD, Gold S, Zinar D. Ten year experience with use of Ilizarov bone transport for tibial defects. Bull Hosp Jt Dis 2003;61:101-7. [PUBMED]
6.	Green SA, Jackson JM, Wall DM, Marinow H, Ishkanian J. Management of segmental defects by the Ilizarov intercalary bone transport method. Clin Orthop Relat Res 1992;280:136-42. [PUBMED]
7.	Chao EY, Aro HT, Lewallen DG, Kelly PJ. The effect of rigidity on fracture healing in external fixation. Clin Orthop Relat Res 1989;241:24-35. [PUBMED]
8.	Goulet JA, Senunas LE, DeSilva GL, Greenfield ML. Autogenous iliac crest bone graft. Complications and functional assessment. Clin Orthop Relat Res 1997;339:76-81. [PUBMED]
9.	Cattaneo R, Catagni M, Johnson EE. The treatment of infected nonunions and segmental defects of the tibia by the methods of Ilizarov. Clin Orthop Relat Res 1992;280:143-52. [PUBMED]