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Fragmental bone transport in conjunction with acute shortening followed by gradual lengthening for a failed infected nonunion of the tibia
J Orthop Sci (2010) 15:420–424 DOI 10.1007/s00776-009-1423-y
Case report Fragmental bone transport in conjunction with acute shortening followed by gradual lengthening for a failed infected nonunion of the tibia MITSUHIKO TAKAHASHI, YOSHITERU KAWASAKI, YOSHITO MATSUI, and NATUO YASUI Department of Orthopaedics, Institute of Health BioSciences, the University of Tokushima Graduate School, 3-18-15 Kuramoto, Tokushima 770-8503, Japan
Introduction Ilizarov reconstructions have been regarded as potent techniques to treat infected nonunion with a large bone defect. These techniques generally include bone transport and acute shortening if it is applicable followed by gradual lengthening as well as simple bone lengthening. Fragmental bone transport has been also applied to a hemicircumferential bone defect, which is often described by cavitary osteomyelitis or hemicortical sequestrate.1,2 In these conditions, bony continuity is maintained in some part despite a bone defect on the other side that chronically drains.3 This technique allows sparing bone stock while preventing sacrifice of bony continuity from unnecessary débridement. In the following case report, we present fragmental bone transport in conjunction with acute shortening followed by gradual lengthening for treatment of an infected nonunion of the tibia. The treatment was performed according to the strategy in which living bone is efficiently utilized so long as vascularity is confirmed. As a result, the defect of the tibia had anterior longer and posterior shorter lengths at the single bone segment. To our knowledge, this is the first report of a successful unique technique for a failed infected nonunion of the tibia with a huge bone defect that had circumferentially nonuniform defect length.
Report of the case The patient was involved in a traffic accident while riding his motorcycle at the age of 24 years and suffered
Offprint requests to: M. Takahashi Received: July 17, 2009 / Accepted: September 22, 2009
a Gustilo IIIB open fracture on the right tibial shaft. The anterolateral muscle compartment, including the deep fibular nerve might be damaged, and angiography revealed that the right anterior tibial artery was occluded at the level of the fracture. Débridement of the wound and stabilization with a unilateral external fixator were given as first aid. The anterior soft tissue defect was covered by a latissimus dorsi free vascularized flap with an anastomosis to the peroneal artery, and then autologous iliac bone graft was performed for the bone defect 4 months after the injury at which no infectious sign was confirmed. However, methicillin-resistant Staphylococcus aureus (MRSA) infection became evident 2 weeks after the bone graft, which required multiple débridements over the next 6 months and eventually left infected nonunion of the tibia with huge segmental bone loss in the anterior part of the tibia. After repression of the infection, a vascularized fibular graft (VFG) with an anastomosis to the dorsalis pedis artery was performed for the anterior tibial defect with stabilization using an Ilizarov external fixator. Unfortunately, the monitoring skin flap developed necrosis. The grafted fibula broke 9 months after the VFG, which had not healed after approximately 1 year of conservative treatment including wearing a functional brace and applying low-intensity pulsed ultrasound probably owing to the loss of vascularity. Moreover, bony union had not been accomplished in the posterior tibia. He was referred to our institution about 3 years after being involved in the accident. Cancellous bone has already been taken from the bilateral anterior ilia and the right posterior ilium in addition to sacrifice of the right fibula. On examination, the length of the right leg was ∼1.5 cm shorter. Ranges of motion of the right knee and ankle were slightly restricted, and dorsiflexors of the ankle and toes were paralyzed. Plain radiography (Fig. 1), magnetic resonance imaging (MRI) (Fig. 2A), and
M. Takahashi et al.: New technique of bone transport
Fig. 1. Anteroposterior (AP) (A) and lateral (B) radiographs of the right lower leg at the patient’s first presentation to our institution. The grafted fibula did not show any callus formation (black arrows), although bony union was achieved between the grafted fibula and the host tibia (white arrowheads). The tibia also fell into nonunion (black arrowheads), although the grafted fibula or the united ipsilateral fibula made it difficult to see the nonunion site
computed tomography (CT) (not shown) of the right lower leg demonstrated a fracture at the midportion of the grafted fibula that had been placed into the anterior part (Fig. 1) and nonunion of the posterior element of the tibia (Fig. 1). The fracture of the grafted fibula did not show any callus formation. Bone scans that could be used to detect vascularity of bone4–6 indicated that the most of the grafted fibula fell into avascular necrosis (Fig. 2B), although radiological bony unions to the host tibia were observed proximal and distal to the grafted fibula (Fig. 1B). We concluded that it would be necessary to excise all the necrotic bone followed by a combination of bone transport and lengthening. However, relatively high uptake seen around the nonunion of the posterior tibia on bone scans (Fig. 2B) indicated minimum excision would be needed from the posterior.
421
The nonunion site was exposed between the grafted skin and host skin. The grafted fibula presented as yellow and sclerotic, and it did not adhere to the surrounding soft tissue, which looked less vascular. We verified vascularity sufficient for bone healing by creating microfractures in 5-mm increments along the grafted fibula and the posterior tibial element. As a result, an 8-cm excision from the grafted fibular was needed. The removal of fibrous tissue and avascular bone from the posterior tibial element left a 3-cm defect. Acute shortening was performed to close up the defect on the posterior tibial element (Fig. 3B), but there was still a residual 5-cm bone defect on the anterior element. A 7 cm long hemicircumferential bone fragment was made by longitudinal corticotomy from the anterior diaphysis of the tibia with the remaining grafted fibula distal to the excised part. A four-ring Ilizarov fixator was applied. The hemicircumferential bone fragment was connected to the proximal ring by a hooked wire, allowing proximal transport of the fragment over the anterior defect (Fig. 3). After a latency period of 7 days, lengthening was begun at a rate of 0.75 mm/day at a proximal corticotomized site between the most proximal and the second proximal rings and was continued until limb-length equality was achieved (∼4.5 cm). After an additional 3 days, transport of the hemicircumferential bone fragment was begun at the average rate of 0.6 mm/day and lasted until completion of closing the anterior defect. At 3.5 months after the operation, the anterior fragmental segment had contact with the proximal segment (Fig. 4). Radiographs also demonstrated callus formation at the proximal lengthening (Fig. 4) and at the anterior fragmental bone transport. Eight months after the initial Ilizarov procedure, sufficient callus was successfully observed across both the distraction gaps. Because bony union was not enough at the docking site of the fragmental bone transport at that time, an autologous bone graft from the left posterior ilium was performed to the docking site after excision of interposed soft tissue. Three months after the second procedure, bony union was achieved and the Ilizarov external fixator was removed. The leg was protected in a cast for 4 weeks followed by a short leg brace for several months. Radiographs demonstrated bony union of the docking site (Fig. 5) as well as mature consolidation of the generated callus and no limb-length discrepancy. At the latest follow-up (∼2 years) evaluation, there was no sign of osteomyelitis, and the patient was able to walk without a limp. Ranges of motion were not affected compared to the preoperative evaluations. The patient was informed that the data obtained from the case would be submitted for publication and gave his consent.
422
M. Takahashi et al.: New technique of bone transport
Fig. 2. A Coronal magnetic resonance image of the proximal tibia. B Oblique view of both lower legs on a 99mTcmethylene diphosphonate bone scan
Fig. 3. Postoperative photograph of the lower leg (A) and AP (B) and lateral (C) radiographs demonstrate a hooked wire (arrows) for proximal transport of the anterior hemicircumferential bone fragment. Black arrowhead in B indicates the docking site of the posterior tibial element after acute shortening. White arrowhead in C indicates the transverse corticotomy at the distal end of the hemicircumferential bone fragment
Discussion Many successful cases using the Ilizarov method have been reported for treatment of infected nonunion of long bones.1,2,7–14 Still, treatment of infected nonunion of the long bone is quite challenging, especially in cases accompanied by a large bone defect. The case we have
presented would be one of the most difficult cases if we considered the amount and shape of the bone defect after the débridement and the fact that the anterior tibial and peroneal arteries had already been sacrificed. Furthermore, a large amount of bone stock had already been used, which made it difficult to manage this case mainly by bone graft. Despite only a 3-cm posterior
M. Takahashi et al.: New technique of bone transport
423
Fig. 4. AP (A) and lateral (B) radiographs 3.5 months after the operation. Black arrow and white arrows indicate callus formation at the proximal lengthening site and at the anterior fragmental bone transport, respectively. The anterior fragmental segment has contact with the proximal segment (arrowheads)
defect, the anterior defect was found at the surgery to be 8 cm long from the ∼13-cm failed grafted fibula, which meant a circumferentially nonuniform defect length. If the preexistent shortening was also considered, the amount of defect was substantially larger. Approximately 10 cm of lengthening or bone transport — which would have had to be performed if we had simply resected the posterior tibial element equal to the anterior avascular grafted fibula — would have required a longer treatment period and might lead to a greater chance of complications Consequently, we decided to perform the fragmental bone transport over the residual anterior defect after the acute shortening that closed up the posterior tibial elements. Although there are several reports on fragmental bone transport,1,2 the current report is the first one of fragmental bone transport over the residual defect after acute shortening of the same bone segment. Although a large part of the grafted fibula appeared to be avascular, bony union was observed between the fibula and the host tibia, which indicated that both ends of the grafted fibula had been revascularized and were viable (Figs. 1, 2B). It is important that dead bone is distinguished and removed from living bone for suc-
Fig. 5. AP (A) and lateral (B) radiographs 18 months after the operation show bony union of the docking sites (arrowheads) and mature consolidation of the lengthened segments (arrows)
cessful limb lengthening and bone transport. For these purposes, we first evaluated the patient through technetium-99 methylene diphosphonate bone scans (Fig. 2B), which could discriminate vascularity and viability of bone4–6 before the surgical procedure. That enabled us to determine an outline of the surgical procedure, including the amount of bone resection, which could not be foreseen by plain radiographs, CT, or MRI. Vascularity of the posterior tibial element was thought to be maintained except the nonunion site (Fig. 2B), which indicated circumferentially nonuniform length. Finally, we made microfractures in 5-mm increments along the bones to confirm sufficient vascularity of the bone at the surgery. Then, we decided the extent of resection, leaving viable bone that would be subjected to transport. It is also important to maintain vascularity throughout the surgery. Longitudinal corticotomy to obtain the hemicircumferential bone fragment was performed
424
with special care not to disrupt the existing vascularity. To transport successfully over the anterior defect, we surmised that the fragment needed to be longer than the defect length. Despite the long (∼7 cm) hemicircumferential corticotomy, no more than two 1-cm skin incisions were needed on the medial side for the longitudinal corticotomy and just one incision for the transverse corticotomy at the distal site using multiple drilling. Consequently, bleeding from the bone fragment had been observed until the end of the surgery. The principles mentioned above should be kept in mind throughout the reconstruction. Autologous bone graft at the docking site was needed in this case. The docking bone segments were derived from the necrotic grafted fibula. Although we maintained vascularity of the bone fragment, bone viability and potential for union might be impaired during the transport. Because a bone graft is generally required at the docking site after bone transport,1,2,7–14 we do not consider it to be a complication. Conversely, we believe that the amount of bone graft was minimized by the techniques we used in regard to available bone stock in this case.
Conclusions Fragmental bone transport over the residual anterior defect after acute shortening followed by gradual lengthening comprised effective procedures for treatment of the infected nonunion of the tibia presented here. Although this case had failed with a vascularized fibular graft, leaving no other available artery for a vascularized graft, Ilizarov methods were still applicable. We think that the procedures we used greatly spared the bone stock and avoided undesirable complications that often occur in cases of prolonged lengthening. Even in this case, the general principles of the Ilizarov method, including minute evaluation and meticulous preservation of vascularity, are dominant if we were to achieve successful results.
M. Takahashi et al.: New technique of bone transport All the authors did not receive and will not receive any benefits or funding from any commercial party related directly or indirectly to the subject of this article.
References 1. Cattaneo R, Catagni M, Johnson EE. The treatment of infected nonunions and segmental defects of the tibia by the methods of Ilizarov. Clin Orthop 1992;280:143–52. 2. Aronson J. Cavitary osteomyelitis treated by fragmentary cortical bone transportation. Clin Orthop 1992;280:153–9. 3. May JW Jr, Jupiter JB, Weiland AJ, Byrd HS. Clinical classification of post-traumatic tibial osteomyelitis. J Bone Joint Surg Am 1989;71:1422–8. 4. Greenberg BM, Jupiter JB, McKusick K, May JW Jr. Correlation of postoperative bone scintigraphy with healing of vascularized fibula transfer: a clinical study. Ann Plast Surg 1989;23:147–54. 5. Malizos KN, Soucacos PN, Vragalas V, Dailiana ZH, Schina I, Fotopoulos A. Three phase bone scanning and digital arteriograms for monitoring vascularized fibular grafts in femoral head necrosis. Int Angiol 1995;14:319–26. 6. McMahon SJ, Young D, Ballok Z, Badaruddin BS, Larbpaiboonpong V, Hawdon G. Vascularity of the femoral head after Birmingham hip resurfacing: a technetium Tc 99m bone scan/single photon emission computed tomography study. J Arthroplasty 2006;21:514–21. 7. Aronson J, Johnson E, Harp JH. Local bone transportation for treatment of intercalary defects by the Ilizarov technique: biomechanical and clinical considerations. Clin Orthop 1989;243:71–9. 8. Paley D, Catagni MA, Argnani F, Villa A, Benedetti GB, Cattaneo R. Ilizarov treatment of tibial nonunions with bone loss. Clin Orthop 1989;241:146–65. 9. Dendrinos GK, Kontos S, Lyritsis E. Use of the Ilizarov technique for treatment of non-union of the tibia associated with infection. J Bone Joint Surg Am 1995;77:835–46. 10. De Pablos J, Barrios C, Alfaro C, Canadell J. Large experimental segmental bone defects treated by bone transportation with monolateral external distractors. Clin Orthop 1994;298:259–65. 11. Paley D, Maar DC. Ilizarov bone transport treatment for tibial defects. J Orthop Trauma 2000;14:76–85. 12. Maini L, Chadha M, Vishwanath J, Kapoor S, Mehtani A, Dhaon BK. The Ilizarov method in infected nonunion of fractures. Injury 2000;31:509–17. 13. Catagni MA, Ottaviani G, Camagni M. Treatment of massive tibial bone loss due to chronic draining osteomyelitis: fibula transport using the Ilizarov frame. Orthopedics 2007;30:608–11. 14. Mekhail AO, Abraham E, Gruber B, Gonzalez M. Bone transport in the management of posttraumatic bone defects in the lower extremity. J Trauma 2004;56:368–78.
Case report Fragmental bone transport in conjunction with acute shortening followed by gradual lengthening for a failed infected nonunion of the tibia MITSUHIKO TAKAHASHI, YOSHITERU KAWASAKI, YOSHITO MATSUI, and NATUO YASUI Department of Orthopaedics, Institute of Health BioSciences, the University of Tokushima Graduate School, 3-18-15 Kuramoto, Tokushima 770-8503, Japan
Introduction Ilizarov reconstructions have been regarded as potent techniques to treat infected nonunion with a large bone defect. These techniques generally include bone transport and acute shortening if it is applicable followed by gradual lengthening as well as simple bone lengthening. Fragmental bone transport has been also applied to a hemicircumferential bone defect, which is often described by cavitary osteomyelitis or hemicortical sequestrate.1,2 In these conditions, bony continuity is maintained in some part despite a bone defect on the other side that chronically drains.3 This technique allows sparing bone stock while preventing sacrifice of bony continuity from unnecessary débridement. In the following case report, we present fragmental bone transport in conjunction with acute shortening followed by gradual lengthening for treatment of an infected nonunion of the tibia. The treatment was performed according to the strategy in which living bone is efficiently utilized so long as vascularity is confirmed. As a result, the defect of the tibia had anterior longer and posterior shorter lengths at the single bone segment. To our knowledge, this is the first report of a successful unique technique for a failed infected nonunion of the tibia with a huge bone defect that had circumferentially nonuniform defect length.
Report of the case The patient was involved in a traffic accident while riding his motorcycle at the age of 24 years and suffered
Offprint requests to: M. Takahashi Received: July 17, 2009 / Accepted: September 22, 2009
a Gustilo IIIB open fracture on the right tibial shaft. The anterolateral muscle compartment, including the deep fibular nerve might be damaged, and angiography revealed that the right anterior tibial artery was occluded at the level of the fracture. Débridement of the wound and stabilization with a unilateral external fixator were given as first aid. The anterior soft tissue defect was covered by a latissimus dorsi free vascularized flap with an anastomosis to the peroneal artery, and then autologous iliac bone graft was performed for the bone defect 4 months after the injury at which no infectious sign was confirmed. However, methicillin-resistant Staphylococcus aureus (MRSA) infection became evident 2 weeks after the bone graft, which required multiple débridements over the next 6 months and eventually left infected nonunion of the tibia with huge segmental bone loss in the anterior part of the tibia. After repression of the infection, a vascularized fibular graft (VFG) with an anastomosis to the dorsalis pedis artery was performed for the anterior tibial defect with stabilization using an Ilizarov external fixator. Unfortunately, the monitoring skin flap developed necrosis. The grafted fibula broke 9 months after the VFG, which had not healed after approximately 1 year of conservative treatment including wearing a functional brace and applying low-intensity pulsed ultrasound probably owing to the loss of vascularity. Moreover, bony union had not been accomplished in the posterior tibia. He was referred to our institution about 3 years after being involved in the accident. Cancellous bone has already been taken from the bilateral anterior ilia and the right posterior ilium in addition to sacrifice of the right fibula. On examination, the length of the right leg was ∼1.5 cm shorter. Ranges of motion of the right knee and ankle were slightly restricted, and dorsiflexors of the ankle and toes were paralyzed. Plain radiography (Fig. 1), magnetic resonance imaging (MRI) (Fig. 2A), and
M. Takahashi et al.: New technique of bone transport
Fig. 1. Anteroposterior (AP) (A) and lateral (B) radiographs of the right lower leg at the patient’s first presentation to our institution. The grafted fibula did not show any callus formation (black arrows), although bony union was achieved between the grafted fibula and the host tibia (white arrowheads). The tibia also fell into nonunion (black arrowheads), although the grafted fibula or the united ipsilateral fibula made it difficult to see the nonunion site
computed tomography (CT) (not shown) of the right lower leg demonstrated a fracture at the midportion of the grafted fibula that had been placed into the anterior part (Fig. 1) and nonunion of the posterior element of the tibia (Fig. 1). The fracture of the grafted fibula did not show any callus formation. Bone scans that could be used to detect vascularity of bone4–6 indicated that the most of the grafted fibula fell into avascular necrosis (Fig. 2B), although radiological bony unions to the host tibia were observed proximal and distal to the grafted fibula (Fig. 1B). We concluded that it would be necessary to excise all the necrotic bone followed by a combination of bone transport and lengthening. However, relatively high uptake seen around the nonunion of the posterior tibia on bone scans (Fig. 2B) indicated minimum excision would be needed from the posterior.
421
The nonunion site was exposed between the grafted skin and host skin. The grafted fibula presented as yellow and sclerotic, and it did not adhere to the surrounding soft tissue, which looked less vascular. We verified vascularity sufficient for bone healing by creating microfractures in 5-mm increments along the grafted fibula and the posterior tibial element. As a result, an 8-cm excision from the grafted fibular was needed. The removal of fibrous tissue and avascular bone from the posterior tibial element left a 3-cm defect. Acute shortening was performed to close up the defect on the posterior tibial element (Fig. 3B), but there was still a residual 5-cm bone defect on the anterior element. A 7 cm long hemicircumferential bone fragment was made by longitudinal corticotomy from the anterior diaphysis of the tibia with the remaining grafted fibula distal to the excised part. A four-ring Ilizarov fixator was applied. The hemicircumferential bone fragment was connected to the proximal ring by a hooked wire, allowing proximal transport of the fragment over the anterior defect (Fig. 3). After a latency period of 7 days, lengthening was begun at a rate of 0.75 mm/day at a proximal corticotomized site between the most proximal and the second proximal rings and was continued until limb-length equality was achieved (∼4.5 cm). After an additional 3 days, transport of the hemicircumferential bone fragment was begun at the average rate of 0.6 mm/day and lasted until completion of closing the anterior defect. At 3.5 months after the operation, the anterior fragmental segment had contact with the proximal segment (Fig. 4). Radiographs also demonstrated callus formation at the proximal lengthening (Fig. 4) and at the anterior fragmental bone transport. Eight months after the initial Ilizarov procedure, sufficient callus was successfully observed across both the distraction gaps. Because bony union was not enough at the docking site of the fragmental bone transport at that time, an autologous bone graft from the left posterior ilium was performed to the docking site after excision of interposed soft tissue. Three months after the second procedure, bony union was achieved and the Ilizarov external fixator was removed. The leg was protected in a cast for 4 weeks followed by a short leg brace for several months. Radiographs demonstrated bony union of the docking site (Fig. 5) as well as mature consolidation of the generated callus and no limb-length discrepancy. At the latest follow-up (∼2 years) evaluation, there was no sign of osteomyelitis, and the patient was able to walk without a limp. Ranges of motion were not affected compared to the preoperative evaluations. The patient was informed that the data obtained from the case would be submitted for publication and gave his consent.
422
M. Takahashi et al.: New technique of bone transport
Fig. 2. A Coronal magnetic resonance image of the proximal tibia. B Oblique view of both lower legs on a 99mTcmethylene diphosphonate bone scan
Fig. 3. Postoperative photograph of the lower leg (A) and AP (B) and lateral (C) radiographs demonstrate a hooked wire (arrows) for proximal transport of the anterior hemicircumferential bone fragment. Black arrowhead in B indicates the docking site of the posterior tibial element after acute shortening. White arrowhead in C indicates the transverse corticotomy at the distal end of the hemicircumferential bone fragment
Discussion Many successful cases using the Ilizarov method have been reported for treatment of infected nonunion of long bones.1,2,7–14 Still, treatment of infected nonunion of the long bone is quite challenging, especially in cases accompanied by a large bone defect. The case we have
presented would be one of the most difficult cases if we considered the amount and shape of the bone defect after the débridement and the fact that the anterior tibial and peroneal arteries had already been sacrificed. Furthermore, a large amount of bone stock had already been used, which made it difficult to manage this case mainly by bone graft. Despite only a 3-cm posterior
M. Takahashi et al.: New technique of bone transport
423
Fig. 4. AP (A) and lateral (B) radiographs 3.5 months after the operation. Black arrow and white arrows indicate callus formation at the proximal lengthening site and at the anterior fragmental bone transport, respectively. The anterior fragmental segment has contact with the proximal segment (arrowheads)
defect, the anterior defect was found at the surgery to be 8 cm long from the ∼13-cm failed grafted fibula, which meant a circumferentially nonuniform defect length. If the preexistent shortening was also considered, the amount of defect was substantially larger. Approximately 10 cm of lengthening or bone transport — which would have had to be performed if we had simply resected the posterior tibial element equal to the anterior avascular grafted fibula — would have required a longer treatment period and might lead to a greater chance of complications Consequently, we decided to perform the fragmental bone transport over the residual anterior defect after the acute shortening that closed up the posterior tibial elements. Although there are several reports on fragmental bone transport,1,2 the current report is the first one of fragmental bone transport over the residual defect after acute shortening of the same bone segment. Although a large part of the grafted fibula appeared to be avascular, bony union was observed between the fibula and the host tibia, which indicated that both ends of the grafted fibula had been revascularized and were viable (Figs. 1, 2B). It is important that dead bone is distinguished and removed from living bone for suc-
Fig. 5. AP (A) and lateral (B) radiographs 18 months after the operation show bony union of the docking sites (arrowheads) and mature consolidation of the lengthened segments (arrows)
cessful limb lengthening and bone transport. For these purposes, we first evaluated the patient through technetium-99 methylene diphosphonate bone scans (Fig. 2B), which could discriminate vascularity and viability of bone4–6 before the surgical procedure. That enabled us to determine an outline of the surgical procedure, including the amount of bone resection, which could not be foreseen by plain radiographs, CT, or MRI. Vascularity of the posterior tibial element was thought to be maintained except the nonunion site (Fig. 2B), which indicated circumferentially nonuniform length. Finally, we made microfractures in 5-mm increments along the bones to confirm sufficient vascularity of the bone at the surgery. Then, we decided the extent of resection, leaving viable bone that would be subjected to transport. It is also important to maintain vascularity throughout the surgery. Longitudinal corticotomy to obtain the hemicircumferential bone fragment was performed
424
with special care not to disrupt the existing vascularity. To transport successfully over the anterior defect, we surmised that the fragment needed to be longer than the defect length. Despite the long (∼7 cm) hemicircumferential corticotomy, no more than two 1-cm skin incisions were needed on the medial side for the longitudinal corticotomy and just one incision for the transverse corticotomy at the distal site using multiple drilling. Consequently, bleeding from the bone fragment had been observed until the end of the surgery. The principles mentioned above should be kept in mind throughout the reconstruction. Autologous bone graft at the docking site was needed in this case. The docking bone segments were derived from the necrotic grafted fibula. Although we maintained vascularity of the bone fragment, bone viability and potential for union might be impaired during the transport. Because a bone graft is generally required at the docking site after bone transport,1,2,7–14 we do not consider it to be a complication. Conversely, we believe that the amount of bone graft was minimized by the techniques we used in regard to available bone stock in this case.
Conclusions Fragmental bone transport over the residual anterior defect after acute shortening followed by gradual lengthening comprised effective procedures for treatment of the infected nonunion of the tibia presented here. Although this case had failed with a vascularized fibular graft, leaving no other available artery for a vascularized graft, Ilizarov methods were still applicable. We think that the procedures we used greatly spared the bone stock and avoided undesirable complications that often occur in cases of prolonged lengthening. Even in this case, the general principles of the Ilizarov method, including minute evaluation and meticulous preservation of vascularity, are dominant if we were to achieve successful results.
M. Takahashi et al.: New technique of bone transport All the authors did not receive and will not receive any benefits or funding from any commercial party related directly or indirectly to the subject of this article.
References 1. Cattaneo R, Catagni M, Johnson EE. The treatment of infected nonunions and segmental defects of the tibia by the methods of Ilizarov. Clin Orthop 1992;280:143–52. 2. Aronson J. Cavitary osteomyelitis treated by fragmentary cortical bone transportation. Clin Orthop 1992;280:153–9. 3. May JW Jr, Jupiter JB, Weiland AJ, Byrd HS. Clinical classification of post-traumatic tibial osteomyelitis. J Bone Joint Surg Am 1989;71:1422–8. 4. Greenberg BM, Jupiter JB, McKusick K, May JW Jr. Correlation of postoperative bone scintigraphy with healing of vascularized fibula transfer: a clinical study. Ann Plast Surg 1989;23:147–54. 5. Malizos KN, Soucacos PN, Vragalas V, Dailiana ZH, Schina I, Fotopoulos A. Three phase bone scanning and digital arteriograms for monitoring vascularized fibular grafts in femoral head necrosis. Int Angiol 1995;14:319–26. 6. McMahon SJ, Young D, Ballok Z, Badaruddin BS, Larbpaiboonpong V, Hawdon G. Vascularity of the femoral head after Birmingham hip resurfacing: a technetium Tc 99m bone scan/single photon emission computed tomography study. J Arthroplasty 2006;21:514–21. 7. Aronson J, Johnson E, Harp JH. Local bone transportation for treatment of intercalary defects by the Ilizarov technique: biomechanical and clinical considerations. Clin Orthop 1989;243:71–9. 8. Paley D, Catagni MA, Argnani F, Villa A, Benedetti GB, Cattaneo R. Ilizarov treatment of tibial nonunions with bone loss. Clin Orthop 1989;241:146–65. 9. Dendrinos GK, Kontos S, Lyritsis E. Use of the Ilizarov technique for treatment of non-union of the tibia associated with infection. J Bone Joint Surg Am 1995;77:835–46. 10. De Pablos J, Barrios C, Alfaro C, Canadell J. Large experimental segmental bone defects treated by bone transportation with monolateral external distractors. Clin Orthop 1994;298:259–65. 11. Paley D, Maar DC. Ilizarov bone transport treatment for tibial defects. J Orthop Trauma 2000;14:76–85. 12. Maini L, Chadha M, Vishwanath J, Kapoor S, Mehtani A, Dhaon BK. The Ilizarov method in infected nonunion of fractures. Injury 2000;31:509–17. 13. Catagni MA, Ottaviani G, Camagni M. Treatment of massive tibial bone loss due to chronic draining osteomyelitis: fibula transport using the Ilizarov frame. Orthopedics 2007;30:608–11. 14. Mekhail AO, Abraham E, Gruber B, Gonzalez M. Bone transport in the management of posttraumatic bone defects in the lower extremity. J Trauma 2004;56:368–78.