OTA 1998 Posters

Segmental Bone Transport after Unreamed Intramedullary Tibial Nailing in the Acute Trauma Patient

Gary A. Rosenberg, MD; John Sontich, MD, Case Western Reserve University, Cleveland, OH

Purpose: The treatment of acute bone loss following severe tibial shaft fractures traditionally has been a complex reconstructive problem. Many procedures have been devised to reconstitute bone stock, obtain fracture union, and provide a stable, functional limb. These procedures include cancellous grafting, fibular bypass, tibial-fibular synostosis, ipsilateral direct fibular transfer, free vascularized fibular transplants, acute shortening, and bone transport using either tensioned wire ring systems or a monolateral external fixator. We have been using internal bone transport over an unreamed intramedullary tibial nail as our primary method of bony reconstruction in acute tibial shaft fractures with bone loss greater than 4 cm. The purpose of this paper is to review our results in seven patients using this technique.

Methods: Seven patients with severe open tibial shaft fractures with a minimum of 4 cm of bone loss were included in this study. Stage I of the treatment protocol included irrigation and debridement of the wound bed, unreamed intramedullary nailing of the tibia, and ORIF of the fibula in distal 1/3 tibia/fibula fractures. The patients were returned to the operating room every 24-48 hours until a biologically sound wound was obtained. Flap coverage and/or skin grafting were performed within the first week of injury. Stage II of the treatment protocol commenced 6 weeks after injury and included application of the Ilizarov frame, and corticotomy of the non-traumatized metaphysis. A latency period of 7-10 days following corticotomy was allowed prior to the initiation of transport. The frame was not removed until a neocortex could be seen on three of the four cortices of the regenerate on anteroposterior and lateral radiographs.

Results: Seven patients were reviewed for this study. One patient underwent early amputation three days after injury secondary to failure of his revascularization graft, leaving six patients who completed their lengthening. There were six males and one female patients with an average age of 29 years (range, 17-45 years). The mechanism of injury was a MVA in one, MCA in four, pedestrian vs. automobile in one, and a work/crush injury in one. The average length of segmental bone loss was 7.1 cm (range, 4-11 cm). There were two Gustilo and Anderson open type IIIA, four type IIIB, and one type IIIC injuries. The location of bone loss was in the proximal 1/3 of the tibia in 1 patient, middle 1/3 in four patients, and the distal 1/3 in two patients. The average time spent in the Ilizarov frame was 354 days (range, 266-465 days). The average number of surgical procedures per patient was 9.2 (range 7-17 surgeries). Five patients obtained union at both the docking site and the regenerate site. One patient underwent amputation 3 years and 10 months after injury secondary to chronic osteomyelitis. Of the five patients who obtained successful union, all were able to return to work.

Discussion and Conclusion: We have found the technique described here to be a reliable means to reconstruct bone loss following an acute tibial shaft fracture. Five of the seven patients went on to solid functional union, with no cases of malunion. The addition of an intramedullary nail offers many advantages. The statically locked intramedullary nail maintains anatomic length and alignment and ensures subsequent docking of the transported segment. The added stability achieved with the interlocked nail minimizes the stability required from the Ilizarov frame. An intramedullary nail allows earlier frame removal and maintains the functional length of the muscle. Interlocking of the transported segment allows protection of the regenerate callus and compression at the docking site. Additionally an intramedullary nail allows easier access to the wound for flap coverage and prevents invagination at the docking site. In conclusion, bone transport over an intramedullary nail with an Ilizarov frame is a reliable technique and appears to offer many advantages as compared with ringed and unilateral devices.