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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 5  |  Issue : 2  |  Page : 94-99

Regenerative techniques in the management of post-traumatic segmental bone defects at a level one trauma center


Departments of Orthopaedics, Royal Melbourne Hospital, Victoria, Australia

Date of Submission18-May-2019
Date of Decision28-Oct-2019
Date of Acceptance14-Nov-2019
Date of Web Publication31-Dec-2019

Correspondence Address:
Dr. Simon C Lau
Department of Orthopaedics, Royal Melbourne Hospital, Victoria 3050
Australia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jllr.jllr_10_19

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  Abstract 


Introduction: Segmental loss of bone after traumatic injury can be managed with primary amputation or attempted limb salvage with bony regeneration. We aimed to describe our experience of treating traumatic bone loss at a tertiary level one trauma center and propose an approach to help in the treatment of these patients. Methods: Ten patients were identified via a search of the hospital's medical records covering a 5-year period. Each patient was then retrospectively reviewed with injury factors, treatment options, and final outcomes. Each patient was treated based on an anatomic approach developed by the unit to manage segmental bone loss. Results: Of the patients who underwent bony regeneration, we had four distal tibial fractures: three in the upper limb and one distal femoral fracture. Both primary amputation patients had tibial fractures. The mean bone loss was 88.5 mm. We employed bone transport in four cases, Masquelet in two, a free vascularized fibular graft and soft-tissue flap in one instance, and a combination of free vascularized fibula graft and Masquelet in another case. All patients achieved union, although the mean time to union in smokers was 1403 days, compared to 499 days in nonsmokers. Complications included three returns to theater for bone grafting and three recurrent soft-tissue infections. Post regeneration, the patients had a mean Short Form-36 score of 54.2, and most of the patients were “very satisfied” with the outcome of their surgeries. Conclusion: The regeneration of bone after traumatic loss is onerous on patients, is demanding for clinicians, and requires significant health resources. It should only be considered with appropriate patient buy-in and in the absence of contraindications.

Keywords: Bone regeneration, osteogenesis, posttraumatic segmental bone loss, primary amputation, traumatic


How to cite this article:
Lau SC, Taylor P, De Villiers D, Lahy J, Chambers S, Oppy A. Regenerative techniques in the management of post-traumatic segmental bone defects at a level one trauma center. J Limb Lengthen Reconstr 2019;5:94-9

How to cite this URL:
Lau SC, Taylor P, De Villiers D, Lahy J, Chambers S, Oppy A. Regenerative techniques in the management of post-traumatic segmental bone defects at a level one trauma center. J Limb Lengthen Reconstr [serial online] 2019 [cited 2020 Jul 4];5:94-9. Available from: http://www.jlimblengthrecon.org/text.asp?2019/5/2/94/274577




  Introduction Top


A mangled limb poses great challenges in terms of primary stabilization and definitive reconstruction options. They are typically the result of high-energy trauma. Conventionally, surgical options for the mangled limb were limited to primary amputation. However, with advances in surgical techniques such as soft tissue coverage, micro vascular procedures, and bony regeneration, a greater proportion of limbs have been able to undergo salvage. The best evidence to date regarding amputation versus salvage comes from the Lower Extremity Assessment Project (LEAP) study, which found roughly equal satisfaction rates between the two treatment options. Patient selection and education was found to be vital for successful outcomes.[1],[2] More recently, the Military Extremity Trauma Amputation/Limb Salvage study in military veterans has found primary amputation offers a better overall outcome than salvage procedures.[3]

Posttraumatic segmental bone defects (PTSBDs) commonly occur in the mangled limb. Critical segmental defects are difficult to characterize but can be considered when circumferential bone loss of >50% occurs, or with a length of >2 cm.[4] However, before lengthy and demanding limb and bone regeneration can be considered, patient and injury suitability needs to be considered.

Patient factors/optimization

Selection of the right patient for bony regeneration is the most crucial step of treatment. Medically, factors such as smoking, glycemic control, and nutrition have been identified as key factors in achieving bony union.[5] Psychological and social variables are also crucial. The LEAP study identified that patients involved in significant lower extremity trauma were more likely to be neurotic, extroverted and less open to experiencing new activities when compared to the general population.[6] It is well documented that chronic illness is associated with poorer quality of life.[7] Repeated surgery spanning months to years in the form of bone regeneration takes a psychological toll on patients, so selection and patient preparation plays a key role.

Injury characteristics

PTSBDs are usually associated with significant soft-tissue injuries.[8] Combined decision making between Orthopaedics, Plastics and Vascular teams is necessary to determine limb viability and potential salvage. Lasanianos have argued that in instances of complex soft-tissue injuries and muscle and nerve defects, primary amputation should be considered.[9] From a bony perspective, factors such as length of bone loss, location of bone loss, and articular involvement need to be considered. If articular bone loss has occurred, arthrodesis is an option. Finally, high-velocity trauma to the limb can often be associated with polytrauma to the head, chest, or abdomen, and this can influence whether or not emergent primary amputation should occur.

Once the decision to proceed with limb salvage surgery and bony regeneration is made numerous techniques have been described to achieve this goal. Each technique has its advantages and disadvantages and the patient experience with each is different. Options include, vascularized bone grafting, often utilizing the free fibula transfer in either single, double or triple barreled formation,[10],[11],[12] bone transport, utilizing distraction osteogenesis with the help of numerous lengthening devices,[13],[14] and Vascularized Pseudomembranes (Masquelet) grafting, a two-stage technique of cancellous bone grafting within a previously created vascularized pseudomembrane.[15],[16],[17]

This study represents our experience of the management of ten difficult cases of bone loss requiring bony regeneration techniques. We aim to provide both an overview of how these many techniques can be utilized for the similar but disparate cases of significant bone loss a trauma surgeon can face as well as an overview of what the patient experience is with each of these options.


  Methods Top


At our level one trauma center, the management of patients with significant bony deficits in limb trauma follows an established protocol. Patients are admitted via our Trauma Unit and urgent surgical debridement and temporary external fixation performed in conjunction with other units such as Plastic or Vascular surgery along with any other surgical priorities. The overall management of the patient, particularly those with polytrauma, remains under the direction of the Trauma Unit.

In patients with PTSBDs, all patients are referred to an orthopedic surgeon specializing in limb reconstruction surgery. Patients are counseled at least twice about the likely prognosis of bone regeneration versus primary amputation. Where possible, this involves a formalized meeting with the patient and their family. Each patient is also given the opportunity to discuss amputation formally with a specialized amputee prosthetist and rehabilitation specialist before an ultimate decision about treatment is made. Decision-making regarding technique for bony regeneration was based on each clinical scenario and surgeon dependent.

We assessed all patients who initially presented to our tertiary level one trauma center over a 5-year period with a mangled extremity. From this cohort, we identified any patient with a segmental bone defect of >2 cm using the hospital's Health Information System. This yielded ten patients. We retrospectively reviewed each case for factors such as injury etiology, patient, fracture and soft-tissue factors. Bony reconstruction techniques were recorded (or primary amputation if this was performed). Complications and other follow-up data were also recorded. Our results included functional outcome and satisfaction scores. This was performed at a mean of 35 months. Finally, data were collected in accordance with the World Medical Association Helsinki declaration of 1975.


  Results Top


Epidemiology

We had a total of ten patients. Their mean age at the time of injury was 36 years. There were nine males and one female. There were three smokers. Seven of the ten patients were involved in high-velocity motorized accident. The remainder had direct trauma to the limb [Table 1].
Table 1: Epidemiology of patients presenting with segmental bone loss

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Injury characteristics

All injuries were classified based on the Gustilo–Anderson grading system. The majority were 3B injuries, and there were three 3Cs, including both patients who underwent primary amputation. The tibia was the most common site of injury. Isolated limb trauma occurred in seven cases and in the remainder, polytrauma was present. The mean bony deficit was 101.8 mm, but if the cases undergoing primary amputation were excluded, this mean decreased to 88.5 mm [Table 2].
Table 2: Injury characteristics of posttraumatic segmental bone defects, Injury Severity Score, and Mangled Extremity Severity Score

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Treatment

Bone transport with a fine wire external fixator was performed under a radiologically derived program of gradual lengthening in four instances – all of them in cases of segmental mid or distal tibial bone loss. The mean bone loss in these cases was 94.2 mm. Both primary amputations occurred after injuries to the distal tibia, with a mean bone loss segment of 155.0 mm (135.3–174.6 mm). In cases of upper limb trauma, we employed a Masquelet/pseudomembrane technique twice and a vascularized fibular-free graft once. The mean deficits in the upper limb cases were lower at 51.1 mm. We had one case of a distal femoral fracture with intact condyles which underwent a vascularized free fibula graft in a double-strutted fashion and spanning internal fixation and subsequently a delayed Masquelet procedure to fill in the remaining cortical deficits. The bony loss in this case measured 177.6 mm. Including initial debridement, the patients took a mean of eight trips to the operation theater. Most patients required soft-tissue coverage of their wounds, and this was performed by a mixture of skin grafting (3), anterolateral thigh (ALT) free flap (4), or primary closure (1) at a mean of 12.8 days postinjury. Primary amputation was performed when the treating surgeon felt the limb to be unsalvageable. In both cases, this was due to concurrent severe soft-tissue deficits.

Short-term outcomes

Bony union was achieved in all cases where regeneration was attempted. The mean time to union was 725 days. For tibial fractures, this occurred in 847 days. In smokers, the mean time to union was 1403 days compared to 499 days in nonsmokers. Complications were seen in most cases. We had three patients who needed one or multiple returns to theater for autologous bone grafting (including both smokers in the regeneration group). Three cases including one bone transport with fine wireframe had recurrent soft-tissue infection, requiring antibiotic treatment (but no operative debridement). There was one wound dehiscence of an ALT free flap that needed further debridement in theater in a patient undergoing primary amputation. Other complications included a deep-vein thrombosis, chronic regional pain syndrome (CRPS), clawing of the toes requiring a flexor tenotomy (possibly from Flexor Hallicus longus or Flexor Digitorum longus contracture), and phantom limb pain in one of the primary amputation patients. We had no instances of fracture through the regenerated bone and no instances of free fibular donor-site infection. In the amputee group, there were no instances of circumferential skin loss or lymphedema, and both patients were able to utilize a below-knee prosthesis without major difficulty.

Long-term outcomes

Patients were followed up for a mean of 2 years and 11 months (10 months–5 years and 3 months) in outpatient clinics. The mean number of appointments was 28. Tibial fractures with bone transport had a mean of forty clinic appointments – to allow for careful monitoring of limb alignment and strut or programming changes. Functionally, all patients had Short Form-36 scores performed with a mean of 54.9, and there was no correlation between smoking or satisfaction scores (P = 0.70). All patients underwent a satisfaction survey. When asked what they would do if they had their time again, all the eight patients who underwent salvage surgery agreed that they would again undergo bone regeneration. Seven of the eight patients were very satisfied with the limb salvage outcome, and one (who developed CRPS) was somewhat satisfied. Of the primary amputations, one was somewhat satisfied and the other was somewhat dissatisfied [Table 3].
Table 3: Results of bony regeneration versus primary amputation

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  Discussion Top


Key findings

There are a number of documented case reports, case series, and surgical techniques, which describe the methods of bony regeneration. What is missing is how these strategies and techniques can be employed in clinical traumatic scenarios, where a range of patient and anatomical factors, such as upper versus lower (or weightbearing) limb, degree of bone loss, and involvement of articular surfaces, need to be considered.

We found that the regeneration of significant diaphyseal and metaphyseal fractures and traumatic bone loss is possible. However, the decision to embark on bone regeneration should not be taken lightly – the “right” patient is difficult to describe, but absolute and relative contraindications can be identified. Above all, we have found that patient empowerment and active participation in the decision and their recovery is vital.

We principally employed vascularized bone grafting in upper limb defects. We were successful in minimizing recognized complications of donor-site morbidity, which have been documented as high as 30%.[18] Further, a study by Song et al. on the use of vascularized fibula transfer in femoral bone defects saw inferior results when compared to bone transport, secondary to problems with donor-site morbidity.[19] In addition, by taking a conservative approach to weightbearing, we had no instances of perifibular fracturing, which has been documented at 20%.[20] We found the fibulas useful as the natural cross section of the fibula could be readily used to fill cortical defects in the forearm.

We treated all our tibial defects with either primary amputation or bone transport in a Taylor spatial frame (Smith and Nephew, Memphis), a hybrid external fixator fine wire frame. A systematic review of distraction osteogenesis reported an eventual union rate of 94%, although this was associated with an increased risk of re-fracture in defects >8 cm.[21] The duration of regeneration is also lengthy in bone transport. Aronson et al. reported a mean duration of 10.8 months,[13] whereas in our series, we saw union at 27.3 months. Partly, this reflects the conservative approach to the rate of lengthening we adopted with framing. It may also reflect the extended time between initial injury and starting definitive bony regeneration for some patients in whom soft-tissue defects, wound contamination, and multiple other traumatic injuries were an issue. At our center, bone transport was usually commenced approximately 6 weeks after initial temporary external fixation. Further, their series included a large number of chronic malunion patients, which we did not include in our cohort. We did not employ novel techniques of bone transport such as dual external fixation and internal lengthening tibial nails [22] or bifocal distraction osteogenesis.[23] Late amputation is also a documented complication, which reflects the significant psychological burden prolonged framing entails. Despite our longer duration to union, we did not have any instances of late amputation, and this may reflect our rigid screening of patients for suitability for bone transport [Figure 1].
Figure 1: Use of a fine wireframe and distraction osteogenesis to reconstruct a segmental tibial shaft fracture. (a) initial midshaft tibial fracture, (b) Sequential distraction osteogenesis using the fine wireframe, (c) bony union 2 years after original injury

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We utilized a Masquelet approach in the upper limb. There are reports of failure with graft resorption in defects >5 cm,[24] but we did not see this in our small series. Re fracture is another consideration, but we did not see this either. We had one instance of a lengthy time to union, but this is probably the result of multiple re-operations and grafting for infection. This patient was also a smoker [Figure 1], [Figure 2].
Figure 2: Use of the Masquelet technique in a distal humeral fracture. (a) segmental humeral loss, (b) 1st-stage Masquelet, (c) post 2nd-stage Masquelet

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Interpretation and implications

Bony regeneration in trauma is a complex clinical scenario. Because they occur rarely and patients come from a variety of socioeconomic backgrounds, decision- making can be challenging. Through a retrospective review, we have been able to document the lessons we have learned in treating these patients. Most importantly, we have determined that the appropriate selection of patients remains the most important step. The results of our study including time to union and number of theater visits and outpatient appointments have been useful in the consenting process for patients. Further, the expectation of complications should be emphasized to any patient consideration regeneration. Despite achieving radiological union and relatively high satisfaction scores, it is possible that some of our patients would have been better off with primary amputation – particularly smokers. When regeneration is considered, we largely employed an anatomic approach to help determine the method of regeneration. This is documented.

Strengths and limitations

This was a small retrospective series. There is clear selection and collection bias associated with any such study, and ours was no exception.


  Conclusion Top


The trauma required to cause segmental bone loss is high. Significant soft-tissue defects and polytrauma are often associated with these injuries. Added to this is the swirling background of mental illness, lower socioeconomic status, and smoking. Decision-making can be complex indeed! We found an anatomic approach useful in determining which type of bony regeneration should be considered.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Higgins TF, Klatt JB, Beals TC. Lower Extremity Assessment Project (LEAP)--the best available evidence on limb-threatening lower extremity trauma. Orthop Clin North Am 2010;41:233-9.  Back to cited text no. 1
    
2.
MacKenzie EJ, Bosse MJ. Factors influencing outcome following limb-threatening lower limb trauma: Lessons learned from the Lower Extremity Assessment Project (LEAP). J Am Acad Orthop Surg 2006;14:S205-10.  Back to cited text no. 2
    
3.
Doukas WC, Hayda RA, Frisch HM, Andersen RC, Mazurek MT, Ficke JR, et al. The Military Extremity Trauma Amputation/Limb Salvage (METALS) study: Outcomes of amputation versus limb salvage following major lower-extremity trauma. J Bone Joint Surg Am 2013;95:138-45.  Back to cited text no. 3
    
4.
Nauth A, McKee MD, Einhorn TA, Watson JT, Li R, Schemitsch EH. Managing bone defects. J Orthop Trauma 2011;25:462-6.  Back to cited text no. 4
    
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Mauffrey C, Barlow BT, Smith W. Management of segmental bone defects. J Am Acad Orthop Surg 2015;23:143-53.  Back to cited text no. 5
    
6.
MacKenzie EJ, Bosse MJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, et al. Characterization of patients with high-energy lower extremity trauma. J Orthop Trauma 2000;14:455-66.  Back to cited text no. 6
    
7.
Keles H, Ekici A, Ekici M, Bulcun E, Altinkaya V. Effect of chronic diseases and associated psychological distress on health-related quality of life. Intern Med J 2007;37:6-11.  Back to cited text no. 7
    
8.
Parrett BM, Matros E, Pribaz JJ, Orgill DP. Lower extremity trauma: Trends in the management of soft-tissue reconstruction of open tibia-fibula fractures. Plast Reconstr Surg 2006;117:1315-22.  Back to cited text no. 8
    
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Lasanianos NG, Kanakaris NK, Giannoudis PV. Current management of long bone large segmental defects. Orthop Trauma 2010;24:149-63.  Back to cited text no. 9
    
10.
Lin CH, Wei FC, Chen HC, Chuang DC. Outcome comparison in traumatic lower-extremity reconstruction by using various composite vascularized bone transplantation. Plast Reconstr Surg 1999;104:984-92.  Back to cited text no. 10
    
11.
Hou SM, Liu TK. Reconstruction of skeletal defects in the femur with 'two-strut' free vascularized fibular grafts. J Trauma 1992;33:840-5.  Back to cited text no. 11
    
12.
Zaretski A, Amir A, Meller I, Leshem D, Kollender Y, Barnea Y, et al. Free fibula long bone reconstruction in orthopedic oncology: A surgical algorithm for reconstructive options. Plast Reconstr Surg 2004;113:1989-2000.  Back to cited text no. 12
    
13.
Aronson J, Johnson E, Harp JH. Local bone transportation for treatment of intercalary defects by the Ilizarov technique. Biomechanical and clinical considerations. Clin Orthop Relat Res 1989;243:71-9.  Back to cited text no. 13
    
14.
Paley D, Herzenberg JE, Paremain G, Bhave A. Femoral lengthening over an intramedullary nail. A matched-case comparison with Ilizarov femoral lengthening. J Bone Joint Surg Am 1997;79:1464-80.  Back to cited text no. 14
    
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Pelissier P, Martin D, Baudet J, Lepreux S, Masquelet AC. Behaviour of cancellous bone graft placed in induced membranes. Br J Plast Surg 2002;55:596-8.  Back to cited text no. 15
    
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Masquelet AC, Fitoussi F, Begue T, Muller GP. Reconstruction of the long bones by the induced membrane and spongy autograft. Ann Chir Plast Esthet 2000;45:346-53.  Back to cited text no. 16
    
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Pelissier P, Masquelet AC, Bareille R, Pelissier SM, Amedee J. Induced membranes secrete growth factors including vascular and osteoinductive factors and could stimulate bone regeneration. J Orthop Res 2004;22:73-9.  Back to cited text no. 17
    
18.
Zhen P, Hu YY, Luo ZJ, Liu XY, Lu H, Li XS. One-stage treatment and reconstruction of Gustilo Type III open tibial shaft fractures with a vascularized fibular osteoseptocutaneous flap graft. J Orthop Trauma 2010;24:745-51.  Back to cited text no. 18
    
19.
Song HR, Kale A, Park HB, Koo KH, Chae DJ, Oh CW, et al. Comparison of internal bone transport and vascularized fibular grafting for femoral bone defects. J Orthop Trauma 2003;17:203-11.  Back to cited text no. 19
    
20.
Khira YM, Badawy HA. Pedicled vascularized fibular graft with Ilizarov external fixator for reconstructing a large bone defect of the tibia after tumor resection. J Orthop Traumatol 2013;14:91-100.  Back to cited text no. 20
    
21.
Papakostidis C, Bhandari M, Giannoudis PV. Distraction osteogenesis in the treatment of long bone defects of the lower limbs: Effectiveness, complications and clinical results; a systematic review and meta-analysis. Bone Joint J 2013;95-B: 1673-80.  Back to cited text no. 21
    
22.
Kocaoglu M, Eralp L, Rashid HU, Sen C, Bilsel K. Reconstruction of segmental bone defects due to chronic osteomyelitis with use of an external fixator and an intramedullary nail. J Bone Joint Surg Am 2006;88:2137-45.  Back to cited text no. 22
    
23.
El-Alfy B, El-Mowafi H, Kotb S. Bifocal and trifocal bone transport for failed limb reconstruction after tumour resection. Acta Orthop Belg 2009;75:368-73.  Back to cited text no. 23
    
24.
Masquelet AC, Begue T. The concept of induced membrane for reconstruction of long bone defects. Orthop Clin North Am 2010;41:27-37.  Back to cited text no. 24
    


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