Debate: I Do Bone Transport. Disclosures. Bone Defects 5/10/2017

Transcription

1 Debate: I Do Bone Transport David W. Lowenberg, M.D. Clinical Pressor Department Orthopaedic Surgery Stanford University School Medicine Disclosures Board Directors: Foundation for Orthopaedic Trauma (FOT) Osteosynthesis & Trauma Care Foundation (OTC) Consultant: Stryker Bone Defects Size Defect can vary. Conventional methods work well for small bony defects. The larger the defect, the harder it is to fill with conventional methods. 1

2 Free Fibula A nice operation. Ideal for a bone or combined bone and st tissue fill in the upper extremity. But why would you do it to substitute for a weight bearing bone in the lower extremity? 2

3 15 cm Defect Seriously Fill it with a Pencil There is a reason such a wide array options have been described for use the fibula 3

4 Free Fibula Until the early 1990 s we would routinely utilize this procedure But we abandoned it except for limited indications due to the success bone transport. 4

5 Problems we encountered in San Francisco with Free Fibula ~ 1/3 incidence fracture with resultant bending, deformity, malunion. Extended limitation in weight bearing on the affected lower extremity. Morbidity to the unaffected limb. K.H.: 59 y/o F with left knee pain K.H.: 55 y/o F with left knee pain 29 years ago suffered an open left tibial shaft fracture. Developed an infected nonunion with chronic osteomyelitis. 24 years ago underwent a vascularized free fibular transfer and flap coverage. 5

6 K.H.: 55 y/o F with left knee pain Suffered repetitive fractures the free fibula with deformity. 16 years ago underwent attempted Ilizarov frame correction and lengthening. Fractured her midshaft regenerate with recurrent deformity. K.H.: 55 y/o F with left knee pain 6

7 K.H.: Following correction 7

8 K.H.: Following Correction K.H.: 8 year follow up (now 63) K.H. 8 year follow up 8

9 K.H.: 8 year follow up BONE TRANSPORT ADVANTAGES Permits early weight-bearing. Minimizes donor site morbidity. Promotes joint mobilization. Allows the creation normal bone. No bridges burned. Bone Transport My Complications in ~ 350 Bone Transports 18 cases required re-intervention at docking site, with all subsequently healing. 5 cases requiring ICBG to regenerate due to poor regenerate. 4 cases bent regenerate. 3 cases later fracture through regenerate. 3 cases BKA due to flap problems related to social issues. 9

10 Combined Bone Transport & Free Tissue Transfer (now >150) D.C.: 23 y/o M s/p MCA Suffered a 3A open tibial fracture. Treated with rodding, infection developed, rod removed, external fixator placed. Now 1 year s/p injury with chronic sinus tracts and infected nonunion. 10

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13 Transverse Hemi-Fibular Transport A great salvage procedure for extremely large tibial defects. Technically more difficult. Requires great attention to detail for corticotomy. 13

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15 K.C.: 28 y/o M s/p MCA Developed Aspergillus osteomyelitis with resultant 22 cm tibial shaft resection. Treated over a 5 year time frame with recurrent attempts at tibiibular synostoses. 15

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18 Previous Bone Transport/Free Flap Series Author Ilizarov + Free Flap Regenerate Length Limb Salvage Rate Jupiter, % Tukiainen, cm 100% Spiro, cm 100% Feibel, patient 6.0 cm 100% Musharafieh, % Lowenberg, cm 100% Ring, cm 90% Carrington, patient 13.0 cm 100% Gopal, % Duman, cm 100% Gonzalez, % Naique, % Lowenberg, cm 96% Methods Retrospective review complex lower extremity bony and st tissue defects Combined Ilizarov bony reconstruction and microsurgical st tissue cover from 1990 to 2005 Gustillo IIIB/IIIC open fractures Chronic nonunions or osteomyelitis Post-ablative defects Now with ~ 160 cases performed Function The key to this method is the rapid return to activity while still undergoing treatment. 18

19 Puno Score FACTOR MAXIMUM POINTS AVERAGE 1. Freedom from Pain Activities Daily Living Range Motion Residual Clinical Bony Deformity Radiographic Changes Muscle Strength Sensation Aesthetic Outcome Free Flap 15 TOTAL 100 XX Scale 1 Freedom from Pain n= % 33.3% 9.5% Scale 1 Freedom from Pain Average score % 33.3% n=42 9.5% 19

20 Scale 2 Restoration Function 52.4% n= % 23.8% Scale 2 Restoration Function Average score % n= % 23.8% Scale 3 Range Motion 47.4% N= % 10.5% 10.5% 20

21 Scale 3 Range Motion Average score % 10.5% 31.5% 47.4% N=42 Scale 4 Residual Clinical Deformity Bony Structures 42.2% 36.8% N= % Scale 4 Residual Clinical Deformity Bony Structures Average score % 36.8% N= % 21

22 Scale 5 X-Ray Changes 63.2% N= % 21.0% 5.3% Scale 5 X-Ray Changes Average score % 10.5% 21.0% 63.2% N=42 Scale 6 Subjective Muscle Strength 47.4% N= % 5.3% 10.5% 22

23 Scale 6 Subjective Muscle Strength Average score % 47.4% N=42 5.3% 10.5% Scale 7 Sensation 47.4% N= % 5.3% 10.5% Scale 7 Sensation Average score % 36.8% N=42 5.3% 10.5% 23

24 Total P 60 Total P Length regenerate (cm) Gracilis Latissimus Rectus Type Free Flap Total Puno Score Total P Time to Frame (months) Time in Frame (months) 5/10/2017 Scale 8 Aesthetic Outcome Flap 42.1% N= % 15.8% 10.5% 5.3% Scale 8 Aesthetic Outcome Flap Average score % N= % 15.8% 10.5% 5.3% Statistical Analysis: No Significant Associations Length Regenerate versus Outcome Correlation = 0.06, p = 0.84 Time to Frame versus Outcome Correlation = , p = 0.98 Type Free Flap versus Outcome Latissimus vs. Rectus = 1.14, p = 0.27 Time in Frame versus Outcome Correlation = , p =

25 My Knee Puno Score 41 years after open medial meniscectomy Pain 12 Restoration Function 12 ROM 10 Clinical Deformity 12 X-ray Changes 7 Muscle Strength 10 Sensation 10 Aesthetics 9 Puno Score My Menisectomy Cohort Study Group 82 Points 73.3 Points Conclusions Bone Transport is a very useful tool in limb salvage. Ideally suited for larger defects. Allows for maintenance and restoration limb length. Rarely burns bridges. 25

26 Thank You 26