Is Distraction Histiogenesis a Reliable Method to Reconstruct Segmental Bone and Acquired Leg Length Discrepancy in Tibia Fractures and Non Unions?

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2 Is Distraction Histiogenesis a Reliable Method to Reconstruct Segmental Bone and Acquired Leg Length Discrepancy in Tibia Fractures and Non Unions? James J Hutson Jr MD Professor Orthopedic Trauma Ryder Trauma Center University of Miami Miami, Florida

3 Financial Disclosure Statement Conflict of Interest: James J Hutson Jr MD I have a consulting contract with Smith Nephew, Memphis, Tennessee. The terms of the contract are to provide education and training at educational programs scheduled intermittently over the course of the contract. The subject of the training is the Methods of Ilizarov and the Taylor Spatial Frame application of tensioned wire external fixators to congenital deformities, traumatic fractures and post traumatic complications of the musculoskeletal system

4 J Trauma 2002; 52: Injury Salvage(%) Severe bone loss > 2 cm 54.2% Severe muscle crush injury 47.9% Moderate severe deep vein injury 21.7% Skin defect > ¾ circumference 35.0% Massive contamination 56.9% Initial pulseless 46.3% Plantar sensation absent 31.2%

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7 Clinical Outcomes Distraction Histiogenesis Acute and Reconstruction Tibial Trauma Distraction Histiogenesis Reconstruction Bone Loss Acute Fracture Reconstruction 71 Non Union 80 Infected Non Union 21 Mal Union Acquired Shortening Tibial Calcaneal Arthrodesis 16 10

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13 Inclusion Criteria: Hypertrophic Nonunion of Pilon Fracture with Functional Ankle Joint The plafond must have a reasonable joint surface

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17 Patients L e n g t h

18 Lengthening vs. Frame Time 73 GIIIB Tibia Reconstructions

19 Transport Complications 23 (11%) Transport Collapse 1 Bone Graft Transport 1 Premature Consolidation 5 Deformation Transport Frame Removal 6 Plating 2 2 nd Frame 2 No Correction 2 Noncompliance 8 Unequal Leg Length 7 Frame Distortions 2 Bone Graft Spacer Tunnel 2 Abandon Transport Lawyer Interference 1 Frame Removal Orthopedic Consultant Stress Fracture Late IMN 1

20 Failure to Transport 44 YO Female Prior attempt to lengthen with nonunion distal tibia Hepatitis C 40+ Pack years smoking

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22 Abandonment with compression of transport to achieve union with shortening

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25 AW Infected nonunion tibia with loose nail Enterobacter cloacae November Debridement Nail removal Antibiotic beads Repeat debridement Antibiotic beads

26 Reconstruction 1.5 cm acute shortening Fibula osteotomy Proximal tibial lengthening

27 cm lengthening 9.5 Month Post Corticotomy Distraction index 2.0 Iliac crest bone graft distraction site Revision painful wire

28 Month post corticotomy 5 Month post bone graft Distraction index 2.4 Month/cm

29 Month post corticotomy Distraction index 4.4 Month/cm Frame removal anesthesia

30 December 2004 Progressed to independent gait

31 TO 21yo Male

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45 10 CM Intercalary transport to ankle arthrodesis infected nonunion pilon fracture fibula osteotomy 2 nd lengthening

46 Premature removal of frame results in valgus deformation with nonunion of distal docking site ankle arthrodesis Nonunion docking site

47 2 nd Frame Revision docking site and proximal angular lengthening

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49 Corrected alignment with corticotomy

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51 DC Noncompliance Failed to return for spacer removal Over compression No transport for 6 weeks Consolidation of transport

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53 Distraction Histiogenesis Bone Graft

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58 Conclusions: Distraction histiogenesis is a very reliable method to reconstruct bone loss in acute fractures, nonunions and malunion of the tibia Noncompliance is the most common complication when using distraction histiogenesis resulting in the need for revision surgeries and acceptance of unequal leg lengths The distraction site in 198 cases had no incidence of infection The increase in frame time directly related to the length of the bone transport is the most negative factor when considering distraction histiogenesis to reconstruct large defects