Salvage of bone defects

DR. FATHI NEANADR. FAKHRY & ALRAJHY HOSPITAL

March 7, 2017

Salvage of Bone Defects

LIMB SALVAGE PROCEDURE

Irrigation & Debridement

External fixation

Antibiotic bead spacers

Soft tissue coverage

Restore Skeletal Stability (Salvage of Bone Defect)

Restore Skeletal StabilitySalvage of Bone Defects

Sterilization and Re-implantation?

Young, Healthy patient Well Vascularized soft tissue bed (femur,

not tibia) Single cleanable fragment Early, Aggressive, Meticulous wound care Adequate sterilization of the fragment Antibiotics, Local and Systemic

Sterilization and Re-implantation?

Restore Skeletal StabilityArticular Defects

Significant loss of joint surface

Osteochondral Allograft

Total joint or Hemi- Arthroplasty

Arthrodesis

MANAGEMENT OF ARTICULAR

CARTILAGE DEFECT

DR. FATHI NEANADR. FAKHRY &

ALMOUHOWES HOSPITAL

Restore Skeletal StabilityDiaphyseal Defects

Conventional

Non conventional

Other modalities

Future directions

Restore Skeletal Stability Diaphyseal Defects

Conventional

Autogenous bone graftCancellous

CorticalVascularized

Allogenous bone graftCancellous

CorticalDBM (Demineralised bone matrix)Composite Bone graft substitutes 

Other Salvage ProceduresShortening

One bone forearm

•22 y. man•RHD•MCA•open segmental humerus fracture with bone loss and radial nerve cut

Irrigation and DebridementApplication of

external fixatorWound careAntibiotics

Posterior plate fixation

Iliac crest bone grafting

+ antibiotic CaSo4 beads

Implantable bone stimulator

2 months 3 months

Autogenous Bone GraftingPapineau Technique

5 months

NB The Biggest series from one centre other series 42 cases collected from different centres. Complex nonunion of fractures of the femoral shaft treated by wave-plate osteosynthesis. J Bone Joint Surg Br.1997 Mar;79(2):289-94. AbstractWe have treated 42 consecutive complex ununited fractures of the femoral shaft by wave-plate osteosynthesis at five different medical centres

Restore Skeletal Stability Diaphyseal DefectsNon-Conventional

Bone TransportSegmental Transport

Shortening-Lengthening

CompressionDirect bone healing

Distraction OsteogenesisCallus distraction

GavrilAbramovich

Ilizarov

(1921-1992)

Distraction – Compression

BONE TRANSPORTUsing Callus Distractionto close Bone Defects

BONE TRANSPORT

Regeneration of Bone Defect

by a combination of

A- DistractionOsteogenesis

B-Transformation Osteogenesis

BONE TRANSPORT

A- Distraction Osteogenesis

Endochondral+ Intramemranous ossification + transchondroid bone formation’ between two living

bone surfaces slowly separated mechanically

B- Transformation Osteogenesis

Conversion (Differentiation) of Non-osseous interposition material into normal bone by

Compression and/or Distraction

BONE TRANSPORT1- No soft tissue defect

Segmental transport(Monorail)

2- Soft tissue defect Shortening – Lengthening

(Accordion)

NO SOFT TISSUE DEFECTSEGMENTAL TRANSPORT

NO SOFT TISSUE DEFECTSEGMENTAL TRANSPORT

NO SOFT TISSUE DEFECTSEGMENTAL TRANSPORT

SOFT TISSUE DEFECT SHORTENING – LENGTHENING

SOFT TISSUE DEFECT SHORTENING – LENGTHENING

SOFT TISSUE DEFECT SHORTENING – LENGTHENING

TYPES OF SEGMENTAL TRANSPORTUNIFCAL – BIFOCAL – TRIFOCAL - TETRAFOCAL

TYPES OF SEGMENTAL TRANSPORTUNIFCAL – BIFOCAL – TRIFOCAL - TETRAFOCAL

No donner site morbidity

Soft tissue cover by shortening

Regenerated bone like original

Exact restoration of length & alignment

High rate of ultimate success

Functional during treatment

BONE TRANSPORTADVANTAGES

Requires prolonged time in the frame ~ 2 mon/cm

Frequent docking site problems requiring bone grafting

Frequent complications

BONE TRANSPORTDISADVANTAGES

Other ModalitiesBone Graft Extenders

Bone Graft SubstitutesTitanium Mesh Cages

Bone Morphogenic ProteinsElectrical Stimulation

Future directionsTissue engineering

Gene transferStem cells

Bioabsorbable structural carriers

Restore Skeletal StabilityDiaphyseal Defects

Conclusions

Orthopedics is aReconstructive Surgery

Nothing to be done in such devastating irrepairable injuries

Mangled extremity

Is an injury to at least three out of four systems (soft tissue, bone, nerves, and vessels)

A Decision have to be made

Amputation + ProsthesisVs.

Limb salvage procedure

Conclusions

Mangled extremitiesAmputation vs Reconstruction

Amputation group

Better functional outcome than reconstructionRapid return to work

Reconstruction groupHigher complication rate

More surgeriesMore hospital admissions6.4% risk of amputation

Conclusions

Leap study : Increasing trend towards limb salvage rather than immediate amputation in complex open lower limb injuries

(DCO) in mangled extremities

Spanning external fixator

Antibiotic pead pouches

Vacuum assisted wound closure

Conclusions

THANK YOU