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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