ObjectiveTo investigate the effect of transverse tibial bone transport on the expression of angiogenesis-related growth factors in the serum of diabetic foot patients.MethodsBetween January 2018 and December 2018, 10 patients who suffered from diabetes mellitus accompanied with Wagner stage 4 diabetic foot underwent transverse tibial bone transport. There were 5 males and 5 females with an average age of 59.2 years (range, 51-70 years). The duration of diabetes was 2-60 months, with an average of 24.2 months. The duration of diabetic foot was 30-120 days, with an average of 54.1 days. Peripheral venous blood was taken at 1 day before operation and at 1, 4, 11, 18, 28, and 35 days after operation. The serum was centrifuged and subjected to ELISA test to detect the expression levels of serum vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), epidermal growth factor (EGF), and platelet-derived growth factor (PDGF).ResultsThe levels of serum VEGF, bFGF, and EGF increased rapidly at 11 days after operation, and the expression levels of the factors at 11, 18, 28, and 35 days were significantly higher than those before operation (P<0.05). The expression level of PDGF increased suddenly at 18 days after operation, and the expression level of PDGF at 18, 28, and 35 days was significantly higher than that before operation (P<0.05).ConclusionTransverse tibial bone transport for the treatment of diabetic foot can significantly increase the expression of serum angiogenesis-related growth factors in early stage, which may be the mechanism of promoting the healing of diabetic foot wounds.
Objective To evaluate the limbs shortening and re-lengthening in the treatment of tibial infectious bone defect and chronic osteomyelitis. Methods Between January 2011 and April 2016, 19 cases of tibial infectious bone defect and chronic osteomyelitis were treated with the limbs shortening and re-lengthening technique. There were 13 males and 6 females, aged from 22 to 62 years (mean, 44 years). The causes of injury included traffic accident injury in 16 cases, crush injury in 1 case, and falling from height in 2 cases. One patient was infected after plate internal fixation of closed tibial fracture and 18 patients after external fixation of open tibial fractures (Gustilo type IIIB). The mean previous operation times was 3 times (range, 2-5 times). The time from injury to bone transport operation was 3-11 months (mean, 6.5 months). The bone defect length was 2.0-5.5 cm (mean, 4.3 cm) after debridement. After tibial shortening, limb peripheral blood supply should be checked after release of the tourniquet. Seven wounds were closed directly, 5 were repaired with adjacent skin flap, 5 were repaired with sural neurovascular flap, 1 was repaired with medial head of gastrocnemius muscle flap, and 1 underwent skin grafting. Single arm external fixator or ring type external fixator were used, and completely sawed off between 2 sets of external fixation screws at proximal and distal metaphysis of the tibia. Limb lengthening was performed after 1 week with the speed of 1 mm/d. Results All patients were followed up 10-36 months with an average of 14 months. Two cases delayed healing of the wound after operation, and the other wounds healed primarily. Natural healing of the opposite end of the bone were found in 18 cases, and 1 case had nonunion in the opposite end of the bone because of incomplete removal of lesion bone. There were 5 cases of slow growth of the callus, and healed smoothly by " accordion” technology and injecting red bone marrow in 4 cases, and by bone grafting and internal fixation in 1 case. The time of bone lengthening was 1-3 months, the prolongation index was 1.6-2.7 cm/month (2.20 cm/month). The bone healing time was 7-13 months (mean, 11.1 months). According to tibial stem diagnostic criteria Johner-Wruhs score, 9 cases were excellent, 8 cases were good, 2 cases were fair, with an excellent and good rate of 89.5%. Conclusion Limbs shortening and re-lengthening is an effective method for the treatment of tibial infectious bone defect and chronic osteomyelitis, with the advantages of improving the immediate alignment of the osteotomy ends, significantly shortening the bone healing time of opposite ends of bone.
ObjectiveTo summarize the effectiveness of bone transport with unilateral external fixator combined with locked plate internal fixation in treatment of infected tibial nonunion.MethodsBetween January 2010 and December 2014, 23 patients with infected tibial nonunion were treated with bone transport with unilateral external fixator combined with locked plate internal fixation. There were 19 males and 4 females with an average age of 37.8 years (range, 19-54 years). The mean length of the bone defect was 6.5 cm (range, 5.2-8.1 cm). The number of previous operations ranged from 2 to 4 times, with an average of 2.5 times. The time from injury to this treatment was 7-23 months, with an average of 11.8 months. The time of bone transport, time of the external fixation, fracture healing time, external fixation index, healing index, and complication were recorded; and the Association for the Study and Application of the Methods of Ilizarov (ASAMI) bone healing and function scores were used to evaluate the effectiveness.ResultsAll patients were followed up 3-6 years with an average of 4.8 years. Wounds and bone defects healed in all patients. No complication such as infection recurrence, nonunion, re-fracture, malunion, iatrogenic nerve paralysis, or stiffness of knee and ankle joints occurred. Five patients had needle infections which were treated by local care and no deep infection occurred. The time of bone transport was 65-120 days (mean, 75.6 days); the time of the external fixation was 75-145 days (mean, 97.8 days); the fracture healing time was 4-17 months (mean, 8.7 months); the external fixation index was 18-28 days/cm (mean, 22.4 days/cm); and the healing index was 31-52 days/cm (mean, 40.2 days/cm). At last follow-up, according to ASAMI criteria, the result of bone healing was excellent in 15 cases and good in 8 cases, and the result of function was excellent in 18 cases and good in 5 cases, all with the excellent and good rate of 100%.ConclusionFor infected tibial nonunion, bone transport with unilateral external fixator combined with locked plate internal fixation can reduce the time of external fixation and related complications, with a satisfactory effectiveness.
ObjectiveTo summarize the effectiveness and experience of Wanger grade 3-5 diabetic foot treated with vacuum sealing drainage (VSD) combined with transverse tibial bone transport.MethodsBetween March 2015 and January 2018, 21 patients with refractory diabetic foot who failed conservative treatment were treated with VSD combined with transverse tibial bone transport. There were 15 males and 6 females, aged 55-88 years (mean, 65 years). The diabetes history was 8-15 years (mean, 12.2 years). The duration of diabetic foot ranged from 7 to 84 days (mean, 35.3 days). The size of diabetic foot ulcer before operation ranged from 2 cm×2 cm to 8 cm×5 cm. According to Wanger classification, 8 cases were rated as grade 3, 11 cases as grade 4, and 2 cases as grade 5. Among the 21 cases, angiography of lower extremity before operation was performed in 5 cases, CT angiography of lower extremity in 16 cases, all of which indicated that the arteries below the knee were narrowed to varying degrees and not completely blocked. Preoperative foot skin temperature was (29.28±0.77)℃, C-reactive protein was (38.03±31.23) mg/L, leukocyte count was (9.44±2.21)×109/L, and the visual analogue scale (VAS) score was 6.8±1.5, and ability of daily living (Barthel index) was 54.3±10.3.ResultsAfter operation, 2 patients with Wanger grade 4 and smoking history failed treatment and had an major amputation (amputation above ankle joint) at 30 days and 45 days after operation, respectively. One patient with Wanger grade 5 and chronic heart failure died of cardiac arrest at 60 days after operation. The remaining 18 patients were followed up 6-24 months (mean, 9.2 months). The external fixator was removed at 40-62 days after operation, with an average of 46 days. All the wounds healed, with a healing time of 50-120 days (mean, 62.5 days). The pain of 18 patients’ feet was relieved obviously, and there was no recurrence of ulcer in situ or other parts. There was no complication such as tibial fracture and ischemic necrosis of lower leg skin after operation. After ulcer healing, the foot skin temperature was (30.86±0.80)℃, C-reactive protein was (22.90±18.42) mg/L, VAS score was 2.4±1.2, and Barthel index was 77.3±4.6, all showing significant differences when compared with preoperative ones (P<0.05); the leukocyte count was (8.91±1.72)×109/L, showing no significant difference (t=1.090, P=0.291).ConclusionVSD combined with transverse tibial bone transport can effectively promote the healing of Wanger grade 3-5 diabetic foot wounds, but smokers, unstable blood glucose control, and chronic heart failure patients have the risk of failure.
ObjectiveTo investigate the effectiveness of modified tibial transverse bone transport technique combined with vancomycin calcium phosphate bone cement local filling and covering in the treatment of diabetic foot (DF). MethodsThe clinical data of 22 DF patients treated with modified tibial transverse bone transport technique combined with vancomycin calcium phosphate bone cement local filling and covering between October 2019 and December 2021 were retrospectively analyzed. There were 13 males and 9 females with an average age of 61.3 years (range, 41-74 years). The duration of diabetes mellitus was 8-30 years, with an average of 12.5 years, and the duration of DF was 10-42 days, with an average of 28.2 days. There were 2 cases of grade 3 and 20 cases of grade 4 according to Wagner classification. CT angiography was performed on both lower extremities of the patients, and the blood vessels of the affected extremities were narrowed to varying degrees and the blood supply was poor. The preoperative skin temperature of affected foot was (28.27±0.91)°C, the ankle brachial index (ABI) was 0.42±0.11, and the visual analogue scale (VAS) score was 7.7±0.6. Preoperative size of DF ulcer ranged from 2.5 cm×2.0 cm to 3.5 cm×3.0 cm. The skin temperature of affected foot, ABI, VAS score, and skin wound healing of the affected foot were recorded and compared between before operation and at 3 months after operation. ResultsAll patients were followed up 3-18 months, with an average of 10.5 months. The infection of 1 patient with Wagner grade 4 did not improve significantly after operation, and there was a trend of further deterioration, and the amputation of the left leg was finally performed at 22 days after operation.The remaining 21 patients recovered well after operation, the external fixator was removed at 1 month after operation, the wound healed at 3 months after operation, and there was no recurrence of ulcer in situ or other sites during follow-up. At 3 months after operation, the skin temperature of affected foot was (31.76±0.34)°C, the ABI was 0.94±0.08, and the VAS score was 2.1±0.3, which significantly improved when compared with those before operation (t=25.060, P<0.001; t=32.412, P<0.001; t=–51.746, P<0.001). ConclusionModified tibial transverse bone transport technique combined with vancomycin calcium phosphate bone cement local filling and covering for DF patients can effectively improve the blood supply of the affected limb, promote wound healing, and improve effectiveness.
ObjectiveTo evaluate the effectiveness of transverse tibial bone transport in treatment of diabetic foot ulcer. MethodsBetween June 2014 and December 2017, 17 patients with diabetic foot ulcer were treated. There were 11 males and 6 females, with a median age of 57 years (range, 46-72 years). The duration of diabetes was 2.4-32.0 years (mean, 16.0 years). According to the Wagner grading criteria, 7 cases were rated as grade 2, 8 cases as grade 3, and 2 cases as grade 4. The CT angiography (CTA) showed the arterial occlusion or stenosis of varying degrees below knee joint. All cases were treated with transverse tibial bone transport. Bone transport started at 3 to 5 days after placing external fixator and lasted 14 days (1 mm per day), and then reverse transport started. The total transport time was 28-30 days. ResultsAll 17 patients were followed up 5-12 months (mean, 8.5 months). During transportation, 4 cases had screw orifice infection, and 3 cases had liquefaction and seepage. And other 15 cases ulcers healed and the healing time was 35-72 days (mean, 48 days). There were significant differences in visual analogue scale (VAS) scores, skin temperature, ankle brachial index (ABI) between before and after ulcer healed (P<0.05). The CTA showed that the collateral circulation was established. The foot ulcer of 2 cases (Wagener grade 3 in 1 case and grade 4 in 1 case) still progressed after treatment, and amputation was performed. ConclusionTransverse tibial bone transports has good effectiveness for diabetic foot ulcer.
ObjectiveTo discuss the effectiveness of femoral-femoral artery bypass grafting combined with transverse tibial bone transporting in treatment of lower extremity arteriosclerosis obliterans (ASO) or combined with diabetic foot. MethodsBetween March 2014 and June 2016, 9 patients with lower extremity ASO or combined with diabetic feet were treated with femoral-femoral artery bypass grafting and transverse tibial bone transporting. All patients were male, aged from 63 to 82 years with an average of 74.2 years. The disease duration of ASO was 1.5-22.0 months (mean, 10.5 months). All cases were severe unilateral iliac arterial occlusion, including 5 cases of the left side and 4 cases of the right side. There were 7 cases with superficial femoral and/or infrapopliteal artery disease. There were 7 cases of ASO and 2 cases of ASO combined with diabetic foot (Wagner grade 4); all the ASO were grade Ⅳ according to Fontaine criteria. All patients had rest pain before operation, and the ankle brachial index was 0.24±0.12. In femoral-femoral artery bypass grafting operations, artificial blood vessels were used in 7 cases and autologous saphenous vein were used in the other 2 cases. The tibial bone transverse transporting began on the 8th day after operation by 1 mm per day and once per 6 hours; after transported for 2-3 weeks, it was moved back. The whole course of treatment was 10-14 weeks. ResultsThe incision of tibial bone transverse transporting was necrotic in 1 case, and healed after dressing change. There was no obvious complication at the orifice of the needle. The other patients had no incision complication. The granulation tissue of foot wound was growing quickly after tibial bone transverse transporting, and the wound was reduced after 2-3 weeks. All the 9 patients were followed up 12-32 months (mean, 19 months). The ankle brachial index was 0.67±0.09 at 2 months postoperatively, which was significantly higher than that before operation (t=17.510, P=0.032). All the feet ulcer wounds healed and the healing time was 6.7-9.4 weeks (mean, 7.7 weeks). During follow-up, color Doppler ultrasound or CT examination revealed grafted blood vessel patency. The external fixator was removed at 12-14 weeks after operation. One case died of sudden myocardial infarction at 14 months after operation, and there was no lymphatic leakage. The patency rate of femoral-femoral bypass was 100% at 1 year after operation. The tibial transverse bone grafting healed with tibia at 4-6 months after operation. At last follow-up, the effective rate was 100%. ConclusionFemoral-femoral artery bypass grafting combined with transverse tibial bone transporting is an effective method in the treatment of lower extremity ASO or combined with diabetic foot.
ObjectiveTo study the effectiveness of trifocal bone transport by using monolateral rail system in the treatment of bone defects caused by post-traumatic tibial osteomyelitis.MethodsThe clinical data of 28 patients with tibial defects caused by post-traumatic osteomyelitis treated with trifocal bone transport technique by using monolateral rail system between January 2012 and June 2017 were retrospectively analyzed. There were 26 males and 2 females, aged 22-59 years (mean, 41.3 years). The causes of injury included 13 cases of traffic accident injury, 9 cases of falling from height, 4 cases of heavy object injury, and 2 cases of crushing injury. The disease duration was 4.5-17.0 months (mean, 7.1 months). The length of bone defect was 6.5-16.8 cm (mean, 10.3 cm). And the range of soft tissue defect ranged from 3.5 cm×2.0 cm to 18.0 cm×11.0 cm. The bone transporting time, external fixation time, duration of regenerate consolidation, and external fixation index were recorded, and the complications were observed. At last follow-up, the bone and functional results were evaluated according to the criteria given by Association for the Study and Application of the Method of the Ilizarov (ASAMI).ResultsAll patients were successfully followed up after removing the external fixator with an average of 35 months (range, 24-65 months). The bone transporting time was 41-136 days (mean, 60.2 days), the external fixation time was 7.5-20.0 months (mean, 13.4 months), the external fixation index was 1.1-1.9 months/cm (mean, 1.4 months/cm), the duration of regenerate consolidation was 6.0-16.5 months (mean, 10.5 months). Pin tract infection occurred in 12 cases, delayed union on docking site was occurred in 9 cases, axial deviation was observed in 2 cases, poor regenerate consolidation was presented in 1 case, and refracture on docking site after fixator removal was occurred in 1 case. There was no recurrence of infection, amputation, vascular and neurologic complications, and osteofascial compartment syndrome. At last follow-up, according to ASAMI criterion, the bone healing results were excellent in 17 cases, good in 7 cases, and fair in 4 cases, with an excellent and good rate of 85.7%; the functional results were excellent in 15 cases, good in 10 cases, and fair in 3 cases, with an excellent and good rate of 89.3%.ConclusionTrifocal bone transport by using monolateral rail system is an effective method in the treatment of bone defect caused by post-traumatic osteomyelitis which can reduce bone transport time, external fixation time, and complications.
ObjectiveTo evaluate the effectiveness of Ilizarov technique-based transverse tibial bone transport on the treatment of severe diabetic foot ulcer (Wagner grades 3 to 5) complicated with systemic inflammatory response syndrome (SIRS).MethodsBetween August 2014 and December 2017, 33 patients with severe diabetic foot and SIRS were treated with Ilizarov technique-based transverse tibial bone transport. There were 27 males and 6 females, with a mean age of 60.6 years (range, 34-79 years). All of them suffered from type 2 diabetes mellitus. The duration of diabetes was 1-28 years (mean, 10 years) and the duration of diabetic foot was 1-12 months (mean, 2.7 months). According to Wagner classification, there were 8 cases in grade 3, 23 cases in grade 4, and 2 cases in grade 5. The wound healing condition was observed after operation, and the limb salvage rate was calculated. The changes in body temperature, heart rate, respiratory rate, white blood cell count, erythrocyte sedimentation rate, and C-reactive protein concentration were assessed. The skin temperature of the dorsum of the foot was measured, and the visual analogue scale (VAS) score was used to evaluate the improvement of foot pain.ResultsAll 33 patients were followed up 3-30 months (mean, 14.1 months). All ulcers healed and the healing time was 3-12 months (mean, 5.3 months); the limb salvage rate was 100%. Postoperative body temperature, heart rate, respiratory rate, white blood cell count, erythrocyte sedimentation rate, and C-reactive protein concentration were significantly lower than those before operation (P<0.05). The skin temperature of the dorsum of the foot was (32.64±2.17)℃ at 1 month after operation, which was significantly improved when compared with preoperative value [(31.28±1.99)℃] (t=0.05, P=0.00); but there was no significant difference in skin temperature compared with healthy side [(32.46±2.10)℃] (t=2.04, P=0.41). The VAS score was 2.4±0.7 at 1 month after operation, which was significantly improved when compared with preoperative score (4.3±0.8) (t=3.10, P=0.00).ConclusionIlizarov technique-based transverse tibial bone transport is an effective way to treat severe diabetic foot complicated with SIRS. It can promote foot ulcer healing and avoid amputations.
Objective To explore the methods, fixation points, and effectiveness of staged therapy using external fixation frame in treatment of infectious nonunion near knee joint. Methods A retrospective analysis was conducted on the clinical data of 60 patients with infectious nonunion near knee joint, who underwent staged therapy using external fixation frame between June 2021 and June 2024 and were followed up. There were 48 males and 12 females with an average age of 47.9 years (range, 16-70 years). The disease duration ranged from 9 months to 20 years, with a median duration of 14 months. Among them, 21 cases of infectious nonunion located in the distal femur, 36 cases in the proximal tibia, and 3 cases in the patella; 12 cases exhibited segmental bone defects (≥4 cm), while 48 cases presented with localized bone defects (<4 cm). Osteomyelitis was classified using the Cierny-Mader system, with 3 cases classified as type Ⅰ, 6 cases as type Ⅱ, 35 cases as type Ⅲ, and 16 cases as type Ⅳ. Preoperative C-reactive protein levels ranged from 15.1 to 55.8 mg/L (mean, 36.4 mg/L). The erythrocyte sedimentation rate was 35-80 mm/1 h (mean, 56.9 mm/1 h). The Hospital for Special Surgery (HSS) score for knee joint was 69.3±17.7 and the range of motion was (70.61±40.60)°. After debridement and placement of antibiotic carriers at the first-stage operation, unilateral orbital frames (n=14), combined frames (n=27), or Ilizarov frames (n=19) were used for cross joint fixation (n=9) or joint preservation fixation (n=51). After 6-8 weeks of infection control, the bone grafting or bone transport was performed at the second-stage operation based on the type of bone defect, with internal fixation employed as an adjunct if necessary. After operation, the infection control and fracture healing were observed and the bone healing time was recorded. The knee joint function was assessed using the HSS score, and the knee joint range of motion was measured as well as the angle of motion loss. Patients were grouped according to the site of nonunion, type of external fixation frame, and fixation method. The bone healing time, change value of HSS score (difference between pre- and post-operation), and knee joint range of motion loss were compared between groups. Results All infection markers returned to the normal range within 6 weeks after the first-stage operation. All patients were followed up 12-48 months (mean, 22.0 months) after the second-stage operation. There were 5 cases of needle tract infection during the external fixation period, and 3 cases of infection recurrence after the second-stage operation, all of which were cured after symptomatic treatment. The bone healing time was 6-18 months (mean, 11.0 months). At last follow-up, the HSS score was 88.5±7.9 and the range of motion was (61.84±40.59) °, with significant differences compared to preoperative values (P<0.05); the knee joint range of motion loss was (8.77±11.07) °. The bone healing time was significant longer in the distal femur group than in the proximal tibia group (P<0.05), and the unilateral orbital frames group than in the Ilizarov frames group and the combined frames group (P<0.05). There was no significant difference in the change values of HSS score between groups (P>0.05). Conclusion During the first-stage operation, debridement is performed and antibiotic carriers are placed to control infection. External fixation frames are then precisely positioned based on the distance between the lesion and the joint surface, avoiding the infected wound while ensuring mechanical balance. During the second-stage operation, bone grafting options are selected according to the extent of bone defects to enhance the bone union. Postoperative early functional exercises of the knee joint are permitted to improve joint function.