Bone Transport Under Plates

By: Dr. John Mukhopadhaya

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Large bone defects—which may be associated with causes such as bone tumors, high-velocity accidents, or infections after osteosynthesis—are challenging to treat.

Conventional methods of dealing with bone defects include the use of cancellous and corticocancellous bone grafts, and either vascularized or nonvascularized fibular strut grafts. Although bone transport using ring fixators or unilateral fixators can be an excellent and adaptable treatment option, there are several drawbacks, including prolonged fixator times, the possibility of pin tract infections that complicate treatment, and the risk of refracture.

Various methods have been used to avoid some of these problems, including acute docking and lengthening, transport over nails, fibular transport, and plating after transport. However, all of these methods have their limitations.

At Paras Hospital in Patna, India, we started using bone transport under plates for some of the more difficult problems we faced with bone defects, especially in the distal femur. The first case we undertook was in 2007, when a 25-year-old male presented to us a few days after an open fracture of his distal femur. He had been treated elsewhere with inadequate débridement and presented with exposed bone and some discharge (Fig 1). We performed a radical débridement with excision of the necrotic bone segment, and fixation with a locking plate using antibiotic beads and a muscle flap cover. Once the wound had healed, we had to deal with the bone gap. We used an Ilizarov fixator with the plate in situ. The fixator spanned the knee joint. A proximal corticotomy was performed and the screws in the intermediate segment removed. After bone transport was completed, docking was done, with two locked screws inserted into the intermediate segment and the fixator removed. A few days later—after the pin sites had healed—the docking site was grafted with cancellous bone graft from the iliac crest. The fracture healed well and the patient obtained reasonable function at the knee. Subsequently, we have used this method in a number of distal femur open fractures with bone gaps, because it is adaptable to other situations.

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Fig. 1 Radiographs and a photo of a 25-year-old male who sought treatment a few days after sustaining an open fracture of the distal femur. He had been treated elsewhere with inadequate débridement and presented with exposed bone and some discharge.
Courtesy of Dr. John Mukhopadhaya

In summary, segmental bone defects are a significant clinical problem. There are many methods to deal with them, all of which have advantages and disadvantages. This method of transport under plates is a very useful addition to our armamentarium for treating this challenging problem.    

Dr. John Mukhopadhaya is director of orthopaedics and joint replacement at Paras Hospital in Patna, India, and is a member of the Indian Orthopaedic Association.

 

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