RESUMO
Purpose: Distal femur non-union is difficult to deal with because of limited or no bone stock left for holding pins. Also, knee range of motion is a major concern in case of distal femur non-union to deal with. ALFA is a new modality of definitive external fixator with limited literatures. This paper aims to present the series of cases of gap non-union of the distal femur managed with an ALFA fixator and their outcome as an initial experience on a new device. Methods: Eight patients of gap non-union distal femurs where the ALFA fixator application was done between January 2022 to June 2022 were evaluated. Patients with intra-operative bone gap <5 cm were acutely docked and >5 cm were left as it is as a bon gap and gradual distraction was done to achieve bone gap length and limb length discrepancy. Patients were assessed for functional, radiological, and clinical outcomes, at the time of surgery, completion of distraction, and completion of consolidation. The scores from our study were compared with the Ilizarov and mono-lateral fixator with the available data. Results: Eight patients managed with ALFA fixator had mean age of 32.12 ± 6.82 years. The mean limb length discrepancy at the time of operation was 5.25 ± 3.11 cm, with Intra-operative bone gap of 4.68 ± 3.47 cm where 5 patients managed with acute docking and 3 patient managed with leaving the bone-gap. The mean regenerate gained after distraction was 9 ± 4.63 cm at the mean distraction duration of 113.37 ± 67.34 days. The mean time of removal of the fixator (n = 5), was 203 ± 111 days, and the mean external fixator index, days/cm (n = 5) was 34 days/cm. The number of complications per patient was 0.25 per patient. The Mean residual LLD was, 0.43 ± 0.58, with significant improvement of Limb Length compared to pre-operative LLD with a p-value of 0.0014. Conclusion: ALFA fixator for gap non-union as an alternative to Ilizarov, and LRS provides adequate distraction osteogenesis, less neurovascular complication due to pins, better patient tolerability, and user-friendly distraction of the distal femur with preserved knee range of motion. Level of evidence: III.
RESUMO
Introduction: The management of gap non-union is a major challenge to both the clinician and the patient as it is technically difficult, time-intensive, and physically arduous for the patient along with an unpredictable result. Gap non-union can arise from extrusion of bony fragment at the time of trauma or after debridement of unhealthy bone later. Moreover, Tibia because of its subcutaneous anatomy can easily undergo bone-loss and segmental defect. Among various methods available for managing gap non-union of tibia distraction osteogenesis using either ilizarov fixator or mono-rail fixator is the most popular one. Here we present functional and bony outcomes of combined use of locking plate and Limb Reconstruction System (LRS) in tibial gap non-union and assess whether it decreases fixator time and related complications. Patients and methods: A prospective intervention study constituting 10 patients with Paley's type B1 tibial gap non-union over a period of 22months. In first stage, debridement was done; tibial locking plate and mono-rail fixator were applied along with corticomy at proximal tibia. Distraction was started 7-14 days later. At the end of distraction phase, fixator was removed and transported segment was fixed with screws with or without bone grafting at docking site. Patients were followed up every 6 weeks for radiological and clinical assessment. Functional assessment using Application for the Study and Application of the Method of Ilizarov (ASAMI) functional score, and Musculoskeletal Tumour Society (MSTS) functional score while bone outcome was assessed with ASAMI bone score. Quality of regenerate was assessed by Fernandez-Esteve grading. Detailed scoring was done at the time of index surgery, at the time of LRS removal and at the time of consolidation phase. Results: All the 10 patients were male with mean age of 33 years. The mean defect size was 4.94 cm after debridement. Minimum duration of follow up was 30 weeks after removal of LRS. Mean duration between trauma and inclusion in the study was 17.7 months. The median external fixator index was 15.63 days/cm. The complication rate was 1.3/patient. According to Paley's classification, there were eleven problems and two obstacles, and no true complications. Both ASAMI bone score and functional scores were excellent in three and good in six patients. The median MSTS composite score was 76.66%. Conclusion: The integrated fixation is an effective and satisfactory method enabling early external fixator removal with low rate of complication. So, this technique can be recommended for the management of segmental tibial defects. Level of evidence: II.