Analysis of functional outcomes and complications of tibial bone defects treated with Ilizarov bone transport technique

Analysis of functional outcomes and complications of tibial bone defects treated with Ilizarov bone transport technique | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Analysis of functional outcomes and complications of tibial bone defects treated with Ilizarov bone transport technique Dongwei Feng, jidong wang, Baoliang Jiao, yaxin zhang, Heping Jia, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4746581/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 25 Feb, 2025 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted 18 You are reading this latest preprint version Abstract Background Trifocal bone transport (TF) rather than bifocal bone transport (BF) can shorten the treatment time when treating of large bone defect in tibia. However, few studies have reported efficacy and complications among different bone transport. Aim To evaluate the effectiveness and complications of bone transport technique for the treatment of large bone defect in tibia. Methods The retrospective study including 48 patients who underwent bone transport for the treatment of large bone defect in tibia from May 2015 to September 2019. A total of 30 were treated by bifocal bone transport (BF group) and 18 by trifocal bone transport (TF group). Patient demographic data, intraoperative outcomes, postoperative variables, complications and clinical outcomes of the two groups were recorded and compared at a minimum follow-up of 24 months. Postoperative complications were also evaluated according to Paley classification. Based on the Association for the Study and Application of Methods of Ilizarov (ASAMI) standard, the bone and functional results were evaluated at the last clinical follow-up. Results All patients with an average follow-up of 23 months. All patients achieved complete union in the docking site and consolidation in the regenerate bone. Compared to the BF group, the TF group had a longer bone defect length(9.08 ± 1.74 > 6.33 ± 3.15, P < 0.01) but a shorter external fixation index (42.22 ± 2.41 < 65.82 ± 6.98, P 0.05). At the postoperative follow-up, there were no significant differences between the 2 groups in the bone and functional results ( P > 0.05). Conclusion For tibial bone defects, both bifocal and trifocal bone transport can achieve good clinical results. Compared to the bifocal bone transport, The trifocal bone transport can significantly shorten the external fixation index without increasing the incidence of associated complications. Bone transport External fixation Ilizarov Complication Tibia Segmental bone loss Background Large tibial bone defects are encountered commonly by trauma surgeons. Such injuries may be caused by high-energy trauma, infection, tumours, and bone nonunion. Managing such injuries has been a challenge for orthopedic surgeons[ 1 ]. In recent years, techniques such as plate osteosynthesis with cancellous bone grafting, bone grafting with autogenous or allogenic bone grafts, bone shortening and lengthening technique, tibialization of the fibula, vascularized fibular grafts, the Masquelet induced membrane technique have achieved certain clinical results for the bone defects. However, the shortcomings and problems of these methods still remain the issues which restrict their overall use[ 2 ] [ 3 ][ 4 ][ 5 ].With the development of microsurgical techniques and the improvement of external fixation devices. At present, Ilizarov bone transport techniques based on the concept of "distraction osteogenesis" have played an irreplaceable role in the treatment of bone defects because of their simplicity and effectiveness and ability to maximize the preservation of the biomechanical environment required for fracture healing[ 6 ]. Bone transport may be bifocal or trifocal[ 7 ]. The regeneration of a long defect by distraction of one osteotomy site in the bifocal technique takes a long time in the frame, which may increases the incidence of complications such as pin tract infection, delayed union, joint stiffness and axial deviation, which often require further surgical and bring great psychological and economic burden to patients[ 8 ]. Trifocal technique has been shown to reduce wear time[ 9 ]. However, the trifocal technique needs a more complex assembly of the frame as well as the additional osteotomy, which may lead to the generation of related complications[ 10 ]. The purpose of this study was to analyze 48 cases of tibial bone defects treated with Ilizarov bone transport technique and to investigate the differences in efficacy and complications between trifocal anf bifocal bone transport. Methods The institutional review board (IRB) approval was gotten from the ethics committee of our institution. All methods were performed according to relevant guidelines and regulations. Patients There are 48 patients with tibial bone defects treated by the Ilizarov bone transport technique from March 2015 to May 2019 in our study. The inclusion criteria were as follows: (1) Patients over 18 years; (2) Patients with tibial bone defects ≥ 3 cm; (3) follow-up time after frame removal ≥ 24months. The exclusion criteria were as follows: (1) Combined with systemic metabolic diseases affecting bone healing; (2) Bone defect caused by pathological fracture; and (3) Poor compliance, can not cooperate with the treatment and follow-up. A total of 53 patients with tibial bone loss who underwent Ilizarov bone transport technique treatment were initially screened, and 48 patients who met the inclusion and exclusion criteria for this study were included. Surgical technique Standard anteroposterior and lateral radiographs of the affected limb were taken for detailed preoperative planning. Perfect relevant examinations, after excluding surgical contraindications, thorough debridement was performed under general anesthesia or epidural anesthesia. Bacterial culture and drug sensitivity test were performed for surface secretions and deep tissue scrapings were retained of infected individuals to guide subsequent anti-infective treatment. All local necrosis, infection, and inflammatory granulation tissue were removed, and sequestrum, nonunion site, or sclerotic bone were completely removed to keep the broken end flat until cortical bleeding at the bone end, described by the so-called “paprika sign[ 11 ]”, was accepted as an indication of vital osseous tissue. A large amount of iodophor, normal saline, and hydrogen peroxide were alternately irrigated to the surgical area. External fixators were installed according to preoperative planning, and antibiotic-impregnated spacers were placed in the infected bone defect site to improve stability. The rail fixator was installed according to the location of bone defect and soft tissue conditions during operation. Close the wound adequately in tension free manner by direct closure or use of free/local fap if necessary. For bone defects larger than 8 cm or exceeding 40% of the original bone length, a trifocal bone transport procedure was performed. Postoperative management and follow-up Sensitive antibiotics for 6 weeks according to the results of bacterial culture and drug sensitivity test, until the ESR and CRP level returned to normal. Encourage patients to perform early muscle isometric contraction exercises and active movement of adjacent joints. Distraction osteogenesis was started 7 days after operation. For cases with bifocal bone transport, the rate and rhythm was 1 mm/day, which was completed 4 times. In cases of trifocal bone transport, if bone transport in the same direction, the fragment near the bone defect was transported at a rate of 0.5 mm f and 4 times/day, and the other fragment far from the defect was transported 0.25 mm and 4 times/day. For converged bone transport, each fragment on both end of the bone defect was transported at a rate of 0.25 mm four times per day. The rate and rhythm of distraction were adjusted according to patient tolerance and radiographic evaluation of the distracted region. The Ilizarov fixator was removed after an X-ray taken in two planes showed corticalization of four cortices[ 12 ]. Additionally, all patients was protected in a long-leg cast or brace for 4 weeks to protect against refracture. Docking time (DT), external fixation time (EFT), external fixation index (EFI), duration of regenerate consolidation time (CT) and complications during treatment were recorded. Complications were classified with the Paley criteria [ 13 ]. ASAMI [ 14 ](Association for the Study and Application of the Method of Ilizarov) criteria were used to assess the bony and functional outcomes at follow-up. Statistical analysis Data analysis was performed using SPSS version 22.0 (IBM Corp, United States) to analyse all data; all variables were examined for normal distribution. The measurement data are expressed as the mean ± standard deviation (SD). The enumeration data are expressed as percentages. Continuous variables were compared by using t tests, and Pearson’s chi-square test or Fisher’s exact test was used to compare categorical variables. and results with p < 0.05 were considered significant. Results Demographic and clinical characteristics All patients in the two groups completed the surgery successfully without neurological or vascular injuries. All patients finished the follow up with 24 to 40 months, with an average of 27.5 months. There were no significant differences between the two groups in terms of age, gender, smoking, affected side, causes of injury and previous treatment( P > 0.05), as detailed in Table 1 . Table 1 Patient demographics at baseline and intraoperative parameter between BF and TF group date BF TF t P Sex(male / female) 6/24 3/15 0.011 0.916 Age(years) 37.00 ± 12.83 38.50 ± 12.69 0.394 0.696 Smoking(yes/no) 13/17 11/7 1.422 0.233 Injured side(left/right) 13/17 9/9 0.201 0.654 The etiology of bone defect(high-energy trauma / fall injury /other) 11/5/2 11/7/6 0.660 0.719 Primary fixation (internal/external) 14/16 7/11 0.277 0.599 Previous operation time(s) 3.30 ± 1.80 3.61 ± 2.15 0.539 0.593 Interval duration before bone transport(months) 31.60 ± 47.03 61.02 ± 103.80 1.135 0.269 Postoperative outcomes In terms of surgical outcomes, in the BF group, the size of bone defect was 6.33 ± 3.15 cm, the DT was 91.10 ± 44.41 days, the CT was 255.87 ± 112.45 days, the EFT was 402.18 ± 172.54 days and the EFI was 65.82 ± 6.98 d/cm. In the TF group, the size of bone defect was 9.08 ± 1.74 cm, the DT was 76.44 ± 27.94 days, the CT was 237.56 ± 53.56 days, the EFT was 379.65 ± 68.77 days and the EFI was 42.22 ± 2.41 d/cm. the TF group exhibited a longer average defect size. Similarly, the EFI was significantly lower in the TF group. But not in the DT, the CT and the EFT( P > 0.05), as shown in Table 2 . Table 2 Comparision of postoperative date between the BF and TF group BF TF t P Size of bone defect(cm) 6.33 ± 3.15 9.08 ± 1.74 3.889 0.000 DT(d) 91.10 ± 44.41 76.44 ± 27.94 1.403 0.165 CT(d) 255.87 ± 112.45 237.56 ± 53.56 0.760 0.451 EFT(d) 402.18 ± 172.54 379.65 ± 68.77 0.636 0.528 EFI(d/cm) 65.82 ± 6.98 42.22 ± 2.41 16.922 0.000 Table 3 ༎Comparision of the evaluation of ASAMI bone and functional grade between the BF and TF group Grade bony functional BF TF BF TF Excellent 16 11 15 10 Good 11 4 10 5 Fair 2 3 4 2 Poor 1 0 1 1 Failure / / 0 0 P = 0.508 P = 0.958 Bone and functional outcomes The bone result was excellent, good, fair and poor in 16, 11, 2 and 1 in group BF; and 15, 10, 4, and 1 in group TF, respectively. The functional results were excellent, good, fair, poor and failure in 11, 4, 3, 0 and 0 in group BF; and 10, 5, 2, 2 and 0 in group TF, respectively. With respect to bone and function results, there was no significant differences between the two groups p = 0.508 and p = 0.958, respectively). Complications Complications were classified according to Paley classification. No case encountered joint luxation, vascular or nerve compromise in both groups and the results are shown in Table 4 . Table 4 ༎Comparision of complications between the BF and TF group Parameter BF TF Total problem obstacle complication problem obstacle complication Pin-site infection 18 2 0 10 1 1 32 Delayed union 3 1 0 2 1 0 7 Muscle contractures 3 2 0 2 2 0 9 Axial deviation 0 5 1 0 2 0 8 Nonuion 0 0 1 0 0 1 2 Soft tissue incarceration 0 0 1 0 0 0 1 Joint stiffness 5 3 1 3 2 1 15 Limb shortening 0 0 3 0 0 1 4 Refracture 0 0 0 0 0 1 1 Total 29 13 7 17 8 5 79 \(\:{\:\:\:\:\:\:\:\:\:x}^{2}\) =0.090 P =0.956 For BF group, there are twenty-nine problems, thirteen obstacles, and seven complications. In TF group, seventeen problems occurred. Eight obstacles happened, and five cases suffered from complications. The mean number of complications per patient was 1.6 for BF patients and 1.7 for TF patients, and the difference was no significant ( p > 0.05). Complications were treated similarly in both groups. Among them, thirty-two patients had a pin tract infection, which was cured in most patients with daily pin site care and oral antibiotics. One patients suffered from a deep pin tract infection, which was successfully treated by pin replacement and intravenous antibiotics. Fifteen patients developed delayed union which were successfully managed by intensive physiotherapy or extending apparatus across the stiffed joint and mobilizing the joint prior to its removal. Muscle contraction was encountered in nine cases were instructed to participate in functional exercises or manual release. Eigth patients had axial deviation were managed by adjusting the transport frame. Seven patients developed delayed union, which were successfully treated by the accordion technique. There were two cases of nonunion at the docking site, which were treated by autocancellous bone graft from iliac crest. One patient developed soft tissue incarceration and underwent soft tissue resection and the iliac bone graft was introduced, and all eventually healed. One case refracture achieved bony union by wearing a protective brace. Discussion The theoretical basis of Ilizarov's technology is the tensionstress law, in which the living tissue is subjected to sustained, slow, and stable traction to produce tension that stimulates the regeneration and growth of the tissue[ 15 ]. Currently, it has emerged as the gold standard for the treatment of massive tibial bone defects, eradicating infection and solving bone and soft tissue defects at the same time. Bone transport tecnique include distraction and consolidation period. The distraction period is generally 7 to 10 days after osteotomy, the bone segment is transported at a rate of 1 mm/d to reach the expected extended length and then enters the consolidation period, and the external fixator is removed after the newly formed bone is completely consolidation[ 16 ]. As a result, large bone defects tend to require longer EFT and increases the frame-related complications such as pin-tract infection, pin loosening, joint stiffness and psychological symptoms[ 17 ]. Several authors have addressed different treatment options in order to shorten treatment period and reduce the incidence of complications. Apivatthakakul[ 18 ] successfully cured 2 cases of distal femoral bone defects using MIPO technique combined with external fixator, and although the alignment of the docking end was maintained, it has also been found that the built-in plate affects the generation of callus at the bone end[ 19 ]. Liodakis[ 20 ] found that external fixation combined with intramedullary nail technique not only shortens the EFT. Moreover, combined external and internal fixation was found to have a greater risk of infection recurrence in the treatment of infected tibial nonunion and chronic osteomyelitis. Some more options of a combined technique have been reported, such as a lengthening nail for transport and a locking plate for docking and a carbon-fiber IMN[ 21 ]. However, besides its high cost, it was found clinically that the nail performs poorly in long-bone surgery and cannot be added to external fixation instead of a titanium nail even for combination. Because accelerated lengthening at one osteotomy site is not possible due to biological and neurovascular considerations, the solution was to add one osteotomy while lengthening, ideally doubles the rate of lengthening effectively. Borzunov[ 22 ] first used double-level bone transport using the Ilizarov technique to treat large tibial bone defects, with a 2.5 times shorter docking time and a 1.3–1.9 times lower EFT compared with the single-level bone transport. Similarly Paley and Maar et al[ 23 ] recommended double-level bone transport for bone defects greater than 10 cm in order to shorten the EFT. It has also been suggested that trifocal bone transport should be considered when the defect length is over 6 cm[ 24 ]. However, the above studies did not describe complications, and bone or functional outcomes in the two groups. We also compared the above two methods in this study, the mean bone defect length was greater in the TF group than in the BF group ( P < 0.05). Although there were no statistically significant differences in DT, CT, and EFT between the two bone transport modes, the means of these data were smaller in the TF group than in the BF group, and the mean EFI was shorter in the TF group ( P < 0.05). This finding suggests that despite the increased complexity of the TF group, it may provide a rapid recovery pathway. Trifocal bone transport equates to faster docking contacts, which leads to early docking healing[ 25 ]. we anticipated that the addition of an osteotomy to the TFT would increase complications associated with the wires and distraction sites. In the study, the complication rate was 1.6 per patient in BF group and 1.7 per patient in TF group, the results showed no statistically significant complication rate between the two groups ( P = 0.956). Possibly due to the relatively early frame removal in the two-level group. Therefore, we believe that the occurrence of complications may is associated with longer EFT. According to our experience and study, we recommend trifocal bone transport was performed when if the bone defect is more than 8.0 cm. Some authors found that hypoplastic bone formation may occur during defect filling when single-level distraction regeneration growth exceeds 5 cm or 40% of the original segment length[ 26 ]. Chaddha[ 27 ] applied trifocal bone transport to treat tibial bone defects and had a higher incidence of delayed consolidation, which was caused by the the more distal osteotom and there was a high incidence of trauma to the nutrient artery in trifocal bone transport. The consolidation time of the distraction gap is also affected by blood supply, such that the closer the regeneration zone is to the metaphysis, the shorter the consolidation time[ 28 ]. No patient developed delayed consolidation in this study. This was done with both proximal-to-distal bone transport technique all cases in our study. In addition, the use of low-energy osteotomy techniques and adjustment of the lengthening rate may reduce the occurrence of such complications. Although bone transport is widely used to treat large bone defects, some unavoidable complications have also been reported[ 29 ][ 30 ]. In our study, pin tract infection is the most common complication in 32 patients (66.7%), including 12 case in the double level group and 20 cases in the single-level group. Dahl[ 31 ] classified pin tract infection into Grade V according to severity. According to the above classification, twenty-eight patients were Grade I, three patients were Grade III and 1 patients were Grade IV. Most pin tract infections are treatable with improved wound care and a short course of oral antibiotics. One patients(Grade IV) suffered from a deep pin tract infection, which was successfully treated by pin replacement and intravenous antibiotics. Our experience is that frequency of needle track cleaning did not reduce the rate of pin track infection, but rather increased allergic reactions around the needle track. In addition, dry sterile gauze is wrapped around each pin site to maintain dryness around the pins sites significantly reduced the incidence of pin tract infection. Relevant literature suggests that nonunion is the rate-limiting step in bone transport for the treatment of bone defects[ 32 ]. Most scholars suggest that early revision and bone grafting can significantly reduce the incidence of nonunion when the transported segment had reached the target site[ 33 ]. In this study, 9 patients showed delayed union or nonunion at the docking site, which healed completely after freshening of the fracture ends with removal of any interposed soft tissue at the docking end. In this study, 15 patients developed joint stiffness, and the incidences of muscle contracture, axial deviation, soft tissue incarceration, limb shortening, and fracture were 31.3% (15/48), 3.6% (16.7/48), 2.1% (1/48), 8.3% (4/48) and 2.1% (1/48), respectively. but all of them were finally solved by various means. No serious complications such as nerve and blood vessel injury occurred. Our present study showed that both bifocal and trifocal bone transport achieved satisfactory bone and functional results in the treatment of tibial bone defects, and there was no significant differences in the incidence of complications between the two groups. All patients achieved complete healing at the docking site and consolidation in the regenerate bone. The present study had several limitations. First, the sample is small and the data has a certain limitations. Second, it is difficult to exclude the influence of subjective factors of doctors in operation and results. Further investigations, especially muti-centered trails with a larger sample size should be conducted to overcome the limitations of our study. Both trifocal and bifocal bone transport can yield satisfactory results for treament of complex segmental tibial defects. Trifocal bone transport significantly reduced the EFI without increasing the associated complications. According to our experience, there are many factors that can influence the success of distraction osteogenesis, such as a comprehensive understanding of the application of external fixators, careful selection of patients, timely follow-up and early detection of predicted complications throughout the treatment. They are specialized surgical techniques that require significant expertise to master. Bone transport is a specialized technique with a long learning curve. No attempt should be made unless performed by an experienced Ilizarov surgeon. Declarations Acknowledgments Not applicable. Authors’ contributions DF: Conducted the study. Collected, analyzed, and interpreted the data. Wrote the manuscript. JW: Designed the study, and interpreted the data, and edited the manuscript. YZ: Interpreted the data. BJ: Interpreted the data. HJ: Planned the project. Interpreted the data. CM: Planned the project. Interpreted the data. All authors read and approved the final manuscript. Funding information This study was not funded by any foundation. Availability of data and materials The datasets analyzed during the current study are available from the corresponding author on reasonable request. Ethics approval and consent to participate This retrospective study was approved by the Ethics Committee of The First Affiliated Hospital of Hebei North University and carried out in accordance with the ethical standards set out in the Helsinki Declaration. Informed consent was received from all participating. Competing interests The authors declare that they have no conflict of interest. Consent for publication Not applicable. Disclosure The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article. References Lasanianos N G, Kanakaris N K, Giannoudis P V. Current management of long bone large segmental defects[J]. Orthopaedics and Trauma, 2010, 24(2):149-163. Masquelet AC, Begue T. The concept of induced membrane for reconstruction of long bone defects[J]. Orthop Clin North Am, 2010, 41(1): 27-37. DOI：10.1016/j.ocl.2009.07.011. Abuomira IE, Sala F, Elbatrawy Y,et al. Distraction osteogenesis for tibial nonunion with bone loss using combined Ilizarov and Taylor spatial frames versus a conventional circular frame. Strategies Trauma Limb Reconstr. 2016;11(3):153-159. doi:10.1007/s11751-016-0264-4. Omololu B, Ogunlade SO, Alonge TO. Limb conservation using non vascularised fibular grafts[J]. West Afr J Med, 2002, 21(4): 347-349. DOI: 10.4314/wajm.v21i4.28020. van Isacker T, Barbier O, Traore A, et al. 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Cite Share Download PDF Status: Published Journal Publication published 25 Feb, 2025 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted Editorial decision: Revision requested 18 Nov, 2024 Reviews received at journal 12 Nov, 2024 Reviews received at journal 07 Nov, 2024 Reviewers agreed at journal 01 Nov, 2024 Reviews received at journal 30 Oct, 2024 Reviewers agreed at journal 29 Oct, 2024 Reviews received at journal 29 Oct, 2024 Reviewers agreed at journal 21 Oct, 2024 Reviewers agreed at journal 20 Oct, 2024 Reviewers agreed at journal 15 Sep, 2024 Reviewers agreed at journal 25 Aug, 2024 Reviewers agreed at journal 21 Aug, 2024 Reviewers agreed at journal 21 Aug, 2024 Reviewers invited by journal 18 Aug, 2024 Editor invited by journal 19 Jul, 2024 Editor assigned by journal 17 Jul, 2024 Submission checks completed at journal 17 Jul, 2024 First submitted to journal 15 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4746581","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":336195198,"identity":"464a67e0-f609-418a-816e-3dd88914b7e2","order_by":0,"name":"Dongwei Feng","email":"","orcid":"","institution":"The First Affiliated Hospital of Hebei North University","correspondingAuthor":false,"prefix":"","firstName":"Dongwei","middleName":"","lastName":"Feng","suffix":""},{"id":336195199,"identity":"6bf5fc69-b624-412e-a3ec-114c287f845f","order_by":1,"name":"jidong wang","email":"","orcid":"","institution":"Qinghai University Affiliated Hospital","correspondingAuthor":false,"prefix":"","firstName":"jidong","middleName":"","lastName":"wang","suffix":""},{"id":336195201,"identity":"50f12ea4-db50-4e99-97df-6b73fd73454e","order_by":2,"name":"Baoliang Jiao","email":"","orcid":"","institution":"The First Affiliated Hospital of Hebei North University","correspondingAuthor":false,"prefix":"","firstName":"Baoliang","middleName":"","lastName":"Jiao","suffix":""},{"id":336195202,"identity":"0b3428d8-eb04-427a-92e3-3058a1a64dd8","order_by":3,"name":"yaxin zhang","email":"","orcid":"","institution":"The First Affiliated Hospital of Hebei North University","correspondingAuthor":false,"prefix":"","firstName":"yaxin","middleName":"","lastName":"zhang","suffix":""},{"id":336195204,"identity":"e3acf13a-0339-4733-8c05-d259f31a5d64","order_by":4,"name":"Heping Jia","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAy0lEQVRIie3RMQrCMBiG4b8EMgWzJiD1CoWCOHiYZOmk0LFDByFiBxWv0tFRCGSKuHZsb2C3jhZBF6Wpm0OeuS/plwB43h/CVOnm3rGQItrWIsvdyYSZJOaHZcwLiKPaGncSwipiBCeyvMGcN1s04sfAiL7RMVeQZHKDgRZ7MZwgdanThe63gKnkeQrMXsuxpwS7SloMEVu7kucWLUuNcCp3aHTSz9cYw7jkfcmKICasIc4ts9PrKakN2i7LQ1och5MP5LfPPc/zvK8engZG4x0kkbgAAAAASUVORK5CYII=","orcid":"","institution":"The First Affiliated Hospital of Hebei North University","correspondingAuthor":true,"prefix":"","firstName":"Heping","middleName":"","lastName":"Jia","suffix":""},{"id":336195205,"identity":"48626511-ec24-4feb-8479-e31c85463325","order_by":5,"name":"Chuang Ma","email":"","orcid":"","institution":"The First Affiliated Hospital of Xinjiang medical University","correspondingAuthor":false,"prefix":"","firstName":"Chuang","middleName":"","lastName":"Ma","suffix":""}],"badges":[],"createdAt":"2024-07-16 03:08:55","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4746581/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4746581/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12891-025-08454-w","type":"published","date":"2025-02-25T15:58:08+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":77622767,"identity":"0cd3ad92-54f7-4954-bc1b-8c242c7763a6","added_by":"auto","created_at":"2025-03-03 16:10:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":712229,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4746581/v1/9058839c-0799-4f57-aec3-f326529cbe53.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Analysis of functional outcomes and complications of tibial bone defects treated with Ilizarov bone transport technique","fulltext":[{"header":"Background","content":"\u003cp\u003eLarge tibial bone defects are encountered commonly by trauma surgeons. Such injuries may be caused by high-energy trauma, infection, tumours, and bone nonunion. Managing such injuries has been a challenge for orthopedic surgeons[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In recent years, techniques such as plate osteosynthesis with cancellous bone grafting, bone grafting with autogenous or allogenic bone grafts, bone shortening and lengthening technique, tibialization of the fibula, vascularized fibular grafts, the Masquelet induced membrane technique have achieved certain clinical results for the bone defects. However, the shortcomings and problems of these methods still remain the issues which restrict their overall use[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e][\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e][\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].With the development of microsurgical techniques and the improvement of external fixation devices. At present, Ilizarov bone transport techniques based on the concept of \"distraction osteogenesis\" have played an irreplaceable role in the treatment of bone defects because of their simplicity and effectiveness and ability to maximize the preservation of the biomechanical environment required for fracture healing[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Bone transport may be bifocal or trifocal[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The regeneration of a long defect by distraction of one osteotomy site in the bifocal technique takes a long time in the frame, which may increases the incidence of complications such as pin tract infection, delayed union, joint stiffness and axial deviation, which often require further surgical and bring great psychological and economic burden to patients[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Trifocal technique has been shown to reduce wear time[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, the trifocal technique needs a more complex assembly of the frame as well as the additional osteotomy, which may lead to the generation of related complications[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe purpose of this study was to analyze 48 cases of tibial bone defects treated with Ilizarov bone transport technique and to investigate the differences in efficacy and complications between trifocal anf bifocal bone transport.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e The institutional review board (IRB) approval was gotten from the ethics committee of our institution. All methods were performed according to relevant guidelines and regulations.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eThere are 48 patients with tibial bone defects treated by the Ilizarov bone transport technique from March 2015 to May 2019 in our study. The inclusion criteria were as follows: (1) Patients over 18 years; (2) Patients with tibial bone defects\u0026thinsp;\u0026ge;\u0026thinsp;3 cm; (3) follow-up time after frame removal\u0026thinsp;\u0026ge;\u0026thinsp;24months. The exclusion criteria were as follows: (1) Combined with systemic metabolic diseases affecting bone healing; (2) Bone defect caused by pathological fracture; and (3) Poor compliance, can not cooperate with the treatment and follow-up.\u003c/p\u003e \u003cp\u003eA total of 53 patients with tibial bone loss who underwent Ilizarov bone transport technique treatment were initially screened, and 48 patients who met the inclusion and exclusion criteria for this study were included.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSurgical technique\u003c/h2\u003e \u003cp\u003eStandard anteroposterior and lateral radiographs of the affected limb were taken for detailed preoperative planning. Perfect relevant examinations, after excluding surgical contraindications, thorough debridement was performed under general anesthesia or epidural anesthesia. Bacterial culture and drug sensitivity test were performed for surface secretions and deep tissue scrapings were retained of infected individuals to guide subsequent anti-infective treatment. All local necrosis, infection, and inflammatory granulation tissue were removed, and sequestrum, nonunion site, or sclerotic bone were completely removed to keep the broken end flat until cortical bleeding at the bone end, described by the so-called \u0026ldquo;paprika sign[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u0026rdquo;, was accepted as an indication of vital osseous tissue. A large amount of iodophor, normal saline, and hydrogen peroxide were alternately irrigated to the surgical area. External fixators were installed according to preoperative planning, and antibiotic-impregnated spacers were placed in the infected bone defect site to improve stability. The rail fixator was installed according to the location of bone defect and soft tissue conditions during operation. Close the wound adequately in tension free manner by direct closure or use of free/local fap if necessary. For bone defects larger than 8 cm or exceeding 40% of the original bone length, a trifocal bone transport procedure was performed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative management and follow-up\u003c/h2\u003e \u003cp\u003eSensitive antibiotics for 6 weeks according to the results of bacterial culture and drug sensitivity test, until the ESR and CRP level returned to normal. Encourage patients to perform early muscle isometric contraction exercises and active movement of adjacent joints. Distraction osteogenesis was started 7 days after operation. For cases with bifocal bone transport, the rate and rhythm was 1 mm/day, which was completed 4 times. In cases of trifocal bone transport, if bone transport in the same direction, the fragment near the bone defect was transported at a rate of 0.5 mm f and 4 times/day, and the other fragment far from the defect was transported 0.25 mm and 4 times/day. For converged bone transport, each fragment on both end of the bone defect was transported at a rate of 0.25 mm four times per day. The rate and rhythm of distraction were adjusted according to patient tolerance and radiographic evaluation of the distracted region. The Ilizarov fixator was removed after an X-ray taken in two planes showed corticalization of four cortices[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Additionally, all patients was protected in a long-leg cast or brace for 4 weeks to protect against refracture. Docking time (DT), external fixation time (EFT), external fixation index (EFI), duration of regenerate consolidation time (CT) and complications during treatment were recorded. Complications were classified with the Paley criteria [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. ASAMI [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e](Association for the Study and Application of the Method of Ilizarov) criteria were used to assess the bony and functional outcomes at follow-up.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData analysis was performed using SPSS version 22.0 (IBM Corp, United States) to analyse all data; all variables were examined for normal distribution. The measurement data are expressed as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD). The enumeration data are expressed as percentages. Continuous variables were compared by using t tests, and Pearson\u0026rsquo;s chi-square test or Fisher\u0026rsquo;s exact test was used to compare categorical variables. and results with \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDemographic and clinical characteristics\u003c/h2\u003e \u003cp\u003eAll patients in the two groups completed the surgery successfully without neurological or vascular injuries. All patients finished the follow up with 24 to 40 months, with an average of 27.5 months. There were no significant differences between the two groups in terms of age, gender, smoking, affected side, causes of injury and previous treatment(\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05), as detailed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient demographics at baseline and intraoperative parameter between BF and TF group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003edate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex(male / female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6/24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3/15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.916\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge(years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37.00\u0026thinsp;\u0026plusmn;\u0026thinsp;12.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.50\u0026thinsp;\u0026plusmn;\u0026thinsp;12.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.394\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.696\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking(yes/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13/17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11/7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.422\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.233\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInjured side(left/right)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13/17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9/9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.201\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.654\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe etiology of bone defect(high-energy trauma / fall injury /other)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11/5/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11/7/6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.660\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.719\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary fixation (internal/external)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14/16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7/11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.277\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.599\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious operation time(s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.30\u0026thinsp;\u0026plusmn;\u0026thinsp;1.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.61\u0026thinsp;\u0026plusmn;\u0026thinsp;2.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.539\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.593\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterval duration before bone transport(months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31.60\u0026thinsp;\u0026plusmn;\u0026thinsp;47.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61.02\u0026thinsp;\u0026plusmn;\u0026thinsp;103.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.135\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.269\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative outcomes\u003c/h2\u003e \u003cp\u003eIn terms of surgical outcomes, in the BF group, the size of bone defect was 6.33\u0026thinsp;\u0026plusmn;\u0026thinsp;3.15 cm, the DT was 91.10\u0026thinsp;\u0026plusmn;\u0026thinsp;44.41 days, the CT was 255.87\u0026thinsp;\u0026plusmn;\u0026thinsp;112.45 days, the EFT was 402.18\u0026thinsp;\u0026plusmn;\u0026thinsp;172.54 days and the EFI was 65.82\u0026thinsp;\u0026plusmn;\u0026thinsp;6.98 d/cm. In the TF group, the size of bone defect was 9.08\u0026thinsp;\u0026plusmn;\u0026thinsp;1.74 cm, the DT was 76.44\u0026thinsp;\u0026plusmn;\u0026thinsp;27.94 days, the CT was 237.56\u0026thinsp;\u0026plusmn;\u0026thinsp;53.56 days, the EFT was 379.65\u0026thinsp;\u0026plusmn;\u0026thinsp;68.77 days and the EFI was 42.22\u0026thinsp;\u0026plusmn;\u0026thinsp;2.41 d/cm. the TF group exhibited a longer average defect size. Similarly, the EFI was significantly lower in the TF group. But not in the DT, the CT and the EFT(\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparision of postoperative date between the BF and TF group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSize of bone defect(cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e6.33\u0026thinsp;\u0026plusmn;\u0026thinsp;3.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e9.08\u0026thinsp;\u0026plusmn;\u0026thinsp;1.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.889\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDT(d)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e91.10\u0026thinsp;\u0026plusmn;\u0026thinsp;44.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e76.44\u0026thinsp;\u0026plusmn;\u0026thinsp;27.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.403\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.165\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCT(d)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e255.87\u0026thinsp;\u0026plusmn;\u0026thinsp;112.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e237.56\u0026thinsp;\u0026plusmn;\u0026thinsp;53.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.760\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.451\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEFT(d)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e402.18\u0026thinsp;\u0026plusmn;\u0026thinsp;172.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e379.65\u0026thinsp;\u0026plusmn;\u0026thinsp;68.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.636\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.528\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEFI(d/cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e65.82\u0026thinsp;\u0026plusmn;\u0026thinsp;6.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e42.22\u0026thinsp;\u0026plusmn;\u0026thinsp;2.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16.922\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e༎Comparision of the evaluation of ASAMI bone and functional grade between the BF and TF group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGrade\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003ebony\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003efunctional\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTF\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFailure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.508\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.958\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eBone and functional outcomes\u003c/h2\u003e \u003cp\u003eThe bone result was excellent, good, fair and poor in 16, 11, 2 and 1 in group BF; and 15, 10, 4, and 1 in group TF, respectively. The functional results were excellent, good, fair, poor and failure in 11, 4, 3, 0 and 0 in group BF; and 10, 5, 2, 2 and 0 in group TF, respectively. With respect to bone and function results, there was no significant differences between the two groups \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.508 and \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.958, respectively).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eComplications\u003c/h2\u003e \u003cp\u003eComplications were classified according to Paley classification. No case encountered joint luxation, vascular or nerve compromise in both groups and the results are shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e༎Comparision of complications between the BF and TF group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eBF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eTF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eproblem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eobstacle\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ecomplication\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eproblem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eobstacle\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ecomplication\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePin-site infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelayed union\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMuscle contractures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAxial deviation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNonuion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSoft tissue incarceration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJoint stiffness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLimb shortening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRefracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{\\:\\:\\:\\:\\:\\:\\:\\:\\:x}^{2}\\)\u003c/span\u003e\u003c/span\u003e=0.090 \u003cem\u003eP\u003c/em\u003e=0.956\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFor BF group, there are twenty-nine problems, thirteen obstacles, and seven complications. In TF group, seventeen problems occurred. Eight obstacles happened, and five cases suffered from complications. The mean number of complications per patient was 1.6 for BF patients and 1.7 for TF patients, and the difference was no significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eComplications were treated similarly in both groups. Among them, thirty-two patients had a pin tract infection, which was cured in most patients with daily pin site care and oral antibiotics. One patients suffered from a deep pin tract infection, which was successfully treated by pin replacement and intravenous antibiotics. Fifteen patients developed delayed union which were successfully managed by intensive physiotherapy or extending apparatus across the stiffed joint and mobilizing the joint prior to its removal. Muscle contraction was encountered in nine cases were instructed to participate in functional exercises or manual release. Eigth patients had axial deviation were managed by adjusting the transport frame. Seven patients developed delayed union, which were successfully treated by the accordion technique. There were two cases of nonunion at the docking site, which were treated by autocancellous bone graft from iliac crest. One patient developed soft tissue incarceration and underwent soft tissue resection and the iliac bone graft was introduced, and all eventually healed. One case refracture achieved bony union by wearing a protective brace.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe theoretical basis of Ilizarov's technology is the tensionstress law, in which the living tissue is subjected to sustained, slow, and stable traction to produce tension that stimulates the regeneration and growth of the tissue[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Currently, it has emerged as the gold standard for the treatment of massive tibial bone defects, eradicating infection and solving bone and soft tissue defects at the same time. Bone transport tecnique include distraction and consolidation period. The distraction period is generally 7 to 10 days after osteotomy, the bone segment is transported at a rate of 1 mm/d to reach the expected extended length and then enters the consolidation period, and the external fixator is removed after the newly formed bone is completely consolidation[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. As a result, large bone defects tend to require longer EFT and increases the frame-related complications such as pin-tract infection, pin loosening, joint stiffness and psychological symptoms[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral authors have addressed different treatment options in order to shorten treatment period and reduce the incidence of complications. Apivatthakakul[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] successfully cured 2 cases of distal femoral bone defects using MIPO technique combined with external fixator, and although the alignment of the docking end was maintained, it has also been found that the built-in plate affects the generation of callus at the bone end[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Liodakis[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] found that external fixation combined with intramedullary nail technique not only shortens the EFT. Moreover, combined external and internal fixation was found to have a greater risk of infection recurrence in the treatment of infected tibial nonunion and chronic osteomyelitis. Some more options of a combined technique have been reported, such as a lengthening nail for transport and a locking plate for docking and a carbon-fiber IMN[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, besides its high cost, it was found clinically that the nail performs poorly in long-bone surgery and cannot be added to external fixation instead of a titanium nail even for combination.\u003c/p\u003e \u003cp\u003eBecause accelerated lengthening at one osteotomy site is not possible due to biological and neurovascular considerations, the solution was to add one osteotomy while lengthening, ideally doubles the rate of lengthening effectively. Borzunov[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] first used double-level bone transport using the Ilizarov technique to treat large tibial bone defects, with a 2.5 times shorter docking time and a 1.3\u0026ndash;1.9 times lower EFT compared with the single-level bone transport. Similarly Paley and Maar et al[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] recommended double-level bone transport for bone defects greater than 10 cm in order to shorten the EFT. It has also been suggested that trifocal bone transport should be considered when the defect length is over 6 cm[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. However, the above studies did not describe complications, and bone or functional outcomes in the two groups.\u003c/p\u003e \u003cp\u003eWe also compared the above two methods in this study, the mean bone defect length was greater in the TF group than in the BF group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Although there were no statistically significant differences in DT, CT, and EFT between the two bone transport modes, the means of these data were smaller in the TF group than in the BF group, and the mean EFI was shorter in the TF group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). This finding suggests that despite the increased complexity of the TF group, it may provide a rapid recovery pathway.\u003c/p\u003e \u003cp\u003eTrifocal bone transport equates to faster docking contacts, which leads to early docking healing[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. we anticipated that the addition of an osteotomy to the TFT would increase complications associated with the wires and distraction sites. In the study, the complication rate was 1.6 per patient in BF group and 1.7 per patient in TF group, the results showed no statistically significant complication rate between the two groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.956). Possibly due to the relatively early frame removal in the two-level group. Therefore, we believe that the occurrence of complications may is associated with longer EFT. According to our experience and study, we recommend trifocal bone transport was performed when if the bone defect is more than 8.0 cm.\u003c/p\u003e \u003cp\u003eSome authors found that hypoplastic bone formation may occur during defect filling when single-level distraction regeneration growth exceeds 5 cm or 40% of the original segment length[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Chaddha[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] applied trifocal bone transport to treat tibial bone defects and had a higher incidence of delayed consolidation, which was caused by the the more distal osteotom and there was a high incidence of trauma to the nutrient artery in trifocal bone transport. The consolidation time of the distraction gap is also affected by blood supply, such that the closer the regeneration zone is to the metaphysis, the shorter the consolidation time[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. No patient developed delayed consolidation in this study. This was done with both proximal-to-distal bone transport technique all cases in our study. In addition, the use of low-energy osteotomy techniques and adjustment of the lengthening rate may reduce the occurrence of such complications.\u003c/p\u003e \u003cp\u003eAlthough bone transport is widely used to treat large bone defects, some unavoidable complications have also been reported[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e][\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. In our study, pin tract infection is the most common complication in 32 patients (66.7%), including 12 case in the double level group and 20 cases in the single-level group. Dahl[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] classified pin tract infection into Grade V according to severity. According to the above classification, twenty-eight patients were Grade I, three patients were Grade III and 1 patients were Grade IV. Most pin tract infections are treatable with improved wound care and a short course of oral antibiotics. One patients(Grade IV) suffered from a deep pin tract infection, which was successfully treated by pin replacement and intravenous antibiotics.\u003c/p\u003e \u003cp\u003eOur experience is that frequency of needle track cleaning did not reduce the rate of pin track infection, but rather increased allergic reactions around the needle track. In addition, dry sterile gauze is wrapped around each pin site to maintain dryness around the pins sites significantly reduced the incidence of pin tract infection.\u003c/p\u003e \u003cp\u003eRelevant literature suggests that nonunion is the rate-limiting step in bone transport for the treatment of bone defects[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Most scholars suggest that early revision and bone grafting can significantly reduce the incidence of nonunion when the transported segment had reached the target site[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In this study, 9 patients showed delayed union or nonunion at the docking site, which healed completely after freshening of the fracture ends with removal of any interposed soft tissue at the docking end.\u003c/p\u003e \u003cp\u003eIn this study, 15 patients developed joint stiffness, and the incidences of muscle contracture, axial deviation, soft tissue incarceration, limb shortening, and fracture were 31.3% (15/48), 3.6% (16.7/48), 2.1% (1/48), 8.3% (4/48) and 2.1% (1/48), respectively. but all of them were finally solved by various means. No serious complications such as nerve and blood vessel injury occurred.\u003c/p\u003e \u003cp\u003eOur present study showed that both bifocal and trifocal bone transport achieved satisfactory bone and functional results in the treatment of tibial bone defects, and there was no significant differences in the incidence of complications between the two groups. All patients achieved complete healing at the docking site and consolidation in the regenerate bone.\u003c/p\u003e \u003cp\u003eThe present study had several limitations. First, the sample is small and the data has a certain limitations. Second, it is difficult to exclude the influence of subjective factors of doctors in operation and results. Further investigations, especially muti-centered trails with a larger sample size should be conducted to overcome the limitations of our study.\u003c/p\u003e \u003cp\u003eBoth trifocal and bifocal bone transport can yield satisfactory results for treament of complex segmental tibial defects. Trifocal bone transport significantly reduced the EFI without increasing the associated complications. According to our experience, there are many factors that can influence the success of distraction osteogenesis, such as a comprehensive understanding of the application of external fixators, careful selection of patients, timely follow-up and early detection of predicted complications throughout the treatment. They are specialized surgical techniques that require significant expertise to master. Bone transport is a specialized technique with a long learning curve. No attempt should be made unless performed by an experienced Ilizarov surgeon.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDF: Conducted the study. Collected, analyzed, and interpreted the data. Wrote the manuscript.\u003c/p\u003e\n\u003cp\u003eJW: Designed the study, and interpreted the data, and edited the manuscript.\u003c/p\u003e\n\u003cp\u003eYZ: Interpreted the data.\u003c/p\u003e\n\u003cp\u003eBJ: Interpreted the data.\u003c/p\u003e\n\u003cp\u003eHJ: Planned the project. Interpreted the data.\u003c/p\u003e\n\u003cp\u003eCM: Planned the project. Interpreted the data.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding information\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was not funded by any foundation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective study was approved by the Ethics Committee of The First Affiliated Hospital of Hebei North University and carried out in accordance with the ethical standards set out in the Helsinki Declaration. Informed consent was received from all participating.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLasanianos N G, Kanakaris N K, Giannoudis P V. Current management of long bone large segmental defects[J]. Orthopaedics and Trauma, 2010, 24(2):149-163.\u003c/li\u003e\n\u003cli\u003eMasquelet AC, Begue T. The concept of induced membrane for reconstruction of long bone defects[J]. Orthop Clin North Am, 2010, 41(1): 27-37. DOI：10.1016/j.ocl.2009.07.011.\u003c/li\u003e\n\u003cli\u003eAbuomira IE, Sala F, Elbatrawy Y,et al. Distraction osteogenesis for tibial nonunion with bone loss using combined Ilizarov and Taylor spatial frames versus a conventional circular frame. Strategies Trauma Limb Reconstr. 2016;11(3):153-159. doi:10.1007/s11751-016-0264-4.\u003c/li\u003e\n\u003cli\u003eOmololu B, Ogunlade SO, Alonge TO. Limb conservation using non vascularised fibular grafts[J]. West Afr J Med, 2002, 21(4): 347-349. DOI: 10.4314/wajm.v21i4.28020.\u003c/li\u003e\n\u003cli\u003evan Isacker T, Barbier O, Traore A, et al. Forearm reconstruction with bone allograft following tumor excision: a series of 10 patients with a mean follow-up of 10 years[J]. Orthop Traumatol Surg Res, 2011, 97(8): 793-799. \u003c/li\u003e\n\u003cli\u003eWalker M, Sharareh B, Mitchell S A. Masquelet Reconstruction for Posttraumatic Segmental Bone Defects in the Forearm[J]. J Hand Surg Am, 2019, 44(4):341-342.\u003c/li\u003e\n\u003cli\u003eZhang Y, Wang Y, Di J, et al. Double-level bone transport for large post-traumatic tibial bone defects: a single centre experience of sixteen cases[J]. Int Orthop, 2018，42(5):1157-1164. \u003c/li\u003e\n\u003cli\u003eBaumgart R, Schuster B, Baumgart T. [Callus distraction and bone transport in the treatment of bone defects][J]. Orthopade, 2017, 46(8):673-680.\u003c/li\u003e\n\u003cli\u003eVesely R, Prochazka V. [Callus Distraction in the Treatment of Post-Traumatic Defects of the Femur and Tibia][J]. Acta Chir Orthop Traumatol Cech, 2016, 83(6):388-392.\u003c/li\u003e\n\u003cli\u003eBorzunov DY, Chevardin AV. Ilizarov non-free bone plasty for extensive tibial defects[J]. Int Orthop, 2013, 37(4):709-14. \u003c/li\u003e\n\u003cli\u003eKocaoglu M, Eralp L, Rashid H U, et al. Reconstruction of segmental bone defects due to chronic osteomyelitis with use of an external fixator and an intramedullary nail[J]. J Bone Joint Surg Am, 2006, 88(10):2137-2145.\u003c/li\u003e\n\u003cli\u003eCatagni M A, Azzam W, Guerreschi F, et al. Trifocal versus bifocal bone transport in treatment of long segmental tibial bone defects[J]. Bone Joint J,2019,101-B(2):162-169.\u003c/li\u003e\n\u003cli\u003ePaley D. Problems, obstacles, and complications of limb lengthening by the Ilizarov technique[J]. Clin Orthop Relat Res, 1990, (250): 81-104.\u003c/li\u003e\n\u003cli\u003ePaley D, Catagni MA, Argnani F et al. Ilizarov treatment of tibial nonunions with bone loss[J]. Clin Orthop Relat Res, 1989, (241): 146-165.\u003c/li\u003e\n\u003cli\u003eBorzunov DY, Kolchin SN, Malkova TA. Role of the Ilizarov non-free bone plasty in the management of long bone defects and nonunion: Problems solved and unsolved[J]. World J Orthop, 2020, 11(6): 304-318. DOI: 10.5312/wjo.v11.i6.304.\u003c/li\u003e\n\u003cli\u003eTaylor GI, Miller GD, Ham FJ. The free vascularized bone graft. A clinical extension of microvascular techniques[J]. Plast Reconstr Surg, 1975, 55(5): 533-544. DOI: 10.1097/00006534-197505000-00002.\u003c/li\u003e\n\u003cli\u003eMasquelet AC, Begue T. The concept of induced membrane for reconstruction of long bone defects[J]. Orthop Clin North Am, 2010, 41(1): 27-37. DOI: 10.1016/j.ocl.2009.07.011.\u003c/li\u003e\n\u003cli\u003eApivatthakakul T, Arpornchayanon O. Minimally invasive plate osteosynthesis (MIPO) combined with distraction osteogenesis in the treatment of bone defects. A new technique of bone transport: a report of two cases[J]. Injury, 2002, 33: 460-5. \u003c/li\u003e\n\u003cli\u003eWindhager R, Groszschmidt K, Tsuboyama T, et al. Recorticalization after bifocal internal bone transport in the double-plated sheep femur[J]. J Orthop Res, 1996, 14(1):94-101. \u003c/li\u003e\n\u003cli\u003eLiodakis Emmanouil, Kenawey Mohamed, Krettek Christian, et al. Comparison of 39 post-traumatic tibia bone transports performed with and without the use of an intramedullary rod: the long-term outcomes[J]. Int Orthop, 2011, 35: 1397-402.\u003c/li\u003e\n\u003cli\u003eOlesen UK, Nygaard T, Prince DE, et al. Plate-assisted Bone Segment Transport With Motorized Lengthening Nails and Locking Plates: A Technique to Treat Femoral and Tibial Bone Defects. J Am Acad Orthop Surg Glob Res Rev. 2019;3(8):e064. doi:10.5435/JAAOSGlobal-D-19-00064.\u003c/li\u003e\n\u003cli\u003eBorzunov DY. Long bone reconstruction using multilevel lengthening of bone defect fragments[J]. International Orthopaedics, 2012, 36(8):1695-1700.\u003c/li\u003e\n\u003cli\u003ePaley D, Maar D C. Ilizarov bone transport treatment for tibial defects[J]. Journal of Orthopaedic Trauma, 2000, 14(2):76.\u003c/li\u003e\n\u003cli\u003eRobert Rozbruch S, Weitzman AM, Tracey Watson J, Freudigman P, Katz HV, Ilizarov S. Simultaneous treatment of tibial bone and soft-tissue defects with the Ilizarov method. J Orthop Trauma. 2006;20(3):197-205. \u003c/li\u003e\n\u003cli\u003eSala F, Thabet AM, Castelli F, et al. Bone transport for postinfectious segmental tibial bone defects with a combined ilizarov/taylor spatial frame technique[J]. Journal of Orthopaedic Trauma, 2011, 25(3):162.\u003c/li\u003e\n\u003cli\u003eBorzunov DY, Chevardin AV. Ilizarov non-free bone plasty for extensive tibial defects. Int Orthop. 2013;37(4):709-714. doi:10.1007/s00264-013-1799-3.\u003c/li\u003e\n\u003cli\u003eChaddha M, Gulati D, et al. Management of massive posttraumatic bone defects in the lower limb with the Ilizarov technique. Acta Orthop Belg. 2010;76(6):811-820.\u003c/li\u003e\n\u003cli\u003eLi Y, Shen S, Xiao Q, et al. Efficacy comparison of double-level and single-level bone transport with Orthofix fixator for treatment of tibia fracture with massive bone defects. Int Orthop. 2020;44(5):957-963. doi:10.1007/s00264-020-04503-2.\u003c/li\u003e\n\u003cli\u003eAntoci V, Ono CM, Antoci V Jr, Raney EM. Pin-tract infection during limb lengthening using external fixation. Am J Orthop (Belle Mead NJ). 2008;37(9):E150-E154.\u003c/li\u003e\n\u003cli\u003eAktuglu K, Erol K, Vahabi A. Ilizarov bone transport and treatment of critical-sized tibial bone defects: a narrative review. J Orthop Traumatol. 2019;20(1):22. Published 2019 Apr 16. doi:10.1186/s10195-019-0527-1\u003c/li\u003e\n\u003cli\u003eDahl MT, Gulli B, Berg T. Complications of limb lengthening. A learning curve. Clin Orthop Relat Res. 1994;(301):10-18.\u003c/li\u003e\n\u003cli\u003eParameswaran AD, Roberts CS, Seligson D, Voor M. Pin tract infection with contemporary external fixation: how much of a problem?. J Orthop Trauma. 2003;17(7):503-507. doi:10.1097/00005131-200308000-00005.\u003c/li\u003e\n\u003cli\u003eBumbasirević M, Tomić S, Lesić A, et al. War-related infected tibial nonunion with bone and soft-tissue loss treated with bone transport using the Ilizarov method. Arch Orthop Trauma Surg. 2010;130(6):739-749. doi:10.1007/s00402-009-1014-6.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Bone transport, External fixation, Ilizarov, Complication, Tibia, Segmental bone loss","lastPublishedDoi":"10.21203/rs.3.rs-4746581/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4746581/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTrifocal bone transport (TF) rather than bifocal bone transport (BF) can shorten the treatment time when treating of large bone defect in tibia. However, few studies have reported efficacy and complications among different bone transport.\u003c/p\u003e\u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003eTo evaluate the effectiveness and complications of bone transport technique for the treatment of large bone defect in tibia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe retrospective study including 48 patients who underwent bone transport for the treatment of large bone defect in tibia from May 2015 to September 2019. A total of 30 were treated by bifocal bone transport (BF group) and 18 by trifocal bone transport (TF group). Patient demographic data, intraoperative outcomes, postoperative variables, complications and clinical outcomes of the two groups were recorded and compared at a minimum follow-up of 24 months. Postoperative complications were also evaluated according to Paley classification. Based on the Association for the Study and Application of Methods of Ilizarov (ASAMI) standard, the bone and functional results were evaluated at the last clinical follow-up.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAll patients with an average follow-up of 23 months. All patients achieved complete union in the docking site and consolidation in the regenerate bone. Compared to the BF group, the TF group had a longer bone defect length(9.08\u0026thinsp;\u0026plusmn;\u0026thinsp;1.74\u0026thinsp;\u0026gt;\u0026thinsp;6.33\u0026thinsp;\u0026plusmn;\u0026thinsp;3.15, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01) but a shorter external fixation index (42.22\u0026thinsp;\u0026plusmn;\u0026thinsp;2.41\u0026thinsp;\u0026lt;\u0026thinsp;65.82\u0026thinsp;\u0026plusmn;\u0026thinsp;6.98, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The mean number of complications per patient was 1.6 and 1.7 for BF and TF patients (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). At the postoperative follow-up, there were no significant differences between the 2 groups in the bone and functional results (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eFor tibial bone defects, both bifocal and trifocal bone transport can achieve good clinical results. Compared to the bifocal bone transport, The trifocal bone transport can significantly shorten the external fixation index without increasing the incidence of associated complications.\u003c/p\u003e","manuscriptTitle":"Analysis of functional outcomes and complications of tibial bone defects treated with Ilizarov bone transport technique","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-09 17:57:20","doi":"10.21203/rs.3.rs-4746581/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-18T12:26:32+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-12T08:09:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-07T16:10:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2199449141121893402484196627006726444","date":"2024-11-01T10:11:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-30T20:36:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"52113794634738501481216241775627028542","date":"2024-10-29T11:24:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-29T09:34:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"5843652932894834149902879001851589354","date":"2024-10-21T11:28:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"208811853330135271442304889552473336506","date":"2024-10-20T21:54:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"117364823622437429792838104994742079401","date":"2024-09-15T18:22:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"334882412938968446549387029672432200826","date":"2024-08-26T03:31:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"260221129824718059866301131841785085918","date":"2024-08-21T20:31:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"181206043396970967922345106701131349269","date":"2024-08-21T07:00:05+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-18T15:16:46+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-07-19T14:20:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-17T10:17:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-17T10:16:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2024-07-16T03:07:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"580f754a-f7d0-4c61-8e85-4a31f186d3c1","owner":[],"postedDate":"August 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-03T16:06:14+00:00","versionOfRecord":{"articleIdentity":"rs-4746581","link":"https://doi.org/10.1186/s12891-025-08454-w","journal":{"identity":"bmc-musculoskeletal-disorders","isVorOnly":false,"title":"BMC Musculoskeletal Disorders"},"publishedOn":"2025-02-25 15:58:08","publishedOnDateReadable":"February 25th, 2025"},"versionCreatedAt":"2024-08-09 17:57:20","video":"","vorDoi":"10.1186/s12891-025-08454-w","vorDoiUrl":"https://doi.org/10.1186/s12891-025-08454-w","workflowStages":[]},"version":"v1","identity":"rs-4746581","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4746581","identity":"rs-4746581","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}