|Year : 2016 | Volume
| Issue : 4 | Page : 171-174
Management of traumatic segmental bone loss using linear rail system, our experience at the University of Maiduguri Teaching Hospital, Maiduguri, Nigeria
Theophilus Maksha Dabkana, Friday Titus Nyaku, Bunu Bukar
Department of Orthopaedic and Trauma Surgery, University of Maiduguri Teaching Hospital, Maiduguri, Borno State, Nigeria
|Date of Web Publication||21-Dec-2016|
Theophilus Maksha Dabkana
Department of Orthopaedic and Trauma Surgery, College of Medical Sciences, University of Maiduguri, Maiduguri
Background: Following road traffic accidents (RTAs) some patients sustain fractures that involve loss of bone segments. This does not do well with the usual bone grafting. To achieve union, docking of the remaining fragments will have to be done which will lead to severe shortening. Vascularized bone graft would be the best. In the absence of vascularized bone graft, bone transport can be used to avoid the shortening and treat the defect. Objective: To assess the effectiveness bone transport/distraction technique using the Linear Rail System for the treatment of segmental bone loss following trauma. Methods: All patients with segmental bone loss of more than 4 cm following RTA were included in the study. 10 patients were involved in the study. Results: All our ten patients achieved adequate defect correction of up to 80% to 100%. Conclusion: H.S. Pitkar LRS System when used properly is good for management of segmental bone loss following trauma.
Keywords: Linear rail system, third world experience, traumatic segmental bone loss
|How to cite this article:|
Dabkana TM, Nyaku FT, Bukar B. Management of traumatic segmental bone loss using linear rail system, our experience at the University of Maiduguri Teaching Hospital, Maiduguri, Nigeria. Sahel Med J 2016;19:171-4
|How to cite this URL:|
Dabkana TM, Nyaku FT, Bukar B. Management of traumatic segmental bone loss using linear rail system, our experience at the University of Maiduguri Teaching Hospital, Maiduguri, Nigeria. Sahel Med J [serial online] 2016 [cited 2020 Feb 29];19:171-4. Available from: http://www.smjonline.org/text.asp?2016/19/4/171/196352
| Introduction|| |
In 1951, Professor Gavril Abramovich Illizarov from Kurgan in Russia developed circular external fixators for the management of long bone fractures and deformities in children. For the next 40 years, he discovered many other uses of the device and these included the management of limb length inequalities by way of lengthening the bone. This takes the advantages of the body's ability to grow and regenerate new bone and soft tissue. This was popularized in the USA and Canada by Prof. Dror Paley, a Canadian Orthopedic Surgeon, who trained under Prof. Illizarov among others. ,,,
H.S. Pitkar Orthotools Industry, India, produced a device called linear rail system (LRS), which has the ability to distract bone at a controlled rate to allow bone lengthening just like the Orthofix and the equivalent background input (EBI) systems, in a monoplanar fashion.  Its use is less cumbersome compared to the Ilizarov frame and when used properly, gives same good results. The device consists of a rail to which 4.5-6.5 mm Schanz screws are attached via sliding components. These components can be immobilized on the rail with bolts while the one carrying the moving bone loosened and tightened as the distraction progresses. A compression distraction unit is usually attached, depending on the length of the segment to be replaced.  The type we used is shown in [Figure 1].
| Methodology|| |
This is a prospective study done at the University of Maiduguri Teaching Hospital (UMTH) and Borno Orthopaedic Centre and Trauma Services (BOCATS) from 2008 to 2011, involving ten patients that had a segmental bone loss of 5-10 cm following road traffic accident. Three of the patients had their wounds treated before being referred to us whereas seven of them reported to us with fresh injuries. All the seven patients had their wounds treated and skin cover achieved during the process of distraction. Eight of the patients had distal or mid tibial segmental loss whereas two had mid-femoral segmental loss following RTA. The femoral segmental fractures were infected, and the segments were subsequently lost before coming to us, with the wounds healed. Six of the eight patients with tibial segmental loss had proximal tibial distraction, followed by plating when distal docking was achieved, with bone grafting.  The other two had docking and plating at the time of the device fixation. We thought there will be concertina effect when we observed that the tissues buckled up but this disappeared by the time the distraction was finished. The femoral defects were treated with distal femoral distraction and plating of docked fragments with plate and screws. The amount of length required was determined by the length of the contralateral bone. In case of the tibia, if the fibular was intact, the gap was used to determine length. Corticotomy was done using osteotomes in all cases. 
The pins were inserted along the subcutaneous borders of the tibia for the tibial defects and between the vastus lateralis and hamstrings in the femoral cases. , Distraction was done at the rate of 0.5 mm 12 hourly starting 7 days after the corticotomy and device fixation. , All our patients stayed in the hospital for the whole time of the distraction, ranging from 55 to 110 days, after which the device was locked, and patients discharged and seen at the outpatient department every 2 weeks, and progress of the new bone formation monitored radiologically. Any pin tract infection was treated accordingly. Plating of the docked fragments and bone grafting with LRS in situ was done in the other cases before discharge. Since the fibula was involved in the trauma, we divided it only in some cases.
Once there was evidence of calcification on radiograph, patients were readmitted, cast applied, and LRS removed and discharged as soon as pin tracts healed. The cast was removed once there was evidence of remodeling on radiograph, and weight bearing started as soon as the plated area could permit. ,, We started with partial weight bearing for 4 weeks and then full weight bearing thereafter. All our patients did well, achieving 80-100% of the required length. One of the patients X-rays are shown in [Figure 2] below.
|Figure 2: One of the cases treated. (a) Just before surgery, (b and c) after surgery, LRS in place and corticotomy done, (d) after docking, ORIF and bone grafting with LRS in-situ, (e) after removal of LRS with evidence,of good union|
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| Results|| |
There were ten patients involved in this study, eight males and two females, giving a ratio of 4:1, aged between 22 and 48 years. The tibia was involved in eight patients, 7 males, 1 female whereas the femur in two patients, one male, one female. The left tibia was involved in 5 cases whereas the right in 3 cases. There was one left femoral and one right femoral defect both had the wounds healed before presentation. There were two pin tract infections, which were treated and the frame got broken when the patient bore weight on the affected limb. This was changed and did not affect the procedure much (got 5 cm of the required 5.5 cm). The distraction device got jammed in one patient. This was changed and did not affect the procedure much. These are depicted in [Table 1].
All the patients stayed 5-10 days longer than the time required to achieve the required length except for two of the patients who had pin tract infection and stayed about 25 days longer. None of the patients had the distracted or plated site infected and all wounds healed well. Seven of the patients had their procedure done at UMTH whereas the other three had it done at a private hospital (BOCATS), also in Maiduguri. There were no neurovascular complications in all the patients. 
| Discussion|| |
Limb-length discrepancy (LLD) of 2.5 cm or less can be tolerated by most patients, and a shoe raise will be able to correct the abnormal gait. It however becomes functionally problematic if the LLD is more than 2.5 cm. , A shoe raise will lead to an obvious cosmetic problem and gait remains abnormal whenever the patient takes off the raised shoe. Correction by bone transport (distraction osteogenesis) therefore becomes handy. , This will save these patients the problems associated with short lower limbs such as joint osteoarthritis in the contralateral limb and spinal scoliotic changes.
The Ilizarov frame remains the best for these procedures. The frame is however expensive and requires training and experience to use. We did not use this device in our study because we do not have the device and have limited experience in its use. The Orthofix, EBI, and the LRS systems are easier to use. Anatomy of the limbs involved should be sound to avoid damage to nerves and vessels. Our use of the LRS is because of its availability and ease of use. The time the patients carry the device can be shortened if lengthening is done over the intramedulary nail (lengthening over nails) and hospital stay shortened. 
Though we had only ten patients in this study, one can say that management of traumatic segmental bone loss is good using the "distraction osteogenesis" method.  This however requires patient's patience and understanding. We could not allow our patients to go home and do the distraction because most of them are far from the centers and were afraid to do the procedure themselves. There was also need to monitor them closely and treat things such as pin tract infection,  follow-up ranged from 2 to 4 years. We are already using this technique to treat limb shortening following malunions with bone overlap where osteoclasis and plating will not solve the problem with good results and hope to publish these very soon. 
| Conclusion|| |
The use of the H. S. Pitkar LRS can, when properly used, be used for the treatment of traumatic segmental bone loss. We advocate that all orthopedic surgeons avail themselves with its use. All tertiary hospitals should acquire the device and send its surgeons for training in its use. All tertiary Hospitals should acquire the device and send its surgeons for training in its use, especially in the third world like Nigeria. 
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Paley D, Maar DC. Ilizarov bone transport treatment for tibial defects. J Orthop Trauma 2000;14:76-85.
Paley D. Bone transport. The Ilizarov treatment of bone defects. Tech Orthop 1989;4:80-93.
De Coster TA, Gehlert RJ, Mikola RA, Pirela-Cruz MA. Management of posttraumatic bone defects. J Am Accad Orthop Surg 2004; 1:28-35.
Paley D, Tetsworth K. Percutaneous osteotomies. Osteotome and Gigli saw techniques. Orthop Clin North Am 1991;22:613-24.
Nogueira MP, Paley D, Bhave A, Herbert A, Nocente C, Herzenberg JE. Nerve lesions associated with limb-lengthening. J Bone Joint Surg Am 2003;85-A:1502-10.
Rozbruch SR, Herzenberg JE, Tetsworth K, Tuten HR, Paley D. Distraction osteogenesis after high tibial osteotomy. Clin Orthop 2002;394:227-33.
De Bastiani G, Aldegheri R, Renzi-Brivio L, Trivella G. Limb lengthening by callus distraction (callotasis). J Pediatr Orthop 1987;7:129-34.
Thonse R, Herzenberg JE, Standard SC, Paley D. Limb lengthening with a fully telescopic intramedulary rod. Oper Tech Orthop 2005;15:355-62.
Tetsworth K, Paley D. Basic science of distraction histogenesis. Curr Opin Orthop 1995;6:61-8.
O′Carrigan T, Paley D, Herzenberg JE. Obstacles in limb lengthening, fractures. In: Rozbruch SR, Ilizarov S, editors. Limb Lengthening and Reconstructive Surgery. Ch. 34. New York: Informa Healthcare; 2007. p. 485-94.
McCarthy JJ, MacEwen GD. Management of leg length inequality. J South Orthop Assoc 2001;10:73-85.
Yongu WT, Isa N. Bone gap management using linear rail system (LRS): Initial observation at a national orthopaedic hospital. Niger J Orthop Trauma 2009;8.
[Figure 1], [Figure 2]