Journal of Limb Lengthening & Reconstruction

REVIEW ARTICLE
Year
: 2021  |  Volume : 7  |  Issue : 2  |  Page : 88--97

Acquired long bone defect classifications of the diaphysis: A literature review


Artem V Komarov1, Anton A Semenistyy2, Gerard A Sheridan3, S Robert Rozbruch3, Leonid N Solomin4,  
1 Department of Military Traumatology and Orthopedics, S.M. Kirov Military Medical Academy, 13 Botkinskaya str., Moscow, Russian Federation
2 Department of Orthopaedic Trauma, Moscow City Clinical Hospital #13, 1/1 Velozavodskaya str., Moscow, Russian Federation
3 Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, New York, USA
4 Department of Traumatology and Orthopedics, Vreden National Medical Research Center of Traumatology and Orthopedics, 8 Akademik Baykov str.; Chair of Traumatology and Orthopedics, Saint Petersburg State Pediatric Medical University, 2 Litovskaya str., Moscow, Russian Federation

Correspondence Address:
Dr. Gerard A Sheridan
Hospital for Special Surgery, New York, NY
USA

Abstract

Introduction: The management of acquired long bone defects (LBDs) is a persistent problem in modern orthopedics with few effective solutions. The goal of this review is to conduct a thorough analysis of existing diaphyseal LBD classifications and to identify if any of these may be adopted for universal application in future. Materials and Methods: A literature review was performed analyzing articles between 1970 and 2019 on PubMed (English) and CyberLeninka (Russian) databases. All studies developing or utilizing a classification tool were eligible for inclusion. The search retrieved a total of 1032 articles from PubMed, 477 from CyberLennika, and 28 articles from reference lists. Any disagreement regarding the inclusion of articles was resolved by consensus between all authors. Results: A total of 18 classifications in the literature underwent analysis. Among the classifications we analyzed, 12 described posttraumatic defects, 6 described osteomyelitis defects or infected nonunions, and 5 described, among other defects, iatrogenic bone. Of the 18 classifications, 12 have a focus on a specific treatment method. We found that consensus exists between most authors regarding the criteria necessary to measure to determine the most appropriate treatment method. These key factors include the size and location of the bone defect. Conclusion: This analysis showed that despite the large number of publications devoted to the classification and treatment of LBD, there is still no consensus among authors regarding not only a universal clinical classification but also a general definition of the term “bone defect.” The classification proposed by Solomin et al. is very useful but in its present form, has significant drawbacks and requires further improvement before it can be adopted as a universal classification system for LBDs.



How to cite this article:
Komarov AV, Semenistyy AA, Sheridan GA, Rozbruch S R, Solomin LN. Acquired long bone defect classifications of the diaphysis: A literature review.J Limb Lengthen Reconstr 2021;7:88-97


How to cite this URL:
Komarov AV, Semenistyy AA, Sheridan GA, Rozbruch S R, Solomin LN. Acquired long bone defect classifications of the diaphysis: A literature review. J Limb Lengthen Reconstr [serial online] 2021 [cited 2022 Dec 1 ];7:88-97
Available from: https://www.jlimblengthrecon.org/text.asp?2021/7/2/88/334366


Full Text



 Introduction



The management of acquired long bone defects (LBD) is a persistent problem in modern orthopedics with few effective solutions. This pathology is relatively common and often results in chronic disability.[1],[2],[3] The most common etiologies of LBD are high-energy trauma, infection, aggressive open techniques of osteosynthesis, and neoplasms.[4],[5],[6],[7],[8]

There is no single optimal treatment algorithm for bone defects due to multiple etiologies, diverse locations, varying morphology, and a variable condition of the overlying soft tissue.[9] Classifications are utilized to facilitate clinical decision-making. The Muller AO Classification for fractures is a “gold standard” in orthopedics. Muller stated that “a classification is useful only if it considers the severity of the bone lesion and serves as a basis for treatment and evaluation of the results.”[10] These requirements should also be met when designing a classification of acquired LBDs. The goal of this review is to conduct a thorough analysis of existing diaphyseal LBD classifications and to identify if any of these may be adopted for universal application in future.

Terminology

Such a classification system should be based on generally accepted terminology that is universal among specialists in the field.[11],[12],[13] According to the Cambridge Dictionary, the word “defect” means “an imperfection, failure, or absence of something.”[14] “LBD” is a commonly used term in the orthopedic literature; however, there is no generally accepted definition of LBD to date. Gordon (1988) and Paley (1990) propose the following definition of bone defect: “A bone defect is a lack of bone where it should normally occur.”[15],[16] Ilizarov (1971) took into account a “hidden” bone defect due to shortening.[17] According to Ilizarov, a bone defect is bone loss coming from the summation of the anatomical segment shortening and diastasis. The most comprehensive definition was proposed by Barabash (1985): “Bone defect is bone loss as a result of trauma or disease that changes the anatomical structure, physiology, and limb function as an organ of the musculoskeletal system.”[18]

Many authors often use the term “bone loss” as a synonym for “bone defect.”[19],[20],[21] According to Wiese (2010), bone loss can be divided into microstructural bone loss (e.g., osteopenia and osteoporosis) and macrostructural bone loss (e.g. bone defect) which can be either primary (as a result of trauma, osteolytic tumor) or secondary (as a result of resection and nonunion).[1] Special attention should be paid to the frequently used term “nonunion with bone loss.” This term was first used by Catagni (1986) in his classification of pseudarthroses as a group of nonunions with no contact between bone fragments.[22]

The term “critical size bone defect” is often used in literature[22],[23],[24],[25],[26] [Table 1]. Currently, there are disagreements in the criteria and parameters of this term. To determine the size of “critical” defect, Court-Brown et al. use the absolute values. According to the authors, a 20-mm defect is “critical” for tibia.[27] Other investigators propose to use relative values for this purpose: “critical size bone defect is a segmental bone deficiency of a length exceeding 2–2.5 times the diameter of the affected bone.”[24],[28],[29] This approach allows us to unify the classification for different segments. Many factors make the size of defect “critical:” the actual bone loss, the integrity of bone circumference, anatomical localization (diaphyseal, metaphyseal, and articular), the condition of surrounding soft tissue, including periosteum, the patient's age, and comorbidities.[20],[25],[30] Some authors use the term “critical size defect” to justify the indications of various techniques of bone grafting.[23],[25],[26],[29] Others use this term to choose the most appropriate treatment strategy: one stage versus two stage.[20]{Table 1}

Shevtsov et al. use the term “true bone defect,” which means the actual lack of bone. The term “estimated bone defect” is used in cases where the planned surgery results in a bone defect greater than it was preoperatively, for example, the defect caused by bone resection in osteomyelitis.[31]

When discussing the etiology of LBD, it is also necessary to define the difference between congenital and acquired defects. Congenital defects are most often associated with complex skeletal and soft-tissue developmental abnormalities. In the literature, they are usually defined as “congenital limb deficiencies” instead of “congenital bone defects,” thus emphasizing the complex nature of the pathology. The treatment of congenital limb deficiencies requires a different approach, the use of special classifications, and advanced surgical techniques.[3] Therefore, this congenital pathology is beyond the scope of this review.

 Materials and Methods



This review was performed in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.[32]

Search strategy

A literature review was performed analyzing articles between 1970 and 2019 on PubMed (English) and CyberLeninka (Russian) databases [Figure 1].{Figure 1}

The following search terms were used across all databases: “bone defect, bony defects, nonunion, nonunions, bone defects and bone loss AND nonunion, diaphyseal, treatment, classification, fractures, technique, techniques.” The search retrieved a total of 1032 articles from PubMed and 477 from CyberLennika. Any disagreement regarding the inclusion of articles was resolved by consensus between all authors.

Eligibility criteria

All studies developing or utilizing a classification tool were eligible for inclusion. Only articles published in peer-reviewed journals were included. Articles on congenital limb deficiencies were excluded from this review due to the complexity and variation of the underlying pathology which often reduces the generalizability of these findings.

The main goals of treatment for the diaphyseal bone defect are to:

Restore the integrityRestore lengthRestore alignmentRestore rotation of the segment.

In periarticular defects, we often have the different goals:

To preserve or restore the joint anatomy and function through reconstructionTo replace the joint surface through arthroplastyTo relieve pain and restore stability of the extremity with joint arthrodesisIn some cases, amputation may be the best option to restore painless functionality.

In this review, we deal with diaphyseal LBDs only. Periarticular LBDs will be dealt with in subsequent work.

 Results



Classifications of diaphyseal bone defects

A total of 18 classifications in the literature underwent analysis [Table 2]. Winquist and Hansen presented one of the first classifications of diaphyseal bone defects in 1980.[33] The authors identified five types of femoral fractures with bone defects ranging from simple to complex. Robinson et al. proposed a separate classification for fracture defects.[34] This classification takes into account several criteria: the defect length, the presence/absence of contact between the fragments, and the contact area between the fragments. This classification reflected the volume of bone loss and acts as a guide for surgeons in choosing the treatment option.{Table 2}

The conducted review has shown that many authors have specific areas of interest, and therefore, most classifications are specific to differing treatment methods, etiology, or the relevant location of the defect. Of the 18 classifications, 12 have a focus on a specific treatment method.[1],[15],[16],[22],[34],[35],[36],[37],[38],[39],[40] We found that consensus exists between most authors regarding the criteria necessary to measure to determine the most appropriate treatment method. These key factors include the size and location of bone defect[20],[34],[36],[37],[41],[42],[43],[44] [Table 2]. Some authors developed classifications to determine the most appropriate method of segmental bone defect reconstruction,[35],[39] whereas others proposed classifications intended to select a specific method of distraction osteosynthesis by Ilizarov.[40],[42],[43] In the analyzed articles, authors described mainly the use of external fixation,[15],[16],[23],[36],[38],[39],[41] intramedullary osteosynthesis,[15],[22],[34],[35],[38],[39],[42] and classifications associated with the use of the Masquelet technique[35],[37],[39] for the treatment of bone defects.

Among the classifications we analyzed, 11[15],[16],[22],[23],[34],[35],[36],[37],[38],[39],[41] described posttraumatic defects, 6 described osteomyelitis defects or infected nonunions,[15],[23],[35],[39],[41] and 5 described, among other defects, iatrogenic bone defects[16],[23],[35],[39],[41] [Table 3]. Most classifications describe defects of the lower extremities.[15],[16],[23],[24],[34],[35],[36],[37],[38],[41],[42] The total number of segments described is 762, of which 436 were tibial, 128 femoral, and 198 were not verified. Upper extremity defects were represented in 49, with the humerus in 24, forearm in 16, and 9 that were not verified[36],[37],[38],[39] [Table 4].{Table 3}{Table 4}

The Wiese classification[1] includes a broader concept of “bone loss” with less of a clinical significance and more of a focus on the origin of the qualitative and quantitative loss of bone tissue. The Brizhan and Vovchenko classifications are unique because they are specific for gunshot injuries. These classifications are clinically relevant and take into account many criteria, including the condition of the soft tissue.[23],[41] Other classifications characterize only segmental defects.[36],[37] In some cases, authors use site-specific classifications, most often for the tibia[34],[42] and femur.[33]

Some authors use different approaches to determine the size of the defect. For example, Haines et al. proposed the use of a radiographic apparent bone gap (RABG) to determine a “critical bone defect” in open diaphyseal tibial fractures. To determine a RABG, the authors used standard AP and lateral views.[42] Other authors use computed tomography scans to measure the size of the defect. With the development of new techniques for bone graft harvesting, such as the “reamer-irrigator-aspirator” system (Synthes, Paoli, PA, USA), a new classification for bone grafting was introduced, where the main criterion is the volume of bone loss in cubic centimeters. The authors calculated the size of the diaphyseal defect intraoperatively by determining the volume of bone marrow aspirate in cubic centimeters.[39]

In 2016, Solomin et al. published the new classification of LBD, which meets the requirements for clinical classification postulated by Muller. This classification is organized similarly to AO fractures classification: “from simple to complex,” “from general to specific,” and number-letter coding is used for specification of bone defect localization, type, and severity.[45] This classification has good utility and may be adapted in future for the purposes of a universal LBD classification.

 Discussion



We believe it is inappropriate to use terminology that does not have great clinical significance and, at the same time, overlaps with other concepts, significantly complicating the analysis of the literature. Most authors propose classifications of posttraumatic bone defects, ignoring other etiologies.[35],[36],[37] Our analysis has shown that the size of the bone defect is one of the key factors determining management. Most authors use absolute values for determining the length of the diaphyseal defect.[15],[22],[34],[36],[37],[38],[39],[41],[42],[44] However, this method ignores the difference in defect diameter and so can lead to underestimation of the severity of some defects and overestimation of the severity of others. The use of relative values in assessing bone defects helps to avoid this problem.[23],[33],[35],[45] In our opinion, the most reasonable approach is to assess the diaphyseal bone defect relative to the diameter and length of the bone. In addition to the size of the defect, factors such as the presence or absence of contact between fragments, the percentage of the circumference of this contact area,[16],[22],[33],[34],[35],[36],[45] and the presence of limb deformity or shortening should all be taken into account.[16],[19],[23],[33],[34],[35],[36],[40],[45]

The AO-principles-based LBD classification proposed by Solomin[45] has significant limitations. According to this classification, the segmental defects C1 are classified based on the absolute values, namely the size of fragmentary diastasis. However, for C2 defects, the authors use a different descriptor – the shape of the bone fragments ends. Type C3.1 (subtotal defects of two-osseous segments) defects imply functional equality of both bones of two-osseous segments, which may be true for the forearm segment, but is controversial for the lower leg segment. Types A, B, and C are suitable for periarticular and diaphyseal defects. D is only suitable for complete articular defects, however. Despite these limitations, in our opinion, this classification has the most utility, and we believe that it should be adapted and used as the basis for the new LBD classification.

In addition to the bone defect itself, Vovchenko offers a multivariate assessment of a gunshot defect.[23] This allows objective assessment of the severity of limb damage, including the soft-tissue condition and it guides authors in making clinical decisions. However, this classification is very specific and cannot take into account all relevant factors in the treatment of LBD due to the complexity of this pathology. An attempt to create a comprehensive and universal classification, which assesses other factors in addition to the bone defect itself, would result in the creation of an overly complex system that cannot be pragmatically used in clinical practice. In our opinion, the most effective approach is to use a separate classification for soft-tissue considerations that are unrelated to bone.

Conducting this review, we could not identify one universal classification of diaphyseal LBD that is currently appropriate for future use. Most criteria used for making clinical decisions are experience based rather than evidence based. The studies that we have analyzed had a limited number of cases, had a level IV evidence [Table 2], and tended to use a variety of unrelated criteria. Therefore, this area is of special attention for future research and classification formation. The invention of a universal classification will make it possible to compare the management of defects of long bones and various surgical techniques together with the short-term and long-term results.

 Conclusion



This analysis showed that despite the large number of publications devoted to the classification and treatment of LBD, there is still no consensus among authors regarding not only a universal clinical classification but also a general definition of the term “bone defect.” The classification proposed by Solomin et al. is very useful but in its present form, has significant drawbacks and requires further improvement before it can be adopted as a universal classification system for LBDs.

Highlights

The terms “LBD,” “bone loss,” “nonunion with bone loss” and “critical size bone defect” should be used following their definitions, but not as synonymsThe lack of a universally accepted clinical classification of LBD creates difficulties in assessing the degree of bone damage, determining the optimal management approach, and predicting and evaluating clinical outcomesThe principles of AO classification for fractures are a promising basis for developing a classification of defects of long bones.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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