# Comparison of Iliac Bone Transplantation with Bone Transport in the Treatment of Femur Fracture and Bone Defect

Authors: Wei Huang; Wenfeng Zhu; Wei Lu
Journal: Evidence-Based Complementary and Alternative Medicine
 (2022)

---

## Abstract

Objective. To compare the curative effect of iliac bone transplantation with the bone transport in the treatment of femur fracture complicated with a bone defect. Methods. Patients with femur fractures and defects who were admitted to our hospital from January 1, 2020, to January 31, 2022, and met the inclusion criteria were retrospectively selected and allocated into an iliac bone transplantation group or a bone transport group. The treatment effect and quality of life of the two groups were compared. Results. A total of 98 patients who met the inclusion standards were enrolled, including 50 cases in the iliac bone transplantation group and 48 cases in the bone transport group. There were no significant differences in IL-6, IL-8, TNF-α, visual analog scale (VAS) score, or Japanese Orthopedic Association (JOA) score between the two groups on postsurgical day 1 (p=0.051, 0.150, 0.102, 0.564, and 0.826 respectively), but there were significant differences in the above index on postsurgical day 7 (all p<0.01). There were no significant differences in social function, physical function, role function, and cognitive function between the two groups one week after the operation (p=0.245, 0.051, 0.102, and 0.067, respectively), but there were significant differences in the above parameters at one month after operation (p=0.001, 0.005, 0.005, and 0.001, respectively). The total effective rate of the bone transplantation group was significantly better than that of the iliac bone transplantation group (p=0.026). The number of postoperative complications in the bone removal group was significantly fewer than that of the iliac bone graft group (p=0.001). Conclusion. Bone transport is effective in treating femur fractures complicated with bone defects, with fewer postoperative complications.


---

## Body

## 1. Introduction

A femur fracture is a relatively common disease, mainly caused by traffic accidents and falls from height, often accompanied by bone defects. The treatment methods for such patients are complicated; the results are not ideal; and the incidence of disability is high. During surgery, large pieces of sequestrum need to be removed, and local bone defects will also occur during the removal, which has a certain impact on the postoperative recovery of patients [1]. At present, for such patients, autologous iliac bone transplantation is mostly used. Although this method has a certain osteogenic effect, the operation is complicated and the complication rate is high. Bone transplantation is based on the principle of “tension-stress law.” Extracorporeal puncture technology has been used to fix steel nails on the bone at the fracture site and gradually elongate the bone through the force of osteotomy. Both the extension and the compression zone allow callus formation until the bone defect heals [2, 3]. Here, we showed the efficacy of autologous iliac bone transplantation vs. bone transport in the treatment of femur fractures and bone defects.


## 2. Materials and Methods

### 2.1. Methods

Patients with femur fractures and defects who were admitted to our hospital from January 1, 2020, to January 31, 2022, who met the inclusion criteria were retrospectively selected. All patients in this study gave informed consent, and the patients themselves or their representatives signed the relevant consent forms. The inclusion criteria were as follows: femur fracture with the bone defect; surgical treatment required; and no relevant treatment was performed prior to inclusion in the study. The exclusion criteria were as follows: accompanied by malignant diseases, severe infection, organ failure, malignancy, mental illness, or drug allergy. The study protocol was approved by the institutional ethical committee of our hospital.Patients in the iliac bone transplantation group received autologous iliac bone transplantation, whereas patients in the bone transport group received surgical bone transport [4]. Patients in both groups were treated with broad-spectrum antibiotics within 2 days of surgery to prevent swelling of the limbs. One week after the operation, the observation group continued to stretch for 5 days on the 8th day, and X-ray examinations were taken to observe the changes in osteotomy distraction. After 5 days of traction, the traction was carried out at a speed of 0.75 mm/day starting from 4 days. An X-ray examination was performed 4 weeks after the operation in the treatment group.


### 2.2. Evaluation of Efficacy

Visual analog scale (VAS) pain scale [5]: 0 is the best, no pain; 1–3 points or less mild pain, tolerable; 4–6 points or the pain is more severe, slightly affecting sleep; and 7–10 points or unbearable severe pain, inability to sleep seriously affects the normal life. The Japanese Orthopedic Association (JOA) score was used to evaluate the treatment efficacy, including subjective symptoms, clinical signs, and daily activities limitation. The total score is 0 to 29 points, and the higher the score, the better the function. The quality of life score (out of 100) was used, including social function, role function, cognitive function, and physical function [6]. The higher the score, the better the quality of life.


### 2.3. Statistical Methods

The data in this experiment need to be verified by SPSS21.0 software (SPSS, Chicago, IL, USA), in which the count data (n, %) were analyzed by χ2 test, and the continuous data (mean ± SD) were analyzed by t-test. p<0.05 (2-tailed) was set as the threshold of statistical significance.


## 2.1. Methods

Patients with femur fractures and defects who were admitted to our hospital from January 1, 2020, to January 31, 2022, who met the inclusion criteria were retrospectively selected. All patients in this study gave informed consent, and the patients themselves or their representatives signed the relevant consent forms. The inclusion criteria were as follows: femur fracture with the bone defect; surgical treatment required; and no relevant treatment was performed prior to inclusion in the study. The exclusion criteria were as follows: accompanied by malignant diseases, severe infection, organ failure, malignancy, mental illness, or drug allergy. The study protocol was approved by the institutional ethical committee of our hospital.Patients in the iliac bone transplantation group received autologous iliac bone transplantation, whereas patients in the bone transport group received surgical bone transport [4]. Patients in both groups were treated with broad-spectrum antibiotics within 2 days of surgery to prevent swelling of the limbs. One week after the operation, the observation group continued to stretch for 5 days on the 8th day, and X-ray examinations were taken to observe the changes in osteotomy distraction. After 5 days of traction, the traction was carried out at a speed of 0.75 mm/day starting from 4 days. An X-ray examination was performed 4 weeks after the operation in the treatment group.


## 2.2. Evaluation of Efficacy

Visual analog scale (VAS) pain scale [5]: 0 is the best, no pain; 1–3 points or less mild pain, tolerable; 4–6 points or the pain is more severe, slightly affecting sleep; and 7–10 points or unbearable severe pain, inability to sleep seriously affects the normal life. The Japanese Orthopedic Association (JOA) score was used to evaluate the treatment efficacy, including subjective symptoms, clinical signs, and daily activities limitation. The total score is 0 to 29 points, and the higher the score, the better the function. The quality of life score (out of 100) was used, including social function, role function, cognitive function, and physical function [6]. The higher the score, the better the quality of life.


## 2.3. Statistical Methods

The data in this experiment need to be verified by SPSS21.0 software (SPSS, Chicago, IL, USA), in which the count data (n, %) were analyzed by χ2 test, and the continuous data (mean ± SD) were analyzed by t-test. p<0.05 (2-tailed) was set as the threshold of statistical significance.


## 3. Results

A total of 98 patients who met the inclusion standards were enrolled. All patients in this study gave informed consent, and the patients themselves or their representatives signed the relevant consent forms. The baseline data of the included subjects are detailed below (Table1).Table 1
General information of patients.
CharacteristicsIliac bone graft groupBone transport groupt/χ2valuepvalueNumber of cases5048Age36.43 ± 5.4335.28 ± 6.811.8120.074Gender0.3970.529Male2628Female2420Nationality2.1240.000Han nationality4843Other25Whether they have other bone diseases in the past0.2010.654Yes00No4545Bone defect site0.5441.421Femur condyle3127Mid femur1921Smoking0.5210.000Never3433Have1615Alcohol drinking0.1420.003Never2123Have2925Hypertension/diabetes/cerebrovascular disease1.2440.012None2026Have3022


### 3.1. Comparison of Inflammatory Factors

On the 1st day after surgery, there was no significant difference in IL-6, IL-8, and TNF-α between the study group ((45.85 ± 3.64) (74.41 ± 5.37) and (67.23 ± 6.21)) and the control group ((46.63 ± 2.82), (75.45 ± 5.18) and (67.52 ± 6.31)) (t = 2.315, 2.175, 2.452, p=0.051, 0.150, 0.102). Seven days after surgery, there were significant differences in IL-6, IL-8, and TNF-α between the study group ((22.83 ± 1.35), IL-8 (45.53 ± 3.82) and (42.37 ± 5.36)) and the control group ((28.58 ± 3.26), IL-8 (54.32 ± 4.27) and (55.85 ± 6.24)) (t = 11.001, 11.014, 10.310, p=0.001, 0.001, 0.000). See Table 2 for details.Table 2
Comparison of inflammatory factors (x¯±s).
GroupCaseIL-6 (μg/L)IL-8 (pg/L)TNF-α (ng/L)Day 1 after surgeryDay 7 after surgeryDay 1 after surgeryDay 7 after surgeryDay 1 after surgeryDay 7 after surgeryIliac bone graft group5046.63 ± 2.8228.58 ± 3.2675.45 ± 5.1854.32 ± 4.2767.52 ± 6.3155.85 ± 6.24Bone transport group4845.85 ± 3.6422.83 ± 1.3574.41 ± 5.3745.53 ± 3.8267.23 ± 6.2142.37 ± 5.36T2.31511.0012.17511.0142.45210.310p0.0510.0010.1500.0010.1020.000


### 3.2. Comparison of VAS Score and JOA Score between the Two Groups before and after Surgery

There was no significant difference in the VAS score (7.58 ± 2.13) and JOA score (12.57 ± 0.38) of the study group compared with the control group (7.47 ± 2.25) (12.26 ± 0.50), before surgery (t = 1.673, 1.538, p=0.564, 0.826). After surgery, the VAS score (4.41 ± 0.56) and JOA score (19.50 ± 0.51) of the study group were significantly different from those of the control group (4.36 ± 0.89) (19.41 ± 0.69) (t = 12.274, 8.379, p=0.005, 0.000). See Table 3 for details.Table 3
Comparison of VAS scores and JOA scores between the two groups (x¯±s).
GroupVAS scoreJOA scoreBefore surgeryAfter surgeryBefore surgeryAfter surgeryBone transport group (n = 48)7.58 ± 2.133.10 ± 0.1812.57 ± 0.3823.42 ± 0.36Iliac bone graft group (n = 50)7.47 ± 2.254.41 ± 0.5612.26 ± 0.5019.50 ± 0.51T1.67312.2741.5388.379p0.5640.0050.8260.000


### 3.3. Comparison of Quality of Life

One week after operation, there was no significant difference in social function, physical function, role function, and cognitive function between the study group ((63.80 ± 3.62), (64.23 ± 5.51), (67.00 ± 6.02), and (62.97 ± 4.28)) and the control group ((65.61 ± 2.80), (64.35 ± 5.08), (66.53 ± 6.25), and (64.33 ± 3.14)) (t = 2.019, 1.631, 1.461, 2.130, p=0.245, 0.051, 0.102, and 0.067, respectively). One month after operation, there were significant differences in social function, physical function, role function, and cognitive function between the study group ((82.84 ± 1.15), (84.50 ± 3.80), (83.30 ± 5.38), and (80.61 ± 4.85)) and the control group ((79.13 ± 3.20), (75.44 ± 4.26), (76.82 ± 6.34), and (74.35 ± 3.52)) (t = 15.943, 12.005, 13.325, 10.142, p=0.001, 0.005, 0.005, and 0.001, respectively). See Table 4 for details.Table 4
Comparison of quality of life between the two groups of patients (x¯±s).
GroupSocial functionPhysical functionRole functionCognitive function1 week after surgery1 month after surgery1 week after surgery1 month after surgery1 week after surgery1 month after surgery1 week after surgery1 month after surgeryIliac bone graft group65.61 ± 2.8079.13 ± 3.2064.35 ± 5.0875.44 ± 4.2666.53 ± 6.2576.82 ± 6.3464.33 ± 3.1474.35 ± 3.52Bone transport group63.80 ± 3.6282.84 ± 1.1564.23 ± 5.5184.50 ± 3.8067.00 ± 6.0283.30 ± 5.3862.97 ± 4.2880.61 ± 4.85T2.01915.9431.63112.0551.46113.3252.13010.142p0.2450.0010.0510.0050.1020.0050.0670.001


### 3.4. Comparison of Treatment Effects

The total effective rate of the bone transplantation group was 93.75% (45/48), which was significantly better than that of the iliac bone transplantation group 78.00% (39/50,χ2 = 4.961, p=0.026, Table 5).Table 5
Comparison of clinical efficacy between the two groups of patients (cases (%)).
GroupEffective rateIneffective rateIliac bone graft group (n = 50)39 (78.00)11 (22.00)Bone transport group (n = 48)45 (93.75)3 (6.25)χ24.961p0.026


### 3.5. Comparison of Postoperative Complications

Postoperative complications occurred in patients in the bone removal group: delayed fracture union (3 cases), osteoarthritis (6 cases), infection (3 cases), pulmonary embolism (1 case), and the total incidence of complications was 27.08%. Compared with the iliac bone graft group: delayed fracture union (5 cases), osteoarthritis (7 cases), infection (6 cases), pulmonary embolism (3 cases), and the total incidence of complications was 42.00%, there was a significant difference between the two groups (χ2 = 2.405, p=0.121). See Table 6.Table 6
Comparison of postoperative complications between the two groups (cases, %).
GroupDelayed fracture unionOsteoarthritisInfectionPulmonary embolismThe total incidence of complicationsIliac bone graft group (n = 50)5 (10.00)7 (14.00)6 (12.00)3 (6.00)21 (42.00)Bone transport group (n = 48)3 (6.25)6 (12.50)3 (6.25)1 (2.08)13 (27.08)χ2—2.626p—0.105


## 3.1. Comparison of Inflammatory Factors

On the 1st day after surgery, there was no significant difference in IL-6, IL-8, and TNF-α between the study group ((45.85 ± 3.64) (74.41 ± 5.37) and (67.23 ± 6.21)) and the control group ((46.63 ± 2.82), (75.45 ± 5.18) and (67.52 ± 6.31)) (t = 2.315, 2.175, 2.452, p=0.051, 0.150, 0.102). Seven days after surgery, there were significant differences in IL-6, IL-8, and TNF-α between the study group ((22.83 ± 1.35), IL-8 (45.53 ± 3.82) and (42.37 ± 5.36)) and the control group ((28.58 ± 3.26), IL-8 (54.32 ± 4.27) and (55.85 ± 6.24)) (t = 11.001, 11.014, 10.310, p=0.001, 0.001, 0.000). See Table 2 for details.Table 2
Comparison of inflammatory factors (x¯±s).
GroupCaseIL-6 (μg/L)IL-8 (pg/L)TNF-α (ng/L)Day 1 after surgeryDay 7 after surgeryDay 1 after surgeryDay 7 after surgeryDay 1 after surgeryDay 7 after surgeryIliac bone graft group5046.63 ± 2.8228.58 ± 3.2675.45 ± 5.1854.32 ± 4.2767.52 ± 6.3155.85 ± 6.24Bone transport group4845.85 ± 3.6422.83 ± 1.3574.41 ± 5.3745.53 ± 3.8267.23 ± 6.2142.37 ± 5.36T2.31511.0012.17511.0142.45210.310p0.0510.0010.1500.0010.1020.000


## 3.2. Comparison of VAS Score and JOA Score between the Two Groups before and after Surgery

There was no significant difference in the VAS score (7.58 ± 2.13) and JOA score (12.57 ± 0.38) of the study group compared with the control group (7.47 ± 2.25) (12.26 ± 0.50), before surgery (t = 1.673, 1.538, p=0.564, 0.826). After surgery, the VAS score (4.41 ± 0.56) and JOA score (19.50 ± 0.51) of the study group were significantly different from those of the control group (4.36 ± 0.89) (19.41 ± 0.69) (t = 12.274, 8.379, p=0.005, 0.000). See Table 3 for details.Table 3
Comparison of VAS scores and JOA scores between the two groups (x¯±s).
GroupVAS scoreJOA scoreBefore surgeryAfter surgeryBefore surgeryAfter surgeryBone transport group (n = 48)7.58 ± 2.133.10 ± 0.1812.57 ± 0.3823.42 ± 0.36Iliac bone graft group (n = 50)7.47 ± 2.254.41 ± 0.5612.26 ± 0.5019.50 ± 0.51T1.67312.2741.5388.379p0.5640.0050.8260.000


## 3.3. Comparison of Quality of Life

One week after operation, there was no significant difference in social function, physical function, role function, and cognitive function between the study group ((63.80 ± 3.62), (64.23 ± 5.51), (67.00 ± 6.02), and (62.97 ± 4.28)) and the control group ((65.61 ± 2.80), (64.35 ± 5.08), (66.53 ± 6.25), and (64.33 ± 3.14)) (t = 2.019, 1.631, 1.461, 2.130, p=0.245, 0.051, 0.102, and 0.067, respectively). One month after operation, there were significant differences in social function, physical function, role function, and cognitive function between the study group ((82.84 ± 1.15), (84.50 ± 3.80), (83.30 ± 5.38), and (80.61 ± 4.85)) and the control group ((79.13 ± 3.20), (75.44 ± 4.26), (76.82 ± 6.34), and (74.35 ± 3.52)) (t = 15.943, 12.005, 13.325, 10.142, p=0.001, 0.005, 0.005, and 0.001, respectively). See Table 4 for details.Table 4
Comparison of quality of life between the two groups of patients (x¯±s).
GroupSocial functionPhysical functionRole functionCognitive function1 week after surgery1 month after surgery1 week after surgery1 month after surgery1 week after surgery1 month after surgery1 week after surgery1 month after surgeryIliac bone graft group65.61 ± 2.8079.13 ± 3.2064.35 ± 5.0875.44 ± 4.2666.53 ± 6.2576.82 ± 6.3464.33 ± 3.1474.35 ± 3.52Bone transport group63.80 ± 3.6282.84 ± 1.1564.23 ± 5.5184.50 ± 3.8067.00 ± 6.0283.30 ± 5.3862.97 ± 4.2880.61 ± 4.85T2.01915.9431.63112.0551.46113.3252.13010.142p0.2450.0010.0510.0050.1020.0050.0670.001


## 3.4. Comparison of Treatment Effects

The total effective rate of the bone transplantation group was 93.75% (45/48), which was significantly better than that of the iliac bone transplantation group 78.00% (39/50,χ2 = 4.961, p=0.026, Table 5).Table 5
Comparison of clinical efficacy between the two groups of patients (cases (%)).
GroupEffective rateIneffective rateIliac bone graft group (n = 50)39 (78.00)11 (22.00)Bone transport group (n = 48)45 (93.75)3 (6.25)χ24.961p0.026


## 3.5. Comparison of Postoperative Complications

Postoperative complications occurred in patients in the bone removal group: delayed fracture union (3 cases), osteoarthritis (6 cases), infection (3 cases), pulmonary embolism (1 case), and the total incidence of complications was 27.08%. Compared with the iliac bone graft group: delayed fracture union (5 cases), osteoarthritis (7 cases), infection (6 cases), pulmonary embolism (3 cases), and the total incidence of complications was 42.00%, there was a significant difference between the two groups (χ2 = 2.405, p=0.121). See Table 6.Table 6
Comparison of postoperative complications between the two groups (cases, %).
GroupDelayed fracture unionOsteoarthritisInfectionPulmonary embolismThe total incidence of complicationsIliac bone graft group (n = 50)5 (10.00)7 (14.00)6 (12.00)3 (6.00)21 (42.00)Bone transport group (n = 48)3 (6.25)6 (12.50)3 (6.25)1 (2.08)13 (27.08)χ2—2.626p—0.105


## 4. Discussion

Evidence published over the past few decades has led to some consensus on the surgical management of femur fractures. However, in daily clinical practice, the exact choice of the implant is still unclear to the individual surgeon, necessitating the use of an easy-to-use, evidence-based surgical approach that covers all types of femur fractures. Many articles recommend treatment of some aspect of surgery, but only a few authors have published a more or less explicit decision tree algorithm for surgical management of proximal femur fractures [5, 7, 8]. In some Western European countries, national guidelines for many aspects of hip fracture management have evolved over the past decade, including recommendations for surgical options for implants.In car accidents, femur fracture combined with the bone defect is most common, and in accidents such as falls from height and heavy object crushing, due to the high risk of femur fracture combined with bone defect, the treatment is complicated, the prognosis is poor, and the disability rate is high. Bone displacement is based on bone extension, and 1 mm of bone movement is evidenced every day so that the soft tissue is in a state of tension. Vascular endothelial cells will gradually move to polymorphic mesenchymal cells and to some extent evolve into osteoblasts [9–12].With the elongation of bone, the callus site changes to a certain extent, and the central fibroblasts gradually differentiate into a parallel structure similar to the bone. Femur fractures and bone defects can be effectively treated by shaping the trabecular plate [13]. Bone grafting can completely eliminate sequestrum and has a traction effect on osteogenesis without artificial bone grafting. Autologous iliac bone transplantation technology builds a three-dimensional structure in the human body through bone tissue, induces bone conduction through osteogenesis, and realizes the fusion of bone junctions. Because the iliac bone contains a large amount of cancellous bone and medullary cavity and because the site where it is located is easy to cut, a good bone connection is formed after transplantation [14, 15]. However, different from the traditional artificial pelvis transplantation, after the autologous iliac bone flap transplantation, the soft tissues such as skin flaps and tendons in the donor and recipient areas must be removed, leading to many incisions, complicated procedures, and long operation times. The amount of bleeding during surgery increases, the incidence of postoperative trauma increases, and the probability of postoperative complications also increase. In the surgical treatment of femur fracture and bone defect, if the wound is large and there are multiple wounds, the blood flow at the fracture will be aggravated, and the surrounding soft tissue will be damaged, easily leading to postoperative infection, and the surrounding tissue will be necrotic or fractured. Healing in this situation is slow or complete recovery is not possible [16, 17]. Because of its simple operation, small trauma, and faster bone repair, bone transplant surgery is used in clinical practice. In this study, the surgical effect of the patients in the bone transport group was better than that in the iliac bone transplantation group, and the recovery indices were also faster than those in the iliac bone transplantation group. The applications of bone transport in other conditions are infections, wound healing problems, or neurological disorders [18–23].In conclusion, bone transport is effective in the treatment of femur fracture and bone defects, and the incidence of postoperative complications is low.



---

*Source: 5358923-2022-10-03.xml*