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ABOUT RRBTT

Rakesh Remote Bone Transport Technique

Autogenous Bone grafting without Incision

RRBTT – An Innovation

Rakesh Remote Bone Transportation Technique (RRBTT): is a technique recently developed by Dr Rakesh Tripathi MS, Mch (Ortho) in the month of Oct 2005 where synthetic bone was transported and 35cases were operated successfully.

this method was further re innovated as AUTOGENOUS BONE GRAFTING WITHOUT INCISION AND MANAGEMENT OF LARGE BONE GAP, in month of Nov 2009. this technique is not been done in the world of orthopaedic surgery till today

Dedicated To My Late Father
Dr.B.N. Tripathi
(M.B.B.S.-Lko.)

AUTOGENOUS BONEGRAFTIN WITHOUT INCISION
(Rakesh Remote Bone Transportation Technique)

RRBTT

  • Dr. Rakesh Tripathi M.S. (Ortho)
  • Director, Traumatologist & Spinal Surgeon-Upchar Hospital, Jhansi
  • Consultant & Head, Deptt. of Ortho , St. Jude Hospital Jhansi.
  • Ex-Consultant Medical College Jhansi
  • Ex-Consultant St.Stephens Hospital New Delhi
  • Ex-Member Implant Committee IOA
  • BEST PAPER AWARDEE- IOACOE KOLKATA 2007
  • NATIONAL (SUSHRUT) GOLD MEDAL AWARDEE – IOACON BANGLURU 2008

ABSTRACT

Recent era of minimal invasive surgery has revolutionised orthopaedic surgical out come.For the first time bone grafting segment is been explored and various advantages has made this technique fruitful called RRBTT(Rakesh Remote Bone Transportation Technique)

Newly innovated instruments has helped placement of bone at the fracture site without any incision.

Further innovation in innovation was achieved a year back and autogenous bone was harvested and transported to the fracture site without providing any incision nether at donor nor at recipient site. Initially this method is successfully used in fractures of long bones treated with interlock nails.

This technique of bone grafting has shown encouraging results in trauma like reduced healing time, avoiding infection and increased percentage of union.

Back Ground

Fast traffic has change fracture trauma pattern from simple to poly trauma. Desire of patients to get back to work in much shorter time has always compelled ortho surgeon to innovate new techniques.

Bone grafts has played its major role to help and to developed new bone formation.

Recent era of minimal of MIS has revolutionized healing of fracture pattern and has shown of better union and less morbidity in shorter period.

Name RRBTT (Rakes Remote Bone Transportation Technique) has been given for the name sake, convenience and to establish by name.

Introduction

Till now bone grafting segment is not been touched at all with MIS technique. New attempt of RRBTT has been developed to heal primary fracture repair as well as in patients presenting with wound around fracture site. It became essential not to open the fracture site either to put implant or to put bone grafts.Normally ortho surgeon has to wait till wound heal then he can plan for secondary bone grafting.

With new technique of RRBTT (MIS) technique new hope are developed where we can surpass bad lacerated wound with the hope of new bone formation in a shorter time.

At the start of this technique I transported artificial substitute (HYDROXYAPETITE & TRICACIUM PHOSPHATE) bone graft in the month of Dec 2005. These ortografts transported are ranging the size from 3 to 5mm and are in the form of palletts. This has shown encouraging results in terms of filling bone gaps, igniting osteogenesis etc.

Still a new thought came in my mind in Nov 2006 “why not to utilize cortical cencellous bone from the entry point of the fractured bone”. This provoked me to innovate newer bone scooping instruments and then transport it to the fracture site. This highly osteogenic potential tissue with STEM CELLS and its BMP showed fabulous and tremendous encouraging result.

These newly developed instrumentation are very cheap, simple and an average orthopaedic surgeon can perform it with ease.

Enough literature is been explored to view past history in which bone excavation and then transportation with precision and perfection without bisecting skin at the fracture site, but no literature shows any work to perform closed (Internal) bone grafting.

Material & Method

Material:-

  1. Boone Scoop with cover
  2. Bone starter
  3. Bone graft gauge
  4. RRBTT transportation tube:It has a provision of handle at the proximal end which helps to rotate and pull phenomenon. At the distal end of the tube radiographic marker helps it’s position under IITV.The internal diameter of the tube ranges from 6mm to 10mm.
  5. flexible bone pusher. (courtesy. Mamman, Pune)

Method:-

preparation of fractured bone with complete sterilization, draping are done in usual manner. Think always RRBTT before starting inter lock nailing.
A. For Fracture Tibia:-Mid patellar incision given, inferior patellar ligament dissected. Never start entry pioint with bone ALW. Place a pointed guide pin at the entry point superior to tibial tuberosity and view under IITV so exact central point is located. Now put cannulated bone scoop or cannulated bone cutter and start rotating so that scoop gradually deepens down.

Now take out the instrument by depressing hand and this scoop, then take cortico cancellous bone graft out. Place the bone graft in a bowl and repeat the procedure 2 to 3 times so a good amount of bone grafts are scooped out.Plan out the placement of bone graft either at proximal and of tube or at the distal end of the tube. Pass guide wire from the entry point and it should be pushed in such a manner that curved tip end of guide wire goes out of fracture site which can easily we confirmed under IITV.

Transportation Tube:-a transportation tube of desired diameter selected. Mount the transportation tube on guide wire and start sliding down. With this manure distal end of the tube essentially goes out of the marrow. Take the guide wire out holding the tube in position, then withdraw guide wire.

Place the bone graft at the proximal end of transportation tube it can be rotated so the bone graft is placed at the desired site, i.e. medial, lateral, anterior or posterior. To facilitate bone placement distal fragment should always be angulated. e.g. varus angulations will create opening at the lateral site and valgus tilt will create opening at medial site in a right sided fracture tibia/fibula.

Take the transportation tube out gradually in anticlock wise fashion. This completes internal autogenous bone grafting. Now usual interlocking can be done which need not to be elaborated.
B. For Facture Femur:-:- patient is positioned on fracture table and limb is positioned accordingly to start interlocking nail. Think always RRBTT bone graft before starting interlock. 2 to 3 inch incision given at tip of greater trochentar and gluteus musele splitted, place tip of guide pin either at piriformis fossae or at the tip of greater trochentar as per make and selection of interlocking nail. Cannulated sharp bone cutter is mounted over the guide pin and start rotating and piercing in to the upper end fenmur. Guide pin and bone starter removed back which contains good amount of cortico cancellous bone.

Proper size of bone graft measured via diameter gauge and then placed again in two different manner. i.e. either packing at the distal end or placing at proximal end and then pushing down with help of exact size flexible bone pusher. Normally we encounter displaced position of fracture fragment which make easy placement of autogenous graft i.e. subperiosteal region. Guide wire and transportation tube withdrawn and then usual interlock procedure can be performed.

C. Facture Inter Trochentar Femur :- place the fractured patient on fracture table before planning of PFN think always of RRBTT bone graft. Place a guide pin at the tip of greater trochentar mount sharp bone cutter and start rotating and deepening into the trochentar. Sharp bone starter is taken out and a good amount of bone graft achieved which then transportated through the transportation tube and placed at the medial fractured cortex.

Indication :-

  1. All simple #s can be grafted to reduced to healing time. (Primary bone grafting)
  2. grade I or Grade II compound (Gastillo type II & III).
  3. scarred tissue around the fracture site.
  4. skin disease at # site.
  5. delayed & nonunion of long bones.

Contra Indication:- as this technique of bone grafting has no flaws hence contra – indication is NONE.

Relative Contra–indication:- Relative Contra indication can be-

  1. Osteomylitis with pathological.
  2. Grade 3 and grade 4 open fracture.
  3. Fracture of EPIPHYSEAL plate.

Advantage :-

  1. RRBTT is the only method in which INTERAMEDULLARY BONE GRAFTS can be placed to enhance osteogenic activity.
  2. Cortico cancellous bone graft has been utilised for the first time from the same (Parental) fractured long bone which was crushed earlier.
  3. no incision required at the donor or recipient site, hence no donor site morbidity
  4. Internal transportation of bone graft through marrow is vascular friendly.
  5. Presence of STEM cells & BMP in cortico cancellous graft augments osteo induction & osteo synthesis.
  6. In segmental # two sites can be grafted without incising at two site.
  7. Not opening fracture site helps lesser or no chances of infection which could have been disastrous to the patient and to the orthopaedic surgeon as well.
  8. Cheap instrumentation hence cost effective to surgeon and no cost to patient
  9. Easy technique of transportation hence each & every othopaedic can do this
  10. During transportation through the tube there is no waste or spillage of precious bony tissue.
  11. 100% trasportation of live bone and exact placement of graft at the desired site makes this technique fool proof.
  12. Reduces chances of non-union considerably (80-90%)
  13. Reduces healing time (by 4-6 wks)
  14. Abolishes secondary bone grafting procedure hence saves lot of money and time.
  15. Artificial synthetic bone (4-5 mm pellets) can also be transported through the tubes.
  16. # of junction of middle 1/3 & lower 1/3, has less vascularity hence this procedure helps to achieved union in definitive manner.

Dis advantage :- The only disadvantage can be that small amount of autogenous bone graft can be placed at # site. while if we use synthetic bone pallets then any amount can be transported.

Discussion :-

  • Since Dec 2005 – 67 cases were grafted with synthetic bone
  • 87 cases of # Tibia/Fibula with autogenous RRBTT bone graft operated & shows mean healing period of 10 weeks duration.
  • 45 cases of # Femur shows mean healing period of 8-12 weeks. (Autogenous bone graft with RRBTT)(Hence healing period of # has greately reduced by 3-5 weeks)Infection was noticed only in 1 case

Review of Series # Tibia (ROCKWOOD AND GREEN’S)Volume II/Six Edition

Fracture Type Total Average Union
Time(weeks)
Bone Grafting Nonunions
(%)
Recommended Exchange
Nailing Time (Weeks)
Closed
C0 38 12.5 0 No Requirement
C1 61 16.5 0 3.1 10 to 12
C2 110 18.7 0 5.5 12 to 14
Open
GI 29 14.7 0 7.1 10 to 12
GII 30 23.5 0 7.4 12 to 16
GIIa 23 27.5 0 21.4 16 to 18

Table I-Series of # Tibia Review with closed Bone Grafting (RRBTT)

Fracture Type Total Average Union Time Bone Grafting Nonunions
(%)
Recommended Exchange
Nailing Time (Weeks)
Closed
C0 27 10 to 11 X
C1 10 10 to 12 0 X
C2 09 10 to 12 0 X
Open
GI 22 10 to 13 0 X
GII 10 10 to 13 0 X
GIIa 09 10 to 13 0 1
total 87

Treatment of ILN of shaft Femur

Fracture Type Total Nonunion (%) Infection (%) Average Union
Wolinksy et al 551 6 0 12.5
Wiss 112 2 1 16.2
Hammacher 129 5 3 14.7
Canadian Orthopaedic 107 8 ? 18.5
Ricci 134 6 ? 18.7

Table II – ILN of # Femur with closed Bone Grafting (RRBTT)

Fracture Type Total Nonunion (%) Infection (%) Average Union Time Infection n(%)
Simple 22 6 X 8 to 10 N
Grade I 10 2 X 9 to 11 O
Delayed 09 5 X 11 to 13 N
Nonunion 04 8 X 11 to 13 E

Conclusion:-To conclude, age old method of making entry point by crushing with the help of AWL has been diverted towards scooping & preserving cancellous bone from the parental fractured bone.

In the era of high velocity trauma more and more compound – communitted fractures coming with bad skin coverage and contamination which enables us open the fracture site. Hence RRBTT has shown wide vision and opened a new window which can show us encouraging results of Osteoconduction and Osteogenesis. Reduced chance of infection and increased chances of union is a boon to orthopeadic world. With RRBTT and its advantages future will show more developed technique of close internal method of bone grafting.

I am thankful to my senior colleagues who helped me in various aspects to innovate and develop this technique.

  1. Dr. BALU SANKARAN – MS, FRCS Padma Vibhushan Ex. DGHS Govt. of India
  2. Dr. H.K.T. RAZA – Jabalpur
  3. Dr. N.S. LAUD – Mumbai
  4. Dr. D.D. TANNA – Mumbai
  5. Dr. ANURAG PURWAR – Mahoba
  6. Dr. A.S. PRASAD – Kanpur
  7. Dr. SABBARWAL – Agra
  8. Dr. N.R. RATHOD – MUMBAI
  9. Mr. GOKHALE – CEO Manman Pune
  10. Dr. Anupam Singh

References (Bibliography) :-Since this technique is not been discussed or seen any where in the literature of orthopaedic surgery, references could not be collected.

Reference for other bone grafting procedures are reviewed :-

  1. Hydroxy apetite as a bone graft substitute: Use in cortical and cancellous bone, Sanjay agrawal & Abhijit Bhagwat. IJO, Oct 2005 volume 39 No.4, p.254-256
  2. Vaccaro Ar, The role of the osteocondictive scaffoid in synthetic bone graft, orthopaedics, 2002 supplement.
  3. Johnson KID, Frierson KE Keller TS, Cook C, Scheinber R., Zerwekh J, Meyers L, Sciadini MF, Porous ceramics as bone graft substitutes in long bone defects: a bioimecchanical histological, and radiographic analysis. J othop Res. 1996: 14:351-69
  4. Parikh SN Bone graft substitute: past, present, future. J postgrad Med. 2002:48:142-8.
  5. Bucholz RW, Carloth.4., Holmes R. Interporous hydroxyapatite as a bone graft substitute in metaphyseal defects. A histometricstudy. J bone Joint Surg (Am). 1986;68: 904-911.
  6. Uhthoff HK, Rahn BA, Healing patterns of meetaphyseal fractures. Clin Orthop Relat Res 1981; 160:295-303.
  7. Srevenson S. Biology of bone grafts. Orthop Clin North Am 1999;39:543-552.
  8. Younger EM, Chapman MW. Morbidity at bone graft donor sites. J Orthop Trauma 1989;3:192-195.
  9. Banwart JC, Asher MA, Hassanein RS. Iliac crest bone graft harvest donor site morbidity: a statistical evaluatuin. Spine 1995;20:1055-1060.
  10. .Goulet JA, Senunas LE, DeSilva GL, et al. Autogenous iliac crest bone graft: Complication and function assessment. Clin Orthop Realt Res 1997;339:76-81.
  11. Enneking WF, Eady JL, Burchardt, H. Autogenous cortical bone grafts I the reconstruction of segmental skeletal defects J Bone Joint Surg Am 1980;62A:1039-1058.
  12. .Finkemeier CG. Bone grafting and bone graft substitute. J Bone Joint Surg Am 2002;84A:454-464.
  13. Gazdag AR, Lane JM, Glaser D, et al. Alternatives to autogenous bone graft: efficacy and indication. J Am Acad Orthop Surg 1995;3:1-8.
  14. Beresford JN. Osteogenic stem cells and the stromal system of bone and marrow. Clin Orthop Relat Res 189;240:270-280.
  15. Connolly JF, Guse R, Tiedemen J, et al. autogenous marrow injection as a substitute for operative grafting of tibial nonunions. Clin Orthop Relat Res 1991;266:259-270.
  16. Connolly JF, Shindell R Percutaneous marrow injection for ununited tibia. Nebrmed J 1986;71:105-107.
  17. Garg NJ, Gaur S, Sharma S. Percutaneous autogenous bone marrow grafting in 20 cases of ununited fracture. Acta Orthop Scand 1993;64:671-672.
  18. Beza RR Limitation of autograft and allograft: new synthetic solutions. Orthopeadics 2002;25(5 Suuple):561-570.
  19. Burchardt H. Biology of bone transportation. Orthop Clin North Am 1987;18:187-196.
  20. Hydroxy apetite as a bone graft substitute: Use in cortical and cancellous bone, Sanjay agrawal & Abhijit Bhagwat. IJO, Oct 2005 volume 39 No.4, p.254-256
  21. Thompson RC Jr, Pickvance EA, Garry D. Fractures in large-segment allografts. J Bone Joint Surg Am 1993;75A:1663-1773. Chapman MW, Bucholz R, cornell C. Treatment of acute fractures with a collagen calcium phosphate graft material. J Bone Joint Surg Am1997;79:495-502.
  22. Borrelli J Jr, Prickett WD, Ricci WM. Treatment of nonunions and asseous defects with bone graft and calcium sulfate. Clin Orthop Relat Res 2003;411:245-254.
  23. Schildhauer TA, Bauer TW, Josten C et al. Open reduction and augmentation of internal fixation with an injectable skeletal cement for the treatmen of complex calcaneal frartures. J Orthop Trauma 2000;14:309-317.
  24. Johnaon EE, Urist MR, Finerman GA. Repair of segmental defects of the tibia with cancellous bone grafts augmented with human bone morphogenetic protein. A preliminary report. Clin Orthop Relat Res 1988;236:249-257.
  25. Lewallen DG, chao EY, Kasman RA, et al. Comparison of the effects of compression plates and external fixators on early bone – healing. J Bone Joint Surg Am 1984;66:1084-1091.