Zeta-focal bone lengthening for bone defects after fracture-related infection: a two-case based research_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

Aihemaitijiang·Yusufu ^1,2 , Yiliyaer·Wumaierjiang ¹ , Xiayimaierdan·Maimaiti ^1,2 , Maimaiaili·Yushan ^2,3 , Abulaiti·Abula ¹ ,  XU Yongqing ⁴

1. Department of Microsurgery and Repair, First Affiliated Hospital of Xinjiang Medical University, Urumqi Xinjiang, 830054, P. R. China;
2. Xinjiang Key Laboratory of Trauma Reconstruction, Urumqi Xinjiang, 830054, P. R. China;
3. Department of Orthopedic Surgery, the Fourth Affiliated Hospital of Xinjiang Medical University (Traditional Chinese Medicine Hospital of Xinjiang Uyghur Autonomous Region), Urumqi Xinjiang, 841700, P. R. China;
4. Department of Orthopedic Surgery, 920th Hospital of Joint Logistic Support Force of Chinese PLA, Kunming Yunnan, 650118, P. R. China;

Corresponding?author：

XU Yongqing, Email: xuyongqingkm@sina.cn

Keywords：

Fracture-related infection; bone defect; Zeta-focal bone lengthening; distraction osteogenesis; external fixation index

DOI：

10.7507/1002-1892.202512082

Video：

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Objective To summarize the clinical experiences of using Zeta-focal bone lengthening to treat bone defects caused by fracture-related infection (FRI) in two cases, and to preliminarily explore its feasibility and efficacy. Methods In 2023, two male patients with bone defects caused by FRI were treated, aged 19 and 40 years, respectively. After admission, stage Ⅰ treatment consisted of thorough debridement and infection control based on bacterial culture and drug susceptibility test results. The lengths of bone defects were 6 cm and 22 cm, respectively. When the erythrocyte sedimentation rate and inflammatory markers returned to normal ranges, stage Ⅱ treatment (debridement and reconstruction with Zeta-focal bone lengthening) was performed. Distraction was initiated at 7 days after the second-stage operation. Docking of the bone segments was achieved at 11 and 40 days of distraction, respectively, and obvious mineralization in the distraction zones was observed at 65 and 104 days postoperatively. The external fixator was removed after radiographic evidence of cortical continuity at four sites was confirmed on anteroposterior and lateral X-ray films. The external fixation time was 112 and 357 days, respectively, and the external fixation indexes were 18.5 and 17.9 days/cm, respectively. Complications during the distraction period were observed. During follow-up, bone healing and functional recovery were evaluated with the Paley D score, the Association for the Study and Application of the Method of Ilizarov (ASAMI) score, the Lower Extremity Functional Scale (LEFS), and the American Orthopaedic Foot & Ankle Society (AOFAS) score. Results Both patients completed the two-stage treatment. Their hospital stays were 21 and 16 days, respectively. Only mild pin-tract reactions occurred during the distraction period. Both patients were followed up for 18 months. At last follow-up, 2 patients achieved excellent functional results according to the ASAMI score, and bone healing was rated as excellent by the Paley D score. In 1 patient, the LEFS score was 76 and the AOFAS score was 95. The other patient was not scored because of knee arthrodesis. Conclusion Under the prerequisites of strict infection control and individualized segmental design, Zeta-focal bone lengthening can achieve effective reconstruction of infectious bone defects and significantly reduce the external fixation time and the external fixation index.

Citation： Aihemaitijiang·Yusufu, Yiliyaer·Wumaierjiang, Xiayimaierdan·Maimaiti, Maimaiaili·Yushan, Abulaiti·Abula, XU Yongqing. Zeta-focal bone lengthening for bone defects after fracture-related infection: a two-case based research. Chinese Journal of Reparative and Reconstructive Surgery, 2026, 40(4): 604-609. doi: 10.7507/1002-1892.202512082 Copy

1.	Moriarty TF, Metsemakers WJ, Morgenstern M, et al. Fracture-related infection. Nat Rev Dis Primers, 2022, 8(1): 67. doi: 10.1038/s41572-022-00396-0.
2.	DeCoster TA, Gehlert RJ, Mikola EA, et al. Management of posttraumatic segmental bone defects. J Am Acad Orthop Surg, 2004, 12(1): 28-38.
3.	Bezstarosti H, Metsemakers WJ, van Lieshout EMM, et al. Management of critical-sized bone defects in the treatment of fracture-related infection: a systematic review and pooled analysis. Arch Orthop Trauma Surg, 2021, 141(7): 1215-1230.
4.	Metsemakers WJ, Morgenstern M, Senneville E, et al. General treatment principles for fracture-related infection: recommendations from an international expert group. Arch Orthop Trauma Surg, 2020, 140(8): 1013-1027.
5.	Walter N, Rupp M, Lang S, et al. The epidemiology of fracture-related infections in Germany. Sci Rep, 2021, 11(1): 10443. doi: 10.1038/s41598-021-90008-w.
6.	Zhang Z, Liu P, Wang W, et al. Epidemiology and drug resistance of fracture-related infection of the long bones of the extremities: a retrospective study at the largest trauma center in Southwest China. Front Microbiol, 2022, 13: 923735. doi: 10.3389/fmicb.2022.923735.
7.	中華醫學會骨科學分會創傷骨科學組, 中華醫學會骨科學分會外固定與肢體重建學組, 中華醫學會創傷學分會, 等. 中國-中亞五國骨折相關感染診斷與治療指南(2024). 中華創傷骨科雜志, 2024, 26(1): 6-15.
8.	蔡鵬, 方向, 李嘉, 等. Ilizarov技術在足踝部創傷治療中的臨床應用進展. 中國修復重建外科雜志, 2025, 39(8): 950-957.
9.	Masquelet AC, Begue T. The concept of induced membrane for reconstruction of long bone defects. Orthop Clin North (Am), 2010, 41(1): 27-37.
10.	Mao Y, Yao L, Li J, et al. No superior bone union outcomes with allografts compared to no grafts and autografts following medial opening wedge high tibial osteotomy: a retrospective cohort study. Orthop Surg, 2024, 16(2): 363-373.
11.	Aktuglu 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. doi: 10.1186/s10195-019-0527-1.
12.	Borzunov DY. Long bone reconstruction using multilevel lengthening of bone defect fragments. Int Orthop, 2012, 36(8): 1695-1700.
13.	Liu Y, Yushan M, Liu Z, et al. Complications of bone transport technique using the Ilizarov method in the lower extremity: a retrospective analysis of 282 consecutive cases over 10 years. BMC Musculoskelet Disord, 2020, 21(1): 354. doi: 10.1186/s12891-020-03335-w.
14.	郭杰坤, 王楹, 楊軒, 等. Ilizarov骨搬移技術在急診一期修復GustiloⅢB型脛骨長段開放粉碎性骨折的臨床效果. 中華損傷與修復雜志(電子版), 2024, 19(6): 507-510.
15.	郭保逢, 秦泗河, 焦紹鋒, 等. 秦泗河手術策略結合Ilizarov技術治療56例瀕臨截肢足踝畸形. 中國修復重建外科雜志, 2025, 39(8): 958-964.
16.	Yilihamu Y, Keremu A, Abulaiti A, et al. Outcomes of post-traumatic tibial osteomyelitis treated with an Orthofix LRS versus an Ilizarov external fixator. Injury, 2017, 48(7): 1636-1643.
17.	Ramaker RR, Lagro SW, van Roermund PM, et al. The psychological and social functioning of 14 children and 12 adolescents after Ilizarov leg lengthening. Acta Orthop Scand, 2000, 71(1): 55-59.
18.	Patterson M. Impact of external fixation on adolescents: an integrative research review. Orthop Nurs, 2006, 25(5): 300-308.
19.	Wen H, Yang H, Xu Y. Extreme bone lengthening by bone transport with a unifocal tibial corticotomy: a case report. BMC Musculoskelet Disord, 2019, 20(1): 555. doi: 10.1186/s12891-019-2927-z.
20.	Feng D, Zhang Y, Wu W, et al. Docking site complications analysis of Ilizarov bone transport technique in the treatment of tibial bone defects. J Orthop Surg Res, 2023, 18(1): 889. doi: 10.1186/s13018-023-04356-6.
21.	Feng D, Zhang Y, Jia H, et al. Complications analysis of Ilizarov bone transport technique in the treatment of tibial bone defects-a retrospective study of 199 cases. BMC Musculoskelet Disord, 2023, 24(1): 864. doi: 10.1186/s12891-023-06955-0.
22.	Abulaiti A, Liu Y, Cai F, et al. Bone defects in tibia managed by the Bifocal vs. Trifocal bone transport technique: a retrospective comparative study. Front Surg, 2022, 9: 858240. doi: 10.3389/fsurg.2022.858240.
23.	Liu K, Zhang H, Maimaiti X, et al. Bifocal versus trifocal bone transport for the management of tibial bone defects caused by fracture-related infection: a meta-analysis. J Orthop Surg Res, 2023, 18(1): 140. doi: 10.1186/s13018-023-03636-5.
24.	Hamiti Y, Abudureyimu P, Lyu G, et al. Trifocal versus Pentafocal bone transport in segmental tibial defects: a matched comparative analysis for posttraumatic osteomyelitis treatment. BMC Musculoskelet Disord, 2024, 25(1): 383. doi: 10.1186/s12891-024-07507-w.
25.	Yushan M, Abulaiti A, Maimaiti X, et al. Tetrafocal (three osteotomies) and pentafocal (four osteotomies) bone transport using Ilizarov technique in the treatment of distal tibial defect-preliminary outcomes of 12 cases and a description of the surgical technique. Injury, 2022, 53(8): 2880-2887.
26.	Zhang Y, Wang J, Jiao B, et al. Analysis of functional outcomes and complications of tibial bone defects treated with Ilizarov bone transport technique. BMC Musculoskelet Disord, 2025, 26(1): 198. doi: 10.1186/s12891-025-08454-w.
27.	De Bastiani G, Aldegheri R, Renzi-Brivio L, et al. Limb lengthening by callus distraction (callotasis). J Pediatr Orthop, 1987, 7(2): 129-134.
28.	唐佳昕, 劉銘. 肢體延長手術的應用、發展及其并發癥. 中華骨與關節外科雜志, 2023, 16(9): 849-853.
29.	Paley D, Catagni MA, Argnani F, et al. Ilizarov treatment of tibial nonunions with bone loss. Clin Orthop Relat Res, 1989, (241): 146-165.
30.	Ilizarov GA. The principles of the Ilizarov method. Bull Hosp Jt Dis Orthop Inst, 1988, 48(1): 1-11.
31.	Blázquez-Carmona P, Mora-Macías J, Sanz-Herrera JA, et al. Mechanical influence of surrounding soft tissue on bone regeneration processes: a bone lengthening study. Ann Biomed Eng, 2021, 49(2): 642-652.
32.	Yushan M, Hamiti Y, Yalikun A, et al. Bifocal femoral lengthening assisted by preoperative 3-dimensional design in the restoration of posttraumatic limb length discrepancy. BMC Surg, 2022, 22(1): 245. doi: 10.1186/s12893-022-01697-7.
33.	Matsuo T, Thompson AL, Yuan BJ, et al. The latest approaches to fracture-related infection. Curr Infect Dis Rep, 2025, 27: 15. doi: 10.1007/s11908-025-00864-0.

1. Moriarty TF, Metsemakers WJ, Morgenstern M, et al. Fracture-related infection. Nat Rev Dis Primers, 2022, 8(1): 67. doi: 10.1038/s41572-022-00396-0.
2. DeCoster TA, Gehlert RJ, Mikola EA, et al. Management of posttraumatic segmental bone defects. J Am Acad Orthop Surg, 2004, 12(1): 28-38.
3. Bezstarosti H, Metsemakers WJ, van Lieshout EMM, et al. Management of critical-sized bone defects in the treatment of fracture-related infection: a systematic review and pooled analysis. Arch Orthop Trauma Surg, 2021, 141(7): 1215-1230.
4. Metsemakers WJ, Morgenstern M, Senneville E, et al. General treatment principles for fracture-related infection: recommendations from an international expert group. Arch Orthop Trauma Surg, 2020, 140(8): 1013-1027.
5. Walter N, Rupp M, Lang S, et al. The epidemiology of fracture-related infections in Germany. Sci Rep, 2021, 11(1): 10443. doi: 10.1038/s41598-021-90008-w.
6. Zhang Z, Liu P, Wang W, et al. Epidemiology and drug resistance of fracture-related infection of the long bones of the extremities: a retrospective study at the largest trauma center in Southwest China. Front Microbiol, 2022, 13: 923735. doi: 10.3389/fmicb.2022.923735.
7. 中華醫學會骨科學分會創傷骨科學組, 中華醫學會骨科學分會外固定與肢體重建學組, 中華醫學會創傷學分會, 等. 中國-中亞五國骨折相關感染診斷與治療指南(2024). 中華創傷骨科雜志, 2024, 26(1): 6-15.
8. 蔡鵬, 方向, 李嘉, 等. Ilizarov技術在足踝部創傷治療中的臨床應用進展. 中國修復重建外科雜志, 2025, 39(8): 950-957.
9. Masquelet AC, Begue T. The concept of induced membrane for reconstruction of long bone defects. Orthop Clin North (Am), 2010, 41(1): 27-37.
10. Mao Y, Yao L, Li J, et al. No superior bone union outcomes with allografts compared to no grafts and autografts following medial opening wedge high tibial osteotomy: a retrospective cohort study. Orthop Surg, 2024, 16(2): 363-373.
11. Aktuglu 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. doi: 10.1186/s10195-019-0527-1.
12. Borzunov DY. Long bone reconstruction using multilevel lengthening of bone defect fragments. Int Orthop, 2012, 36(8): 1695-1700.
13. Liu Y, Yushan M, Liu Z, et al. Complications of bone transport technique using the Ilizarov method in the lower extremity: a retrospective analysis of 282 consecutive cases over 10 years. BMC Musculoskelet Disord, 2020, 21(1): 354. doi: 10.1186/s12891-020-03335-w.
14. 郭杰坤, 王楹, 楊軒, 等. Ilizarov骨搬移技術在急診一期修復GustiloⅢB型脛骨長段開放粉碎性骨折的臨床效果. 中華損傷與修復雜志(電子版), 2024, 19(6): 507-510.
15. 郭保逢, 秦泗河, 焦紹鋒, 等. 秦泗河手術策略結合Ilizarov技術治療56例瀕臨截肢足踝畸形. 中國修復重建外科雜志, 2025, 39(8): 958-964.
16. Yilihamu Y, Keremu A, Abulaiti A, et al. Outcomes of post-traumatic tibial osteomyelitis treated with an Orthofix LRS versus an Ilizarov external fixator. Injury, 2017, 48(7): 1636-1643.
17. Ramaker RR, Lagro SW, van Roermund PM, et al. The psychological and social functioning of 14 children and 12 adolescents after Ilizarov leg lengthening. Acta Orthop Scand, 2000, 71(1): 55-59.
18. Patterson M. Impact of external fixation on adolescents: an integrative research review. Orthop Nurs, 2006, 25(5): 300-308.
19. Wen H, Yang H, Xu Y. Extreme bone lengthening by bone transport with a unifocal tibial corticotomy: a case report. BMC Musculoskelet Disord, 2019, 20(1): 555. doi: 10.1186/s12891-019-2927-z.
20. Feng D, Zhang Y, Wu W, et al. Docking site complications analysis of Ilizarov bone transport technique in the treatment of tibial bone defects. J Orthop Surg Res, 2023, 18(1): 889. doi: 10.1186/s13018-023-04356-6.
21. Feng D, Zhang Y, Jia H, et al. Complications analysis of Ilizarov bone transport technique in the treatment of tibial bone defects-a retrospective study of 199 cases. BMC Musculoskelet Disord, 2023, 24(1): 864. doi: 10.1186/s12891-023-06955-0.
22. Abulaiti A, Liu Y, Cai F, et al. Bone defects in tibia managed by the Bifocal vs. Trifocal bone transport technique: a retrospective comparative study. Front Surg, 2022, 9: 858240. doi: 10.3389/fsurg.2022.858240.
23. Liu K, Zhang H, Maimaiti X, et al. Bifocal versus trifocal bone transport for the management of tibial bone defects caused by fracture-related infection: a meta-analysis. J Orthop Surg Res, 2023, 18(1): 140. doi: 10.1186/s13018-023-03636-5.
24. Hamiti Y, Abudureyimu P, Lyu G, et al. Trifocal versus Pentafocal bone transport in segmental tibial defects: a matched comparative analysis for posttraumatic osteomyelitis treatment. BMC Musculoskelet Disord, 2024, 25(1): 383. doi: 10.1186/s12891-024-07507-w.
25. Yushan M, Abulaiti A, Maimaiti X, et al. Tetrafocal (three osteotomies) and pentafocal (four osteotomies) bone transport using Ilizarov technique in the treatment of distal tibial defect-preliminary outcomes of 12 cases and a description of the surgical technique. Injury, 2022, 53(8): 2880-2887.
26. Zhang Y, Wang J, Jiao B, et al. Analysis of functional outcomes and complications of tibial bone defects treated with Ilizarov bone transport technique. BMC Musculoskelet Disord, 2025, 26(1): 198. doi: 10.1186/s12891-025-08454-w.
27. De Bastiani G, Aldegheri R, Renzi-Brivio L, et al. Limb lengthening by callus distraction (callotasis). J Pediatr Orthop, 1987, 7(2): 129-134.
28. 唐佳昕, 劉銘. 肢體延長手術的應用、發展及其并發癥. 中華骨與關節外科雜志, 2023, 16(9): 849-853.
29. Paley D, Catagni MA, Argnani F, et al. Ilizarov treatment of tibial nonunions with bone loss. Clin Orthop Relat Res, 1989, (241): 146-165.
30. Ilizarov GA. The principles of the Ilizarov method. Bull Hosp Jt Dis Orthop Inst, 1988, 48(1): 1-11.
31. Blázquez-Carmona P, Mora-Macías J, Sanz-Herrera JA, et al. Mechanical influence of surrounding soft tissue on bone regeneration processes: a bone lengthening study. Ann Biomed Eng, 2021, 49(2): 642-652.
32. Yushan M, Hamiti Y, Yalikun A, et al. Bifocal femoral lengthening assisted by preoperative 3-dimensional design in the restoration of posttraumatic limb length discrepancy. BMC Surg, 2022, 22(1): 245. doi: 10.1186/s12893-022-01697-7.
33. Matsuo T, Thompson AL, Yuan BJ, et al. The latest approaches to fracture-related infection. Curr Infect Dis Rep, 2025, 27: 15. doi: 10.1007/s11908-025-00864-0.

Chinese Journal of Reparative and Reconstructive Surgery

Zeta-focal bone lengthening for bone defects after fracture-related infection: a two-case based research

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