Orthopaedic firsts at Mediclinic Durbanville

Two surgeons are leading advanced limb reconstruction at Mediclinic Durbanville

Using modern bone transport techniques that improve blood supply, heal severe ulcers and infections, and prevent amputations.

Professor Nando Ferreira and Dr Gadi Epstein are internationally recognised orthopaedic surgeons who specialise in limb reconstruction at Mediclinic Durbanville. Working together in the hospital’s dedicated Limb Reconstruction and Musculoskeletal Infection Unit, they explain how new, not yet widely available procedures – transverse tibia bone transport and balanced cable bone transport – can help save limbs and avoid the need for amputations.

The revival of transverse tibia bone transport (TTT)

The transverse tibia bone transport (TTT) technique was first used in the 1950s by the pioneering Russian orthopaedic surgeon Gavriil Ilizarov. While working on limb-lengthening and bone transport procedures, he treated a patient who’d had polio as a child and was left with a very thin lower leg. She asked him to make the leg wider, so he performed a longitudinal split of the tibia, applied an external fixator, and gradually widened the bone.

“When we lengthen a limb or do a bone transport, we do a longitudinal lengthening – stretching the length of the leg,” Professor Ferreira says. “This is different in that it stretches the bone in its breadth.” Tests on Ilizarov’s patient showed a major improvement in blood flow. “They did vascular studies and saw that along that widening of the limb, massive new blood vessels grew into that area, also improving blood supply to the rest of the limb,” Professor Ferreira adds.

The method faded from use for many years until it was recently rediscovered – first in China and South Korea, and later in Western countries. According to Professor Ferreira, its renewed popularity is largely driven by the growing number of patients with diabetes and diabetic foot ulcers.

Today, the technique is far more advanced and uses a very small external fixator designed specifically for this procedure. “This external fixator fits onto the tibia,” Professor Ferreira explains. “We cut a small slot in the bone, and the external fixator has a tiny knob that, when turned, moves a piece of bone out from the surface of the tibia and then back in again. This movement increases blood supply to the limb, which helps heal stubborn ulcers that are especially hard to treat because of poor blood flow.”

First transverse tibia bone transport in the Southern Hemisphere

Patients with long-lasting diabetic foot ulcers often struggle to heal, and many eventually face the risk of amputation, Dr Epstein explains. This procedure offers them another option. “Performing the first TTT procedure in the Southern Hemisphere was a special achievement both for Durbanville Mediclinic and for us as a unit,” he says.

They carried out the procedure in December 2024 on a 70-year-old patient with diabetes who had been dealing with a stubborn ulcer on the outer side of his foot for about six months. He had already undergone several debridements – procedures to remove dead or infected tissue – but the wound still wasn’t healing. His surgeons were considering partially amputating his foot when Professor Ferreira was asked to assess the case.

“We did a debridement, a local antibiotic installation, and wound care and then performed the TTT,” he says. “His ulcer was healed in six weeks after the surgery, which is not always the case. It was remarkable how quickly it healed.”

Professor Ferreira emphasises that treating diabetic foot ulcers still requires a full team approach. “It’s a collaborative effort and the patient, endocrinologist, wound care nurse and theatre staff have a massive role to play.” He explains that the ulcer still needs regular debridement and careful treatment with local antibiotics. The TTT procedure is an additional tool used alongside these established treatments, but it offers a key advantage by improving blood flow, which wasn’t possible before.

Balanced cable bone transport another first for Mediclinic Durbanville

Professor Ferreira and Dr Epstein also recently performed the first balanced cable bone transport (BCBT) case in private practice in South Africa. “We had a 17-year-old patient who had a previous operation for a fractured tibia,” Dr Epstein says. Afterwards, he developed severe osteomyelitis – a bone infection.

“He was referred to our unit to manage this infection – he had a big section of soft tissue and a large segment of bone that had to be resected.” In other words, the infected parts of the tissue and bone had to be surgically removed and the piece of missing bone that remained then had to be reconstructed.

“One of the ways to reconstruct such a large defect of bone is a bone transport,” Dr Epstein explains, “which can be done in different ways including through a balanced cable transport.” Here, surgeons perform an osteotomy – the surgical cutting of a bone to allow for realignment.

“We apply ring fixators onto the proximal and distal ends of the bone”– the proximal end being the end closer to the body, and the distal end being the end farther away – “and then through a pulley mechanism, we advance a cable that’s attached to the proximal segment of bone and pull it slowly down into the bone defect.”

The bone transport worked very well for the patient. His limb was saved, and the infection did not return.

These two cases highlight the range of advanced limb-reconstruction techniques available at Mediclinic Durbanville and its dedicated Limb Reconstruction Unit, Dr Epstein says. “The types of treatment on offer here meet the standards of any centre around the world.”