Management of infected non-union of lower limb long bone fractures using ilizarov technique: a study of outcomes
Keywords:Ilizarov, Infected nonunion, Tibia, Femur
Background: Nonunion of long bone fractures is a common condition treated by an orthopaedic surgeon. Many nonunions can be treated effectively by internal fixation with or without bone grafting but, an infected nonunion can prove to be a tough challenge. The Ilizarov method is effective in managing infected nonunion of long bones. This study aims to assess the outcome of management of infected nonunions of long bones of lower limb with Ilizarov Ring fixator using bone and functional results as per Association for the Study and Application of Methods of Ilizarov (ASAMI) Scoring System.
Methods: We retrospectively analysed 18 patients (16 Male: 2 Female; Mean age 43.2 years) managed with Ilizarov technique for an infected tibial or femoral nonunion between 01 January 2013 and 31 December 2014. They were followed up for an average of 25.4 months after removal of fixator. They were assessed for functional and Bone (radiological) outcomes using the Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria.
Results: 17 limbs were salvaged and union could be achieved. One limb required amputation due to severe persistent intractable infection. None required any additional skeletal stabilisation after removal of fixator frame except casting in a few patients for a period of 6 weeks. Mean time to union was 211.83 days (range 136 - 320days/median 184) or 7.01 months. As per the ASAMI score, Bone results were excellent in 10, good in 5, fair in 2 and poor in 1. Functionally 7 were graded as excellent, 6 as good, 3 as fair and 1 as poor and 1 patient underwent amputation.
Conclusions: The Ilizarov’s method remains one of the most versatile and successful means of achieving bone healing in infected nonunions of long bones of lower limbs with additional benefits of correcting bone defects, deformities and limb length inequalities.
Ring D, Jupiter JB, Gan BS, Israeli R, Yaremchuk MJ. Infected nonunion of the tibia. Clin Orthop Relat Res. 1999;369:302-11.
Ilizarov G, Deviatov A, Trokhova V. Surgical lengthening of the shortened lower extremities. Vestnik khirurgii imeni II Grekova. 1972;108(2):100-3.
Rohilla R, Siwach K, Devgan A, Singh R, Wadhwani J, Ahmed N. Outcome of distraction osteogenesis by ring fixator in infected, large bone defects of tibia. J Clin Orthop Trauma. 2016;7(2):201-9.
Shortt NL, Keenan GF, Muir AY, Simpson A. The use of a nerve stimulator to allow safe placement of Ilizarov wires. Oper Orthop Traumatol. 2006;18(4):364-76.
Patil S, Montgomery R. Management of complex tibial and femoral nonunion using the Ilizarov technique, and its cost implications. J Bone Joint Surg Br. 2006;88(7):928-32.
Madhusudhan TR, Ramesh B, Manjunath K, Shah HM, Sundaresh DC, Krishnappa N. Outcomes of Ilizarov ring fixation in recalcitrant infected tibial nonunions–a prospective study. J Trauma Manag Outcomes. 2008;2(1):6.
Paley D, Catagni MA, Argnani F, Villa A, Bijnedetti GB, Cattaneo R. Ilizarov treatment of tibial nonunions with bone loss. Clin Orthop Relat Res. 1989;241:146-65.
McKee MD, DiPasquale DJ, Wild LM, Stephen DJ, Kreder HJ, Schemitsch EH. The effect of smoking on clinical outcome and complication rates following Ilizarov reconstruction. J Orthop Trauma. 2003;17(10):663-7.
Cierny Iii G, Mader JT, Penninck JJ. The Classic: A Clinical Staging System for Adult Osteomyelitis. Clin Orthop Relat Res. 2003;414:7-24.
Gustilo R, Anderson J. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58(4):453-8.
Eralp L, Kocaoglu M, Rashid H. Reconstruction of segmental bone defects due to chronic osteomyelitis with use of an external fixator and an intramedullary nail. Surgical technique. J Bone Joint Surg Am. 2007;89(2):183–95.
Paley D, Herzenberg JE. Intramedullary infections treated with antibiotic cement rods: preliminary results in nine cases. J Orthop Trauma. 2002;10:723–9.
Thonse R, Conway J. Antibiotic cement-coated interlocking nail for the treatment of infected nonunions and segmental bone defects. J Orthop Trauma. 2007;21:258–68.
Klemm K. Treatment of infected pseudarthrosis of the femur and tibia with an interlocking nail. Clin Orthop Rel Res. 1986;212:174–81.
Zalavras CG, Patzakis MJ, Holtom P. Local Antibiotic Therapy in the Treatment of Open Fractures and Osteomyelitis. Clin Orthop Relat Res. 2004;(427):86-93.
Yajima H, Tamai S, Mizumoto S, Inada Y. Vascularized fibular grafts in the treatment of osteomyelitis and infected nonunion. Clin Orthop Rel Res. 1993;293:256–64.
Schöttle PB, Werner CML, Dumont CE. Two-stage reconstruction with free vascularized soft tissue transfer and conventional bone graft for infected nonunions of the tibia. Acta Orthop Scand. 2005;76:878–83.
Minami A, Kaneda K, Itoga H. Treatment of infected segmental; defect of long bone with vascularized bone transfer. Microsurgery. 1992;8:75–82.
Emami A, Mjo¨berg B, Larsson S. Infected tibial nonunion. Good results after open cancellous bone grafting in 37 cases. Acta Orthop Scand. 1995;66:447–51.
Esterhai JL Jr, Sennett B, Gelb H, Heppenstall RB, Brighton CT, Osterman AL, et al. Treatment of chronic osteomyelitis complicating nonunion and segmental defects of the tibia with open cancellous bone graft, posterolateral bone graft, and soft-tissue transfer. J Trauma. 1990;30:49–54.
Green SA, Dlabal TM. The open bone graft for septic nonunion. Clin Orthop Rel Res. 1983;180:117–24.
McKee MD, Wild LM, Schemitsch EH, Waddell JP. The use of an antibiotic-impregnated, osteo-conductive, bioabsorbable bone substitute in the treatment of infected long bone defects: early results of a prospective trial. J Orthop Trauma. 2002;16:622–7.
Cattaneo R, Catagni M, Johnson EE. The treatment of infected nonunion and segmental defects of the tibia by the methods of Ilizarov. Clin Orthop Relat Res. 1992;280:143–52.
Jain AK, Sinha S. Infected nonunion of the long bones. Clin Orthop Relat Res. 2005;(431):57-65.
Checkets RG, Otterburn M. Pin tract infection: definition, prevention, incidence. Abstracts of the 2nd Riva Congress, Riva di Garda (Italy): University of Verona and University of Montpellier I; 1992: 98–99.
Struijs PA, Poolman RW, Bhandari M. Infected Nonunion of the Long Bones. J Orthop Trauma. 2007;21(7):507-11.
Dendrinos G, Kontos S, Lyritsis E. Use of the Ilizarov technique for treatment of nonunion of the tibia associated with infection. J Bone Joint Surg Am. 1995;77(6):835-46.
Atesalp AS, Basbozkurt M, Komurcu M, Kurklu M. The treatment of infected tibial nonunion with aggressive Debridement and internal bone transport. Mil Med. 2002;167(12):978-81.
Sala F, Thabet AM, Castelli F, Miller AN, Capitani D, Lovisetti G, et al. Bone transport for postinfectious segmental tibial bone defects with a combined Ilizarov/Taylor Spatial Frame technique. J Orthop Trauma. 2011;25(3):162–8.
Emara KM, Allam MF. Ilizarov external fixation and then nailing in management of infected nonunions of the tibial shaft. J Trauma-Injury Infect Critical Care. 2008;65(3):685–91.
Krishnan A, Pamecha C, Patwa JJ. Modified Ilizarov technique for infected nonunion of the femur: the principle of distraction-compression osteogenesis. J Orthop Surg (Hong Kong). 2006;14(3):265–72.
Magadum MP, Basavaraj Yadav CM, Phaneesha MS, Ramesh LJ. Acute compression and lengthening by the Ilizarov technique for infected nonunion of the tibia with large bone defects. J Orthop Surg (Hong Kong). 2006;14(3):273–9.
Kelsey JL, Keegan TH, Prill MM, Quesenberry Jr CP, Sidney S. Risk factors for fracture of the shafts of the tibia and fibula in older individuals. Osteoporos Int`. 2006;17(1):143-9.
McKee MD, Yoo D, Schemitsch EH. Health status after Ilizarov reconstruction of post-traumatic lower-limb deformity. J Bone Joint Surg Br. 1998;80(2):360-4.
Maini L, Chadha M, Vishwanath J, Kapoor S, Mehtani A, Dhaon B. The Ilizarov method in infected nonunion of fractures. Injury. 2000;31(7):509-17.
Yin P, Zhang L, Li T, Zhang L, Wang G, Li J, et al. Infected nonunion of tibia and femur treated by bone transport. J Orthop Surg Res. 2015;10:49.