Infected nonunion of the tibia

Bifocal versus trifocal bone transport for the management of tibial bone defects caused by fracture-related infection: a meta-analysis

BACKGROUND

The purpose of this meta-analysis was to compare the efficacy and outcomes of bifocal bone transport (BFT) and trifocal bone transport (TFT) for the treatment of tibial bone defects caused by fracture-related infection (FRI).

METHODS

The literature searches of Cochrane Library, Embase, Google Scholar databases, PubMed/Medline, and Web of Science for literature published up to September 20, 2022, were performed. The quality of the included studies was evaluated according to the MINORS scale. Patients were divided into the BFT group and the TFT group, depending on the site of the osteotomy. The demographic data, defect size (DS), external fixation time (EFT), external fixation index (EFI), bone and functional results, complications, and autologous bone grafting (ABG) were extracted and analyzed using the Review Manager software (version 5.3).

RESULTS

Five studies included 484 patients with tibial bone defects treated by bone transport investigated in this meta-analysis, with a mean bone defect of 9.3 cm. There were statistical differences in DS (MD =  - 2.38, 95% CI - 3.45 to - 1.32, P < 0.0001), EFT (MD = 103.44, 95% CI 60.11 to 146.77, P < 0.00001), and EFI (MD = 26.02, 95% CI 14.38 to 37.65, P < 0.00001) between BFT group and TFT group. There was no statistical difference in bone results (RR = 0.98, 95% CI 0.91 to 1.06, P = 0.67), functional results (RR = 0.94, 95% CI 0.82 to 1.07, P = 0.37), complications (OR = 1.57, 95% CI 0.59 to 4.14, P = 0.36), and ABG (RR = 1.2, 95% CI 0.78 to 1.84, P = 0.42) between two groups.

CONCLUSIONS

TFT was a feasible and practical method in the treatment of massive tibial bone defects caused by FRI to receive shorter EFT and satisfactory bone and functional results.

A nomogram for decision-making assistance on surgical treatment of chronic osteomyelitis in long bones: Establishment and validation based on a retrospective multicenter cohort

BACKGROUND

Chronic osteomyelitis remains a major challenge for orthopedic surgeons due to its high recurrence rate. Surgeons currently have few tools to estimate the likelihood of individual recurrence. We here aimed to develop a nomogram to better estimate individual recurrence rate after surgical treatment of chronic osteomyelitis in long bones.

METHODS

We first retrospectively identified patients as training cohort who had received surgical treatment of chronic osteomyelitis in long bones between January 2010 and January 2016 from four hospitals. Patient demographic, microbiological, clinical, and therapeutic variables were collected and analyzed. Univariate and multivariate analyses were performed successively to identify independently predictive factors for recurrence. To reduce overfitting, the Bayesian information criterion was used to reduce variables in the original model. Nomograms were created with the reduced model after model selection. The nomogram was then internally validated with bootstrap resampling. We then further validated the performance of the established nomogram in validation cohort (data from two distinct institutions).

RESULTS

Recurrence was found in 136 of 655 (20.8%) and 52 of 201 patients (25.9%) in training and validation cohorts respectively. We included six independent prognostic factors for recurrence in our prediction model: number of previous recurrences, epiphysial involvement, preoperative serum albumin level, axial length of the infectious lesion, lesion-removal method, and application of a muscular flap. After incorporating these six factors, the nomogram achieved good discrimination, with concordance indexes of 0.82 (95% CI, 0.79-0.85) and 0.80 (95% CI, 0.78-0.83) in predicting recurrence in the training and validation cohorts, respectively. Calibration curves were well fitted for both training and validation cohorts.

CONCLUSIONS

Our nomogram achieved good preoperative prediction of recurrence in chronic osteomyelitis of long bones. Using this nomogram, the recurrence risk can be confidently predicted for each patient and treatment plan. After considering and discussing the functional prognosis with patients, physicians can establish a rational therapeutic plan.

LEVEL OF EVIDENCE

Prognostic, Level III.

Treatment of Posttraumatic Tibial Diaphyseal Bone Defects: A Systematic Review and Meta-Analysis

OBJECTIVE

To describe evidenced-based treatment options for patients who sustained trauma and/or posttraumatic osteomyelitis of the tibia resulting in diaphyseal bone defects and to compare outcomes between patients treated with nonvascularized bone grafts (NBGs), bone transport (BT), or vascularized bone grafts (VBGs).

DATA SOURCE

The Preferred Reporting Items for Systematic Review and Meta-Analyses of individual participant data and Cochrane guidelines were followed. PubMed, EMBASE, Cochrane Library, Web of Science, Scopus, and CINAHL were searched from inception to June 2020.

STUDY SELECTION

Patients who were ≥18 years, had sustained trauma to the tibia resulting in fracture and/or osteomyelitis with measurable diaphyseal bone defects, and were treated by interventions such as NBGs, BT, or VBGs were eligible. Excluded studies were non-English, reviews, nonreviewed literature, cadavers, animals, unavailable full texts, nondiaphyseal defects, atrophic nonunions, malignancy, and replantations.

DATA EXTRACTION

A total of 108 studies were included with 826 patients. Two reviewers systematically/independently screened titles/abstracts, followed by full texts to ensure quality, accuracy, and consensus among authors for inclusion/exclusion of studies. A third reviewer addressed disagreements if investigators were unable to reach a consensus. Studies were quality assessed using "Methodological Quality and Synthesis of Case Series and Case Reports".

DATA SYNTHESIS

Analyses were performed with IBM SPSS version 25.0 (IBM Corporation, Armonk, NY) and G*Power3.1.9.2.

CONCLUSIONS

NBGs may be considered first line for trauma defect sizes ≤ 10 cm or posttraumatic osteomyelitis defect sizes <5 cm. BT may be considered first line for posttraumatic osteomyelitis defect sizes <5 cm. VBGs may be considered first line for trauma and posttraumatic osteomyelitis defect sizes ≥5 cm.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A Review of Proximal Tibia Entry Points for Intramedullary Nailing and Validation of The Lateral Parapatellar Approach as Extra-articular

Tibial shaft fractures are the most common long bone injury and are often treated surgically in an attempt to minimize complications. Although treatment options for tibial shaft fractures vary based on factors including open injury, severity of fracture, and soft tissue status, intramedullary nailing in adults has emerged as the preferred definitive option for stabilization. Therefore, the primary purposes of this review and cadaveric study were to evaluate the entry points for reamed tibial nails and the risks, benefits, and advantages of each approach. Due to concerns of violating the joint capsule and the generalized applicability to everyday practice of the extra-articular lateral parapatellar semi-extended technique, the secondary goal of this manuscript was to evaluate whether an intramedullary tibial nail can be consistently placed extra-articularly using the lateral parapatellar technique described by Kubiak et al. and generalizability to surgeons of varying experience.

The Fate of Patients After a Staged Nonunion Procedure for Known Infection

OBJECTIVES

To determine the factors associated with successful union and eradication of infection in the setting of staged procedures to treat obviously infected nonunions of long bones. We hypothesize that patients with positive intraoperative cultures obtained at the time of definitive surgery for infected nonunions are more likely to have persistent nonunion than those with negative cultures.

DESIGN

Multicenter retrospective review.

SETTING

Eight academic Level 1 trauma centers.

PATIENTS/PARTICIPANTS

Patients who underwent staged management for obviously infected nonunion of a long bone.

MAIN OUTCOME MEASUREMENTS

For each patient, initial fracture management, management of retained implants, number of debridements, grafting, bacteriology, antibiotic course, bone defect management, soft-tissue coverage, and definitive surgery performed were reviewed.

RESULTS

A total of 134 patients were treated with staged procedures for obviously infected nonunion of a long bone (mean age 49 years, 60% open fractures, and mean follow-up 22 months). During definitive procedures, 120 patients had intraoperative cultures taken with 43% having positive cultures. For culture-positive patients, 41 patients achieved eventual union and 10 had persistent nonunion. Of 69 culture-negative patients, 66 achieved eventual union and 3 had persistent nonunion. The number of patients with union versus persistent nonunion was statistically significant between culture-positive and culture-negative groups (P = 0.015).

CONCLUSIONS

Management of infected nonunion in long bones with staged treatments before definitive fixation are beneficial but ultimately less effective when performed in the setting of positive bacterial cultures at the time of definitive management.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of Clinico-radiological Outcomes of Monolateral Fixator in Infected Non-union of Tibia Based on Bone Gap Quantification

INTRODUCTION

Monolateral rail fixators are more comfortable to the patients and have a lesser learning curve compared to ring fixators. Guidelines are still lacking for rational use of monolateral fixator for bone transport. This retrospective study aimed to analyze and compare the clinico-radiological outcomes of monolateral fixator in infected non union of tibia based on bone gap quantification.

MATERIALS AND METHODS

This retrospective study included 35 patients of post traumatic infected osteocutaneous defects of tibia operated from May 2013 to May 2016. Group I having bone gap of 6 cm or less (n = 20) and group II with > 6 cm bone gap (n = 15). The mean age was 29.56 (range 18-62) years in group I and 29.67 (range 20-65) years in group II. The mean bone gap was 4.62 (2-6 cm) in group I and 7.6 cm (6.5-10 cm) in group II (P < 0.00001, Mann-Whitney test). The results were assessed by Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria.

RESULTS

Union was achieved primarily in 90% (n = 18) cases in group I and 73.34% (n = 11) cases in group II. The bone result was excellent, good, fair/poor in 14, 5, 1 in group I; and in 4, 6, 5 in group II, respectively (P = 0.020, Chi-square test). The functional results were excellent, good, fair/poor in 15, 4, 1 in group I; and 5, 8, 2 in group II, respectively (P = 0.0479, Chi-square test).

CONCLUSION

We recommend use of monolateral fixator in patients with infected diaphyseal non union of tibia with bone gap ≤ 6 cm. Use of monolateral fixator in patients with bone gap > 6 cm is associated with higher incidence of residual problems and complications.

Comparison of Ilizarov Bifocal, Acute Shortening and Relengthening with Bone Transport in the Treatment of Infected, Segmental Defects of the Tibia

This prospective study compared bifocal acute shortening and relengthening (ASR) with bone transport (BT) in a consecutive series of complex tibial infected non-unions and osteomyelitis, for the reconstruction of segmental defects created at the surgical resection of the infection. Patients with an infected tibial segmental defect (>2 cm) were eligible for inclusion. Patients were allocated to ASR or BT, using a standardized protocol, depending on defect size, the condition of soft tissues and the state of the fibula (intact or divided). We recorded the Weber-Cech classification, previous operations, external fixation time, external fixation index (EFI), follow-up duration, time to union, ASAMI bone and functional scores and complications. A total of 47 patients (ASR: 20 patients, BT: 27 patients) with a median follow-up of 37.9 months (range 16-128) were included. In the ASR group, the mean bone defect size measured 4.0 cm, and the mean frame time was 8.8 months. In the BT group, the mean bone defect size measured 5.9cm, and the mean frame time was 10.3 months. There was no statistically significant difference in the EFI between ASR and BT (2.0 and 1.8 months/cm, respectively) (p = 0.223). A total of 3/20 patients of the ASR and 15/27 of the BT group needed further unplanned surgery during Ilizarov treatment (p = 0.006). Docking site surgery was significantly more frequent in BT; 66.7%, versus ASL; 5.0% (p < 0.0001). The infection eradication rate was 100% in both groups at final follow-up. Final ASAMI functional rating scores and bone scores were similar in both groups. Segmental resection with the Ilizarov method is effective and safe for reconstruction of infected tibial defects, allowing the eradication of infection and high union rates. However, BT demonstrated a higher rate of unplanned surgeries, especially docking site revisions. Acute shortening and relengthening does not reduce the fixator index. Both techniques deliver good functional outcome after completion of treatment.

Prospective randomized comparison of quality of regenerate in distraction osteogenesis of ring versus monolateral fixator in patients with infected nonunion of the tibia using digital radiographs and CT

Aims

In this randomized study, we aimed to compare quality of regenerate in monolateral versus circular frame fixation in 30 patients with infected nonunion of tibia.

Patients and Methods

Both groups were comparable in demographic and injury characteristics. A phantom (aluminium step wedge of increasing thickness) was designed to compare the density of regenerate on radiographs. A CT scan was performed at three and six months postoperatively to assess regenerate density. A total of 30 patients (29 male, one female; mean age 32.54 years (18 to 60)) with an infected nonunion of a tibial fracture presenting to our tertiary institute between June 2011 and April 2016 were included in the study.

Results

The regenerate mineralization on radiographs was comparable in both groups at two, four, six, and ten months’ follow-up but the rail fixator group had statistically significant higher grades of mineralization when compared with the circular frame group at eight and 12 months’ follow-up. The regenerate mineralization was also higher in the rail fixator group than in the circular frame group on CT at three and six months, although this difference was not statistically significant.

Conclusion

Overall, the regenerate mineralization was higher in the monolateral than the circular frame group. A monolateral fixator may be preferred in patients with infected nonunion of the tibia with bone defects up to 7 cm. Cite this article: Bone Joint J 2019;101-B:1416–1422.

Comparison of treatment indices associated with the correction and lengthening of deformities along various lower limb frontal plane directions

PURPOSE

The Taylor spatial frame (TSF) provides higher precision in the dimensional correction of some lower limb deformities. However, no study to date has compared the osteogenesis outcome of correction and lengthening among various directions in the frontal plane. We examined the relationship between the external fixation index (EFI) and the direction of correction in the frontal plane.

METHODS

We classified 25 patients undergoing correction with the TSF into three groups: Group A (8 patients, varus deformity), Group B (6 patients, valgus deformity), and Group C (9 patients, non-correction in the frontal plane). We excluded patients who underwent chemotherapy, were converted to internal fixation, had infection or pseudarthrosis, and in whom the corrected gain was <2.4 cm.

RESULTS

No significant differences in age, sex, etiology of deformity, complication due to deformity in another plane, osteotomy distribution, TSF use duration, and correction distance were found. The average EFI was 83.4, 60.5, and 51.2 days/cm in Groups A, B, and C, respectively, with the EFI being significantly higher in Group A than in Group C (P < 0.05).

CONCLUSIONS

Osteogenesis of varus deformities was more prolonged than that of non-correction in the frontal plane. These results provide useful insights that can aid in minimizing complications due to external fixation and improving our understanding of the mechanism of osteogenesis in the tibia.

Non-union: Indications for external fixation

External fixation is currently used as the definitive mode of fracture stabilisation in the management of ˜50% of long-bone non-unions. Distinction between non-union and delayed union is a diagnostic dilemma especially in fractures healing by primary bone repair. This distinction is important, as non-unions are not necessarily part of the same spectrum as delayed unions. The aetiology of a fracture non-union is usually multifactorial and the factors can be broadly categorized into mechanical factors, biological (local and systemic) factors, and infection. Infection is present in ˜40% of fracture non-unions, often after open fractures or impaired wound healing, but in 5% of all non-unions infection is present without any clinical or serological suspicion. General indications for external fixation include clinical scenarios where; 1) percutaneous correction of alignment, or mechanical stimulation of the non-union site is required; 2) fixation of juxta-articular or 'emmental' bone fragments is necessary; and 3) staged bone or soft tissue reconstruction is anticipated. Specific anatomical indications include infected non-unions of the tibia, humerus, and juxta-articular bone. External fixation is an essential tool in the management of fracture non-unions. However, with greater understanding of the outcomes associated with both external and internal fixation the relative indications are now being refined.

Management of an Infected Nonunion of an Opening-Wedge High Tibial Osteotomy with 2-Stage Implantation of Rotating Hinge Knee Prosthesis

Introduction

High tibial osteotomy (HTO) is a frequent and effective treatment for unicompartmental gonarthritis. Only a few articles are focused on the treatment of infected nonunion.

Patient and Method

A 50-year-old obese patient was operated on by medial opening-wedge HTO. She developed a painful nonunion treated by hardware removal, allograft, and plate fixation. However, the nonunion persisted. 2 years later, cellulitis appeared with an abscess adjacent to the HTO plate. Despite surgical debridement and antibiotics, septic knee arthritis occurred. In a situation of infected nonunion and septic arthritis with chondrolysis, she was scheduled for a 2-stage total knee replacement (TKR). The infected tibial articular block was first resected and replaced by a cement spacer. After a short interval, the TKR was implanted. After 2 years, the patient walked pain-free with good knee function.

Discussion

In the literature, different efficient treatments exist for infected nonunion after HTO, but comprehensive studies are missing for a consensus treatment. Current data are mostly based on case reports, since this pathology is quite rare.

Conclusion

In a difficult situation of infected nonunion with septic knee arthritis, we performed a 2-stage knee prosthesis implantation. This led to an early mobilization and fast recovery.

Ilizarov Treatment Protocols in the Management of Infected Nonunion of the Tibia

OBJECTIVES

We present a treatment algorithm comprising 4 Ilizarov methods in managing infected tibial nonunion, using nonunion mobility and segmental defect size to govern treatment choice.

DESIGN

Decision protocol analysis study.

SETTING

A university-affiliated teaching hospital.

PATIENTS/PARTICIPANTS

Seventy-nine patients were treated with 1 of 4 Ilizarov protocols. All patients had undergone at least one previous operation, 38 had associated limb deformity, and 49 had nonviable nonunions. Twenty-six had a new muscle flap at the time of Ilizarov surgery, and 25 had preexisting flaps reused.

INTERVENTION

Twenty-six cases were treated with monofocal distraction, 19 with monofocal compression, 16 with bifocal compression/distraction, and 18 with bone transport.

MAIN OUTCOME MEASUREMENTS

The primary outcome measure was the absence of recurrent infection. Secondary outcomes included bone union, complications, the Association for the Advancement of Methods of Ilizarov (ASAMI) bone and functional classification scores, and any need for further unplanned surgery.

RESULTS

Infection was eradicated in 76 cases (96.2%) with a mean follow-up duration of 40.8 months (range 6-131). All 3 infection recurrences occurred in the monofocal compression group. Following the initial Ilizarov method alone, union was achieved in 68 cases (86.1%) and was highest among the monofocal distraction (96.2%) and bifocal compression/distraction groups (93.8%). Monofocal compression achieved the lowest union rate (73.7%), significantly lower ASAMI scores, and a refracture rate of 31.6%. Bone transport secured union in 77.8% with a 44.4% unplanned reoperation rate. However, infection-free union was 100% after further treatment.

CONCLUSIONS

Monofocal compression is not recommended for treating infected, mobile nonunions. Distraction (monofocal or bifocal) was effective and achieved higher rates of union and infection clearance.

LEVEL OF EVIDENCE

Level III.

Current treatment of infected non-union after intramedullary nailing

Non-union is a devastating consequence of a fracture. Non-unions cause substantial patient morbidity with patients suffering from loss of function of the affected extremity, increased pain, and a substantial decrease in the quality of life. The management is often associated with repeated, unsuccessful operations resulting in prolonged hospital stays, which has social and economic consequences to both the patient and the healthcare system. The rates of non-union following intramedullary (IM) nailing vary according to anatomical location. There is currently no consensus regarding the treatment of infected non-unions following IM nailing, but the most common procedures reported are; exchange IM nail with antibiotic suppression or excision of the non-union, (stabilisation with external fixation or less commonly plate or IM nail) and then reconstruction of the bone defect with distraction osteogenesis or the Masquelet technique. This article explores the general principles of treatment, fixation modalities and proposes a treatment strategy for the management of infected non-unions following intramedullary nailing.

Prospective randomised comparison of ring versus rail fixator in infected gap nonunion of tibia treated with distraction osteogenesis

AIMS

This is a prospective randomised study which compares the radiological and functional outcomes of ring and rail fixators in patients with an infected gap (> 3 cm) nonunion of the tibia.

PATIENTS AND METHODS

Between May 2008 and February 2013, 70 patients were treated at our Institute for a posttraumatic osseocutaneous defect of the tibia measuring at least 3 cm. These were randomised into two groups of 35 patients using the lottery method. Group I patients were treated with a ring fixator and group II patients with a rail fixator. The mean age was 33.2 years (18 to 64) in group I and 29.3 years (18 to 65) in group II. The mean bone gap was 5.84 cm in group I and 5.78 cm in group II. The mean followup was 33.8 months in group I and 32.6 months in group II. Bone and functional results were assessed using the classification of the Association for the Study and Application of the Method of Ilizarov (ASAMI). Functional results were also assessed at six months using the short musculoskeletal functional assessment (SMFA) score.

RESULTS

The bone result was excellent, good, fair and poor in 21, 12, 0 and 2 in group I; and 14, 15, 3, and 3 in group II, respectively. The functional results were excellent, good, fair, poor and failure in 16, 17, 1, 0 and 1 in group I; and 22, 10, 0, 3 and 0 in group II, respectively. Both fixator systems achieved comparable rates of union and functional outcomes. The rate of deep pintract infection was significantly higher in the rail fixator group but patients found it more comfortable.

CONCLUSION

We recommend the use of a ring fixator in patients with a bone gap of more than 6 cm. Patients with a bone gap up to 6 cm can be managed with either a ring or rail fixator. Cite this article: Bone Joint J 2016;98B:1399-1405.

Outcome of distraction osteogenesis by ring fixator in infected, large bone defects of tibia

BACKGROUND

Salvage of large, infected bone defects in tibia poses a formidable problem. The present prospective study aimed to evaluate radiologic and functional outcome of ring fixator in infected, large (≥6 cm) bone defects of tibia treated with distraction osteogenesis.

MATERIALS AND METHODS

The study included 35 patients (30 males and 5 females) who had minimum of 6 cm gap after radical resection of necrotic bone and presence or history of active infection. Mean age was 36.1 years. Mean bone gap was 7.27 cm. Mean follow-up period was 25.4 months.

RESULTS

Fracture united primarily in 17 cases and after fixator adjustment with freshening of fracture margins in 15 cases. Fixator adjustment with bone grafting was done in one patient to achieve union. One patient had nonunion and another had amputation. The bone result was excellent, good, and poor in 19, 13, and 3 patients, respectively. The functional results were excellent, good, fair and failure in 14, 19, 1, and one patient, respectively. 24 patients had superficial pin tract infection and 18 patients had ankle stiffness.

CONCLUSION

Ring fixator systems reliably achieve union in infected, large bone defects of tibia and help in treating infection, shortening, bone and soft tissue loss simultaneously. We advocate early freshening of fracture ends and removal of interposed soft tissue at docking sites to achieve union. Superficial pin tract infection and ankle stiffness are common problems in managing large tibial defects. But good to excellent functional outcomes can be achieved in majority of patients.

A Systematic Review and Meta-Analysis of Ilizarov Methods in the Treatment of Infected Nonunion of Tibia and Femur

Background

Infected nonunion of tibia and femur are common in clinical practice, however, the treatment of these diseases has still been a challenge for orthopaedic surgeons. Ilizarov methods can eradicate infection, compensate bone defects and promote the bone union through progressive bone histogenesis. The objective of this systematic review was to review current available studies reporting on Ilizarov methods in the treatment of infected nonunion of tibia and femur, and to perform meta-analysis of bone and functional results and complications to evaluate the efficacy of Ilizarov methods.

Methods

A comprehensive literature search was performed from the SCI, PubMed, Cochrane Library; and Embase between January 1995 and August 2015. Some major data were statistically analyzed using weighted means based on the sample size in each study by SPSS 13.0, including number of patients, mean age, mean previous surgical procedures, mean bone defects, mean length of follow-up, bone union, complications per patient, external fixation time, and external fixation index(EFI). Bone results (excellent, good, fair and poor rate), functional results (excellent, good, fair and poor rate) and complications were analyzed by Stata 9.0.

Findings

A total of 590 patients from 24 studies were included in this systematic review. The average of bone union rate was 97.26% in all included studies. The poor rate in bone results and functional results was 8% (95%CI, 0.04–0.12; I² = 44.1%, P = 0.065) and 10% (95%CI, 0.05–0.14; I² = 34.7%, P = 0.121) in patients with infected nonunion of tibia and femur treated by Ilizarov methods. The rate of refracture, malunion, infectious recurrence, knee stiffness, amputation, limb edema and peroneal nerve palsy was respectively 4%, 7%, 5%, 12%, 4%, 13% and 13%.

Conclusions

Our systematic review showed that the patients with infected nonunion of tibia and femur treated by Ilizarov methods had a low rate of poor bone and functional results. Therefore, Ilizarov methods may be a good choice for the treatment of infected nonunion of tibia and femur.

Management of infected nonunion of the long bones by a multidisciplinary team

Infected nonunion of a long bone continues to present difficulties in management. In addition to treating the infection, it is necessary to establish bony stability, encourage fracture union and reconstruct the soft-tissue envelope. We present a series of 67 infected nonunions of a long bone in 66 patients treated in a multidisciplinary unit. The operative treatment of patients suitable for limb salvage was performed as a single procedure. Antibiotic regimes were determined by the results of microbiological culture. At a mean follow-up of 52 months (22 to 97), 59 patients (88%) had an infection-free united fracture in a functioning limb. Seven others required amputation (three as primary treatment, three after late failure of limb salvage and one for recalcitrant pain after union). The initial operation achieved union in 54 (84%) of the salvaged limbs at a mean of nine months (three to 26), with recurrence of infection in 9%. Further surgery in those limbs that remained ununited increased the union rate to 62 (97%) of the 64 limbs treated by limb salvage at final follow-up. The use of internal fixation was associated with a higher risk of recurrent infection than external fixation.

Infected nonunion of tibia and femur treated by bone transport

Objective

The objective of this study was to evaluate the effectiveness of the treatment of infected nonunion of tibia and femur by bone transport.

Material and methods

We retrospectively reviewed 110 patients with infected nonunion of tibia and femur treated by bone transport. Our study included 92 males and 18 females with a mean age of 38.90 years. The site of infected nonunion involved 72 tibias and 38 femurs. The mean length of the bone defects after radical debridement was 6.15 cm (range 3–13 cm).

Results

The mean follow-up after removal of the apparatus was 23.12 months (14–46 months). Ten patients including seven patients with infected tibia nonunion and three patients with infected femur nonunion were lost to follow-up. All the patients achieved bone union, and no recurrence of infection was observed. The time of bone transport took a mean of 67.50 days (range 33 to 137 days), and the mean external fixation index was 1.48 months/cm (range 1.15–1.71 months/cm). According to Association for the Study and Application of the Method of Ilizarov (ASAMI) classification, bone results were excellent in 68, good in 28, fair in 12, and poor in 2; functional results were excellent in 37, good in 42, fair in 21, and no poor.

Conclusions

Our study and the current evidence suggested that Ilizarov methods in the treatment of infected nonunion of tibia and femur acquired satisfied results. Radical debridement is the key step to control bone infection.

Combined use of Ilizarov external fixation and Papineau technique for septic pseudoarthrosis of the distal tibia in a patient with diabetes mellitus

The surgical treatment of open pilon fractures has a high complication rate especially in diabetic patients. In this article, we present a case of an infected tibial non-union after an open reduction and internal fixation in a diabetic patient, treated with Ilizarov external fixation combined with Papineau technique. Combined use of external fixation and Papineau technique can provide an alternative option for the treatment of septic pseudoarthrosis of the distal tibia.

Distraction osteogenesis in the treatment of long bone defects of the lower limbs: effectiveness, complications and clinical results; a systematic review and meta-analysis

We carried out a systematic review of the literature to evaluate the evidence regarding the clinical results of the Ilizarov method in the treatment of long bone defects of the lower limbs. Only 37 reports (three non-randomised comparative studies, one prospective study and 33 case-series) met our inclusion criteria. Although several studies were unsatisfactory in terms of statistical heterogeneity, our analysis appears to show that the Ilizarov method of distraction osteogenesis significantly reduced the risk of deep infection in infected osseous lesions (risk ratio 0.14 (95% confidence interval (CI) 0.10 to 0.20), p < 0.001). However, there was a rate of re-fracture of 5% (95% CI 3 to 7), with a rate of neurovascular complications of 2.2% (95% CI 0.3 to 4) and an amputation rate of 2.9% (95% CI 1.4 to 4.4).The data was generally not statistically heterogeneous. Where tibial defects were > 8 cm, the risk of re-fracture increased (odds ratio 3.7 (95% CI 1.1 to 12.5), p = 0.036). The technique is demanding for patients, illustrated by the voluntary amputation rate of 1.6% (95% CI 0 to 3.1), which underlines the need for careful patient selection.

Clinical outcomes of the Ilizarov method after an infected tibial non union

Background

The Ilizarov technique has been used in the UK for the last 20 years in the management of infected non-union of long bones. This method uses fine wires inserted percutaneously which are attached and tensioned to provide a strong frame construct. The majority of tibial and femoral non unions can be treated successfully by internal fixation. However, an infected non-union of the tibia can prove a difficult problem. The Ilizarov method can prove useful for treating these complex injuries.

Objectives

To assess whether a new limb reconstruction centre in the UK has comparable results.

Patients and Methods

Twelve patients (10 M: 2 F; Avg age 43.3 years) who had an infected tibial non-union between March 2009 and August 2010 treated with the Ilizarov technique. Intervention method was Ilizarov technique and main outcome measures include functional and radiological outcomes assessed using the Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria, American Orthopaedic Foot and Ankle Score (AOFAS) and Visual Analogue Pain scores.

Results

All twelve patients united. None required amputation. Mean time to union was 46 weeks (range 24 - 70/median 50). The average follow up time was 62 weeks (39 - 164/ median 59). According to the ASAMI score bone/radiological results ten were classed as excellent with the remainder being good. Functionally six were graded as excellent, four as good and two as poor. The average AOFAS score was 83/100 (70 - 90) and pain visual analogue scale (VAS) was two.

Conclusions

Our results in terms of ASAMI scores are comparable with the published literature. Furthermore, our return to work is better than most European studies (63%). All our patients said they would have the procedure again. We attribute this success partly to the multidisciplinary approach. We recommend early referral to a dedicated unit if there is any evidence of a non-union.

Metaphyseal locking compression plate as an external fixator for the distal tibia

PURPOSE

Recently we coined the term supercutaneous plating using a locking compression plate (LCP) as an external fixator. The use of this technique in peri-articular areas is facilitated by the development of anatomical plates with various screw sizes. The purpose of this report is to describe our results using the metaphyseal locking plate (LCP) as an external fixator in the treatment of infected post-traumatic problems of the distal tibia.

METHODS

Between August 2008 and January 2012 a total of seven patients underwent external plating ("supercutaneous plating") of the distal tibia using a metaphyseal locking plate. Average age was 43 years (range 20-79). Six out of seven patients had a documented infection at the time of external plate application. All patients in this cohort were followed prospectively at regular intervals by the senior author (PK).

RESULTS

The plate was in situ for an average of 17.5 weeks (range 6-60). There were no clinically significant pin site infections. In four patients the plate was kept in place until there was complete consolidation. In three patients the external plate was exchanged for formal internal fixation once the infection had subsided. At the latest follow-up (average 12.8 months, range 4-31), all patients were fully weight bearing with a fully healed tibia. All patients were infection-free with well-healed wounds.

CONCLUSION

Infection of the distal tibia after treatment of traumatic and post-traumatic problems is a challenging problem. It is common practice that after initial debridement and hardware removal, temporary bony stabilisation is provided by external fixation. Most external frames for the lower leg are bulky and cumbersome, causing significant problems for the patient. To circumvent these issues, we have successfully used an anatomically-contoured metaphyseal locking compression plate as external fixator in a series of seven patients for acute or post-traumatic problems of the tibia.

Outcome in patients with an infected nonunion of the long bones treated with a reinforced antibiotic bone cement rod

OBJECTIVES

This study looks at the treatment of 16 cases of infection in long bone fractures that had an adverse effect on healing. The goal was to find a method that may be effective in getting these most difficult injuries to heal. The use of reinforced antibiotic-impregnated bone cement rods was studied to see if this could be an effective form of treatment. The use of such devices makes sense because they provide stability that the fractures need for healing while also providing a high concentration of antibiotics locally. The concept was to reduce the amount of metal used for stability while still giving the fracture the correct milieu for healing.

DESIGN

This was a retrospective analysis of 16 patients with infected nonunions of long bones. A protocol for the use of intravenous and per oral antibiotics was developed based on the type of bacteria found from cultures of the infected sites. All cases included operative débridement and stabilization with a reinforced antibiotic-impregnated bone cement rod.

PATIENTS

The patient population was selected from all those who presented to the Department of Orthopaedic Surgery of Dayanand Medical College & Hospital, Ludhiana, India.

MAIN OUTCOME

Success was considered when the nonunion healed and the limb became functional.

RESULTS

The infected nonunions were treated successfully in 14 of 16 cases. This represents an alternative to external fixation alone as a means of stabilizing nonunions while providing a high concentration of antibiotic locally for combating this most difficult problem.

CONCLUSIONS

The use of reinforced antibiotic-impregnated bone cement rods with appropriate surgical débridement and antibiotics may be an effective way of treating infected nonunions of long bones.

LEVEL OF EVIDENCE

Therapeutic Level IV. See page 128 for a complete description of levels of evidence.

Treatment for large skeletal defects by free vascularized fibular graft combined with locking plate

BACKGROUND

Reconstruction of large skeletal defects secondary to osteomyelitis or open fracture is a challenging problem. The purpose of this study was to evaluate the results of using free vascularized fibular graft (FVFG) combined with locking plate in the treatment of large skeletal defects from open fracture and infection.

METHODS

Ten patients with a mean age of 34 years (ranged 13-57 years) and a mean length of 8.7 cm (range 6-17 cm) skeletal defect were treated with FVFG and locking plate. The mean follow-up time was 26 months.

RESULTS

Grafting union occurred in all patients, with a mean healing time of 4.5 months. No recurrence of osteomyelitis and stress fractures was observed. The mean time to full weight-bearing was 10 months, and all patients were pain-free and able to walk without supportive devices.

CONCLUSIONS

FVFG combined with locking plate is a viable option for the management of large skeletal defects from open fracture and infection.

Soft tissue and biomechanical challenges encountered with the management of distal tibia nonunions

A thoughtful treatment algorithm is required to optimally treat distal tibia nonunion. A healthy respect for the tenuous soft tissue envelope, compromised vascularity, and challenging mechanical environment is advisable. Achieving osseous union and improved functionality requires an individualized plan of care based on the personality of the nonunion and host. Attention must be focused on providing mechanical stability at the site of nonunion and providing biologic supplementation.

Management of vascular graft infections with soft tissue flap coverage: improving limb salvage rates--a veterans affairs experience

Graft infections are one of the most challenging issues in surgery with an incidence of 0.7 to 7 per cent, with femoral site infections being the most common (13% incidence). The gold standard treatment has been graft removal, wide débridement, and extra-anatomical bypass. Routine excision of infected peripheral arterial grafts and vascular reconstruction with extraanatomic conduits are associated with mortality rates ranging from 10 to 30 per cent and amputation rates of up to 70 per cent. As a result of the high morbidity and mortality associated with this approach, selective graft preservation techniques have been developed. Newer treatment plans discuss preservation of the graft with débridement and coverage of the infected region. Better wound care, nutrition optimization, and robust flap coverage have led to significantly improved graft salvage, lower amputation rates, and improved outcomes. The objective of this study was to evaluate the Veterans Affairs (VA) experience with flap coverage for femoral vascular graft infections. A retrospective review was conducted of all VA data from 1997 to 2008 with inclusion criteria of patients with deep groin wound infections requiring flap coverage after femoral bypass surgery. Eleven such patients were identified with a mean age of 73 years and with multiple comorbidities (hypertension, malnutrition, diabetes mellitus, chronic obstructive pulmonary disease, coronary artery disease, chronic renal insufficiency). Patients presented with wound drainage, exposed graft, hematoma, perigraft fluid collection, and pseudoaneurysm. Treatment protocol included: 1) aggressive débridement of the wound bed; 2) early soft tissue (flap) coverage; 3) wound vacuum assisted closure device or frequent dressing changes; and 4) skin graft once the bed was prepared. Eighty-two per cent of wounds had positive cultures with equal numbers of patients with Staphylococcus epidermidis, Pseudomonas, Escherichia coli (22%), and higher methicillin-resistant Staphylococcus aureus (33%), whereas in the literature Staphylococcus is the most common (greater than 50%). Average hospital length of stay was 94 days with average follow up at 10 months. Fifty-five per cent graft salvage (one Dacron [50%], two polytetrafluoroethylene [33%], two saphenous vein graft [100%], one cryovein [100%]) was achieved with 91 per cent limb salvage. Complications included graft blowout (two) requiring partial flap loss (one), retroperitoneal hematoma (one), limb loss (one), sepsis (one), and death (one). Infected vascular grafts remain a challenging problem requiring multidisciplinary care. Careful débridement and aggressive wound care followed by selective flap coverage appears to decrease morbidity and increase graft and limb salvage.

Do successful surgical results after operative treatment of long-bone nonunions correlate with outcomes?

There has been increased emphasis on validated, patient-reported functional outcomes after orthopaedic interventions for various conditions. The few reports on these types of outcomes after treatment of fracture nonunions are limited to specific anatomic sites, limited by small numbers, and retrospective. To determine whether successful healing of established long-bone nonunions resulted in improved functional outcomes and reduction in patient-reported pain scores, we prospectively followed 80 patients. These patients had a mean of 1.4 surgical procedures before enrollment and a mean of 18 months had elapsed from previous surgery until enrollment. Baseline data and functional scores were obtained before intervention. Seventeen of the 80 patients (21%) had positive intraoperative cultures. At a mean of 18.7 months (range, 12-36 months), 72 (90%) nonunions had healed. Patients with healed nonunions scored better on the Short Musculoskeletal Functional Assessment. Pain scores among all patients improved compared with baseline, but to a greater degree in patients who achieved healing by final followup. Our data suggest improvement in pain scores is seen in all patients after surgery, whereas successful internal fixation leads to improved function.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Management of infected femoral nonunions with a single-staged protocol utilizing internal fixation

PURPOSE

There are no reported series that specifically deal with repair of infected nonunions of the femur with revision internal fixation. We sought to determine whether a standardised treatment protocol we have used for 13 patients since 1992 results in a high union rate, resolution of infection, and a good functional outcome.

METHODS

The study cohort included seven male and six female patients who presented to the senior author with an infected nonunion of the shaft of the femur. Eleven patients with a minimum of 2-year follow-up and between the ages of 19 and 75 years (mean 53.2 years) were included and evaluated. All patients underwent a single-staged protocol that includes an antibiotic "holiday", then treating the infected nonunion with surgical debridement and hardware removal, local and systemic antibiotics, revision open reduction and internal fixation, and use of supplemental bone grafting. Great emphasis at the time of surgery is placed upon aggressive debridement, correction of any deformity, and obtaining stable internal fixation. We sought to report our success rate of nonunion repair, number of re-interventions, complication rate, final knee range of motion, and the ability to eradicate the infection using this treatment regimen.

RESULTS

At most recent follow-up (mean 5.6, range 2-12 years), all patients had united and resolved their infections. Ten of the patients healed their nonunions with the fixation placed at the time of initial revision by us. Five patients required re-interventions to ultimately attain fracture union. Four patients had additional bone grafting procedures at the time of antibiotic bead removal. One of these four patients, who was later diagnosed with a nickel allergy, required three subsequent revision open reduction and internal fixations with bone grafting for hardware failure and persistent nonunion. A final patient underwent nail dynamisation with achievement of osseous union. Only one patient had less than 90 degrees of knee flexion, although he previously had an extensor mechanism disruption and had only 15 degrees of flexion noted at the time of initial surgery performed by us.

CONCLUSION

The results of this study indicate that our standard protocol for treatment of infected nonunion of the shaft of the femur is reliable at obtaining fracture union with a good functional result, while resolving infection despite the reliance upon internal fixation.

Distal tibia nonunions

Although tibia metaphyseal nonunion is rare, its treatment is often complex. The merits of related management techniques are discussed. These techniques include: intramedullary nailing, fine wire fixation, and blade plate reconstruction, which is the method preferred by the authors.

Ilizarov methodology for infected non union of the Tibia: Classic circular transfixion wire assembly vs. hybrid assembly

INTRODUCTION

Conventional wire fixation of Ilizarov rings often fails to provide 90-90 configuration because of vital structures, which is essential for optimum stability. Hybrid assembly with half pins is an alternative. The aim of this study is to compare the results of Hybrid assembly with that of conventional classic circular transfixion wire Ilizarov assembly in 50 cases of infected nonunion of tibia between 1994 and 2003.

MATERIALS AND METHODS

This study includes two groups with 25 patients in each group: Group (A) conventional Ilizarov assembly and Group (B) hybrid Ilizarov assembly. Thirty-five cases developed infected nonunion following road traffic accidents while others after fall (6) bullet injury (4), infected osteosynthesis (3) and assault (2). There were 45 males and five females with mean age (18 to 56 years). All active cases (n=28) were treated by debridement including removal of implants in infected osteosynthesis. Twenty out of 22 cases in the quiescent group (non draining for last three consecutive months) were treated without open debridement; only two cases required open debridement for various reasons. All the cases were finally treated as atrophic aseptic nonunion with bone defect and were classified according to ASAMI. Type B1: length of the limb maintained with bone gap (14 cases in both Group A and B) and Type B3: combined shortening with defect (five and seven cases in Group A and B respectively), were treated by bifocal osteosynthesis. Only one case in the B3 group was treated by trifocal osteosynthesis to shorten the time. Type B2: segments in contact with limb shortening (total nine cases; five and four cases in Group A and B respectively) with shortening up to 2 cm (total five cases) were treated with monofocal osteosynthesis while shortening up to 5 cm and beyond (total four cases) were treated with bifocal osteosynthesis.

RESULTS

The cases were followed up for two to six years and the results were evaluated by Paley criteria of bony results (union, infection, deformity and leg-length discrepancy) and Functional Results (significant limp, equinus rigidity of the ankle, soft-tissue dystrophy, pain and inactivity). In both the groups, 24 cases out of 25, had excellent to good bony result with Group B having twice more excellent result than Group A. Functional results were found to be similar in both the groups. Although persistence of infection and Grade III pin tract infection (PTI) were slightly higher in Group B, complications like delayed consolidation of regenerate, refracture, deformity and aneurysm of vessel were less in this group.

DISCUSSION AND CONCLUSION

Ilizarov methodology produced a satisfactory result in infected nonunion of the tibia. Hybrid assembly was a fruitful advancement in the Ilizarov armamentarium. The results were comparable to Conventional assembly in terms of docking site problems, corticotomy site problems, PTIs and other problems.

Antibacterial effect of autologous platelet gel enriched with growth factors and other active substances

Platelet-rich plasma is a new inductive therapy which is being increasingly used for the treatment of the complications of bone healing, such as infection and nonunion. The activator for platelet-rich plasma is a mixture of thrombin and calcium chloride which produces a platelet-rich gel.

We analysed the antibacterial effect of platelet-rich gel in vitro by using the platelet-rich plasma samples of 20 volunteers. In vitro laboratory susceptibility to platelet-rich gel was determined by the Kirby-Bauer disc-diffusion method. Baseline antimicrobial activity was assessed by measuring the zones of inhibition on agar plates coated with selected bacterial strains.

Zones of inhibition produced by platelet-rich gel ranged between 6 mm and 24 mm (mean 9.83 mm) in diameter. Platelet-rich gel inhibited the growth of Staphylococcus aureus and was also active against Escherichia coli. There was no activity against Klebsiella pneumoniae, Enterococcus faecalis, and Pseudomonas aeruginosa. Moreover, platelet-rich gel seemed to induce the in vitro growth of Ps. aeruginosa, suggesting that it may cause an exacerbation of infections with this organism. We believe that a combination of the inductive and antimicrobial properties of platelet-rich gel can improve the treatment of infected delayed healing and nonunion.

Modified Ilizarov technique for infected nonunion of the femur: the principle of distraction-compression osteogenesis

PURPOSE

To evaluate the treatment outcome of the modified Ilizarov technique in infected nonunion of the femur.

METHODS

Between 1989 and 2002, records of 20 patients with infected nonunion of the femur treated with the modified Ilizarov technique were retrospectively reviewed. The modified Ilizarov frame was fixed after necrectomy of the dead infected bone and tissues. A proximal or distal corticotomy was performed following biological principles. For regeneration of gap, segmental transport was performed in 11 patients with a gap of more than 5 cm; acute docking followed by lengthening at the corticotomy site was performed in 9 patients with a gap of smaller than 5 cm. Mobilisation was started early with active participation of the physical therapist and the patients. Bone and functional results were measured and complications were categorised according to the Association for the Study and Application of the Method of Ilizarov guidelines.

RESULTS

The mean follow-up period was 62.8 months. Bony union and eradication of the infection was achieved in all patients except one who underwent amputation due to uncontrolled infection. Bone results were excellent in 13 patients, good in 4, fair in one, poor in one, and treatment failure (amputation) in one. Functional results were excellent in 3 patients, good in 9, fair in 3, poor in 4, and failure in one. A total of 71 complications occurred: 35 problems, 6 obstacles, and 30 true complications. The mean healing index was 38.3 day/cm (standard deviation, 1.6 day/cm).

CONCLUSION

The Ilizarov technique is a good salvage operation for infected nonunion of the femur. Limb salvage is preferable to prosthesis if the limb is viable, adequately innervated and the patient is mentally and financially committed to save the limb.

Acute compression and lengthening by the Ilizarov technique for infected nonunion of the tibia with large bone defects

PURPOSE

To assess the Ilizarov technique in treating large infected tibial defects by resection of the infected focus, its acute compression, and gradual distant site lengthening.

METHODS

27 men (mean age, 39 years) with infected nonunion and large bone defects of the tibia underwent complete resection of the nonunion site, debridement, sequestrectomy, lavage, and Ilizarov ring fixator application. Patients underwent acute compression of the defect site, followed by distant site metaphyseal corticotomy for simultaneous lengthening. The mean length of resection was 10 (range, 6-17) cm. The mean follow-up was 27 (range, 25-39) months.

RESULTS

The mean lengthening achieved was 10 cm, mean union time 6.3 months, and mean duration of consolidation 10.2 months. Functional results were excellent in 19 patients and good in 5. The union time was longer in older patients.

CONCLUSION

Acute compression and simultaneous lengthening can be used safely for treatment of large bone defects in the tibia. This avoids secondary operations at the docking site and reduces the duration of treatment.

Temporary intentional leg shortening and deformation to facilitate wound closure using the Ilizarov/Taylor spatial frame

Infected tibial nonunions with bone loss pose an extremely challenging problem for the orthopaedic surgeon. A comprehensive approach that addresses the infection, bone quality, and overlying soft-tissue integrity must be considered for a successful outcome. Acute shortening with an Ilizarov frame has been shown to be helpful in the treatment of open tibia fractures with simultaneous bone and soft-tissue loss. Cases in which the soft-tissue defect considerably exceeds bone loss may require an Ilizarov frame along with a concomitant soft-tissue procedure; however, there are a number of potential difficulties with vascularized pedicle flaps and free tissue flaps, including anastomotic complications, partial flap necrosis, and flap failure. The technique described in this report involves acute shortening and temporary bony deformation with the Ilizarov apparatus to facilitate wound closure and does not require a concomitant soft-tissue reconstructive procedure. Once the wound is healed, osseous deformity and length are gradually corrected by distraction osteogenesis with the Ilizarov/Taylor Spatial frame.

Chronic posttraumatic osteomyelitis and infected nonunion of the tibia: current management concepts

Chronic posttraumatic osteomyelitis and infected nonunion of the tibia are complex problems that result in considerable morbidity and can threaten viability of the limb. Development of infection may result from compromised soft tissue and bone vascularity, systemic compromise of the host, and virulent or resistant organisms. Biofilm formation on implant and devascularized bone surfaces protects pathogens and may lead to persistence of infection. Management is based on a detailed evaluation of the patient, the involved bone and soft tissues, degree of associated lower extremity injury, and type of bacterial pathogens. Infection control is achieved with radical débridement, skeletal stabilization, and microbial-specific antibiotics. Local antibiotic delivery is a useful supplement to systemic administration. Local or free muscle flaps may be necessary to achieve soft-tissue coverage. Restoration of bone defects and bony union can be accomplished with bone grafting. However, large defects require complex reconstructive procedures, such as distraction osteogenesis and vascularized bone grafting.

Reconstruction with Distraction Osteogenesis for Juxta-articular Nonunions with Bone Loss

BACKGROUND

Nonunions of a juxta-articular lesion with bone loss, which represent a challenging therapeutic problem, were treated using external fixation and distraction osteogenesis.

METHODS

Seven juxta-articular nonunions (five septic and two aseptic) were treated. The location of the nonunion was the distal femur in four patients, the proximal tibia in one patient, and the distal tibia in two patients. All of them were located within 5 cm from the affected joints. Preoperative limb shortening was present in six cases, averaging 2.9 cm (range, 1-7 cm). The reconstructive procedure consisted of refreshment of the nonunion site, deformity correction, stabilization by external fixation, and lengthening to eliminate leg length discrepancy or to fill the defect. Shortening-distraction was applied to six patients and bone transport to one patient for reconstruction. Intramedullary nailing to reduce the duration of external fixation was simultaneously performed in two cases. All the patients had at least 1 year of follow-up evaluation.

RESULTS

Osseous union without angular deformity or leg length discrepancy greater than 1 cm was achieved in all patients. The mean amount of lengthening was 5.8 cm (range, 2.2-10.0 cm). The mean external fixation period was 219 days (range, 98-317 days), and the mean external fixation index was 34.4 days/cm (range, 24.5-47.6 days/cm). All patients reported excellent pain reduction. There were no recurrences of infection in five patients with prior history of osteomyelitis. The functional results were categorized as excellent in two, good in three, and fair in two.

CONCLUSION

Despite the length of postoperative external fixation, distraction osteogenesis can be a valuable alternative for the treatment of juxta-articular nonunions.

Infected nonunion of the long bones

The problems in infected nonunion include multiple sinuses, osteomyelitis, bone and soft tissue loss, osteopenia, adjacent joint stiffness, complex deformities, limb-length inequalities, and multidrug-resistant polybacterial infection. Bone gap and active infection are the crucial factors relating to treatment and prognosis. Gaps larger than 4 cm likely cannot be effectively bridged by corticocancellous bone grafting. If the limb has intact distal circulation and sensation, limb salvage and reconstruction generally is preferable to amputation. The fracture generally unites if adequate debridement of the nonunion site is done with fracture stabilization and bone grafting. We reviewed 42 consecutive patients with infected nonunion of the long bones. These patients have been categorized into two groups. Type A is infected nonunion of long bones with nondraining (quiescent) infection, with or without implant in situ; Type B is infected nonunion of long bones with draining (active) infection. Both are classified further into two subtypes: 1) nonunion with a bone gap smaller than 4 cm or 2) nonunion with a bone gap larger than 4 cm. Single-stage debridement and bone grafting with fracture stabilization are the methods of choice for Type A1 infected nonunions. Adequate debridement, fracture stabilization, and second-stage bone grafting gives desirable results in Type B1 infected nonunions. Distraction histiogenesis is the preferred procedure for Type A2 and B2. The autogenous nonvascularized fibular graft, posterolateral bone grafting for the tibia, and centralization of the ulna over distal radial remnant (single bone forearm) may be good treatment options in selected cases.

Ununited diaphyseal forearm fractures with segmental defects: plate fixation and autogenous cancellous bone-grafting

BACKGROUND

With current techniques of plate-and-screw fixation, diaphyseal nonunions of the radius and ulna are unusual. The few reports that have been published have discussed the use of structural corticocancellous bone grafts for the treatment of atrophic nonunions that are associated with osseous defects. We reviewed the rate of union and the functional results in association with the use of plate-and-screw fixation and autogenous cancellous (nonstructural) bone grafts.

METHODS

Thirty-five patients with an atrophic ununited diaphyseal fracture of the forearm were treated with 3.5-mm plate-and-screw fixation and autogenous cancellous bone-grafting. A segmental osseous defect with an average size of 2.2 cm (range, 1 to 6 cm) was present in each patient. Twenty of the original fractures had been open. Eleven patients had had treatment of a deep infection before referral to us. The nonunion involved both forearm bones in eight patients, the radius alone in sixteen patients, and the ulna alone in eleven patients.

RESULTS

The atrophic nonunion was associated with an open fracture in twenty patients, suboptimal fixation in twenty-two, a fracture-dislocation of the forearm in nine, and infection in eleven. All fractures healed without additional intervention within six months. Two patients had a subsequent Darrach resection of the distal part of the ulna for the treatment of arthrosis of the distal radioulnar joint. After an average duration of follow-up of forty-three months, the final arc of motion averaged 121 degrees in the forearm, 131 degrees at the elbow, and 137 degrees at the wrist, with an average grip strength of 83% compared with that of the contralateral limb. According to the system of Anderson and colleagues, five patients had an excellent result, eighteen had a satisfactory result, eleven had an unsatisfactory result (because of elbow stiffness related to associated elbow injuries in three and because of wrist stiffness in eight), and one had a poor result (because of malunion).

CONCLUSIONS

When the soft-tissue envelope is compliant, has limited scar, and consists largely of healthy muscle with a good vascular supply, autogenous cancellous bone-grafting and stable internal plate fixation results in a high rate of union and improved upper limb function in patients with diaphyseal nonunion of the radius and/or ulna.

Nonunions of the distal tibia treated by reamed intramedullary nailing

OBJECTIVE

The purpose of this study is to determine the efficacy of reamed intramedullary nailing in the treatment of nonunions of the distal one-fourth of the tibia. Nonunions of the distal tibia are particularly difficult to treat given the short distal segment, the proximity to the ankle joint, and the fragile soft-tissue envelope. Intramedullary nailing is an attractive solution to this problem because it avoids extensive dissection, and the implant remains intraosseous, posing minimal problem for the soft tissues.

DESIGN

Retrospective review of patient charts and radiographs.

SETTING

Tertiary care orthopaedic hospital.

PATIENTS/PARTICIPANTS

Thirty-two patients with nonunions of the distal one-fourth of the tibia. Prior treatments included casting, internal fixation with plates and screws, intramedullary nailing, and external fixation. Seven patients had a history of infection, but no patient had signs of active infection at the time of surgery.

INTERVENTION

Study patients were treated by reamed, locked intra-medullary nailing.

MAIN OUTCOME MEASUREMENTS

Main outcome measurements included time to union, correction of deformity, and complications including infection and reoperation.

RESULTS

Average length of follow-up was 25 months (range 4-81 months). Twenty-nine out of 32 patients achieved union at an average of 3.5 months after reamed, locked intramedullary nailing. Of the remaining three, 2 patients united after dynamization (one at 4 months after dynamization and the other at 7 months), and the third patient united 4 months after exchange nailing. Deformity was corrected to a maximum of 4 degrees in all planes. Four patients had positive intraoperative cultures, and only 2 required removal of the nail after achieving union to control infection. There were no signs of chronic osteomyelitis in these 2 patients at the date of the last follow-up visit; 5.5 years and 2 years following nail removal.

CONCLUSIONS

Reamed, locked intramedullary nailing is a reliable and safe procedure in the treatment of nonunions in the distal one-fourth of the tibia, even in the setting of prior infection or external fixation. It allows for excellent correction of deformity, which is an essential component of the procedure.

Bone transport in the management of posttraumatic bone defects in the lower extremity

BACKGROUND

The aim of this study was to evaluate the clinical and functional outcomes of traumatic bone defects of the lower extremity managed by internal bone transport using the Ilizarov technique.

METHODS

We retrospectively reviewed 19 patients who underwent internal bone transport for traumatic bone defects in the lower extremity. Mean follow-up was 68.7 months (5.7 years). Eighteen cases were open: grade IIIA, 10 cases; grade IIIB, 4 cases; and grade IIIC, 4 cases.

RESULTS

Clinical outcome was 2 excellent, 11 good, 4 fair, and 2 poor. Eighteen of 19 patients reported being satisfied. The results of the SF-36 Health Survey showed a significant difference between the population norm and the mean of the study group in Physical Functioning, Bodily Pain, and Role-Emotional. The mean length of time in external fixation for all patients was 13.8 months. The mean length of regenerate was 5.7 cm (range, 0.8-20.4 cm). The total number of complications was 39 (20 minor and 19 major). Major complications included two transtibial amputations and four fractures at the docking site.

CONCLUSION

Although the number of complications was high, the patients in this study were satisfied to have their limbs preserved. The SF-36 Health Survey showed that patients suffer mainly from physical and emotional consequences after these major injuries. Their general, social, and mental health is usually not affected. Infection significantly increased the healing index. The limb should be protected for a long time, with careful evaluation to avoid fracture at the docking site after fixator removal.

Long-Term Results of Multiple-Stage Treatment for Posttraumatic Osteomyelitis of the Tibia

BACKGROUND

The treatment of posttraumatic osteomyelitis of the tibia requires meticulous debridement and adequate soft tissue coverage. At our institution, we perform a staged procedure consisting of surgical debridement followed by muscle coverage. If necessary, implantation of a cancellous iliac bone graft was always performed as a three-stage treatment.

METHODS

We performed a retrospective analysis of 47 patients treated for posttraumatic osteomyelitis of the tibia between 1987 and 1998.

RESULTS

Twenty-two patients originally had a Gustilo grade III fracture, 21 patients had a Gustilo grade I or II or closed fracture, the Gustilo grade was not known for 2 patients, and 2 patients had no fracture. Using the Cierny-Mader classification, most patients had a localized osteomyelitis. To cover the debrided area, 20 pedicled muscle transfers and 28 microvascular free flaps were used; one patient had two localizations of osteomyelitis (both proximal and distal) and received two muscle flaps. Flap failure was 8% and was successfully treated by additional flap coverage in two cases; one was closed by a split skin graft and one was closed by secundum. Twenty-six patients received a cancellous bone graft. During an average follow-up of 94 months, 9% had a recurrence of osteomyelitis for which additional surgical interventions were necessary. Finally, all the infections were eventually cured.

CONCLUSION

Our staged surgery proved to be an excellent method of treating osteomyelitis after open or closed fractures of the tibia.

Treatment of nonunions and osseous defects with bone graft and calcium sulfate

The treatment of long bone nonunions and fractures with osseous defects is challenging. The results of 26 patients with either a persistent long bone nonunion or an osseous defect after an open fracture were reviewed. Each patient was treated with debridement of devitalized tissue, open reduction and internal fixation, and bone grafting using a mixture of autogenous iliac crest bone graft and medical grade calcium sulfate. The current study evaluated the union rate and associated complications for treatment of these injuries using this protocol. Each nonunion was confirmed intraoperatively, and healing was determined clinically by the patients' return to full activities without pain and radiographically by the presence of bridging trabeculae. Complications included persistent nonunion (four patients), wound drainage (five patients), wound drainage and cellulitis (one patient) and cellulitis alone (one patient). Using this treatment protocol, 22 patients (85%) achieved healing after one surgery and an additional two patients (92%) achieved healing after a second surgery. Medical grade calcium sulfate increases the volume of graft material, facilitates bone formation, and is safe in the treatment of nonunions and fractures with osseous defects.