微创Ilizarov外固定架治疗胫骨感染性骨不连

目的评价Ilizarov外固定架下采用骨延长技术治疗胫骨感染性骨不连的临床结果及功能情况。方法22例胫骨感染性骨不连患者感染端进行清创后骨缺损的长度为4．1～12．6（6．72±2．42）cm。其中21例为小面积软组织缺损者,采用局部皮瓣转移覆盖,1例大面积软组织缺损者（8cm×5cm）,采用腓肠肌皮瓣转移术覆盖创面,22例均采用Ilizarov外固定架进行骨延长治疗。结果22例均获得随访,时间12～24（17．64±3．84）个月。骨不连均获得愈合,愈合时间7～19（9．86±3．01）个月,感染均得到控制。10例在延长过程中有局部针道渗液,治疗后愈合。牵引成骨的长度为4．1～12．6（6．72±2．42）cm。根据Paley骨折愈合评分标准：优13例,良7例,中2例。结论对于胫骨感染性骨不连,使用Ilizarov外固定架进行骨延长治疗临床结果及功能恢复满意。     

The treatment of infected nonunion of the tibia following intramedullary nailing by the Ilizarov method

The purpose of this study was to demonstrate the effectiveness of the Ilizarov method and circular external fixator in order to eradicate the infection and restore bone union, limb anatomy and functionality in cases with infected nonunion of the tibia following intramedullary nailing.During 7 years nine patients suffering from infected nonunion of the tibia after intramedullary nailing were treated in our department. The series comprised seven men and two women with an average age of 39.7 years (range 21-75 years). The patients had previously undergone an average of 4.8 operations (range 3-6 operations). Active purulent bone infection occurred in all nine patients. Bone defect was present in all patients with a mean size of 5 cm (range 2-12 cm). In three cases with bone defect less than 2 cm, monofocal compression osteosynthesis technique was used. In the rest cases where bone defect exceeded 2 cm, bifocal consecutive distraction-compression osteosynthesis technique was applied. Three patients required a local gastrocnemius flap. The mean follow-up period was 26.6 months (range 13-42 months). Results were evaluated using Paley's functional and radiological scoring system.Bone union was achieved in all nine patients without recurrence of infection during the follow-up period. Bone results were graded as excellent in five cases and good in the rest four cases. Functional results were graded as excellent in three cases, good in four and fare in two cases. Mean external fixation time was 187.4 days (range 89-412 days) and mean lengthening index was 32 days/cm (range 27-39 days/cm). Complications observed included eight grade II pin tract infections, axial deformity at the lengthening site in two cases and at the nonunion site in another two cases. Ankle joint stiffness was detected in five cases.The Ilizarov method may be an effective method in infected nonunions of the tibia following intramedullary nailing.     

Ilizarov技术自体骨段延长治疗胫骨感染性骨折不愈合伴骨缺损

目的 探讨Ilizarov技术自体骨段延长治疗胫骨感染性骨折不愈合的疗效.方法 2000年9月至2006年6月共收治胫骨感染性骨折不愈合伴骨缺损患者14例,男11例,女3例;年龄19～49岁,平均31.9岁;胫骨近端3例,中段8例,远端3例.原始损伤:5例为开放骨折钢板内固定,3例为开放骨折髓内钉内固定,4例为开放骨折外固定架固定,2例为闭合骨折钢板内固定术后所致.患者自受伤至此次治疗时间为2～24个月,平均7.54个月;手术次数平均6次(3～14次).根据Jain骨缺损和感染程度分型:A2型5例,B1型2例,B2型7例.窦道形成10例,骨外露4例;骨外露面积最大7 cm×5 cm,最小2 cm×1 cm;清创后骨缺损长度3～12 cm,平均6.71 cm.14例患者均采用清创联合Ilizarov技术自体骨段延长治疗.结果 14例患者均获8个月～6年(平均20个月)随访,均获稳定骨折愈合.住院时间1～7个月,平均3个月;骨折愈合时间6～12个月,平均7.79个月;骨外固定时间8～14个月,平均9.64个月.并发症:针道感染1例,皮肤过敏1例,骨折畸形愈合再截骨1例,提前矿化再截骨1例,断针1例,无深部感染、骨折不愈合和膝关节僵直发生.根据Paley骨折愈合评分标准:优13例,良1例.结论 Ilizarov骨段延长是治疗胫骨感染性骨折不愈合伴大段骨缺损的一种有效方法.     

Knee arthrodesis with simultaneous lengthening using the Ilizarov method

OBJECTIVE: To determine whether knee arthrodesis with simultaneous lengthening using the Ilizarov method for a nonreconstructable knee joint with bone loss and infection is a successful salvage procedure. DESIGN: Retrospective review of patients. SETTING: University hospital-based orthopaedic practice. PATIENTS: From 1999 to 2001, 4 consecutive patients with a nonreconstructable knee joint, bone loss, and infection after trauma underwent knee arthrodesis with simultaneous lengthening. INTERVENTION: Arthrodesis of the knee with simultaneous limb lengthening through an osteotomy of the tibia and/or femur and the use of an Ilizarov frame. External bone stimulation was used at the knee arthrodesis site and the lengthening sites. Application of this device began during the early distraction phase and continued until frame removal. MAIN OUTCOME MEASURES: Bony union at the arthrodesis and bone lengthening sites, alignment of the lower extremity, limb length discrepancy, infection, pain, and outcome scales (SF-36 scores and American Academy of Orthopaedic Surgeons lower limb modules). RESULTS: Bony union of the knee arthrodesis and lengthening sites and good alignment were achieved in all 4 patients. Mean amount of lengthening was 5.4 cm (range 2.5-11.5 cm). Average time in frame was 11 months (range 6-17 months). Limb length discrepancy after treatment averaged 1.8 cm (range 0.6-3.7 cm). Mean duration of follow-up after frame removal was 35 months (range 28-48 months). At follow-up, infection had not recurred, pain was not present, and assistive devices were not needed for ambulation. Average SF-36 scores improved in all 8 categories, and the average American Academy of Orthopaedic Surgeons lower limb modules improved from a mean of 33 (range 11-37) to a mean of 68 (range 51-76). CONCLUSION: Knee arthrodesis with simultaneous lengthening can be performed successfully using the Ilizarov method. It enables surgeons to optimize limb length during knee arthrodesis. The use of external fixation and the avoidance of internal implants may be advantageous in the presence of or history of infection. The Ilizarov frame provides stability that allows weight bearing during treatment.     

外固定技术治疗骨折内固定术后难治性骨不连并骨缺损

目的 探讨外固定技术不植骨治疗骨折内固定术后难治性骨不连并骨缺损的临床疗效.方法 自2002年4月至2008年12月收治17例骨折内固定术后难治性骨不连及骨缺损患者,男12例,女5例;年龄ll～50岁,平均34.7岁.骨不连部位:胫骨10例,股骨5例,肱骨2例;骨不连时间8～21个月,平均16.3个月;既往接受手术次数1～3次,平均1.6次;骨缺损长度2.5～11.0 cm,平均3.5 cm.采用短缩加压结合延长和骨节段延长转位两种外固定基本方法治疗,观察骨折愈合及伤肢功能情况.结果 17例骨不连均骨性愈合,愈合时间3～21个月,平均5.2个月.12例伴有肢体短缩的骨不连并骨缺损患者同期或二期重建了肢体长度,达到了肢体长度均衡,平均骨延长4.8 cm,愈合时间4～11个月,平均5.2个月,骨愈合指数平均32 d/cm.结论 采用外固定技术治疗难治性骨不连并骨缺损,其弹性固定有利于骨折愈合,干骺端截骨延长有效重建了肢体长度,达到了肢体长度平衡并可早期下地活动,可视为一种疗效确切的微创生物学治疗技术.     

Functional outcome following treatment of segmental skeletal defects of the forearm bones by Ilizarov application

Managing a segmental skeletal defect is a challenge, even more so if the combination of local infection with bone defect exacerbates the problem and provides an even more negative prognosis. Several techniques have been tried, among which skeletal allografts, autologous cortical or cancellous bone graft and vascularised bone graft, each with its limitation and success. In this study, we report our results with the Ilizarov method of bone transport to overcome bone defects of forearm bones due to infection. This series included 16 patients with bone defects of forearm bones, following either debridement of osteomylitis or infected nonunion. The mean time from injury to the Ilizarov procedure was 11.7 months. The mean number of operative procedures before application of the Ilizarov device was 3.4. The mean length of the defects after debridement was 6.4 cm. Monofocal osteotomy was performed. The mean external fixation index, distraction index and maturation index were 41.5 days/cm, 19.8 days/ cm, and 21.7 days/cm respectively. The mean time in the frame was 8.9 months. The mean total duration of treatment was 11.4 months. There were 14 complications in 11 patients including pin-track infection, premature consolidation, delayed union at the docking site and refracture. Ilizarov's technique of bone transport is an ideal solution for a large skeletal defect in spite of the high incidence of associated complications.     

Ilizarov treatment of tibial nonunions with bone loss

Twenty-five patients aged 19-62 years were treated for tibial nonunions (22 atrophic, three hypertrophic) with bone loss (1-23 cm, mean 6.2 cm) by the Ilizarov technique and fixator. Thirteen had chronic osteomyelitis, 19 had a limb-length discrepancy (2-11 cm), 12 had a bony defect (1-16 cm), and 13 had a deformity. Six had a bone defect with no shortening, 13 had shortening with no defect, and six had both a bone defect and shortening. Nonunion, bone defects, limb shortening, and deformity can all be addressed simultaneously with the Ilizarov apparatus. Bone defects were closed from within without bone grafts by the Ilizarov bone transport technique of sliding a bone fragment internally, producing distraction osteogenesis behind it until the defect is bridged (internal lengthening). Length was reestablished by distraction of a percutaneous corticotomy or through compression and subsequent distraction of the pseudarthrosis site (external lengthening). Distraction osteogenesis resulting from both processes obviated the need for a bone graft in every case. Deformity was corrected by means of hinges on the apparatus. Infection was treated by radical resection of the necrotic bone and internal lengthening to regenerate the excised bone. Union was achieved in all cases. The mean time to union was 13.6 months, but it was only 10.6 months if the time taken for unsuccessful compression-distraction of the nonunion is eliminated from the calculation. The bone results were excellent in 18 cases, good in five, and fair in two based on union in all cases, persistent infection in three, deformity in four, and limb shortening in one. The functional results were excellent in 16 cases, good in seven, fair in one, and poor in one based on return to work and daily activities in all cases, limp in four cases, equinus deformity in five cases, dystrophy in four cases, pain in four cases, and voluntary amputation for neurogenic pain in one case.     

骨搬移治疗胫骨感染性骨不连

目的分析骨搬移治疗胫骨感染性骨不连的临床疗效。方法2002年10月至2007年10月采用胫骨感染骨端清创、重建外固定支架加压固定及胫骨干骺端截骨骨搬移治疗胫骨感染性骨不连、纠正肢体短缩畸形45例。结果45例胫骨感染均得到一期控制,软组织缺损创面消灭,4例出现钉道感染;44例骨折愈合,1例骨折端再次形成骨不连;39例双下肢长度基本恢复一致,6例仍有1．5～3cm肢体短缩畸形存在,1例因截骨端提前愈合使肢体未能达到预期长度;术后截骨端骨延长2～9cm,平均延长6cm,无血管及神经损伤的症状出现;术后外固定支架固定6～12个月,平均8个月,所有病例延长区新骨组织形成良好。结论采用骨搬移治疗胫骨感染性骨不连,能达到一次手术兼顾控制骨端感染、消灭皮肤创面、骨折端不需植骨达到骨性愈合及均衡肢体长度的临床治疗作用,是治疗胫骨感染性骨不连的理想方法。     

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.     

镶嵌式外固定器治疗胫骨创伤后感染性骨不连

目的评价镶嵌式外固定器治疗胫骨骨干创伤感染性骨不连的临床疗效。方法43例胫骨创伤感染性骨不连均采用镶嵌式外固定器治疗,20例采用两段式镶嵌式外固定器加压,23例采用三段式外固定器行截骨延长,骨不连端加压。结果术后随访10～41个月,43例骨不连均获得骨性愈合,愈合时间6～25个月。根据改良ASAMI标准评定：非延长组：骨评定优14例,良3例,差3例;功能评定优13例,良3例,中4例。延长组：骨评定优16例,良4例,中2例,差1例;功能评定优14例,良4例,中3例,差2例。14例43处钉道感染,1例再发骨髓炎,经再次手术后治愈。结论镶嵌式外固定器治疗胫骨创伤后感染性骨不连可实现骨延长与加压及一定程度的角度和长度矫正,技术操作简单,初步应用疗效满意,且骨折端开放换药的方法更容易被医师和患者接受。     

Treatment of malunion and nonunion at the site of an ankle fusion with the Ilizarov apparatus

BACKGROUND: Malunion and nonunion of an ankle fusion site are associated with pain, osteomyelitis, limb-length discrepancy, and deformity. The Ilizarov reconstruction has been used to treat these challenging problems. METHODS: We reviewed the results in twenty-one ankles that had undergone a revision of a failed fusion, with simultaneous treatment of coexisting pathologic conditions, with use of the Ilizarov technique. Eight patients had undergone ankle fusion only, eleven had undergone ankle and subtalar fusion, and two had undergone pantalar fusion. Eighteen patients with an average limb-length discrepancy of 4 cm underwent limb lengthening simultaneously with the revision surgery. The average patient age was forty years. Indications for treatment were malunion (eleven patients), aseptic nonunion (eight patients), and infected nonunion (two patients). Clinical, subjective, objective, gait, and radiographic analyses were performed after an average duration of follow-up of 83.4 months. RESULTS: Solid union was achieved in all ankles. The functional result was excellent for fifteen patients, good for three, fair for two, and poor for one. The bone result was excellent for ten ankles, good for nine, fair for one, and poor for one. All eighteen patients who underwent gait analysis had a heel-to-toe progression gait, and twelve achieved normal walking velocity with their shoes on. A plantigrade foot was achieved in each case, and only two patients had >5 degrees of residual deformity. During the Ilizarov treatment, forty-one minor complications (treated conservatively) and twenty major complications (treated surgically) occurred. After removal of the circular frame, seven other complications, which required four additional operations, occurred. CONCLUSIONS: In patients with a failed ankle fusion, infection, limb-length discrepancy, and foot deformity can be addressed simultaneously with use of the Ilizarov apparatus to achieve a solid union and a plantigrade foot, usually with a clinically satisfactory result.     

Distraction osteogenesis for tibial nonunion with bone loss using combined Ilizarov and Taylor spatial frames versus a conventional circular frame

This retrospective review assesses 55 tibial nonunions with bone loss to compare union achieved with combined Ilizarov and Taylor spatial frames (I–TSF) versus a conventional circular frame with the standard Ilizarov procedure. Seventeen (31 %) of the 55 nonunions were infected. Thirty patients treated with I–TSF were compared with 25 patients treated with a conventional circular frame. In the I–TSF group, an average of 7.6 cm of bone was resected and the lengthening index (treatment time in months divided by lengthening amount in centimeters) was 1.97. In the conventional circular frame group, a mean of 6.5 cm was resected and the lengthening index was 2.1. Consolidation at the docking site and at the regenerate bone occurred in 49 (89 %) of 55 cases after the first procedure. No statistically significant difference was shown between the two groups. Superiority of one modality of treatment over the other cannot be concluded from our data. Application of combined Ilizarov and Taylor spatial frames for bone transport is useful for treatment of tibial nonunion with bone loss. Level of evidence Case series, Level III.     

应用Ilizarov技术治疗长管状骨缺损性骨不连

目的探讨和总结应用Ilizarov技术治疗长管状骨复杂缺损性骨不连的重建方式及疗效。方法1996年1月至2005年1月,收治长管状骨缺损性骨不连患者61例,男46例,女15例;年龄6～55岁,平均28.2岁。胫骨29例,股骨9例,肱骨11例,桡骨7例,尺骨5例。骨缺损长度4～14cm,平均6.4cm。选择骨缺损4￣6cm的30例患者行Ilizarov截骨肢体延长术,骨缺损6￣9cm的21例患者行Ilizarov骨节段截骨后传送延长术,骨缺损超过9cm的10例患者行同侧腓骨转移结合Ilizarov架固定术。平均骨延长4.8cm;随访时间10～84个月,平均47个月。结果61例骨缺损最终均达到骨性愈合,平均带架时间9个月,平均骨愈合时间7.1个月。21例78个针道低度感染和积液,原因为针道骨吸收和针道局部清洁护理差。1例腓骨转移患者带架期间摔伤后再骨折。股骨轴向偏移<3mm、向前外侧成角<10°者5例,其中股骨3例,肱骨2例,经调架后逐步矫正。结论应用Ilizarov技术修复长管状骨复杂缺损性骨不连的原则是彻底切除病灶,其次是考虑功能重建。Ilizarov技术是治疗长管状骨复杂缺损性骨不连、成功重建肢体长度的有效方法。     

Ten year experience with use of Ilizarov bone transport for tibial defects

Tibial defects greater than 4 cm and secondary to high-energy trauma or debridement for infected nonunion pose a significant challenge to the treating orthopaedic surgeon. Twelve patients who had been treated with Ilizarov bone transport for tibial defects over the past ten years were retrospectively reviewed. All patients were male with an average age of thirty-two. Ten of the twelve limbs were categorized as Grade IIIB fractures initially. The average tibial defect at initiation of bone transport was 9.45 cm (range 4 to 20 cm). The mean external fixator time (EFT) was 16.7 months with a mean external fixator index (EFI) of 2.0 months per centimeter. There were a total of 36 complications. Twenty were minor, fourteen were major without sequelae and two were major with sequelae. Overall bone results were good or excellent in nine patients. Overall functional results were good or excellent in eight patients. Ten patients achieved union after Ilizarov bone transport. Use of Ilizarov bone transport can be an effective tool for treating large tibial defects. However, the treatment time is lengthy with a considerable risk of complications.     

单臂外固定架下骨内移位技术治疗胫骨感染性骨不连

目的评价单臂外固定延长支架下采用骨内移位技术治疗胫骨感染性骨不连的临床结果及功能情况。方法回顾性分析了2003年6月至2005年10月28例胫骨感染性骨不连患者的临床资料。其中23例开放性胫骨骨折,ⅢA型5例,ⅢB型11例,ⅢC型7例;内固定后感染5例。根据改良的ASAMI评定标准进行骨具体内容和功能结果评定。结果所有患者均获得随访,平均随访时间16个月。所有骨折获得初期愈合,感染均得到控制,骨折愈合时12例仍有局部窦道和渗液,治疗后软组织愈合。骨评定结果优14例,良9例,中等2例,差3例;功能评定结果优10例,良13例,中等2例,差3例。牵引成骨的平均形成长度为6．6cm,平均愈合所需时间为9个月。最常见的并发症为针道感染,2例在外固定支架拆除后对接点再骨折。结论对于胫骨感染性骨不连,使用单臂延长外固定支架通过骨内移位技术治疗是一种良好的方案。     

Ilizarov bone transport for massive tibial bone defects

This article reports the treatment of massive tibial bone defects by bone transport using the Ilizarov external fixator. Fifteen patients were treated using this technique (3 females and 12 males). The defect size ranged between 7 and 22 cm (average: 10.6 cm). Etiology was infected nonunion in 9 patients, nonunion in 5 patients, and recurrent giant-cell tumor in 1 patient. The affected site was the tibial diaphysis in 10 patients, the lower tibial metaphysis in 4, and the upper tibial epiphysis in 1 patient. The external fixation time ranged from 9 months to 17 months (average: 12.27 months). External fixation index ranged from 21.8 to 42.5 day/cm (average: 35.7 day/cm). There was no recurrence of infection, no recurrence of the tumor, nor fractures after frame removal. We had to graft the docking site in 2 patients for delayed union and 2 patients developed equinus deformity and had tenoplasty for the Achilles tendon at the time of frame removal. Four patients had pin tract infection at > or =1 of the wires and this was successfully treated by antibiotic injection at the wire site. This study suggests that Ilizarov bone transport is a reliable method to fill massive bone defects.     

混合式单臂外固定架骨延长术治疗感染性骨不连

目的评价混合式单臂外固定架骨延长术治疗长骨干骺端感染性骨不连的初步临床结果。方法2003年1月至2006年2月采用混合式单臂外固定架固定、局部清创和截骨延长法治疗感染性骨不连21例,男17例,女4例;年龄18～48岁,平均31.5岁。16例为开放骨折内固定术后感染,5例为闭合骨折内固定术后感染。胫骨近端12例,胫骨远端6例,股骨远端3例。12例行骨折端植骨,其中2例二次植骨。结果21例术后随访10～36个月,平均18个月。18例骨折获得初期愈合,3例骨折愈合时仍有局部窦道和渗液,2例骨折尚未完全愈合,1例行截肢术,20例感染得到控制。改良ASAMI骨评定结果为优良13例,中4例,差4例;功能评定结果为优良11例,中6例,差4例。平均骨延长5.6cm,平均愈合时间为11个月。15例发生钉道感染。结论对长骨干骺端感染性骨不连可使用混合式单臂外固定架骨延长术、骨折端开放换药的方法。该方法控制感染好,可自体修复骨缺损,供区畸形发生率低。但固定需采用HA涂层螺钉,严格控制延长速度,一般在1mm/d以内,分次进行延长,手术风险小。     

The use of an antibiotic-impregnated,osteoconductive, bioabsorbable bone substitute in the treatment of infected long bone defects: early results of a prospective trial

OBJECTIVE: We sought to evaluate the use of a bioabsorbable, tobramycin-impregnated bone graft substitute (calcium sulfate alpha-hemihydrate pellets) in the treatment of patients with infected bony defects and nonunions. STUDY DESIGN/METHODS: Twenty-five patients (15 male and 10 female, mean age 43 years (range 27-69 years) requiring surgical debridement of culture-positive long bone infection (16 with associated nonunion) were entered into an ongoing consecutive, prospective clinical trial. Involved bones included the tibia ( 15), femur ( 6), ulna ( 3), and humerus ( 1). All defects were posttraumatic in origin, and each patient had had previous surgery at the involved site (mean 4.3 surgeries; range 1-8 surgeries). The duration of infection ranged from 4 months to 20 years (mean 43 months). According to the Cierny-Mader classification system, there was 1 stage I (medullary osteomyelitis), 6 stage III (localized osteomyelitis), and 18 stage IV (diffuse osteomyelitis) lesions. There were 4 normal (A) hosts and 21 locally and/or systemically compromised (B) hosts. Mean bone defect/void was 30.5 cm (range 3-192 cm ). RESULTS: Mean follow-up was 28 months (range 20-38 months). Radiographically, pellets were resorbed at a mean of 2.7 months postoperatively. Infection was eradicated in 23 of 25 patients (92%). Isolated bony defects healed in all nine patients without further treatment. Fourteen of 16 patients with nonunion achieved union, although nine required autogenous bone grafting. Union was achieved in five of seven nonunion patients treated with bone graft substitute in isolation. Complications included refracture (three), recurrence of infection (two), persistent nonunion (two), and superficial wound necrosis (one). Eight patients developed sterile draining sinuses that healed upon radiographic resorption of the pellets. CONCLUSIONS: In patients with posttraumatic osteomyelitis, the bone graft substitute was effective in eradicating bone infection in 23 of 25 patients. Isolated bony defects healed reliably (nine of nine) following addition of bone graft substitute alone. The role of the bone graft substitute in isolation in the treatment of nonunion is unclear at present.     

Reconstruction of segmental bone defects due to chronic osteomyelitis with use of an external fixator and an intramedullary nail

BACKGROUND: Callus distraction over an intramedullary nail is a rarely used technique for the reconstruction of intercalary defects of the femur and tibia after radical débridement of chronic osteomyelitic foci. The aim of this study was to summarize our experience with distraction osteogenesis performed with an external fixator combined with an intramedullary nail for the treatment of bone defects and limb-shortening resulting from radical débridement of chronic osteomyelitis. METHODS: Thirteen patients who ranged in age from eighteen to sixty-three years underwent radical débridement to treat a nonunion associated with chronic osteomyelitis of the tibia (seven patients) and femur (six patients). The lesions were classified, according to the Cierny-Mader classification system, as type IVA (nine) and type IVB (four). The resulting segmental defects and any limb-length discrepancy were then reconstructed with use of distraction osteogenesis over an intramedullary nail. Two patients required a local gastrocnemius flap. Free nonvascularized fibular grafts were added to the distraction site for augmentation of a femoral defect at the time of external fixator removal and locking of the nail in two patients. At the time of the latest follow-up, functional and radiographic results were evaluated with use of the criteria of Paley et al. RESULTS: The mean size of the defect was 10 cm (range, 6 to 13 cm) in the femur and 7 cm (range, 5 to 10 cm) in the tibia. The mean external fixator index was 13.5 days per centimeter, the consolidation index was 31.7 days/cm, and the mean time to union at the docking site was nine months (range, five to sixteen months). At a mean follow-up of 47.3 months, eleven of the thirteen patients had an excellent result in terms of both bone and functional assessment. There were two recurrences of infection necessitating nail removal. These patients underwent revision with an Ilizarov fixator. Subsequently, the infection was controlled and the nonunions healed. CONCLUSIONS: This combined method may prove to be an improvement on the classic techniques for the treatment of a nonunion of a long bone associated with chronic osteomyelitis, in terms of external fixation period and consolidation index. The earlier removal of the external fixator is associated with increased patient comfort, a decreased complication rate, and a convenient and rapid rehabilitation.     

Ilizarov external fixator: acute shortening and lengthening versus bone transport in the management of tibial non-unions

Eighteen patients with tibial shaft non-unions were treated by the Ilizarov method between March 1995 and September 2001 by the senior author. Three subgroups of six patients each were treated by either acute shortening and lengthening, bone transport or simple stabilisation with a frame. All aspects of non-union, infection, shortening, deformity and bone loss were addressed by using Ilizarov principles. There were 10 cases of infected non-unions in the entire series. Bone resection in the shortening group was between 3 and 6 cm (median 4.6) compared to 3-7.5 cm (median 5.9) in the bone transport group. Union was achieved in all the patients with the average time to union at 12.1 months, 17.2 months and 8.0 months, respectively. The bone transport group required additional bone grafting in five patients (83.3%) prior to union compared to one (16.7%) in the acute shortening group.