Treatment of post-traumatic humeral diaphyseal nonunion with bone loss

Four patients with post-traumatic nonunion and shortening of the humeral diaphysis were treated with a hybrid advanced Ilizarov technique. The mean age of the patients was 32 years, and the mean total amount of humeral shortening was 6.63 cm. Three nonunions were atrophic and infected, and one was hypertrophic. All patients obtained union of the humeral fracture with resolution of infection at a mean external fixation time of 8 months. Restoration of normal humeral length was achieved in two patients, with a third having a residual discrepancy of 1 cm. The final patient, who had an infected nonunion with 11 cm of total humeral shortening, had a residual limb length discrepancy of 3 cm. All had improvement in shoulder and elbow motion after treatment. Superficial pin tract infections were seen in all patients, but all responded to pin-site care and oral antibiotics. Two patients had three refractures after removal of the fixator, two of which were treated by a second application of an Ilizarov frame and one by a cast. All patients had reduced pain and improved function at completion of the treatment. The Ilizarov method, though not a panacea for all humeral nonunions with extensive bone loss, does offer a viable salvage procedure in this unusual and often complex clinical problem.     

Ilizarov treatment of tibial nonunions results in 16 cases

Treatment with the Ilizarov technique was performed in 16 patients with complex tibial nonunions. Two years post treatment the functional stage and patient satisfaction were recorded. There were 4 hypertrophic, 3 atrophic and 9 infected nonunions. Eleven patients had segmental bone loss. Fifteen nonunions united, and limb length discrepancy was reduced within 1.5 cm of the contralateral leg. Average time in the frame was 182 days. Fifteen of the 16 patients were satisfied with the treatment. One patient demanded an amputation after 3 months of treatment, despite good signs of healing. There were no refractures or recurrent infections. In conclusion the Ilizarov technique for complex nonunions has a high rate of success in achieving union and eradicating infection, bone loss and malalignment. The treatment is demanding both to the surgeon and to the patient, but we strongly recommend the Ilizarov treatment for tibial nonunion, especially in cases with chronic infection and severe bone loss.     

Circular external fixation in tibial nonunions

The Ilizarov method based on compression-distraction and subperiostic corticotomy was used in 82 lower extremities. There were 45 tibial nonunions without a significant bone defect and 37 tibial nonunions with a bone defect that required radical removal of the necrotic bone and bone lengthening or bone transport. Bone healing was obtained in 39 of the 45 tibial nonunions without bone defect (mean bone healing, 5.4 months) and in all patients with bone defect (mean bone healing, 15 months for patients treated with bone transport) although secondary surgeries (autografting and tibial nails) were frequent (23 patients). Infection was eradicated in all patients after necrotic bone removal and bone transport. The final mean limb length discrepancy was 0.7 cm for the patients without a bone defect and 2.03 cm for the patients with a bone defect. In the patients in the bone transport group, residual axial deviation and residual limb shortening were common. Circular external fixation is a useful method to solve complex tibial nonunions in patients in whom internal devices and autografting have failed. Patients must be cooperative, and must understand the length of time the frame needs to be worn, and that complications are a probability.     

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.     

Posterolateral bone grafting for nonunion of the tibia.

Sixty-two tibial diaphyseal nonunions in 60 patients were treated with a posterolateral bone graft over an 18-year period (1969-1987). The majority were complicated by severe soft tissue damage or segmental bone loss. Thirty-four had a deep infection. Primary healing was achieved in 92%. Three types of bone grafts have been used: from 1969 to 1978 either a whole iliac bone graft (10 tibiae) or a nonvascularized fibular graft (11 tibiae) was used. Since 1978 small iliac cancellous bone chips (41 remaining tibiae) were applied to the posterior surfaces of tibia and interosseous membrane. In three tibiae with major bone defects, cancellous allografts were added to the autogenous bone. The use of cortico-cancellous bone chips resulted in a shorter healing time, compared to a nonvascularized fibular graft or a massive corticocancellous bone block.     

Resistant nonunions and partial or complete segmental defects of long bones. Treatment with implants of a composite of human bone morphogenetic protein (BMP) and autolyzed, antigen-extracted, allogeneic (AAA) bone.

Twenty-five patients with resistant nonunions including partial or complete segmental defects were treated with a composite alloimplant of human bone morphogenetic protein (h-BMP) and autolyzed, antigen-free, allogeneic bone (AAA). The series consisted of 16 females and nine males; average age was 45 years. Preoperative symptoms averaged 30 months (range, five to 83 months); 22 of 25 patients had failed multiple attempts at electrical stimulation. Twenty-three of 25 patients had an average of three prior failed surgical attempts at union (range, one to ten). There were ten segmental defects with an average length of 4 cm (range, 2-9 cm). The composite implant was incorporated as an onlay in 15 extremities and as an inlay graft supported by internal fixation in ten extremities. Seven patients received supplementary autogeneic cancellous bone grafting. Average healing time was six months (range, three to 14 months). Average follow-up time was 21 months (range, five to 82 months). Functional results were rated as excellent, 14; good, five; and fair, five. One failed to unite because of a recurrent infection. Union was obtained in 24 of 25 patients. There were five failures of the original operation that required reoperations; union eventually occurred in four of five extremities by repeat composite grafting and replacement of the failed internal fixation. Bony union between host bone and the composite implant began at an average of eight weeks postoperatively. Present results indicate that h-BMP/AAA composite implants represent adjunctive treatment of difficult nonunions. The h-BMP/AAA composite implants may be implanted in either partial or complete segmental defects of long bones.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cement spacers with antibiotics for the treatment of posttraumatic infected nonunions and bone defects of the upper extremity

Treatment of patients with posttraumatic infected nonunions or highly contaminated open fractures with segmental bone loss of the long bones of the upper extremity is demanding. The use of a 2-stage reconstruction technique, being the first stage characterized by thorough debridement, copious lavage, soft tissue coverage, and placement of a cement spacer with antibiotics at the infected site, and the second stage by cement spacer removal, internal fixation, and placement of bone graft with local antibiotics, is presented. We carried out this technique in 20 cases, in 12 cases the cement was molded to fit the defect and placed as a solid interposition mass, in 3 cases it was placed lateral to the affected bone, and in the remaining 5 cases a Rush nail covered with a cement mantle was used. Follow-up averaged 18 months. All nonunions and fractures healed after an average of 5 months. Disabilities of the arm, shoulder, and hand (DASH) score at last follow-up in nonunions averaged 14 points and 21 points in bone losses. Although generally 2 surgical procedures are needed, 1 to cure or prevent infection and another to achieve bony union, this approach for complex open fractures with segmental bone loss and for infected nonunions of the long bones of the upper extremity represents a valid treatment alternative.     

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.     

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.     

Management of massive posttraumatic bone defects in the lower limb with the Ilizarov technique

Massive bone defects have been treated by various methods with variable success rates. The Ilizarov technique has been advocated as a preferred method for treatment of large segmental defects. Twenty five patients with massive post traumatic bone defects of the lower limb (22 tibiae, 3 femurs) were treated using Ilizarov's technique. After radiological evaluation, the patients were subjected to bone transport. Bifocal osteosynthesis was performed in all except those needing >12 cm of bone transport. Distraction was started between day 4 and 7 at the rate of 1 mm per day in four increments. All were males with a mean gap of 8.9 cm (range: 5-17 cm), mean age of 28.24 years (16-40) and having undergone a mean of 2.6 previous surgeries. Mean time in Ilizarov frame was 8.8 months and external fixator index was 0.98 months. Mean duration of follow-up after frame removal was 23.5 months. Union was achieved in 23 (92%) cases. Bone grafting was required in 9 (36%) According to ASAMI criteria, bone results were excellent in 13, good in 1, and poor in 11 patients. Functional results were excellent in 6 patients, good in 9, fair in 4, and poor in 6 patients. A total of 72 complications occurred (2.88 complications per patient). Union was achieved in all except two patients. The Ilizarov external fixator offers a limb salvage solution even in large bone defects but the surgeon should set realistic goals both for himself and his patients while offering this method of treatment.     

Repair of tibial nonunions and bone defects with the Taylor Spatial Frame

OBJECTIVE: To investigate the outcomes of tibial nonunions and bone defects treated with the Taylor Spatial Frame (TSF) using the Ilizarov method. DESIGN: Retrospective. SETTING: Limb Lengthening and Deformity Service at an academic medical center. PATIENTS: Thirty-eight consecutive patients with 38 tibial nonunions were treated with the TSF. There were 23 patients with bone defects (average 5.9 cm) and 22 patients with leg-length discrepancy (LLD) (average 3.1 cm) resulting in an average longitudinal deficiency (sum of bone defect and LLD) of 6.5 cm in 31 patients (1-16). The average number of previous surgeries was 4 (0-20). At the time of surgery, 19 (50%) nonunions were diagnosed as infected. INTERVENTION: All patients underwent repair of the nonunion and application of a TSF. Patients with bone loss were additionally treated with lengthening. Infected nonunions were treated with 6 weeks of culture-specific antibiotics. MAIN OUTCOME MEASUREMENTS: Bony union, time in frame, eradication of infection, leg-length discrepancy, deformity, Short Form-36 (SF-36) scores, American Academy of Orthopaedic Surgeons (AAOS) lower-limb scores, and Association for the Study of the Method of Ilizarov (ASAMI) bone and functional results. RESULTS: Bony union was achieved after the initial treatment in 27 (71%) patients. The presence of bone infection correlated with initial failure and persistent nonunion (P=0.03). The 11 persistent nonunions were re-treated with TSF reapplication in 4, intramedullary rodding in 3, plate fixation in 2, and amputation in 2 patients. This resulted in final bony union in 36 (95%) patients. The average LLD was 1.8 cm (0-6.8) (SD 2). Alignment with deformity less than 5 degrees was achieved in 32 patients and alignment between 6 degrees and 10 degrees was achieved in 4 patients. Significant improvement of Short Form-36 (SF-36) scores was noted in physical role (P=0.03) and physical function (P=0.001). AAOS lower-limb module scores significantly improved from 56 to 82 (P<0.001). ASAMI bone and functional outcomes were excellent or good in 36 and 34 patients, respectively. The number of previous surgeries correlated inversely with the ASAMI bone (P=0.003) and functional (P=0.001) scores. CONCLUSIONS: One can comprehensively approach tibial nonunions with the TSF. This is particularly useful in the setting of stiff hypertrophic nonunion, infection, bone loss, LLD, and poor soft-tissue envelope. Infected nonunions have a higher risk of failure than noninfected cases. Treatment after fewer failed surgeries will lead to a better outcome. Internal fixation can be used to salvage initial failures.     

Infected nonunion of the tibia

The treatment of infected nonunited fractures of the tibia using the techniques of Ilizarov was compared with autogenous cancellous bone graft application under a well vascularized soft tissue envelope. There were 10 patients in the Ilizarov group and 17 in the bone graft group. Soft tissue coverage with a free vascularized or a rotational muscle flap was used more frequently among the patients having bone graft (71%) than the Ilizarov group (30%). All 27 patients had bony defects (average, 3.7 cm; range, 1-18 cm). At an average followup of 6 years, 26 patients had a functional limb, and one patient (Ilizarov group) ultimately required a below knee amputation. Three patients in each group required a second plate and bone graft procedure to gain union. Infection persisted in four patients (all in the Ilizarov group). If a well vascularized soft tissue envelope is present (particularly after flap coverage), bone grafting procedures are safe and efficacious. The Ilizarov technique may be best suited for the treatment of very proximal or distal metaphyseal nonunions and nonunions associated with large leg length discrepancies.     

Ilizarov’s method: a solution for infected bone loss

We report the results of 22 infected nonunions treated by radical resection and bone transport technique according to Ilizarov with a minimal follow-up period of 2 years. This series involves four fractures of the femur diaphysis, ten at tibial level, four defects of the knee and four of the upper limb. The mean length of the bone defect was 7.7 cm. The mean time from the transport procedure to frame removal was 14.5 months. In 15 cases the docking site was reviewed to refresh the bone ends at the end of the transport procedure, of which eight had a bone graft performed. Five refractures were noticed at the docking site in the nonrevised group and one in the other group. Two of them were treated conservatively and four with a new external fixator. Consolidation was achieved in all but two nonunions at the knee level, which means a succesrate of 91%. The infection could be eradicated in all 22 patients. A revision of the docking site at the end of the bone transport procedure with or without bone grafting is recommended.     

Acute shortening versus bone transport for the treatment of infected femur non-unions with bone defects

BackgroundThe bone transport technique has been a well-known method in the treatment of osteomyelitis of the long bones with large segmental bone defects. However, one of the major drawbacks with this traditional technique is the long-lasting consolidation period, which may entail infectious and non-infectious complications. To overcome this drawback, several techniques were developed, one of which is acute shortening and re-lengthening. The aims of this study were: 1) to present our experience with a new modified technique of acute shortening and re-lengthening using a monolateral external fixator combined with a retrograde intramedullary nail, and 2) to compare its results with the classic Ilizarov bone transport method in the management of infected non-unions of the distal femur with bone loss.MethodsThis retrospective study compared these two techniques. 17 patients were treated using our modified technique of acute shortening and re-lengthening (Group A); 15 patients were treated using segmental bone transport (Group B). The average follow-up was 66 months (range: 24–180) in Group A and 70 months (range: 24–240) in Group B. The mean bone loss was 5.5 cm (range: 3–10) in Group A and 5.9 cm (range: 3–10) in Group B. The primary outcome of the present study was to compare the external fixator time (EFT) and external fixation index (EFI) between the two groups. The bone and functional status were also assessed.ResultsThe mean EFI was lower in Group A (mean: 31.8 days/cm; range: 24–50) than in Group B (mean 48.7 days/cm; range: 40–100) (p = 0.02). The mean EFT was shorter in Group A (mean: 120 days; range: 100–150) than in Group B (mean: 290 days; range: 100–400) (p = 0.0003). With respect to the bone and functional results, no difference was observed.ConclusionsAlthough both techniques could be employed safely in the treatment of infected non-union of the distal femur with size defects ranging between 3 cm and 10 cm, our modified technique of acute shortening and re-lengthening may confer greater patient satisfaction because of shorter EFI.     

Bone transport versus acute shortening for the management of infected tibial non-unions with bone defects

IntroductionThis study compared bone transport to acute shortening/lengthening in a series of infected tibial segmental defects from 3 to 10 cm in length.MethodsIn a retrospective comparative study 42 patients treated for infected tibial non-union with segmental bone loss measuring between 3 and 10 cm were included. Group A was treated with bone transport and Group B with acute shortening/lengthening. All patients were treated by Ilizarov methods for gradual correction as bi-focal or tri-focal treatment; the treating surgeon selected either transport or acute shortening based on clinical considerations. The principle outcome measure was the external fixation index (EFI); secondary outcome measures included functional and bone results, and complication rates.ResultsThe mean size of the bone defect was 7 cm in Group A, and 5.8 cm in Group B. The mean time in external fixation in Group A was 12.5 months, and in Group B was 10.1 months. The external fixation index (EFI) measured 1.8 months/cm in Group A and 1.7 months/cm in Group B (P = 0.09). Minor complications were 1.2 per patient in the transport group and 0.5 per patient in the acute shortening group (P = 0.00002). Major complications were 1.0 per patient in the transport group versus 0.4 per patient in the acute shortening group (P = 0.0003). Complications with permanent residual effects (sequelae) were 0.5 per patient in the transport group versus 0.3 per patient in the acute shortening group (P = 0.28).ConclusionsWhile both techniques demonstrated excellent results, acute shortening/lengthening demonstrated a lower rate of complications and a slightly better radiographic outcome. Bone grafting of the docking site was often required with both procedures.Level of evidence: Level III; Retrospective comparative study     

Multistaged surgical management of posttraumatic segmental tibial bone loss

Fracture nonunions associated with segmental diaphyseal bone loss challenge present methods of sustaining bone length and securing bony union. In the tibia, single-stage grafting procedures to accomplish this reconstruction requires major tissue sacrifice from adjacent areas and often results in amputation. A series of nine patients with tibial segmental diaphyseal bone loss were treated with multistaged surgical reconstruction. All nine were patients with severe trauma, with soft-tissue loss and local sepsis, who were candidates for amputation. The follow-up period averaged 5.5 years. All of the patients achieved healed, stable legs. All but one were fully ambulatory without a brace eight to 15 months after the first stage of bone grafting. There were several minor complications, which were satisfactorily treated. Multistaged bone graft operations were relatively low-risk, with a high incidence of success for treatment of major tibial segmental bone loss.     

Ilizarov compression over a nail for aseptic femoral nonunions that have failed exchange nailing: a report of five cases

OBJECTIVE: To evaluate a new operative treatment of femoral nonunion following failed exchange nailing. DESIGN: Retrospective review, consecutive series.SETTING Office-based orthopaedic practice. PATIENTS: Five consecutive patients (ages 31-67 years) were referred in with a femoral nonunion following exchange nailing an average of 28 months (range 11-55) after the initial traumatic injury. The patients had undergone an average of 5 (range 2-8) previous surgeries on the femur. No patient had signs or history of bone infection or segmental bone loss at presentation. All patients had diaphyseal or diaphyseal-metaphyseal oligotrophic nonunions and had failed an average of 2 (range 1-3) previous exchange nailings. INTERVENTION: Slow compression (0.25 to 0.50 mm per day) of the nonunion site over a new, smaller diameter nail using an Ilizarov external fixator. MAIN OUTCOMES MEASUREMENTS: Clinical and radiographic evidence of bone union, ambulation, pain, residual deformity, or shortening. RESULTS: All nonunions healed without the need for further nonunion surgery. The external fixator was removed at an average of 133 days (range 86-238 days). No deep infections occurred in any patient. All patients experienced some degree of pin site irritation. At the most recent follow-up (average 45 months; range 12-75 months), all patients had improved their functional ambulatory status and had discontinued or decreased the use of assistive devices to walk. All patients were full weight bearing. Average pain, as rated on a 0 to 10 Visual Analogue Scale, decreased from 8 of 10 before treatment to 1 of 10 after treatment. No patient experienced a clinically significant worsening of leg length discrepancy. CONCLUSIONS: Slow compression over an intramedullary nail using external fixation successfully promotes the healing of problematic femoral nonunions that have failed one or more prior exchange nailings.     

Ilizarov technique. Results and difficulties.

Of 100 cases treated by the Ilizarov method, 91 patients were reviewed from February 1985 to March 1990. There were 32 tibial fractures (29 open) and 21 nonunions (nine infected). There were 47 cases of limb lengthening (28 tibia and 19 femur). The results were as follows: good, 83%; fair, 13%; and poor, 4%. Slight and intermittent pain in some wire of the device was frequent (69%). Average bone healing time in tibial fractures was 4.95 months and 5.83 months in tibial nonunions. In bone-lengthening operations, the average lengthening index in the tibia was 1.02 months/cm (lengthenings ranged from 3 cm to 10 cm, with a mean of 5.71 cm), whereas in the femur, the average lengthening index was 1.14 months/cm (lengthenings ranged from 3 cm to 7 cm, with a mean of 5.34 cm). Manually-tensed wires produced frequent problems (24.5%), whereas wire tensed by the dynamometric tensioner produced problems in only 7.8% of the cases. Despite good results, the Ilizarov technique requires adequate training to reduce an overall complication rate (approximately 30%).     

Management of difficult lower extremity fractures and nonunions

Difficult fractures and nonunions of the lower extremities are defined as compound fractures with soft-tissue loss, segmental bone fractures, and infected nonunions. A variety of methods for managing these defects are presented, including the use of modern fixation techniques and the application of highly vascularized bone and soft tissues. Vascularized bone grafts play a significant role in the treatment of difficult fractures that previously would have required amputation.     

Augmentative Ilizarov external fixation after failure of diaphyseal union with intramedullary nailing

OBJECTIVE: To investigate the use of the Ilizarov circular fixator and nail retention in treating diaphyseal nonunion following previous intramedullary nailing. DESIGN: Retrospectively reviewed, consecutive series. Mean duration of follow-up after achieving bone union: 19.2 months (range 6 to 33 months). SETTING: A tertiary referral center for nonunion surgery. PATIENTS: Nine patients (two femoral, three tibial, and four humeral nonunions) were included in the study. All patients were referred from other centers after failure to achieve union with intramedullary nailing. Patients who had nonunion with other fixation devices in situ, those with active infection and nonunion following nonoperative treatment, were excluded from the study. The patients had undergone an average of 2.4 operations (range 1 to 5 operations) before application of the Ilizarov fixator. All patients completed the study. INTERVENTION: The circular fixator was used to compress the nonunion site from without, retaining the intramedullary nail in each case. We excluded a patient who had his nonunion site explored followed by bone excision and transport. The mean duration of fixator treatment was 6.2 months (3 to 11 months). MAIN OUTCOME MEASUREMENTS: Clinical and x-ray evidence of bone union, infection, residual deformity, shortening, and assessment of functional outcome. RESULTS: Bone union was achieved in all nine patients using the circular fixator over the nail. The bone results were graded as six excellent, one good, and two fair. All patients reported a reduction in pain and satisfaction with their final outcome. CONCLUSIONS: There is a role for the use of the Ilizarov fixator with nail retention in resistant long bone diaphyseal nonunion in carefully selected patients. This method can achieve high union rates where other treatment methods have failed.