Distraction histogenesis for hypertrophic nonunion of the tibia with deformity and shortening

The results of distraction histogenesis using Ilizarov techniques for 18 consecutive patients were evaluated. There were 13 male and 5 female patients. Their ages ranged from 11 to 74 years (average 36.8 years). All patients presented with established hypertrophic nonunion of the tibia, associated deformity ≥15° and leg shortening. There were no cases of active infection at the time of our treatment. The procedure included fibular osteotomy, application of a pre-constructed Ilizarov frame. Controlled distraction was done until complete deformity correction and equalization of leg length. Weight bearing was allowed during treatment. All patients (100%) had their nonunions consolidated with deformity correction and restoration of the normal mechanical axis of the limb. The leg length discrepancy was corrected in all cases. The follow up ranged from 29 to 50 months (average 37.2 month) after fixator removal. Distraction histogenesis, using Ilizarov techniques, is a reliable method for consolidation of hypertrophic nonunion, deformity correction and equalization of leg length all in one procedure through minimal surgical interference.     

Ilizarov外固定器治疗肥大性骨不连

 目的 探讨采用Ilizarov外固定器治疗肥大性骨不连的疗效。方法 回顾性分析2008年6月至2010年12月,采用Ilizarov环型外固定器直接牵张治疗肥大性骨不连患者的病例,男10例,女2例;年龄22～62岁,平均46.5岁;肱骨中段1例,股骨髁上2例,胫骨中段3例,胫骨中下1/3交界处6例;患肢畸形成角10°～35°,平均25°,其中2例为双平面畸形,10例为单平面畸形;肢体短缩2～6 cm,平均3.5 cm。所有患者术前均拍摄双下肢全长X线片。对骨断端尽量不切开,局部不植骨,直接安装预构的Ilizarov外固定器。对局部留存内固定物者,采用微创的方法取出,尽量保护骨断端血供。术后第7天开始进行矫形延长,断端处每天延长0.25 mm。在恢复肢体长度的同时,矫正成角畸形,对双平面畸形,先矫正冠状面畸形,再矫正矢状面畸形。结果 12例骨不连患者均通过断端直接牵张成骨而获得骨性愈合, 骨断端无需植骨。骨性愈合时间6～12个月,平均8个月。成角畸形和肢体不等长全部获得矫正。畸形矫正时间15～35 d,平均24 d。畸形矫正10°～30°,平均23°。患肢延长2.0～5.5 cm,平均3.0 cm。随访6～18个月,平均14个月,所有患者获得的矫形均未丢失。结论 肥大性骨不连断端间纤维骨痂有活跃的成骨潜能,采用Ilizarov外固定器治疗肥大性骨不连可取得满意的疗效。     

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.     

应用牵拉成骨技术治疗股骨、胫骨肥大型骨不愈合合并畸形患者的疗效

目的探讨应用牵拉成骨技术治疗股骨、胫骨肥大型骨不愈合合并畸形患者的疗效。方法回顾性分析2016年11月至2019年11月在北京积水潭医院创伤骨科应用牵拉成骨技术治疗的3例股骨、胫骨肥大型骨不愈合合并畸形患者的病历资料。3例均为男性。所有骨折不愈合端均不切开。胫骨不愈合者均需经皮截断腓骨,使用Taylor Spatial Frame(施乐辉公司)固定,将13个参数输入计算机,设定牵开速度1 mm/d,生成电子处方。股骨不愈合者使用Orthofix外固定架固定。术后第2天按照1 mm/d的速度牵拉,在牵开恢复长度的过程中逐渐纠正畸形。随访期间,观察患者畸形纠正情况和骨愈合情况。结果病例A术后20 d畸形完全纠正,术后15个月获得骨性愈合。病例B术后25 d畸形完全纠正,术后15个月获得骨性愈合。病例C术后29 d成角畸形纠正,术后19个月获得骨性愈合。结论牵拉成骨技术可纠正肥大型骨不愈合的成角畸形及短缩,可作为肥大型骨不愈合的一种微创治疗方法。     

Distraction osteogenesis for nonunion after high tibial osteotomy.

The purpose of this study was to determine whether distraction osteogenesis can be used to treat hypertrophic nonunion associated with angular deformity and shortening after Coventry style high tibial osteotomy. Five consecutive patients were retrospectively reviewed. In all patients the alignment had collapsed into excessive varus or valgus and leg length discrepancy was present. The leg length discrepancy, malalignment, and nonunion were treated simultaneously with distraction. Union was achieved by the time of fixator removal, which averaged 4.4 months. The Hospital for Special Surgery knee score significantly improved from 42 to 89. The mechanical axis deviation significantly improved by 5 cm. The coronal plane deformity significantly improved by 13 degrees, and leg length discrepancy improved significantly from 2.3 to 0.5 cm. Metaphyseal bone stock increased by 43%, and the Insall-Salvati ratio increased from 1.1 to 1.2 and remained within normal limits. All patients were satisfied with the procedure, and none have had or need a total knee replacement at an average followup of 4 years. Distraction osteogenesis of nonunion after high tibial osteotomy is a minimally invasive and successful procedure. It leads to bony union with correction of deformity and leg length discrepancy and prevents the need for total knee replacement at intermediate-term followup. The increase in metaphyseal bone stock may make total knee replacement technically easier.     

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.     

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 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.     

Distraction osteogenesis of the femur using conventional monolateral external fixator

INTRODUCTION: The author has developed a new simple technique of distraction osteogenesis using conventional monolateral external fixator for femoral lengthening. The primary purpose of the present study was to evaluate the results of treatment with this new technique of femoral lengthening and also to evaluate the effect of preoperative and intraoperative variables on the outcome of distraction osteogenesis in general. MATERIALS AND METHODS: Fifty-one femora in 50 patients were lengthened. Limb-length discrepancy was the primary indication in all patients. The mean age of the patients at the time of the surgery was 21.9 years (range 5-48 years). The average follow-up period was 24.6 months after removal of the fixator (range 6-120 months). All lengthenings were performed using conventional AO/ASIF external fixator. Twenty-two femora had associated axial or rotational deformities. Gradual distraction was performed to increase length and to correct angular deformity in coronal plane. Acute closed wedge angular correction in sagittal plane or derotation was performed in 12 femora in this study. RESULTS: The length of the 51 femora was increased by an average 4.4 cm (range 1-13 cm), or 12% (range 2.5-40.9%). The average healing index was 50.5 days/cm (range 22.5-110.6 days/cm). Average gradual angular correction in coronal plane in 14 femora was 20.4 degrees (range 10-45 degrees ). Average acute correction in sagittal plane in five femora was 17 degrees (range 10-20 degrees ). Average acute derotation in six femora was 24.2 degrees (range 10-60 degrees ). There were a total of 61 complications, including 26 problems, 18 obstacles, and 17 sequelae. The overall rate of complications was 1.2 per femur. Fifteen femora had delayed consolidation (healing index >54 days/cm). Three of 51 lengthening procedures did not lead to consolidation (nonunion). A significant negative parabolic relationship was noted between the healing index and the amount of length gained (R = -0.47 and P = 0.004). There was a significantly positive exponential relationship between age and healing index (R = 0.51 and P < 0.001). Acute deformity correction, level of osteotomy (submetaphysis versus diaphysis) had no significant effect on healing index. The greater amount of length gained was associated with complications. CONCLUSIONS: The newly presented technique of distraction osteogenesis is a useful and cost-effective method for femoral lengthening. Increased lengthenings produced a better healing index but might associate with complications. Younger age was associated with better bone healing but age had no effect on complication rate. Level of osteotomy, acute deformity correction had no effect on healing index and rate of complications.     

Treatment of tibia vara by the Ilizarov method

Sixty-nine lower extremities of 45 patients (mean age, 10 years 8 months) with tibia vara were treated with the Ilizarov circular external fixator and distraction osteogenesis. Twenty-four of the patients had bilateral involvement, six of whom had simultaneous surgery and the remaining 18 had staged operations 8 to 12 months apart. In 11 limbs with femoral valgus deformity greater than 10 degrees simultaneous corrections were done. Active movements of the joints of the extremity were encouraged the day after surgery and partial weightbearing began 2 days later. All patients were followed up 27 to 178 months (mean, 80 months) after surgery. No neurovascular complications, delayed union, or nonunions were observed. The mean 28.6 degrees varus tibiofemoral angle preoperatively (range, 15 degrees -45 degrees ) improved to 7.5 degrees valgus (range, 0 degrees -18 degrees ) postoperatively. The preoperative internal torsion angle also improved from 20.7 degrees (range, 0 degrees -48 degrees ) to 3.5 degrees external torsion (range, 0 degrees -9 degrees ) postoperatively. Residual deformity was seen in six patients, and they had successful revision surgery using the same technique. The Ilizarov method allows early weightbearing and motion and allows all components of the deformity to be corrected.     

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.     

Closed treatment of canine nonunions by controlled compression and distraction using an Ilizarov fixator: a preliminary study

The Ilizarov fixator was used for closed treatment of canine nonunions by controlled compression and distraction. The fibrous matrix and cartilage formed within the nonunion site transformed to osteoid and bone with increased vascularity. Healing was demonstrated by substantial bone bridging the nonunion at 6 weeks. The Ilizarov method appears to be a viable treatment for nonunions.     

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.     

Treatment of rigid hypertrophic posttraumatic pseudarthrosis of the tibia in children using distraction osteogenesis

Posttraumatic tibial pseudarthrosis is a relatively uncommon complication of tibia fractures in children. Although reported as a successful method of treating tibial nonunions in adults, distraction osteogenesis through a nonunion site via ring external fixation has not been described in children. The authors report three consecutive cases of distraction through an angulated, shortened, hypertrophic, posttraumatic nonunion to achieve successful union and concurrent correction of deformity. Distraction was carried out using a ring fixator with computer-guided correction. Union was achieved in each of the three patients with complete correction of deformity and length. Lengthening of 8 to 31 mm was achieved. The length of time in the external fixator ranged from 7 to 27 weeks. Pin tract infections developed in all patients; they were treated successfully using oral antibiotics. No deep infections or other significant complications developed. Each patient was followed up for at least 1 year.     

Appraisal of the role of external skeletal fixation in the management of sequelae of open tibial fractures

Background:

Severe open tibial fractures are more apt to be followed by complications even with the universally accepted lines of treatment. The present study investigated the role of external skeletal fixation, based on Ilizarov techniques, in the management of the sequelae of open tibial fractures with modifications to meet the requirements of each case.

Materials and Methods:

We reviewed the results of treatment of 148 cases of late presentation with complicated open tibial fractures. Their ages ranged from 12 to 74 years (average, 34 years). Active infection was present in 40 cases. We performed acute shortening and relengthening in 60 cases; excision of nonunion, acute deformity correction, and lengthening for nonunion with deformity in 30 cases; segmental excision and bone transport in 20 cases; gradual deformity correction after osteotomy in 15 cases; and distraction and gradual deformity correction for hypertrophic nonunion with deformity in 23 cases. Ilizarov external fixator was used in 96 (65%) cases, and monolateral fixator was used in 52 (35%) cases. The mean follow-up was 35 months (range 24 to 118 months).

Results:

Fracture union was achieved in all cases (100%). Evaluation of results were based on both objective (clinical and radiological) and subjective criteria and patients'' satisfaction. The results were satisfactory in 139 cases (94%) and unsatisfactory in nine (6%) cases because of residual leg length discrepancy, joint stiffness, and persistent pain.

Conclusions:

The use of external fixation, based on Ilizarov techniques, is invaluable in the management of difficult open tibia fractures. However, the technique should be tailored to the requirements of each case. The functional outcome is predetermined by the soft tissue status before treatment.     

Distraction osteogenesis for the treatment of post traumatic complications using a conventional external fixator. A novel technique

PURPOSE: To evaluate the clinical results of post traumatic complications treated by the author's own technique using an AO/ASIF conventional external fixator (without special distraction device). MATERIALS AND METHODS: There were 70 patients (77 limbs) with an average of 26.8 years (range, 4-54). There were 33 femurs, 43 tibias and one ulna. The following post traumatic complications were treated: 14 limb shortening, 20 nonunion, 28 malunion 14 infected open fractures with bone loss and 1 chronic osteomyelitis. Linear lengthening was performed in 29 limbs, acute de-rotation and subsequent lengthening in two limbs, gradual angular correction in six limbs, combined gradual angular correction and subsequent lengthening in 10 limbs, combined acute angular correction and subsequent lengthening in eight limbs and 22 limbs with bony defects were treated with the technique so-called "bone transportation". All of the limbs were treated with an AO/ASIF conventional external fixator, using the author's own technique with distraction rate of 1 mm in one step on alternate day (1 mm/48 h). RESULTS: A new bone formation in the distraction gap was achieved in 73 of the 77 limbs. Four cases without consolidation were successfully treated with an iliac bone graft combined with plating or reapplication of the external fixator. Average new bone formation was 5.6 cm (range, 1-17 cm). The average follow-up period was 10.8 months (range, 1-71 months) after removal of the fixator. The average healing time was 244.7 days (range, 60-836 days) and the healing index was 50 days/cm (range, 17-100 days). In the group with associated angular deformity the mean correction was 18.5 degrees (range, 10-40). CONCLUSIONS: The author's technique of distraction osteogenesis, using a conventional external fixator combined with a distraction rate of 1 mm/48 h (1 mm/step) adequately treated the post traumatic complications. No extra equipment was needed other than readily available AO/ASIF fixation systems. The described technique, using an AO/ASIF fixator as a lengthening apparatus was simple and cost-effective.     

Parafocal osteotomy and the Ilizarov method in the treatment of femoral pseudarthrosis. Case report

The case presented is that of a man aged 54 years, with hypertrophic pseudarthrosis shortening by 3 cm and a femoral mechanical axis measuring 13 degrees varus. Parafocal osteotomy according to Paltrinieri was carried out with the aim of correcting the varus femur, the shortening and, secondarily, of obtaining recovery from the pseudarthrosis. Osteosynthesis was achieved by the Ilizarov apparatus. Axial correction and lengthening were obtained after 33 days. The fixator was removed after 5 months and 10 days, during which the nonunion appeared healed.     

Outcome of rail fixator system in reconstructing bone gap

Background:

Bone loss following open fracture or infected gap nonunion is a difficult situation to manage. There are many modes of treatment such as bone grafting, vascularized bone grafting and bone transport by illizarov and monolateral fixator. We evaluated the outcome of rail fixator treatment in reconstructing bone and limb function. We felt that due to problems such as heavy apparatus, persistent pain, deformity of joints and discomfort caused by an Ilizarov ring fixator, rail fixator is a good alternative to treat bone gaps.

Materials and Methods:

20 patients (17 males and 3 females with mean age 30.5 years) who suffered bone loss due to open fracture and chronic osteomyelitis leading to infected gap nonunion. Ten patients suffered an open fracture (Gustilo type II and type III) and 10 patients suffered bone gap following excision of necrotic bone after infected nonunion. There were 19 cases of tibia and one case of humerus. All patients were treated with debridement and stabilization of fracture with a rail fixator. Further treatment involved reconstructing bone defect by corticotomy at an appropriate level and distraction by rail fixator.

Result:

We achieved union in all cases. The average bone gap reconstructed was 7.72 cm (range 3.5-15.5 cm) in 9 months (range 6-14 months). Normal range of motion in nearby joint was achieved in 80% cases. We had excellent to good limb function in 85% of cases as per the association for the study and application of the method of ilizarov scoring system[ASAMI] score.

Conclusion:

All patients well tolerated rail fixator with good functional results and gap reconstruction. Easy application of rail fixator and comfortable distraction procedure suggest rail fixator a good alternative for gap reconstruction of limbs.     

Modification of the Ilizarov external fixator for aseptic hypertrophic nonunion of the clavicle: an option for treatment

OBJECTIVE: To assess the results of treatment of aseptic hypertrophic nonunion of the clavicle by external fixation using a modified Ilizarov apparatus. DESIGN: Prospective study. SETTING: A consecutive series of 12 patients from 2 specialized orthopaedic institutions, treated by the 3 senior authors. PATIENTS: Twelve patients (5 females) with a mean age of 38.7 +/- 12.4 (range, 18-50) years with an aseptic hypertrophic nonunion of the clavicle were treated operatively during the period 1994 to 1998. Ten patients had previously been treated nonoperatively, whereas 2 had been treated surgically; the treatment in all had failed. All patients had pain with shoulder stiffness. INTERVENTION: Patients were treated using the Ilizarov external fixation technique. The operation was performed under general anesthesia and an Ilizarov external fixator was applied percutaneously under fluoroscopic control, without a skin incision or bone grafting. The patients were then monitored clinically and radiologically for 24 to 96 (mean, 45.4) months. MAIN OUTCOME MEASUREMENTS: Radiologic evaluation and clinical assessment by the Constant numerical score. RESULTS: The mean Constant preoperative score was 30.4 +/- 9 (range, 18-44). Healing of the nonunion occurred in all patients treated by the Ilizarov technique. Nine patients had pain relief and gained unlimited range of motion, whereas 3 patients had mild pain during elevation of the arm. A mean period of 75.4 (range, 50-95) days was needed for gradual bone reduction and union. The mean Constant outcome score was 68.8 +/- 14.7 (range, 46-85). Complications: 2 patients had superficial pin infections that cleared with local therapy and antibiotics, and 1 patient had a reoperation for a nonunion after a fall onto the floor. CONCLUSIONS: Ilizarov fixation seems to be an effective method in the treatment of aseptic hypertrophic clavicle nonunions, even in patients where previous surgery has failed.