Treatment of chronic osteitis of the tibia]

Since the beginning of May 1990, we have been using the original Ilisarov apparatus in our treatment of osteomyelitis. It has been used both statically and dynamically after corticotomy for segment transport and lengthening. So far we have treated 24 patients, of whom 13 had defect osteomyelitis, 9 had unstable infections and 2 had stable osteomyelitis with deformities. On average the bone defects measured 7.6 cm, and nine patients had soft tissue defects larger than 6 cm2. The Ilisarov apparatus performed a holding function in seven cases after defect grafting using autogeneic spongiosa. It was used in four cases for gradual compression, in seven cases for segment or fragment transport, in three cases for secondary lengthening and in three cases for correction. In all cases the infections were eliminated and stability was obtained. The duration of segment transport corresponded to the defect size, with a daily lengthening of approximately 1 mm. The fixation times ranged from 112 to 483 days (mean: 240 days). Apart from one special situation, no bone regeneration problems were observed. Some of the complications we encountered must be regarded as beginners' mistakes. We observed problems with segment transport (early corticotomy healing, deformity, non-union at the docking site) and problems with equipment, which has now been improved. For closure of the soft tissue defects it was sufficient to use mesh grafting. Its versatility and advantages as a stabilizing apparatus have made the Ilisarov fixator the instrument of our choice, especially in the treatment of circular infected defects larger than 3 cm.     

Angiosarcoma of the femur following chronic osteomyelitis]

Available literature concerning neoplastic metaplasia of the bone undergoing chronic osteomyelitis has been cited. The treatment of 62 years old patient with lasting 47 years chronic osteomyelitis of the femur after shotgun wound was presented in details. The diagnosis of angiosarcoma following chronic osteomyelitis has been established histologically. The extremity has been amputated with good result--no metastasis or recurrence was found during follow-up.     

Treatment civilian gunshot fractures of the femur shaft]

35 consecutive cases of fractures of the femoral diaphysis due to gunshot wounds (GSW) treated at Jackson Memorial Hospital of the University of Miami between January 1988 and February 1990 were reviewed. There were 32 low velocity and 3 high energy transfer wounds. The treatment protocol for low velocity GSW consisted of 3 days i.v. antibiotics, balanced skeletal traction (for logistic reasons) and delayed closed intramedullary nailing. There was no formal debridement performed. 3 out of 32 patients declined any operative intervention. The remaining 29 patients were treated according to the above protocol. 12 patients could be followed until complete osseous consolidation. In this group the only complication consisted of one late infection. 17 patients were lost to follow-up before complete consolidation. Out of this group, 8 showed advanced fracture callus formation on the last radiograph available, whereas 9 patients were lost to follow-up almost immediately after discharge. Since GSW victims were generally uninjured and treatment of indigent patients in the Miami area is declined by all other hospitals, we assume that there were non major complications even in the group of patients lost to follow-up. We therefore conclude, that intramedullary nailing of low velocity gunshot fractures of the femoral diaphysis without formal debridement is the treatment of choice under civilian circumstances.     

Treatment of pseudarthrosis of the lower third of the femur]

The results of surgical for pseudarthrosis of the lower third of the femur in 11 patients, using a modified King technic, are reported. To improve fixation of a distal fragment the authors suggest to employ two CITO pins with diverging ends at the level of femoral condyles with an additional compression by two rings of the Ilizarov apparatus. Plaster cast immobilization was not utilized. This method of fragments fixation provides an early motion of the knee joint. Roentgenologically and clinically the consolidation of fragments was noted after 4--5 months, the knee joint function being restored.     

Pathologic fracture of the distal femur in osteitis fibrosa cystica simulating metastatic disease

A 32-year-old woman sustained a minor sliding accident with moderate to severe pain about the left distal thigh and hip and the right shoulder. Radiographs showed marked osteopenia, multiple osteolytic bone lesions, and a pathologic fracture of the left distal femur. Surgical intervention was conducted for the pathologic fracture, and the pathological findings confirmed the diagnosis of primary hyperparathyroidism with osteitis fibrosa cystica. We report this rare case here because it may be mistaken for neoplastic metastatic disease on radiographs and bone scan. The pathologic fracture usually heals and the bone mineral density improves significantly within 6 months after parathyroidectomy.     

Treatment of periprosthetic fractures of the distal femur with the LISS system]

Authors present two cases of periprosthetic fractures of the distal femur. Both patients were female, 77 and 78 years old, formerly treated with total knee replacement. After stabilization of the fractures with the LISS system very good functional results and union were achieved in four months.     

Clinical considerations on posttraumatic osteitis]

Posttraumatic bone infection very often signifies a life threatening complication. However, it must no longer be accepted that amputation of the afflicted limb be the logical treatment of such a complication. A surgeon who offers the advantages of operative treatment of a fracture to his patient must also be able to control its complications. Osteitis can be treated with a good chance of success. In our clinic 29 bone infections were treated, 13 of them healing without substantial restrictions, 7 with distinct discomfort and 4 with arthrodesis, i.e. 83% healed. However, the treatment may require months and may necessitate further operative interventions. The transfer of such a patient from an acute care hospital to a high altitude clinic offers -- besides the medical and psychological advantage of a continuous long-term treatment plan -- the climatic conditions of sun and high altitude air which apparently act very favorably on the healing process of chronic infections. Of course, the possibility of competent surgical interventions must exist. Thus, with proper therapy the disastrous chain of errors beginning mainly with poor initial care through insufficient treatment can be broken.     

Surgical treatment of total forms of chronic osteomyelitis of the femur in children]

In the article is described a new method of treatment of chronic hematogenic osteomyelitis of femur in children in case of its total affection. The essence of the method consists in making a longitudinal groove along the whole length of a bone by means of chisels and milling cutters till the medullar canal is reached and removal of pus, sequesters, pathologic granulations and zones of excessive osteosclerosis. The cavity after bathing is subjected to ultrasound cavitation; fibrinous film and gauze plastrons, impregnated with hemostatic sponge, are placed in it with the proximal and distal ends connection to the tubular drainage in order to ensure permanent lavage of cavity with antiseptic solution and active vacuum aspiration of its content with the subsequent application of sutures on the wound, tight bandaging of a limb and its immobilization. 6 patients have been subjected to treatment by this method with good outcomes in all cases. The results have been followed through 2.5-8 years.