Management of 30 infected nonunited tibial fractures by Ilizarov external fixator with acute shortening distraction technique with consideration of the causative organism

Abstract

Background: Long-standing infected nonunion and gap nonunion tibial fractures are difficult to treat and pose a challenging problem to orthopaedic surgeons. They may lead to residual deformity, persistent infection, knee or ankle contracture, and, at worst, can result in a painful and useless limb requiring amputation. Methods: This prospective study involved 30 patients (27 males and three females) with infected tibial nonunions treated by Ilizarov external fixation with acute shortening and distraction. The mean age was 40 yr with an average bone defect of 3.85 cm (range 2.5 cm to 6 cm). The duration of nonunion before treatment ranged from 6 to 48 mo with an average of 14 mo. The average number of prior surgeries was 1.5 (range 1 to 4). Eleven (36.66%) of the 30 patients had overlying soft-tissue compromise. The causative bacteria were identified and treated with the appropriate antibiotic for at least 6 wk (range 6 to 12 wk). Results: Most infected nonunited fractures in this series (86.66%) occurred in the productive age (four in the 3rd, eight in the 4th, nine in the 5th, and 5 in the 6th decades of life) indicating the socioeconomic impact of this severe injury. The time to consolidation ranged from 3.5 mo to 9 mo, with an average of 6 mo. All fractures united except one (3.33%), with 19 (63.27%) and eight (26.64%) patients having an excellent and good result and two (6.66%) patients having a fair result when applying the Association for the Study and Application of the Method of Ilizarov (ASAMI) classification. Functional results per ASAMI were 12 (39.96%), and 14 (46.62%) patients had excellent and good results. Twenty-seven (89.91%) had bony consolidation with complete remission of infection. The most common isolated bacteria were Staphylococcus aureus (10 patients) and Staphylococcus epidermis (four patients). The most common complication was pin track infection which occurred in all patients. All were uneventfully treated with proper wire/pin care and the appropriate antibiotics. Conclusions: Ilizarov fixation with acute shortening distraction technique is a safe and reliable method for treatment of infected tibial nonunion, however, with the potentially devastating complication of vascular injury during acute compression. The amount of acute shortening is done on an individualized basis as we could not identify safe limits for acute shortening. This technique deals with soft-tissue defects that may require treatment and precludes the need for complex microvascular procedures and secondary bone grafting at the fracture site.

Distraction osteogenesis versus induced membrane technique for infected tibial non-unions with segmental bone loss: a systematic review of the literature and meta-analysis of available studies

“… nr 14 7 Xu [ 36 ] 29 (12–72) 6 (3–14) AS – use of local soft tissue IV AB for 1 wk p-op 10 (8–14) nr 8 Moghaddam [ 17 ] 12 6.7 (1–31) nr 2–4 wks: IV, 2–4 wks: orally na RIA: 50, Il crest: 13, BMP: 50, Allog. 37 9 Barakat [ 37 ] At 2, 6,12, and 24 months 1.5 (1–4) AS/PC Adequate ABs for at least 8 wks nr nr 10 Meleppuram [ 38 ] 14 (10–24) nr nr Appropriate IV Abs for a week (8–10) 13 11 Tong [ 39 ] Mq: 23.1 ± 9.5 DO: 27.5 ± 10.1 nr VAC, Free flaps, STSG in 50% of cases 2–4 wks: IV, 2–4 wks: orally Mq: 10.1 ± 1.7 DO: 17.2 ± 3.8 Il. crest: 13, BMP: 13 nr 12 Morris [ 18 ] 23 (13.4–32) nr Free flaps: 3, Local flaps: 5, STSG: 3, PC:1 Not specified n.a Il.…”

“… ASAMI Functional Results The pooled effect estimate of excellent or good functional results, obtained from 21 primary studies reporting on a total of 823 patients, was 87% (95% CI 80–92%, Q = 118, df : 20, p < 0.0001, I 2 = 83%) [ 30 – 35 , 37 , 38 , 40 , 42 – 51 , 53 , 56 ].…”