War-related infected tibial nonunion with bone and soft-tissue loss treated with bone transport using the Ilizarov method

Abstract

This single centre retrospective study reviews the outcomes of 30 war-injured patients with established infected tibial nonunion after sustaining grade IIIB open fractures. Patients were treated by radical bony and soft-tissue resection and bone transport using the Ilizarov bifocal technique, without the use of systemic antibiotics or bone grafting. The series comprised 29 males and 1 female with a mean age of 30.4 years and a mean nonunion of 8.6 months at index operation. Patients had previously undergone a mean of 1.3 operations (range 1-3), and the mean size of tibial defect was 6.9 cm (range 4-11 cm) post radical debridement. Bony union was achieved at the tibial docking sites after a mean of 4.5 months in 29 patients (97%) and frames were worn for a mean of 9.7 months (range 7.2-15 months), giving a mean fixation index of 1.48 months/cm. One patient failed to unite at their tibial docking site. Soft-tissue transport successfully closed the soft-tissue defects in all but four patients, who required split-skin grafting. According to the Paley scoring system 19 patients had excellent bony results, 10 good and 1 poor; the functional results were excellent in 13 patients, good in 14, fair in 2 and poor in 1; and there were 1.4 complications per patient. Over a mean follow-up of 99 months no patient refractured their reconstruction, developed any symptoms or signs of recurrent infection, or required amputation. The Ilizarov technique with bone transport continues to be the most versatile, adaptive and effective method of treatment in these complex cases, and can very successfully deal with the associated large soft-tissue and bony defects without the use of routine bone-grafting, systemic antibiotics or soft-tissue flaps.