Complex Nonunion Research Articles

Compression distraction for the management of complex femoral nonunion

Background Complex nonunion is defined as established nonunion of at least 6 months’ duration with one of the following criteria: infection, bone defect or shortening of more than 4 cm, deformity, and an attempt to achieve union that failed to heal after at least one supplementary surgical intervention such as bone graft. Internal fixation methods are limited in their ability to deal with infection, bone defect, or shortening, and they involve extensive dissection around the fracture site for realignment of severe deformity. The Ilizarov method of compression distraction is particularly valuable in these complex cases. Patients and methods Between January 2004 and December 2010, 52 patients were treated for complex femoral nonunion using Ilizarov circular fixator. A monofocal treatment confined to the nonunion site (simple stabilization of the nonunion with compression and then stimulation of healing by distraction) was used in 23 patients; four of them had infected nonunion. Bifocal compression distraction technique with corticotomy (compression of the nonunion with distraction at the corticotomy) was used in 29 patients; 10 of them were infected. Results Bone healing was identified radiologically as callus bridging three cortices in 48 patients after a mean of 6.3 (4–12) months. Twenty patients of 23 treated using the monofocal technique had a mean healing time of 5.6 (4–9) months. Totally, 28 patients of 29 treated with bifocal compression distraction had healing after a mean of 6.8 (4–12) months. Using the criteria proposed by Paley and Maar, 30 patients had excellent functional results, 15 patients had good results, two had fair results, and five had poor results. The bony results were excellent in 35 patients, good in eight, fair in four, and poor in five. Conclusion Both monofocal and bifocal compression distraction techniques are effective in the treatment of complex femoral nonunion. Less treatment time is achieved for monofocal cases (mean: 5.6 months). In bifocal cases, acute shortening and lengthening has a much lower treatment time (mean: 5.5 months) compared with bone transport (mean: 9.3 months) and should be used when possible.

Reconstruction of patellar tendon following implantation of proximal tibia megaprosthesis for the treatment of post-traumatic septic bone defects

IntroductionLatest advances made in joint replacement implants allows reconstruction of entire limbs. These special prostheses or megaprostheses were originally designed for the treatment of severe oncological bone loss. Nowadays, however, the indications and applications of these devices are expanding to other orthopaedic and trauma clinical conditions. Since 2008 we have implanted 152 megaprostheses in non-oncological conditions: 87 were implanted for post-traumatic failures aseptic/septic (represented by complex non-unions and critical size bone defects); 26 total femur, 52 distal femur and 9 proximal tibia. In this group of patients bone and soft tissues conditions are completely different compared to patients with oncological back ground. The presence of infection and previous surgeries can lead to adhesion, scar interference, muscular and tendon impairment and skin problems that lead to reduced function and severe joint stiffness. The purpose of this study is to evaluate the results of treatment of reconstruction of patellar tendon during implantation of proximal tibia megaprosthesis for the treatment of septic post traumatic critical bone defects. Patients and methodsIn this retrospective study, we evaluated 9 patients treated with proximal tibia megaprosthesis who underwent patellar tendon reconstruction. All patients presented a complete patellar tendon disruption at the time of prosthesis implantation. Procedures of reconstruction included a tendon-plasty of quadriceps and/or patellar tendons, a pie crusting of quadriceps fascia, a reinforcement of the apparatus with synthetic tendon graft substitutes (LARS) and a medial gastrocnemius muscular flap to reconstruct the extensor mechanism and obtain skin coverage when needed. The average follow up was 18 months (9–36). For each of the cases, we analysed the complications occurred regarding septic recurrence, patellar fracture, quadriceps and patellar tendon rupture and number of reinterventions. The clinical outcome was assessed by the WOMAC Score. Results: In all cases there was no infection recurrence or skin related problems. None of the patients require prosthesis revision due to loosening or device failure. No patellar fracture or quadriceps tendon failure was recorded.One patient presented a rupture of the reconstructed patellar tendon due to a trauma incident 18 months after the implantation and he required revision surgery. From a clinical point of view the average WOMAC score was 62.4 at 1 month rising to 72.6 at 3 months, 78.2 at 6 months, 76.4 at 1 year and 74.8 at 18 months. ConclusionWhen proximal tibia megaprosthesis is implanted and there are soft tissue and patellar tendon deficiency, soft tissue reconstruction can be achieved by appropriate lengthening of the tendon and a gastrocnemius flap reinforced by LARS. Such an approach allows restoration of the extensor mechanism and coverage of the prosthesis in an area where skin problems are frequently very common.

Treatment of complex nonunion of the shaft of the tibia using Ilizarov technique and its functional outcome.

Background:A complex nonunion of the shaft of the tibia is a major cause of morbidity and mortality in patients with lower extremity injuries.Aims:The aim of this study was to evaluate the outcome of the functional and radiological outcome of complex nonunion shaft of tibia, treated by radical debridement, Ilizarov ring fixator with compression and distraction osteogenesis.Methods:From 2005 to 2010, sixty cases of complex nonunion shaft of tibia were included in our study. All infected nonunions were managed by radical debridement, fixed with Ilizarov ring fixator, monofocal/bifocal compression, and distraction osteogenesis. The average duration of follow-up is 36 months (26–50 months). The functional evaluation was done by using Association for the Study and Application of Methods of Ilizarov (ASAMI) scoring system and bone union with serial radiographs.Results:All patients had a successful union. The mean time for union was 7 months (5–9 months). The mean time of fixator removal is 12 months (8–14 months). Every patient had pin tract infections which were successfully treated with oral antibiotics. Four patients had an equinus deformity, one patient had insignificant limb shortening (1.5 cm), and three patients had soft tissue dystrophy. Using the ASAMI scoring system, we obtained 45 excellent, 10 good, 3 fair, and 2 poor functional results.Conclusions:The Ilizarov technique for complex nonunions has a high rate of success in achieving union and eradicating infection, bone loss, and malalignment. Radical debridement is the key step to control bone infection.

The Ilizarov method for the treatment of complex tibial fractures and non-unions in a mass casualty setting: the 2005 earthquake in Pakistan.

We report our experience in treating victims of the recent earthquake disaster in Pakistan. Our experience was based on two humanitarian missions to Islamabad: one in October 2005, 10 days after the earthquake, and the second in January 2006. The mission consisted of a team of orthopaedic surgeons and a second team of plastic surgeons. The orthopaedic team bought all the equipment for application of Ilizarov external fixators. We treated patients who had already received basic treatment in the region of the disaster and subsequently had been evacuated to Islamabad. During the first visit, we treated 12 injured limbs in 11 patients. Four of these patients were children. All cases consisted of complex multifragmentary fractures associated with severe crush injuries. All fractures involved the tibia, which were treated with Ilizarov external fixators. Nine fractures were type 3b open injuries. Eight were infected requiring debridement of infected bone and acute shortening. During a second visit, we reviewed all patients treated during our first mission. In addition, we treated 13 new patients with complex non-unions. Eight of these patients were deemed to be infected. All patients had previous treatment with monolateral fixators as well as soft tissue coverage procedures, except one patient who had had an IEF applied by another team. All these patients had revision surgery with circular frames. All patients from both groups were allowed to fully weight-bear post-operatively, after a short period of elevation to allow the flaps to take. Overall, all fractures united except one case who eventually had an amputation. Four patients had a corticotomy and lengthening, and three of them had a successful restoration of limb length. The fourth patient was the one with the eventual amputation.

Fixator-assisted nailing for revision ankle fusion with deformity, bone loss and or infection

Context: Ankle nonunions with deformity and bone loss are challenging cases, often with broken hardware and infection. These cases are often associated with multiple previous surgeries making revision surgery difficult. Ankle fusion for failed total ankle arthroplasty or neuropathic joints are particularly challenging, which is reflected in high reported failure rates. Aims: Fixator-assisted nailing combines Taylor spatial frame (TSF) with an intramedullary nail, allowing for correction of deformity and compression at the nonunion site, as well as internal fixation protecting the fusion after frame removal. Subjects and Methods: Between 2001 and 2014, 24 patients with 26 failed ankle fusions, with bone loss and deformity, were treated using this technique. After removal of the original internal fixation hardware and revision of the fusion surfaces, a Taylor frame is used for acute or gradual correction of deformity and compression at the nonunion site. This was followed by insertion of intramedullary nail. The nail was locked at the time of fixator removal. Results: Acute correction was possible in 23 of the 26 cases with gradual correction in the others. Union was obtained in 25 cases (96.2%) and maintained at 24 months in 23 cases (88.4%). The overall salvage rate (avoidance of amputation) was 96.2% (25/26 cases). All salvaged limbs remain free of clinical infection and do not require ongoing antibiotic treatment. The foot was in neutral position in all salvaged cases. The average time in external fixation was 11 weeks (6-13 weeks). The average AOFAS ankle/hindfoot score was 74 (range: 61-80). Conclusions: Fixator-assisted nailing, combining a TSF and an intramedullary nail, is a reliable technique for revision ankle fusion for complex nonunion with deformity and/or infection.

Megaprosthesis in post-traumatic and periprosthetic large bone defects: Issues to consider

IntroductionThe recent evolution of prosthesis technology has enabled the surgeon to replace entire limbs. These special prostheses, or megaprostheses, were developed for the treatment of severe oncological bone loss; however, the indications and applications of these devices have expanded to other orthopaedic and trauma situations. For some years, surgeons have been implanting megaprostheses in non-oncological conditions, such as acute trauma in severe bone loss and poor bone quality; post-traumatic failures, both aseptic and septic (represented by complex non-unions and critical size bone defects); major bone loss in prosthetic revision, both aseptic and septic; periprosthetic fractures with component mobilisation and poor bone stock condition. The purpose of this study was to evaluate retrospectively the complications during and after the implantation of megaprosthesis of the lower limb in post-traumatic and prosthetic bone loss, and to propose tips about how to avoid and manage such complications. Materials and methodsAll the complications and difficulties we have encountered during or after the implantation of megaprosthesis in non-oncology patients were evaluated retrospectively. A total of 72 patients were treated with large resection mono-and bi-articular prostheses between January 2008 and January 2014. ResultsThe main critical problems found in the study were: restoration of the correct length and rotation of the limb; reconstruction of the knee extensor mechanism; trochanteric reconstruction; stability/dislocation of the implant; mobility/range of motion (ROM) of the implant; skin cover; sepsis, and bone quality. ConclusionMegaprosthesis in severe bone loss can be considered as an available solution for the orthopaedic surgeon in extreme, appropriately selected cases. This type of complex surgery must be performed in specialised centres where knowledge and technologies are present. Patients with severe bone loss should not be treated in the same way as oncology patients because life expectancy is definitely longer; therefore, the surgical technique and the system implantation must be extremely rigorous to ensure longevity of the prosthesis. The characteristics of the bone and soft tissue conditions in these patients are very different from those presented by oncology patients, which creates critical problems that the surgeon should be able to manage to avoid serious complications.

Management of complex non-union of shaft of tibia using Ilizarov technique and its functional outcome

Background: Complex non-union shaft of tibia is challenging to treat and it needs coordinated multidisciplinary team work. Ilizarov ring fixator is mainly used as a salvage option in treatment of complex non-union. We studied retrospectively the functional and radiological outcome of 21 complex non-union shaft of tibia, treated by radical debridement, Ilizarov ring fixator with compression and distraction osteogenesis. Methods: From 2008 to 2013, 21 cases of complex non-union shaft of tibia were included in our study. Eighteen patients were males and three patients were females with mean age of 37.5 years (19-56). The average number of surgeries before the index operation is 3.3 (1-5). Non-union was classified according to Paley’s classification of non-union. All infected non unions were managed by radical debridement, fixed with Ilizarov ring fixator, monofocal / bifocal compression and distraction osteogenesis. The average duration of follow up is 45 months (30-70 months). The functional evaluation was done using ASAMI Scoring system, and bone union with serial radiographs. Results: All patients had successful union. The mean time for union was 7 months (5-9 months). The mean time for fixator removal is 10 months (7-14 months). The mean amount of regenerate is 3 cm (2-4 cm).Two patients had re-fracture, which united successfully after reapplication of Ilizarov frame. The complications were pin tract infection (90 pins out of 220 pins), pin loosening, skin maceration, and limb oedema. Using the ASAMI (Association for the study and application of the methods of Ilizarov) scoring system we obtained 10 excellent, 8 good, 2 fair, 1 poor functional results. Conclusions: The Ilizarov method is a viable option for complex non-union of shaft of tibia. The union was achieved successfully in all cases with good union and functional results, however, the results were compromised in cases, who underwent previous multiple surgeries before the index procedure. Thus the outcome can be improved if early osteosynthesis attempted with Ilizarov ring fixator in complex infective non unions.

Management of complex long bone nonunions using limb reconstruction system

Background:Management of complex nonunions is difficult due to the presence of infection, deformities, shortening and multiple surgeries in the past. Complex nonunions are traditionally managed by Ilizarov fixation. The disadvantages of Ilizarov are poor patient compliance, inconvenience of the frame and difficult frame construction. We conducted a study on 30 long bone complex nonunions treated by the limb reconstruction system (LRS).Materials and Methods:Between April 2009 and September 2012, we treated 30 cases of complex nonunion of long bone with the LRS. 28 were male and 2 females. Average shortening was 5.06 cm and 14 cases presented with infected implants. Initially we managed with implant removal, radical debridement followed by fixation with the LRS. In 16 cases, corticotomy and lengthening was done. The average duration of treatment was 9.68 months. We compressed the fracture site at the rate of 0.25 mm per day for 1-2 weeks and distracted the corticotomy at the rate of 1 mm/day till lengthening was achieved.Result:The union occurred in 89.28% cases and eradication of infection in 91.66% cases. Average lengthening done was 4.57 cm. We had 79% excellent, 11% good and 10% poor bony result and fnctional result was excellent in 40% cases, good in 50% and failure in 10% cases using ASAMI scoring system.Conclusion:LRS is an alternative to the Ilizarov fixation in their management of complex nonunion of long bones. It is less cumbersome to the patient and more surgeon and patient friendly.

Perdita di sostanza ossea omerale trattata secondo il principio della camera biologica: case report

Studies have estimated that 5–10% of all fractures are associated with impaired healing, resulting in delayed union or non-union. Bone defects can result from a high-energy traumatic event, from large bone resection for different pathologies such as tumours or infections or from the treatment of complex non-unions. A large bone defect represents a challenge for the orthopaedic surgeon. This clinical condition is considered critical in relation to the skeletal segment involved: 3 cm for the forearm, 5 cm in the femur and tibia, 6 cm in the humerus. Excluding the traditional surgical techinques (distraction osteogenesis, autologous bone grafts or arthrodesis), the use of biotechnology can be very useful. We treated a 42 years old patient, that came to our observation through the ambulatory of nonunion of our Institute with a diagnosis of “humeral large bone septic defect”; this patient had in his history multiple previous osteosynthesis surgeries. The patient therefore underwent corrective surgery according to the Masquelet’s technique in two surgical times. The postoperative course was uneventful; during the follow-up the patient showed a good functional recovery with great satisfaction.

Reattachment of Complex Femoral Greater Trochanteric Nonunions with Dual Locking Plates

The goal of this retrospective study was to evaluate complex nonunions of the trochanter fixed with dual locking plates after failed cable fixation devices. Fifteen consecutive patients were operated on for greater trochanteric nonunion and with a mean follow-up of 53.1 months (range, 26-88 months). Fixation was achieved with dual locking plates contoured on the anterolateral and posterolateral surface of the greater trochanter. Trochanteric union was achieved in 13 patients (87%). Failures occurred only when the trochanter was reattached to a proximal femoral allograft. The average total hip score was 14.8 ± 2.2 (Merle d'Aubigné ) and 77.6 (±12.8) (Harris Hip score). However, 20% of successful cases needed painful hardware removal. Greater trochanter nonunions can be successfully reattached with locking plates especially if bone-to-bone apposition is achieved at surgery.

Posttraumatic Taylor Spatial Frame Deformity Correction in Adults

Abstract The Taylor Spatial Frame (Smith & Nephew, Inc., Memphis, TN) has become an important tool in the treatment of post-traumatic deformities. This article concentrates on the technical indications, preoperative planning, frame construction, intraoperative strategies, and postoperative regimes used to correct post-traumatic problems. Chronic and Total Residual mode are discussed and advantages and disadvantages of each technique are considered. Clinical examples are given. Posttraumatic osteomyelitis, malunions and complex nonunions are emphasized and detailed treatment outlines are suggested depending on the severity of the problem. Stacked bone transport is reviewed in the setting of significant bone loss, poor surrounding soft tissue, infection, and nonunion.

Successful Reconstruction for Complex Malunions and Nonunions of the Tibia and Femur

Successful Reconstruction for Complex Malunions and Nonunions of the Tibia and Femur

External skeletal fixation technology to treat refractory nonunion in long bones following prior internal fixation

Objective To observe clinical outcomes of external skeletal fixation technology without bone graft in treatment of complex bone nonunion and defect following prior internal fixation. Methods From April, 2002 to December, 2008 in our hospital, a total of 17 patients with complex bone nonunion and bone defect were treated with external skeletal fixation withont bone graft. They were 12 men and 5 women,aged 11 to 50 years (average, 34. 7 years). The nonunion involved tibia in 10, femur in 5 and humerus in 2 cases. The duration for nonunion ranged from 8 to 21 months (average, 16.3 months). Bone defects ranged from 2. 5 to 11.0 cm (average, 3.5 cm) . End-to-end compression followed by lengthening and segmental bone transport by lengthening were conducted for the management. Twelve cases complicated with bone defect or limb shortening received epiphysiotomy to restore the limb length in the period of compressive fixation. The patients were followed regularly to assess their healing of nonunion and defects. Results According to clinical follow-up, all patients obtained fracture healing after a mean time of 5. 2 months (range, 3 to 21 months). The 12 patients with bone defects sustained a mean bone lengthening of 4. 8 cm, obtaining a balance in limb length. Their healing time ranged from 4 to 11 months (average, 5.2 months). Their mean bone union index was 32 d/cm.Conclusions The plastic external skeletal fixation can promote bone healing. Bone lengthening through epiphysiotomy can restore the balance in limb length without bone graft. Therefore, this tecnology is an effective treatment for complex bone nonunion and defect in long bones. Key words: External fixators; Fractures, ununited; Treatment outcome

Available biological treatments for complex non-unions

The treatment of complex non-unions may be lengthy and very expensive. The majority of aseptic non-union cases require a variable degree of biological enhancement. Autologous iliac crest bone graft remains the gold standard of treatment. However, other means of biological stimulation are currently available in the armamentarium of the treating physician. This review article reports on the different available biological treatment options for the management of complex aseptic bone non-unions.

Management of complex tibial and femoral nonunion using the Ilizarov technique, and its cost implications

We reviewed 78 femoral and tibial nonunions treated between January 1992 and December 2003. Of these, we classified 41 in 40 patients as complex cases because of infection (22), bone loss (6) or failed previous surgery (13). The complex cases were all treated with Ilizarov frames. At a mean time of 14.1 months (4 to 38), 39 had healed successfully. Using the Association for the Study and Application of the Methods of Ilizarov scoring system we obtained 17 excellent, 14 good, four fair and six poor bone results. The functional results were excellent in 14 patients, good in 14, fair in two and poor in two. A total of six patients were lost to follow-up and two had amputations so were not evaluated for final functional assessment. All but two patients were very satisfied with the results. The average cost of treatment to the treating hospital was approximately pound 30,000 per patient. We suggest that early referral to a tertiary centre could reduce the morbidity and prolonged time off work for these patients. The results justify the expense, but the National Health Service needs to make financial provision for the reconstruction of this type of complex nonunion.

Complex nonunion of fractures of the femoral shaft treated by wave-plate osteosynthesis.

We have treated 42 consecutive complex ununited fractures of the femoral shaft by wave-plate osteosynthesis at five different medical centres. There were 13 with previous infection, 12 with segmental cortical defects, and 3 were pathological fractures. In 39 cases there had been previous internal fixation and 21 patients had had more than one earlier operation. Union was achieved in 41 patients at an average of six months, although three had required a second bone graft. Two patients had recurrence of infection and in one this resulted in the persistence of nonunion. There were no failures of the implant. All 41 patients with union are now fully weight-bearing, but four have a leg-length discrepancy, one has axial malalignment, and nine have residual stiffness of the knee. These results are surprisingly good, despite the complexity of the initial problem, and appear to confirm the biological and mechanical advantages of the wave plate over the conventional plate for such cases.

Sternal plating for the treatment of sternal nonunion

Sternal nonunion, defined as sternal pain with clicking, instability, or both for more than 6 months in the absence of infection, is an uncommon complication of median sternotomy. Nonunion is frequently complicated by the presence of multiple transverse fractures, which make simple rewiring inadequate. Six patients with debilitating pain secondary to sternal nonunion were treated with the technique of sternal plating between 1989 and 1995. Sternal plating corrected sternal instability and provided excellent pain relief in all 6 patients. All patients reported an improved quality of life and were able to resume recreational activities. Two patients have had plate removal for late bursa formation. Sternal healing was complete in both instances. Sternal plating, which is based on the tension-band principle, is an effective treatment of sternal nonunion. The technique is applicable to both simple and complex nonunions. The stainless steel plates resist bending stresses, and the cortical bone resists compressive forces. The technique requires minimal dissection of the posterior sternal border, is not circumferential, and provides secure sternal approximation.

Locked intramedullary nailing for complex non-union of the tibia

Ten patients with complex non-union of the tibia were treated by locked intramedullary nailing. These patients had scarred skin as a result of initial severe open fractures, multiple debridement or fasciotomies with external fixators and skin grafts applied. Seven of the patients also had previous osteomyelitis or pin track infections. Fully pain-free walking was achieved in all patients and radiological union in nine patients without the need for a bone graft. Four patients developed infection after nailing, of which three resolved with treatment.

The Ilizarov method for complex fracture nonunions.

Nonunion of complex fractures continues to challenge orthopedic trauma surgeons. Although traditional management results in a successful outcome in 50% to 80% of cases, the Ilizarov method has been reported to be more effective. We evaluated the efficacy of the Ilizarov method for treatment of nonunions. Patients were selected based on the presence of nonunion associated with osteomyelitis, treatment failure, or extensive segmental bone loss. Treatment principles include surgical debridement, stabilization, and bone regeneration for correction of defects. Patients were given maximum mobility and were required to function as normally as possible during the course of treatment. Seventeen patients were treated for complex nonunions with the Ilizarov method during a 33-month period. Seven patients were facing the alternative of amputation. Causes of nonunion were osteomyelitis (65%), failure of conventional treatment (23%), and segmental bone loss (12%). Fractures involved the lower (82%) and upper (18%) extremities. Using the Ilizarov method, union was achieved in 94% (16 of 17) of patients over an average time of 6 months. Our results indicate that the Ilizarov method is superior to traditional techniques of managing complex nonunions.

Intraoperative distraction in the treatment of complex nonunions of the radius

Two unique cases of complex nonunions of the radius are presented. Each was characterized by bone loss, disruption of the distal radioulnar joint, and loss of axial alignment. Indirect reduction and lengthening of the radius were accomplished intraoperatively with the use of a femoral distractor, and the nonunion was treated with autogenous iliac crest graft and a long AO/ASIF dynamic compression plate. A functional result occurred in each case.