Ilizarov Research Articles

The deleterious relationship of Pseudomonas aeruginosa and Induced Membranes in infected non-union treatment

The Masquelet technique was originally described for the treatment of an infected non-union with an extensive bone defect where a staged protocol was needed to first eliminate an infection then secondarily bone graft a defect. Though this is a versatile technique, certain limitations/ complications must be recognized. The study was done between 2012 to 2019 at SRIHER university. 19 patients in whom the Masquelet technique has failed is taken into study. 17 male and two females, with a mean age of 31 years (range of 13 yrs. – 51 yrs.) with a mean follow up of 12 months. The 19 patients who presented with Pseudomonas aeruginosa infected non-union of the tibia and femur with bone defects underwent the Masquelet technique. All patients failed to form adequate induced membrane at the non-union site. Infected non-union with a bone defect is difficult to treat. Bone defects of 2cms can be treated by cancellous bone grafting. Defects more than 4-5cms will require specialized reconstructive procedures to prevent amputation. The two common techniques used are Ilizarov technique with bone transport and bone graft into an induced membrane as described by Masquelet. This study shows a high failure rate of the Masquelet technique with Pseudomonas infection. The most difficult issue faced by the surgeon in treating P. aeruginosa is its ability to develop resistance to multiple classes of antibiotics during the course of treating the patient. Masquelet technique is used extensively for the treatment of infective non-union. Pseudomonas secretes a slime layer that may lead to a weak or deficient formation of the induced membrane. And the elution of antibiotics may not be adequate for intramedullary osteomyelitis with pseudomonas growth. This limits the Masquelet technique in the management of infected non-union with pseudomonas infection.

Infected regenerate in ilizarov surgery

Background: The regenerate is the newborn of the distraction process, and it passes by many changes during its growth and maturation. Many complications can take place at the regenerate site. The aim of this study is to highlight infection as a possible complication that may affect the regenerate during bone lengthening. Patients and Methods: In this study, we present three cases who were complicated by infection of the regenerate. The diagnosis and management were described in details. Results: The predisposing factors for this complication may be patient-related or technically related factors. The isolated organisms were Escherichia coli, Staphylococcus epidermidis, and Staphylococcus aureus. Infection was controlled in all cases. The desired length was achieved in two cases, and one case was left with residual shortening of 2 cm. Conclusion: Infection of the regenerate is a rare but serious complication. A high index of suspicion is required for its diagnosis, and few options are available for its management.

Orthopaedic Replantation and functional reconstruction of an amputated lower extremity

Objective To evaluate our replantation and functional reconstruction of amputated lower extremities. Methods From February 2013 to October 2017, 13 patients with an amputated lower extremity were treated at Orthopaedic Department, The 960th Hospital of the PLA Joint Logistics Support Force. They were 10 males and 3 females, aged from 15 to 63 years (average, 39 years). In all the patients, large segmental shortening and extremity replantation was conducted at the first stage and Ilizarov extremity lengthening at the secondary stage. After desired extension was achieved, the frame of Ilizarov external fixator was removed and replaced by external fixation with a locking plate under closed reduction. Postoperatively, functions of the knee and ankle joints, sensory recovery of the foot sole, length and appearance of the extremity were observed. Results All the 13 patients were followed up for 12 to 24 months (average, 16 months). All the limb replants survived well. Of them, 12 were satisfied with their weight-bearing walking and therapeutic outcomes. Conclusions For an amputated lower extremity, the first-stage shortening and replantation can result in fine extremity salvage and the secondary Ilizarov extremity lengthening can lead to fine therapeutic outcomes. Key words: Replantation; Bone lengthening; External fixators; Amputated lower extremities

Comparison of Ilizarov and Masquelet techniques in the treatment of long bone defects

Comparison of Ilizarov and Masquelet techniques in the treatment of long bone defects

Qualitative study on care needs in parents of children with congenital pseudarthrosis of the tibia during Ilizarov fixation

Objective To deeply explore the care needs in parents of children with congenital pseudarthrosis of the tibia (CPT) during Ilizarov fixation. Methods Totally 10 parents of CPT children during Ilizarov fixation hospitalized in the Department of Orthopedics, Hu'nan Children's Hospital between March and December 2017 were selected using purposive sampling and received semi-structural interview. Colaizzi phenomenological methods were used to analyze the data. Results Totally 4 themes were refined, including informational support needs (needle way care, functional exercise and feeding) , psychological support needs, economic support needs, and children's educational support needs. Conclusions The parents of CPT children during Ilizarov fixation have many care needs. Nursing workers should pay attention to their needs and take targeted measures to accelerate the postoperative recovery of children. Key words: Pseudarthrosis; Tibia; Ilizarov; Parents; Home care needs; Qualitative study

Ilizarov method combined with reversed sural or saphenous neurocutaneous island flaps transfer for posttraumatic equinus with soft tissue defects on ankle and foot

Objective To evaluate the clinical effects of the Ilizarov method combined with two kinds of reversed neurocutaneous island flaps transfer for posttraumatic equinus with soft tissue defects on ankle and foot. Methods Data of 21 cases of posttraumatic equinus with soft tissue defects on ankle and foot who were treated with the Ilizarov external fixation combined with the two kinds of reversed neurocutaneous island flaps transfer from June 2006 to January 2018 were retrospectively analyzed. There were 17 males and 4 females, aged from 26 to 65 years, with an average age of 43.9 years. The soft tissue defect dimensions ranged from 6 cm×5 cm to 10 cm×9 cm, and the time from the initial trauma to the operation ranged from 2.5 to 240.0 months. The mean preoperative equinus contracture was -38.9° (range, -25° to -66°), and total ankle range of motion (ROM) was 7.1° (range, 0°-18°). All cases were treated with the Ilizarov external fixation combined with the two kinds of reversed neurocutaneous island flaps transfer. Two weeks after the flap transfer, distraction of the Ilizarov fixator was initiated to gradually correct the equinus foot. The flap survival was observed in the postoperative period, and the International Club Foot Study Group (ICFSG) score was collected at the latest follow-up. The criteria were used to assess the morphological and functional outcome. Results A total of 21 resversed flaps were transferred, including 15 sural neurocutaneous flaps and 6 saphenous neurocutaneous flaps. The sizes of flaps were from 7 cm×6 cm to 11 cm×10 cm. Among them, 17 patients underwent primary flap transfer, and 4 patients underwent a delayed second-stage procedure 2 weeks after primary surgery. The 4 delayed flaps contain 3 sural neurocutaneous flaps and 1 saphenous neurocutaneous flap. All 21 patients were followed up and the average periodof follow-up was 20.3 months (range, 8-96 months). Among the 21 flaps, 19 survived completely. Although marginal necrosis was observed in 2 cases, these wounds healed after subsequent debridement and dressing change treatment. No major complication was seen, but superficial pin tract infection was present in 4 cases who then received dressing change and oral antibiotic. Deformities were corrected, and ankle motion had increased significantly. The mean ankle activity at the latest follow up was 22° (range, 8°-38°), and postoperative ICFSG score at the latest follow-up was 5.67±3.09, which significantly reduced compared with preoperative one (30.81±3.63). The difference was statistically significant (t=32.815, P=0.035) . The results were excellent in 13 feet, good in 7, and fair in 1, with the excellent and good rate of 95.24% (20/21). The local infections were cured without recurrence at operative site. Equinus deformities were corrected, and the latest follow-up results showed that all patients walked normally without recurrence. Conclusion Ilizarov method combined with reversed sural and saphenous neurocutaneous island flap can improve the limb function and the flap can survival with good clinical effect. Key words: External fixators; Surgical flaps; Equinus deformity

Accordion technique in the treatment of tibial delayed union or nonunion

Objective To assess the clinical curative effect of accordion technique in the treatment of tibial delayed union or nonunion. Methods From February 2016 to December 2017, data of 11 patients with tibial delayed union (n=8) or non-union (n=3) who had been treated by accordion technique with an Ilizarov ring external fixator were retrospectively analyzed. 10 males and 1 female were included in our study, with an average age of 41.9 years (range, 21-63 years). There were 5 cases of docking site delayed union after Ilizarov transport for chronic tibial osteomyelitis. There were 3 cases of fracture site delayed union after external fixation for open tibia comminuted fracture. There were 3 cases of nonunion after tibia closed fracture, including 2 cases who had hybrid external fixation treatment, and 1 case who had conservative treatment. All the cases received accordion technique using Ilizarov ring external fixators. First, gradual compression at the fracture site was conducted until the bony contact was seen on a radiograph. After bony contact, compression was continued at a rate of 0.85 mm/d for a week, followed by distraction of 0.85 mm/d for 2-3 weeks. Afterward, a second compression was conducted using same rate and time with the distraction procedure. And there was a 7-day latent period between compression and distraction. One or two cycles of compression-distraction were needed before union was present radiographically. Results Bony union was obtained in all 11 patients after a mean time of 5.4 months (from 3 to 9 months). The mean follow-up for the 11 patients was 15.2 months (from 11 to 29 months). The mean duration of the accordion technique treatment was 50.2 d (range, 35-67 d). The accordion technique was used 1 time for 8 patients, and 2 times for 3 patients. The mean duration of bone consolidation was 114.9 d (range, 64-239 d). According to Paley evaluation criteria, osseous results were excellent in 8 cases, good in 3 cases, with a good to excellent rate of 100%(11/11); functional results were excellent in 7 cases, and good in 4 cases, with a good to excellent rate of 100%(11/11). Conclusion The accordion technique is a minimal invasive, safe and reliable treatment program for tibial delayed union or nonunion. Key words: Tibial fractures; Fractures, ununited; External fixators

Ilizarov technique in combination with bone grafting and ankle traction for treatment of periarticular nonunion at the distal tibia

Objective To evaluate the clinical efficacy of a combination of Ilizarov technique, bone grafting and ankle traction for treatment of nonunion of the distal tibia within 2 cm around the ankle joint. Methods A retrospective study was performed on the patients who had been treated at Department of Orthopaedics, Sir Run Run Shaw Hospital from September 2014 to January 2018 for nonunion of the distal tibia within 2 cm around the ankle joint. They were 8 men and 4 women, aged from 32 to 56 years (average, 41 years). Their injury was all unilateral, involving 5 left and 7 right ankles. They had all received internal fixation at other hospitals for 6 to 18 months. After we treated them simultaneously with Ilizarov technique, bone grafting and ankle traction, they could walk with crutches as soon as 3 days after surgery in some cases. Their affected limbs were then subjected to gradual weight-bearing walking until they could walk normally without any aid 3 to 6 months after surgery. Their postoperative ankle functions were evaluated according to the ankle-hindfoot scores of the American Orthopedic Foot and Ankle Society (AOFAS) system. Results The 12 patients were effectively followed up for 12 to 24 months (average, 19 months). All their incisions healed well with no incision or pin-tract infection. All their bone nonunions healed after circular external fixation for 12 to 36 weeks. Their AOFAS scores ranged from 75 to 96 points, showing good functional recovery of the ankle joint. Conclusion A combination of Ilizarov technique, bone grafting and ankle traction is an effective treatment for nonunion of the distal tibia within 2 cm around the ankle joint, leading to preservation of the ankle function and prevention of posttraumatic ankle osteoarthritis. Key words: Fractures, ununited; Bone grafting; Osteoarthritis; Ilizarov technique; Ankle traction

Clinical efficacy of bone transport technique in treatment of large segment infective nonunion of femoral shaft

Objective To investigate the clinical effect of bone transport technique in the treatment of large segment infective nonunion of femoral shaft. Methods A retrospective case series study was conducted to analyze the clinical data of 33 patients with large segment infective nonunion of femoral shaft admitted to Chinese PLA General Hospital from June 2012 to October 2015. There were 25 males and eight females, aged 19-58 years (mean, 34.6 years). In terms of the initial injury, 23 patients were with open fracture and 10 with closed fracture. All patients previously received 1-9 times of operation, with an average of 2.3 times. The duration from injury to operation ranged from 7-60 months, with an average of 34 months. All patients underwent treatment with bone transport technique. After thorough debridement, the length of femoral defect ranged from 6 cm to 18 cm, with an average of 10.5 cm. The single arm limb reconstruction external fixator was placed on the lateral side of the femur under C-arm X-ray fluoroscopy. The wound healing, bone healing time, external fixation index (EFI), and complications were recorded. The function of the affected limb was evaluated using the modified criteria of Association for the Study and Application of the Method of Ilizarov (ASAMI). Results All patients were followed up for 21-53 months (average, 38.5 months). Femoral defects were completely repaired, with no recurrent infection reported. Bone healing time ranged from 8 months to 25 months (average, 13 months). The external fixation index (EFI) ranged from 1.13 months/cm to 1.83 months/cm, with an average of 1.26 months/cm. The infection rate of the nail tract was 55% (18/33). There were 12 patients with Type A, five with Type B, and one with Type C. The function of the affected limb was graded as excellent in 18 patients, good in six, fair in five, and poor in four, with an excellent and good rate of 73% (24/33). Conclusions In the treatment of large segment infective nonunion of femoral shaft, bone transport technique can control the infection, promote defect repair, and restore the function of affected limbs. Key words: Femur fractures; Infection; Ilizarov technique; Fracture, ununited

Treatment of infected nonunion by external fixation

Objective To explore the curative effects of external fixation in the treatment of infected nonunion. Methods From June 2009 to December 2016, 45 patients with infected nonunion were treated by external fixation at Department of Orthopaedics, West China Hospital. They were 36 males and 9 females with an average age of 45.3 years (range, from 14 to 65 years). The sites of fracture included tibia in 31 patients, femur in 12, humerus in one, and ulna-radius in one. The median time from injury to application of external fixation was 16.8 months and the average number of previous operations was 2.3 times. After debridement, 24 cases had a bone defect of 6.0 cm in length on average (range, from 3.5 to 10.4 cm). After discharge, the patients were regularly followed up at the outpatient department and any of their complications was recorded in detail. At the final follow-ups, the protocol of ASAMI (Association for the Study and Application of the Method of Ilizarov) was used to evaluate their bone and functional results. Results All the 45 patients were followed up for 16 to 106 months (average, 43.9 months). One patient had to receive amputation because of uncontrollable infection and all the other 44 cases achieved bony union. The bone defects were successfully reconstructed by external bone transport in 24 patients. The time for external fixation averaged 20.5 months. According to the evaluation by ASAMI at the final follow-ups, the bone was rated as excellent in 28 patients, as good in 12, as fair in one and as poor in 3, giving an excellent to good rate of 90.9%; the function was rated as excellent in 11 patients, as good in 21, as fair in 8 and as poor in 4, giving an excellent to good rate of 72.7%. Conclusion In eradication of infection and treatment of fracture nonunion, external fixation can be used not only to avoid the infection risk due to internal fixation but also to correct a complex deformity and repair a large bone defect, allowing early weight-bearing for the patients. Key words: Fractures, ununited; Infection; External fixation; Bone transport

Treatment of intertrochanteric fracture femur by Ilizarov fixator in elderly patients

Objective To assess the effectiveness of fixation of intertrochanteric fracture femur in elderly high-risk patients using Ilizarov fixator. Background Internal fixation of intertrochanteric fractures is a routine procedure, but in patients with anesthetic risks, external fixation can be considered a semiconservative method to reduce operative time and complications. In this study, the functional and radiological results of management of intertrochanteric fracture femur in elderly patients using Ilizarov fixator is evaluated. Patients and methods A total of 20 elderly high-risk patients with intertrochanteric fracture were treated by Ilizarov fixator. All patients had uncontrolled concomitant medical disorders such as hypertension, diabetes mellitus, and chronic hepatic or renal failure. The age range was 50–85 years. Results The patients were followed up for a mean of 7.5 months with a range from 6 to 9 months. Excellent and good (satisfactory) results were found in 16 patients and fair and poor (unsatisfactory) results were found in four patients. The time of radiological union and fixator removal ranged from 10 to 16 weeks. Pin-tract infection occurred in all patients. Varus malalignment occurred in 20% of patients. Shortening ranged from 0 to 3°. There were two cases of penetration of the femoral head. Conclusion It was found that external fixation of intertrochanteric fractures in elderly high-risk patients is a reliable, effective, and safe treatment option. It offers minimal operative risk, no blood loss, early mobilization, short hospital stay, and low morbidity and mortality.

Results of management of tibial plateau fractures Schatzker types V and VI using Ilizarov fixator

Background Management of comminuted bicondylar tibial plateau fractures remains a challenge to orthopedic surgeons. Studies on long-term outcomes of treatment of the tibial plateau have included a mixture of fracture types, including low-energy split and split-depressed fractures. Thus, the middle-to-long-term results of management of high-energy fractures are still lacking. Objective The aim of this study was to evaluate the knee function and development of arthrosis after a minimum of 3 years in high-energy tibial plateau fractures treated with the Ilizarov external fixator. Patients and methods There were 30 patients in this study and they were followed up for a minimum of 3 years. Completion of the Iowa knee score and the Short Form-36 General Health Survey was a must. This retrospective study was performed at an academically supervised level III, trauma center, in which percutaneous and/or limited open internal fixation and an Ilizarov frame were applied for displaced bicondylar high-energy tibial plateau fractures (Schatzker types V and VI, and Orthopedic Trauma Association types C1, C2, and C3). Results After healing, none of the studied patients needed a secondary reconstructive procedure. The knee motion ranged between 15° of extension and 155° of flexion, with an average of 88% of the total arc of the contralateral knee. Conclusion Patients suffering from high-energy bicondylar tibial plateau fractures could be safely treated with minimal internal fixation and Ilizarov external fixation. This procedure has good prognosis for satisfactory knee function for up to 16 years of follow-up.

Application of Ilizarov technique combined with internal implants for bone nonunion

Bone nonunion, a common complication after fracture surgery, is one of the most challenging problems an orthopedist has to face. Although Ilizarov technique has been proved an effective treatment of infected nonunions or bone defects, it bears such shortcomings as long frame-wearing time and poor compliance. In order to tackle them, many scholars have suggested a combination of Ilizarov technique and internal implants for bone nonunion which greatly shortens the time a patient wears the frame and allows for early ambulation, leading to good outcomes. This article reviews the mechanisms of distraction osteogenesis for Ilizarov technique and advances in application of Ilizarov technique combined with internal implants for treatment of bone nonunions. Key words: External fixators; Internal fixators; Fractures, ununited; Distraction osteogenesis

Flow-through anterolateral thigh flap transfer combined with bone transport technique for repairing the segamental mutilating injury in lower extremity

Objective To explore the clinical application and effect of Flow-through anterolateral thigh flap transfer combined with bone transport technique for repairing the segamental mutilating injury in lower extremity. Methods From June, 2010 to June, 2016, Flow-through anterolateral thigh flap transfer combined with Ilizarov technique were applied to repair the segamental mutilating injury in lower extremity in 10 cases. Of the 10 cases, there were 8 males and 2 females (their ages ranged from 26 to 55, 36 on average). Four caused by road accident, 4 caused by crush injury, 2 cases caused by squeeze injury. First stage, Flow-through anterolateral thigh flap transfer were applied to revascularize the lower limb and repair the soft tissue defect in emergency. Second stage, bone transfort with external fixator were applied to repair bone defect in second stage. The area of the flap ranged from 12.0 cm×15.5 cm to 20.0 cm×25.0 cm. The repair of bone defect ranged from 4.0 cm to 10.0 cm. Time interval between two stages ranged from 2 to 4 months, 3 months on average. Followed-up method was regular outpatient-care after discharge. The main contents include: the presence of red swollen with pus, the condition of infection in the pin, if the fixed pin was loosening, and adjust the speed of bone transport according to the mineralization of new bone. Results All cases were successfully repaired in 10 cases. Ten cases were followed-up with a mean followed-up time of 42 months. All flaps survived, in with 6 cases were healed in first stage, 4 case were healed in second stage (healing time ranged from 14 to 30 days), and bone transfort time ranged from 6 to 16 months. The docking site union occurred in 6 cases and were healed by use of bone debridement, bone graft and compression. Deformity in foot and ankle occurred during the bone transport in 2 cases and were cured by draft therapy with adding ring fixator. The functions of donor sites were not found malfunctional. Conclusion Flow-through anterolateral thigh flap transfer combined with bone transport have high success rate of limb salvage, good quality of osteogenesis, and satisfactory function recovery. It is an optimal method to repair the segamental mutilating injury of the lower extremity. Key words: Anterolateral thigh flap; Flow-through flap; Bone transport technique; Segamental mutilating injury; Lower extremity

Clinical research of Ilizarov technique for treatment of lower limb infected bone defect

Objective To explore the clinical efficacy of Ilizarov technique for infected-bone defect in lower extremity. Methods From January 2013 to December 2016, data of 31 consecutive patients with lower limb infected bone defect were retro-spectively analyzed. There were 23 males and 8 females, with an average age of 35.8 years (range, 5-57 years). 16 cases of infect-ed bone defect were on femur while the other 15 were on tibia. The infected bone defects were developed from blood-borne osteo-myelitis in 3 cases, from open fracture (according to Gustlio classification, Gustilo Ⅱ 8, Ⅲa 5, Ⅲb 4) surgery in 17 cases (12 cas-es after external fixation and 5 cases after internal fixation), and from closed fracture surgery of plate or intramedullary nail fixation in 11 cases. Soft-tissue defects were observed in 5 cases, including 1 femur and 4 tibia. The previous operations were performed with an average operation time of 3.2 (range, 2-5 times) and treatment duration of 9.6 months (range, 3-21 months). The operation process was one stage debridement, external fixation, combined with bone osteotomy and transportation. Bone transportation start-ed 7 to 10 days after osteotomy with a speed of 1 mm/d, and 0.25 mm/time. Healing rate and complications were recorded during the follow-up period and were assessed by Paley fracture healing score. Results The length of bone defect after debridement was 6.9 cm (range, 3-13.5 cm). There were 27 cases positive in bacterial culture, who were treated by sensitive antibiotics. The other 4 cases were negative and treated by broad-spectrum antibiotics. The bone lengthening speed was 0.76 mm/d (range, 0.56-0.86 mm/d). All bone and soft-tissue defects healed, with average bone healing time of 11.5 months (range, 6-18.5 months). All patients were followed-up for 12 to 48 months (average, 25.5 months). Pin infection appeared in 11 cases (8 cases on femur and 3 cases on tibia) who were cured by oral antibiotics, serial dressing and debridement. Axial displacement was presented in 4 cases on femur and were corrected by external fixation adjustment. No recurrent infection was observed and the limb length restored normal. Postoper-ative complications in femur were 106.3% (17/16) comparing 46.7% (7/15) in tibia. According to Paley fracture healing score, 12 cases were excellent, 14 were good and 5 were fair, yielding an excellent to good rate of 83.9% (26/31). Conclusion Ilizarov tech-nique is an effective way in the treatment of infected-bone defects. The complication rates on femur observed in this study were slightly higher than that on tibia. Key words: Ilizarov technique; Femur; Tibia; Infection

Successful management of intramedullary nail associated infection with reaming and antibiotic cement beads/rod

Objective To assess the efficacy of using reaming and antibiotic cement beads/rod for intramedullary nail as-sociated infection. Methods Data of 12 patients with intramedullary infection of tibia or femur following intramedullary nailing from October 2014 to April 2016 were retrospectively analyzed. There were 10 men and 2 women aged from 19 to 63 years old with an average age of 39.2 years. In 5 cases the disease was localized in the femur with one case of nonunion, and in other 7 cases the disease was localizedin the tibia with two cases of nonunion. The initial injury included closed fracture in 8 patients and open fracture in 4 patients which were all Gustilo-AndersonⅡ. According to the Cierny-Mader classification of adult osteomyelitis, 6 cases were typeⅠ (medullary osteomyelitis), 4 cases were type Ⅰcombined with type Ⅲ (medullary and localized osteomyelitis), and 2 cases were typeⅠ combined with type Ⅳ (medullary and diffuse osteomyelitis). Surgical technique included removal of the intramedullary nailand reaming and irrigation of the medullary canal to remove intramedullary debris. The drainage sinus and soft tissues abscess were excised if existed. An local or enbloc resection for the infected or necrotic bone was performed if there was lo-cal or diffuse infection in the fracture sites. Ilizarov technique was performed for segment bone defect. The bone union was ob-served in nine patients and stable nonunion in one. Antibiotic PMMA beads were inserted into intramedullary canal for these ten cases after debridement, and the antibiotic beads were removed approximately 12-14 days after implantation. The antibiotic ce-ment rod was inserted into the medullary canal to provide stabilization in the other 2 cases. All the patients received intravenous antibiotics systemically for three weeks, and followed by three weeks of oral antibiotics. Results At a mean follow-up period of 23.5 months (range, 15-33 months), no recurrence of infection was observed. There were 3 cases of nonunions. One case of tibial nonunion had been achieved union 10 months after insertion of an antibiotic cement rod. One with stable nonunion of tibia was treated with antibiotic PMMA beads, and enbloc resection for the infected bone was performed after the extension of infection had been narrowed at the nonunion. 6 cm of bone defect was treated with bone transport and then union was obtained 16 months after operation. The third case was infected nonunion in the femur with 4 cm bone defect after debridement. The femur was shortened and temporarily stabilized with the intramedullary antibiotic cement rod. The rod was removed three months after the operation, and then the femur was lengthened. The docking site and the regeneration area were healed 12 months after the lengthening opera-tion. Conclusion The clinical results shows that reaming and antibiotic cement beads/rod appears an effective and safe alterna-tive for management of intramedullary nail associated infection of the tibia and femur. Key words: Femur; Tibia; Infection; Fracture fixation, intramedullary

Accordion technique used in treatment of hypertrophic nonunion

Objective To evaluate the therapeutic effects of the accordion technique used in external fixation for long bone hypertrophic nonunion. Methods From August 2013 to December 2015, 13 patients with hypertrophic nonunion were treated by the accordion technique (distraction, compression and re-distraction) used together with an Ilizarov ring external fixator or a monolateral external fixator. They were 10 males and 3 females with an average age of 44.6 years (from 18 to 63 years). The nonunion occurred in the middle femur in 5 patients, in the femoral supracondyle in one, in the tibial diaphysis in 4, and in the distal tibia in 3. The procedure was performed with a preassembled external fixator without open surgery or bone graft. The pathological sites were gradually distracted (0.25 mm/day) from the seventh day postoperatively. In case of deformity, correction was conducted to restore the alignment. At the same rate of distraction, compression was started after the equal length was achieved and next followed by distraction. The frequency of cycle depended upon the callus observed in the X-rays. Results The mean follow-up for the 13 patients was 19 months (from 10 to 38 months) after removal of the external fixator. All the cases of hypertrophic nonunion obtained bony union after a mean duration of 7.5 months (from 5 to 13 months). No nonunion or deformity recurred during the follow-up. The complications such as pin-site infection (in 4 cases) and mild Achilles's tendon contracture (in 2 cases) were prevented or treated by careful nursing and rehabilitation. Conclusion The accordion technique together with an external fixator is a reliable and effective treatment for hypertrophic nonunion. Key words: External fixators; Bone regeneration; Fractures, ununited; Accordion technique

Clinical study of bone transport combined with bone graft and internal fixation at the docking site in the treatment of large segmental bone defect in lower limb

Objective To explore the feasibility and clinical value of Ilizarov bone transport technique combined with bone graft and internal fixation at the docking site in the treatment of large segmental bone defect of the lower limbs. Methods Thirty patients with large lower limbs bone defects were prospectively divided into two groups according to the random number table: pure bone transport group (Ilizarov bone transport technique alone, n=15, 10 males and 5 females, average age 34.4±4.6 years old, 2 cases bone defect of femur, 13 cases tibia, and the length of bone defect 6.2±2.4 cm), and combined bone transport group (Ilizarov bone transport technique with bone graft and internal fixation at the docking site, n=15, 12 males and 3 females with the average age of 33.8±5.2 years, 1 case of bone defect and 14 tibia, and the length of bone defect 6.5±2.2 cm). The preoperative hospital for special surgery (HSS) knee functional scores, Baird-Jackson ankle function scores, external fixation time, external fixation index, bone union time, bone union index, postoperative ASAMI scores and incidence of complications were compared between the two groups. Results All patients were followed up for 9 to 24 months (mean 16.2 months). Pure bone transport group was followed up for 9 to 24 months (mean 16.2 months), and combined bone transport group was 10 to 24 months (mean 16.4 months). In pure bone transport group, the external fixation time was 17.6±5.4 months, and the bone union time was 11.2±3.1 months with the average bone union index 42.4±4.6 d/cm. While in combined bone transport group, the external fixation time of group B was 8.4±2.1 months, and the bone union time was 7.2±2.1 months with the average bone union index 21.1±2.7 d/cm. The external fixation index of pure bone transport group was 32.4±2.1 d/cm, while in combined bone transport group it was 32.1±2.5 d/cm, and there was no significant difference between these two groups (t=0.812, P=0.884) . According to the bone and function score of the ASAMI, in pure bone transport group, bone healing: excellent 6 cases, good 6 cases, fair 2 cases, poor 1 case, excellent rate was 80%. While in combined bone transport group: excellent in 8 cases, good 6 cases, fair 1 case, excellent rate was 93.3%. The difference between the two groups was statistically significant (χ2=10.6, P=0.032). The lower limb function in pure bone transport group: excellent in 5 cases, good in 5, fair in 4, poor in 1, excellent rate was 66.7%; while in combined bone transport group: excellent in 6 cases, good in 7, fair in 2, excellent rate was 86.7%. There was also a significant difference in the incidence of complications between the two groups. Conclusion Both the pure Ilizarov bone transport technique and the Ilizarov technique with bone graft and internal fixation at the docking site could satisfactorily treat the large bone defect and shortening of the lower limb. But the latter technique had shorter healing time, higher healing rates, better limb function and fewer complications. Key words: Ilizarov technique; Femur; Tibia; Internal fixators

Flap transplantation combined with Masquelet technique in the treatment of bone and soft defect

Objective To explore the effect of the use of flap transplantation combined with Masquelet tech- nique in the repair of long bone accompanied with soft tissue defect. Methods The retrospective study includes 16 cases of bone defects over 6.0 cm combined with soft tissue defect from March, 2013 to March, 2016, 13 males and 3 females, of which the ages range from 16 to 65 years. The length of bone defect ranged from 6.0 to 12.0 cm, with an average of 8.5 cm, while the wound defect ranged from 5.2 cm×3.5 cm to 16.0 cm×7.5 cm. There were 8 cases out of 16 involve an infection: 3 cases of Staphylococcus aureus (including 1 MRSA) , 2 cases of Staphylococcus epidermidis, 2 cases of Enterobacter cloacae, and 1 case of Acinetobacter baumannii. The 1 stage surgery in all patients admitted to hospital after complete debridement and external fixation, the clean wounds with bone defect received antibiotic-impregnated bone cement filling operation and a flap transplantation or transposition directly after the debridement, but the infected wounds received vacuum sealing drainage treatment firstly, associated with adequate use of antibi- otics for 1-2 weeks and then the bone cement filling and flap transplantation with infection totally controlled. After 8- 12 weeks, we conducted the secondary internal fixation surgery replacing antibiotic -impregnated bone cement with autogenic cancellous bone, vancomycin artificial bone as well as rhBMP-2. All the cases were followed for 6 to 18 months. Results All patients with primary surgery are effectively controlled after 1-4 weeks of anti-infection treat- ment exclusive of the case with MRSA. As the condition of the patient with MRSA relapse, we changed to onvention- al treatment: placed a continuous irrigation and suction equipment instead of the bone cement filling, the wound healed completely without fistula formation of osteomyelitis in 6 months after the treatment of Ilizarov technique.All transplantation and transposition flaps survived. As for those who received a secondary bone graft operation, all achieved a bony union in a period of 4 -6 months. Conclusion The combination of flap transplantation and Masquelet technique is an effective method to repair limb long bone and soft tissue defect currently. Key words: Masquelet technique; Perforator flap; Composite defect; Stage treatment

Treatment of chronic tibial osteomyelitis of Cierny-Mader type IV with Ilizarov technique and lesion osteotomy

Objective To evaluate surgical treatment of chronic tibial osteomyelitis of Cierny-Mader type Ⅳ with Ilizarov technique and lesion osteotomy. Methods From January 2010 to May 2016, 39 patients with chronic tibial osteomyelitis of Cierny-Mader type Ⅳ were treated at our center. They were 33 males and 6 females, 8 to 54 years of age (average, 33.8 years) . After debridement and lesion osteotomy, the tibia was fixated with Ilizarov external fixator. Bone was transported to the bone defect after corticotomy was performed on the proximal and/or distal tibial metaphyses simultaneously. Bifocal corticotomy was performed in 11 cases, proximal corticotomy in 21 cases, and distal corticotomy in 7 cases. The transport began 3 to 5 days after operation at a speed of 0.5 to 1.0 mm/d initially. The speed was lowered according to the bone healing and pain. Radiographic examination was done every 2 weeks to observe transporting deviation and osteogenesis in the transporting area. The transporting was adjusted whenever any abnormality was observed. The bone transporting lasted for 50 to 130 days (average, 62.4 days) . Results The patients were followed up for 11 to 49 months (average, 21 months) . All the soft tissue wounds healed uneventfully and there was no relapse of osteomyelitis. The bone defects in the 32 cases were reconstructed primarily. Nonunion of fracture ends happened in 5 cases and nonunion of the bone lengthening zone in 2 cases. The 7 cases of nonunion were healed after secondary bone grafting. Malalignment happened in 5 cases, 4 of which responded to timely adjustment of the external fixation and one of which had to receive secondary bone grafting after failure in adjustment of the external fixation. Ankle joint dysfunction occurred in 7 cases, 5 of which responded to functional exercise and 2 of which accepted joint dysfunction because they refused surgery after unsatisfactory functional exercise. Pin tract infection of different severities occurred in 9 cases, one of which was treated by replacement of the K-wires under local anesthesia and the other 8 of which responded to reinforced dressing change. Conclusions Chronic tibial osteomyelitis of Cierny-Mader type Ⅳ can be treated by Ilizarov technique and lesion osteotomy. However, the Ilizarov technique should be improved because of the risks of multiple complications which can be reduced significantly by strengthening postoperative instruction, nursing, and regular follow-up. Key words: Tibia; Osteomyelitis; External Fixators; Ilizarov technique; Bone lengthening