Infected Nonunion Of Tibia Research Articles

Les pseudarthroses infectées du tibia: évaluation de la méthode d’Ilizarov avec compression distraction sans geste de débridement local

BackgroundThe treatment of infected nonunion requires radical debridement with stable fixation. Sever soft tissue compromise of the nonunion site might interfere with radical debridement. This study discussed the outcome of treatment of infected tibial nonunion with sever soft tissue compromise by a cyclic compression distraction technique using Ilizarov without radical debridement. MethodsThis study comprised 17 patients with unilateral infected tibial nonunion; 10 with diaphyseal and 7 with metaphysial locations. Their mean age was 21.9 years. There were 12 males and 5 females. The right side was affected in 11 patients and the left side in 6 patients. According toGustilo and Anderson classification, all patients were grade III. The mean limb shortening was 1.3cm. All patients were treated initially in another institute by uniplanner external fixator with rotational skin flap done in 11 patients and thiersch graft in 6 patients. One patient had common peroneal nerve affection. Distal circulation was sufficient in all patients. None of our patients had chronic diseases. Two to three cycles of gradual distraction compression were done. Each cycle consisted of distraction, followed by compression, then distraction, and lastly compression. The mean follow up period was 29.35 months. ResultsUnion was achieved in all patients at a mean time of 23.9 weeks. According to Hammer et al.; there were 8 patients with grade 1, and 9 patients with grade 2. According to Johner and Wruhs’ criteria; the outcome was excellent in 6 patients, goodin 3 patients, poor in 4 patients, and fair in 4 patients. Complications had occurred as pin tract infection(47.1%), persistent discharging sinus (5.9%), and valgus ankle deformity (11.8%). Refracture did not occur in any case till the final follow up. ConclusionAlthough debridement is essential in the treatment of infected tibial nonunion, it could harm the limb in severe soft tissue compromise. Cyclic compression distraction by Ilizarov had a satisfactory outcome in the treatment of such cases through enhancement of a biological environment to achieve union. Level of evidenceIV; prospective case series.

Antibiotic Cement Coated Nailing in Infected Nonunion of Tibia

Non-union infected bone is a chronic impairment disorder that causes severe complications for surgeons. In Pakistan a very limited literature was produced in recent years to evaluate the role of antibiotic impregnated cemented nail in infected non-union of tibia. To fill this gap this prospective study was designed to investigate the role of antibiotic Cement Coated Nailing in Infected Nonunion of Tibia in the Orthopedic Department of Liaqat University of medical and health science, Jamshoro, Pakistan, from February 2019 to February 2020. A total of 30 patients with infected "nonunion of the tibia" was enrolled during the research period. Patients within the age range of 22-61 years were part of this research. For surgery, polymer beads were added into the 40 gm cement which was prepared by adding 2 gm vancomycin and 2 gm teicoplanin. After that endotracheal tube was cut by a surgical knife to recover antibiotic and cement coated k nail. The nail was then inserted into the tibia. Resuts demonstrate that in 28 patients 93% utilization of antibodies cement coated nails helped to eradicate the infection. 24 patients achieved complete bone unification without any need for further procedure. The overall ratio of single-time antibiotic cement coated nail was observed as 70%. The infected nonunion tibia can be effectively treated if the protocol of debridement is correctly followed. Results demonstrate that bone stability can be regained with 22 to 44 weeks. We concluded that antibiotic-impregnated cemented nail is an ideal procedure to control the postoperative infection and achieve reunion.

A Systematic Review and Meta-Analysis of treatment of infected Tibial non union

Objectives: The aim of this work is to systematically review and make metaanalysis for treatment of the infected non-union of the tibia.Methodology: A systematic review was completed, Study objective and comprehensive literature search were performed from the SCI, PubMed, Cochrane Library; and Embase between January 2000 and Feb. 2019. Some major data were statistically analyzed, including number of patients, mean age,external fixation time, Searches will be performed in the MEDLINE, Life Science Citations, PubMed, GoogleScholar and EMBASE Biochemical (http://www.embase.com) databases will be accessed to search studies with no limits set during research, Terms aimed at capturing the target diagnosis, such as “infected tibial nonunion” and “fixation” were combined using the Boolean operator “or” and MeSH terms.Result: 318 abstracts were identified during the search, 10 were excluded, 308 full articles were fully reviewed, 295 articles were excluded, 13 studied matched the inclusion criteria and were included in this review, 2 additional articles were identified during searching, a total 652 patients of 15 studies were presented in this systemic review. Conclusion: radical debridment of the infected non union is mandatory , a satisfactory bone results and functional results were obtained. On the other hand Ilizaov technique proved as the most useful method in the treatment of the infected non- union of the tibia.

Prospective randomized comparison of bone transport versus Masquelet technique in infected gap nonunion of tibia.

The present prospective randomized study compared the bone transport technique (BT) and Masquelet technique (MT) in the treatment of infected gap non-union of the tibia. Total 25 patients with infected gap non-union of the tibia with bone gap upto 6cm were randomised into BT group (group I, 13 patients) and MT (group II, 12 patients). The mean age was 31.77years in group I and 39.67years in group II. The mean intra-operative bone gap was 3.92cm in group I and 3.79cm in group II. Monolateral fixator was applied in nine patients each in both groups, while four and three fractures were stabilized with ring fixators in group I and II, respectively. Mean follow-up was 31.62months and 30.42months in group I and II, respectively. Bone and functional results were compared using the association for the study and application of the method of Ilizarov (ASAMI) criteria. The average fixator period was 9.42 and 16.33months in group I and II, respectively (p < 0.001). Union was achieved in 12 (92%) patients and 6 (50%) patients in group I and II, respectively. The functional results were excellent (eight and two), good (four and six), fair (zero and three) and poor (one and one) in group I and II respectively, (p 0.23). The Bone results were excellent, good and poor in nine, three and one patients in group I, and three, three and six patients in group II respectively, (p 0.109). The functional and bone results were comparable but more reliable in bone transport than the Masquelet technique. The fixator duration and incidence of non-union were higher in MT group. Ilizarov bone transport technique should be preferred in infected non-union of the tibia with bone loss upto 6cm.

Infected non-union of tibia treated with limb reconstruction system (LRS): A prospective study

Infected non-union of tibia treated with limb reconstruction system (LRS): A prospective study

An assessment of the C-reactive protein, erythrocyte sedimentation rate and white blood cell count, values during the post-operative period of infected tibial nonunions treated with antibiotic- loaded PMMA-coated nails

&lt;p&gt;In this study, our aim was to assess the changes in the serum C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and white blood cell count (WBC) values during the follow-up period of infected tibial pseudoarthrosis treated using antibiotic-loaded nails. Three patients with infected femoral nonunions and 11 patients with infected tibial nonunions were included in the study. All patients were treated with intramedullary nails coated with antibiotic-loaded PMMA after local extensive debridement. Postoperatively, parenteral antibiotic therapy was administered. The CRP, ESR and WBC values were noted preoperatively and on the first day, and then on the second, sixth, and 12&lt;sup&gt;th&lt;/sup&gt; weeks postoperatively. The changes in these values over time were analyzed comparatively. The preoperative CRP level was found to be significantly lower than the early postoperative period (1&lt;sup&gt;st&lt;/sup&gt; day), while no significant differences were detected during the follow-up period. The CRP level constantly decreased between the first postoperative control (1&lt;sup&gt;st&lt;/sup&gt; day) and the final follow-up time (12&lt;sup&gt;th&lt;/sup&gt; week). The postoperative ESR showed a significant difference when compared to the preoperative value, and also showed a decreasing trend in the postoperative period, having its highest value on the first day. The WBC did not exhibit a significant difference when comparing the preoperative and postoperative values. C-reactive protein level and ESR can be used to monitor the adequacy of the treatment after antibiotic-loaded nail application, whereas WBC may be insufficient in the diagnosis and follow-up of osteomyelitis treated with antibiotic-loaded nails.&lt;/p&gt;

English

BACKGROUND Open fractures and fractures caused by high-energy trauma are likely to get infected and result in non-union. Infected non-union of long bones is a problem in developing countries like India. Ilizarov external fixator was employed to correct all the complications associated with non-union such as bone gap, infection, shortening, and deformities. Stable fixation, corticotomy and bone transport was employed to reduce or eliminate infection at the same time achieving bone union and correction of limb length discrepancy. Our study assesses the efficacy and safety of Ilizarov external fixation in patients with infected non-union tibial fractures. METHODS A series of 30 patients with infected non-union of tibia were treated with Ilizarov external fixation in Yashoda super speciality hospital and regularly followed-up between May 2014 and April 2016 (2 years). Bony and functional results were estimated and correlated with existing studies. RESULTS Out of thirty patients treated, bony results were excellent in 17 patients, good in 8 patients, fair in 4 patients and poor in 1 patient. Functional results were excellent in 17 patients, good in 5 patients, fair in 5 patients, and poor in 3 patients. Average duration of the fixator period was 8.1 months (min - 3 months, max - 14 months). Average length of regenerate was 3.64 cm (min - 2 cm, max - 6 cm). Average lengthening index in the study was 2.09 months / cm. Our study in all 4 categories of Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria had approached Dror Paley’s Bony results and functional results. CONCLUSIONS In our study results have been encouraging in addressing all the complex problems by Ilizarov principle. Ilizarov external fixator system is the best device to treat infected non-union of tibia. Distal third of tibia is more prone for infection and non-union. Corticotomy or bone grafting is required for augmentation of the healing process. Almost all patients had varying degrees of oedema and pin track infections. Infection was controlled in all the cases and bony union was achieved, no patient had persistence of non-union and infection at the end of 2 years. KEYWORDS Ilizarov External Ring Fixator, Infected Non-Union, ASAMI Criteria, Bony Results, Functional Results, Bony Union

Infected Tibial Nonunion: Assessment of compression distraction Ilizarov technique without debridement

BackgroundThe treatment of infected nonunion requires radical debridement with stable fixation. Sever soft tissue compromise of the nonunion site might interfere with radical debridement. This study discussed the outcome of treatment of infected tibial nonunion with sever soft tissue compromise by a cyclic compression distraction technique using Ilizarov without radical debridement. MethodsThis study comprised 17 patients with unilateral infected tibial nonunion; 10 with diaphyseal and 7 with metaphysial locations.Their mean age was 21.9 years. There were 12 males and 5 females. The right side was affected in 11 patients and the left side in 6 patients. According toGustilo and Anderson classification, all patients were grade III. The mean limb shortening was 1.3cm. All patients were treated initially in another institute by uniplanner external fixator with rotational skin flap done in 11 patients and thiersch graft in 6 patients. One patient had common peroneal nerve affection. Distal circulation was sufficient in all patients. None of our patients had chronic diseases. Two to three cycles of gradual distraction compression were done. Each cycle consisted of distraction, followed by compression, then distraction, and lastly compression. The mean follow up period was 29.35 months. ResultsUnion was achieved in all patients at a mean time of 23.9 weeks. According to Hammer et al.; there were 8 patients with grade 1, and 9 patients with grade 2. According to Johner and Wruhs’ criteria; the outcome was excellent in 6 patients, goodin 3 patients, poor in 4 patients, and fair in 4 patients. Complications had occurred as pin tract infection (47.1%), persistent discharging sinus (5.9%), and valgus ankle deformity (11.8%). Refracture did not occur in any case till the final follow up. ConclusionAlthough debridement is essential in the treatment of infected tibial nonunion, it could harm the limb in severe soft tissue compromise. Cyclic compression distraction by Ilizarov had a satisfactory outcome in the treatment of such cases through enhancement of a biological environment to achieve union. Level of evidenceIV; prospective case series.

A Systematic Review and Meta-Analysis of Combined Antibiotic Spacer with Ilizarov Methods in the Treatment of Infected Nonunion of Tibia.

Background The objective of this systematic review was to evaluate current studies available reporting the antibiotic spacer combined with Ilizarov methods in the treatment of infected nonunion of tibia and to perform meta-analysis of bone results and infection recurrence to assess the efficacy of an antibiotic spacer combined with Ilizarov methods. Methods The MEDLINE, Embase, Cochrane Library, CNKI, and CBM (Chinese Biological Medicine) databases were searched for articles published between January 2000 and July 2020. Assessment of study quality was performed using a modified version of the Newcastle-Ottawa scale. Effect size and 95% confidence intervals were calculated for the main outcome. Heterogeneity was assessed. Fixed-effect modeling and Stata version 15.1 were used to analyze the data. Sensitivity analyses were conducted with the evidence of heterogeneity. Results 11 studies involving 210 patients with infected nonunion of tibia were finally included in our meta-analysis. Bone results and infection recurrence were analyzed based on the single-arm meta-analysis. The average of external fixation index (EFI) was 46.88 days/cm in all studies included. The excellent rate in bone results and the rate of infection recurrence was 65% (95% CI: [0.22, 0.97], I2 = 0.0%, P = 0.932) and 6.99% (95% CI: [0.052, 0.325], I2 = 0.0%, P = 1.000) in patients with infected nonunion of tibia treated with an antibiotic spacer combined with Ilizarov methods. Conclusions Our meta-analysis revealed that the patients with infected nonunion of tibia treated with an antibiotic spacer combined with Ilizarov methods had a high rate of excellent bone results and a low rate of infection recurrence. Therefore, combining the antibiotic spacer with Ilizarov methods may be an applicable choice for repairing and reconstructing infected nonunion of tibia.

Treatment of Infected Tibial Non-union: A Systematic Review and Meta-Analysis

Treatment of Infected Tibial Non-union: A Systematic Review and Meta-Analysis

Differentially expressed microRNAs as diagnostic biomarkers for infected tibial non-union

BackgroundInfected tibial non-union is a challenging clinical complication of fracture treatment. Improper treatment of infected tibial non-union may result in high treatment costs and a long treatment period, and lead to medical disputes and decreased patient satisfaction. An increasing number of studies have indicated the significant role of microRNAs (miRNAs) in the development and progression of different bone diseases. Therefore, the identification of a specific miRNA expression profile associated with infected tibial non-union is a key step toward establishing a novel strategy for the diagnosis and treatment of infected tibial non-union. MethodsWe utilised a microarray analysis to compare the specific expression of bone tissue miRNA in patients with infected tibial non-union and closed tibial fractures. Quantitative real-time reverse transcription-polymerase chain reaction was performed to validate the microarray results. Receiver operating characteristic (ROC) curve analysis was performed to assess the diagnostic efficacy of the identified regulated miRNA(s) isolated from bone tissue as potential biomarker(s). ResultsMicroarray analysis showed 20 differentially expressed miRNAs. Differential expression of miR-649, miR-29b-3p, miR-498, miR-365a-5p, miR-328-5p, and miR-345-3p was further confirmed in a validation cohort. ROC curve analyses showed an AUC (Areas Under the ROC Curve) of 0.808 (95% confidence interval [CI]: 0.675-0.940), 0.778 (95% CI: 0.634-0.921), 0.769 (95% CI: 0.619-0.919), 0.798 (95% CI: 0.662-0.933), 0.818 (95% CI: 0.690-0.945), 0.839 (95% CI: 0.715-0.963) for miR-649, miR-29b-3p, miR-498, miR-365a-5p, miR-328-5p, and miR-345-3p, respectively. The combined use of three miRNAs (miR-649, miR-328-5p, and miR-345-3p) yielded an overall diagnostic accuracy of AUC = 0.953, indicating a robust diagnostic value. Conclusion: Our findings highlight the role of miR-649, miR-328-5p, and miR-345-3p as novel candidate biomarkers for infected tibial non-union diagnosis, suggesting that these differentially expressed miRNAs could be utilised as novel diagnostic and therapeutic tools to identify infected tibial non-union.

Treatment of infected tibial non-unions using a BMAC and S53P4 BAG combination for reconstruction of segmental bone defects: A clinical case series.

Treatment of infected non-unions of the tibia is a challenging problem. The cornerstones of optimal infected non-union treatment consist of extensive debridement, fracture fixation, antimicrobial therapy and creation of an optimal local biological bone healing environment. The combination of S53P4 bioactive glass (BAG), as osteostimulative antibacterial bone graft substitute, and bone marrow aspirate concentrate (BMAC) for the implantation of mesenchymal stem cells and growth factors might be a promising combination. In this paper, preliminary results of a new treatment algorithm for infected non-unions of the tibia is presented. In this retrospective case series patients with infected non-unions of the tibia are treated according to a new treatment algorithm. Patients are treated with extensive debridement surgery, replacement of the osteosynthesis and implantation of S53P4 BAG and BMAC in a one-stage or two-stage procedure based on non-union severity. Subsequently patients are treated with culture based antibiotic therapy and followed until union and infection eradication. Five patients with an infected non-union were treated, mean age was 55, average NUSS-score was 44 and the average segmental bone defect was 4.6cm. One patient was treated in a one-stage procedure and four patients in a two-stage induced membrane-, or "Masquelet"-procedure. On average, 23 ml S53P4 BAG and 6.2 ml BMAC was implanted. The mean follow-up period was 13.6 months and at the end of follow-up all patients had clinical consolidation with an average RUST-score of 7.8 and complete eradication of infection. These early data on the combined implantation of S53P4 BAG and BMAC in treatment of infected non-unions shows promising results. These fracture healing results and eradication rates resulted in promising functional recovery of the patients. To substantiate these results, larger and higher quality studies should be performed.

Functional and Radiological outcome of Limb Reconstruction system &amp;#40;LRS&amp;#41; in infected nonunion of Tibia

Introduction: Infected non-union of tibial diaphysis has been a challenging problem. Tibia being subcutaneous bone, fracture healing especially following compound fracture with any pre or postoperative infection leads to notorious non union. Though there have been various treatment modalities to deal with the condition, Limb reconstruction system (LRS) provides simple effective and versatile treatment modality where liberal resection of long segment of infected bone, can be reproduced by combining the masquelet technique with the distraction osteogenesis. It’s light weight and allows better wound management, makes it more patients compliant. Materials and Methods: In this retrospective study, 20 patients of infected non-union of tibial diaphysis were treated by using the Limb reconstruction system during April 2017 to may 2019 at our institute. The final assessment was done upon only those patients who were followed for at least one year post-operatively, using Association for the Study and Application of Methods of Ilizarov (ASAMI) score. Results: According to ASAMI score, bony results were excellent in 75%, good in10%, fair in 5% and poor in 10% and functional results were excellent in 60%, good in 20%, fair in 10% and poor in 10% of patients. The mean bone resection was 7.3 cm, the mean duration of bone transport was 10.4 weeks, the mean bony union time was 11.1 weeks and the mean duration of consolidation of regenerate was 37.8 weeks. Conclusion: The LRS is simple effective and versatile treatment modality in infected non-union of tibia. Itnot only provides bone transport, fusion of the bone ends and finally consolidation of the regenerate on itself but also facilitates in dealing with limb length discrepancies along with early mobilization and better wound management. Keywords: LRS, Infected non-union, Bone regenerate, Resected bone, ASAMI score.

Two-stage treatment with sliding fibular flap technique for chronic infected nonunion of the tibia

PurposeTo assess the effectiveness of two-stage treatment with the fibular sliding technique in chronic infected nonunion of the tibia. MethodsThe study included patients who were diagnosed with long-term chronic infected tibial nonunion following trauma and treated with the two-stage technique between January 2010 and November 2017. Patients with (1) intra-articular fractures of the distal third of the tibia and fibula, (2) pathological fracture resulting in bone loss or (3) neurological and vascular pathologies of the limbs were excluded. The operation consisted of two stages and the main goal in the first stage was to control the infection and in the second stage to control the healing of the bone. Functional & radiographic results and complications were evaluated according to Paley's criteria. ResultsThe patients comprised 14 males and 5 females with a mean age of 37.4 years (range, 21–52 years). Patients were followed up for an average of 27 months (range, 15–38 months). The microorganisms produced from these patients were Staphylococcus aureus in 13 patients, Pseudomonas aeruginosa in 4 patients and no bacteria in 2 patients. After the first stage operation, superficial skin necrosis developed in 1 patient. In another patient, there was a persistent infection, although union was achieved. For the entire patient group, union was observed at the end of 7.44 months (range, 7–11 months). Based on Paley's criteria, there were 16 (84.2%) patients with excellent scores, 2 (10.5%) good scores and 1 (5.3%) fair scores radiologically; while regarding the tibial function, 15 (78.9%) patients had excellent scores, 3 (15.8%) good scores, and 1 (5.3%) fair scores. No patients had poor radiological or functional score. ConclusionTwo-stage treatment can be considered as an alternative for fractures in regions that are susceptible to many and persistent complications, such as the tibia. This technique has the advantages of short operation time, minimal blood loss, no excessive tissue damage and not very technique-demanding (a short learning curve with no requirement for an experienced team).

Acute Shortening and Re-Lengthening (ASRL) in Infected Non-union of Tibia - Advantages Revisited.

Introduction:A gap non-union in various conditions has been treated successfully by the Ilizarov method. The gap can be filled up either by an acute shortening and re-lengthening (ASRL) procedure or by an internal bone transport (IBT). We compared the functional and clinical outcome of ASRL and IBT in gap non-unions of the infected tibia.Material and Methods:A retrospective study was conducted in our department from the data collected in the period between 1997 and 2010. There were 86 cases of infected non-union of the tibia, in patients of the age group 18 to 65 years, with a minimum two-year follow-up. Group A consisted of cases treated by ASRL (n=46), and Group B, of cases by IBT (n=40). The non-union following both open and closed fractures had been treated by plate osteosynthesis, intra-medullary nails and primary Ilizarov fixators. Radical debridement was done and fragments stabilised with ring fixators. The actual bone gap and limb length discrepancy were measured on the operating table after debridement. In ASRL acute docking was done for defects up to 3cm, and subacute docking for bigger gaps. Corticotomy was done once there was no infection and distraction started after a latency of seven days. Dynamisation was followed by the application of a patellar tendon bearing cast for one month after removal of the ring with the clinico-radiological union.Results:The bone loss was 3 to 8cm (4.77±1.43) in Group A and 3 to 9cm (5.31± 1.28) in Group B after thorough debridement. Bony union, eradication of infection and primary soft- tissue healing was 100%, 85% and 78% in Group A and 95%, 60%, 36% in Group B respectively. Nonunion at docking site, equinus deformity, false aneurysm, interposition of soft-tissue, transient nerve palsies were seen only in cases treated by IBT.Conclusion:IBT is an established method to manage gap non-union of the tibia. In our study, complications were significantly higher in cases where IBT was employed. We, therefore, recommend ASRL with an established protocol for better results in terms of significantly less lengthening index, eradication of infection, and primary soft tissue healing. ASRL is a useful method to bridge the bone gap by making soft tissue and bone reconstruction easier, eliminating the disadvantages of IBT.

Role of Ilizarov’s ring fixator for treatment of infected nonunion of Tibia

Infection is the most dreaded complication of the surgery and management of the infected non-union bones is also a challenging task. The aim of our study is to evaluate the efficacy of Ilizarov’s ring fixator in the treatment with infected nonunion of tibia. 17 patients were included in our study. Rate of union was 100%. 10 patients had excellent results, 5 patients had good result and 2 patients had fair result. The minimal duration for union was 9 months with average duration lasting for 12 months. One patient needed a bone marrow injection at 2 month follow-up. Ilizarov ring fixator is an effective tool in treating Infection Non Union of Tibia and is a limb salvage procedure. Keywords: Ilizarov’s ring fixator; infected nonunion; tibia

Treatment of Infected Tibial Non-Unions with Ilizarov Technique: A Case Series.

Background: The Ilizarov external fixation technique has been widely used for the treatment of long-bone infected non-unions. After surgical infected bone resection, to allow filling of the remaining bone gap, biomaterials with antibacterial properties could be used. The aim of this study was to report outcomes of infected tibial non-unions treated using the Ilizarov technique and antibacterial bioactive glass. Methods: Between April 2009 and December 2014, 26 patients with infected tibial non-unions were treated with the Ilizarov technique and possible use of the bioactive glass, S53P4. The Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria, a clinical and radiographic evaluating tool, was used for assessing the sample. Results: The average age at the start of treatment was 51 years. The mean follow-up time was 113 weeks. According to the ASAMI Functional Scoring System, 10 excellent (38.5%) cases and 12 good (46.1%) values were recorded. According to the ASAMI Radiological System, they were excellent in 16 (61.5%) cases and good in nine (34.6%). Conclusions: Treatment of infected tibial non-unions using the Ilizarov technique was effective in bone segment regeneration. To fill the remaining bone gap, additional bioactive glass S53P4 could be used, allowing a decrease in re-interventions and minimizing complications.

ILIZAROV BONE TRANSPORT AS A METHOD IN RECONSTRUCTING BONE DEFECT

In our study we reported 16 patients (12 males and 4 female) with age ranged from 18 to 55 years with average (31.3years old) and presented to academic level 1 trauma center during the period from January 2015 to January 2018 with infected non-union of tibia (10 cases), infected non-union of femur (5 cases), infected nonunion of radius and ulna (1 case).The infected fractures were treated by debridement including removal of implants and resection of sequestrated bone, and longitudinal bone transport using Ilizarov ring fixator after doing proximal or distal corticotomy. We evaluated the results of Ilizarov bone transport as a method of reconstructing bone defect. Infection was eradicated and union was achieved in all cases (100 %). Mean duration of treatment was 13 months. Both the bone and the soft tissues healed without further complications. Distraction osteogenesis performed with Ilizarov device is an excellent technique for bridging large infected post-traumatic bone defects of the long bones by resection of the infected segment, and gradual bone transport.

Comparison of Clinico-radiological Outcomes of Monolateral Fixator in Infected Non-union of Tibia Based on Bone Gap Quantification

Monolateral rail fixators are more comfortable to the patients and have a lesser learning curve compared to ring fixators. Guidelines are still lacking for rational use of monolateral fixator for bone transport. This retrospective study aimed to analyze and compare the clinico-radiological outcomes of monolateral fixator in infected non union of tibia based on bone gap quantification. This retrospective study included 35 patients of post traumatic infected osteocutaneous defects of tibia operated from May 2013 to May 2016. Group I having bone gap of 6cm or less (n = 20) and group II with > 6cm bone gap (n = 15). The mean age was 29.56 (range 18-62) years in group I and 29.67 (range 20-65) years in group II. The mean bone gap was 4.62 (2-6cm) in group I and 7.6cm (6.5-10cm) in group II (P < 0.00001, Mann-Whitney test). The results were assessed by Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria. Union was achieved primarily in 90% (n = 18) cases in group I and 73.34% (n = 11) cases in group II. The bone result was excellent, good, fair/poor in 14, 5, 1 in group I; and in 4, 6, 5 in group II, respectively (P = 0.020, Chi-square test). The functional results were excellent, good, fair/poor in 15, 4, 1 in group I; and 5, 8, 2 in group II, respectively (P = 0.0479, Chi-square test). We recommend use of monolateral fixator in patients with infected diaphyseal non union of tibia with bone gap ≤ 6cm. Use of monolateral fixator in patients with bone gap > 6cm is associated with higher incidence of residual problems and complications.

Comparison of Ilizarov Bifocal, Acute Shortening and Relengthening with Bone Transport in the Treatment of Infected, Segmental Defects of the Tibia.

This prospective study compared bifocal acute shortening and relengthening (ASR) with bone transport (BT) in a consecutive series of complex tibial infected non-unions and osteomyelitis, for the reconstruction of segmental defects created at the surgical resection of the infection. Patients with an infected tibial segmental defect (>2 cm) were eligible for inclusion. Patients were allocated to ASR or BT, using a standardized protocol, depending on defect size, the condition of soft tissues and the state of the fibula (intact or divided). We recorded the Weber–Cech classification, previous operations, external fixation time, external fixation index (EFI), follow-up duration, time to union, ASAMI bone and functional scores and complications. A total of 47 patients (ASR: 20 patients, BT: 27 patients) with a median follow-up of 37.9 months (range 16–128) were included. In the ASR group, the mean bone defect size measured 4.0 cm, and the mean frame time was 8.8 months. In the BT group, the mean bone defect size measured 5.9cm, and the mean frame time was 10.3 months. There was no statistically significant difference in the EFI between ASR and BT (2.0 and 1.8 months/cm, respectively) (p = 0.223). A total of 3/20 patients of the ASR and 15/27 of the BT group needed further unplanned surgery during Ilizarov treatment (p = 0.006). Docking site surgery was significantly more frequent in BT; 66.7%, versus ASL; 5.0% (p < 0.0001). The infection eradication rate was 100% in both groups at final follow-up. Final ASAMI functional rating scores and bone scores were similar in both groups. Segmental resection with the Ilizarov method is effective and safe for reconstruction of infected tibial defects, allowing the eradication of infection and high union rates. However, BT demonstrated a higher rate of unplanned surgeries, especially docking site revisions. Acute shortening and relengthening does not reduce the fixator index. Both techniques deliver good functional outcome after completion of treatment.