Original
Article
MANAGEMENT OF INFECTED NON-UNION TIBIA
BY INTERCALARY BONE TRANSPORT
MEHTAB A. PIRWANI, M. ASLAM SIDDIQUI, YUNIS H. SOOMRO
Department of Orthopaedics, Unit II, Dow University of Health Sciences & Civil Hospital, Karachi
ABSTRACT
Objective: To evaluate the efficacy of Ilizarov ring fixator in treating infected non-union tibia by intercalary bone
transport.
Design & Duration: Quasi experimental study from March 2004 to June 2006.
Setting: Orthopaedics Unit II at Civil Hospital, Karachi.
Patients: Sixteen patients, all males, aged 20-60 years (mean 32 years),with infected non-union tibia (Lax/Cierney
Type IV Osteomyelitis); the commonest cause being open fracture and the commonest site being lower 1/3rd.
Methodology: In infected non-union of tibia with draining sinus, wound swab was sent for culture and sensitivity,
and sinogram done. Debridement and sequestrectomy was done, leaving behind a gap ranging from 2-8 cms (mean
4.5 cms) and Ilizarov ring fixator, a transport assembly, applied. A navigation wire was passed through medial
malleolus, irrigation system set up and the wound closed in a single layer. Proximal metaphyseal corticotomy was
done. Irrigation with 2-3 litres of normal saline with appropriate antibiotic was continued for five days. On the 5th
day irrigation system was removed and the transport started. Patients remained on partial weight bearing till soft
tissue healing occured. Transport took place over the navigation wire at the rate of 1mm/day till docking achieved.
Full weight bearing was allowed after soft tissue healing; knee and ankle physiotherapy was started from day one.
Navigation wire was removed after 2-3 weeks of docking. Follow up ranged from 12-27 months (mean 16 months).
Results: Union was achieved at the docking site in all the cases at the time of frame removal i.e. 8-13 months. The
duration of union at docking site ranged from 3.5 months to 6 months (mean 4.5 months). Two patients needed bone
graft at the docking site. The regenerate was broken in one case due to fall which was treated in cast. All the patients
were satisfied except a 60 years old who had severe osteoarthritis of knee. Pin tract infection occurred on & off in
all the patients; appropriate antibiotic was given. The infection subsided in all the cases except two in whom debridement was followed by application of a local flap.
Conclusion: Intercalary bone transport by Ilizarov ring fixator is the treatment of choice for lax, infected non-union
of tibia without leg length discrepancy.
KEY WORDS: Ilizarov Ring Fixator, Infection, Non-Union Tibia, Navigation Wire, External Fixator
after the debridement.1 Many procedures have been
tried to treat this particular problem including radical
debridement, flaps, bone grafting, etc. None are satisfactory and the morbidity is high during treatment.2-4
INTRODUCTION
Infected non-union and gap non-union are challenges
that orthopaedic surgeons have to face globally. By
definition, infected non-union is a Cierney IV osteomyelitis, meaning that the fracture is unstable before and
Debridement and sequestrectomy results in large gaps
which are difficult to treat with conventional methods.
Internal fixation with dynamic compression plate (DCP)
or interlocking nail (ILN) is impossible due to the gap
at the non-union site, defective quality of bone, and
above all the presence of infection. In these conditions
external fixator is the treatment of choice, especially
the ring fixator of Ilizarov.5-8 With this apparatus intercalary bone transport is possible along with soft tissue
transport, resulting in elimination of the gap and soft
tissue cover without any leg length discrepancy and
Correspondence:
Dr. Mehtab A. Pirwani
A-73, C.G.E.H.S., Block 10-A,
Gulshan-e-Iqbal, Karachi, Pakistan.
Phones: 0300-9279892.
E-mail: [email protected]
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Management of Infected Non-Union Tibia by Intercalary Bone Transport
M. A. Pirwani, et al
stiffness.
In this technique the basic transport assembly consists
of two rings in the proximal segment, two rings in the
distal segment and one ring in the segment to be transported. Navigation wire is placed, in most of the cases,
through the medial malleolus to navigate the transport
to the docking site. Proximal metaphyseal corticotomy
was done. Irrigation system of the wound with normal
saline along with appropriate antibiotic has a definitive
role in eradicating the infection.With this techniques
resection of infected tissue and sequestrated bone and
defect produced by it can be reconstructed. In this study
we have attempted to treat the cases of infected nonunion by intercalary bone tranplant, compression and
distraction technique.
PATIENTS & METHODS
Fig. 2. The irrigation system
Sixteen patients, all males aged 20-60 years (mean age
32 years), with infected non-union tibia (Lax/Cierney
Type IV osteomyelitis) were treated between March
2004 to June 2006 at the Orthopaedics Unit II of Civil
Hospital Karachi. The average duration of infection
and non-union was two years. The commonest cause
being open fracture of tibia and the commonest site the
lower 1/3rd. Wound swab for culture and sensitivity
was sent in all the cases and a sinogram was done. After
preparation the debridement and sequestrectomy was
done and the Ilizarov ring fixator, transport assembly,
was applied, leaving behind a gap ranging from 2cms
to 8cms (mean 4.5cms). Proximal metaphyseal corticotomy was done and a navigation wire passed through
the medial mallelous (Fig.1). Irrigation system was set
up and wound closed in a single layer. Irrigation with
2-3 liters of normal saline/day with appropriate antibiotics was continued for five days (Fig.2), after which
Fig. 1.
the irrigation system was removed and transport started.
The patient remained on partial weight bearing for about
three weeks till soft tissue healing. Appropriate antibiotics were given. Transport took place over the navigation
wire at the rate of 1mm/day, till docking was achieved,
with full weight bearing (Figs.3 & 4). Knee and ankle
physiotherapy was continued from day one. Navigation
wire was removed after docking, but the patient remained
on frame till the regenerate got consolidated and union
occured at the docking site (Fig.5). After frame removal,
above knee slab was applied for two weeks without
weight bearing and then patellar weight bearing cast
for two weeks. Patients were followed-up for atleast
six months and advised gait training (Fig.6).
RESULTS
Union achieved at docking site in all the cases at the
Fig. 4.
Fig. 3.
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Management of Infected Non-Union Tibia by Intercalary Bone Transport
No.
M. A. Pirwani, et al
Age
Site of
Non-Union Tibia
No. of Previous
Operations
Duration of Union
at Docking site
1
22 years
Junction of middle and distal 1/3
4
2
21 years
Mid-diaphyseal
1
4.5 months
3
26 years
Junction of middle and distal 1/3
3
4.3 months
4
32 years
Junction of middle and distal 1/3
1
3.6 months
5
20 years
Mid-diaphyseal
1
3.2 months
6
36 years
Junction of middle and distal 1/3
2
5.4 months
7
51 years
Junction of middle and distal 1/3
2
6.0 months
8
31 years
Junction of middle and distal 1/3
3
4.4 months
9
26 years
Mid-diaphyseal
1
5.2 months
10
23 years
Mid-diaphyseal
2
4.8 months
11
32 years
Junction of middle and distal 1/3
4
3.5 months
12
60 years
Junction of middle and distal 1/3
1
5.4 months
13
45 years
Mid-diaphyseal
3
4.9 months
14
34 years
Junction of middle and distal 1/3
1
4.3 months
15
20 years
Junction of middle and distal 1/3
3
3.8 months
16
33 years
Junction of middle and distal 1/3
2
4.0 months
Table I. Patients’ Data and Duration of Union
time of frame removal i.e. 8-13 months (Fig.7). The
duration of union at docking site ranged from 3.5 months
to 6 months (mean 4.5 months) as shown in Table I.
Bone grafting was done in two cases at the docking site
because of delay in union. The regenerate was broken
in one case due to fall which was treated in cast. All
Fig. 5.
the patients were satisfied except a 60 years old male
who developed severe osteoarthritis of the knee. Superficial Grade-I pin tract infection was noticed in all the
cases on and off which was treated by local care and
antibiotics. Infection subsided in all the cases except
two in which debridement was done and local flap was
Fig. 7.
Fig. 6.
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Management of Infected Non-Union Tibia by Intercalary Bone Transport
M. A. Pirwani, et al
distraction was utilized, yielding noticeable results.9
The duration of frame application is a disadvantage but
when all other treatment modalities have failed, this
technique is probably the only alternative and the only
hope for many suffering patients, though the patients’
compliance is important for a successful outcome.
applied.
DISCUSSION
Long standing infected non-union and gap non-union
is difficult to treat and is a challenging problem for the
orthopaedicians. It usually leads to residual deformity,
persistent infection, contracture and at worst - a useless
limb.2
CONCLUSION
The conclusion derived from this study is that intercalary
bone transport by Ilizarov ring fixator is the treatment
of choice for lax infected non-union of tibia without
leg length discrepancy.
Many methods have been employed to treat this situation
e.g. radial debridement, local flaps, muscle flaps, bone
grafting, tibiofibular synostosis, cancellous allograft,
fibrin mixed with antibiotics, antibiotic beads, micro
vascular flaps and vascularized bone transplants. All
have improved results but none has been able to fully
solve this clinical situation.9
REFERENCES
1. Wheeless CR. Infected Tibial Non-Unions. In: Wheeless' Internet Textbook of Orthopaedics. www.
wheeless on line.com/ortho/tibiatnon-unions-42k.
The Ilizarov ring fixator gives an option of compression,
distraction and bone transport, and is effective in the
treatment of infected non-union of tibia where other
types of treatment have failed.10 Weight bearing and
the functioning of the joints while on the treatment is
an advantage that cannot be matched by any other
technique.
2. Dinesh-Shankar AN, Anoop A. Short term followup and results of gap non-union tibia (including
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treatment of infected non-union. J Hand Surg 1984;
9A: 653.
The Ilizarov apparatus is axially elastic and as the
weight bearing forces are directly applied to the bone
ends, maintaining the weight bearing function of the
extremity actually becomes one of the prerequisites for
the success of the method. The cyclic axial telescoping
mobility, not rigidity, at the non-union or fracture site
is an important requirement for the formation of a reparative callus. Ilizarov experimentally showed that when
gradual distraction tension stress is applied to the corticotomy site, the vascularity of the entire limb is increased, which in turn enhances the ability of the bone ends
to unite.11
4. Palely FB, Christianson D. A biomechanical analysis of Illizarov and external fixators. Clin Orthop
Rel Res 1989; 241: 195.
5. Ilizarov GA, Lediaev VI, Degtiarev VE. Operative
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In a study performed by Tranquilli et al in Italy on 20
patients with non-union of tibia, the result was union
in all the cases; mean time of union being 4.5 months.12
In another study Marsh et al showed union in 40 out of
46 non-union cases treated with Ilizarov method, with
a high level of patient satisfaction.13 Menon and associates also concluded in their study that there is a role of
Ilizarov ring fixator with nail retention in resistant long
bone diaphyseal non-union and that this method could
achieve high union rates where other methods failed.14
7. Ilizarov GA. The tension-stress effect on the genesis
and growth of tissues: Part II. The influence of the
rate and frequency of distraction. Clin Orthop 1989;
239: 263-85.
8. Ilizarov GA, Lediaev VI. Replacement of defects
of long tubular bones by means of one of their fragments [in Russian]. Vestn Khir Im I I Grek 1969;
102: 77-84.
Several modifications have undergone to increase the
efficacy of treatment with Ilizarov method and patient’s
acceptability, e.g. Rozbruch et al. used a computer programmable Ilizarov Spatial frame in two cases of hypertrophic non-union of tibia with deformity for which
9. Johnson EE, Urist MR, Finerman. Repair of segmental defects of tibia with cancellous bone graft aug29
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Management of Infected Non-Union Tibia by Intercalary Bone Transport
mented by human bone morphogenetic protein–a
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method in non-union, malunion and infection of
fractures. J Bone Joint Surg Br 1997 Mar; 79(2):
273-279.
10. Tahmasebi MN, Mazlouman SJ. Ilizarov method
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battlefield wounds. Acta Medica Iranica 2004; 42
(5): 343-9.
14. Menon DK, Dougall TW, Pool RD, Simonis RB.
Augmentative Ilizarov external fixation after failure
of diaphyseal union with intramedullary nailing. J
Orthop Trauma 2002 Aug; 16(7): 491-7.
11. Schwartsman V, Choi SH, Schwartsman R. Tibial
Non-union Treatment Tactics with the Ilizarov Method. Orthop Clin N Am 1990; 21(4): 639-53.
15. Rozbruch SR, Helfet DL, Blyakher A. Distraction
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using Ilizarov/ Taylor Spatial Frame. Report of two
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12. Tranquilli LP, Merolli A, Perrone V, Caruso L,Giannotta L. The effectiveness of the circular external
fixator in the treatment of post-traumatic tibia nonunion. Chir Organi Mov 2000 Jul-Sep; 85(3): 235-
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