RESULTS AND TECHNIQUES OF THE TREATMENT OF INFECTED NONUNION OF THE LONG BONES, A REPORT OF

40 CASES

Ebrahimzadeh Mohammad H. MDDepartment of Orthopedic surgery Ghaem HospitalMashhad University of Medical Sciences, Mashhad, Iran.Ebrahimzademh@MUMS.ac.ir

Infected nonunion

40 patients; 34 men, 6 women

28 tibia 12 femur

23 (57%) Smoker

Infected nonunion

infected nonunion of tibia; 28 patients

17 middle third 60% 8 distal third 28% 3 proximal third 12%

Infected nonunion

infected nonunion of the femur; 12 case

7 distal third 58% 3 middle third 25% 2 proximal third 16%

Infected nonunion of the tibia28 cases

Treatment modalities

Ilizarov apparatus; 21 patients

Plate/ IM rod removal and sequential debridement,…, grafting and plating again; 7 cases

Infected nonunion of the femur,12 case

Ilizarov apparatus: 5 casesPlate/ IM rod removal and sequential debridement,…, grafting and plating again; 4 casesPlate removal and sequential debridement,…, grafting and girdle stone; 2 casesPlate removal and sequential debridement,…, grafting and external fixatore, 1 case

Ilizarov Results(26 patients)

all patients with Ilizarov apparatus were united and the infection was eradicated finally; 6-30 months

in 4 patients we did rotation flap

Ilizarov Results(26 patients)

Complications:Pin tract infection 15 casesKnee stiffness 12 Ankle/foot stiffness 15Proneal nerve palsy 3 Refracture 0

Results

Infection was eradicated in 2 Gildelston cases and in one case of them after 4 years of being free of infection,,, the patient is in line for THA.

Results

Plate/ IM rod removal and sequential debridement,…, grafting and plating again 11 patients

10 finally successful1 amputation

Results

Plate removal and sequential debridement,…, grafting and external fixatore, 1 case Successful

Infected nonunion treatment methods depend on

Type of nonunion; atrophic? Hypertrophic?

Extent of infection

Presence of atrophic skin changes

Ilizarov`s concept for infected nonunion:

Osteomylitis burns in the fire of regenerationActivate biosynthetic process, increasing local resistant to infection

Three ways of elimination of infection in Ilizarov method

Controlled osteogenesis, filling of cavities by newly formed tissueResection of infected bone and subsequent intercalary bone lengtheningGradual bone transport of one wall of the cavity

Ilizarov

Distraction osteogenesisTension-stress effectMechanical induction of new bone formationNeovascularizationStimulation of biosynthetic activityActivation and recruitment of osteoprogenitor cellsIntramembranous ossification

Ilizarov`s plan depends on

Size and thickness of bone fragmentDegree and type of displacementThe extent of mobilityAmount and character of scar tissuePrevalence of purulent processCharacteristics of the individual case

Important

Nutritional Index #WBC Functional WBC Stop Smoking

Monofocal longitudinal compression

Hypertrophic nonunion Minimal infectionNo sequestrum, smallest sequester left in place, they are assimilated in the process of active osteogenesis

-spontaneous eradication of infection and achievement of union

Bifocal Method

Atrophic nonunion with diffuse infection and sequestrum

Infected segment should be resectedCreating an intercalary defect

Bifocal Method

Acute shortening, opposing ends under compression; 1-2 Cm defect

Poor skinBig necrotic bone Numerous fistula

Bilocal simultaneous compression-distraction osteosynthesis

Small gap & substantial bone shortening

Persistent drainage And gross motion afterMultiple attempts atSurgical treatment

Treatment consistedOf resection of Infected bone, acuteShortening and External fixation

Followed by proximalCorticotomy andDistraction to restorelength

Bilocal consecutive distraction-compression osteosynthesis

Large gap

A little Literature Review

Acute compression and lengthening by Ilizarov method for infected

nonunion of tibiaMagadum MP at al, J of Orthopedic Surgery, 2006;14(3).27 patientComplete debridment of nonunion, sequestrectomy, lavage and Ilizarov applicationGap; 10 (6-17)19 excellent, 5 good, 1 fair, 1 poor,1 above-knee amputation in 10-24 months.

Ilizarov method as a salvage procedure in infected nonunion of

the distal femur with bone lossSaridis A et al. JBJS Br. 2006; 8(2).

13 patients; 10 men, 3 womenRadical debridement and Ilizarov application3.1 previous surgeries8.3 mean length of defect(3-18)MEAN external fixator time 309 daysUnion and elimination of infection achived in all 13 patients. 8 excellent, 4 good, 1 fair.1 re-fracture

Conclusion

Ilizarov is a golden method for the management of nonunion osteomylitis for both achieving union and eradication of infection, however generous, careful sequential debridement and hardware/dead tissue removal and bone grafting is also an option for some selected cases.