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CASE REPORT
Year : 2016  |  Volume : 16  |  Issue : 2  |  Page : 159-161

Ilizarov ring fixator in treatment of infected nonunion of tibia


1 Department of Orthopedics, BMCH, Burdwan, West Bengal, India
2 Department of Physiology, BMCH, Burdwan, West Bengal, India

Date of Web Publication13-Apr-2016

Correspondence Address:
Dr. Arunima Chaudhuri
Krishnasayar South, Borehat, Burdwan - 713 102, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-6308.180189

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  Abstract 

Infective nonunion of a long bone is very notorious to be treated and prone to limb shortening when treated by conventional methods. In this case report, we treated a patient having infected nonunion of tibia initially by complete excision of all devitalized tissue from site of nonunion causing bone gap of 7 cm, followed by application of Ilizarov ring fixator using bifocal osteosynthesis by single upper tibial osteotomy. Bone transportation done at a rate of 1 mm/day followed by compression-distraction at the nonunion site following accordion maneuver. Results showed satisfactory bony union by bifocal osteosynthesis with single osteotomy.

  Abstract in Arabic 

حلقة الزاروف المثبتة في علاج عظم الساق الاعظم الملهتب وغير الملتئم:
خلفية البحث: من الشائع عند علاج العظم الطويل الملتهب وغير الملتئم سوء برئه وقابليته لتقصير الطرف حين يتم علاجه بواسطة الطرق التقليدية. في تقرير هذه الحالة عالجنا مريضا يعاني من عدم التئام والتهاب لعظم الساق الأعظم اولياً باستئصال لجميع الانسجة التالفة من موضع عدم الالتئام مما ادى الى نقصان 7سم من العضل تبعه استخدام لحلقة الزاروف المثبتة باستخدام تصنيع العظم ثنائي البؤرة عن طريق الاستئصال الاحادي العلوي لعظم الساق الاعظم. تم اجراء نقل العظم بمعدل 1mm يوميا تبع بالضغط والتهشيم في الموضع غير الملتئم بطريقة اوكورديون. اظهرت النتائج التئام مرضي لتصنيع العظم ثنائي البؤرة مع استئصال فردي للعظم.

Keywords: Fracture tibia, Ilizarov ring fixator, nonunion


How to cite this article:
Samanta AK, Ghosh S, Chaudhuri A, Mondal SC. Ilizarov ring fixator in treatment of infected nonunion of tibia. Saudi J Sports Med 2016;16:159-61

How to cite this URL:
Samanta AK, Ghosh S, Chaudhuri A, Mondal SC. Ilizarov ring fixator in treatment of infected nonunion of tibia. Saudi J Sports Med [serial online] 2016 [cited 2022 Aug 13];16:159-61. Available from: https://www.sjosm.org/text.asp?2016/16/2/159/180189


  Introduction Top


Fractures of long bones are not only complex surgical problems but also chronic and at times debilitating conditions. Nonunion of long bones is not only a source of functional disability but also can lead to economic hardship and loss of self-esteem. The incidence seems to be increasing, especially in view of increasing high-velocity trauma, which is more frequently treated with internal fixation. [1],[2],[3],[4],[5],[6]

Chronic infection of the diaphyseal shaft of long bones is one of the most perplexing dilemmas in orthopedic surgery. To obtain eradication of the infection, bony union, and a functional extremity often requires courageous measures with increasing risks of failure or amputation. Standard principles of debridement and antibiotic therapy alone may result in an acceptable cure rate of less severe types of infections. Difficult or resistant infections usually require a more radical debridement of the septic bone and soft tissues in addition to the application of stable fixation to enhance soft tissue healing and bony union. There are many alternatives available in the management of chronic diaphyseal infection. These include extensive debridement and local soft tissue rotational flaps, packing the defect with antibiotic impregnated beads. [2],[3],[4],[5],[6],[7],[8] Papineau-type open cancellous bone grafting, tibiofibular synostosis, cancellous allograft in fibrin sealant mixed with antibiotics, and/or free microvascular soft tissue and bone transplants. All these treatments have variable rates of success and failure and are limited in their ability to re-establish extremity length and correct deformity. The definitive environment required for many of these techniques to achieve their maximum bone grafting potential prerequisites the extremity to be free of infection and have acceptable soft tissue coverage. [2],[3],[4],[5],[6],[7],[8],[9] Many of these techniques also lack, to varying degrees, the ability to provide early functional rehabilitation of the limb during treatment. [2]

In the following report, we describe our successful experience in the treatment of infected tibial nonunion by bone transport using Ilizarov external fixator. Two hypotheses are proposed: (1) Ilizarov methods in the treatment of infected tibial nonunion can acquire satisfied effects in bone results and functional results. (2) Radical debridement is the key step to control bone infection. [3]


  Case Report Top


A 45-year-old male patient suffered from a road traffic accident on the 17 th of August 2013 leading to Gustilo type II open fracture right midshaft tibia. He was treated by open reduction and internal fixation with 4.5 mm dynamic compression plate and bone grafting 2 days after injury in a private institute. He was discharged on the 7 th day with a poor skin condition and pus discharge from the operative site. He was admitted in our institution 10 months after the first surgery with infected nonunion of right both bone leg with exposed bone and plate at the fracture site.

Operative procedure

In supine posture, under spinal anesthesia, we removed the plate, all necrosed bone was resected until punctate bleeding was seen at bony ends to make fracture end freshened. Ilizarov ring fixator was applied two ring above and rings below fracture site maintaining limb length with a gap at fracture site of 7 cm. One 2.5 mm rush nail was introduced from proximal to distal fragment to maintain bony alignment during bone transport. After complete stabilization, upper tibial corticotomy was done in between first and second ring.

Postoperative follow-up

Seven days we started bone transportation, initially 1 mm/day, later reduced to the rate of 0.5 mm/day according to the pattern of regenerated bone column at corticotomy site. Four months after transported bone reached the target site, we started compression-distraction after releasing tethered skin at fracture site according to accordion maneuver. After solid consolidation, fixator was removed 1΍ year later. Leg guard applied for another 3 months.


  Results Top


There was no distal residual neurovascular deficit in affected limb. No limb length discrepancy was found.


  Discussion Top


Ilizarov apparatus is a very good option for treating infected nonunion with a huge bone gap. [10],[11],[12],[13],[14] It can be done either by trifocal osteosynthesis or bifocal osteosynthesis. Usually, up to 5 cm of bone gap can be lengthened using bifocal osteosynthesis. [10],[11],[12],[13],[14],[15] When bone gap >5 cm, it is treated with bifocal osteosynthesis, bony sclerosis occurs in fracture end during bone transportation which prevents union at the fracture site. [10],[11],[12],[13],[14],[15],[16] Hence, bone gap >5 cm may be treated with trifocal osteosynthesis to reduce time required for bone transportation as the treatment with Ilizarov ring fixator in the present case yielded significant positive results.


  Conclusion Top


Bifocal osteosynthesis using Ilizarov ring fixator may be used to treat bone gap more than 5 cm in infected nonunion of tibia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Vignes GS, Arumugam S, Ramabadran P. Functional outcome of infected non-union tibia fracture treated by Ilizarov fixation. Int J Sci Study 2014;2:87-92.  Back to cited text no. 1
    
2.
Bansal A, Bansal S, Singh R, Walia JP, Brar BS. Role of Ilizarov ring fixator in infected non union tibia. Int J Med Dent Sci 2014;3:451-9.  Back to cited text no. 2
    
3.
Yu P, Zhang Q, Mao Z, Li T, Zhang L, Tang P. The treatment of infected tibial nonunion by bone transport using the Ilizarov external fixator and a systematic review of infected tibial nonunion treated by Ilizarov methods. Acta Orthop Belg 2014;80:426-35.  Back to cited text no. 3
[PUBMED]    
4.
Menon DK, Dougall TW, Pool RD, Simonis RB. Augmentative Ilizarov external fixation after failure of diaphyseal union with intramedullary nailing. J Orthop Trauma 2002;16:491-7.  Back to cited text no. 4
    
5.
Paley D, Catagni MA, Argnani F, Villa A, Benedetti GB, Cattaneo R. Ilizarov treatment of tibial nonunions with bone loss. Clin Orthop Relat Res 1989;241:146-65.  Back to cited text no. 5
    
6.
Ferreira N, Marais LC. Prevention and management of external fixator pin track sepsis. Strategies Trauma Limb Reconstr 2012;7:67-72.  Back to cited text no. 6
    
7.
Paley FB, Christianson D. An analysis of Illizarov and external fixators. Clin Orthop Relat Res 1989;241:195.  Back to cited text no. 7
    
8.
Dendrinos GK, Kontos S, Lyritsis E. Use of the Ilizarov technique for treatment of non-union of the tibia associated with infection. J Bone Joint Surg Am 1995;77:835-46.  Back to cited text no. 8
    
9.
Magadum MP, Basavaraj Yadav CM, Phaneesha MS, Ramesh LJ. Acute compression and lengthening by the Ilizarov technique for infected nonunion of the tibia with large bone defects. J Orthop Surg (Hong Kong) 2006;14:273-9.  Back to cited text no. 9
    
10.
Dell P, Sheppard TC. Vascularized bone grafts in the treatment of infected forearm nonunions. J Hand Surg 1984;9A: 653-8.  Back to cited text no. 10
    
11.
Ilizarov GA, Lediaev VI, Degtiarev VE. Operative and bloodless methods of repairing defects of the long tubular bones in osteomyelitis. Vestn Khir Im I I Grek 1973;110:55-9.  Back to cited text no. 11
    
12.
McKee MD, DiPasquale DJ, Wild LM, Stephen DJ, Kreder HJ, Schemitsch EH. The effect of smoking on clinical outcome and complication rates following Ilizarov reconstruction. J Orthop Trauma 2003;17:663-7.  Back to cited text no. 12
    
13.
Tranquilli Leali P, Merolli A, Perrone V, Caruso L, Giannotta L. The effectiveness of the circular external fixator in the treatment of post-traumatic of the tibia nonunion. Chir Organi Mov 2000;85:235-42.  Back to cited text no. 13
    
14.
Marsh DR, Shah S, Elliott J, Kurdy N. The Ilizarov method in nonunion, malunion and infection of fractures. J Bone Joint Surg Br 1997;79:273-9.  Back to cited text no. 14
    
15.
Madhusudhan TR, Ramesh B, Manjunath K, Shah HM, Sundaresh DC, Krishnappa N. Outcomes of Ilizarov ring fixation in recalcitrant infected tibial non-unions - A prospective study. J Trauma Manag Outcomes 2008;2:6.  Back to cited text no. 15
    
16.
Arora S, Batra S, Gupta V, Goyal A. Distraction osteogenesis using a monolateral external fixator for infected non-union of the femur with bone loss. J Orthop Surg (Hong Kong) 2012;20:185-90.  Back to cited text no. 16
    




 

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Abstract
Introduction
Case Report
Results
Discussion
Conclusion
References

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