Treatment of Infected Nonunions

Transcription

1 Tretment of Infected Nonunions REDENTO MORA,LUISELLA PEDROTTI,BARBARA BERTANI,FABRIZIO QUATTRINI Tretment Among infected nonunions, tretments re sed on the clssifiction nd on the therpeutic principles developed y Umirov t the Centrl Institute of Trumtology nd Orthopedics (CITO) of Moscow [1 3] (Tle 1). Tle 1. Clssifiction of infected nonunions nd principles of tretment ccording to Umirov [1] Types Tretment Normotrophic nonunion without shortening Déridement, monofocl osteosynthesis (compression-distrction) Hypertrophic nonunion with shortening Déridement, monofocl osteosynthesis (distrction) Atrophic nonunion with shortening Nonunion ssocited with one nd soft tissue loss Déridement, ifocl osteosynthesis (compression-distrction) Déridement, one resection without soft tissue coverge, one trnsport The first three types of the clssifiction outlined in Tle 1 re the infected vriety of the three corresponding types of noninfected nonunion, whose morphologic nd functionl fetures nd whose principles of tretment hve lredy een discussed. Their tretment is similr to tht of the noninfected vriety, ut commences fter ccurte déridement nd dequte specific ntiiotic therpy. Only on rre occsions does infection urn on the fire of the one regenerte, s Ilizrov mentioned with sort of optimism

2 200 R. Mor, L. Pedrotti, B. Bertni, F. Quttrini [4], nd it is etter not to rely only on this fire ut rther to trust in modern ntiiotic therpy, crefully plnned in collortion with the infectious diseses specilists. The fourth type of this clssifiction includes nonunions with one nd soft tissue loss, which re usully oserved fter open frctures with lrge soft tissue dmge, complicted y infection nd one loss. It should e stressed tht one nd soft tissue loss is only directly produced y trum in smll numer of ptients; most often it is due to the wide surgicl déridement performed, usully during numerous opertions in n ttempt to eliminte the necrotic nd infected res [2]. In these cses the choice of tretment requires previous evlution of ll the possile options, ccording to the trum nd the fetures in the individul ptient [5]. The possile options re: - Amputtion nd prosthesis; - Reconstructive tretment. Amputtion rther thn reconstruction my e indicted y certin locl fetures, such s posterior tiil nerve dmge, severe vsculr lesion, nd severe contmintion, nd y fetures relting to the ptient, such s old ge, chronic diseses (dietes or peripherl rteriopthy), smoking, nd inility to tke prt in the tretment. In theory, the evlution nd the tretment decision my e helped y one of the Scoring Systems developed in the pst few yers (Mngled Extremity Syndrome Index, Mngled Extremity Severity Score, Predictive Slvge Index, or Lim Slvge Index); however, these tests hve not shown ny clinic usefulness [6]. If reconstruction is chosen, very complex tretment is usully necessry to solve three relted prolems: infection, lck of one continuity, nd lck of skin coverge. The essentil ims of the tretment re then represented y: infection heling, soft tissue reconstruction, nd one consolidtion with preservtion of the lim length, the most importnt stge in the therpeutic plnning eing the ccurte déridement [7]. The first stge of the reconstructive methods is one stiliztion. The indiction, ccording to most uthors [5] nd lso in our opinion, is lwys the externl osteosynthesis due to the high infection rte ssocited with endomedullry niling. In prticulr, in spite of the (theoreticl) simplicity of ppliction nd the (theoreticlly) etter ccess to soft tissues llowed y the xil fixtion, we prefer circulr fixtion due to its intrinsic dvntges (stility nd immedite functionl weight ering nd esy removl t the end of the tretment) [2]. Soft tissue reconstruction cn e chieved y different mens [8]: splitthickness skin grft is rrely used ecuse it would surely fil if the grft is

3 Tretment of Infected Nonunions 201 pplied on poorly vsculrized soft tissues or one without periosteum. Therefore, lterntive methods re usully employed. A cross-leg flp is lso rrely used ecuse of the prolonged period of immoiliztion nd the mny esthetic prolems tht it produces. Locl muscle flp hs the dvntge of self-vsculriztion: it llows firm coverge nd cn lso e covered y skin grft s n immedite or delyed procedure; however, distnt coverge often is difficult, nd it is often impossile to perform ecuse of the extent of the lesion to the whole lim. An importnt improvement hs een chieved with the use of free microvsculrized grfts [9], with which the grft cn e smpled from res spred y the trum. Among the most frequently used microvsculrized grfts re the groin flp, the ltissimis dorsi flp, nd the tensor fscie lte flp. One very prticulr kind of flp is the composite one-muscle-skin grft, composed of ilic crest nd soft tissues (composite osteocutneous groin flp) sed on the deep circumflex ilic rtery, nd which is indicted in the tretment of comined defects of oth one nd soft tissue. The reestlishment of one continuity cn e chieved with utoplstic one grft, most often tken from the ilic crest, or sometimes from femorl gret trochnter, femorl distl metphysis, or tiil proximl metphysis. Here, it hs een oserved tht one of memrnous origin (ilic one) shows etter osteoinductive ctivity thn one of endochondrl origin (tii nd femur) [10]. A prticulr surgicl technique employing utoplstic one grft is the Ppineu method [11], which consists of excision, stiliztion, nd reconstruction y corticl spongy one grft without skin coverge. This procedure hs the severe disdvntge of eing performed in mny opertive stges nd requires prolonged periods of time to hel. The microvsculrized utoplstic one grft [12] is sed on the employment of ipsilterl or contrlterl fiul or, more rrely, the ilic crest with soft tissue coverge (composite grft s previously descried). The disdvntges of the utoplstic grft re minly due to the quntity of one tissue needed, the prolonged immoiliztion, the complictions t the smpling site (moridity nd pin) nd grft site (sence of heling nd frctures), the frequent need for mny opertions, nd prolonged period to chieve grft hypertrophy. In prticulr in the microvsculrized grft the length of the opertion nd the risks in cses where there is only one vsculr xis must e considered [13]. It is necessry to rememer tht good outcome is lso produced y homoplstic grfts [14, 15], which re generlly stored y refrigertion nd employed s mssive one grft or s thin sheets of corticl one. Oviously

4 202 R. Mor, L. Pedrotti, B. Bertni, F. Quttrini the use of homoplstic one presumes perfectly functionl one nk for oth smpling nd storing one grfts. The complictions most often descried in this kind of tretment re infection nd grft frcture. A good lterntive to one grft is represented y the compression-distrction techniques, minly developed y Ilizrov [4], in the form of ifocl (or multifocl) compression-distrction osteosynthesis, lso known s one trnsport technique. The dvntges consist of lck of moridity t the smple site, lck of limits to the dimensions of one defect, width of regenerted one (which does not ecome hypertrophic), nd esiness of soft tissue lesion heling if the temporry shortening techniques re used. The disdvntges re the necessity of complince y the ptient nd the possile complictions (ngulr deformities in the regenerted one, delyed consolidtion t the docking site). Therefore very ccurte evlution of the cse is needed efore eginning such tretment. The use of the compression-distrction systems [16 19] offers n importnt contriution to solving the severe prolems relted to these lesions. In some ppers descriing monofocl or ifocl osteosynthesis techniques y mens of compression-distrction devices, good results re usully reported in the tretment of infected nonunion with tissue loss. However, the prolem of the correction of one defect is lwys well stressed, ut little ttention is directed to the prolems of treting infection nd soft tissue loss [17, 20 23]. In Umirov type 4 infected nonunion of the tii, the method of epidermofscioosteoplsty, developed y Umirov (from the CITO of Moscow), offers the essentil dvntge of precisely clssifying the opertive phses nd the stges of simultneous one nd soft tissue regenertion nd eliminting wide tissue losses without previous steriliztion of the infected site nd closure of the soft tissue or the use of ny kind of grft [24 30]. Opertive Technique The first step consists in performing corticotomy t the proximl or distl tiil metphysis ccording to the resection site, distl or proximl (Figs. 1, 2). Then n ccurte déridement of the infected nonunion site, with one end resection until helthy one is oserved nd complete excision of the infected nd necrotic soft tissues re performed (Figs. 2, 3). The soft tissue resection level must correspond to the one resection level; otherwise, new infection will develop. The wide déridement re is then kept open. At this time compression-distrction device is pplied to the leg (Fig. 3). The ssemly must e extended to the hindfoot in ptients in whom loss of tissue in the distl tii requires extensive resection nd the length of the distl tiil frgment is only few centimeters in length.

5 Tretment of Infected Nonunions 203 Fig. 1,. X-ry of n infected nonunion of the left tii with one nd soft tissue loss in dietic 38-yer-old mn previously treted with externl osteosynthesis y mens of n xil device. Clinicl feture of the left leg

6 204 R. Mor, L. Pedrotti, B. Bertni, F. Quttrini Fig. 2,. Sme cse s in Fig. 1. Tretment with Umirov s technique: tiil proximl corticotomy. Excision of infected nd necrotic tiil segment nd soft tissue A system of grdul distrction is pplied to the tiil frgment designed to e trnsported, which is mde up of two olique wires with support se connected to the pprtus or of one wire (only for proximl corticotomy),

7 Tretment of Infected Nonunions 205 Fig. 3,. Sme cse s in Fig. 1. Resected one (length: 18 cm). Mounting of the compression-distrction device is lmost completed whose end, ent like hook, is supported on the corticl edge. This wire is pssed through the medullry cnl, the tlus, nd the clcneus, ultimtely protruding from the middle of the sole, nd is then fixed y progressive trction device to the distl ring of the pprtus. The trnsverse wire trnsport technique should only e employed, in our opinion, when multilevel trnsport is performed (Figs. 4, 5).

8 206 R. Mor, L. Pedrotti, B. Bertni, F. Quttrini Fig. 4. Sme cse s in Fig. 1. Clinicl fetures t the end of the surgicl procedure. The wound is kept open Fig. 5,. Sme cse of Fig. 1. X-rys t the end of the surgicl procedure

9 Tretment of Infected Nonunions 207 In the postopertive phse the ptient receives specific ntiiotic therpy [30] nd dily dressings. After 2 weeks grnultion tissue covers the one segment surfces. From this moment, the trnsport of the one frgment t 1 mm dily cuses progressive distrction with regenerting one formtion t the corticotomy site nd grdul nrrowing of the gp etween the frgments t the nonunion site (Fig. 6). Simultneously, the grdul pproch c Fig. 6-d., X-rys fter three months shows good formtion of proximl regenerting one. c, d X-rys fter 3 months: the one trnsport is in progress d

10 208 R. Mor, L. Pedrotti, B. Bertni, F. Quttrini of the tiil frgments closes the edges of the soft tissue gp until the epidermic nd fscil reconstruction is complete ecuse the tiil frgment tkes the fsci nd the skin, oth closely connected to the one, long during the trnsport. This is how true epidermofscioosteoplstic tretment is performed. At this time the distrction system sed on the olique wires or on the hook-shped intrmedullry wire is removed nd the tiil frgment is fixed to n dditionl ring y two cross trnsverse wires, in order to enle more effective interfrgmentry compression nd to otin consolidtion (Figs. 7, 8). Knee nd nkle kinesitherpy nd muscle strengthening re strted immeditely, nd stnding nd wlking strt few dys fter the opertion. Weight ering is llowed soon in the cse of wire fixtion nd is llowed fter the distrction phse in the ent wire technique. Fig. 7,. Sme cse s in Fig. 1. X-rys t the removl of the compression-distrction device (fter 16 months), with corticliztion of the regenerte nd cllus formtion t the docking site

11 Tretment of Infected Nonunions 209 Fig. 8. Sme cse s in Fig. 1. Clinicl fetures t the end of tretment show complete soft tissue reconstruction Ptients nd Methods In ll, 220 infected nonunion were treted (eight humerl, 26 femorl, nd 186 tiil); of the ptients 131 were mles nd 89 femles. Four humerl nonunions were type 1 nd four were type 2 of the Umirov clssifiction [1]. Of the femorl nonunions 16 were of type 1, six were of type 2, nd four were of type 3. There were 81 tiil nonunions of type 1, 28 of type 2, 23 of type 3, nd 54 of type 4. Our indictions re sed on the Umirov principles of tretment [1]. Therefore the tretment of types 1, 2 nd 3 ws similr to tht for corresponding noninfected nonunion, with the ddition of ccurte déridement nd specific ntiiotic therpy. In ll, 101 nonunions were clssified s type 1; 54 ptients were mle nd 47 femle, nd the verge ge ws 35 (rnge 26 61). Type 2 included 38 ptients, ged from 30 to 63 (verge 38). The 27 ptients with type 3 nonunion (15 mle nd 12 femle) were 33 yers old on verge (rnge 24 54). Ptients with infected type 4 nonunion underwent epidermofscioosteoplstic surgery.averge ge ws 36 yers (rnge yers); 47 of these ptients were mle, seven femle.

12 210 R. Mor, L. Pedrotti, B. Bertni, F. Quttrini Of the ptients who lredy hd other kinds of surgery, 35 hd previously hd two opertions, 14 hd hd three opertions, nd five hd hd four opertions. Time from trum to the epidermofscioosteoplstic tretment ws etween 5 nd 27 months, with n verge time of 10 months. In ll cses, cultures were positive for Stphylococcus nd in 16 cses lso for Pseudomons eruginos. At the time of opertion, the tiil one resection ws from 6 to 18 cm, with n verge of 9.5 cm.in ll ptients the Ilizrov pprtus ws used with the olique wires technique, ut in two ptients, in whom multilevel one trnsport ws performed, the technique with trnsverse wires ws employed. In five cses, n utoplstic one grft ws necessry to otin consolidtion t the docking site (Figs. 9 15). Results After surgery, ll ptients were cliniclly, rdiologiclly, sonogrphiclly, nd cteriologiclly controlled (Figs ). Tretment lsted from 4 to 8 months for type 1, 5 to 9 months for type 2, nd 6 to 11 months for type 3 infected nonunions. In Umirov clssifiction type 4 infected nonunions, the heling time ws 7 18 months (verge 10 months). No intropertive complictions were oserved. Fig. 9,. X-ry of n infected nonunion of the proximl left tii with one nd soft tissue loss in 25-yer-old mn previously treted with externl fixtion y mens of Hoffmnn II device

13 Tretment of Infected Nonunions 211 Fig. 10,. Sme cse s in Fig. 9. Clinicl fetures of the lrge one nd soft tissue loss

14 212 R. Mor, L. Pedrotti, B. Bertni, F. Quttrini Fig. 11. Sme cse s in Fig. 9. Tretment with Umirov s technique. After distl tiil corticotomy, excision of the infected proximl tiil segment (length: 12 cm) nd soft tissues is performed Fig. 12. Sme cse s in Fig. 9. The mounting of the Ilizrov device with olique wire trction system is completed. The wound is kept open

15 Tretment of Infected Nonunions 213 c d Fig. 13,. Sme cse s in Fig. 9., X-rys t the eginning of the one nd soft tissue trnsport. c, d X-rys t the end of the one nd soft tissue trnsport

16 214 R. Mor, L. Pedrotti, B. Bertni, F. Quttrini Fig. 14,. Sme cse s in Fig. 9. X-rys t the removl of the circulr externl fixtion device (fter 12 months) Fig. 15,. Sme cse s in Fig. 9. Clinicl fetures t the end of tretment show good soft tissue reconstruction

17 Tretment of Infected Nonunions 215 Fig. 16,. X-rys of n infected nonunion of the left tii with one nd soft tissue loss in 30-yer-old womn previously treted with vsculrized fiulr one grft nd stiliztion y mens of n xil externl fixtor During the follow-up, one ptient, who ws treted y epidermtofscilosteoplsty, died 40 dys fter opertion due to pulmonry emolism. Five ptients developed superficil infection t one or two wire sites: the infection ws successfully treted with locl dressing nd generl ntiiotic therpy. In 21 cses rekge of one or two wires ws oserved. This compliction required wire sustitution in 16 cses. The overll results, divided into one results nd functionl results, were evluted ccording to the Pley clssifiction [17]. In type 4 infected nonunions in prticulr the infection ws eliminted, one nd soft tissue were reconstructed, nd the postopertive rehilittion period ws shortened. An pprently prdoxicl feture is the sence of fir results in the tretment of the most severe cses (type 4 of the Umirov clssifiction), which showed only excellent nd good outcome nd the infection erdicted in ll cses. This nomly is explined y the opertive technique, which completely removes ll the infected nd necrotic tissues nd involves further complete steriliztion of the nonunion site (Tle 2).

18 216 R. Mor, L. Pedrotti, B. Bertni, F. Quttrini Fig.17,.Sme cse s in Fig. 16. Clinicl fetures of the completely exposed nd necrotic fiulr grft. Tretment with the Umirov s technique: proximl tiil corticotomy is performed Tle 2. Bone nd clinicl results Bone results Functionl results Excellent Good Fir Excellent Good Type Type Type Type

19 Tretment of Infected Nonunions 217 Fig. 18,.Sme cse s in Fig. 16. Excision of the infected tiil segment (with the necrotic fiulr grft) nd the infected nd necrotic soft tissues. The resected one (length: 15 cm) Discussion An optimlly performed déridement is, in Gustilo s opinion [7], the most importnt prt of the tretment of open frctures. In the sme wy, the rdicl removl of the necrotic nd infected prts of oth one nd soft tissues represents the most importnt element for the success of tretment y compression-distrction technique in severe, infected nonunions of the tii. This highly ggressive pproch to the prolem, which is reminiscent of the guidelines for stte-of-the-rt surgicl therpy of one tumors, is the key to understnding the effectiveness in the outcomes with these methods.

20 218 R. Mor, L. Pedrotti, B. Bertni, F. Quttrini Fig. 19. Sme cse s in Fig. 16. The mounting of the compression-distrction pprtus is completed. The wound is kept open Fig. 20,. Sme cse s in Fig. 16. X-rys 30 dys fter the eginning of the one nd soft tissue trnsport

21 Tretment of Infected Nonunions 219 Figs. 21,. Sme cse s in Fig. 16. X-rys t the end of the trnsport Fig. 22,. Sme cse s in Fig. 16. X-rys t the removl of the compression-distrction pprtus (fter 14 months), with good proximl corticliztion of the regenerting one nd cllus formtion t the docking site

22 220 R. Mor, L. Pedrotti, B. Bertni, F. Quttrini Fig. 23,. Sme cse s in Fig. 16. Clinicl fetures t the end of tretment, with stisfctory soft tissue reconstruction It is evident tht only with the development of grdul distrction techniques nd the knowledge of distrction osteogenesis cn extremely lrge resections e performed (up to 18 cm in ptient treted t the Deprtment of Orthopedics nd Trumtology of the University of Pvi), resonly ssuming tht the lrge one segments will grdully e regenerted through metphysel corticotomy nd further distrction. Mny Authors limit the one resection to 3 12 cm, over which reconstructive technique should not e performed (s reported y Prokuski nd Mrsh [5]), ut we disgree with this opinion. Since it is prticulr form of compression-distrction osteosynthesis, the osteotomy produces significnt improvement in vsculriztion in ll the one segments nd hs stimulting effect on the dystrophic soft tissue even in such cses. The overll tretment time is prolonged nd directly depends on the width of the resection. It ws quite surprising, though, tht in lmost ll cses, ptients well tolerted the fixtor over the entire tretment period, while mintining good joint function. This is one of the min rguments in support of employing the circulr externl fixtion systems rther thn the xil fixtors. Actully, the stility

23 Tretment of Infected Nonunions 221 of the circulr externl device llows weight ering on the operted lim from the first few dys fter the opertion. Furthermore, during the entire tretment period, the frgment positions cn e esily modified ccording to therpeutic needs. With regrd to the tolerility, moridity of soft tissues is low, even in cses of one trnsport over mny centimeters, which is possile with the olique wires; however, the use of trnsverse screws, which is necessry when xil fixtors re employed, produces deep lesions in soft tissues during the trnsport. These dvntges re otined not only y using the Ilizrov system, ut with ll externl circulr fixtion systems. Umirov himself performed epidermtofscilosteoplsty in more thn 300 ptients using the Volkov- Ognesin circulr externl device [32]. An lterntive to this method is represented y the compression-distrction osteosynthesis with cute shortening of the one segment (to get close nd compress the frgment immeditely) nd further lengthening y mens of distrctionl corticotomy [5, 33 36]. In our opinion this technique produces stisfctory results ut hs some disdvntges, relted to the negtive psychologicl effect on the ptient, the possile limittions of rticulr function, difficulty wlking in the erly stges of tretment, nd the possile dmge to soft tissue produced y shortening of mny centimeters. The multilevel one trnsport technique, suggested y Mouss [36] nd cited y Pley [18] s ipsilterl compression-distrction osteosynthesis, is very smrt nd ims to otin multiple simultneous distrctions y dividing the frgment into mny prts in order to shorten the tretment period. The ssemly is very complex, due to the multiple trnsfixion res of the soft tissues, ut seems to e surprisingly well tolerted y the ptient (the ptient must e highly motivted nd selected for this kind of tretment). Finlly, some other methods employed to shorten the tretment period hve een descried: docking site stimultion with utoplstic spongy one grft, one mrrow injections, decortiction, ssocition with internl osteosynthesis y intrmedullry niling, electric or mgnetic stimultion, ultrsound stimultion, nd use of one growth stimulting fctors (one deminerlized mtrix, one morphogenetic protein, nd osteolst cells cultures). A strong opinion on the true effect of these stimulting techniques is premture, however, considering the few cses reported. The ifocl or multifocl osteosynthesis techniques re prticulrly complex nd compelling for the ptient nd the surgicl tem. However, they re n effective option in the mngement of infected nonunions nd, in experienced hnds, provide results tht previously were solutely unthinkle.

24 222 R. Mor, L. Pedrotti, B. Bertni, F. Quttrini References 1. Umirov GA (1986) Clssifiction of nonunions of the long ones complicted y infection nd principles of tretment. Sorn Trud CITO 30: Mor R, Mccruni A, Pprell F et l (1991) Clssificzione e trttmento delle pseudortrosi infette. Atti SERTOT 33: Mor R (2000) Tecniche di compressione-distrzione. Amplimedicl, Milno 4. Ilizrov GA, Green SA (1992) Trnsosseous osteosynthesis. Springer, Berlin Heidelerg New York 5. Prokuski LI, Mrsh JL (1994) Bone trnsport in cute trum. Curr Orthop 8: Bonnni F, Rhodes M, Lucke JF (1993) The futility of predictive scoring of mngled lower extremities. J Trum 34: Gustilo RB (1989) Orthopedic infection. Dignosis nd tretment. Sunders, Phildelphi 8. Weilnd AJ, Moore JR, Hotchkiss RN (1983) Soft tissue procedures for reconstruction of tiil shft frctures. Clin Orthop Relt Res 178: Dniel RK, Tylor G (1973) Distnt trnsfer of n islnd flp y microvsculr nstomoses. Plst Reconstr Surg 68: Perry CR (1999) Bone repir techniques, one grft, nd one grft sustitutes. Clin Orthop Relt Res 360: Ppineu LJ (1973) L excision-greffe vec fermeture retrdée délierée dns l ostéomyélite chronique. Nouv Presse Med 2: Khleel A, Pool RD (2001) Bone trnsport. Curr Orthop 15: Lewertowski J.M, Lenole E, Goutllier D (1993) Comlement des pertes de sustnces complexes os-prties molles de jme pr corticotomie et régénértion osseuse progressive sous fixteur externe d Ilizrov. Rev Chir Orthop 79[Suppl]: Volkov M, Bizer V (1969) Homotrnsplnttion of one in peditric orthopedics. Meditsin, Moscow 15. Immliev AS (1975) Homoplsty of the rticulr ends of ones. Meditsin, Moscow 16. Cierny G (1990) Chronic osteomyelitis: results of tretment. AAOS Instr Course Lect 39: Pley D, Ctgni M, Argnni F et l (1989) Ilizrov tretment of tiil nonunions with one loss. Clin Orthop Relt Res 241: Pley D (1990) Tretment of tiil nonunions nd one loss with the Ilizrov technique. AAOS Instr Course Lect 39: Ctgni M, Guerreschi F, Cttneo R (1993) Tretment of chronic osteomyelitis using the method of Ilizrov. Intern J Orthop Trum 3[Suppl]: Ilizrov GA, Kplunov AG, Degtyrev VE et l (1972) Tretment of pseudorthroses nd ununited frctures, complicted y purulent infection, with the method of compression-distrction osteosynthesis. Ortop Trvmtol Protez 33: Ilizrov GA, Ledyev VI, Degtyrev VE (1973) Opertive nd loodless methods of repiring defects of long ones in osteomyelitis. Vestn Khir 5: Rycuk OI (1977) Tretment of defects of long ones y the method of compression-distrction. KNIITO, Kiev 23. Morndi M, Zemo MM, Ciotti M (1989) Infected tiil pseudorthrosis. Orthopedics 12: Umirov GA (1982) Epidermto-fscil osteoplsty of tiil defects under conditions of purulent infection. Ortop Trvmtol Protez 6: Umirov GA (1984) Tretment of extensive wounds nd one defects of the tii y redisloction of skin-fscil-one trnsplnt. Sorn Trud CITO 28:36 42

25 Tretment of Infected Nonunions Umirov GA (1984) Plstic repir of trumtic defects of the leg in suppurtive infections. Khirurgii 38: Umirov GA (1985) Repositioning-elongtion for infected post-trumtic leg defects. Adv Orthop Surg 9: Mor R, Soldini A, Rschellà F et l (1989) Le tritement des pseudorthroses infectées du tii selon l technique d Umirov. Z Unfllchir Vers 82: Mor R, Pprell F, Benzzo F et l (1995) Il trttmento delle pseudortrosi infette di tii con perdit di sostnz osse e dei tessuti molli medinte epidermofscio-osteoplstic. Minerv Ortop Trumtol 46: Mor R, Pedrotti L, Benzzo F et l (1999) L epidermo-fscio-osteoplstic nel trttmento delle grvi pseudortrosi infette di gm con perdit di sostnz osse e delle prti molli. Giorn Itl Ortop Trumtol 25 [Suppl. 1]: The Medicl Letter (1998) Profilssi ntimicroic in chirurgi. Itl Edition 27: Umirov GA (1996) Personl communiction 33. Sles de Guzy J, Vidl H, Chuzc JP (1993) Primry shortening followed y cllus distrction for the tretment of post-trumtic one defect: cse report. J Trum 34. Sneddon DG (1996) Open tiil frctures treted with cute shortening nd simultneous lengthening. Proceedings of the Interntionl Congress on Advnces in the Ilizrov Method. Houston (Texs) 35. Lowenerg D, Vn der Reis W (1996) Acute shortening for tii defects. When nd where. Techn Orthop 11: Vrslon R (1999) L fisszione estern irid. Proceedings Intern Meeting Incontri di Trumtologi, Cortin d Ampezzo 37. Mouss M (1989) Multilevel one trnsport. Proceedings of the 3rd Interntionl Seminr on the Improvement of Externl Fixtion Apprtus nd Methods, Rig