Treatment of septic non-union of tibia using compression and distraction technique with ilizarov circular fixator

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1 Original Article Treatment of septic non-union of tibia using compression and distraction technique with ilizarov circular fixator Muhammad Ayaz Khan, Muhammad Salman, Muhammad Imran Khan, Tamjeed Gul, Muhammad Bilal, Mansoor Khan. Orthopaedic and Trauma Unit, Khyber Teaching Hospital, Peshawar, Pakistan Objective and clinically during follow up visits and at time of To determine the outcome of septic non-union of removal of fixator. tibia using compression and distraction technique Results with Ilizarov circular fixator in terms of infection Out of16 patients, 14 (87.5%) were male and 2 free solid union. (12.5%) were female. Mean age was 33.4 years Patients and Methods (range 23-55). Right tibia was affected in 10 This descriptive study was performed on 16 patients (62.5%) and left in 6 patients (37.5%). patients in Orthopaedic and Trauma Unit, Khyber The cause was road traffic accident in 12 patients Teaching Hospital, Peshawar and Khyber Medical (75%), fire arm injuries in 2 patients (12.5%) and Center, Peshawar, Pakistan from June, 2008 to fall in 2 patients (12.5%). Mean external fixator June, Patients of either gender with age duration was 6.2 months. Results were graded as more than 15 years with supple knee and ankle excellent in 9 patients (52.2%), good in 4 patients joints having septic non-union of tibia were (25%) and fair in 3 patients (18.7%). The included in the study. Those with age below 14 complication rate per patient was 1.3%. years and having associated comorbidities like Conclusion diabetes mellitus and immuno-insufficiency etc. By using the distraction and compression which can compound the infective non-union in technique with ilizarov external fixator, it is these patients and patients with poor vascular possible to avoid infection and achieve solid union status of the affected lower limb and those in resistant and infected cases of non-union of the requiring myocutaneous flap for coverage of diaphyseal region of tibia. (Rawal Med J wounds were excluded from the study. These 2012;37: ). patients were followed for two years. Outcome Key words was recorded in terms of infection free union of the Septic non-union of tibia, Ilizarov, circular external tibia at the septic non-union site radiographically fixator. INTRODUCTION impregnated beads, Papineau-type open cancellous Chronic infection of the diaphyseal shaft of long grafting, tibiofibular synostosis, cancellous bones is one of the most perplexing dilemmas in allograft in fibrin sealant mixed with antibiotics, orthopaedic surgery. To obtain eradication of the and/or free microvascular soft tissue and bone infection, bony union and a functional limb, often 1,4 transplants. requires courageous measures with increasing risks None of the previously mentioned techniques afford 1,2 of failure or amputation. Difficult or resistant the surgeon to correct the deformities, eliminates infection usually requires a more radical prolonged pre and postoperative intravenous debridement of the septic bone and soft tissues, in antibiotic therapy, regenerates new bone tissue addition to application of a more stable fixation to without the use of bone grafts, progressively 1,3 enhance soft tissue healing and bony union. There lengthens the extremity and allows weight bearing 1 are many alternatives available in the management during treatment period. All of these capabilities are of chronic diaphyseal infection. These include possible with application of technique of ilizarov 1,5 extensive debridement and local soft tissue using a ring fixator. This circular fixation is rotational flaps, packing the defect with antibiotic extremely versatile and allows simultaneous 329 Rawal Medical Journal: Vol. 37. No. 3, July-September 2012

2 1,6 correction of axial and rotational deformities. alternatively distracted and compressed for 7 days Over the past thirty years, Ilizarov has developed the each until union has been achieved at the infected technique of distraction osteogenesis to regenerate non-union site. The distraction and compression 7 large deficiencies in bone. Distraction osteogenesis was done in 4 equal increments of 0.25mm every 6 is produced locally by a special corticotomy and hours, making a total of 1mm/day distraction and controlled externally by a ring fixator. Distraction compression for every 7 days. Parenteral antibiotics osteogenesis is the mechanical induction of new were given for up to 4-5 days until discharge of the bone between bony surfaces that are gradually patient and then according to the culture and pulled apart. The biological bridge between the sensitivity result for another 6 weeks along with bony surfaces arises from local neovascularization parenteral and oral analgesia. Check radiographs and spans the entire cross-section of the cut were done on next day after surgery and any surfaces. During distraction, a fibrovascular adjustments in fixator were made on 2nd or 3rd day interface is aligned parallel to the direction of if required. Patients were trained for daily wash of distraction while new bone columns add length to fixator, pins, pin care, distraction-compression the gap. When the biological and mechanical technique and mobility of joints and Quadriceps conditions during distraction are ideal, bone is strengthening exercises. formed by pure intramembranous ossification. During the follow up, fixators were checked Conversely, failure to meet these conditions disrupt thoroughly, each and every nut and bolt tightened, the biological sequence, resulting in a malunion and wires tensioned if needed, pin sites were nonunion. 8 cleaned with povidine iodine and hydrogen per Application of ilizarov technique to treatment of oxide and washed thoroughly with Normal saline infected non-union depends on the type of nonor pin loosening, the patients were readmitted solution. If there was any deep pin tract infection, union (hypertrophic or atrophic), the extent of 1,9 infection and the condition of soft tissues. Limb for surgical toilets and treated according to salvage is preferable to prosthesis if the limb is culture and sensitivity isolated organisms result viable, adequately innervated and the patient is with antibiotics and readjustments of fixators th mentally and financially committed to save the respectively. Follow up were made on every 14 day 10 limb. The aim of this study was to determine the in first month and then once a month until solid outcome of septic non-union of tibia using Ilizarov union has been achieved at the tibial infected non- circular fixator in terms of infection free solid union. union site. Check radiographs were performed in two planes every time. PATIENTS AND METHODS Before removal, fixators were dismantled first Patients were enrolled from the out-patient without anesthesia and fracture site was department and after informed consent, they were examined for any movement and pain. If there was admitted and baseline investigations and plain any tenderness and mobility at the fracture site, radiographs of the affected extremity (Anterioweeks. All the fixators were removed without fixators were remained in situ for another 3-4 posterior and lateral views) were performed. All the patients with infected non-union of diaphyseal anesthesia as an out-patient procedure. First, the region of tibia were treated with ilizarov circular distal rings were removed and the wires were fixator under general anesthesia and with spinal taken out with help of hand chuck and then anaesthesia in patients unfit for general anesthesia. similarly proximal construct removed. All the pin On return from the operation theatre, patients were site wounds were washed with saline and povidine allowed with partial weight bearing (toe touch) iodine soaked gauzes. walking on next day and with full weight bearing in a week time or earlier as tolerated. The non-union RESULTS site was kept initially in compression mode for the Out of 16 patients, 14 were male (87.5%) and 2 were first 7 days. After 7 days, the non-union site was then female (12.5%). Mean age was 33.4 years (range 330 Rawal Medical Journal: Vol. 37. No. 3, July-September 2012

3 23-55). The right tibia was involved in 10 cases fire arm injury in 2 patients (12.5%) and fall onto the (62.5%) and left tibia in 6 patients (37.55%). The ground in 2 patients (12.5%). The mean duration of cause was road traffic accident in 12 patients (75%), fixator application was 6.2 months (4 to 12 months). Table 1. Clinical Details of Patients And Outcome. The mean number of procedures performed per patients at first instance after treatment with ilizarov patients prior to application of circular fixator were fixator except in one patient due to fracture at the 2 (range 1-3) and the mean total number of regenerate site which healed subsequently with procedures performed per patients including bone grafting and compression at the non-union site previous treatment plus ilizarov fixator were 3 (Table 1). (range 2-5). The bony union were achieved in all 331 Rawal Medical Journal: Vol. 37. No. 3, July-September 2012

4 Table 2. Complications. DISCUSSION Many surgical techniques have been described for the treatment of tibial non-union. These can achieve bony union, but problems such as malalignment, leg-length discrepancy, deformity and 9 infection may not be corrected. Ilizarov introduced the concept of resection of the site of non-union and acute shortening combined with bone lengthening by distraction osteogenesis using a circular external frame. This method can maintain or regain limb length and also successfully deal with deformity, 19,20,21 infection, joint contracture and mal-alignment. However, there are drawbacks such as the long fixation time and complications related to the docking site including delayed or non-union, mal- Regarding complications in our study, they are.12 alignment and infection divided into problems, obstacles and true In contrast to the two staged study performed by Sen complications. The main problems in our study 12 et al. for the treatment of infected non-union of were pin tract infection and the obstacle was tibia by first performing radical debridement and loosening of wire in 2 patients (Table 2). There were resection of the soft tissues and bones and use of no true complications like chronic osteomyelitis, custom made antibiotics beads and later in second grade-iv pin tract infection or deep venous stage reconstruction with ilizarov fixator, we thrombosis. The complication rate per patient was performed a single stage thorough debridement of 1.3%. infected soft tissues and dead bone and fixation with ilizarov fixator and then using the technique of Table 3. Evaluation of clinic follow-up results. compression and distraction at the non-union site. They have excellent bony results in 94% and good results in 5.8% with excellent functional outcome in 88% and good functional results in 11.76% of patients. Our results are comparable to their study with excellent bony results in 93.7% and good in 6.2% and functional results were excellent in 81% and good in 18.7% of patients. Our study results are also similar to the outcome of 22 study done by Tahmasebi et al. who achieved union with ilizarov fixator in all infected non-union of tibia with single stage procedure as well as to the study result of Patil and Montgomery (95% union rate). Saleh and Rees also achieved excellent to good results with bone union and by using compression-distraction technique they required an The follow-up results were evaluated using the three parameters; union, infection and function according average of one additional operation for the union of 11 to the Cattaneo et al. with 9 patients (56.2%) lower limbs fracture in contrast to 2.2 additional having score of U1-I2-F2 were graded excellent, 4 operations while using bone transport in their study. patients (25%) having the score of U1-I1-F2 were We also had one additional operation in one case due graded good and 3 patients (18.7%) with a score of to fracture of the regenerate who was treated with U1-I1-F1 graded as fair (Table 3). cancellous bone graft and compression. 332 Rawal Medical Journal: Vol. 37. No. 3, July-September 2012

5 The complication rate per patient was 1.3% which is technique for infected non-union of femur. The comparable to the complication rate in the study of principle of distraction-compression osteogenesis. J 12 Orthop Surg 2006;14: Sen et al. of 1.2% per patient. In our study, there 11. Cattaneo R, Marizio C, Eric EJ. The treatment of infected was no true complications like chronic non-union nd segmental defects of the tibia by the osteomyelitis, deep venous thrombosis etc. method of Ilizarov. Clin Orthop 1992;280:142. similarly to the study performed by Saleh and 12. Sen C, Eralp L, Gunes T, Erdem M, Ozden VE, Kocaoglu 24 M. An alternative method for the treatment of non-union Rees. of tibia with bone loss. J Bone Joint Surg (Br) 2006;88- B: CONCLUSION 13. Papineau LJ, Alfageme A, Dolcourt JP, Pilon L. Chronic By using the compression and distraction technique osteomyelitis: open excision and grafting after with ilizarov external fixator, it is possible to get rid saucerization. Int Orthop 1979;3: Lowenberg DW, Freibel RJ, Louie KW, Eshima I. of the infection and achieve solid union in resistant Combined muscle flap and Ilizarov reconstruction for and infected cases of non-union of the diaphyseal bone and soft tissue defects. Clin Orthop 1996;332:37- region of tibia. 51. Correspondence: Dr. Muhammad Ayaz Khan: ayazsabi71@gmail.com Rec. Date: Feb 16, 2012 Accept Date: Jun 23, 2012 REFERENCES 1. Hosny G, Shawky MS. The treatment of infected nonunion of the tibia by compression-distraction techniques using ilizarov external fixator. J Int Orthop1998;22: Gordon L, Chiu EJ. Treatment of infected non-union and segmental defects of tibia with staged microvascular muscle transplantation and bone grafting. J Bone Joint Surg 1998;70A: De Bastiani G, Aldegheriv R, Renzi-Brivio L, Trivella G. Limbing lengthening by distraction of epiphyseal plate.a comparison of the two techniques in rabbit. J Bone Joint Surg (Br) 1986;68: Dell P, Sheppard JE. Vascularized bone grafts in the treatment of infected forearm non-union. J Hand Surg 1984;9A: Ilizarov GA. The tension stress effect on the genesis and growth of tissue part II. The influence of stability and soft tissue preservation. Clin Orthop1989;238: Paley D. Current technique of limb lengthening. J Paediatric Orthop 1988;8: Ilizarov GA. The tension stress effect on the genesis and growth of tissue part II. The influence of the rate and frequency of distraction. Clin Orthop 1989;239: Aldegheri R, Trivella G, Renzi-Brivio L, Tessare G, Agostini S, Lavini F. Lengthening of the lower limbs in achondroplastic patients. A comparative study of four techniques. J Bone Joint Surg (Br) 1988;70: Ilizarov GA. Clinical application of tension-stress for limb lengthening. Clin Orthop 1990;250; Krishnan A, Pamecha C, Patwa JJ. Modified Ilizarov 15. Lenoble E, Lewertowski JM, Goutallier D. Reconstruction of compound tibial and soft tissue loss using a traction histogenesis technique. J Trauma 1995;39: Gordon L, Chiu EJ. Treatment of infected nonunions and segmental defects of the tibia with staged microvascular muscle transplantation and bone grafting. J Bone Joint Surg (Am) 1988;70-A: Atkins RM, Madhavan P, Sudhakar J, Whitwell D. Ipsilateral vascularized fibular transport for massive defects of the tibia. J Bone Joint Surg (Br) 1999;81- B: Tu YK, Yen CY, Yeh WL. Reconstruction of posttraumatic long bone defect with free vascularized bone graft: good outcome in 48 patients with 6 years follow-up. Acta Orthop Scand 2001;72: Aronson J. Current concepts review: limb lengthening, skeletal reconstruction bone transport with the Ilizarov method. J Bone Joint Surg (Am) 1997;79-A: Paley D, Catagni MA, Argnani F. Ilizarov treatment of tibial nonunions with bone loss. Clin Orthop.1989;24: Paley D, Maar DC. Ilizarov bone transport for tibial defects. J Orthop Traum.2000;14: Tahmasebi MN, Mazlouman SJ. Ilizarov method in the treatment of tibial and femoral infected non-union in patients with high energy trauma and battle field wounds. A Med Iran 2004;42(5): Patil S, Montgomery R. Management of complex tibial and femoral non- union using Ilizarov technique and its cost implications. J Bone Joint Surg (Br) 2006;88-B: Saleh M, Rees A. Bifocal surgery for deformity and bone loss after lower limb fracture. Comparison of bone transport and compression distraction methods. J Bone joint Surg (Br) 1995;77-B: Rawal Medical Journal: Vol. 37. No. 3, July-September 2012