STRATEGY OF THE TREATMENT OF INFECTED BONE LOSS IN THE LONG BONES WITH THE ILIZAROV METHOD

Abstract

Introduction: The bone defects in the long bones are traumatic as a consequence of open fractures or resections due to infection or necrotic nonunion. A devitalised bone with no nutrition or vascularity is liable to an infection, with extension proportional to the size of the necrotic bone. To be sure to eliminate the infection and the nonunion it is necessary to perform open surgery and remove the necrotic and infected segments thoroughly, and then proceed to osteosynthesis and internal transport after osteotomy.

Material and Methods: From 1981 to 2002 203 cases were treated with the Ilizarov Method. The previous treatment given before the patients came to our center was as follows: 1) in tibial nonunion intramedullary nail 17%; 2) in femoral nonunion plates 46%, monoaxial external fixator 42%, intramedullary nail 10%, circular external fixator 4%; 3) humerus nonunion Ender 3%, plates 81%, intramedullary nail 16%; 4) forearm nonunion plates 80%, wires and cast 20%. Our treatment was resection of the infected bone segment and then bifocal internal transport in 162 patients, threefocal convergent transport in 41, or threefocal tandem transport. If the resection does not exceed 4–5 cm. it is possible to perform immediate shortening, first by placing the resection stumps in contact and compression, and then by performing bifocal transport. The bifocal method consists of resection and proximal or distal metaphyseal osteotomy and then internal transport of the free bone segment bringing it into contact with the stump where the resection was performed. In the threefocal convergent method, after resection, two osteotomies are performed, one proximal and the other one distal, and the two bone segments are made to converge on the resection site. In the threefocal tandem method, after resection on a clear-cut proximal or distal infection, the osteotomies are performed on the same bone segment with double level transport. The good result is conditioned by satisfying regeneration in the site of the osteotomies. The rhythm of transport is purely individual and proportional to the patient’s age, and ranges from 1 to ¼ mm a day. In case of hypotrophy of the regenerated bone, concertina manoeuvring becomes necessary, that is shortening and subsequent distraction of the transport segments.

Results: According to these techniques we attained both consolidation and elimination of the infection in 181 cases, that is 89%.

Conclusions: In infectious nonunion healing cannot be possibly achieved through antibiotic therapy, so the only resolving action is the eradication of the necrotic-septic site and then its resection. The consequent limb shortening is compensated, in the Ilizarov Method, by internal transport of the healthy bone segment. Our results are good for cases, and the infection is eliminated in any case.