Aims. Ilizarov described four methods of treating non-unions but gave little information on the specific indications for each technique. He claimed, ‘infection burns in the fire of regeneration’ and suggested distraction osteogenesis could effectively treat infected non-unions. This study investigated a treatment algorithm for described Ilizarov methods in managing infected tibial non-union, using non-union mobility and segmental defect size to govern treatment choice. Primary outcome measures were infection eradication, bone union and ASAMI bone and function scores. Patients and Methods. A consecutive series of 79 patients with confirmed, infected tibial non-union, were treated with one of four Ilizarov protocols, consisting of; monofocal distraction (26 cases), monofocal compression (19), bifocal compression/distraction (16) and bone transport (18). Median non-union duration was 10 months (range 2–168). All patients had undergone at least one previous operation (mean 2.2; range 1–5), 38 had associated limb deformity and 49 had non-viable non-unions. Twenty-six cases (33%) had a new simultaneous muscle flap reconstruction at the time of Ilizarov surgery and 25 had pre-existing flaps reused. Treatment algorithm based on assessment of bone gap and non-union stiffness, measured after resection of non-viable bone. Results. The treatment algorithm was easy to apply, being based on easily assessable criteria. Infection was eradicated in 76 cases (96.2%) at a mean follow-up of 40.8 months (range 6–131). All three cases of infection recurrence occurred in the monofocal compression group. They required repeat excision and Ilizarov distraction in two cases and below-knee amputation in one. Union was achieved in 68 cases (86.1%) with the initial Ilizarov methods alone. Union was highest amongst the monofocal distraction and bifocal compression/distraction groups, 96.2% and 93.8% respectively. Mean external fixator time was 7.5 months (range 3–17). Monofocal compression was successful in only 73.7% of mobile non-unions, with significantly lower ASAMI scores and a 26.3% re-fracture rate. Bone transport secured union in 77.8% (14/18) but with a 44.4% unplanned reoperation rate. However, after further treatment, infection-free union following bone transport was 100%. Conclusion. We cannot recommend Ilizarov monofocal compression in the treatment of infected, mobile non-unions. Distraction (monofocal or bifocal) was effective and is associated with higher rates of union and infection clearance

Aims. Double-level lengthening, bone transport, and bifocal compression-distraction are commonly undertaken using Ilizarov or other fixators. We performed double-level fixator-assisted nailing, mainly for the correction of deformity and lengthening in the same segment, using a straight intramedullary nail to reduce the time in a fixator. Patients and Methods. A total of 23 patients underwent this surgery, involving 27 segments (23 femora and four tibiae), over a period of ten years. The most common indication was polio in ten segments and rickets in eight; 20 nails were inserted retrograde and seven antegrade. A total of 15 lengthenings were performed in 11 femora and four tibiae, and 12 double-level corrections of deformity without lengthening were performed in the femur. The mean follow-up was 4.9 years (1.1 to 11.4). Four patients with polio had tibial lengthening with arthrodesis of the ankle. We compared the length of time in a fixator and the external fixation index (EFI) with a control group of 27 patients (27 segments) who had double-level procedures with external fixation. The groups were matched for the gain in length, age, and level of difficulty score. Results. The mean gain in length was statistically similar in the two groups: 3.9 cm (1.5 to 9.0) in the study group and 4.2 cm (3.4 to 5.0) in the control group (p = 0.350). The mean time in a fixator was significantly less in the study group compared with the control group: 8.6 weeks (2.0 to 22.8) versus 30.2 weeks (25.0 to 35.4; p < 0.001). The mean EFI was significantly lower in the study group compared with the control group: 17.7 days/cm (10.6 to 35.6) versus 73.4 days/cm (44.5 to 102.3; p < 0.001). The ASAMI (Association for the Study and Application of the Method of Ilizarov) bone score was excellent in 22, good in four, and fair in one. The ASAMI functional score was excellent in 20 and good in seven. There were no infections, superficial or deep. Conclusion. Double-level osteotomies or two procedures using a custom-made straight nail and external fixation can be used to correct deformities or to treat nonunion or malunion and may be combined with arthrodesis of the ankle with lengthening. It is a reasonably safe procedure that allows accurate and cost-effective treatment with a relatively short time in a fixator

Introduction. The Ilizarov method for non-union comprises a range of treatment protocols designed to generate tissue, correct deformity, eradicate infection and secure union. The choice of specific reconstruction method is difficult, but should depend on the biological and mechanical needs of the non-union. We present a prospective series of patients with non-union of the tibia managed using a treatment algorithm based on the Ilizarov method and the viability of the non-union. Patients and methods. Forty-four patients (34 men and 10 women) were treated with 26 viable and 18 non-viable non-unions. Mean duration of non-union was 19 months (range 2-168). 25 patients had associated limb deformity and 37 cases were infected. 42 patients had undergone at least one previous operation. Bone resection was dictated by the presence of non-viable and infected tissue. Four Ilizarov protocols were used (monofocal distraction in 18 cases, monofocal compression in 11 cases, bifocal compression-distraction in 10 cases and 5 bone transports) depending on the stiffness of the non-union or the presence of segmental defect. Results. Union was achieved in 40 cases (91%) with Ilizarov method alone. Infection was eradicated in 35 cases (95%). Monofocal distraction produced union in all 18 stiff non-unions with little morbidity. Monofocal compression was successful in only 82% of mobile non-unions but failed to eradicate infection in 2 of 10 cases. Bifocal techniques allowed infection-free union in all 15 difficult segmental infected non-unions but required prolonged treatment times and bone grafting to docking sites. Complications included pin infection, hindfoot stiffness, refracture, one below-knee amputation and residual limb length discrepancy. Conclusion. We do not recommend monofocal compression in the treatment of infected, mobile non-unions. Distraction (monofocal or bifocal) was effective and is associated with high rates of clearance of infection

Aim. Simultaneous use of Ilizarov techniques with transfer of free muscle flaps is not current standard practice. This may be due to concerns about duration of surgery, clearance of infection, potential flap failure or coordination of surgical teams. We investigated this combined technique in a consecutive series of complex tibial infections. Method. A single centre, consecutive series of 45 patients (mean age 48 years; range 19–85) were treated with a single stage operation to apply an Ilizarov frame for bone reconstruction and a free muscle flap for soft-tissue cover. All patients had a segmental bone defect in the tibia, after excision of infected bone and soft-tissue defects which could not be closed directly or with local flaps. We recorded comorbidities, Cierny-Mader and Weber-Cech classification, the Ilizarov method used, flap type, follow-up duration, time to union and complications. Results. 26 patients had osteomyelitis and 19 had infected non-union. Staphylococci were cultured in 25 cases and 17 had polymicrobial infections. Ilizarov monofocal compression was used in 14, monofocal distraction in 15, bifocal compression/distraction in 8, and bone transport in 8. 8/45 had an additional ankle fusion, 7/45 had an angular deformity corrected at the same time and 24 also had local antibiotic carriers inserted. Median time in frame was 5 months (3–14). 38 gracilis, 7 latissimus dorsi and 1 rectus abdominus flaps were used. One flap failed within 48 hours and was revised (flap failure rate 2.17%). There were no later flap complications. Flaps were not affected by distraction or bone transport. Mean follow-up was 23 months (10–89). 44/45 (97.8%) achieved bony union. Recurrence of infection occurred in 3 patients (6.7%). Secondary surgery was required to secure union with good alignment in 8 patients (17.8%; docking site surgery in 6, IM nailing in 2) and in 3 patients for infection recurrence. All were infection free at final follow-up. Conclusions. Simultaneous Ilizarov reconstruction with free muscle flap transfer is safe and effective in treating segmental infected tibial defects, and is not associated with an increased flap failure rate. It shortens overall time spent in treatment, with fewer operations per patient. However, initial theatre time is long and a committed multidisciplinary team is required to achieve good results

Aim. Infected segmental defects are one of the most feared complications of open tibial fractures. This may be due to prolonged treatment time, permanent functional deficits and high reinfection and non-union rates. Distraction osteogenesis techniques such as Ilizarov acute shortening with bifocal relengthening (ASR) and bone transport (BT) are effective surgical treatment options in the tibia. The aim of this study was to compare ASL with bone transport in a consecutive series of complex tibial infected non-unions and osteomyelitis, for the reconstruction of segmental defects created at surgical resection of the infection. Method. In this single centre series, all patients with a segmental defect (>2cm) of the tibia after excision of infected non-union or osteomyelitis were eligible for inclusion. Based on clinical features, bone reconstruction was achieved with either ASR or BT using an Ilizarov fixator. We recorded the external fixation time (months), the external fixation index (EFI), comorbidities, Cierny-Mader or Weber-Cech classification, follow-up duration, time to union, number of operations and complications. Results. Overall, 43 patients with an infected tibial segmental defect were included. An ASR was performed in 19 patients with a median age of 40 years (range: 19 – 66 years). In this group, the median bone defect size was three cm (range: 2 – 5 cm); and the median frame time eight months (range: 5 – 16 months). BT was performed in 24 patients with a median age of 44 years (range: 21 – 70 years). The median bone defect size was six cm (range: 3 – 10 cm), and the median frame time ten months (range: 7 – 17 months). The EFI in the ASR group and the BT group measured 2.2 months/cm (range: 1.3 – 5.4 months/cm) and 1.9 months/cm (range: 0.8 – 2.8 months/cm), respectively. The comparison between the EFI of the ASL group and the BT group showed no statistically significant difference (p=0.147). Five patients of the ASR group (7 surgeries) and 19 patients of the BT group (23 surgeries) needed further unplanned surgery (p=0.001). Docking site surgery was significantly more frequent in BT; 66.7%, versus ASL; 5.3% (p=0.0001). Conclusion. Acute shortening/relengthening and bone transport are both safe and effective distraction osteogenesis techniques for the treatment of infected tibial non-unions. They share similar frame times per centimetre of defect. However, ASR demonstrated a statistically significant lower rate of unplanned surgeries

To present the results achieved with the use of external fixation techniques in treating 52 cases of post-traumatic and post-surgical septic non-union in a low resources setting. From 2006 to 2014 52 patients were treated for post-traumatic septic non-union of the lower and upper limb bones. Clinical records and radiographs were reviewed; telephone interviews were done for patients unable to reach our institution. There were 39 males and 13 females, with an average age at the time of admission of 29 years (the youngest patient was 8 years old, the oldest 81). Tibia was involved in 43 cases (24 right side, 19 left side), femur in 9 (4 right, 5 left) and left humerus in 1. All the patients, except two, had been treated in other institutions before admission. At presentation, 19 patients had an external fixator in situ, 18 patients had infected osteosynthesis, 15 had exposed necrotic bone, with loss of soft tissues. In 20 cases hardware removal, debridement and sequestrectomy were followed by application of an external fixator. In 31 cases bone transport was done; the fixator was monolateral in 27 cases. In 1 case sequestrectomy and external fixation were followed by a vascularized fibula graft. Bifocal bone transport was utilized in one patient while the bone transport procedure was associated to limb lengthening in 10 patients. Plastic surgery was required in 13 patients. Rotational flaps, vascularized free flaps and extensive skin grafts were all used. The site of non union was cured in all the patients, in an average time of 11 months (from 4 to 32). Two patients required an amputation a few months after the end of the treatment. There was need for fixator adjustment and screws replacement in 21 patients. Non-union at the docking point was observed in 5 patients; it was septic in two of them. There was need of skin-plasty in 2 cases for skin invagination. In 3 cases an extensive skin ulcer was observed during the transport procedure. Limb length discrepancy was corrected in 10 patients. A residual limb shortening was observed in 14 patients. Ankle fusion, knee fusion, foot drop, sensory loss in the foot, reduced range of joint motion were also observed. The external fixator plays a pivotal role in the treatment of septic non unions, especially in low resources setting. The treatment is long and costly. Strict medical supervision is necessary during the entire process

To compare the costs of treatment and income received for treating patients with tibial osteomyelitis, comparing limb salvage with amputation. We derived direct hospital costs of care for ten consecutive patients treated with limb salvage procedures and five consecutive patients who underwent amputation, for tibial osteomyelitis. We recorded all factors which affect the cost of treatment. Financial data from the Patient-Level Information and Costing System (PLICS) allowed calculation of hospital costs and income received from payment under the UK National Tariff. Hospital payment is based on primary diagnosis, operation code, length of stay, patient co-morbidities and supplements for custom implants or external fixators. Our primary outcome measure was net income/loss for each in-patient episode. The mean age of patients undergoing limb salvage was 55 years (range 34–83 years) whereas for amputation this was 61 years (range 51–83 years). Both groups were similar in Cierny and Mader Staging, requirement for soft-tissue reconstruction, anaesthetic technique, diagnostics, drug administration and antibiotic therapy. In the limb salvage group, there were two infected non-unions requiring Ilizarov method and five free flaps. Mean hospital stay was 15 days (10–27). Mean direct cost of care was €16,718 and mean income was €9,105, resulting in an average net loss of €7,613 per patient. Patients undergoing segmental resection with Ilizarov bifocal reconstruction and those with the longest length of stay generated the greatest net loss. In the amputation group, there were 3 above knee and 2 below knee amputations for failed previous treatment of osteomyelitis or infected non-union. Mean hospital stay was 13 days (8–17). Mean direct cost of care was €18,441 and mean income was €15,707, resulting in an average net loss of €2,734 per patient. Length of stay was directly proportional to net loss. The UK National Tariff structure does not provide sufficient funding for treatment of osteomyelitis of the tibia by either reconstruction or amputation. Average income for a patient admitted for limb salvage is €6,602 less than that for amputation even though the surgery is frequently more technically demanding (often requiring complex bone reconstruction and free tissue transfer) and the length of hospital stay is longer. Although both are significantly loss-making, the net loss for limb salvage is more than double that for amputation. This makes treatment of tibial osteomyelitis in the UK National Health Service unsustainable in the long term

Distal tibial bone loss involving the ankle is a devastating injury with few options for reconstruction. The purpose of our study was to look at the long term results of ilizarov technique used to achieve lengthening of tibia and fusion at the ankle. 17 cases (16 post traumatic and one post tumor resection) admitted to one institution between 1994 and 2003. 13 cases were done in bifocal and four in trifocal mode. The duration of follow up was 12 to 84 months The average age was 33 years (Range 7-71). The mean length of the defect was 4.5 cm (Range 1-12). Union of the fusion site occurred in 88 % (15/17) of the patients with mean duration to docking and union being 8 months. The mean time in fixator was 13 months (Range 5 to 29). Average number of surgeries per patient was 3.2. Five patients required free vascularised grafts before the index procedure and 4 patients required realignment at the docking site. Functional results – Fourteen (77.5%) of the patients could walk without support or bracing and twelve patients (71%) returned to same or modified occupation. Complications – Two non-union. Deformity – Fusion site equinus deformity occurred with non union after re-fracture in one case. There were 2 cases of residual fore-foot equinus. Residual low grade infection with discharging sinus was present in two patients. One patient needed change of wires for Pin tract infection. Our study showed 76% good and excellent scores on functional scoring but also demonstrates the high morbidity associated with this procedure. In spite of the steep learning curve and high complication rates the procedure can be undertaken in specialised centres for highly motivated patients to achieve good functional results

Introduction. The purpose of this study is to evaluate the early functional outcome and activity level in athletes and soldiers with large full thickness cartilage defects of the knee that underwent either ‘classic’ autologous chondrocyte implantation using periosteal flap coverage (ACI-P) or 3-D matrix-assisted chondrocyte implantation (ACI-M). Methods. Between April 2002 and January 2004, 19 patients (15 male, 4 female, average age 32.2 years) with 22 full-thickness cartilage defects in 19 knees were treated with ACI in our centre. The mean post-injury interval was 39.8 months whereas 17 (89.5%) patients had undergone at least one surgical procedure before ACI. The average defect size was 6.54 cm. 2. (located in MFC:7, LFC:7 or trochlear:2 while 3 patients had bifocal lesions in both LFC and TRC). Novocart. ¯. cultured chondrocytes with periosteal flap coverage were used in 11 patients and Novocart-3D. ¯. cell impregnated collagen patch in 8. The functional outcome was evaluated with IKDC form, Tegner activity scale and Lysholm score after a mean follow-up period of 26.5 months. Results. The average IKDC and Lysholm scores were improved from 39.16 and 42.42 pre-operatively to 62.4 and 69.4 at the latest follow-up respectively. The mean Tegner activity scale was 8.73 before injury, 3.63 pre-operatively and 5.21 at the latest follow-up. There was no statistically significant difference between the two groups regarding the clinical outcome and the overall athletic or military performance. Second-look arthroscopy was performed in 11 (57.8%) patients due to persistent pain and/or mechanical symptoms. Generally, the ACI site showed adequate graft integration except for one partial failure. Conclusions. The early results of ACI in high-performance athletes and professional soldiers are not as good as other recent studies suggest. Motivational issues during prolonged rehabilitation, patient age and very large defects may influence early results in this select group of patients

Severe acute respiratory syndrome (SARS) is a newly described infectious disease caused by the SARS coronavirus which attacks the immune system and pulmonary epithelium. It is treated with regular high doses of corticosteroids. Our aim was to determine the relationship between the dosage of steroids and the number and distribution of osteonecrotic lesions in patients treated with steroids during the SARS epidemic in Beijing, China in 2003.

We identified 114 patients for inclusion in the study. Of these, 43 with osteonecrosis received a significantly higher cumulative and peak methylprednisolone-equivalent dose than 71 patients with no osteonecrosis identified by MRI. We confirmed that the number of osteonecrotic lesions was directly related to the dosage of steroids and that a very high dose, a peak dose of more than 200 mg or a cumulative methylprednisolone-equivalent dose of more than 4000 mg, is a significant risk factor for multifocal osteonecrosis with both epiphyseal and diaphyseal lesions. Patients with diaphyseal osteonecrosis received a significantly higher cumulative methylprednisolone-equivalent dose than those with epiphyseal osteonecrosis. Multifocal osteonecrosis should be suspected if a patient is diagnosed with osteonecrosis in the shaft of a long bone.

We present a retrospective review of a single-surgeon series of 30 consecutive lengthenings in 27 patients with congenital short femur using the Ilizarov technique performed between 1994 and 2005.

The mean increase in length was 5.8 cm/18.65% (3.3 to 10.4, 9.7% to 48.8%), with a mean time in the frame of 223 days (75 to 363). By changing from a distal to a proximal osteotomy for lengthening, the mean range of knee movement was significantly increased from 98.1° to 124.2° (p = 0.041) and there was a trend towards a reduced requirement for quadricepsplasty, although this was not statistically significant (p = 0.07). The overall incidence of regenerate deformation or fracture requiring open reduction and internal fixation was similar in the distal and proximal osteotomy groups (56.7% and 53.8%, respectively). However, in the proximal osteotomy group, pre-placement of a Rush nail reduced this rate from 100% without a nail to 0% with a nail (p < 0.001). When comparing a distal osteotomy with a proximal one over a Rush nail for lengthening, there was a significant decrease in fracture rate from 58.8% to 0% (p = 0.043).

We recommend that in this group of patients lengthening of the femur with an Ilizarov construct be carried out through a proximal osteotomy over a Rush nail. Lengthening should also be limited to a maximum of 6 cm during one treatment, or 20% of the original length of the femur, in order to reduce the risk of complications.