Introduction and Objective

Management of gap non-union of the tibia, the major weight bearing bone of the leg remains controversial. The different internal fixation techniques are often weighed down by relatively high complication rates that include fractures which fail to heal (non-union). Minimally invasive techniques with ring fixators and bone transport (distraction osteogenesis) have come into picture as an alternative allowing alignment and stabilization, avoiding a graduated approach. This study was focused on fractures that result in a gap non-union of > 6 cm. Ilizarov technique was employed for management of such non-unions in this case series. The Ilizarov apparatus consists of rings, rods and kirschner wires that encloses the limb as a cylinder and uses kirschner wires to create tension allowing early weight bearing and stimulating bone growth. Ilizarov technique works on the principle of distraction osteogenesis, that is, pulling apart of bone to stimulate new bone growth. Usually, 4–5 rings are used in the setup depending on fracture site and pattern for stable fixation. In this study, we demonstrate effective bone transport and formation of gap non-union more than 6 cm in 10 patients using only 3 rings construct Ilizarov apparatus.

Osteomyelitis is an inflammatory condition accompanied by the destruction of bone and caused by an infecting microorganism. Open contaminated fractures can lead to the development of osteomyelitis of the fractured bone in 3-25% of cases, depending on fracture type, degree of soft-tissue injury, degree of microbial contamination, and whether systemic and/or local antimicrobial therapies have been administered. Untreated, infection will ultimately lead to non-union, chronic osteomyelitis, or amputation. We report a case series of 10 patients that presented with post-operative infected non-union of the distal femur with or without prior surgery. The cases were performed at Padmashree Dr. D. Y. Patil Hospital, Nerul, Navi Mumbai, India. All the patients’ consents were taken for the study which was carried out in accordance with the Helsinki Declaration. The methodology involved patients undergoing a two-stage procedure in case of no prior implant or a three-stage procedure in case of a previous implant. Firstly, debridement and implant removal were done. The second was a definitive procedure in form of knee arthrodesis with ring fixator and finally followed by limb lengthening surgery. Arthrodesis was planned in view of infection, non-union, severe arthritic, subluxated knee, stiff knee, non-salvage knee joint, and financial constraints. After all the patients demonstrated wound healing in 3 months along with good radiographic osteogenesis at the knee arthrodesis site, limb lengthening surgeries by tibial osteotomy were done to overcome the limb length discrepancy. Distraction was started and followed up for 5 months. All 10 patients showed results with sound knee arthrodesis and good osteogenesis at the osteotomy site followed by achieving the limb length just 1-inch short from the normal side to achieve ground clearance while walking. Our case series is unique and distinctive as it shows that when patients with infected nonunion of distal femur come with the stiff and non-salvage knee with severe arthritic changes and financial constraints, we should consider knee arthrodesis with Ilizarov ring fixator followed by limb lengthening surgery

Many studies describe the use of the Ilizarov ring fixator for lower limb lengthening and for the management of the 3-dimensional lower limb deformities in achondroplasia, and most confirm the efficacy of this technique. However, long term follow up of these achondroplastic patients is lacking. Most studies have focused on magnitude of lengthening, treatment time required and complications, but no study has analyzed the long term postoperative condition of these patients using an objective, functional method such as gait analysis. Nineteen (19) achondroplastic patients, 12 males and 7 females, aged 19–38 years (mean 27.3 y) who have undergone tibia and femur lengthening, using the Ilizarov method, at the age of 9–19 years (mean 12.6 y), were evaluated 5–19 years (mean 10.1 y) after their last surgery, using 3-dimensional gait analysis. Nineteen (19) normal, height-matched subjects were used as controls. The VICON Nexus 8 Camera System was used to accurately measure spatiotemporal characteristics (walking velocity, stride length, step length, cadence) and kinematics (range of motion) of lower limb joints. Statistical comparison of deformity parameters between achondroplastic patients and normal population was done using the student t- test. A level of p<0.05 was considered statistically significant. Walking velocity, step length and stride length were statistically significantly decreased (p<0.05) in achondroplastic patients compared to normal population values. The achondroplastic group presented with excessive anterior pelvic tilt (mean 21.9. o. ± 7.3), excessive pelvic rotation (range 28.7. o. ±7.8), decreased hip extension (mean 1.8. o. ±10.1) and decreased plantar flexion (mean 17.1. o. ±5.1) when compared to normal controls. There was no statistically significant difference in the knee kinematics between the operated achondroplastic patients and normal controls. The achondroplastic patients present decreased values in their spatiotemporal characteristics compared to the normal subjects because, despite the height gain, their lower limbs remain shorter. Their excessive anterior pelvic tilt is attributed to their lordosis. Their excessive forward pelvic rotation is an attempt to increase stride and step length. The decreased hip extension is due to their anterior pelvic tilt. The correction of these patients genu varum restored knee kinematics to normal. In order to address the hip and pelvis deformities a proximal femoral osteotomy should be considered. The Ilizarov method provides functional height gain and substantially corrects the three-dimensional lower limb deformities of achondroplastic patients especially around the knee joint but more planning needs to be implemented when the system is applied to correct the disease specific deformities of the hip and pelvis. Gait analysis is an objective tool that can be used to address these design issues

Objectives

The purpose of this study was to compare the results and complications of tibial lengthening over an intramedullary nail with treatment using the traditional Ilizarov method.