Infected nonunion of a long bone continues to
present difficulties in management. In addition to treating the infection,
it is necessary to establish bony stability, encourage fracture
union and reconstruct the soft-tissue envelope. We present a series of 67 infected nonunions of a long bone in
66 patients treated in a multidisciplinary unit. The operative treatment
of patients suitable for limb salvage was performed as a single
procedure. Antibiotic regimes were determined by the results of
microbiological culture. At a mean follow-up of 52 months (22 to 97), 59 patients (88%)
had an infection-free united fracture in a functioning limb. Seven
others required amputation (three as primary treatment, three after
late failure of limb salvage and one for recalcitrant pain after
union). The initial operation achieved union in 54 (84%) of the salvaged
limbs at a mean of nine months (three to 26), with recurrence of
infection in 9%. Further surgery in those limbs that remained ununited
increased the union rate to 62 (97%) of the 64 limbs treated by
limb salvage at final follow-up. The use of internal fixation was
associated with a higher risk of recurrent infection than external
fixation. Cite this article:
We carried out a systematic review of the literature
to evaluate the evidence regarding the clinical results of the Ilizarov
method in the treatment of long bone defects of the lower limbs. Only 37 reports (three non-randomised comparative studies, one
prospective study and 33 case-series) met our inclusion criteria.
Although several studies were unsatisfactory in terms of statistical
heterogeneity, our analysis appears to show that the Ilizarov method
of distraction osteogenesis significantly reduced the risk of deep
infection in infected osseous lesions (risk ratio 0.14 (95% confidence
interval (CI) 0.10 to 0.20), p <
0.001). However, there was a
rate of re-fracture of 5% (95% CI 3 to 7), with a rate of neurovascular
complications of 2.2% (95% CI 0.3 to 4) and an amputation rate of
2.9% (95% CI 1.4 to 4.4).The data was generally not statistically
heterogeneous. Where tibial defects were >
8 cm, the risk of re-fracture
increased (odds ratio 3.7 (95% CI 1.1 to 12.5), p = 0.036). The technique is demanding for patients, illustrated by the voluntary
amputation rate of 1.6% (95% CI 0 to 3.1), which underlines the
need for careful patient selection. Cite this article:
We report the results of intramedullary leg lengthening conducted between 2002 and 2009 using the Intramedullary Skeletal Kinetic Distractor in 69 unilateral lengthenings involving 58 femora and 11 tibiae. We identified difficulties that occurred during the treatment and assessed whether they were specifically due to the implant or independent of it. Paley’s classification for evaluating problems, obstacles and complications with external fixators was adopted, and implant-specific difficulties were continuously noted. There were seven failures requiring premature removal of the device, in four due to nail breakage and three for other reasons, and five unsuccessful outcomes after completion of the lengthening. In all, 116 difficulties were noted in 45 patients, with only 24 having problem-free courses. In addition to the difficulties arising from the use of external fixators, there were almost the same number again of implant-specific difficulties. Nevertheless, successful femoral lengthening was achieved in 52 of the 58 patients (90%). However, successful tibial lengthening was only achieved in five of 11 patients (45%).
We compared the complications and outcome of tibial lengthening using the Ilizarov method with and without the use of a supplementary intramedullary nail. In a retrospective case-matched series assembled from 176 patients with tibial lengthening, we matched 52 patients (26 pairs, group A with nail and group B without) according to the following criteria in order of importance: 1) difference in amount of lengthening (± 2 cm); 2) percentage difference in lengthening (± 5%); 3) difference in patient’s age (± seven years); 4) aetiology of the shortening, and 5) level of difficulty in obtaining the correction. The outcome was evaluated using the external fixator index, the healing index and an outcome score according to the criteria of Paley. It was found that some complications were specific to group A or B respectively, but others were common to both groups. The outcome was generally better in lengthenings with a nail, although there was a higher incidence of rectifiable equinus deformity in these patients.
