Ilizarov fixator in management of nonunited and infected tibial shaft fractures
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0975-2870.148841
Background: Management of nonunion with bony defect and infection in long bones is a challenging problem for orthopedic surgeons. Objectives: Evaluation of Ilizarov circular fixation method of treatment for the management of nonunited and infected fractures of tibia. Materials and Methods: This prospective study was conducted in a tertiary care hospital of eastern region of India on 30 subjects in a time span of 3 years after taking clearance of the Institutional Ethical Committee and informed consent of the patients. Results: All the patients had infected nonunion before undergoing Ilizarov procedure. Following initial injury, 22 patients were treated with external fixation and 8 cases were treated with internal fixation. At the time of presentation, 18 patients had infected gap nonunion, 5 patients had infected hypertrophic and 2 patients had atrophic nonunion. The Ilizarov fixator was kept for an average period of 303.7 days. Based on Association for the Study and Application of Methods of Ilizarov scoring system, bony and functional results were assessed. The bony result was excellent in 16 patients, good in eight, fair in four and poor in two. The functional result was excellent in 10 patients, good in 16, fair in two, poor in two. Conclusion: Ilizarov ring fixator still remains an excellent treatment modality for tibial nonunion with a defect, regarding bone union, deformity correction, infection eradication, limb-length achievement, and limb function. Keywords: Fracture shaft tibia, Ilizarov ring fixator, wound infection
Tibia, the most exposed bone in the body, is vulnerable to trauma, therefore it is the most commonly fractured among the long bone fractures. [1],[2],[3],[4] Because one-third of the tibial surface is subcutaneous throughout most of its length, open fractures are more common in the tibia. Delayed union, nonunion, and infection are relatively common complications of tibial shaft fractures. [4],[5],[6],[7] Management of nonunion with bony defect in long bones is a challenging problem for orthopaedic surgeons. In Ilizarov's treatment technique bone and soft tissue regeneration occurs under tensile forces and this is called theory of tension stress. [8],[9],[10] The Ilizarov fixator, while treating nonunion or bone defect, has the advantages that the chances of angular or rotational deformities are less and can be easily corrected in case of deformity. This device provides good stability and early weight bearing. The disadvantages are that it is cumbersome, difficulty in dressings of the wounds, needs expertise and is an expensive device. Patients must be cooperative, and must understand the length of time the frame needs to be worn, and that complications are a probability. Segmental bone transport or distraction osteogenesis is slow, control and gradual stretching of the callus to fill the bony gap after corticotomy. [9],[10],[11] According to Ilizarov, to eliminate infection and obtain union, vascularity must be increased. Three basic modes of application exist for the Ilizarov frame: Monofocal, bifocal, and trifocal. The Ilizarov frame allows multiple modes of treatment, including compression, distraction, lengthening, and bone transport. In the Ilizarov approach, vascularity is increased by corticotomy and the application of a circular external-fixator. For atrophic nonunions with diffuse infection or sequestered bone, open resection of the infected segment is performed, and bifocal compression is used. If skin quality is poor, the bone is stabilized with the external-fixator after resection of necrotic bone. When skin conditions improve, and the infection has regressed, corticotomy is performed, and bifocal compression is applied. [10],[11],[12],[13] This study was conducted for evaluation of Ilizarov circular fixation method of treatment for the management of nonunited and infected fractures of tibia in a rural population of a developing country.
This prospective study was conducted in a tertiary care Medical College of eastern region of India in 15 subjects in a time span of 3 years after taking clearance of the Institutional Ethical Committee and informed consent of the patients. Medically, physically, and mentally fit patients within the age group 18-60 years with nonunited and infected tibial shaft fractures were included in this study. Careful history was recorded followed by clinical examination. Preoperative X-ray [Figure 1] was done, relevant investigation was done followed by preanaesthetic check-up.
Operative Management All the internal (interlocking nail or plates and screws) or external fixation implants applied earlier were removed and slab applied after taking measurement of both the leg. In infected nonunions, pus sent for culture and sensitivity. Dressing was done on alternate day for the next 2 weeks and antibiotics were given based on C/S report. Predominantly Staphylococcus aureus was the organism found with mixed growth of Coliforms in few. After 2 weeks, the patient was put up for operation. The patient was anaesthetized. Antiseptic painting and draping of the affected limb was done. In infected case, debridement of the nonunion site was done and the material sent for culture and sensitivity examination. An autoclaved preconstruct frame based on the Catagni technique (Lecco Italian center) was used [Figure 2]. The number of rings was decided preoperatively based on the fracture site and site of corticotomy. The frame was free between the internal part of the ring and the soft tissues circumferentially over the bulkiest part of leg. The limb was laid in the center of the construct. The proximal and distal most rings were kept parallel to knee and ankle joint line [Figure 3].
Bayonet tip wires were used for hard cortical bone and trocar tip wires were used for cancellous bone. The wires were first passed proximally fixing proximal ring to the limb. One of the wires was passed through the fibular head. With the help of dynamometric tensioner, appropriate tensioning was done. Then, the distal most ring was fixed to the limb just proximal to the ankle joint line. Here, one wire was passed through the lateral malleolus. Thereafter, based on the fracture position full rings were fixed in between the proximal and the distal most rings keeping the level of anatomical cuts in mind. No wire was passed through the fibula in these rings. Tensioning was done in all wires. Schanz pin if required were fixed with the posts attached to the ring. A stab incision was made and drilling was done. Shanz pin was inserted with the help of T-handle. Goniometric system of 360° was used, the starting reference point, that is, 0° was assumed to be directly anterior. The anatomical cuts were observed from the lower (caudal) face and on the left leg. In this way, the values of the angles were increased clockwise. On the right leg, it corresponded to the mirror image and was therefore counter-clockwise. The level of cuts is explained using the "t" or "thumb" or "tsun" (1 "t" was equal to the length of the middle phalanx of the middle finger or 1 thumb breadth) which was a proportional measurement for each individual, independent of age and size. First wire: 110-310°. Second wire: 60-260°. For additional stability third wire: 80-280°. Corticotomy The level and number of corticotomy was decided based on the site and gap of the nonunion site preoperatively. A longitudinal small skin incision was made over the site of corticotomy where the bone is situated close to the skin. A direct longitudinal cut was made through the adjoining periosteum. Then cortex transaction was done by hammering the corticotome in a fan-shaped manner, directing it medially and laterally. The periosteum and endosteum layers were preserved as much as possible. To cut the opposite cortex, the corticotome is turned alternately with its position at the farthest medial and lateral transaction corners. The crackling sound was the sign of the completed corticotomy. This was also confirmed by the rotational movement of the rings on the both side of corticotomy after loosening or removing the connecting rods between the two rings or under C-arm guidance. The rods were reconnected completely. The nuts of the whole assembly were tightened. Distal pulses were palpated. Intraoperative tissue culture was sent but none yielded any growth. Postoperative Management It was divided into immediate primary and secondary and late treatment. Immediate primary: Distal neurovascular status checked and documented. The wire-skin surface was protected with a piece of gauze soaked in povidone iodine. Non circular bandages applied to the incisions. Limb was kept elevated. Intravenous antibiotics were given for 48 h (cefuroxime and amikacin) followed by oral for next 7 days (cefuroxime and clavulinic acid). Immediate secondary: Daily dressing was done with povidone iodine. Active and passive mobilization of knee and ankle movement started on the same day after anesthesia effect goes. On the 2 nd postoperative day, partial weight bearing was started, postoperative X-rays done, oral antibiotics, calcium, vitamin C tablet, multiple vitamin capsule started. The distraction at the corticotomy site was started on the 3 rd -5 th day at the rate of 1 mm/day (0.25 mm/6 h). Late Treatment The wires must be checked to assure that they remain tight. If not, they were retensioned. The nuts and clamps were also being checked for tightness. Regular pin - tract dressing was done and if infection occurred, the oral antibiotis were restarted. In some cases infection persisted, the wire was replaced. Radiographic evaluation [Figure 4] was done every 2 weeks. The rate of distraction and compression changed based on the radiographic evaluation of the quality of regenerate bone. Once the appropriate amount of lengthening (in cases of acute docking of nonunion site) or compression at the nonunion site was achieved, the apparatus was fixed. The apparatus was left in place until radiologic consolidation and union at the fracture nonunion site. Physiotherapy continued throughout the period. X-rays done were 12-38 in number (average 21) that is, every 2 weekly during fixator period and at 6-8 weeks interval during follow-up period.
Removal of Apparatus When the patient was able to walk without pain and X-rays revealed regenerate calcification and its recanalization, the nuts of the threaded rods were unscrewed and patient was allowed to walk and asked to return back in 2 weeks. If there was no discomfort with weight bearing, the apparatus was removed. While removing, the tension of all the wires was released, then the wires were cut, the rings were separated after removing the connecting rods and rings removed one by one. On an average, the frame was kept at least twice the period of distraction for consolidation to occur at the corticotomy site. Then, the limb was kept in patella tendon bearing (PTB) cast or molded leg brace and weight bearing allowed. All the patients were in regular follow-up in our outpatient department in this short term study and the results are evaluated on the basis of Association for the Study and Application of Methods of Ilizarov (ASAMI) scoring system for bony healing and function [Figure 5], [Figure 6] and [Figure 7].
During the study period, 30 patients were selected for inclusion in the study. The age range of the patients in the study was 18-60 years with a mean of 30.9 years. All patients were from rural areas and they were mostly farmers or daily laborers and so the study population was considered as rural. Of the 30 patients, 18 (60%) were in the age group of 18-30 years. Twenty-six patients (86.67%) were male and 4 patients (13.33%) were female. It was observed in the study that in 80% (24 patients) of cases, the right leg was involved. The most common mode of injury was road traffic accident. Twenty-four patients (80%) suffered road traffic accident and 4 patients (13.33%) suffered bomb blast injury, 2 patients fell from height. All were medicolegal cases, with first information report registered. At the time of initial injury, 20 patients (93.33% cases) suffered open fracture of leg. Two patients (6.33%) had closed fracture of both bone leg which later became infected during open reduction and internal fixation with plate. All the patients (100%) had infected nonunion before undergoing Ilizarov procedure. Following initial injury, 20 patients (73.33%) had treatment with external fixation and 8 cases (26.67%) were treated with internal fixation [Figure 8], [Figure 9] and [Figure 10].
At the time of presentation, 18 patients (60%) had infected gap nonunion, 10 (33.33%) patients had infected hypertrophic and 2 patients (6.67%) had atrophic nonunion. A number of operations were done in all patients before Ilizarov procedure, the mean being 2.27. During operation, the fracture site was debrided. The bone gap range was between 2 and 7 cm and the mean being 3.8 cm. Lengthening at the corticotomy site by the principles of distraction osteogenesis was done in 26 cases. The lengthening achieved ranged from 15 to 70 mm, mean being 36.9 mm. In 4 cases, acute docking at the fracture site was done without corticotomy producing a shortening of 3 cm in each patient. The Ilizarov fixator was kept for an average period of 303.7 days, the range being 170-533 days. Follow-up was done following removal of fixator. The mean duration of follow-up was 7.8 months, the range being 2-18 months. Union at the nonunion site was achieved in 28 patients (93.33%). Two patients with nonunion are still under treatment. There were 10 cases of recurrence of infection (33.33%). Additional procedures done were change of wire in 4 cases, iliac crest bone grafting at the fracture site in 4 cases, bone marrow aspirate injection in 4 cases, sequestrectomy in 2 cases and fibulotomy and PTB in 10 cases. Based on ASAMI scoring system, bony and functional results were assessed. The bony result was excellent in 16 patients (53.33%), good in 8 (26.67%), fair in 4 (13.33%) and poor in 2 (6.67%). The functional result was excellent in 10 patients (33.33%), good in 16 (53.33%), fair in 2 (6.67%), poor in 2 (6.67%) and failure in none (0%). We did not encounter complications such as premature consolidation, nonreporting of patient in time, aneurysms which are very common, especially in the early stages.
Delayed union, nonunion, and infection are relatively common complications of tibial shaft fractures. [1],[2],[3],[4] Recent advances in microvascular anastomosis technology have permitted vascularized osseous transfers for dealing with missing bone tissue. In the lower limb, such grafts whether fibula or iliac crest take years to hypertrophy and often fracture one or more times before remodeling is complete. Furthermore, microvascular bone transfers fail to unite to the recipient osseous tissue at one or both ends. [9],[10],[11],[12] The application of the methods of Ilizarov including compression-distraction osteosynthesis offer alternatives to the standard treatment of infected nonunions. Ilizarov circular frame osteosynthesis allows resection of the infected bone area, repair of the bone defect and stabilization of the bone to consolidation, while maintaining or restoring the length of the limb as desired. Joint function in the involved extremity is encouraged during the period the apparatus must be worn and functional loading can be initiated within the first few days after application of the apparatus. [5],[6],[7],[8] The aim of a successful Ilizarov treatment for nonunion is not just to achieve healing of the nonunion, it is also to achieve a leg without deformities, shortening or infection with a normal range of motion and normal strength of bone and soft tissues. The Ilizarov frame construct is very resistant to torsion and bending forces but is adaptable to axial loading. [1],[2],[3],[4] In our study, 30 patients were included. In 2007 Farmanullah et al. [1] performed a study on 58 patients from 2000 to 2006. The patients were followed-up up to 1 year. The mean duration of follow-up in the present study was 7.8 months, the range being 2-18 months. Of 58 patients, 44 (75%) were male and 14 (25%) were female. Mean age was 30 years (9-58 years). 38 (65.52%) patients had infected nonunion, while 20 (34.48%) had clean nonunion. The cause of initial trauma was road traffic accident in 27 patients (46.55%), firearm injury in 23 patients (39.65%) and a simple fall in 8 patients (13.79%). The length of average bone defect was 2.90 cm. Radiological results were excellent in 33 (58.89%) patients, good in 12 (20.68%) patients, fair in 8 (13.79%) patients and poor in 5 (8.62%) patients. The clinical results were excellent in 33 patients (56.89%), good in 18 patients (31.05%), fair in 4 (6.89%) patients and poor in 3 patients (5.17%). These findings corroborate very well with the findings in the present study. In studies of Green et al. [13] the largest number of complications were associated with wire tract infection whereas the second biggest difficulty was wire loosening associated with infection or osteolysis. In our study, all patients have superficial wire tract infection treated with dressing and oral antibiotics. Four patients had deep wire tract infection (one wire in each) treated with change of wire and antibiotics. To make matters worse, sepsis and loosening cause frame instability, a problem that results in diminished ambulatory capacity and therefore tardy regenerate ossification. For this reason, controlling wire-site sepsis must be a principal objective to the management of a patient with an Ilizarov ring fixator for the purpose of bone transport. The limitation of this study is the small sample size and short duration of follow-up. The follow-up period was too short in some patients to comment on functional scoring as per the ASAMI scoring system as these scores will change with time like stiffness at knee and ankle and pain. Additional surgical procedures for the equinus deformity of foot may be required in future in some patients. The fracture was not united in 2 patients, though there was no limb-length discrepancy and the infection burnt out after corticotomy and lengthening. At present, this patient is under PTB cast after fibulotomy. This patient may require refixation with Ilizarov apparatus later.
In this pilot project, it was found that Ilizarov ring fixator still remains an excellent treatment modality for tibial nonunion with a defect, regarding bone union, deformity correction, infection eradication, limb-length achievement, and limb function.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
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