Session V - Post Traumatic Reconstruction

Infected Fracture Nonunions with Bone Loss Treated with the Ilizarov Bone-Transport Technique

John K. Sontich, MD; Lisa K. Cannada, MD; Brendan M. Patterson, MD, MetroHealth Medical Center, Cleveland, OH

Purpose: Infected nonunions of fractures of patients with segmental bone deficiencies and osteomyelitis are a challenging problem. Limb-salvage options include bone grafting, transfer of vascularized osseous tissue, or bone transport. Multiple autogenous bone grafting is often ineffective for circumferential defects in infected beds. There are inherent problems with donor site morbidity, delayed weight bearing, and high refracture rates with vascularized fibula transfer. The purpose of our study was to analyze the results of the Ilizarov bone-transport technique in the treatment of infected nonunions with bone loss by reviewing patient's radiographic, clinical, and functional outcomes.

Methods: From 1996 to 1999, 24 patients with 22 tibial and 2 humeral fracture nonunions were treated. There were 21 men and 3 women in the study with an average age of 40 (range, 24 to 75 years). Eighteen patients originally had open fractures, and all patients had previous surgical procedures, with 15 patients having five or more prior to our treatment. Twenty-one patients had initiation of transport within 24 months of their original injury. The remaining three had chronic osteomyelitis for several years after the injury. The average bone loss was 7 cm (range, 1 to 15 cm). The infecting organism was S. aureus in many cases, although there were eight gram-negative infections. All patients underwent radical debridement of infected bone and a corticotomy distant from the infected area. Two patients underwent dual corticotomies, secondary to significant bone loss. Two patients underwent fibular transports to fill massive tibial defects, initiated 7 days postoperatively. Seventeen patients also had angular deformities corrected. Autologous iliac crest bone grafting was performed at the docking site 1 to 2 weeks prior to compression. Clinical follow-up information and radiographs were obtained for all patients. Functional outcome was assessed by the SF-36 Health Survey, and patients were also graded on pain, the need for assistive devices for walking, range of motion of the affected joint, and return to work and to the activities of daily living.

Results: The average time of application of frame to removal was 9.7 months. All patients healed within 1 cm of their contralateral limb. The average SF-36 score was 95, and there were 12 excellent results, 6 good, 5 fair, and 1 poor result. Three patients, all smokers, had delay of healing of the regenerate site; all defects were more than 8 cm and two were distal to proximal transports. Two patients had pin-tract infections requiring surgical intervention, and two patients had post-Ilizarov angular deformities of more than 8° which went on to a successful outcome after surgical correction.

Discussion: We believe there are several reasons that may explain the good healing rates in our series. The bone-transport technique provides increased blood supply and increases stem-cell populations, which augments the local biologic processes. The mechanics of external fixation allow compression at the docking site that only improves with weight bearing. The regenerate site may allow some inherent shear motion to be dissipated in the long bone, resulting in reduced lever-arm motion at the docking site. We consider bone transport using the Ilizarov technique and delayed bone grafting to be an effective method of limb salvage in the treatment of infected fracture nonunions, but use of the technique demands Ilizarov experience of the surgeon and strict patient compliance. The technique is resource-intensive and should be reserved for complex deformities when traditional methods are ineffective.