Modified Ilizarov Technique for Infected Nonunion of the Femur: The Principle of Distraction-Compression Osteogenesis

Abstract

Purpose.

To evaluate the treatment outcome of the modified Ilizarov technique in infected nonunion of the femur.

Methods.

Between 1989 and 2002, records of 20 patients with infected nonunion of the femur treated with the modified Ilizarov technique were retrospectively reviewed. The modified Ilizarov frame was fixed after necrectomy of the dead infected bone and tissues. A proximal or distal corticotomy was performed following biological principles. For regeneration of gap, segmental transport was performed in 11 patients with a gap of more than 5 cm; acute docking followed by lengthening at the corticotomy site was performed in 9 patients with a gap of smaller than 5 cm. Mobilisation was started early with active participation of the physical therapist and the patients. Bone and functional results were measured and complications were categorised according to the Association for the Study and Application of the Method of Ilizarov guidelines.

Results.

The mean follow-up period was 62.8 months. Bony union and eradication of the infection was achieved in all patients except one who underwent amputation due to uncontrolled infection. Bone results were excellent in 13 patients, good in 4, fair in one, poor in one, and treatment failure (amputation) in one. Functional results were excellent in 3 patients, good in 9, fair in 3, poor in 4, and failure in one. A total of 71 complications occurred: 35 problems, 6 obstacles, and 30 true complications. The mean healing index was 38.3 day/cm (standard deviation, 1.6 day/cm).

Conclusion.

The Ilizarov technique is a good salvage operation for infected nonunion of the femur. Limb salvage is preferable to prosthesis if the limb is viable, adequately innervated and the patient is mentally and financially committed to save the limb.

Keywords

femoral fractures fixators,external fractures,ununited Ilizarov technique infection osteogenesis,distraction

References

Green

Dlabal

. The open bone graft for septic nonunion. Clin Orthop Relat Res 1983;180:117–24.

Meyer

Weiland

Willenegger

. The treatment of infected non-union of fractures of long bones. Study of sixty-four cases with a five to twenty-one-year follow-up. J Bone Joint Surg Am 1975;57:836–42.

Reckling

Waters

3rd . Treatment of non-unions of fractures of the tibial diaphysis by posterolateral cortical cancellous bone-grafting. J Bone Joint Surg Am 1980;62:936–41.

Slatis

Paavolainen

. External fixation of infected non-union of the femur. Injury 1985;16:599–604.

Barquet

Silva

Massaferro

Dubra

. The AO tubular external fixator in the treatment of open fractures and infected non-unions of the shaft of the femur. Injury 1988;19:415–20.

Ring

Jupiter

Gan

Israeli

Yaremchuk

. Infected non-union of the tibia. Clin Orthop Relat Res 1999;369:302–11.

Jupiter

Bour

May

Jr . The reconstruction of defects in the femoral shaft with vascularised transfers of fibular bone. J Bone Joint Surg Am 1987;69:365–74.

Song

Kale

Park

Koo

Chae

. Comparison of internal bone transport and vascularized fibular grafting for femoral bone defects. J Orthop Trauma 2003;17:203–11.

Bassett

Mitchell

Schink

. Treatment of therapeutically resistant non-unions with bone grafts and pulsing electromagnetic fields. J Bone Joint Surg Am 1982;64:1214–20.

10.

Brighton

Black

Friedenberg

Esterhai

Day

Connolly

. A multicenter study of the treatment of non-union with constant direct current. J Bone Joint Surg Am 1981;63:2–13.

11.

Delima

Tanna

. Role of pulsed electromagnetic fields in recalcitrant non-unions. J Postgrad Med 1989;35:43–8.

12.

Association for the Study and Application of the Method of Ilizarov Group: Non-union of the femur. In: Bianchi-Maiocchi

Aronson

, editors. Operative principles of Ilizarov. Fracture treatment, non-union, osteomyelitis, lengthening, deformity correction. Baltimore: Williams and Wilkins; 1991.

13.

Aronson

Johnson

Harp

. Local bone transportation for treatment of intercalary defects by the Ilizarov technique. Biomechanical and clinical considerations. Clin Orthop Relat Res 1989;243:71–9.

14.

Cattaneo

Catagni

Johnson

. The treatment of infected nonunions and segmented defects of the tibia by the methods of Ilizarov. Clin Orthop Relat Res 1992;280:143–52.

15.

Dendrinos

Kontos

Lyritsis

. Use of the Ilizarov technique for treatment of non-union of the tibia associated with infection. J Bone Joint Surg Am 1995;77:835–46.

16.

Barbarossa

Matkovic

Vucic

Bielen

Gluhinic

. Treatment of osteomyelitis and infected non-union of the femur by a modified Ilizarov technique: Follow-up study. Croat Med J 2001:42;634–41.

17.

Gualdrini

Stagni

Fravisini

Giunti

. Infected nonunion of the femur. Chir Organi Mov 2002;87:225–33.

18.

Paley

. Problems, obstacles, and complications of limb lengthening by the Ilizarov technique. Clin Orthop Relat Res 1990;250:81–104.

19.

Theis

Simpson

Kenwright

. Correction of complex lower limb deformities by the Ilizarov technique: An audit of complications. J Orthop Surg (Hong Kong) 2000;8:67–71.

20.

Ilizarov

. The tension-stress effect on the genesis and growth of tissues. In: Transosseous osteosynthesis: Theoretical and clinical aspects of the regeneration and growth of tissue. Berlin: Springer-Verlag; 1992:137–256.

21.

Dahl

Fischer

. Lower extremity lengthening by Wagner's method and by callus distraction. Orthop Clin North Am 1991;22:643–9.

22.

Oedekoven

Jansen

Raschke

Claudi

. The monorail system–bone segment transport over unreamed interlocking nails [in German]. Chirurg 1996;67:1069–79.

23.

Berven

Athanasou

Simpson

. Bone transport over an intramedullary nail. A case report with histologic examination of the regenerated segment. Injury 1999;30:525–34.

24.

Shevtsov

Popkov

Prevot

. Reduction of the period of treatment for leg lengthening. Technique and advantages [in French]. Rev Chir Orthop Reparatrice Appar Mot 2001;87:248–56.