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 Table of Contents  
Year : 2019  |  Volume : 5  |  Issue : 2  |  Page : 79-87

Ilizarov strategies in the management of nonunions and difficult fractures of the femur

Department of Orthopaedics, Assam Medical College, Dibrugarh, Assam, India

Date of Submission20-Jul-2019
Date of Decision28-Oct-2019
Date of Acceptance19-Nov-2019
Date of Web Publication31-Dec-2019

Correspondence Address:
Dr. Siddharth Kumar
Flat No 4, Sangeeta Society, Tadiwala Road, Near Pune Station, Pune - 411 001, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jllr.jllr_12_19

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Introduction: Infected nonunion, neglected open fractures, aseptic nonunion, and neglected displaced comminuted fractures are difficult fractures of femur requiring tailored management. We used Ilizarov principles and strategies in such difficult presentations and the aim to evaluate results. Materials and Methods: Thirty-eight patients (37 males and 1 female), 3–48 years old, with infected nonunion (11 cases), neglected open fractures (12 cases), aseptic nonunions (9 cases), and neglected displaced comminuted fractures (6 cases) treated during 2000–2015 were evaluated. Cases of infected nonunion were subclassified using Rosens's classification to guide debridement and underwent single-stage monofocal or bifocal treatment. Neglected open fractures were Type 3 open fractures (Gustillo Anderson) after ≥12 h of injury-underwent debridement and single-stage monofocal or bifocal treatments. Aseptic nonunion cases underwent implant removal and monofocal or bifocal treatment. Neglected displaced comminuted fractures were fixed in situ, monofocal treatment, length, and rotation correction was done. Accordion maneuver was used extensively. No bone grafting was done. Results: Thirty-six cases (95%) achieved successful union and 97% cases had infection eradication. Excellent-to-good bony and functional results were seen in 86% and 68% cases, respectively (ASAMI criteria). Complications such as soft-tissue interposition (5%), Grade III pin-tract infection (13%), and hyporegenerate (11%) were seen. Discussion and Conclusion: With Ilizarov strategies tailored for specific situation, satisfactory and predictable results can be obtained offering one-stage solution to the global problems associated with such difficult fractures. The technique obviates need for bone graft or major soft tissue reconstruction.

Keywords: Accordion maneuver, femur delayed communited fractures, femur failed osteosynthesis, femur neglected open fractures, femur nonunion, Ilizarov acute shortening, relengthening

How to cite this article:
Baruah RK, Kumar S. Ilizarov strategies in the management of nonunions and difficult fractures of the femur. J Limb Lengthen Reconstr 2019;5:79-87

How to cite this URL:
Baruah RK, Kumar S. Ilizarov strategies in the management of nonunions and difficult fractures of the femur. J Limb Lengthen Reconstr [serial online] 2019 [cited 2022 Dec 1];5:79-87. Available from: https://www.jlimblengthrecon.org/text.asp?2019/5/2/79/274571

  Introduction Top

Infected nonunion, aseptic nonunion, neglected open fractures and neglected displaced comminuted fractures are difficult fractures of the femur. Circular external fixators using Ilizarov's principles, unlike other techniques produce consistent results in such difficult scenarios. These are often complicated by soft-tissue defects, bone loss, persistent infection, delayed presentation, deformities, limb length discrepancies, osteoporosis, comminution, and scarring due to multiple previous surgeries. It produces new bone without bone grafting [1] and also regenerates soft tissue without any major plastic reconstruction procedures.[2] In this study, we aim to evaluate the results of various Ilizarov strategies employed in such cases and highlight their relevance in current orthopedic practice where multiple newer options have emerged.

  Materials and Methods Top

It is a retrospective study of patients treated for a specific subset of complicated femur fractures, namely, aseptic and infected nonunion, open fractures with delayed (>12 h) intervention, and neglected (>4 weeks old) closed displaced comminuted fractures of femur, over a period of 15 years between 2000 and 2015. A total of 38 patients, 37 male and 1 female, in the age group 3–48 years were included in the study. The mode of injury was road traffic accident in 30 cases and fall from height in 8 cases. Each case was followed up for a minimum of 2 years after completion of treatment. One case lost to follow-up and one with incomplete data was excluded from the study. The patients were divided into four groups depending on their presentation at our center [Table 1], and details have been described in [Table 2].
Table 1: Classification of problem cases

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Table 2: Group characteristics

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Group A-infected nonunion (INU)

Cases of infected nonunion (n = 11) presented with an average delay of 10.2 (1.5–16) months from injury. Infected nonunion was defined and classified as per the Rosen's classification,[3],[4] with some modifications to better formulate a treatment strategy [Table 3].
Table 3: Rosen classification of infected nonunion cases

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Debridement including removal of implant to eradicate infection was done in all active cases; active draining (3 cases) cases required extensive debridement, whereas active nondraining (3 cases) cases required relatively less extensive debridement. Cases in quiescent group (5 cases) did not require debridement except in 1 case which required removal of an intramedullary nail and minimal debridement.

Group B-neglected open fractures (NOF)

All cases (n = 12) were Type 3 open fractures (Gustilo–Anderson classification). Eight out of 12 cases were supracondylar or intercondylar fractures. Limb surgery could be performed only after 12 h of injury as patients either presented late or first needed stabilization of other life-threatening injuries. Four cases had bone loss on presentation. No prior attempts at bone or soft-tissue reconstruction were made.

Group C-aseptic nonunion (ANU)

Cases (n = 9) of aseptic nonunions presented to us after an average delay of 12.6 (range 8–24) months postinjury. Seven cases required implant removal at the time of surgery, while implants were already removed in two cases. Two patients had recalcitrant nonunion, with each having undergone three prior surgeries and autologous cancellous iliac bone grafting.

Group D-Neglected displaced comminuted fractures (NDCF)

A total of 6 cases with average delay in surgery being 6 weeks (range- 4–16 weeks) were operated. All patients had some degree of hip and knee stiffness at presentation.

Details of strategies used

Closed and monofocal with accordion maneuver

This was employed in total of 15 cases of quiescent INU without implant, ANU and NDCF where shortening <2 cm. This was also employed in two cases NDCF group) where shortening was 3 cm, but patients were unwilling for lengthening procedure. Two cycles of accordion maneuver were done to stimulate healing. This was followed by 0.25 mm compression every 3rd day till fracture union.

During the accordion maneuver, initial compression or distraction was decided by the status of nonunion. In hypertrophic (Stiff) nonunion, the first maneuver was distraction followed by compression in one cycle and the sequence was reversed in atrophic (Mobile) nonunion. The maneuver (either compression or distraction) was performed at the rate of 0.25 mm twice a day for 7 days followed by rest for 3 − 4 days, and then, the opposite maneuver was carried out in the same rate for 7 days, and this too followed by rest for 3 − 4 days.

Debridement and monofocal with accordion maneuver

This was employed in a total of 12 cases of NOF and active INU requiring removal of implants where shortening/gap was <2cm after debridement.

Bifocal principle ± debridement

This was used for used in all cases where shortening/gap was more than 2 cm. Two types of bifocal strategies, namely acute shortening and relengthening (gap = 3.5–9 cm) and bone transport (gap = 6–8 cm), were employed to gain length in these cases. Distraction was done at the rate of 1 mm/day divided at 6 hourly intervals. After completion of bone transport, docking site was compressed at 0.25 mm per day to achieve solid union. Only distal corticotomy and lengthening were done to correct length and rotation in 1 case (neglected displaced comminuted fracture group) where shortening was 5 cm. Details of strategies used have been summarized in [Table 4].
Table 4: Bone treatment strategies

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Debridement was done in all cases of open fractures (12 cases) and cases of infected nonunion with active infection (7 cases) which was followed by the Ilizarov application as a single-stage procedure. Debridement was thorough with excision of sinus tracts, reaming of medullary cavity, and removal of unhealthy bone and soft tissue. Intraoperative deep samples were taken for culture and antibiotic sensitivity testing to guide postoperative antibiotic regimen in infected nonunion. Repeat debridement was required in eight cases (1 INU and 7 NOF group) which showed clinical signs of persistent infection and raised erythrocyte sedimentation and C-reactive protein values. No soft-tissue reconstruction or bone grafting procedure was done. All wounds after debridement were either kept open till they healed by secondary intention or vacuum-assisted closure (11 cases – 4 INU and 7 NOF group) was used if adequate soft-tissue cover could not be obtained by soft-tissue mobilization.

Acute shortening and docking of bone fragments [Figure 1] were done in all, but three cases as it provided immediate stability and also allowed for approximation of wound edges without tension. The three cases where acute shortening was not done had larger bone gap (>5 cm) and underwent bone transport.
Figure 1: “Peg-in-hole” construct for stability

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A preconstructed sterilized hybrid Ilizarov frame was used in all cases with 1.8 mm wires and 5 mm short threaded Schanz screws. The frame consisted of an arch proximally [Figure 2] and three full rings. Wires were used only near the knee joint in the 4th ring [Figure 3], while the rest of the rings and arch were fixed to bone with 3-4 Schanz screws with radial preload. The frame was mounted keeping the knee in traction and flexion and also taking care to maintain the mechanical axis of the limb.[5] Additional ring was applied to proximal tibia in distal-third femur fractures to enhance frame stability which was removed at 6 weeks. The knee was manipulated under anesthesia in cases with preoperative knee stiffness.
Figure 2: Proximal ring with Italian arch and Shanz screws

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Figure 3: Distal ring with wire and pin construct

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Corticotomy, when required, was done in the metaphyseal region (proximal or distal) distant from the foci of infection. It was delayed in five cases due to suspicion of local infection. Distraction was started at day 7 after corticotomy. If inadequate regenerate was seen during lengthening, rate of distraction was slowed down or accordion maneuver was used. A stringent postoperatively protocol was followed with adequate diet, avoidance of smoking, physiotherapy of adjacent joints, and crutch-assisted walking. Weight-bearing was delayed by 2 weeks and limb was kept elevated to avoid the development of soft-tissue edema and late vascular compromise in cases involving large bone gaps that were acutely docked.

After radiographic confirmation of union and regenerate consolidation, the frame was gradually deconstructed. Bone healing and functional results were assessed as per the ASAMI criteria.[6] Complications were evaluated as per the Paley's working classification.[7]

  Results Top

All but 2 (both INU group) out of 38 cases achieved successful union (95%). Average duration of treatment was 7.2 (4–16) months in INU group, 7.4 (5–13) months in neglected open fracture group, 7.1 (5-10) months in ANU and 6.3 (5–7) months in NDCF group. Eighty-six percent of the cases (33 patients) had excellent to good bony results, whereas functional results were excellent to good in 68% cases (26 patients) [Table 5] and [Table 6]. Ninety-seven percent cases had infection eradication. Both the poor bony results were in the nonunion group due to persistent nonunion. Single corticotomy was sufficient in all cases.
Table 5: Bony and functional results

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Table 6: Results

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Pin-tract infections were the most common complication [Table 7] and required removal of offending wire in 7 cases. Severe edema was seen in 1 case undergoing acute shortening which delayed weight bearing. Two cases developed interposition of soft tissue during bone transport which required removal of intervening tissue. None of the cases required myofasciocutaneous flap or iliac bone grafting. The reason for cessation of limb lengthening in three cases was patient refusal to continue further treatment on the Ilizarov fixator. Two patients could not continue their previous jobs, one shifted to a sedentary job while the other remained unemployed.
Table 7: Complications

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  Discussion Top

Infected nonunion presents two major problems – infection and nonunion, apart from deformity, bone loss, scarring due to multiple previous surgical procedures, disuse osteoporosis, soft-tissue atrophy, inadequate bone stock for fixation, and questionable vascularity of bone ends.

A variety of treatment modalities such as external fixation with debridement and massive bone grafting [8] external fixator, antibiotics beads, and staged bone grafting [9] have been tried with mixed results. Stabilization using internal fixation devices has been suggested for anatomical sites difficult to fix with external fixators or localized infection that has been well excised [10] or in cases of quiescent infection.[11] However, chances of recurrence or persistence of infection are present.[12] Antibiotic cement has been used to control infection efficiently, but it is only suitable for the treatment of infected nonunion with small defects, and bone grafting is usually necessary to achieve bone union.[13] However, cancellous bone may take years to fully corticalize in the presence of infection.[14] Vascular fibular grafting after debridement is difficult as it is a staged procedure requiring prolonged inactivity and time to heal [15] and high complication rates [16],[17] Uniplanar external fixator systems with cantilever fixation have gained popularity, but they have higher rates of pin-tract infection, refracture and poor control of multiplanar deformity, and regenerate compared to Ilizarov system.[18] They also do not allow early weight bearing. Studies involving bone transport using monorail external fixator have also shown higher rates of delayed union requiring bone grafting.[19],[20]

Ilizarov methodology, on the other hand, offers consistent and satisfactory results in infected nonunion, as it can offer one-stage solution to variety of problems associated with infected nonunion while allowing early weight-bearing during treatment.[18],[21] Although Ilizarov stressed that distraction alone is a potent stimulus for union,[22] researchers have used bone grafting as well as freshening of bone ends to stimulate union. Our results show that the need for such procedures can be reduced by the use of accordion maneuver. All our cases were performed as a single-stage procedure with acceptable union rates (95%) and low reinfection rates (2.6%) when compared to other single- and two-staged procedures.[23],[24] Thorough debridement following the above-mentioned approach was the key to achieving this [Figure 4].
Figure 4: (a) Type A infected nonunion (Rosen classification) following Type 3 Gustillo–Anderson open-communicated segmental fracture femur treated with debridement and IMIL nail (associated ipsilateral- communited tibia fracture treated with IMIL nail healed uneventfully). Debridement, removal of implant, and Ilizarov frame application followed by corticotomy at proximal metaphysis after subsidence of local infection was done. (b) Regenerate forming after lengthening was started. (c) Adequate regenerate formed (5 cm) and union at distal corticotomy site seen. (d) Final X-ray after frame removal at 9 months postoperative. (e) Postframe removal satisfactory function regained

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In patients with Grade III open fractures who could not undergo early operative stabilization, external fixation with early conversion to intramedullary nail, or spanning external fixation followed by delayed internal fixation for metaphyseal areas is advocated. These methods may require additional procedures such as exchange nailing and bone grafting [25] along with increased risk of infection and osteomyelitis.

We obtained successful union in all and no infection in all but one case with our approach of aggressive debridement, acute docking if feasible, primary stabilization with an Ilizarov fixator, and either primary or early skin closure followed by early mobilization and weight bearing as a single-stage alternative treatment method for such injuries [Figure 5], especially communited Gustilo Grade III open supracondylar and intercondylar fractures of the distal femur.[5],[26],[27] In Ilizarov system, stability of short periarticular segments is initially achieved by diverging olive wires that also aid in reduction and provide compression effect and eventually by rapid bone healing on account of minimal additional periosteal stripping.[28] Circular fixators also provide greater stability compared to monolateral external fixators in such situations.[28] Three cases with open Type III fractures of the shaft of femur, with bone gap (2–3 cm), poor skin and wound condition, and post deformity, were also successfully treated highlighting the versatility of this technique.
Figure 5: (a) Type III open subtrochantric femur fracture with bone loss with distal bone fragment protruding outside. Case could not receive early surgical intervention due to associated lung contusion. (b) Highly unstable subtrochantric femur fracture with medial bone loss). (c) Fracture stabilized with primary Ilizarov with acute docking and monofocal osteosynthesis. (d) Union seen after 5 months following two cycles of accordion maneuver. (e) Wound healed by secondary intention. (f) Final clinical picture

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ANU presents with compromised vascularity, soft-tissue scarring, and risk of infection with repeated surgeries. Reamed locked intramedullary nail,[29] plating for nonunions in metaphyseal areas,[30] or plate augmentation over nail [31] are some of the options available, but may need for multiple subsequent procedures such as bone grafting and repeat reamed nailing to achieve union [32],[33] while also risking further devascularization and infection. Vascularized fibular grafting is associated with donor-site morbidity, graft fracture, and nonunion of the graft-host junction.[31]

Ilizarov system has shown good results in such cases,[34] as it provides adequate stability for fracture healing with compression at fracture site. Corticotomy and accordion maneuver [35] can be used to further stimulate healing process [Figure 6]. We achieved successful union in all cases as a single-stage procedure without the need of bone grafting while also allowing concomitant treatment of associated deformity and early weight bearing. Although exchange nailing is an effective procedure, uncomplicated femoral diaphyseal nonunions after previous intramedullary nailing responded very well to our Ilizarov treatment, as in a relatively undisturbed biological surrounding, the modification of the mechanical parameters by restoration of stability and gradual compresssion can stimulate healing without the need of bone graft.[36]
Figure 6: (a) Aseptic nonunion in comminuted distal femur shaft treated with ORIF by condylar plate (plate broken). (b) Implant removed and Ilizarov frame applied with monofocal (accordion maneuver) at nonunion site. (c) 2 months postoperative shows nonunion has healed after 2 cycles of accordion maneuver

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In cases presenting as NDCF, often seen in developing countries, open osteosynthesis entails extensive soft-tissue dissection resulting in devascularization of fracture fragments risking infection and delayed or nonunion. Staged open reduction with intramedullary nailing with bone grafting and with possible shortening of bone ends has been advocated for management of neglected displaced maluniting and malunited shaft femur fractures with shortening up to 4 cm.[37],[38],[39],[40],[41] Neurovascular compromise,[40] delayed weight bearing, high infection rates, and significant blood loss have been reported.[38],[39],[41] Chances of delayed union and need for additional procedures may also arise with these procedures.[41] Distraction with Ilizarov fixator followed by plate fixation without bone grafting [42] for neglected fractures with >4 cm shortening has been reported with good results without risk of neurovascular compromise.

We obtained good results with one-stage Ilizarov method to correct the deformity and provide multidirectional stability for fracture union and early weight bearing without opening the fracture site. It is a “biological method” with minimal soft-tissue dissection and least interference with normal local healing process. The system is especially advantageous in management of comminuted periarticular and subtrochantric fractures where nailing is difficult [Figure 7].[43] Loss of knee motion was the only concern.
Figure 7: (a) Shortening and external rotation deformity of the left lower limb - 16 weeks old injury. (b) X-ray showing communited subtrochantric fracture with overriding and maluniting fracture. (c) Ilizarov frame applied - distal corticotomy done to carry out derotation and lengthening. (d) Frame removed after 7 months; X-ray shows solid regenerate and 5 cm length gain. (e) Clinical correction of deformity achieved

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Bone transport, although a valuable tool for bone regeneration, has its share of problems. Improper alignment of both segments may lead to docking problems. Soft-tissue interposition, seen in two cases, also interferes with docking and requires removal. Freshening of the margins of the leading edge of transported segment which is relatively avascular and bone grafting at docking site to increase contact area, although not required in our study, may be required in some cases.[44],[45] A major drawback is that the healing at target site does not begin till the completion of transport causing prolonged fixator times. Acute limb shortening and relengthening for management of bone gaps does away with many of the difficulties of bone transport. It is of immense value in the management of soft-tissue and bone defects and prevention of formation of pockets of infection seen in distal femur open fractures.[5] Careful application of the procedure can avoid potential neurovascular complications, shorten fixator duration and obviate the need for soft-tissue cover while allowing early weight bearing.[46] We used the technique of “peg in hole,” where one of the fracture ends was shaped into a pencil-like configuration to achieve immediate stability and compression without excessive bone sacrifice [Figure 1].[47] The technique was especially helpful in fractures of the distal metaphysis with extensive communition. The healing index in our study was 1.4–1.6 months/cm, was similar to other studies, except in the “nounion bone transport” group where it was 2.9 months/cm due transport-related complication in one of the cases.

Accordion maneuver, based on the principle of transformational osteogenesis,[35] is often regarded as “bloodless tool” for bone healing, was used extensively in our study. It was used at nonunion site, docking sites during bone transport, and in hyporegenerate. It helped us avoid the need for bone grafting and freshening the edges of transported segments.

The most disabling complication we encountered was loss of knee movement, most of them belonging to the nonunion group, most of whom had preoperative stiffness. Early definite intervention and rehabilitation could have avoided this complication.[34] Pin-tract infections lead to pin loosening, frame instability, and pain-induced nonweight bearing cause delayed fracture healing and regenerate problems and should hence be dealt with aggressively.

In our study, high rates of infection eradication highlight the importance of proper case classification, thorough and if needed repeated debridement and possibly of “infection burning in the fire of regenerate.”[18] Low rates of malunion were achieved because the cases were closely followed and necessary timely frame adjustments were made. We did not encounter any refractures as we followed a methodical deconstruction of the Ilizarov frame.

A high success rate in such varied and difficult clinical scenarios highlights the versatility of this system. Limitations of the study were the retrospective design, small number of patients in each group, and absence of control group.

  Conclusion Top

With Ilizarov strategies tailored for specific situation, satisfactory and predictable results can be obtained offering one stage solution to global problems associated with such difficult fractures.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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