|Year : 2019 | Volume
| Issue : 2 | Page : 88-93
Infected subtrochanteric nonunions of femur - Managed by Ilizarov method
Srinivas Nookala Reddy, Abhilash Rao Vavilala, Karthik Reddy Ratna, Shravan Kumar Yadala
Department of Orthopaedics, Prathima Institute of Medical Sciences, Karimnagar, Telangana, India
|Date of Submission||28-Oct-2019|
|Date of Decision||19-Dec-2019|
|Date of Acceptance||20-Dec-2019|
|Date of Web Publication||31-Dec-2019|
Dr. Abhilash Rao Vavilala
2-10-1990, Bhagyanagar, Karimnagar - 505 001, Telangana
Source of Support: None, Conflict of Interest: None
Background: The management of infected subtrochanteric femoral nonunions is a difficult clinical challenge to the reconstructive surgeon. We analyzed the results of infected subtrochanteric nonunions managed by the Ilizarov method. Materials and Methods: We present a 11-year prospective study of 14 consecutive infected subtrochanteric nonunions treated by the Ilizarov method between 2008 and 2018. The mean age of patients was 45.5 years (range 20–64). All were postoperative infections. The mean shortening of the femur in ten patients was 2.9 cm (range 2–7 cm). Implant removal was done in 12 cases. Wound debridement followed by Ilizarov fixation was done in the same sitting in all the patients except two, where a two-stage procedure was performed. A temporary external fixator was used for two-stage procedure. Long Schanz pins (cephalic pins) were effectively used for improved stability of the proximal fragment. Results: Thirteen of the 14 patients united. Infection was eradicated in thirteen of the fourteen patients. Mean fixator duration was 12.4 months (range 9.5–18) mean range of preserved knee motion was 95°, including two patients who had total knee stiffness. Conclusion: Ilizarov fixation is a reliable method to achieve union in infected subtrochanteric nonunion of femur.
Keywords: Femur, ilizarov method, infected, subtrochanteric nonunion
|How to cite this article:|
Reddy SN, Vavilala AR, Ratna KR, Yadala SK. Infected subtrochanteric nonunions of femur - Managed by Ilizarov method. J Limb Lengthen Reconstr 2019;5:88-93
| Introduction|| |
Subtrochanteric region extends below the lesser trochanter up to a distance of 5 cm. It has cortical bone with poor vascularity leading to longer healing times following a fracture. The medial and posteromedial cortices are subject to high compressive forces, whereas the lateral cortex experiences high tensile forces., These have been estimated to be up to 1200 lb/square inch, the highest in the human skeleton.,,,, This high-stress loading pattern is important in the selection of the fixation device and in understanding the causes of fixation failures. Bone defects, bone loss, and poor bone quality due to infection, disuse, and previous implants make stable fixation a difficult task.
The treatment of infected subtrochanteric nonunion is a challenge to the surgeon. Infection is better dealt with using Ilizarov fixation, with wound debridement, local antibiotics with cement nails, beads, or spacers using the Masquelet technique and subsequent internal fixation. There is a paucity of literature regarding the most appropriate method of treating infected nonunion of a subtrochanteric fracture.
The aim of the study is to evaluate control of infection, union rates, and functional outcome of infected nonunion of the subtrochanteric region of the femur by the Ilizarov method.
| Materials and Methods|| |
This is an 11-year prospective study of a cohort of 14 consecutive infected patients treated between 2008 and 2018 in our medical college hospital. All of them were postoperative failures [Table 1]. All the patients were treated with the Ilizarov fixator. The mean age of the patients was 45.5 years (range 20–64 years). Six patients were diabetics, and nine were smokers, one had chronic renal failure. The mean number of previous surgeries was 1.7. The mean duration of the nonunion was 20.1 months (range 6 months–7 years). The length of follow-up was a mean of 26.8 months. The mean shortening of the femur was 2.9 cm. Variable range of knee stiffness was present in all patients preoperatively (mean range of motion [ROM] 95°), which included two cases of total stiffness.
We included all the infected subtrochanteric nonunions after skeletal maturity. We excluded aseptic nonunions which were not infected, those before skeletal maturity or those following pathological fractures. The thorough preoperative evaluation was done [Figure 1]. [Table 2] describes demographic data and patient details.
|Figure 1: Radiograph showing the nonunion in anteroposterior and lateral views|
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Preoperative counseling about Ilizarov treatment; its advantages and disadvantages were given.
Mean surgical time was 140 min (range 120–150 min). Twelve patients needed one to three blood transfusions during the surgery. Follow-up period was 26.8 months (range 6 months–7 years).
The surgical procedure was performed under epidural anesthesia with these steps.
Step-1: Wound debridement
It was performed in lateral position for the ease of implant removal and debridement. Preexisting implants were removed (dynamic hip screw – Ten cases, intramedullary K-Nail – Two cases, External fixator – Two cases). Thorough wound debridement was performed, and devitalized soft tissues and sequestrae were removed. Tissue cultures were sent for culture and sensitivity. Antibiotic cement beads or rods were not used.
Bone resection was based on appearance and Paprika sign. Bone ends were temporarily stabilized with K wires. The medullary canal was reamed in all cases. Infection was severe in two patients and their definitive Ilizarov fixation was deferred to a second stage, and they had a temporary external fixation.
Step-2: Ilizarov fixation
This was performed on a fracture table in the supine position as a progressive construct from distal to proximal [Figure 2]. Two full rings distally and one Russian arch proximally were used. Standard techniques of hybrid Ilizarov fixation were used. Two long half pins were inserted up the neck, reaching subchondral area in the head of the femur [Figure 3], [Figure 4].
|Figure 3: C-arm IITV image showing the alignment of Schanz pins in the proximal fragment|
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Bone grafting was done in one case only in the second stage.
Intravenous antibiotics were given for 1-week, followed by oral antibiotics for 3 weeks, based on the culture sensitivity reports. Modified beds were not needed due to low profile proximal arches for fixation. Partial weight-bearing walking was started early.
Compression at the nonunion was carried out in increments of 0.25 mm/daily until the pins start bending. Accordion maneuver was done in five patients with delayed healing. Average fixator removal time after its application was 12.4 months (range 9.5–18 months).
| Results|| |
Results were assessed using the ASAMI scoring system. Thirteen united completely [Figure 5]. Valgus malunion occurred in two patients (10 and 150). Bone results and functional results are displayed in [Table 3]. Of the 14 nonunions, infection was eradicated in 13 patients. One patient had the persistence of osteomyelitis, but the nonunion got united. There was no recurrence of infection or refractures in any patient. Mean shortening of 2.9 cm (2–7 cm) was present in ten cases. Lengthening was not done in any patient [Figure 6]. Nine patients resumed their original profession, four changed to other professions.
|Figure 5: Follow-up radiograph after fixator removal showing complete union|
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Complications are listed in [Table 4]. Pin loosening in the proximal femur was seen in three patients, and exchange pinning was done in two. Valgus deformity was seen in two of our patients. Limb edema was seen in ten patients which persisted from 6 to 12 months. Avascular necrosis of the femoral head noted in one patient, presented after 4 years from the date of surgery. Two patients had total stiffness of the knee; only one patient underwent Quadricepsplasty to improve from 100 to 600. In the remaining eleven patients, the mean ROM was 950.
| Discussion|| |
Our priorities in treating these difficult cases were eradication of infection, the achievement of union and preservation of existing knee ROM. Correcting limb length discrepancy was not a priority for our patients. Studies reporting on infected subtrochanteric nonunions are scarce.,,,,,,,,, The key to a successful outcome depends on the stable fixation of the proximal fragment for which we used long half pins going up the neck of the femur. We have not used hydroxyapatite-coated half pins which are advocated in osteoporotic nonunion. Internal fixation may not be reliable or stable due to osteoporosis and fear of recrudescence.
Valgus malunion occurred in two patients. This happened in our initial cases where connections were placed between the proximal arch and middle ring more on the lateral side and compressed the nonunion more laterally. The single case which failed in our series is an extreme obese patient and is due to the pins loosening in the proximal portion for which exchange pinning was advised, but the patient was reluctant and requested removal of the fixator prematurely.
Hegazy and Abdul Alim  published a study of 14 subtrochanteric nonunions, of which 8 were infected nonunions and reported a successful union in all patients managed by Ilizarov external fixator. Sassoon et al. used intramedullary antibiotic spacers to provisionally stabilize the subtrochanteric region after implant removal and debridement. Definitive fixation , (with or without bone grafting) was then done after a period of intravenous antibiotics and infection control. However, they did not provide enough data regarding the number of patients, method of fixation, results, or complications. Haidukewych and Berry  included 2/23 cases treated by implant removal, intravenous antibiotics, and delayed reconstruction after 6 and 8 weeks. De Vries et al. included five nonunions treated with debridement and intravenous antibiotics and blade plate fixation.
Average fixator duration in our series was 12.4 months which was similar to the that reported by Rollo et al. (10.4 months), Tzioupis et al. (10 months), Hegazy (11.6 months). Two patients in our study had significant residual shortening (6 and 7 cm). Hegazy  reported a persistent shortening of 4 cm in one patient. De Vries et al. reported persistent shortening in 15 (of 33) cases ranging from 1 to 8 cm.
Wu  reported 100% union rate after one-stage reconstruction of 21 aseptic subtrochanteric nonunions combined with 2–5 cm shortening and treated by femoral condylar skeletal traction, acute lengthening up to 4 cm, static locked internal lengthening nail stabilization, and corticocancellous bone grafting.
Maintaining knee ROM was a difficult task for us as our patients did not have access to the proper physiotherapy services after discharge from the hospital.
The cost of the treatment is definitely a major issue in these difficult cases in developing countries. These patients could not afford expensive allografts, bone morphogenic protein, or mesenchymal stem cells treatments. Ilizarov fixation allows early ambulation, gives sustained compression at nonunion site and obviates the need for bone grafting, multiple surgeries, and prolonged expensive antibiotic therapy. Ilizarov fixation is a cost-effective therapy in our patient population. Proper preoperative counseling increases compliance of patient toward this cumbersome fixator with its prolonged treatment.
We acknowledge the limitations of our study. It has a small sample size and no meaningful statistical analysis could be performed. We did not perform any corticotomy for the correction of limb length discrepancy. Meaningful comparisons with newer expensive modalities like the Diamond concept of Giannoudis et al.,, have not been performed.
The strength of our study is that a homogeneous group of patients all received monofocal compression using the Ilizarov fixator in infected subtrochanteric nonunions and that it could be one of the larger of such studies.
| Conclusion|| |
The treatment of infected subtrochanteric nonunions is a formidable task to the surgeon. Ilizarov fixation has its own advantages and disadvantages. We conclude that infected subtrochanteric nonunions can be managed effectively by Ilizarov method. Further research and improvements in technique are needed to reduce fixator duration, incidence of pin tract infections, and hasten union.
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]
[Table 1], [Table 2], [Table 3], [Table 4]