[FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

Background: There are few publications specifically discussing the correction of tibial rotational deformities in adults; there are none to our knowledge that address very large deformities, exceeding 45°. We describe here a combination of reliable and predictable techniques for the safe correction of very large tibial rotational deformities. Methods: Retrospective review of a case series of eight adult patients who underwent correction of very large tibial rotational deformities following this surgical treatment protocol, with a minimum 2-year follow-up. These techniques included a formal peroneal nerve release, a subcutaneous anterior fasciotomy, a percutaneous Gigli saw corticotomy, an intramedullary nail, temporary circular external fixation, and gradual correction. The average magnitude of the preoperative rotational deformity measured 54° (45-65°). Seven of the patients had very large external rotation deformities; one had a very large posttraumatic internal rotation deformity (65°). Results: These deformities, all exceeding 45°, were successfully corrected to clinically neutral in eight consecutive cases. For all eight cases, the deformity was fully corrected within 2 weeks, and the patients returned to theater for a planned second minor procedure (locking screw insertion and external fixator removal) at an average of 9.6 (6-14) days after the index procedure. Patients were encouraged to resume full weight bearing by 6 weeks and all were walking unaided by 12 weeks. Clinical and radiographic union was achieved at an average of 15.5 (12-20) weeks. One case was over-corrected 5°; a second procedure was required to revise the deformity correction to clinically neutral. There were no other complications in this series. Conclusions: This combination of surgical techniques has, in this small series, been a consistently safe and effective treatment for this condition.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

[FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

Purpose: Accordion maneuver (AM) is a “Bloodless Tool” to stimulate bone healing as described by Professor Ilizarov by a mechanism called transformation osteogenesis. It has been underdescribed in literature. Furthermore, there is lack of standard protocol for AM. We report our cases where this Bloodless Tool was used and discuss the strategies for its use in various conditions. Materials and Methods: We reviewed our cases that underwent AM during 1994−2015, through this retrospective study. In nonunion, 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. In hyporegenerate, distraction was discontinued, stability restored, and AM was performed with compression first. Results: Twenty-three patients were included. In 15 cases monofocal, 7 cases bifocal, and in 1 case trifocal osteosynthesis was done with Ilizarov. AM was done for hypertrophic nonunion in 6 cases, atrophic nonunion in 15 cases, and hyporegenerate in 5 cases. In 3 cases, AM was done for both hyporegenerate and docking site nonunion. In all the cases of nonunion, union was achieved and in all the cases of hyporegenerate, bone formation improved. Conclusions: Transformation osteogenesis with AM is a bloodless tool in Ilizarov. To achieve desired results, protocol for the maneuver should be based on type of pathology between the fragments.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

The management of large bone defects, atrophic nonunions, and other conditions with poor bone formation presents a formidable challenge to the treating physician, as all available techniques of bone reconstruction have drawbacks. Recent advances in stem cell biology, specifically adipose tissue-derived mesenchymal stem cells (ASCs) and adipose tissue stromal vascular fraction (SVF), have opened up new horizons by providing a reliable and abundant source of stem cells with osteogenic potential that can be used in various bone tissue engineering techniques. In this review, several aspects related to the use of ASCs are addressed, such as harvesting and processing of adipose tissue, advantages of ASCs over bone marrow-derived mesenchymal stem cells, mechanism of action and safety of ASCs, and factors affecting the differentiation of ASCs. Published reports on the use of ASCs in critical size defects, nonunions, and distraction osteogenesis are also reviewed. Innovative trends in stem cell research on musculoskeletal pathologies are highlighted, with special emphasis on the increasing evidence that the direct application of freshly prepared SVF processed from adipose tissue into the bone defect to be treated without a prior differentiation or an ex vivo expansion and culture is possible. This highly promising approach may lead to the development of a one-step intraoperative cell therapy.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

Complex foot deformity correction with conventional techniques has many limitations including neurovascular problems, skin problems, stiffness, and limb shortening. Ilizarov methodology on the contrary is not limited by deformity magnitude and permits a comprehensive approach to foot deformity correction treating all deformities simultaneously, either in foot or leg, combining techniques of soft tissue distraction, bone lengthening, and arthrodesis. Nevertheless, Ilizarov methodology is not exempted from problems and difficulties. It is a technically demanding procedure with a long learning curve. For the patient, treatment time is long, the frame is uncomfortable, pin infection is frequent, and other complication rates are also high. However, if proper technique is used including preoperative planning, preconstruction of the frame, careful ambulatory handling, and this method can be useful in the management of difficult cases and in certain circumstances, the sole method to correct complex foot deformities.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

[FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

Background: External fixation utilizing hydroxyapatite (HA)-coated half pins has produced excellent clinical results revolutionizing the field of limb lengthening and deformity correction surgery. Removal of these pins is a painful patient experience that may be best conducted under anesthesia. Purpose: The current study documents how a deformity practice removes these external fixators (frames) under anesthesia. We asked: (1) How much anesthesia is needed for frame removal? (2) How effective was this protocol in controlling patient pain? (3) How did patients taking narcotic medications at the time of frame removal differ from those not taking narcotics during frame removal surgery? Patients and Methods: We prospectively recorded data during the removal of 53 consecutive external fixators that used HA-coated half pins including the use of pre operative narcotics at the time of frame removal, location and complexity of frames, type and dosages of medications administered, and adequacy of anesthesia. Results: All patients were managed with a combination of midazolam, propofol, fentanyl, and ketamine. Anesthesia was graded as good to excellent in 91% and unsatisfactory to poor in 9% of cases. The preoperatively medicated group was administered significantly less fentanyl (P = 0.020) and had significantly more frames located about the ankle and foot (P = 0.049) than the preoperatively non-medicated cohort. Conclusions: IV sedation administered by an anesthesiologist in the operating room provided adequate pain control to perform fixator removal and pin site debridement in most cases. External fixation used for foot and ankle reconstruction may provide a more painful experience for patients.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

Introduction: Knee flexion contracture (KFC) is a debilitating condition that may affect patients with neurogenic conditions, congenital deformities, posttraumatic deformities, and after total knee replacement. The recurrence rate of the deformity following either operative or nonoperative treatment remains high. The aim of the present study is to assess clinical outcomes of patients with KFCs and associated ankle equinus using gradual correction with a circular external fixator (CEF). Methods: Twenty-one patients with knee flexion contraction were treated using a CEF. Seven patients were also simultaneously treated for ankle equinus. All but two patients underwent a combination of open or arthroscopic knee arthrolysis, distal hamstrings lengthening, and gastrocsoleus release. The CEF was applied to match the residual deformity, following the minimal incision soft-tissue release. Results: Mean follow-up was 13 months. The mean range of motion (ROM) at final follow-up was −10° extension, 64° flexion, 9° ankle dorsiflexion, and 29° ankle plantar flexion. The difference between preoperative and postoperative ROMs was statistically significant (P < 0.05). Discussion: The present study suggests that gradual distraction using a CEF is a safe and effective technique in the management of KFC and concurrent ankle equinus. It is crucial to maintain the postoperative correction with braces for at least 1-3 months, depending on the severity of the condition.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

Depending on the reference, pin track infection rates in external fixation surgery have been stated to be anywhere from 0% to 100%. We critically evaluated the pin track infection rate for external fixation by performing systematic review of the external fixation literature since 1980. Using PubMed, a search of the peer-reviewed literature on external fixation was performed. This systematic review was conducted, as much as possible, in accordance with PICOS and PRISMA guidelines. A total of 150 articles were reviewed, including at least one from each year between 1980 and 2014. The following data were collected from each article: the year of publication, number of patients in the study, average age of the patients, reason for the external fixation, fixation per segment (two or more than two points), body part involved, whether or not hydroxyapatite-coated pins were used, duration of the external fixator, type of fixator used, and number of patients with documented pin track infections. These 150 studies represented 6130 patients. There were 1684 reported pin track infections from these 6130 patients, giving a cumulative pin track infection rate of 27.4%. A more recent year of publication was associated with an increasing infection rate (P = 0.015) while increasing age was associated with a decreased infection rate (P < 0.0005). There were trends toward association of humerus location (P = 0.059), shorter fixator duration (P = 0.056), and circular fixation (P = 0.079) with decreased infection rates. This systematic review of external fixation publications revealed a cumulative pin track infection rate of 27%. Younger age was the factor leading to increased pin track infection rates. Circular fixation trended toward being protective of pin track infection when usage was factored into the multiple regression analysis. Longer duration of fixation trended toward increased infection rate as expected. This data provides important base values for a common complication in external fixation treatment, highlights the importance of a more consistent definition of a pin track infection in future research, and identifies the pediatric population as the group at greatest risk.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

[FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

Pin-track infections are a common problem with external fixation and any other implant that breaks the skin barrier. The literature is rich with reports and techniques for treating these infections, but lacks a universally accepted definition of a pin track infection, a single commonly accepted classification, or a standard method of reporting. However, the surgeon can follow a commonly accepted series of practical steps to reduce the occurrence of infection. Continuing development of improved surfaces, substances, and techniques may make pin track infections rarer in the future. Careful preoperative planning, meticulous surgical technique, patient education, and close patient monitoring are all critical to minimize pin-track infections.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

Introduction: Congenital pseudarthrosis of the tibia (CPT) is a rare condition that can pose a challenge in achieving union after surgical excision of the pseudarthrosis site. Multiple methods have been described for management of fractures complicating this abnormal bone, including intramedullary nails (IMNs) and external fixators. One of the IMN designs is the telescoping nail, which has many models including the Fassier-Duval (FD) rod. This system has been known for its use in the management of osteogenesis imperfecta and different types of dysplasia. In this series, we describe our experience with the use of this system in the management of CPT of the tibia in children. Methods: We conducted a retrospective chart review of four patients with FD rod insertions for CPT management. The mean age at surgery was 7.6 years (range: 1.5-17) and the minimum follow-up was 20 months (average: 52.3 months, range: 20-93 months). Two out of the four patients had a concomitant diagnosis of neurofibromatosis Type 1. Results: All four cases achieved union of the fracture at final follow-up. Complications encountered in these cases included a case of joint intrusion into the knee and a case of rod migration due to the failure of telescoping. Conclusion: The FD rod showed promising results in our cohort, but before this treatment modality can be recommended for the management of CPT, additional studies are required. Level of Evidence: IV

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

The medial compartment osteoarthritis (OA) of knee joint has various surgical options such as high tibial osteotomy (HTO), hemiarthroplasty, and total knee arthroplasty. In the early stages of medial OA, there are no intra-articular deformities. Thus HTO, which is an extra-articular osteotomy, is recommended for the treatment of mild OA, but in moderate and severe medial OA, there are intra-articular deformities. HTO cannot correct these intra-articular deformities. Thus, an intra-articular osteotomy like the Tibial condylar valgus osteotomy (TCVO) is required in cases of moderate to severe medial OA knee. The contact area of the articular surface of the knee joint after TCVO is broader than it is after HTO in cases of moderate/severe OA. TCVO also improves the bony stability, eliminates the lateral thrust and surely corrects the alignment of the lower limb. To conclude, in cases of medial OA knee, the type of deformity must be evaluated and corrected accordingly. Intra-articular deformity must be corrected first. If the correction of varus and the mechanical axis is not enough, then extra-articular deformity must also be corrected, with a simultaneous or subsequent HTO.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

Purpose: We studied 31 individuals whose femur or tibia was elongated with the PRECICE™ intramedullary lengthening nail in a protocol-controlled, multicentric, prospective series. Only skeletally mature individuals were included in the study. Materials and Methods: The protocol entailed 2-year follow-up after consolidation of the regenerate new bone in the distraction gap. Since the external remote controller (that powers the nail's internal rotating magnet) must be within a predetermined distance from the implant, body weight limitations applied to the individuals. Similarly, a history of active or prior bone infection in the involved limb segment, an offset medullary canal that could not be successfully reamed for the implant, an angular deformity that precluded insertion of a straight device, and any potential limitation on regenerate new bone formation (such as metabolic bone disease or vascular compromise) were causes for exclusion. The mean age ± standard deviation was 24.3 ± 15.0, and the median age was 18 years. There were 20 males and 11 females in the series, with 21 Caucasians, 5 Hispanics, and 5 African-American individuals. The mean body mass index was 24.2 ± 4.7. Twentythree (74.2%) cases involved the femur and 8 (25.8%) involved the tibia. Results: One participant died of medical causes during the study period, and one participant was lost to follow-up, but 29 of 29 participants followed at least to consolidation achieved union (100%) although one of these participants was treated with a supplementary cancellous bone graft and another participant was converted to trauma nail before consolidation, to permit full weight-bearing as a stimulus to regenerate consolidation. On an average, participants achieved 96.3% ± 23.2% of the preoperative target lengthening (3.5 cm; range 1.8–6.0 cm) over an average of 48.5 ± 15.6 days. The average time to full weightbearing (permitted when the regenerate was consolidated on three sides) was 141.1 ± 80.7 days. The knee joint, at consolidation, lost an average of 6.5° of flexion and 0.3° of extension. The ankle lost an average of 1.4° of dorsiflexion and 5.4° of plantar flexion. The hip joint lost, on average, 2° of flexion, and gained 1.6° of extension. There was one deep infection involving the implant, successfully treated with intravenous antibiotics and superficial debridement. Nearly 25.8% of the participants had pain issues during lengthening, often over prominent hardware. In one participant, the nail failed to elongate during lengthening at home and had to be exchanged. One interlock screw broke. The internal components separated during implant extraction in the one subject had his nail exchanged by a trauma nail. Only 17 participants exited the protocol by presenting to clinic for evaluation 2 years after consolidation. None experienced significant deterioration of outcome. Conclusion: The PRECICE™ IM nail is a well-tolerated, reliable, fully implantable limb lengthening device that will accurately elongate the femur or tibia in a variety of causes of limb length inequality, with a low implant failure rate, and few complications.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

[FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

Context: Ankle nonunions with deformity and bone loss are challenging cases, often with broken hardware and infection. These cases are often associated with multiple previous surgeries making revision surgery difficult. Ankle fusion for failed total ankle arthroplasty or neuropathic joints are particularly challenging, which is reflected in high reported failure rates. Aims: Fixator-assisted nailing combines Taylor spatial frame (TSF) with an intramedullary nail, allowing for correction of deformity and compression at the nonunion site, as well as internal fixation protecting the fusion after frame removal. Subjects and Methods: Between 2001 and 2014, 24 patients with 26 failed ankle fusions, with bone loss and deformity, were treated using this technique. After removal of the original internal fixation hardware and revision of the fusion surfaces, a Taylor frame is used for acute or gradual correction of deformity and compression at the nonunion site. This was followed by insertion of intramedullary nail. The nail was locked at the time of fixator removal. Results: Acute correction was possible in 23 of the 26 cases with gradual correction in the others. Union was obtained in 25 cases (96.2%) and maintained at 24 months in 23 cases (88.4%). The overall salvage rate (avoidance of amputation) was 96.2% (25/26 cases). All salvaged limbs remain free of clinical infection and do not require ongoing antibiotic treatment. The foot was in neutral position in all salvaged cases. The average time in external fixation was 11 weeks (6-13 weeks). The average AOFAS ankle/hindfoot score was 74 (range: 61-80). Conclusions: Fixator-assisted nailing, combining a TSF and an intramedullary nail, is a reliable technique for revision ankle fusion for complex nonunion with deformity and/or infection.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

Background: The peroneal nerve is often stretched during limb lengthening and deformity correction. If the nerve becomes entrapped under the peroneal muscle fascia and/or anterior intermuscular septum, decompression is indicated to treat nerve compromise. Purpose: The purpose of this study was to quantify peroneal nerve tension after varus osteotomy of the proximal tibia and before and after nerve decompression. Methods: A device, which consisted of a force transducer connected perpendicularly by a hook to the nerve and integrated to a personal computer, was able to indirectly measure the nerve rigidity in 14 lower limbs (seven cadaveric specimens). The nerve was neither cut nor disrupted from its anatomic tract by the rigidity measuring device. We measured the amount of peroneal nerve rigidity before varus angulation, after varus angulation of a proximal tibial osteotomy, and after peroneal nerve decompression in the varus angulation position. Results: Peroneal nerve rigidity increased significantly after limb was angulated into varus (P = 0.0002) and was reduced significantly after decompression (P = 0.0003). No significant difference was noted between measurements obtained before varus angulation and measurements obtained after nerve decompression (P = 0.3664). Conclusions: Varus osteotomy of the proximal tibia significantly increases peroneal nerve rigidity. Peroneal nerve rigidity after decompression is not significantly different from nerve rigidity before varus correction. Clinical Relevance: This study provides biomechanical evidence of the efficacy of nerve decompression in two specific anatomic sites (peroneus longus muscle fascia and lateral, intermuscular septum) in relieving the increase in peroneal nerve rigidity that occurs in association with procedures that stretch the nerve such as limb lengthening and deformity correction.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

Dynamization of fixation has long been used as a strategy to promote fracture healing. Which clinical scenarios would benefit from dynamization, how and when to introduce it and its effectiveness remains to be elucidated. A systematic review of the literature reporting on the use of dynamization in fracture healing using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis was conducted. The primary outcome was time to union and union rate of fractures across all anatomical sites, including adult and pediatric populations. A total of 19 studies fulfilled the inclusion criteria of which 14 studies evaluated the use of dynamization using intramedullary nails, while five studies evaluated external fixator dynamization. The diversity of dynamization strategies, variation in timing of dynamization and contradictory results precludes definitive conclusions. Further research is needed before recommendations for the use of dynamization to improve fracture healing can be considered.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

Background: Lower limb deformities have a substantial impact on the quality of life (QOL) of children. This systematic review was conducted to identify as follows: (a) QOL concepts in existing literature specific to pediatric patients with lower limb deformities; (b) parent-reported outcome and patient-reported outcome (PRO) instruments used to measure QOL in pediatric patients with lower limb deformities; and (c) determinants of QOL in pediatric patients with lower limb deformities. Methods: MEDLINE, EMBASE, CINAHL, and PsycINFO were searched from the inception to January 2016. Studies were included if they (1) had patients with lower limb deformities; (2) included children 18 years of age or under; and (3) measured QOL using a PRO or parent-reported outcome of instruments. Results: Of the 938 publications identified in the search, 10 studies used a total of 24 PRO or parent-reported outcome instruments to measure 1 or more aspects of QOL of pediatric patients with lower limb deformities. Three overarching health concepts (physical, psychological, and social health) and 15 subconcepts were identified. Five studies looked at determinants of QOL including type of deformity, severity of deformity, complications postsurgery, stage of treatment, and type of treatment. Psychological health was measured in 10 studies, social health in 7 studies, and physical health in 6 studies. The most frequently measured subconcepts were physical function, psychological distress, and social function. Conclusion: Existing parent-reported outcome and PRO instruments measure 3 QOL concepts in children with lower limb deformities. There were no validated PRO instruments specifically designed to measure QOL of children with lower limb deformities. Level of Evidence: This was a systematic review of level III studies.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

[FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

Intramedullary nails (IMNs) are commonly used for fracture fixation of the femur and tibia, and internal lengthening nails (ILNs) can be used for deformity correction and limb lengthening. While this form of fixation has demonstrated substantial success, one major limitation is imperfect reduction and malalignment, particularly when used for fractures or osteotomies in the metaphysis. One means of overcoming this challenge is through the use of blocking screws, given their ability to guide the path of the nail, decrease the width of the medullary canal, and maintain reduction. In this literature review, indications, techniques, outcomes, and complications are reported. Searches of PubMed and The Cochrane Collaboration were performed. Technique articles and single case reports were not reviewed. All other English studies reporting outcomes of IMN or ILN fixation of the femur or tibia with concomitant use of blocking screws were reviewed. Blocking screws have been used successfully in the lower extremity for both trauma and in deformity surgery. Key techniques are placing the screws in the concavity and perpendicular to the plane of deformity, with adequate distance from the planned path of the nail and from the fracture or osteotomy site. Current data suggest high rates of union with adequate alignment and a low complication rate, although most studies are small, retrospective case series. Blocking screws appear to be a reasonable strategy for achieving fixation in difficulty, metaphyseal segments. Further, well-designed prospective studies should be carried out to make more definitive conclusions.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

Fractures of the talar body often result from high-energy trauma. These fractures are at risk for nonunion and put the talus at risk for avascular necrosis due to an inadequate blood supply. We present the case of a 57-year-old male that presented to our practice with talus fracture nonunion, talar body osteonecrosis, ankle and subtalar posttraumatic osteoarthritis, and deformity including a mild equinus contracture and mild hindfoot varus. Successful ankle and subtalar fusion, talus fracture union, and deformity correction were performed using a circular external fixator with fine wire fixation and compression. This is the first reported case where fusion of both the tibio-talar-calcaneal joints and the talar body nonunion was achieved using external fixation. At the time of this report, the patient is over 3 years postfusion, stands with neutral alignment, is relatively pain-free, is able to resume normal daily activities, and has no progression of talar osteonecrosis.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

Background: Treatment of displaced intra-articular calcaneal fractures (DIACFs) is still controversial. Aim: The objective of our study was to assess the capability of using Ilizarov frame as a minimally invasive technique to improve foot function and restore calcaneal length, height, width, and Bohler's angle in patients with DIACFs. Patients and Methods: We retrospectively reviewed forty patients (mean age, 25.4 ± 9.6 years, a mean follow-up of 44.9 ± 6.9 months) with 48 closed DIACFs who underwent indirect reduction and external fixation using Ilizarov technique. We applied distraction technique through the mechanical axis of the leg and through the foot axis. The drop wire technique was used to restore depressed subtalar fragments. Bone graft was not used. Results: We achieved good alignment in all cases except four feet who had varus deformity. The mean American Orthopaedic Foot and Ankle Society score was 84.6 ± 5. Superficial pin tract infection occurred in 7 feet. Skin pressure necrosis was seen in 3 feet. Statistically, all radiological measures were improved and significantly different from those measured preoperatively. Conclusion: Closed reduction of DIACFs using Ilizarov frame provides a good functional foot outcome with a low risk of postoperative complications. It also has the capability of restoring normal anatomy of the calcaneus.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

Aims: To retrospectively study infected distal tibial nonunions which have deformity, bone gaps and a small size of distal fragment for union and eradication of infection using staged Ilizarov treatment. Patients and Methods: Thirty seven distal infected tibial nonunions were treated over 11 years. Twelve presented without active discharge and were treated with Ilizarov fixator. Twenty five presented with draining infection and were treated with debridement, Antibiotic Cement Coated (ACC) rods and beads. Five healed without further intervention. Twenty were treated by Ilizarov fixator secondarily. Monofocal compression was used in 16 patients. Ten had a bone transport to fill gaps of 2 to 17.3 cm. Six had bifocal simultaneous treatment. Twenty three had a foot frame applied for stability. None had Iliac Crest bone grafting to achieve union at Nonunion site. Bone Marrow aspirate was injected in 5 patients to hasten union. Results: Five patients united without application of fixator. Twenty nine of 32 nonunions healed with first application of Ilizarov fixator. Three needed repeat fixation to achieve 100% union. Infection was eradicated in all patients. Thirteen (40%) were excellent, 14 good (43%), two were fair and three poor by ASAMI criteria. Mean ex-fix duration was 393.4 days (132-720). Mean 7.6 cm length was achieved in the regenerate. Conclusions: Infected Distal tibial nonunions have a small distal fragment, deformity, bone gap causing difficulties in treatment. Debridement, ACC beads and rods and Ilizarov fixator reliably achieves union and eradicates infection. Residual deformity and prolonged fixator duration were the main problems in our series.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]