Article

Distraction over Nail Using Circular External Fixation for Septic Pseudarthrosis of the Tibia

Authors:
  • University Hospitals Sussex NHS Foundation Trust
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Abstract

We present a report of nine patients (eight women and one man; mean age 37 years) from 2010 to 2012 with septic pseudarthrosis of the tibia treated with bone transport over an intramedullary nail using a circular external fixator. The mean follow-up was 15 months (range: 10-21 months). A twostage approach was used. At the first stage, removal of the primary osteosynthesis and extensive bone debridement to healthy, bleeding bone margins was performed. The bone defect was packed with antibiotic loaded cement beads, and stabilization of the tibia was done with a unilateral external fixator or with a long leg posterior splint. The mean size of bone defect was 4 cm (range: 3.5-5.5 cm). At the second stage, two consecutive negative wound cultures and normal values of blood cell count, C-reactive protein (CRP), and estimated sedimentation rate (ESR) were obtained. Then we reamed and locked the intramedullary nailing of the tibia, applied a circular external fixator, and performed percutaneous corticotomy of the tibia opposite the site of the bone defect. Bone distraction over the nail was initiated at the eighth postoperative day at a rate of 1 mm/day. At the last follow-up, union was achieved in all cases without recurrence of bone infection. All patients experienced excellent (n=3) or good (n=6) knee and ankle function, as well as complete return to their daily activities. Two patients experienced pin-tract infection, and one patient experienced anterior knee pain at the entry point of the nail.

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... Indications: Post-traumatic bone defects from 5 to 12 cm [42,43]; infected or uninfected nonunion [44]; osteomyelitis [45], and tumors [46]. [32]. ...
... In the reconstruction procedures of femoral bone defects, unilateral external fixators [42,48] are mainly used, whereas circular fixators are preferred in reconstructions of tibial bone defects [44]. The external fixator allows for the transport of the bone segment. ...
Chapter
The simultaneous use of external and internal fixation devices is a surgical procedure that combines two different techniques of bone osteosynthesis, with different timing and methods, in order to benefit from the advantages, to eliminate the mutual drawbacks and to reduce treatment time. The association of external and internal fixation on the same bone segment can be used in case of congenital or acquired deformities, limb lengthening, fractures or nonunions in a consecutive, simultaneous, or computer-assisted way. The external fixator acts as a hardware that allows the orthopaedic surgeon to realign the bone gradually, controllably and reversibly. The internal osteosynthesis protects the biological process of bone healing, maintains the gained correction and allows an earlier removal of the external fixator. The hexapod external fixation with computerized assistance is particularly suitable to combine with consecutive or simultaneous internal fixation. The ability to correct a deformity at the same time on all planes or to reduce a fracture allows early replacement with internal fixation and decreases the indispensable duration of treatment with fixator.
... Previous studies have described the use of external fixation in the management of periprosthetic fractures [7]. With refinements in design and technique of fixator assembly the indications for femoral frame construction have been expanded, to include Lengthening over Nail (LON) [8][9][10][11][12], Bone Transport over Nail (BTON) [12][13][14][15] and correction of periprosthetic femoral deformity and malunion [16]. The ECD, due to its novel concept, permits easy application to the femur without disrupting the endosteal space and any intramedullary device. ...
Article
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Introduction: The Extra cortical Clamp Device (ECD) is a novel element used in external fixation. Unlike standard transosseous fixation elements, the ECD avoids the intra medullary canal and is rigidly secured to the external periosteal surface of diaphyseal bone. External fixation offers a solution to the management of periprosthetic fractures with well fixed prostheses; however, infection and implant loosening may be troublesome complications. The ECD has direct potential for utility in their management by avoiding these complications. We postulated that in addition to a favorable mechanism of fixation, the ECD would show equal or superior rigidity compared to standard transosseous external fixation. Methods : Mechanical analysis of the rigidity of the ECD was studied in first and second order external fixation modules using a standardized and accepted testing protocol and compared to accepted fixation techniques in a Sawbones model. Results : Two parallel ECDs inserted at an angle of 60 degrees to each other with an intercalary distance of 10cm showed greater rigidity in both first and second order modules than alternate configurations. This ECD configuration showed improved stiffness compared to standard Schanz screw fixation. Conclusion : The ECD shows favorable rigidity in frame construction compared to standard external fixation elements. This study demonstrates the optimal configuration of the ECD when applied to diaphyseal external fixator assemblies for maximal rigidity, and can therefore be utilized as a standard in ECD application in further studies of periprosthetic fracture stabilization, diaphyseal lengthening and bone transport over nail techniques.
... Defekte mit einem Ausmaß von mehr als ca. 5 cm können relativ zuverlässig mit dem Segmenttransport über Marknagel oder Fixateur externe behandelt werden. [20][21][22] Nach anfänglichen Erfolgen der Defektrekonstruktion mit der Masquelet-Technik scheint dieses Verfahren für größere Defekte (> 5 cm) nur bedingt geeignet [23,24]. ...
Article
Zusammenfassung Infektionen an langen Röhrenknochen und intramedullärem Implantat stellen eine besondere Herausforderung in der chirurgischen Behandlung dar. Der Vorteil der intramedullären Platzierung des Osteosynthesematerials schlägt im Falle einer Infektion in das Gegenteil um, da die Infektion in aller Regel den gesamten Markraum betrifft, in dem das Implantat platziert ist. Bei der operativen Therapie steht die konsequente Sequestrektomie mit Implantatentfernung im Vordergrund. Gerade bei Trümmerzonen im Frakturbereich kann die Sequestrektomie oft nur über einen offenen Zugang erreicht werden, die u. U. auch eine Segmentresektion beinhaltet. Für die Knochen- und Weichteilrekonstruktion ist nach der Infekteradikation die Optimierung der Perfusion zu prüfen. Die Stabilisierung im Sanierungsintervall mit einem Fixateur beeinträchtigt den Markraumzugang und sollte der definitiven Rekonstruktion vorbehalten bleiben. Temporär kann die Immobilisierung im Cast vorgenommen werden, am Femur hat sich die Behandlung mit einem Wechselnagel in unserem Therapiekonzept bewährt. Begleitend zu den chirurgischen Maßnahmen sind die interdisziplinäre Betreuung und die Antibiotikabehandlung entsprechend dem ABS-Prinzip umzusetzen. Infektionen an langen Röhrenknochen und intramedullärem Implantat stellen eine besondere Herausforderung in der chirurgischen Behandlung dar.
... The Ilizarov method has been used successfully for the treatment of septic tibial non-unions (3,4). Many studies have demonstrated the effectiveness of the Ilizarov method and circular external fixation for eradication of infected tibial non-unions (5)(6)(7)(8)(9)(10)(11)(12)(13)(14). Karargyris et al. reported the use of circular external fixation in a two-stage protocol for the treatment of septic pseudoarthrosis of the tibia (10).Acute osseous shortening followed by distraction osteogenesis has also been reported as a successful method for the treatment of tibial non-union with bone loss (12). ...
Article
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Surgical management of open fracture with compromised soft tissue has always remained a challenge for orthopaedic surgeons. Delayed union and non union in such patients are treated by various methods of bone grafting, vascularized pedicle graft, free fibular vascularized graft , papineau methods and Ilizarov. We are reporting an interestingcase of treatment of open fracture of Tibia with soft tissue compromise treated by Ilizarov angiogenesis. In the presence of deep infections treatment of long bone fractures are often faced with the problem associated with wound healing and fracture healing. Poor wound healing and delayed fracture union can be treated by application of Ilizarov and utilizing the principle of neo angiogenesis. Increased vascularity will be favoured by application of Ilizarov wires and tensioning which will initiate aseptic inflammation. Drilling the proximal fragment in S shaped manner will improve the blood supply and enhance the chances of soft tissue and fracture healing.
... The Ilizarov method has been used successfully for the treatment of septic tibial non-unions (22,23). Karargyris et al. reported the use of circular external fixation in a two-stage protocol for the treatment of septic pseudoarthrosis of the tibia (24). Many studies have demonstrated the effectiveness of the Ilizarov method and circular external fixation for eradication of infected tibial nonunions (18, 25Á28). ...
Article
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The surgical treatment of open pilon fractures has a high complication rate especially in diabetic patients. In this article, we present a case of an infected tibial non-union after an open reduction and internal fixation in a diabetic patient, treated with Ilizarov external fixation combined with Papineau technique. Combined use of external fixation and Papineau technique can provide an alternative option for the treatment of septic pseudoarthrosis of the distal tibia.
Article
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The extracortical clamp device (ECD) is a tool used in external fixation which unlike the K-wires and half-pins don’t perforate cortical bone. The use of ECD is prospective for the treatment of periprosthetic femoral fractures and in the lengthening over nail and bone transport over nail. The data on the bench tests of the osteosynthesis rigidity by the external fixation first-order and second-order modules on the base of extracortical clamp devices are observed in the article. Materials and methods. The authors made 240 bench tests using torsional-vibration machine, Indicators measuring linear displacements with a scale of 0.01 mm, bone simulators («Sawbones»), calibrated load, Ilizarov’s apparatus и extracortical fixators. The statistical analysis was performed with use software «STATISTICA» (ver. 6.0). The data obtained are presented in graphs «Box and Whisker Plot». Results. Among the investigated variants of first-order modules the better results of osteosynthesis rigidity were found in the module based on two ECD inserted at angle 60 degrees to each other and at distance of 10 cm from each other. Among the investigated second-order modules, better results of osteosynthesis rigidity were found in the module based on two ECD inserted at an angle 60 degrees to each other at distance of 10 cm from each other. Conclusion. Thus the tested modules can be used in practice in assemblies of external fixation devices in periprosthetic fractures, lengthening and bone transport over the nail.
Article
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Callus distraction over an intramedullary nail is a rarely used technique for the reconstruction of intercalary defects of the femur and tibia after radical débridement of chronic osteomyelitic foci. The aim of this study was to summarize our experience with distraction osteogenesis performed with an external fixator combined with an intramedullary nail for the treatment of bone defects and limb-shortening resulting from radical débridement of chronic osteomyelitis. Thirteen patients who ranged in age from eighteen to sixty-three years underwent radical débridement to treat a nonunion associated with chronic osteomyelitis of the tibia (seven patients) and femur (six patients). The lesions were classified, according to the Cierny-Mader classification system, as type IVA (nine) and type IVB (four). The resulting segmental defects and any limb-length discrepancy were then reconstructed with use of distraction osteogenesis over an intramedullary nail. Two patients required a local gastrocnemius flap. Free nonvascularized fibular grafts were added to the distraction site for augmentation of a femoral defect at the time of external fixator removal and locking of the nail in two patients. At the time of the latest follow-up, functional and radiographic results were evaluated with use of the criteria of Paley et al. The mean size of the defect was 10 cm (range, 6 to 13 cm) in the femur and 7 cm (range, 5 to 10 cm) in the tibia. The mean external fixator index was 13.5 days/cm, the consolidation index was 31.7 days/cm, and the mean time to union at the docking site was nine months (range, five to sixteen months). At a mean follow-up of 47.3 months, eleven of the thirteen patients had an excellent result in terms of both bone and functional assessment. There were two recurrences of infection necessitating nail removal. These patients underwent revision with an Ilizarov fixator. Subsequently, the infection was controlled and the nonunions healed. This combined method may prove to be an improvement on the classic techniques for the treatment of a nonunion of a long bone associated with chronic osteomyelitis, in terms of external fixation period and consolidation index. The earlier removal of the external fixator is associated with increased patient comfort, a decreased complication rate, and a convenient and rapid rehabilitation.
Article
The Ilizarov method based on compression-distraction and subperiostic corticotomy was used in 82 lower extremities. There were 45 tibial nonunions without a significant bone defect and 37 tibial nonunions with a bone defect that required radical removal of the necrotic bone and bone lengthening or bone transport. Bone healing was obtained in 39 of the 45 tibial nonunions without bone defect (mean bone healing, 5.4 months) and in all patients with bone defect (mean bone healing, 15 months for patients treated with bone transport) although secondary surgeries (autografting and tibial nails) were frequent (23 patients). Infection was eradicated in all patients after necrotic bone removal and bone transport. The final mean limb length discrepancy was 0.7 cm for the patients without a bone defect and 2.03 cm for the patients with a bone defect. In the patients in the bone transport group, residual axial deviation and residual limb shortening were common. Circular external fixation is a useful method to solve complex tibial nonunions in patients in whom internal devices and autografting have failed. Patients must be cooperative, and must understand the length of time the frame needs to be worn, and that complications are a probability.