Management of Tibial Infected Nonunion with Segmental Bone Defect by the Ilizarov Technique
DOI:
https://doi.org/10.59167/x74z1870Keywords:
Ilizarov Technique, Tibial Bone Defect, Nonunion, Tibial Bone LengtheningAbstract
Background and Objective: Managing tibial fractures complicated by extensive bone loss, soft tissue defects, and infected nonunion remains a significant orthopedic challenge. While techniques like vascularized bone grafts or bone transport exist, they often fail to address infection and nonunion simultaneously. This study evaluates the effectiveness of the Ilizarov technique in simultaneously managing these complex tibial defects. Patients and Methods: A retrospective analysis was conducted on 79 patients (aged 12–60 years) with tibial diaphyseal defects > 5 cm treated using the Ilizarov technique between 2004 and 2016. The cohort comprised 67 open fractures (84.8%) and 12 closed fractures with postoperative infections (15.2%). Etiologies included gunshot injuries (n=53, 67.1%), traffic accidents (n=21, 26.6%), and falls or osteomyelitis (n=5, 6.3%). In 25 cases (31.6%) with adequate soft tissue and no active infection, 2.5–3 mm flexible intramedullary K-wires were used to guide the transported segment. The remaining 54 patients (69%) with active infection or poor soft tissue coverage were managed exclusively with external fixation. Results: Patients had undergone a mean of 2.8 prior failed surgical procedures (range: 1–16). The mean bone defect length was 9.3 cm (range: 5–18 cm). Infection eradication and bone union were successfully achieved in all 79 cases. The mean external fixation index was 1.3 months/cm. Bone results were excellent in 71 patients (89.9%), good in 5 (6.3%), fair in 2 (3.8%), and poor in 1 (1.3%). Functional results were excellent in 46 patients (58.2%), good in 28 (35.4%), and fair in 2 (3.8%), with no poor or failed outcomes reported. Skin invagination at the gap site occurred in 34 patients (43%), requiring surgical adjustment in 27 (34.2%); notably, such adjustments were unnecessary when intramedullary flexible K-nails were utilized. Conclusion: The Ilizarov technique is a highly effective solution for challenging tibial defects, allowing for the simultaneous resolution of bone loss, infection, nonunion, and soft tissue compromises. Furthermore, the adjunctive use of flexible intramedullary K-nails mitigates the need for subsequent docking site adjustments.References
[1] Kocialkowski, A., Marsh, D.R., Shackley, D.C. (1998) Closure of the skin defect overlying infected non-union by skin traction, British Journal of Plastic Surgery 51: 307-310.
[2] Lenoble, E., Lewertowski, J.M., Goutallier, D. (1995) Reconstruction of Compound Tibial and Soft Tissue Loss Using a Traction Histogenesis Technique, Journal of Trauma and Acute Care Surgery 39: 356-360.
[3] Kesemenli, C., Subasi, M., Kirkgoz, T., Kapukaya, A., Arslan, H. (2001) Treatment of Traumatic Bone Defects by Bone Transport, Acta Orthopaedica Belgica 67: 380-386.
[4] Mahaluxmivala, J., Nadarajah, R., Allen, P.W., Hill, R.A. (2005) Ilizarov external fixator: acute shortening and lengthening versus bone transport in the management of tibial non-unions, Injury 36: 662-668.
[5] Keating, J.F., Simpson, A.H.R.W., Robinson, C.M. (2005) The management of fractures with bone loss, The Journal of Bone & Joint Surgery British Volume 87-B: 142-150.
[6] El-Gammal, T.A., Shiha, A.E., El-Deen, M.A., El-Sayed, A., Kotb, M.M., Addosooki, A.I., Ragheb, Y.F., Saleh, W.R. (2008) Management of traumatic tibial defects using free vascularized fibula or Ilizarov bone transport: A comparative study, Microsurgery 28: 339-346.
[7] Tonoli, C., Bechara, A.H.S., Rossanez, R., Belangero, W.D., Livani, B. (2013) Use of the Vascularized Iliac-Crest Flap in Musculoskeletal Lesions, BioMed Research International 2013: 237146.
[8] Ebraheim, N.A., Haman, S.P., Sabry, F.F., Emara, K. (2005) Tibiofibular synostosis procedure in the management of complex tibia fractures, American Journal of Orthopedics (Belle Mead, N.J.) 34: 493-497.
[9] Masquelet, A.C. (2003) Muscle reconstruction in reconstructive surgery: soft tissue repair and long bone reconstruction, Langenbeck's Archives of Surgery 388: 344-346.
[10] Biermann, J., Prokuski, L., Marsh, J. (1994) Chronic Infected Tibia1 Nonunions With Bone Loss Conventional Techniques Versus Bone Transport, Clinical Orthopaedics & Related Research 301: 139-146.
[11] Song, H.R., Cho, S.H., Koo, K.H., Jeong, S.T., Park, Y.J., Ko, J.H. (1998) Tibial bone defects treated by internal bone transport using the Ilizarov method, International Orthopaedics 22: 293-297.
[12] Rigal, S., Tripon, P. (2005) Traitement des pertes de substance osseuse traumatiques des diaphyses par transport osseux segmentaire, Annales Orthopédiques de l'Ouest 37: 163-5.
[13] Ilizarov, S., Katz, H., Freudigman, P., Tracey Watson, J., Weitzman, A., Robert Rozbruch, S. (2006) Simultaneous Treatment of Tibial Bone and Soft-tissue Defects With the Ilizarov Method, Journal of Orthopaedic Trauma 20: 194-202.
[14] Trigui, M., Ayadi, K., Ellouze, Z., Gdoura, F., Zribi, M., Keskes, H. (2008) Treatment of bone loss in limbs by bone transport, Revue de chirurgie orthopedique et reparatrice de l'appareil moteur 94: 628-634.
[15] Paley, D., Maar, D.C. (2000) Ilizarov bone transport treatment for tibial defects, Journal of Orthopaedic Trauma 14: 76-85.
[16] Paley, D., Catagni, M.A., Argnani, F., Villa, A., Bijnedetti, G.B., Cattaneo, R. (1989) Ilizarov Treatment of Tibial Nonunions With Bone Loss, Clinical Orthopaedics and Related Research 241: 146-165.
[17] Paley, D. (1990) Problems, obstacles, and complications of limb lengthening by the Ilizarov technique, Clinical Orthopaedics and Related Research 250: 81-104.
[18] Joshi, A., Kostakis, G.C. (2004) An investigation of post-operative morbidity following iliac crest graft harvesting, British Dental Journal 196: 167-171.
[19] Li, Y., Shen, S., Xiao, Q., Wang, G., Yang, H., Zhao, H., Shu, B., Zhuo, N. (2020) Efficacy comparison of double-level and single-level bone transport with Orthofix fixator for treatment of tibia fracture with massive bone defects, International Orthopaedics 44: 957-963.
[20] Schnee, C.L., Freese, A., Weil, R.J., Marcotte, P.J. (1997) Analysis of Harvest Morbidity and Radiographic Outcome Using Autograft for Anterior Cervical Fusion, Spine 22: 2222-2227.
[21] Nkenke, E., Weisbach, V., Winckler, E., Kessler, P., Schultze-Mosgau, S., Wiltfang, J., Neukam, F.W. (2004) Morbidity of harvesting of bone grafts from the iliac crest for preprosthetic augmentation procedures: A prospective study, International Journal of Oral and Maxillofacial Surgery 33: 157-163.
[22] Skaggs, D.L., Samuelson, M.A., Hale, J.M., Kay, R.M., Tolo, V.T. (2000) Complications of Posterior Iliac Crest Bone Grafting in Spine Surgery in Children, Spine 25: 2400-2402.
[23] Swan, M.C., Goodacre, T.E.E. (2006) Morbidity at the iliac crest donor site following bone grafting of the cleft alveolus, British Journal of Oral and Maxillofacial Surgery 44: 129-133.
[24] Robertson, P.A., Wray, A.C. (2001) Natural History of Posterior Iliac Crest Bone Graft Donation for Spinal Surgery: A Prospective Analysis of Morbidity, Spine 26: 1473-1476.
[25] Westrich, G.H., Geller, D.S., O'Malley, M.J., Deland, J.T., Helfet, D.L. (2001) Anterior Iliac Crest Bone Graft Harvesting Using the Corticocancellous Reamer System, Journal of Orthopaedic Trauma 15: 500-506.
[26] Hill, N.M., Geoffrey Horne, J., Devane, P.A. (1999) Donor Site Morbidity in the Iliac Crest Bone Graft, Australian and New Zealand Journal of Surgery 69: 726-728.
[27] Silber, J.S., Anderson, D.G., Daffner, S.D., Brislin, B.T., Leland, J.M., Hilibrand, A.S., Vaccaro, A.R., Albert, T.J. (2003) Donor Site Morbidity After Anterior Iliac Crest Bone Harvest for Single-Level Anterior Cervical Discectomy and Fusion, Spine 28: 134-139.
[28] Sasso, R.C., LeHuec, J.C., Shaffrey, C., The Spine Interbody Research Group (2005) Iliac Crest Bone Graft Donor Site Pain After Anterior Lumbar Interbody Fusion: A Prospective Patient Satisfaction Outcome Assessment, Clinical Spine Surgery 18: S77-S81.
[29] Kager, A.N., Marks, M., Bastrom, T., Newton, P.O. (2006) Morbidity of Iliac Crest Bone Graft Harvesting in Adolescent Deformity Surgery, Journal of Pediatric Orthopaedics 26: 132-134.
[30] Heary, R.F., Schlenk, R.P., Sacchieri, T.A., Barone, D., Brotea, C. (2002) Persistent iliac crest donor site pain: independent outcome assessment, Neurosurgery 50: 510-517.
[31] Toh, C.L., Jupiter, J.B. (1995) The Infected Nonunion of the Tibia, Clinical Orthopaedics and Related Research 315: 176-191.
[32] Corona, P.S., Pujol, O., Vicente, M., Ricou, E., de Albert, M., Maestre Cano, D., Salcedo Cánovas, C., Martínez Ros, J. (2022) Outcomes of two circular external fixation systems in the definitive treatment of acute tibial fracture related infections, Injury 53: 3438-3445.
[33] Ziran, B.H., Smith, W.R., Morgan, S.J. (2007) Use of Calcium-Based Demineralized Bone Matrix/Allograft for Nonunions and Posttraumatic Reconstruction of the Appendicular Skeleton: Preliminary Results and Complications, Journal of Trauma and Acute Care Surgery 63: 1324-1328.
[34] Hariri, A., Mascard, E., Atlan, F., Germain, M.A., Heming, N., Dubousset, J.F., Wicart, P. (2010) Free vascularised fibular graft for reconstruction of defects of the lower limb after resection of tumour, The Journal of Bone & Joint Surgery British Volume 92-B: 1574-1579.
[35] Wood, M.B. (2007) Free Vascularized Fibular Grafting—25 Years' Experience: Tips, Techniques, and Pearls, Orthopedic Clinics of North America 38: 1-12.
[36] Chen, C.M., Disa, J.J., Lee, H.-Y., Mehrara, B.J., Hu, Q.-Y., Nathan, S., Boland, P., Healey, J., Cordeiro, P.G. (2007) Reconstruction of Extremity Long Bone Defects after Sarcoma Resection with Vascularized Fibula Flaps: A 10-Year Review, Plastic and Reconstructive Surgery 119: 915-924.
[37] McClure, P.K., Abouei, M., Conway, J.D. (2021) Reconstructive Options for Tibial Bone Defects, JAAOS - Journal of the American Academy of Orthopaedic Surgeons 29: 901-909.
[38] Chang, D.W., Weber, K.L. (2005) Use of a Vascularized Fibula Bone Flap and Intercalary Allograft for Diaphyseal Reconstruction after Resection of Primary Extremity Bone Sarcomas, Plastic and Reconstructive Surgery 116: 1918-1925.
[39] Minami, A., Kasashima, T., Iwasaki, N., Kato, H., Kaneda, K. (2000) Vascularised fibular grafts, The Journal of Bone & Joint Surgery British Volume 82-B: 1022-1025.
[40] Vail, T.P., Urbaniak, J.R. (1996) Donor-Site Morbidity with Use of Vascularized Autogenous Fibular Grafts, The Journal of Bone & Joint Surgery British Volume 78: 204-11.
[41] Kanaya, K., Wada, T., Kura, H., Yamashita, T., Usui, M., Ishii, S. (2002) Valgus deformity of the ankle following harvesting of a vascularized fibular graft in children, Journal of Reconstructive Microsurgery 18: 091-096.
[42] Lavini, F., Dall’Oca, C., Bartolozzi, P. (2010) Bone transport and compression-distraction in the treatment of bone loss of the lower limbs, Injury 41: 1191-1195.
[43] Magadum, M., Yadav, C.B., Phaneesha, M., Ramesh, L. (2006) Acute compression and lengthening by the Ilizarov technique for infected nonunion of the tibia with large bone defects, Journal of Orthopaedic Surgery 14: 273-279.
[44] Shetu, N.H., Balo, N.R., Rahaman, M.S., Mahmud, B.R., Islam, M.O. (2025) Clinical Outcomes of Bone Transport Over Intramedullary Nail by Ilizarov Method, Scholars Journal of Applied Medical Sciences 13: 377-385.
[45] Abdel-Aal, A.M. (2006) Ilizarov bone transport for massive tibial bone defects, Orthopedics 29: 70.
[46] Liu, T., Yu, X., Zhang, X., Li, Z., Zeng, W. (2012) One-stage management of post-traumatic tibial infected nonunion using bone transport after debridement, Turkish Journal of Medical Sciences 42: 1111-1120.
[47] Xu, Y.-Q., Fan, X.-Y., He, X.-Q., Wen, H.-J. (2021) Reconstruction of massive tibial bone and soft tissue defects by trifocal bone transport combined with soft tissue distraction: experience from 31 cases, BMC Musculoskeletal Disorders 22: 34.
[48] Bumbaširević, M., Tomić, S., Lešić, A., Milošević, I., Atkinson, H.D.E. (2010) War-related infected tibial nonunion with bone and soft-tissue loss treated with bone transport using the Ilizarov method, Archives of Orthopaedic and Trauma Surgery 130: 739-749.
[49] Green, S.A. (1991) Osteomyelitis. The Ilizarov perspective, The Orthopedic Clinics of North America 22: 515-521.
[50] Svesnikov, A., Barabash, A., Cheplenko, T., Smotrova, L., Larionov, A. (1984) Radionuclide studies of osteogenesis and circulation in substitution of large defects of the leg bones in experiment, Ortopediia, Travmatologiia i Protezirovanie 33-37.
[51] Green, S.A., Jackson, J.M., Wall, D.M., Marinow, H., Ishkanian, J. (1992) Management of Segmental Defects by the Ilizarov Intercalary Bone Transport Method, Clinical Orthopaedics and Related Research 280: 136-142.
[52] Sen, C., Eralp, L., Gunes, T., Erdem, M., Ozden, V.E., Kocaoglu, M. (2006) An alternative method for the treatment of nonunion of the tibia with bone loss, The Journal of Bone & Joint Surgery British Volume 88-B: 783-789.
[53] Atesalp, A.S., Basbozkurt, M., Erler, K., Sehirlionğlu, A., Tunay, S., Solakoğlu, C., Gür, E. (1998) Treatment of tibial bone defects with the Ilizarov circular external fixator in high-velocity gunshot wounds, International Orthopaedics 22: 343-347.
[54] Cattaneo, R., Catagni, M., Johnson, E.E. (1992) The Treatment of Infected Nonunions and Segmental Defects of the Tibia by the Methods of Ilizarov, Clinical Orthopaedics and Related Research 280: 143-152.
[55] Zorn, K., Iii, G. (1994) Segmental Tibia1 Defects Comparing Conventional and Ilizarov Methodologies, Clinical Orthopaedics & Related Research 301: 118-123.
[56] Saleh, M., Rees, A. (1995) Bifocal surgery for deformity and bone loss after lower-limb fractures. Comparison of bone-transport and compression-distraction methods, The Journal of Bone & Joint Surgery British Volume 77-B: 429-434.
[57] Dendrinos, G.K., Kontos, S., Lyritsis, E. (1995) Use of the Ilizarov technique for treatment of non-union of the tibia associated with infection, The Journal of Bone & Joint Surgery British Volume 77: 835-846.
[58] Polyzois, D., Papachristou, G., Kotsiopoulos, K., Plessas, S. (1997) Treatment of tibial and femoral bone loss by distraction osteogenesis, Acta Orthopaedica Scandinavica 68: 84-88.
[59] Yin, P., Zhang, Q., Mao, Z., Li, T., Zhang, L., Tang, P. (2014) The treatment of infected tibial nonunion by bone transport using the Ilizarov external fixator and a systematic review of infected tibial nonunion treated by Ilizarov methods, Acta Orthopaedica Belgica 80: 426-435.
[60] Thirumal, M., Shong, H.K. (2001) Bone transport in the management of fractures of the tibia, The Medical Journal of Malaysia 56: 44-52.
[61] Maini, L., Chadha, M., Vishwanath, J., Kapoor, S., Mehtani, A., Dhaon, B.K. (2000) The Ilizarov method in infected nonunion of fractures, Injury 31: 509-517.
[62] Ring, D., Jupiter, J.B., Gan, B.S., Israeli, R., Yaremchuk, M.J. (1999) Infected Nonunion of the Tibia, Clinical Orthopaedics and Related Research 369: 302-311.
[63] Li, R., Zhu, G., Chen, C., Chen, Y., Ren, G. (2020) Bone Transport for Treatment of Traumatic Composite Tibial Bone and Soft Tissue Defects: Any Specific Needs besides the Ilizarov Technique?, BioMed Research International 2020: 2716547.
[64] Schultz, J.H., Schmidt, H.G., Jürgens, C., Kortmann, H.R. (1994) Change in the treatment method of infected pseudarthrosis with bone loss of the tibia, Zentralblatt fur Chirurgie 119: 714-721.
[65] Aronson, J. (1997) Current Concepts Review - Limb-Lengthening, Skeletal Reconstruction, and Bone Transport with the Ilizarov Method, The Journal of Bone & Joint Surgery British Volume 79: 1243-58.
[66] Miraj, F., Nugroho, A., Dalitan, I.M., Setyarani, M. (2021) The efficacy of ilizarov method for management of long tibial bone and soft tissue defect, Annals of Medicine and Surgery 68: 102645.
[67] Hernández-Irizarry, R., Quinnan, S.M., Reid, J.S., Toney, C.B., Rozbruch, S.R., Lezak, B., Fragomen, A.T. (2021) Intentional Temporary Limb Deformation for Closure of Soft-Tissue Defects in Open Tibial Fractures, Journal of Orthopaedic Trauma 35: e189-e194.
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