Results and techniques of the treatment of infected nonunion of the long bones, a report of 40 cases

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Results and techniques of the treatment of
infected nonunion of the long bones, a report of
40 cases

• Ebrahimzadeh Mohammad H. MD
• Department of Orthopedic surgery
• Ghaem Hospital
• Mashhad University of Medical Sciences, Mashhad,
  Iran.
• Ebrahimzademh_at_MUMS.ac.ir

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Infected nonunion

• 40 patients 34 men, 6 women
• 28 tibia
• 12 femur
• 23 (57) Smoker

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Infected nonunion

• infected nonunion of tibia 28 patients
• 17 middle third 60
• 8 distal third 28
• 3 proximal third 12

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Infected nonunion

• infected nonunion of the femur 12 case
• 7 distal third 58
• 3 middle third 25
• 2 proximal third 16

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Infected nonunion of the tibia28 cases

• Treatment modalities
• Ilizarov apparatus 21 patients
• Plate/ IM rod removal and sequential
  debridement,, grafting and plating again 7
  cases

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Infected nonunion of the femur,12 case

• Ilizarov apparatus 5 cases
• Plate/ IM rod removal and sequential
  debridement,, grafting and plating again 4
  cases
• Plate removal and sequential debridement,,
  grafting and girdle stone 2 cases
• Plate removal and sequential debridement,,
  grafting and external fixatore, 1 case

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Ilizarov Results(26 patients)

• all patients with Ilizarov apparatus were united
  and the infection was eradicated finally 6-30
  months
• in 4 patients we did rotation flap

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Ilizarov Results(26 patients)

• Complications
• Pin tract infection 15 cases
• Knee stiffness 12
• Ankle/foot stiffness 15
• Proneal nerve palsy 3
• Refracture 0

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Results

• Infection was eradicated in 2 Gildelston cases
  and in one case of them after 4 years of being
  free of infection,,, the patient is in line for
  THA.

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Results

• Plate/ IM rod removal and sequential
  debridement,, grafting and plating again
  11 patients
• 10 finally successful
• 1 amputation

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Results

• Plate removal and sequential debridement,,
  grafting and external fixatore, 1 case
  Successful

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Infected nonunion treatment methods depend on

• Type of nonunion atrophic? Hypertrophic?
• Extent of infection
• Presence of atrophic skin changes

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Ilizarovs concept for infected nonunion

• Osteomylitis burns in the fire of regeneration
• Activate biosynthetic process, increasing local
  resistant to infection

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Three ways of elimination of infection in
Ilizarov method

• Controlled osteogenesis, filling of cavities by
  newly formed tissue
• Resection of infected bone and subsequent
  intercalary bone lengthening
• Gradual bone transport of one wall of the cavity

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Ilizarov

• Distraction osteogenesis
• Tension-stress effect
• Mechanical induction of new bone formation
• Neovascularization
• Stimulation of biosynthetic activity
• Activation and recruitment of osteoprogenitor
  cells
• Intramembranous ossification

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Ilizarovs plan depends on

• Size and thickness of bone fragment
• Degree and type of displacement
• The extent of mobility
• Amount and character of scar tissue
• Prevalence of purulent process
• Characteristics of the individual case

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Important

• Nutritional Index
• WBC
• Functional WBC
  
• Stop Smoking

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Monofocal longitudinal compression

• Hypertrophic nonunion
• Minimal infection
• No sequestrum, smallest sequester left in place,
  they are assimilated in the process of active
  osteogenesis
• -spontaneous eradication of infection and
  achievement of union

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Bifocal Method

• Atrophic nonunion with diffuse infection and
  sequestrum
• Infected segment should be resected
• Creating an intercalary defect

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Bifocal Method

• Acute shortening, opposing ends under
  compression 1-2 Cm defect
• Poor skin
• Big necrotic bone
• Numerous fistula

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Bilocal simultaneous compression-distraction
osteosynthesis

• Small gap substantial bone shortening

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Persistent drainage And gross motion
after Multiple attempts at Surgical treatment
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Treatment consisted Of resection of Infected
bone, acute Shortening and External fixation
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Bilocal consecutive distraction-compression
osteosynthesis

• Large gap

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• A little Literature Review

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Acute compression and lengthening by Ilizarov
method for infected nonunion of tibia

• Magadum MP at al, J of Orthopedic Surgery,
  200614(3).
• 27 patient
• Complete debridment of nonunion, sequestrectomy,
  lavage and Ilizarov application
• Gap 10 (6-17)
• 19 excellent, 5 good, 1 fair, 1 poor,1 above-knee
  amputation in 10-24 months.

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Ilizarov method as a salvage procedure in
infected nonunion of the distal femur with bone
loss

• Saridis A et al. JBJS Br. 2006 8(2).
• 13 patients 10 men, 3 women
• Radical debridement and Ilizarov application
• 3.1 previous surgeries
• 8.3 mean length of defect(3-18)
• MEAN external fixator time 309 days
• Union and elimination of infection achived in all
  13 patients. 8 excellent, 4 good, 1 fair.
• 1 re-fracture

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Conclusion

• Ilizarov is a golden method for the management of
  nonunion osteomylitis for both achieving union
  and eradication of infection, however generous,
  careful sequential debridement and hardware/dead
  tissue removal and bone grafting is also an
  option for some selected cases.

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