Abstract
Aims
Ilizarov described four methods of treating non-unions but gave little information on the specific indications for each technique. He claimed, ‘infection burns in the fire of regeneration’ and suggested distraction osteogenesis could effectively treat infected non-unions.
This study investigated a treatment algorithm for described Ilizarov methods in managing infected tibial non-union, using non-union mobility and segmental defect size to govern treatment choice. Primary outcome measures were infection eradication, bone union and ASAMI bone and function scores.
Patients and Methods
A consecutive series of 79 patients with confirmed, infected tibial non-union, were treated with one of four Ilizarov protocols, consisting of; monofocal distraction (26 cases), monofocal compression (19), bifocal compression/distraction (16) and bone transport (18). Median non-union duration was 10 months (range 2–168). All patients had undergone at least one previous operation (mean 2.2; range 1–5), 38 had associated limb deformity and 49 had non-viable non-unions. Twenty-six cases (33%) had a new simultaneous muscle flap reconstruction at the time of Ilizarov surgery and 25 had pre-existing flaps reused.
Treatment algorithm based on assessment of bone gap and non-union stiffness, measured after resection of non-viable bone.
Results
The treatment algorithm was easy to apply, being based on easily assessable criteria.
Infection was eradicated in 76 cases (96.2%) at a mean follow-up of 40.8 months (range 6–131). All three cases of infection recurrence occurred in the monofocal compression group. They required repeat excision and Ilizarov distraction in two cases and below-knee amputation in one.
Union was achieved in 68 cases (86.1%) with the initial Ilizarov methods alone. Union was highest amongst the monofocal distraction and bifocal compression/distraction groups, 96.2% and 93.8% respectively. Mean external fixator time was 7.5 months (range 3–17).
Monofocal compression was successful in only 73.7% of mobile non-unions, with significantly lower ASAMI scores and a 26.3% re-fracture rate.
Bone transport secured union in 77.8% (14/18) but with a 44.4% unplanned reoperation rate. However, after further treatment, infection-free union following bone transport was 100%.
Conclusion
We cannot recommend Ilizarov monofocal compression in the treatment of infected, mobile non-unions. Distraction (monofocal or bifocal) was effective and is associated with higher rates of union and infection clearance.
