Aims

To investigate a treatment algorithm of various Ilizarov methods in managing infected tibial non-union.

Introduction

The Ilizarov method for non-union comprises a range of treatment protocols designed to generate tissue, correct deformity, eradicate infection and secure union. The choice of specific reconstruction method is difficult, but should depend on the biological and mechanical needs of the non-union. We present a prospective series of patients with non-union of the tibia managed using a treatment algorithm based on the Ilizarov method and the viability of the non-union.

Introduction

Ankle fusion presents a difficult problem in the presence of infection, inadequate soft tissue, poor bone stock and deformity. Nonunion and infection remains a problem even with internal fixation. Ilizarov frame provides an elegant solution to the problem with stable remote fixation while allowing lengthening, deformity correction and weight bearing.

OBJECTIVES: To review the short-term functional results of the surgical treatment of tibial plateau fractures using low profile peri-articular plates.

METHODS: Forty-nine displaced fractures of the tibial plateau in forty-nine patients were treated with open reduction and buttress plate fixation using low profile plate between 2002–2006. All aspects of their care, including tibial plateau fracture type, operative management and associated injuries, were documented. Preoperative and postoperative follow-up radiographs were analyzed for fracture classification and adequacy of reduction. All patients were followed up with clinical assessment and given Iowa knee functional outcome questionnaires. Data were also collected regarding return to work and sporting activities. The average age of the patients was thirty-eight years and the mean follow-up was 25 months, with a range of 12 to 52 months.. Of the forty-nine fractures studied, twenty-six were classified as Schatzker types I, II, or III, and the remaining twenty-three were types IV, V, or VI. Forty-six patients had closed injury while three had open fractures.

RESULTS: 48 of the fractures healed without additional surgical intervention or bone grafting except for one bicondylar fracture which needed amputation because of deep infection and soft tissue problem. Thirty eight patients had follow-up of greater than 1 year. The average time to radiographic callus was 6.2 weeks, and the average time to complete union was 16 weeks. The articular step-off average was 0.8 mm, with a range of 0 to 5 mm. The range of motion of the knee averaged 3° of extension to 120° flexion, which was an average of 87% of the total arc of the contralateral knee. The average Iowa Knee Score was 88 points (range, 72 to 100 points). The postoperative alignment demonstrated 1 patient with a malalignment of 4 degrees procurvatum and 1 patient with 3 degrees of valgus. There were two superficial wound infections and one case of deep infection.

CONCLUSIONS: Open reduction and internal fixation is a satisfactory technique for the treatment of displaced fractures of the tibial plateau, particularly for patients younger than fifty years. The use of low profile tibial plates appears to stabilize complex fractures of the tibial plateau with a low incidence of complications. The low profile plate functioned well in maintaining alignment and obtaining union in these high-energy fractures.

Chronic osteomyelitis is a very difficult condition to treat. It presents a considerable challenge. A structured approach with a multidisciplinary team is important.

Fifty-three patients with chronic femoral osteomyelitis were treated. Thirty-one cases followed fracture fixation, fourteen haematological, two knee fusion and two iatrogenic. Cierny and Mader grade was IV in twenty-eight cases(twelve non-unions). Union was achieved in eleven of twelve nonunions. 85% of cases were infection free with the current treatment. 92% union rate was achieved. Eradication of infection and functional preservation can be achieved by wide local debridement with good soft tissue coverage and skeletal stabilisation.

Chronic osteomyelitis is a very difficult condition to treat. It presents a considerable challenge. A structured approach with a multi-disciplinary team is important.

85% of cases were infection free with the current treatment. 92% union rate was achieved. Eradication of infection and functional preservation can be achieved by wide local debridement with good soft tissue coverage and skeletal stabilisation.

Fifty-three patients with chronic femoral osteomyelitis were treated. Mean age at onset was thirty-one years and mean duration of infection was one hundred and six months (range 2–504). Thirty-one cases followed fracture fixation, fourteen haematological, two- knee fusion and two iatrogenic. Cierny and Mader grade was IV in twenty-eight cases(twelve non-unions), III in twelve, II in two and I in eleven cases. Intramedullary disease was treated by reaming and cortical disease by local excision. Radical excision was done for local disease. Radical/segmental excision reserved for type IV disease. This was followed by dead space management (local antibiotics in thirty-eight patients), stabilization and iv antibiotics(four to six weeks). Infected nonunion was treated with excision and stabilization or Ilizarov reconstruction. Union was achieved in eleven of twelve nonunions. 85% of cases were infection free at a mean follow-up of thirty months (7–48).

Introduction: Ankle fusion presents a difficult problem in the presence of infection and poor bone stock. Ilizarov method provides stability with remote fixation and allows weight bearing.

Patients and Methods: Fourteen consecutive patients were studied. The mean age at onset of disease was 50 years(range 4–70). 13 of the patients had either clinical or radiological evidence of infection prior to ankle fusion surgery. Mean duration of problem was 52 months(range 8–372). Aetiology included traumatic arthritis in 5, failed fusion in 6, septic arthritis in 1, infected ankle fracture nonunion in 1 and avascular necrosis of talus in 1. There were 10 males and 4 females. Local excision was followed by Ilizarov frame compression. Diagnosis of infection was based on microbiology and histology. Antibiotics treatment was continued until union. On radiological evidence of union the frame was dynamized and removed. Below knee cast was applied for 4 weeks.

Results: 13 of 14 patients had complete ankle fusion at a mean period of 5 months. 1 patient who had partial fusion of the ankle had recurrence of infection requiring amputation. Complications included pin site infection, lateral impingement, deep infection, hind-foot pain and neuroma at amputation site.

Conclusion: The Ilizarov ankle fusion is a reliable salvage procedure in difficult ankle problems.

Introduction Ankle fusion presents a difficult problem in the presence of infection and poor bone stock. The Ilizarov method provides stability with remote fixation and allows weight bearing.

Patients and method Fourteen consecutive patients were studied (10 males, 4 females). The mean age at onset of disease was 50 years (range 4–70). Thirteen of the patients had either clinical or radiological evidence of infection prior to ankle fusion surgery. Mean duration of problem was 52 months (range 8–372). Aetiology included traumatic arthritis in five, failed fusion in six, septic arthritis in one, infected ankle fracture non-union in one and avascular necrosis of talus in one. Local excision was followed by Ilizarov frame compression. Diagnosis of infection was based on microbiology and histology. Antibiotic treatment was continued until union. On radiological evidence of union the frame was dynamized and removed. A below-knee cast was applied for 4 weeks.

Results At a mean period of 5 months, complete ankle fusion was found in 13/14 patients. One patient who had partial fusion of the ankle had recurrence of infection requiring amputation. Complications included pin site infection, lateral impingement, deep infection, hind-foot pain and neuroma at amputation site.

Conclusion The Ilizarov ankle fusion is a reliable salvage procedure in difficult ankle problems.

We describe a technique of ‘cross-hip distraction’ to reduce a dislocated hip with subsequent reconstruction of the joint for septic arthritis with extensive femoral osteomyelitis. A 27-year-old woman presented with a dislocated, collapsed femoral head and chronic osteomyelitis of the femur. Examination revealed a leg-length discrepancy of 7 cm and an irritable hip. A staged technique was used with primary clearance of osteomyelitis and secondary reconstruction of the hip. A cross-hip monolateral external fixator was used to establish normal anatomy followed by an arthroplasty. A good functional outcome was achieved. The use of cross-hip distraction avoids soft-tissue and nerve damage and achieved improved abductor function before arthroplasty.