|Dinesh Shankar A.N*,Anoop. A**
* Associate Professor
**D Ortho, DNB Student, Dept. of Orthopaedics, MCH, Calicut
Address for Correspondence
Associate Professor of Orthopaedics,
Medical College Hospital, Calicut 8,
With increase in high velocity injuries the incidence of compound fractures have been on increase especially in subcutaneous bones like tibia. The only option available in such clinical situation is probably only illizarov technique. In this study we attempted to analyse the clinical outcome regarding function and fitness regarding occupation.
15 cases were selected between the period 1999 and 2003 irrespective of age and sex. Majority were males and between the ages of 25 to 35. Duration of illness on an average was 5 years. Unifocal lengthening was usually done, bifocal lengthening was done for external bone loss. Foot assembly was given to patients whenever indicated.
Of 15 patients operated, 8 fractures had already united and frames removed. In 4 patients fractures united and are in a static phase. 2 cases are in the process of union and in 1 patient fracture did not unite where illizarov frame was removed and a transarticular intramedullary nail was done. Later bone grafting was done and fracture united.
The gap non union incidence is increasing due to high velocity injuries and many of the conventional treatment options cannot be applied in such clinical problem. Illizarov technique with bone transport is a good clinical option for such patients. The overall results i.e., 80% union rate was good and early partial weight bearing was allowed.
To conclude illizarov technique is probably the only option in gap non union / infected gap non union were other conventional modalities of treatment fail.
AIMS AND INTRODUCTION
Gap non union and infected non union are challenging problems to orthopaedic surgeons all over the world. Many methods have been used to treat this particular problem. Radical debridement, local flaps, muscle flaps, bone graft (Papineau technique), tibiofibular synostosis, cancellous allograft, fibrin mixed with antibiotic, antibiotic beads, microvascular flaps and vascularised bone transplants. But none of these techniques are satisfactory and morbidity during treatment is high.
Radical debridement often results in large gaps which are difficult to reconstruct without disability. Internal fixation is often not possible due to anatomical reasons like loss of bone or defective quality of bone or infection. External fixators definitely has the advantage of introducing less foreign body inside the bone. Internal fixation results in recurrent infections. With fixators like illizarov method weight bearing during treatment is definitively an advantage which reduces fracture disease and improves quality of bone.There is a definitive advantage of correction of deformity and there is no need for long term iv antibiotics.
Basic fixator system consists of rings and tensioned wires (transosseous), compression distraction technique and bone transport, and deformity correction is easily achieved by changing distraction between rings and changing alignment between rings(2,3,4). Distraction of corticotomy site regenerates new bone tissue which later undergo ossification. Newly regenerated soft bone can be moulded into any length for deformity correction and gap reconstruction.
Internal bone transport is a special feature of this fixator. A thorough debridement and removal of sequestrum and its subsequent sequelae can be managed by this principle. Revascularisation of partially sequestrated bone is an added advantage. After bone transport compression is applied at non union site after correction of non union site. Varying degrees of weight bearing is allowed according of construct of frame and quality of bone. With this technique resection of infected tissue and sequestrated bone and defect produced by it can be reconstructed. In this study we attempted to follow up cases of infected non union and gap non union treated by bone transport, compression distraction technique.
PATIENTS AND METHODS
15 patients treated during the period of 1999-2003 at Medical College, Calicut were followed up for an average period of 2 years. Average duration of infection and non union was 1½ years. Of 15 cases, 8 cases were associated with sequestration of circumferential bone with an average shortening of 5cm. Of 15 cases operated previous open reduction and internal fixation were done in 6 cases. Bone graft was done in 7 cases. In 1 case cross legged flap was done previously. All cases were treated by upper tibial corticotomy. 4 patients had bifocal distraction with trifocal correction. In 5 cases, there was no shortening. But sequestrectomy and debridement resulted in shortening. 3 cases were treated by internal bone transport by olive wires. 9 cases were treated by principle of compression and distraction.
OBSERVATION AND RESULTS
Of 15 cases treated, 8 fractures healed at the time of latest follow up and fixators removed. In 4 patients fracture united but are in static phase. 2 cases are in the process of union and in 1 case fracture did not unite in whom fixators were removed early because of pin tract infection and patient was diabetic. The average shortening was 5cm and post operative limb length discrepancy was not seen in any patient. Average defect was 4.5cm. Average length of bone by bone transport or distraction was 10cm (after sequestrectomy). One patient had stress fracture at the lengthened site after removal of fixator. 3 patients had recurrent infection after union. Follow up was assessed by criteria of union, infection and function. 8 patients had good function and no infection with fracture union. 3 patients had fracture union but with infection. Joint function was initially impaired but gradually improved after fracture union. No added procedure like flaps or bone graft were used.
Long standing bone infection is difficult to treat. Gap non union with infection is all the more a challenging problem. Such clinical situations tend to have residual deformity, persistent infection, contractures, prolonged fracture disease and even a useless limb. Newer techniques like local flaps, microvascular flaps, microvascular bone transplant have improved results but have not fully solved this clinical problem(1,5). These techniques have promising advantages but early weight bearing is not possible and fracture disease is accelerated. The mechanical advantage of rings and wires gives us an option of compression, distraction and bone transport. This technique have definitive advantages over other conventionally available surgical techniques. Illizarov technique after resection of infection, sequestrated bone and repair of defect with restoration of activity and limb length is a unique advantage. Joint function and weight bearing while on treatment is an advantage which cannot be matched by another technique.
This frame is stable to axial load but not to torsional or bending forces.
Micro movements at fracture site is allowed with advantage of weight bearing but stability of frame on axial loading should be achieved at any cost.
% of patients had discharging sinuses.
% of patients were not treated by long term antibiotics
Fracture disease is eliminated by early weight bearing and joint mobilization. The new bone formed at distraction site may take years for a perfect remodeling but early weight bearing can be allowed even before remodeling.
The duration of application of frame is a disadvantage but when all other treatment process have failed, this technique is probably only alternative and only hope for many suffering patients. Disuse osteoporosis is not a problem with this technique. Elimination of bone graft and open reduction and internal fixation are advantages. This is a bloodless surgery and less invasive technique in treating non union and infective non union.
The clinical conditions like infected non union and gap non union were all other treatment modalities fail,
Illizarov give excellent results. It is probably the only alternative available in current scenario to manage such a clinical situation.
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2. Fleming B Palely, D Christianson. A biomechanical analysis of illizarov and external fixators. Clinical orthopaedics and related research. 241 – 195, 1989.
3. Guinarop Biaseibetti A, Damango SJ. Treatment of long bone diaphysial pseudoarthrosis by means of external fixators.
4. Recent advances in external fixators. Reva Dell, Garda. Italy University of Verona. Sept.28, 30, 1986 pp94, 97.
5. Johnson EE, Urist MR, Finerman. Repair of segmental defects of tibia with cancellous bone graft augmented by human bone morphogenetic protein – a preliminary report. Clinical Orthopaedics 236, 249 – 1998.