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. MDDepartment of Orthopedic surgery Ghaem HospitalMashhad University of Medical Sciences, Mashhad, [email protected]
Infected nonunion
40 patients; 34 men, 6 women
28 tibia 12 femur
23 (57%) Smoker
Infected nonunion
infected nonunion of tibia; 28 patients
17 middle third 60% 8 distal third 28% 3 proximal third 12%
Infected nonunion
infected nonunion of the femur; 12 case
7 distal third 58% 3 middle third 25% 2 proximal third 16%
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
Infected nonunion of the femur,12 case
Ilizarov apparatus: 5 casesPlate/ IM rod removal and sequential debridement,…, grafting and plating again; 4 casesPlate removal and sequential debridement,…, grafting and girdle stone; 2 casesPlate removal and sequential debridement,…, grafting and external fixatore, 1 case
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
Ilizarov Results(26 patients)
Complications:Pin tract infection 15 casesKnee stiffness 12 Ankle/foot stiffness 15Proneal nerve palsy 3 Refracture 0
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.
Results
Plate/ IM rod removal and sequential debridement,…, grafting and plating again 11 patients
10 finally successful1 amputation
Results
Plate removal and sequential debridement,…, grafting and external fixatore, 1 case Successful
Infected nonunion treatment methods depend on
Type of nonunion; atrophic? Hypertrophic?
Extent of infection
Presence of atrophic skin changes
Ilizarov`s concept for infected nonunion:
Osteomylitis burns in the fire of regenerationActivate biosynthetic process, increasing local resistant to infection
Three ways of elimination of infection in Ilizarov method
Controlled osteogenesis, filling of cavities by newly formed tissueResection of infected bone and subsequent intercalary bone lengtheningGradual bone transport of one wall of the cavity
Ilizarov
Distraction osteogenesisTension-stress effectMechanical induction of new bone formationNeovascularizationStimulation of biosynthetic activityActivation and recruitment of osteoprogenitor cellsIntramembranous ossification
Ilizarov`s plan depends on
Size and thickness of bone fragmentDegree and type of displacementThe extent of mobilityAmount and character of scar tissuePrevalence of purulent processCharacteristics of the individual case
Important
Nutritional Index #WBC Functional WBC Stop Smoking
Monofocal longitudinal compression
Hypertrophic nonunion Minimal infectionNo sequestrum, smallest sequester left in place, they are assimilated in the process of active osteogenesis
-spontaneous eradication of infection and achievement of union
Bifocal Method
Atrophic nonunion with diffuse infection and sequestrum
Infected segment should be resectedCreating an intercalary defect
Bifocal Method
Acute shortening, opposing ends under compression; 1-2 Cm defect
Poor skinBig necrotic bone Numerous fistula
Bilocal simultaneous compression-distraction osteosynthesis
Small gap & substantial bone shortening
Persistent drainage And gross motion afterMultiple attempts atSurgical treatment
Treatment consistedOf resection of Infected bone, acuteShortening and External fixation
Followed by proximalCorticotomy andDistraction to restorelength
Bilocal consecutive distraction-compression osteosynthesis
Large gap
A little Literature Review
Acute compression and lengthening by Ilizarov method for infected
nonunion of tibiaMagadum MP at al, J of Orthopedic Surgery, 2006;14(3).27 patientComplete debridment of nonunion, sequestrectomy, lavage and Ilizarov applicationGap; 10 (6-17)19 excellent, 5 good, 1 fair, 1 poor,1 above-knee amputation in 10-24 months.
Ilizarov method as a salvage procedure in infected nonunion of
the distal femur with bone lossSaridis A et al. JBJS Br. 2006; 8(2).
13 patients; 10 men, 3 womenRadical debridement and Ilizarov application3.1 previous surgeries8.3 mean length of defect(3-18)MEAN external fixator time 309 daysUnion and elimination of infection achived in all 13 patients. 8 excellent, 4 good, 1 fair.1 re-fracture
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.