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 Table of Contents  
Year : 2020  |  Volume : 12  |  Issue : 1  |  Page : 62-66

Outcomes of ilizarov ring fixation in infected nonunion of tibia

Department of Orthopaedics, NKP Salve Institute of Medical Sciences and Lata Mangeshkar Hospital, Nagpur, Maharashtra, India

Date of Submission13-Jan-2020
Date of Acceptance20-Apr-2020
Date of Web Publication26-Jun-2020

Correspondence Address:
Dr. Faizan Mohammed
Department of Orthopaedics, NKP Salve Institute of Medical Sciences and Lata Mangeshkar Hospital, Nagpur, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jotr.jotr_3_20

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Objective: The objective of this study was to determine the outcomes with the use of Ilizarov's external fixator in infected nonunion of tibia. Materials and Methods: In this single-center, retrospective study at a teaching medical institute, patients who were treated with Ilizarov's external fixator for infected nonunion of tibial fractures were assessed. Achievement of union and the Association for the Study and Application of the Method of Ilizarov (ASAMI) outcomes were assessed. Results: Between January 1995 and December 2018, a total of 20 patients identified who underwent Ilizarov's procedure. The median age was 43.5 years (range: 7–65 years). The median level of bone defect was 60 mm. In 20 cases, 18 had infected nonunion. The median consolidation time was 8 months. During the median follow-up of 2 years, 83.3% (15/18) achieved complete union. The median union time was 11 months. Pin-tract infections were observed in 33.3% (6/18) of the patients. As per ASAMI outcomes, bone results were excellent in 72.2% (13/18), good in 11.1% (2/18), and poor in 16.7% (3/18), and the function results were excellent in 50% (9/18), good in 33.3% (6/18), and poor in 16.7% (3/18). Conclusion: Ilizarov's ring fixation is a reliable and suitable method for providing excellent bone and functional results in infected nonunion of tibia.

Keywords: Ilizarov fixation, infection, nonunion, tibial fracture

How to cite this article:
Mankar S, Mohammed F, Bhutada G, Sakhare R. Outcomes of ilizarov ring fixation in infected nonunion of tibia. J Orthop Traumatol Rehabil 2020;12:62-6

How to cite this URL:
Mankar S, Mohammed F, Bhutada G, Sakhare R. Outcomes of ilizarov ring fixation in infected nonunion of tibia. J Orthop Traumatol Rehabil [serial online] 2020 [cited 2020 Oct 22];12:62-6. Available from: https://www.jotr.in/text.asp?2020/12/1/62/287715

  Introduction Top

Tibial fracture is a common occurrence in road traffic accidents (RTAs), falls, and other types of injuries.[1] The incidence rate of 16.9/100,000/year for tibial shaft fractures has been reported.[2] Infected nonunion of tibial fractures is a dreadful and challenging issue faced by orthopedicians.[3] In long bone fractures, nonunion prevalence of 34.64% has been reported from India.[4] In proximal tibial fracture, an infection rate of 9.8% has been reported and that was higher in open fractures (12.9%) compared to closed fractures (10.3%).[5] Nonunion occurs in 2.5% of the closed tibial fractures and increases 5–7-fold in open fractures with gross soft-tissue damage and contamination.[6] Principally, the infected nonunion of tibia is treated with debridement along with either internal or external fixation.[3]

The use of Ilizarov's fixator to provide external fixation has been a revolutionary treatment in infected nonunions of tibial fractures.[3] It is being used widely around the world.[6],[7],[8],[9],[10],[11] A study from China reported satisfactory results in bone and functional outcomes.[7] Multiple studies in India also reported improved outcomes in infected nonunion of tibia with radical debridement and Ilizarov's ring fixator.[6],[8],[9] Although Ilizarov fixation has been identified as a reliable, versatile, and effective treatment,[12] its experience and outcome evidence from Central Indian population is lacking. Being used as one of the treatments in infected nonunions of tibia, we aimed to understand the outcomes with its use at our center from Central India.

  Materials and Methods Top

Study setting

This study was performed in a tertiary care medical teaching institute in Central India. The institute caters to the urban, semi-urban, and rural population. This center also provides operative and interventional orthopedic services.

Study design

This was a single-center, retrospective, observational study in the orthopedic department of a tertiary teaching institute.

Study duration

We scanned the database from January 1995 to December 2018 for identifying the patients who underwent Ilizarov's external fixation for nonunion of fracture tibia.

Study population

In this study, database of our institution was screened for inclusion of patients who had underwent Ilizarov's procedure for radiologically proven infected nonunion of fracture in tibia with bone defect of more than 2 cm shortening and previous failed surgery. Patients who had malunion or whose data on outcome parameters were not available were excluded from the analysis.

Study outcome assessments

The main outcome assessment was achievement of union at fracture site. The nonunion was considered based on the opinion of the treating orthopedic surgeon where there was no possibility of healing without further intervention.[13] The outcomes assessed were development of pin-tract infection or persistence of infections. The Association for the Study and Application of the Method of Ilizarov (ASAMI) outcomes in terms of bone results and functional results were also assessed in all patients.[14] The ASAMI criteria are summarized in [Table 1].
Table 1: Association for the Study and Application of the Method of Ilizarov bone result and function result criteria

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Study methodology

From the patient records, we identified demographic, clinical, and outcome data which were recorded in a structure pro forma. Demographic data included age and gender. Clinical data included fracture etiology, details of fracture, details of fracture healing, and past surgeries performed. Furthermore, abnormalities in gait in terms of pain, limp, limb length discrepancy, and deformity were recorded.

Fractures were graded according to the Gustilo-Anderson classification into Type I (open fracture with a clean wound of size <1 cm), Type II (open fracture with a laceration >1 cm without extensive soft-tissue damage, flaps, or avulsions), and Type III (open segmental fracture, open fracture with extensive soft-tissue damage, or a traumatic amputation). Type III fractures were also further categorized as IIIa (open fractures, extensive soft-tissue laceration or flaps but with adequate soft-tissue coverage of a fractured bone, or high-energy trauma irrespective of the wound size), IIIb (open fractures, extensive soft-tissue injury, periosteal stripping, and bone exposure with contamination), and IIIc (open fractures and injury to vessels necessitating repair).[15],[16] Bone defect measurement was done on radiographic assessments.

Ilizarov's procedure

Under aseptic procedure, spinal anesthesia was given to all patients. Ilizarov's frame was constructed as per radiological and clinical finding preoperatively. The nonunion site was approached in aseptic way. After careful and adequate debridement at the nonunion site, bone ends were freshened. Any sequestrate bone fragments were removed. Any hardware such as plating and intramedually nails were removed. After removal of the nails, thorough lavage of canal was performed. The defect was assessed for size. Docking of the site was done in defects <2.5 cm in size. For defects >2.5 cm, acute docking was not performed. Single corticotomy was done for defects <5 cm, while for defects more than 5 cm in diaphysis, double corticotomy at both metaphyses was done. Barring initial few cases, bone transport was done over intramedullary thin nail to guide the transport and achieve proper docking. In general, we use 180 mm and 4–5 ring construct using 1.8-mm Ilizarov wires, but this was modified as per patient need. In case of lower end fracture, we used foot frame to avoid the development of the equinus deformity. Fibulectomy was performed if fracture in fibula would affect the union at tibial site or else it was left alone.

In immediate postoperative period, limb raising was done and neurovascular integrity in operated limb was checked. Antibiotics administered based on culture and sensitivity report. In all cases, on the first postoperative day, frame stability was checked manually by ensuring appropriate fitting of all nut-bolts and proper tension in the wires. Pin sites were also checked. Limited mobility adjacent joint was allowed. On the 2nd postoperative day, all patients were asked to bear weight on limbs. Pin site care was continued during the hospital stay. On the 10th day, accordion maneuver was initiated. Patients were discharged between 10 and 15 days after training on accordion maneuver and pin site care.

During follow-ups, stability of frame, pin sites, and adjacent joint mobility were checked. Union or quality of regenerate was assessed with radiographs taken at appropriate times. Pin sites were assessed for pin-track infection.

Statistical analysis

The data of patients were entered in Microsoft Excel spreadsheet version 2016. (© Microsoft 2020), Microsoft Corporation, Redmond, Washington, US. The categorical variables were presented as frequency and percentages. Continuous data were presented as medians. Data were analyzed with descriptive statistics.

  Results Top

Baseline characteristics

Between January 1995 and December 2017, a total of 20 patients underwent Ilizarov's procedure at our institute. The baseline characteristics of these patients are shown in [Table 2]. The median age was 43.5 years and ranged from 7 to 65 years. Ninety percent of the patients were males. RTAs were the most common (90%) etiology of tibial fractures, with 55% fractures being of Grade IIIb. The median level bone defect was 60 mm. Fifty-five percent of the patients had undergone external fixation before being subjected to Ilizarov's procedure. The clinical abnormalities are described in [Table 3]. Limb length discrepancy was <2.5 cm in 50% of the cases, whereas it was >2.5 cm in only one patient, and the rest could achieve almost normal length. The deformity was <7° in 20% of the cases. Among symptoms, 10% had pain, 15% had limp, and 5% had limb stiffness.
Table 2: Baseline characteristics

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Table 3: Clinical abnormalities

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Outcome of Ilizarov's procedure

Among these patients who underwent Ilizarov's procedure, the etiology nonunion of tibial fracture was found to be infective in 90% (18/20) cases, whereas 10% (2/20) cases had nonunion unrelated to infection. These patients who had infected nonunion were assessed for outcome, as shown in [Table 4]. The median consolidation period was observed to be 8 months. During the median follow-up of 2 years, 83.3% (15/18) of the patients achieved complete union of tibial bone. The median union time was 11 months. [Figure 1] shows the complete union outcome in one of the patients from our center. The nonunion was persistent in 16.7% (3/18) of the cases. Among complications, 33.3% (6/18) of the patients had pin-tract infection and two patients had persistent deep infection. Refracture occurred in two patients after the removal of the frame. In one patient who had a refracture at fracture site, repeat Ilizarov's procedure was performed which resulted in bone union. The other patient with refracture at the regenerate was treated with plating and union was achieved. One patient had development of appreciable equinus. After frame removal, one patient needed plating and bone grafting, whereas other one required intramedullary interlocking nail without bone grafting.
Table 4: Outcome of Ilizarov's technique

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Figure 1: Course to complete union outcome in one study patient. (a) Fixator with infected non-union, (b) After fixator removal, (c) Corticotomy distracted and bone transport done over nail, (d) Bone transport completed, e. After removal of Ilizarov ring, regenerate consolidated and union achieved, (f) At 2 years – follow-up

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The ASAMI outcomes of the patients are shown in [Table 5]. Bone results were excellent in 72.2% (13/18), good in 11.1% (2/18), and poor in 16.7% (3/18). Function outcome result was excellent in 50% (9/18), good in 33.3% (6/18), and poor in 16.7% (3/18).
Table 5: Association for the Study and Application of the Method of Ilizarov score outcomes

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  Discussion Top

Infected nonunion of tibial fractures is one of the problematic situations faced by orthopedicians. Its treatment necessitates appropriate planning and execution to derive optimal outcomes. Since long, Ilizarov ring fixation is being used for the treatment of nonunions of bones and is especially used in infected nonunions of tibia.[3] Distraction histogenesis is considered a procedure of choice of nonunions of ≥4 cm.[16] The use of single debridement procedure followed by the use of Ilizarov ring fixation achieves union in 70%–100% of the cases.[17] The union was achieved in 83.3% of the patients in our study. Nonachievement of union after Ilizarov's procedure for a considerable time can be due to many factors. However, in patients with infected nonunions, persistent infection can be the major cause. We observed persistent infection in two cases. A study from Sakale et al. observed no persistent infections in any patients, and this probably resulted in achievement of union in 100% of the cases.[6] The age is also important factor in determining union in tibial fracture with infected nonunions. The median age in our study was 43.5 years, and only one patient was above the age of 60 years. A study from Brinker and O'Connor in older adults (>60 years) reported union in all cases treated with Ilizarov ring fixation for tibial nonunions.[11] ASAMI outcomes for bone and functional results were excellent to good in majority of the cases in our study. The comparative evaluation of ASAMI outcome to previous studies[6],[17],[18],[19] is shown in [Table 6]. As seen from [Table 6], excellent-to-good results are achieved in all the studies in majority of the patients establishing utility of Ilizarov fixation in infected nonunion of tibia.
Table 6: Association for the Study and Application of the Method of Ilizarov bone result and functional result comparison to previous studies

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One more important aspect in the use of Ilizarov's procedure is prevention of pin-tract infections. We found pin-tract infection in one-third patients. This can be managed with oral antibiotics and local tract care with iodine application. A similar study from Sahu and Ranjan reported pin-tract infection in all sixty cases which were treated with oral antibiotics.[20] Equinus deformity was observed in one patient only, whereas Sahu and Ranjan reported the same in four cases.[7] Thus, proper care is necessary to reduce the occurrence of pin-tract infections.

  Conclusion Top

Infected nonunion of tibia is a disastrous situation affecting the quality of life of patients. Radical debridement with external fixation using Ilizarov ring fixator remains the mainstay of treatment. With such, bone union was achieved in over 80% of the cases. Nonunion even after the use of Ilizarov's method can occur which necessitates appropriate action with either internal fixation with hardware or repeat Ilizarov fixation after correction of any persistent infection. Our experience is in line with previously published evidence suggesting Ilizarov's ring fixation to be the most reliable and outstanding method in providing excellent bone and functional results in infected nonunion of tibia.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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