Results and techniques of the treatment of infected nonunion of the long bones, a report of 40 cases

1. Ebrahimzadeh Mohammad H. MD Department of Orthopedic surgery Ghaem Hospital Mashhad University of Medical Sciences, Mashhad, Iran. Ebrahimzademh@MUMS.ac.ir Results and techniques of the treatment of infected nonunion of the long bones, a report of 40 cases

2. Infected nonunion • 40 patients; 34 men, 6 women • 28 tibia • 12 femur • 23 (57%) Smoker

3. Infected nonunion • infected nonunion of tibia; 28 patients • 17 middle third 60% • 8 distal third 28% • 3 proximal third 12%

4. Infected nonunion • infected nonunion of the femur; 12 case • 7 distal third 58% • 3 middle third 25% • 2 proximal third 16%

5. 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

6. Infected nonunion of the femur,12 case • Ilizarov apparatus: 5 cases • Plate/ IM rod removal and sequential debridement,…, grafting and plating again; 4 cases • Plate removal and sequential debridement,…, grafting and girdle stone; 2 cases • Plate removal and sequential debridement,…, grafting and external fixatore, 1 case

7. 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

8. Ilizarov Results(26 patients) • Complications: • Pin tract infection 15 cases • Knee stiffness 12 • Ankle/foot stiffness 15 • Proneal nerve palsy 3 • Refracture 0

9. 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.

10. Results • Plate/ IM rod removal and sequential debridement,…, grafting and plating again 11 patients • 10 finally successful • 1 amputation

11. Results • Plate removal and sequential debridement,…, grafting and external fixatore, 1 case Successful

12. Infected nonunion treatment methods depend on • Type of nonunion; atrophic? Hypertrophic? • Extent of infection • Presence of atrophic skin changes

13. Ilizarov`s concept for infected nonunion: • Osteomylitis burns in the fire of regeneration • Activate biosynthetic process, increasing local resistant to infection

14. Three ways of elimination of infection in Ilizarov method • Controlled osteogenesis, filling of cavities by newly formed tissue • Resection of infected bone and subsequent intercalary bone lengthening • Gradual bone transport of one wall of the cavity

15. Ilizarov • Distraction osteogenesis • Tension-stress effect • Mechanical induction of new bone formation • Neovascularization • Stimulation of biosynthetic activity • Activation and recruitment of osteoprogenitor cells • Intramembranous ossification

16. Ilizarov`s plan depends on • Size and thickness of bone fragment • Degree and type of displacement • The extent of mobility • Amount and character of scar tissue • Prevalence of purulent process • Characteristics of the individual case

17. Important • Nutritional Index • #WBC • Functional WBC • Stop Smoking

18. Monofocal longitudinal compression • Hypertrophic nonunion • Minimal infection • No sequestrum, smallest sequester left in place, they are assimilated in the process of active osteogenesis • -spontaneous eradication of infection and achievement of union

24. Bifocal Method • Atrophic nonunion with diffuse infection and sequestrum • Infected segment should be resected • Creating an intercalary defect

25. Bifocal Method • Acute shortening, opposing ends under compression; 1-2 Cm defect • Poor skin • Big necrotic bone • Numerous fistula

26. Bilocal simultaneous compression-distraction osteosynthesis • Small gap & substantial bone shortening

27. Persistent drainage And gross motion after Multiple attempts at Surgical treatment

28. Followed by proximal Corticotomy and Distraction to restore length Treatment consisted Of resection of Infected bone, acute Shortening and External fixation

29. Bilocal consecutive distraction-compression osteosynthesis • Large gap

38. A little Literature Review

39. Acute compression and lengthening by Ilizarov method for infected nonunion of tibia • Magadum MP at al, J of Orthopedic Surgery, 2006;14(3). • 27 patient • Complete debridment of nonunion, sequestrectomy, lavage and Ilizarov application • Gap; 10 (6-17) • 19 excellent, 5 good, 1 fair, 1 poor,1 above-knee amputation in 10-24 months.

40. Ilizarov method as a salvage procedure in infected nonunion of the distal femur with bone loss • Saridis A et al. JBJS Br. 2006; 8(2). • 13 patients; 10 men, 3 women • Radical debridement and Ilizarov application • 3.1 previous surgeries • 8.3 mean length of defect(3-18) • MEAN external fixator time 309 days • Union and elimination of infection achived in all 13 patients. 8 excellent, 4 good, 1 fair. • 1 re-fracture

41. 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.