Infected Tibial Nonunion: Assessment of compression distraction Ilizarov technique without debridement.

BACKGROUND: The treatment of infected nonunion requires radical debridement with stable fixation. Sever soft tissue compromise of the nonunion site might interfere with radical debridement. This study discussed the outcome of treatment of infected tibial nonunion with sever soft tissue compromise by a cyclic compression distraction technique using Ilizarov without radical debridement. METHODS: This study comprised 17 patients with unilateral infected tibial nonunion; 10 with diaphyseal and 7 with metaphysial locations.Their mean age was 21.9 years. There were 12 males and 5 females. The right side was affected in 11 patients and the left side in 6 patients. According toGustilo and Anderson classification, all patients were grade III. The mean limb shortening was 1.3cm. All patients were treated initially in another institute by uniplanner external fixator with rotational skin flap done in 11 patients and thiersch graft in 6 patients. One patient had common peroneal nerve affection. Distal circulation was sufficient in all patients. None of our patients had chronic diseases. Two to three cycles of gradual distraction compression were done. Each cycle consisted of distraction, followed by compression, then distraction, and lastly compression. The mean follow up period was 29.35 months. RESULTS: Union was achieved in all patients at a mean time of 23.9 weeks. According to Hammer et al.; there were 8 patients with grade 1, and 9 patients with grade 2. According to Johner and Wruhs' criteria; the outcome was excellent in 6 patients, goodin 3 patients, poor in 4 patients, and fair in 4 patients. Complications had occurred as pin tract infection (47.1%), persistent discharging sinus (5.9%), and valgus ankle deformity (11.8%). Refracture did not occur in any case till the final follow up. CONCLUSION: Although debridement is essential in the treatment of infected tibial nonunion, it could harm the limb in severe soft tissue compromise. Cyclic compression distraction by Ilizarov had a satisfactory outcome in the treatment of such cases through enhancement of a biological environment to achieve union. LEVEL OF EVIDENCE: IV; prospective case series.

Treatment of large posttraumatic tibial bone defects using the Ilizarov method: a subjective outcome assessment.

BACKGROUND: The treatment of large posttraumatic tibial bone defects using the Ilizarov method was shown to be successful in several studies. These studies, however, typically focus on the radiological and functional outcome using objective parameters only. The aim of the present study was therefore to assess the objective and subjective outcome of a consecutive series of patients with large posttraumatic tibial bone defects using the Ilizarov method. Additionally, it was our goal to assess the physical and mental stress for the patients and their relatives during the long treatment period and the general health status at final follow-up. METHODS: A consecutive series of 15 patients with posttraumatic tibial bone defects of >30 mm after sustaining open tibial fractures and failure of internal fixation was included. The objective outcome was assessed at final follow-up using Paley's criteria. For the assessment of the subjective outcome, all patients were asked to evaluate their satisfaction with the function of the lower leg, the cosmetic appearance and overall outcome as well. The physical and mental stress of the treatment for the patients and the nearest relative of patients were assessed at the time of frame removal using a custom-made questionnaire. The SF-36 was used to evaluate the general health status at final follow-up. RESULTS: Solid bone union with stable soft tissue coverage and eradication of infection was achieved in all patients despite a high complication rate. The functional outcome at final follow-up was excellent or good in all patients. The patients' satisfaction with the overall outcome and the function of the lower extremity was high as well. The fear of amputation and complications was the major subjective burden for both the patients and their relatives. The long external fixation time is another relevant issue. CONCLUSION: The Ilizarov method is a safe option for the treatment of large posttraumatic tibial bone defects after failure of internal fixation despite the high complication rate. It is essential to comment this to the patients and their relatives prior to the application of the frame increase their compliance with the long and emotionally draining treatment. The Ilizarov method is worth the effort only in patients, who will presumably comply with this treatment option and all of its drawbacks.

Adaptation of Ilizarov ring fixator to the economic situation of developing countries.

Especially in countries with low per capita income, poor patients with open fractures and non-unions are unable to purchase modern, commercially produced surgical implants. To alleviate this situation, we initiated the production of a locally made ring fixator. The rings were cut from tubes cast from scrap aluminium. It was applied in 40 patients to test its utility for the typical indications for the Ilizarov technique. The fixator was tolerated well. All fractures united except in one case where there was refracture of the consolidate due to too early removal of the fixator. Two arthrodeses were successful. Bone transport showed adequate regeneration. A single radial non-union united successfully. Loosening occurred in 11 wires and breakage in 6. The subacute infections in 11 (27.5%) patients were not due to the fixator itself but to low standards of hygiene and the delay of treatment in the prehospital phase. Reusing the fixator at least three times reduces the cost for the individual patient to US$ 13.60. A locally made fixator is cost-effective and can be recommended for surgical treatment under similar economic situations.

Reflections of a novice researcher.

Nurses can benefit from active participation in research activities. Involvement in research is not just an academic pursuit but is essential for effective, quality care. Nurses should actively seek the support of colleagues and research support structures to enable involvement in research. Clinical nurses are capable of making an important research contribution.