Use of the 95-degree angled blade plate with biological and mechanical augmentation to treat proximal femur non-unions: a case series.

BACKGROUND: Intertrochanteric and subtrochanteric non-union are rare but challenging complications. In the present study, we investigate the use of a 95° blade, in association with biological and mechanical augmentation, in the management of intertrochanteric and subtrochanteric femoral non-unions. METHODS: Between October 2015 and February 2021, a retrospective cohort study was conducted at our institution to investigate the use of a 95° blade, in association with biological and mechanical augmentation, in the management of intertrochanteric and subtrochanteric femoral non-unions, following the mechanical failure of the first device. All the patients underwent a clinical and radiographic follow-up at 6 weeks, 3, 6, 9, 12 and 18 months; at each follow-up, a plain radiograph of the femur was performed and patients were assessed using Harris Hip Score (HHS) and the Short Form-12 (SF-12) questionnaire. RESULTS: From October 2015 and February 2021, 40 proximal femur non-unions were managed at our Institution. Fifteen patients out of forty (37.5%) met the inclusion criteria. The main data of the study are summarized in Table 1; patients' mean was 57 years old (range 19-83); 10 males and 5 females were included in the study. All the patients completely healed clinically and radiologically at an average of 6.1 months (range 4-13). All these patients returned to their pre-injury mobility status. During an average follow-up period of 25 months (range 8-60), the observed complications included wound dehiscence, which was treated with a superficial surgical debridement, a below-the-knee deep vein thrombosis, and a blade plate failure 3 months after the first revision surgery. CONCLUSIONS: This study shows the treatment of inter-and sub-trochanteric non-unions with a 95° blade plate, medial strut allograft, and bone autograft obtained with RIA system, together with a varus malalignment correction, leads to a high percentage of bone healing, with a low incidence of complications and good clinical outcome.

Clinical Application of Adipose Derived Stem Cells for the Treatment of Aseptic Non-Unions: Current Stage and Future Perspectives-Systematic Review.

Fracture non-union is a challenging orthopaedic issue and a socio-economic global burden. Several biological therapies have been introduced to improve traditional surgical approaches. Among these, the latest research has been focusing on adipose tissue as a powerful source of mesenchymal stromal cells, namely, adipose-derived stem cells (ADSCs). ADSC are commonly isolated from the stromal vascular fraction (SVF) of liposuctioned hypodermal adipose tissue, and their applications have been widely investigated in many fields, including non-union fractures among musculoskeletal disorders. This review aims at providing a comprehensive update of the literature on clinical application of ADSCs for the treatment of non-unions in humans. The study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Only three articles met our inclusion criteria, with a total of 12 cases analyzed for demographics and harvesting, potential manufacturing and implantation of ADSCs. The review of the literature suggests that adipose derived cell therapy can represent a promising alternative in bone regenerative medicine for the enhancement of non-unions and bone defects. The low number of manuscripts reporting ADSC-based therapies for long bone fracture healing suggests some critical issues that are discussed in this review. Nevertheless, further investigations on human ADSC therapies are needed to improve the knowledge on their translational potential and to possibly achieve a consensus on their use for such applications.

Preliminary outcomes of the combination of demineralized bone matrix and platelet Rich plasma in the treatment of long bone non-unions.

BACKGROUND: A variety of bone graft substitutes have been introduced into the treatment of bone non-unions. However, clinical outcomes from current evidences are various and conflicting. This study aimed to present the preliminary outcomes of a treatment protocol in which the combination of demineralized bone matrix (DBM) and platelet rich plasma (PRP) was used as a bone graft substitute for long bone non-unions. METHODS: Data of this retrospective study were reviewed and collected from a consecutive case series involving 43 patients who presented with a long bone non-union and were treated in our department from October 2018 to May 2019. The combination of DMB and PRP was applied as a bone defect filler in 16 patients, whilst the other 27 patients were treated with iliac bone autografting. Patients' demographics, postoperative complications and the result of bone union were compared and evaluated. RESULTS: The demographic data between the two groups were comparable. No significant difference was found with regard to the incidence of postoperative complications. No graft rejection, heterotopic ossification or other complications were noted. The distribution of bony healing time was rather scattered but did not differ significantly between the groups (7.533 ± 3.357 months vs. 6.625 ± 2.516 months; P=0.341). Union was identified radiographically in 15 of 16 patients in the DBM+PRP group and in 24 of 27 patients in autograft group. CONCLUSIONS: The present study identified that low incidence of postoperative complications and satisfactory bony healing rate could be achieved in the treatment of long bone non-unions augmented with the combination of DBM and PRP. Although these findings might indicate the promising future of this treatment protocol, larger and higher quality studies should also be executed to assess its routine use.

The role of biophysical stimulation with pemfs in fracture healing: from bench to bedside.

Clinical biophysics investigates the relationship between non-ionizing physical energy and the human body. This narrative review aims to summarize the current evidence on the efficacy of PEMF-therapy in the promotion of fracture healing. The effectiveness of PEMFs has been deeply investigated in preclinical in vitro ed in vivo studies and level-I clinical studies. All these studies depicted only PEMF-devices with specific physical wave features - i.e. pulse shape, frequency and amplitude- could significantly promote bone repair. Moreover, the dose-response relationship was also defined in preclinical studies, thus providing the minimum exposure time needed in PEMF-therapy. PEMFs are currently employed in the management several bone injuries, including acute fractures at non-union risk, non-unions, osteotomies, stress fractures and osteonecrosis. Moreover, several ongoing studies are investigating the effectiveness of PEMFs on emerging clinical conditions, thus the indications to PEMF-therapy could potentially raise in future years.

Variable fixation promotes callus formation: an experimental study on transverse tibial osteotomies stabilized with locking plates.

BACKGROUND: A new locking screw technology, named variable fixation, has been developed aiming at promoting bone callus formation providing initial rigid fixation followed by progressive fracture gap dynamisation. In this study, we compared bone callus formation in osteotomies stabilized with standard locking fixation against that of osteotomies stabilized with variable fixation in an established tibia ovine model. METHODS: A 3 mm tibial transverse osteotomy gap was stabilized in three groups of six female sheep each with a locking plate and either 1) standard fixation in both segments (group LS) or 2) variable fixation in the proximal and standard fixation in the distal bone segment (group VFLS3) or 3) variable fixation in both segments (group VFLS6). The implantation site and fracture healing were compared between groups by means of radiologic, micro tomographic, biomechanical, and histological investigations. RESULTS: Compared to LS callus, VFLS3 callus was 40% larger and about 3% denser, while VFLS6 callus was 93% larger and its density about 7.2% lower. VFLS3 showed 65% and VFLS6 163% larger amount of callus at the cis-cortex. There wasn't a significant difference in the amount of callus at the cis and trans-cortex in groups featuring variable fixation only. Investigated biomechanical variables were not significantly different among groups and histology showed comparable good healing in all groups. Tissues adjacent to the implants did not show any alteration of the normal structure in all groups. CONCLUSIONS: Variable fixation promoted the formation of a larger amount of bone callus, equally distributed at the cis and trans cortices. The histological and biomechanical properties of the variable fixation callus were equivalent to those of the standard fixation callus. The magnitude of variable fixation had a biological effect on the formation of bone callus. At the implantation site, the usage of variable fixation did not raise additional concerns with respect to standard fixation. The formation of a larger amount of mature callus suggests that fractures treated with variable fixation might have a higher probability to bridge the fracture gap. The conditions where its usage can be most beneficial for patients needs to be clinically defined.

[Stimulation of fracture healing by growth factors and cell-based technologies]. / Stimulation der Frakturheilung durch Wachstumsfaktoren und zellbasierte Technologien.

Bone has the special capability to completely regenerate after trauma and to re-establish its original geometry and biomechanical stability corresponding to the pretrauma conditions. Nevertheless, in daily clinical practice impaired fracture healing and nonunions are regular complications as a result of inadequate mechanical stability and/or insufficient biological processes around the fracture region. Since the beginning of the millennium, intensive research on the physiological processes in bone healing as well as the production and clinical administration of growth factors have enabled the possibility to improve the local biological processes during fracture healing by osteoinduction. Although the initial clinical results, particularly of bone morphogenetic proteins, in fracture healing were promising, growth factors did not become established for unrestricted use in the clinical application. Currently, additional growth factors are being investigated with respect to the potential supportive and osteoinductive characteristics for enhancement of fracture healing and possible clinical applications. Furthermore, the development of cell-based technologies is another promising approach to positively stimulate fracture healing. In addition to the gold standard of autologous bone grafting, harvesting of mesenchymal stroma cells by aspiration has gained in importance in recent years. Allogeneic bone cell transplantation procedures and in particular gene therapy are promising new strategies for the treatment of disorders of fracture healing. This review gives an overview of present and future possibilities for modulation of fracture healing by growth factors and cell-based technologies.

Outcome of complex non-unions of femoral fractures managed with Ilizarov method of distraction osteogenesis.

OBJECTIVE: To evaluate the management outcome of complex non-union of femoral fractures with Ilizarov method in terms of bone union, functional results and any complications. METHODS: This case series study was carried out at the Departments of Orthopedic Surgery, National Institute of Rehabilitation Medicine (NIRM), Islamabad and Civil hospital, Quetta over a period of three and half years, January 1, 2015 to June 30,2018. RESULTS: There were 50 patients in the study. There were 48(96%) males and 2(4%) females. The ages ranged between 17-54 years with a mean of 33.58±8.9 years. As per ASAMI criteria, the bone results were excellent in 17(34%), good in 30(60%), fair in 1(2%) and poor in 2(4%) patients. The functional results were excellent in 15(30%), good in 24(48%), fair in 8(16%) and poor in 3(6%). The bone union rate was 98% whereas infection eradication rate was 94%. The most frequent complications were pin tract infection affecting 80% patients, knee stiffness 60% patients and K-wires loosening 20% patients. CONCLUSION: The Ilizarov method provides an effective solution to address the complex non-union of femur fractures. It helps to ensure fracture healing, eradicates infection and provides good functional outcome. The attended complications are mild to moderate and manageable with conservative means.

Presentation and management outcome of tibial infected non-union with Ilizarov technique.

OBJECTIVE: To document the presentation of tibial infected non-union and analyze the management outcome with Ilizarov technique in terms of bone results, functional outcome, bone transport time, external fixation time, external fixation index and any complications. METHODS: This case series was conducted at the Departments of Orthopedic Surgery, National Institute of Rehabilitation Medicine (NIRM), Islamabad and Civil hospital, Quetta over a period of 3-years. RESULTS: There were 56 patients with 53(94.64%) males and 3(5.35%) females. The age range was 16-50 years with a mean of 32.58±9.98years. According to ASAMI criteria, bone results were excellent in 37(66%), good in 10(17.85%), fair in 6(10.71%) and poor in 3(5.35%). The functional results were excellent in 37(66%), good in 9(16%), fair in 7(12.5%) and poor in 3(5.35%). The bone union rate was 98.21%. CONCLUSION: Ilizarov method beautifully addresses the formidable issue of infected non union of tibia with good outcome in terms of bone healing and infection eradication. The treatment period is relatively lengthy and hence patience on part of patient as well as the surgical team is imperative for achieving favourable outcomes.

Management and outcome of diaphyseal aseptic non-unions of the lower limb: a systematic review.

OBJECTIVES: To review current treatments utilising biological enhancement modalities and their efficacy for the management of lower limb long bone aseptic non-unions. MATERIALS & METHODS: A systematic review of English articles using PubMed Medline; Ovid Medline; Embase; and the Cochrane Library was performed, supplemented by a manual search of bibliographies. RESULTS: Thirteen manuscripts met the inclusion criteria reporting on 428 patients. The overall healing had a pooled estimate of effect size at 94.3%. The calculated summarised estimate of effect size for deep infection rate (413 patients) was 2.3%. Three subgroups were then created on the basis of the exact type of graft used at the non-union site (ABG, BMP-7, BMP-7 + ABG). Comparison between the above subgroups revealed that ABG resulted in approximately 3-fold increase of the odds of healing compared with the use of BMP-7. Combined use of ABGs and BMP-7 improved the odds of healing by 3.5 times compared with BMP-7 alone. However, the previous median operations prior to the implantation of ABG or BMP-7 treatment was 1.09 versus 2.3 respectively (p = 0.02). Although the implantation of ABG was associated with a greater incidence of infection the documented differences did not reach significance. CONCLUSIONS: Although ABG was found to have a higher success rate compared to BMP-7 (95% Vs 87%), patients treated with BMP-7 had a higher number of previous failed interventions, statistically significantly so (BMP-7 is used for the treatment of more recalcitrant non-unions). It is the surgeon's judgement that should determine the most suitable treatment modality, depending on the nature and characteristics (personality) of the non-union and the patient.

Effect of Tricalcium Phosphate on Healing of Non-Unions: An Observational Study of over 400 Non-Unions.

Purpose: A central aspect of the treatment of non-unions is the filling of bone defects. The quantity of available autologous bone for this purpose is limited. Alternatively, or additionally, bone substitutes may be used. The aim of this retrospective, single-center study including 404 non-unions in 393 patients is to investigate the effect of tricalcium phosphate (TCP) on the healing of non-unions. Furthermore, the influence of gender, age, smoking status, comorbidities, type of surgical procedure, presence of infection, and length of treatment was investigated. Methods: We evaluated three groups of patients. Group 1 received TCP + BG, group 2 received BG alone and group 3 received no augmentation. Bone stability was assessed 1 and 2 years after non-union revision surgery through analysis of radiographs using the Lane Sandhu Score. Scores ≥3 were rated as stable Other influencing factors were collected from the electronic medical record. Results: In 224 non-unions, bone defects were filled with autologous bone and TCP (TCP+BG). In 137 non-unions, bone defects were filled with autologous bone (BG), and in 43 non-unions presenting non-relevant defects, neither autologous bone nor TCP were used (NBG). After 2 years, 72.7% of the TCP+BG patients, 90.1% of the BG patients and 84.4% of the NBG patients achieved a consolidation score ≥3. Advanced age, presence of comorbidities and longer treatment period had a significantly negative effect on consolidation 1 year after surgery. Longer treatment periods also showed a negative significant effect after 2 years. It is notable that larger defects, mainly treated with the combination of autologous bone and TCP, showed similar healing rates to that of smaller defects after 2 years. Conclusion: The combination of TCP and autologous bone-grafts shows good results in the reconstruction of complicated bone-defects, but patience is required since the healing period exceeds 1 year in most patients.

Pharmacokinetic and pharmacodynamic considerations for optimizing antimicrobial therapy used to treat bone and joint infections: an evidence-based algorithmic approach.

INTRODUCTION: Bone and joint infections (BJIs) are a major health concern causing remarkable morbidity and mortality. However, which antimicrobial treatment could be the best according to specific clinical scenarios and/or to the pharmacokinetic/pharmacodynamic (PK/PD) features remains an unmet clinical need. This multidisciplinary opinion article aims to develop evidence-based algorithms for empirical and targeted antibiotic therapy of patients affected by BJIs. AREAS COVERED: A multidisciplinary team of four experts had several rounds of assessment for developing algorithms devoted to empirical and targeted antimicrobial therapy of BJIs. A literature search was performed on PubMed-MEDLINE (until April 2023) to provide evidence for supporting therapeutic choices. Four different clinical scenarios were structured according to specific infection types (i.e. vertebral osteomyelitis, prosthetic joint infections, infected non-unions and other chronic osteomyelitis, and infectious arthritis), need or not of surgical intervention or revision, isolation or not of clinically relevant bacterial pathogens from blood and/or tissue cultures, and PK/PD features of antibiotics. EXPERT OPINION: The proposed therapeutic algorithms were based on a multifaceted approach considering the peculiar features of each antibiotic (spectrum of activity, PK/PD properties, bone penetration rate, and anti-biofilm activity), and could be hopefully helpful in improving clinical outcome of BJIs.

Radial diaphysis infected non-union treated with combination of Masquelet technique and autologous bone grafting harvested by RIA: A case report.

We present a case of infected non-union of radial diaphysis following closed fracture and open reduction and internal fixation (ORIF) of the fracture. Treatment included combining the Masquelet technique of induced membrane and autologous bone graft using Reamer-Irrigator-Aspirator harvesting technique. At 10 months post PMMA extraction and autografting (i.e.: second stage) full union was achieved with excellent functional results.

Percutaneous injection of platelet-rich plasma to treat atrophic nonunion after internal fixation of ulnar fracture: a case report.

Non-union is a serious postoperative complication of fracture. Early detection and intervention can avoid revision surgery. Platelet-rich plasma releases many active tissue factors and has potential to promote fracture healing. Percutaneous injection of platelet-rich plasma at the fracture site may avoid surgical treatment when non-union occurs. We present a case of atrophic non-union of an ulna fracture treated conservatively with percutaneous injection of platelet-rich plasma.

Epidemiology of long bone non-unions in Spain.

Epidemiological and ecological studies on long bone non-unions (NU) are scarce, based on different populations and methodologies. The aim of this study was to produce a descriptive analysis of the femur, tibia, and humerus non-union epidemiology in Spain. Methods Data were obtained from the Minimum Basic Data (Conjunto Mínimo Básico de Datos, CMBD) Hospital Discharge Database of the Spanish Ministry of Health, according to the ICD9-CM coding for diagnoses and procedures, and from the National Institute of Statistics for population, generating secondary databases with the reported cases that included the code 733.82 in a disaggregated manner, by age (categorized in 5 intervals), gender, Spanish region, and calendar year (1997-2015). Percentage of non-unions related to fractures in the previous year, annual prevalence (expressed per 100,000 person-years) and period prevalence (expressed per 100,000 person-period) were calculated by age, gender, and Spanish regions. The Odds ratio (OR) was estimated with a confidence of 95% using a logistic regression model per anatomical site. Results A mean of 235,446 fractures in all locations were annually reported in Spain from 1997 to 2015. Regarding non-union of long bones (femur, tibia and humerus), a total of 37,053 cases were found, representing a yearly mean of 1,950 cases. The proportion of long bone fractures that evolved into a non-union was 4% (1.4% femur, 1.5% tibia, and 1% humerus). The mean annual prevalence rate of NU in Spain was estimated in 4.5 (3.7-4.9) cases per 100,000 persons-year. The overall NU prevalence in Spain was estimated in 86 cases per 100,000 persons. By the type of bone, the period prevalence (per 100,000 persons-period) of the femur NU was 31, of the tibia 33, and of the humerus 22. Conclusions This description of the epidemiology of long bone non-unions in Spain confirms that the overall non-union rate has been stable from 2000 to 2015, higher in the tibia and in the femur compared to the humerus. NU occurred more frequently in aged females than in males in the femur and the humerus, while the tibia non-unions were more frequent in males and younger age.

Treatment of infected tibial non-unions using a BMAC and S53P4 BAG combination for reconstruction of segmental bone defects: A clinical case series.

INTRODUCTION: Treatment of infected non-unions of the tibia is a challenging problem. The cornerstones of optimal infected non-union treatment consist of extensive debridement, fracture fixation, antimicrobial therapy and creation of an optimal local biological bone healing environment. The combination of S53P4 bioactive glass (BAG), as osteostimulative antibacterial bone graft substitute, and bone marrow aspirate concentrate (BMAC) for the implantation of mesenchymal stem cells and growth factors might be a promising combination. In this paper, preliminary results of a new treatment algorithm for infected non-unions of the tibia is presented. METHODS: In this retrospective case series patients with infected non-unions of the tibia are treated according to a new treatment algorithm. Patients are treated with extensive debridement surgery, replacement of the osteosynthesis and implantation of S53P4 BAG and BMAC in a one-stage or two-stage procedure based on non-union severity. Subsequently patients are treated with culture based antibiotic therapy and followed until union and infection eradication. RESULTS: Five patients with an infected non-union were treated, mean age was 55, average NUSS-score was 44 and the average segmental bone defect was 4.6cm. One patient was treated in a one-stage procedure and four patients in a two-stage induced membrane-, or "Masquelet"-procedure. On average, 23 ml S53P4 BAG and 6.2 ml BMAC was implanted. The mean follow-up period was 13.6 months and at the end of follow-up all patients had clinical consolidation with an average RUST-score of 7.8 and complete eradication of infection. DISCUSSION: These early data on the combined implantation of S53P4 BAG and BMAC in treatment of infected non-unions shows promising results. These fracture healing results and eradication rates resulted in promising functional recovery of the patients. To substantiate these results, larger and higher quality studies should be performed.

Acute shortening versus bone transport for the treatment of infected femur non-unions with bone defects.

BACKGROUND: The bone transport technique has been a well-known method in the treatment of osteomyelitis of the long bones with large segmental bone defects. However, one of the major drawbacks with this traditional technique is the long-lasting consolidation period, which may entail infectious and non-infectious complications. To overcome this drawback, several techniques were developed, one of which is acute shortening and re-lengthening. The aims of this study were: 1) to present our experience with a new modified technique of acute shortening and re-lengthening using a monolateral external fixator combined with a retrograde intramedullary nail, and 2) to compare its results with the classic Ilizarov bone transport method in the management of infected non-unions of the distal femur with bone loss. METHODS: This retrospective study compared these two techniques. 17 patients were treated using our modified technique of acute shortening and re-lengthening (Group A); 15 patients were treated using segmental bone transport (Group B). The average follow-up was 66 months (range: 24-180) in Group A and 70 months (range: 24-240) in Group B. The mean bone loss was 5.5 cm (range: 3-10) in Group A and 5.9 cm (range: 3-10) in Group B. The primary outcome of the present study was to compare the external fixator time (EFT) and external fixation index (EFI) between the two groups. The bone and functional status were also assessed. RESULTS: The mean EFI was lower in Group A (mean: 31.8 days/cm; range: 24-50) than in Group B (mean 48.7 days/cm; range: 40-100) (p = 0.02). The mean EFT was shorter in Group A (mean: 120 days; range: 100-150) than in Group B (mean: 290 days; range: 100-400) (p = 0.0003). With respect to the bone and functional results, no difference was observed. CONCLUSIONS: Although both techniques could be employed safely in the treatment of infected non-union of the distal femur with size defects ranging between 3 cm and 10 cm, our modified technique of acute shortening and re-lengthening may confer greater patient satisfaction because of shorter EFI.

A novel bimodal approach for treating atrophic bone non-unions with extracorporeal shockwaves and autologous mesenchymal stem cell transplant.

We propose a novel approach for the treatment of atrophic bone non-unions via parallel applications of extracorporeal shock wave therapy (ESWT) and an autologous mesenchymal stem cell transplant. The hypothesis resides on the potentiality of shock waves (SWs) to act as a tool for manipulating the patient's mesenchymal stem cells (MSCs). In addition to the conventional physical stimulus achieved by delivering SWs at the site of non-union to stimulate the well-known trophic effects on bone tissue, a series of concomitant ESWT would be administered in tandem at a bone marrow donor site, such as the iliac crest, to precondition resident bone marrow stromal cells (BMSCs) in vivo, priming resident MSCs by enlarging and conditioning their population prior to bone marrow aspiration. The resulting sample could then be treated to further augment cell concentration and injected, under fluoroscopic control, into the non-union site through a percutaneous approach.

Long-term safety and efficacy of human bone morphogenetic protein (HBMP) in the treatment of resistant non-unions and failed arthrodesis.

The bone morphogenetic protein (BMP) has emerged as a suitable alternative to autogenous cancellous bone grafting and despite current knowledge about its mechanism; few studies provide evidence about the long-term safety of BMP. The aim of this investigation is to determine if BMP implantation is a safe and effective agent in a long-term setting for the treatment of patients with resistant non-unions and failed arthrodesis. This study is a retrospective case series study that was conducted on 55 patients who had received BMP. Collected data included all related surgical history, and clinical and X-ray data both pre-operatively and post-operatively. All patients were scheduled for follow-up evaluations at one week and 1, 3, 6, and 12 months post-operatively. Seven patients (13%) experienced adverse events related to their surgery with hBMP. Six patients (11%) experienced persistent non-union; five of these underwent further revision surgery. One patient (2%) developed an infected non-union. No patients experienced tumor induction, allergic reaction to hBMP. The remaining 48 patients achieved osseous union within six months of hBMP implantation. This study differs from previous studies that the use of hBMP is a safe and efficacious treatment method for resistant non-unions and failed arthrodesis in the long-term setting.

Ilizarov ring fixator in the management of infected non-unions of tibia.

PURPOSE: The purpose of the study was to evaluate the effectiveness of debridement and application of Ilizarov ring fixator (IRF) in the management of infected tibial non-unions. PATIENTS AND METHODS: Twenty six patients with infected non-unions of tibia were managed by debridement and resection of infected portion ± partial fibulectomy and stabilization by Ilizarov ring fixator. Bone segment transport was done in 18 patients who had greater than 2.5 cm bone defect after debridement. Bone grafting was required in three patients to augment union. RESULTS: All fractures united and infection eradicated completely. There were 13 excellent, nine good, and four fair results. Functional results were excellent in nine, good in 11, fair in five and poor in one. Pin site inflammation was the most common problem and occurred in 23 (88%) patients. There were no major complications or neurovascular complications. CONCLUSION: We conclude that debridement combined with Ilizarov ring fixator with or without partial fibulectomy is a reliable method of treatment of infected non-unions of tibia.

Revision of 120 tibial infected non-unions with bone and soft tissue loss treated with epidermato-fascial osteoplasty according to Umiarov.

Treatment of tibial infected non-unions with bone and soft tissue loss has to solve three problems: infection, lack of bone continuity and lack of skin coverage. The aims of treatment are infection healing, bone consolidation with preservation of limb length and soft tissue reconstruction. The most important stage in the planning is an accurate débridement. Soft tissue reconstruction can be achieved using plastic surgery, and bone reconstruction is accomplished with bone grafts or induced membrane technique, but these methods may present disadvantages and risks. Epidermato-fascial osteoplasty is a modified procedure of compression-distraction osteosynthesis that was first described by Umiarov in 1982. This procedure offers the advantages of exactly classifying the phases of simultaneous bone and soft tissue regeneration, and of eliminating large tissue losses without previous closure of soft tissues or use of grafts, because the transported fragment takes fascia and skin along during the transport and closes the edges of the soft tissue gap until the epidermic and fascial reconstruction is complete. A total of 120 patients underwent this kind of surgery between 1986 and 2010 and were followed up for 2-26 years. Average age was 34 years (range 21-57 years). Cultures were positive for Staphylococcus in all cases, and for Pseudomonas in 27 cases. Adequate antibiotic therapy was administered in collaboration with the Infectious Diseases Specialist. Tibial bone resection was from 6 to 18cm (average 9.5cm). The Ilizarov apparatus was used with the oblique wire technique for bone transport in all patients. No intraoperative complications were observed. One patient died 40 days after the operation because of pulmonary embolism. The duration of treatment for the remaining 119 patients was 7-18 months. In all cases, infection eradication, healing of regenerate bone, consolidation at the docking site (with the aid of an autoplastic bone graft in only 11 patients), and epidermic and fascial reconstruction were observed, and functional results were very good. These techniques are particularly demanding for the patient and for the surgical team, but our results demonstrate that they can provide excellent outcomes in the management of difficult cases of infected non-unions.