Refracture after Ilizarov fixation of infected ununited tibial fractures-an analysis of eight hundred and twelve cases.

INTRODUCTION: Refracture of the tibia after union is a challenging problem for the patients and the surgeons. The purpose of the current study is to present our experience in conservative management of such patients with refracture of infected ununited tibia after successful treatment by Ilizarov external fixator and bone transport. MATERIAL AND METHODS: We reviewed the files of 812 patients with infected ununited tibia who were treated by debridement, corticotomy, and bone transport using Ilizarov methods in our institute between 1997 and 2017. Inclusion criteria were patients with refracture after union and removal of the Ilizarov apparatus. Twenty-two patients with 23 refracture tibia were included in the study. All the 23 tibias were treated conservatively by above knee cast that was converted to Sarmiento below knee cast after early callus formation, except in the case of upper tibial fracture that continued in above knee cast till union. Afterwards, a protective splint was used for additional two months. RESULTS: There were 19 males (86.4%) and three females (13.6%), the mean age of the patients was 38.39 years, the mean time of Ilizarov external fixator application was 10.86 months (range, 6-17), and the mean time of refracture after fixator removal was 2.33 months. Union was achieved in 19 tibias (82.6%), with a mean time of 7.2 months (range, 4-12). Complications included five cases of skin irritation that was treated by large windows in the cast and changing the casts more frequently, three cases developed DVT (deep venous thrombosis), and axial deviation occured in four tibias (17.3%). CONCLUSION: Conservative treatment of refractured tibia after removal of Ilizarov external fixator following treatment of infected non-union tibia by above knee cast is effective in achieving union. However, complications as skin irritation, DVT (deep venous thrombosis), and axial deviation can be anticipated.

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.

Outcome of Induced Membrane Technique in Treatment of failed previously operated Congenital Pseudarthrosis of the Tibia.

BACKGROUND: Although a remarkable success in the treatment of congenital pseudarthrosis tibia (CPT) had been achieved, failure rate is still high and the likelihood of amputation is still considerable. The current study evaluates the outcome of induced membrane technique in the treatment of failed previously operated patients of congenital pseudarthrosis of the tibia. We hypothesized that induced membrane technique will improve union rates in CPT with failed previous multiple operations. PATIENTS AND METHODS: Nineteen consecutive patients of failed previously operated CPT were prospectively included in the study. All patients were treated by induced membrane technique with autogenous free non-vascularized fibular strut graft augmented by autogenous iliac graft and fixed by intramedullary K-Wire as well as Ilizarov external fixator. RESULTS: The mean interval between the 1st and 2nd stages of the procedure was 4.9 weeks. Sound union was achieved in all cases in a mean time of 25.3 weeks. The mean follow up period was 5.02 years (range, 2.4-6.5). No refracture was documented till last follow up. CONCLUSION: Induced membrane technique had proved as a successful method in the treatment of failed previously operated CPT with a satisfactory outcome and low complication rates. LEVEL OF EVIDENCE: IV.

Gradual fibular transfer by ilizarov external fixator in post-traumatic and post-infection large tibial bone defects.

INTRODUCTION: Several reconstructive procedures have been used in management of large tibial bone defects including bone graft, bone transport (distraction osteogenesis) using various external fixators, and vascularized bone graft. Each of these procedures has its limitations and complications. The study describes gradual medial fibular transfer using Ilizarov external fixators in management of patients with large tibial defect, either following infection or trauma. PATIENTS AND METHODS: Between May 2011 and June 2013, 14 patients were prospectively included in the current study. The inclusion criteria were large tibial defect due to trauma or infection with severe soft tissue compromise, and small or poor tibial bone remnants making bone lengthening difficult. Exclusion criteria were patients with vascular or nerve injuries. The average age of the patients was 31.64 (± 6.5) years. Medial fibular transfer was done for all patients using Ilizarov at a rate of 0.5 mm twice daily. Iliac bone graft was used in all patients after the transfer. RESULTS: The average segmental bone defect of the tibia was (13.2 ± 2.6), ranging between 8 and 18.6 cm. Union was achieved in all patients with average fixator time was 32.42 (± 4.32) weeks. Average follow-up after removal of the fixator was 40.5 (± 6.9) months. CONCLUSION: Gradual fibular transfer by Ilizarov external fixator is a reliable technique in management of post-traumatic and post-infection large tibial bone defects with good clinical outcome, and with few complications.

Management of proximal humeral fractures by the Ilizarov external fixator.

INTRODUCTION: External fixation can be performed in poor bone and soft tissue conditions, and can be used in patients with poor general conditions or multiple injuries as a rapid, mini-invasive procedure. The purpose of the current study was to evaluate the effectiveness and safety of the Ilizarov external fixator in the management of proximal humeral fractures. MATERIALS AND METHODS: Between May 2011 and December 2013, 14 patients with displaced proximal humeral fractures were enrolled in the current study. Nine patients were males and five were females, with mean age 42.9 years (range 21-55). All fractures were acute. The mode of injury was road traffic accident in eight patients and fall in six patients. There were six patients with two-part fracture, one of them with fracture dislocation, and eight patients presented with three-part fracture, two of them with fracture dislocation. All fractures were fixed using the Ilizarov external fixation. RESULTS: The average operative time was about 67 min (range 50-90). The mean follow-up period was (18) months (range 12-28). Healing was obtained in all 14 patients in a mean of 10.4 weeks (range 8-14). At the final follow-up, the mean constant score was 73.1 points (range 60-97 points), the mean visual analog score (VAS) for pain 3.2 (range 1-5), the mean DASH score 31.8 points (range 10-55 points), and the mean satisfaction VAS 7.6 (range 4-10). CONCLUSION: The Ilizarov external fixation is an effective technique in managing proximal humeral fractures with good outcome and low complication rates. LEVEL OF EVIDENCE: Level IV, case series.