The Archives of Bone and Joint Surgery

The Archives of Bone and Joint Surgery

The Outcomes of Distraction Osteogenesis over an Intramedullary Nail for the Treatment of Bone Defects in Infectious Nonunions

Document Type : RESEARCH PAPER

Authors
Farzad Amouzadeh Omrani 1
Mohammad Mahdi Sarzaeem 1
Mohsen Noorbakhsh 2
Mojtaba Baroutkoub 1
Sina Afzal 1
Hasan Barati 1
Ali Panjeshahi 1
1 Department of Orthopedic Surgery, School of medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2 Cellular and Molecular Research Center, Shahrekord University of Medical Sciences, Shahrekord, Iran
10.22038/abjs.2023.73572.3407
Abstract
Objectives: The concurrent utilization of an external fixator and intramedullary nail (IMN) for segment 
transportation may potentially decrease the duration of external fixator implementation and reduce 
associated complications. This study aimed to report the outcomes of bone transport utilizing a 
combination of IMN and Ilizarov frame in a cohort of individuals who had tibia or femur critical -sized 
bone deficiency resulting from nonunion.
Methods: The present research used a single-arm clinical trial design to enroll a series of patients presenting with 
critical-sized bone defects resulting from infectious nonunion of the tibia or femur. The study was conducted during 
the period of 2017-2020 in a referral Orthopedic Surgery Center located in Tehran, Iran. The management of patients 
with infectious nonunion was carried out through two main stages, including infection eradication and bone 
transportation. The process of bone healing and segment transportation was evaluated by radiographic assessment 
throughout the follow-up period.
Results: A total of 39 patients with bone defects in the tibia (19 cases) or femur (20 cases) with a mean age of 
31.44 (±11.95, range=18-60) were included in this study. Twenty-nine (74.3%) patients had open fractures. The 
bone defect exhibited an average size of 6.31 ± 1.95 cm. The mean of the consolidation index (CI) was 0.97 
(range=0.51–1.32) mo/cm, and the mean of the external fixator index was 0.67 (range=0.41-1.10). Although the CI 
was longer in patients with open fracture compared to those with closed fracture, the difference was not statistically 
significant (P=0.353). After the end of the two-year follow-up, complete union was observed in 35 patients (89.7%).
Conclusion: Intercalary segmental bone transportation using the Ilizarov technique over an IMN, as well as 
preserving the advantages of the conventional callotasis method, reduces the complications of long-term use of the 
Ilizarov frame and increases patient adherence to treatment.
 Level of evidence: IV
Keywords
Bone defect
Ilizarov technique
Infectious nonunion
Intramedullary nail
Segment transport
Subjects
  1. Andrzejowski P, Giannoudis PV. The 'diamond concept' for long bone non-union management. J Orthop Traumatol. 2019; 20(1):21. doi:10.1186/s10195-019-0528-0.
  2. Jain AK, Sinha S. Infected Nonunion of the Long Bones. Clin Orthop Relat Res. 2005; 431:57-65. doi:10.1097/01.blo.0000152868.29134.92.
  3. Mekhail AO, Abraham E, Gruber B, Gonzalez M. Bone Transport in the Management of Posttraumatic Bone Defects in the Lower Extremity. J Trauma. 2004; 56(2):368-378. doi:10.1097/01.Ta.0000057234.48501.30.
  4. Ilizarov GA. The principles of the Ilizarov method. Bull Hosp Jt Dis Orthop Inst. 1988 1988; 48(1):1-11.
  5. Castelein S, Docquier PL. Complications associated with bone lengthening of the lower limb by callotasis. Acta Orthop Belg. 2016; 82(4):806-813.
  6. Oh C-W, Song H-R, Roh J-Y, et al. Bone transport over an intramedullary nail for reconstruction of long bone defects in tibia. Arch Orthop Trauma Surg. 2008; 128(8):801-808. doi:10.1007/s00402-007-0491-8.
  7. Hofmann GO, Gonschorek O, Bühren V. Segment transport employing intramedullary devices in tibial bone defects following trauma and infection. J Orthop Trauma. 1999; 13(3):170-7. doi:10.1097/00005131-199903000-00004.
  8. Feltri P, Solaro L, Di Martino A, Candrian C, Errani C, Filardo G. Union, complication, reintervention and failure rates of surgical techniques for large diaphyseal defects: a systematic review and meta-analysis. Sci Rep. 2022; 12(1):9098. doi:10.1038/s41598-022-12140-5.
  9. Kalantar SH, Bagheri N, Beheshti Fard S, Afzal S. Management of proximal femur malunion and distal femur nonunion via proximal femoral nailing and free fibular graft: A case report. International Journal of Surgery Case Reports. 2023; 112:108979. doi:10.1016/j.ijscr.2023.108979.
  10. Motsitsi NS. Management of infected nonunion of long bones: the last decade (1996–2006). Injury. 2008; 39(2):155-160. doi: 10.1016/j.injury.2007.08.032.
  11. Wang Y, Jiang H, Deng Z, et al. Comparison of Monolateral External Fixation and Internal Fixation for Skeletal Stabilisation in the Management of Small Tibial Bone Defects following Successful Treatment of Chronic Osteomyelitis. Biomed Res Int. 2017; 2017:6250635. doi:10.1155/2017/6250635.
  12. Bas A, Daldal F, Eralp L, Kocaoglu M, Uludag S, Sari S. Treatment of Tibial and Femoral Bone Defects With Bone Transport Over an Intramedullary Nail. J Orthop Trauma. 2020; 34(10):e353-e359. doi:10.1097/bot.0000000000001780.
  13. OOh CW, Apivatthakakul T, Oh JK, et al. Bone transport with an external fixator and a locking plate for segmental tibial defects. Bone Joint J. 2013; 95-B (12):1667-1672. doi:10.1302/0301-620x.95b12.31507.
  14. Giotakis N, Narayan B, Nayagam S. Distraction osteogenesis and nonunion of the docking site: is there an ideal treatment option? Injury. 2007; 38(1):S100-S107. doi: 10.1016/j.injury.2007.02.015.
  15. Zhang Z, Swanson WB, Wang Y-H, Lin W, Wang G. Infection-free rates and Sequelae predict factors in bone transportation for infected tibia: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2018; 19(1):442. doi:10.1186/s12891-018-2363-5.

 

 

The Archives of Bone and Joint Surgery
Volume 12, Issue 3
March 2024
Pages 204-210

  • Receive Date 06 July 2023
  • Revise Date 04 December 2023
  • Accept Date 18 December 2023