Management of unstable open and closed tibial fractures using the Ilizarov method

Abstract

Forty-one consecutive tibial diaphyseal fractures that required operative stabilization were treated using the external fixator and concepts of compression-distraction of Ilizarov. Eleven fractures had bone loss greater than 1 cm and were managed by simultaneously compressing the fracture gap and distracting through a corticotomy site to maintain extremity length. Thirty tibial fractures consisted of closed unstable and open fractures that were managed using the external fixator, emphasizing immediate weight bearing and gradual compression at the fracture site. Twenty-six fractures in 23 patients were available for follow-up evaluation six to 9.5 months after bone healing. There were six closed, two Grade I, eight Grade II, five Grade IIIA, and five Grade IIIB fractures. Serial wound debridements, wet-to-dry-dressing changes, wound- and fracture-site compressions (13 fractures), and split-thickness skin grafts (eight wounds) were used to accomplish wound closure. Chronic infections did not occur. All fractures healed from 12 to 47 weeks without bone grafting. Eight transosseous fixation wires are used, only two of which transfixed significant muscle. Approximately 10% of the 248 wire sites became inflamed and nine wire sites were treated for infection with antibiotics, skin release around the offending wire, or wire removal. Three wires fractured and one wire was replaced. One ring sequestrum occurred and responded to curettement. Angulation of 7 degrees-9 degrees occurred in five fractures (19%). The results were good or excellent in 25 fractures. One patient with 9 degrees varus in a distal fracture refused correction. Operative time was 60 to 90 minutes after developing a satisfactory protocol for frame application. This method allows immediate functional stabilization of tibial diaphyseal fractures and postoperatively allows ease of fracture gap closure and compression. The frame can be left in place for the duration of the fracture care. Application of the Ilizarov external fixator is slightly more complicated than traditional large pin fixators and requires more attention to detail intraoperatively and postoperatively, but can be a versatile tool in the management of complex tibial shaft fractures.