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. 2009 Apr;52(2):103-11.

Distraction osteogenesis technique using an intramedullary nail and a monolateral external fixator in the reconstruction of massive postosteomyelitis skeletal defects of the femur

Zhihong Li  1 , Xiangsheng Zhang, Liqun Duan, Xiaoming Chen
Affiliations

Distraction osteogenesis technique using an intramedullary nail and a monolateral external fixator in the reconstruction of massive postosteomyelitis skeletal defects of the femur

Zhihong Li et al. Can J Surg. 2009 Apr.

Abstract
in English, French

Background: Large skeletal defects due to postosteomyelitis are uncommon, and they present a challenging reconstructive problem. The aim of our study was to summarize our experience performing a distraction osteogenesis technique using an intramedullary nail and a monolateral external fixator in the reconstruction of massive postosteomyelitis skeletal defects of the femur.

Methods: Between January 1998 and October 2004, 17 patients with massive postosteomyelitis skeletal defects of the femur (11 men and 6 women), underwent the reconstruction procedure. After osteotomy of diaphysis of the femur, we inserted an intramedullary nail into the femur, and we placed a monolateral external fixator with half-pins lateral to the nail. Lengthening was started on the seventh postoperative day at a rate of 1 mm/d. Once we achieved solid bone union, we removed the monolateral external fixator; the intramedullary nail remained for bone consolidation until reconsruction was complete. We assessed the outcomes clinically and radiographically at a mean of 70.3 months postoperatively.

Results: At follow-up (mean 70.3, range 14.0-96.0 mo), all the skeletal defects were filled, bone union at docking sites was achieved without bone graft and leg length discrepancies were less than 2.5 cm in all patients. The mean gain in length was 12.9 (range 10.2-18.4) cm. According to Paley and Maar's evaluation criteria, we graded the bone results as excellent for 10 patients, good for 5, fair for 1 and poor for 1. We graded the functional results as excellent for 12 patients, good for 4 and fair for 1. The mean external fixator index was 18.1 d/cm; the consolidation index was 35.7 d/cm. Ten patients experienced pin infection, and 1 patient experienced a recurrence of deep infection. There were no neurologic or vascular injuries.

Conclusion: Our study demonstrates that a distraction osteogenesis technique using an intramedullary nail and a monolateral external fixator is a reliable method for the reconstruction of massive postosteomyelitis skeletal defects.

Contexte: Les lacunes osseuses majeures consécutives à une ostéomyélite sont rares et causent des problèmes de reconstruction difficiles. Notre étude visait à résumer notre expérience d'une technique d'ostéogénèse par distraction utilisant un clou intramédullaire et un fixateur externe monolatéral pour reconstruire des lacunes osseuses massives du fémur consécutives à une ostéomyélite.

Méthodes: Entre janvier 1998 et octobre 2004, 17 patients ayant des lacunes osseuses massives du fémur consécutives à une ostéomyélite (11 hommes et 6 femmes) ont subi une intervention de reconstruction. Après une ostéotomie de la diaphyse du fémur, nous avons introduit un clou intramédullaire dans le fémur et mis en place un fixateur externe monolatéral avec des demi-broches posées latéralement au clou. On a commencé l'allongement le septième jour après l'intervention à raison de 1 mm/j. Après la fusion solide de l'os, nous avons enlevé le fixateur externe monolatéral. Le clou intramédullaire est demeuré en place pour la consolidation de l'os jusqu'à ce que la reconstruction soit terminée. Nous avons évalué les résultats par des examens cliniques et radiographiques 70,3 mois en moyenne après l'intervention.

Résultats: Au suivi (moyenne de 70,3, intervalle de 14,0 à 96,0 mois), toutes les lacunes osseuses étaient comblées, la fusion de l'os au site d'amarrage s'était produite sans greffe osseuse et la différence au niveau de la longueur des jambes était inférieure à 2,5 cm chez tous les patients. L'allongement moyen s'est établi à 12,9 (intervalle de 10,2 à 18,4) cm. Selon les critères d'évaluation de Paley et Maar, nous avons jugé les résultats osseux excellents chez 10 patients, bons chez 5, moyens chez 1 et médiocres chez 1 autre. Nous avons jugé les résultats fonctionnels excellents chez 12 patients, bons chez 4 et moyens chez 1. L'indice moyen du fixateur externe était de 18,1 j/cm, l'indice de consolidation s'est établi à 35,7 j/cm. Dix patients ont eu une infection aux broches et un patient a été atteint d'une infection profonde répétitive. Il n'y a pas eu de traumatisme neurologique ou vasculaire.

Conclusion: Notre étude démontre qu'une technique d'ostéogénèse par distraction utilisant un clou intramédulaire et un fixateur externe monolatéral constitue une méthode fiable de reconstruction de lacunes osseuses massives consécutives à une ostéomyélite.

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Figures

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Fig. 1. A 2-segment monolateral external fixator. The monolateral external fixator is composed of 2 screw rods and link rails. It is a stable rectangular plane fixator, which is connected with bone by the link rails to form a polyrectangular structure. When the bone is elongated or compressed, the press board is removed. An S needle is used to rotate through the modulating hole in the middle of the screw rod in the external fixator. A bidirectional screw rod displaces the T-shape structure and elongates or compresses the bone by the link rails, leading to the elongation of the bone, pressed and stable. Image published with permission of the Third Medical Instrument Company.
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Fig. 2. A 17-year-old girl presented with nonunion and a skeletal defect 4 years after hematogenous osteomyelitis due to radical débridement, absorption and lysis of the right femur. (A) The preoperative photograph shows a 16.4-cm leg length discrepancy (LLD). Radiographs show (B) the 2-cm skeletal defect, (C) distraction and (D) bone union 2 years and (E) 3 years after surgery. Union at the docking site was achieved, but regenerated bone was not substantial enough for weight-bearing. Three years after surgery, the LLD is no longer apparent (F).
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Fig. 3. A 19-year-old woman presented with nonunion and a skeletal defect 6 years after hematogenous osteomyelitis. She had a 2-cm skeletal defect and 14.6-cm leg length discrepancy (A). We performed distraction osteogenesis using an external fixator (B); however, an angulation of about 30° occurred at the distal femur (C), so we switched to a combined technique (D), and at the latest follow-up bone union with equal leg length was achieved (E).
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Fig. 4. An 18-year-old man presented with nonunion and a skeletal defect 5 years after hematogenous osteomyelitis. Radiographs show (A) a 2.5-cm skeletal defect with a leg length discrepancy of 12.2 cm, (B) obvious bone regeneration (arrow) at the docking site during distraction and (C) bone consolidation 10 months after surgery. Bone union at the docking site was achieved.
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References

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