Ilizarov fixator combined with an intramedullary nail for tibial nonunions with bone loss: is it effective?

Abstract

Background: Treatment of tibial nonunion with bone loss is extremely difficult. A variety of techniques have been described, but each has shortcomings, in particular prolonged external fixation time as well as serious complications such as nonunion and infection. Accordingly, we developed a technique that seeks to reduce these complications by using a circular external fixator in addition to an intramedullary nail to achieve union, limb lengthening, and stability of the regenerated segment.

Description of technique: First, the pseudoarthrosis area is resected, and acute compression is continued until bone contact at the docking site was achieved. Then primary grafting is applied to the docking site using a graft harvested from the patient's iliac bone, and the predrilled nail holes localized on the middle segment of the tibia are locked with a free-hand technique. Finally, lengthening is performed to overcome the leg-length discrepancy with an external fixator.

Methods: Between 2008 and 2011, this technique was used to treat five patients with tibial nonunion with bone loss. All patients were available for a minimum of a 14-month followup (mean, 30 months; range, 14-58 months). General indications for the procedure were age older than 16 years, tibial nonunion with bone loss, and the absence of any psychiatric disorder. We evaluated external fixation time, external fixation index (defined as the duration of external fixation in months divided by the total amount of bone transported and/or the amount of lengthening in centimeters), and time to union on plain radiographs, clinical results using the Paley bone and functional assessment scores, and postoperative complications from chart review.

Results: The external fixation time was 4 months (range, 3-5 months), and the average external fixation index was 0.4 months/cm. The mean time to bone union was 4.6 months (range, 3.5-5.5 months). All angles were determined to be in the normal range. No patients developed refracture or malalignment either on the docking site or the osteotomy site. Paley bone evaluation results were excellent in all five patients, and Paley functional results were excellent in four and good in one. We observed 10 pin-site infections as minor complications, and one patient was left with a residual equinus deformity of 5° as a major complication according to the Paley classification.

Conclusions: Our technique combining acute shortening and distraction osteogenesis had promising results for the treatment of tibial nonunion with bone loss in a small group of patients. However, future studies directly comparing available approaches to this difficult problem are required. Because this problem is uncommon, these studies will almost certainly require the cooperation of multiple large participating centers.

Level of evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Fig. 1

Drawing of an AP and lateral tibia view showing a template over a tibia to determine the length and width of the tibial nail and also the levels at which the extra locking holes should be predrilled.

Fig. 2

Treatment of a patient (Patient 5) with chronic osteomyelitis of the distal part of the tibia with transverse exposure is shown.

Fig. 3

Lateral image intensifier view depicting a clear space between the Schanz screws and the nail.

Fig. 4A–B

A fixator is shown on a 57-year-old man (Patient 4) who had three unsuccessful operations resulting from an open tibial fracture. Resection bone length was 9.5 cm. Acute shortening of the tibia was up to 5 cm at the nonunion site. (A) AP radiographic image of the tibia at postoperative Day 1 showing acute shortening. (B) Lateral radiographic image of the tibia at postoperative Day 1 showing acute shortening.

Fig. 5A–C

Radiographic images and drawing of the tibia after autografting of the docking site and the predrilled nail holes localized on the middle segment of the tibia were locked with a free-hand technique. (A) Postoperative AP radiograph showing the intramedullary nail and the circular external fixator. The bone contact was achieved at the docking site, autogenous bone grafting of the docking site, and predrilled holes of the nail were locked with a free-hand technique. (B) Postoperative lateral radiograph showing the intramedullary nail and the circular external fixator, bone contact, primary autogenous grafting at the docking site, and predrilled holes of the nail were locked. (C) Drawing of the lateral tibia showing the bone contact and grafting at the docking site and locking of the predrilled holes of the nail.

Fig. 6A–C

Radiographic images and drawing of the tibia at 5 months followup showing removal of the circular external fixator; the proximal holes of the nail were locked with a free-hand technique. (A) AP radiograph showing the consolidated lengthening regenerate, the nail is locked proximally, and union at the docking site. (B) Lateral radiograph showing the consolidated lengthening regenerate, the nail is locked proximally, and union at the docking site. (C) Drawing of a lateral tibia image showing union at the docking site, the nail locked proximally, and the consolidated lengthening regenerate.

Fig. 7A–C

Drawing and radiographs of a tibia are shown indicating the margins of resection as determined on AP and lateral radiographs. (A) Drawing of a lateral tibia showing the margins of resection (red dotted lines). (B) A 57-year-old man (Patient 4) who had tibial nonunion after three unsuccessful operations resulting from an open tibial fracture. AP radiograph of the right tibia showing a broken intramedullary nail and margin of the resection (black lines). (C) Lateral radiograph of the right tibia showing a broken intramedullary nail and margin of the resection (black lines).