Ilizarov bone transport combined with antibiotic cement spacer for infected tibial nonunion

Abstract

Purpose: To evaluate the curative effect of Ilizarov bone transport combined with antibiotic cement spacer for infected tibial nonunion with bone defect.

Methods: We retrospectively reviewed the outcomes of 58 patients with infected tibial nonunion from January 2008 to March 2011 at our institution. Patients were treated with complete debridement, radical sequestrectomy, antibiotic cement spacer implantation, bone transport using the Ilizarov external fixator, and soft tissue reconstruction. Clinical efficacy was assessed using Paley's grading system and patient satisfaction at the last follow-up.

Results: Follow-up ranged from 24 to 63 months (average, 31.6 months). Mean size of the tibial defect was 9.2 cm (range, 6-15 cm). The soft tissue defect was closed successfully in all cases. Patients eventually achieved union with a mean bone union index of 1.2 months/cm at an average of 10.6 months (range, 8-31 months). In terms of Paley grade, 30 patients had excellent results, 23 good, and 5 fair. Functional results were excellent in 28 patients, good in 18, and fair in 12. Thirty-five patients felt extremely satisfied, 18 satisfied, and 5 acceptable with the functional outcome. Complications included pin site infection in 18 cases, limb length discrepancy less than 1.5 cm in 10, knee stiffness in 5, equinus deformity in 4, infectious recurrence in 1 and pin breakage in 1. There was no refracture at the reconstruction site.

Conclusion: Ilizarov bone transport combined with antibiotic cement spacer is a versatile and effective method for treatment of infected tibial nonunion.

Keywords: Ilizarov bone transport; antibiotic cement; bone defect; infected tibia nonunion.

Figure 1

A 46-year-old patient experienced 1 year proximal infected tibial nonunion with equinus deformity after open reduction and internal fixation for the tibial fracture in local hospital. Sinus was present at the anterior leg, and the fracture was nonunion because of persistent infection (A); MRI was accomplished in order to determine the extent of the infection (B); thorough debridement of the infected soft tissue and bone combined with implant of antibiotics cement spacer and distal tibial bone transport was carried out (C); the equinus deformity was corrected by extension of frame to the foot (D); eleven months later, the external fixators was removed, and excellent union was obtained at the docking site and the lengthening region (E).

Figure 2

A 38-year-old patient, undergone several times of debridement and flap transfer after open and comminuted fracture of right tibial due to vehicle accident, still presented infection nonunion with bone loss (A); removal of the external fixator, thorough debridement of the infected soft tissue and bone which leaded to 15 cm bone and large soft tissue defect, treatment with implant of the antibiotics cement spacer and distal tibial bone transport was fulfilled at our hospital (B); as the transported bone segment arrived toward its destination, the bead-like antibiotic cement were crimped together, which were then gradually removed out to leave space for the bone transport (C); eighteen months later, bone transport and docking site were union with excellent soft tissue recovery (D, E).