Outcome of distraction osteogenesis by ring fixator in infected, large bone defects of tibia

Abstract

Background: Salvage of large, infected bone defects in tibia poses a formidable problem. The present prospective study aimed to evaluate radiologic and functional outcome of ring fixator in infected, large (≥6 cm) bone defects of tibia treated with distraction osteogenesis.

Materials and methods: The study included 35 patients (30 males and 5 females) who had minimum of 6 cm gap after radical resection of necrotic bone and presence or history of active infection. Mean age was 36.1 years. Mean bone gap was 7.27 cm. Mean follow-up period was 25.4 months.

Results: Fracture united primarily in 17 cases and after fixator adjustment with freshening of fracture margins in 15 cases. Fixator adjustment with bone grafting was done in one patient to achieve union. One patient had nonunion and another had amputation. The bone result was excellent, good, and poor in 19, 13, and 3 patients, respectively. The functional results were excellent, good, fair and failure in 14, 19, 1, and one patient, respectively. 24 patients had superficial pin tract infection and 18 patients had ankle stiffness.

Conclusion: Ring fixator systems reliably achieve union in infected, large bone defects of tibia and help in treating infection, shortening, bone and soft tissue loss simultaneously. We advocate early freshening of fracture ends and removal of interposed soft tissue at docking sites to achieve union. Superficial pin tract infection and ankle stiffness are common problems in managing large tibial defects. But good to excellent functional outcomes can be achieved in majority of patients.

Keywords: Distraction osteogenesis; Ilizarov; Infected; Nonunion; Tibia.

Fig. 1

(A) Radiographs of 40-year-old male showing fractures of both bones of right leg (Open grade IIIB). (B) Immediate postoperative radiographs of the same patient showing 7 cm bone gap with ring fixator and proximal metaphyseal corticotomy. (C) Radiographs showing transported bone fragment and regenerate formation at 9 months follow-up. (D) Radiographs after ring fixator removal at final follow-up. (E) Clinical photographs at final follow-up showing stiffness at knee and ankle. Patient had excellent bone result and good functional result.

Fig. 2

(A) Immediate postoperative radiographs of 45-year-old male showing proximal metaphyseal corticotomy and 9 cm bone gap. (B) Radiographs of the same patient after 9 months follow-up showing transported bone fragment and regenerate formation. (C) Radiographs at 3 years follow-up showing union and remodeling of regenerate. (D) Clinical photographs at final follow-up showing stiffness of ankle, full knee range of motion, and no limb length discrepancy. (Bone result = excellent, functional result = good.)

Fig. 3

(A) Radiographs of 28-year-old male showing complete loss of right side distal tibia. (B) Immediate postoperative radiographs showing proximal metaphyseal corticotomy and 7 cm bone gap with ring fixator. (C) Radiographs at 6 months follow-up showing transported bone fragment and regenerate formation. (D) Radiographs at 4 years follow-up showing tibiotalar arthrodesis. (E) Radiographs at 4 years follow-up showing remodeling and canalization of regenerate. (F) Clinical photographs at final follow-up showing stiffness of ankle, full knee range of motion. (Bone result = excellent, functional result = good.)