Management of complex non union of tibia using rail external fixator

Abstract

Introduction: Management of the complex non union of tibia is a challenging task due to infection, bony gap, deformity, poor bone quality and poor soft tissue cover at fracture site. The limb reconstruction system (LRS) or Rail fixator has emerged as a viable option for the treatment of the same as it can address most of all above problems. It is more patient friendly and easier to apply in comparison to Ilizarov ring fixator.

Material and methods: Twenty two patients (17 males and 5 females) with complex non union of tibia underwent thorough debridement and resection of non viable bone followed by bone transport to fill the gap and then lengthening (8 patients) or acute docking & lengthening (14 patients) by the use of rail fixator. The average time to union, bone gap filled, lengthening achieved, treatment index were measured. The bone and functional outcome assessment was done by ASAMI score. The complications were classified according to Paley's classification.

Results: Union without residual infection was achieved in 20 (90.1%) patients while 2 patients had failure. As per ASAMI criteria bone results were excellent in 12 (54.5%), good in 5 (22.7%), fair in 3 (13.6%) and poor in 2 (9.1%). Functional results were excellent in 11 (50%), good in 5 (22.72%), fair in 4 (18.18%) and failure in 2 (9%). Mean treatment duration was 8.2 months (range 7-19 months). Mean follow up duration was 11.3 months (range - 8.3 to 22 months). Average lengthening achieved was 4 cm (0-9 cm). Treatment index was 2.1 month/cm.

Conclusion: The monolateral rail fixator is simple, effective, easier to apply and more patient compliant with acceptable functional and radiological outcome.

Keywords: Bone transport; Complex non-union; Corticotomy; Limb reconstruction system; Rail fixator; Tibia.

Fig. 1

Twenty year old male with infected non union left Tibia proximal 1/3rd (10 months old) with tubular external fixator and discharging sinus, a)Preop xray; b)Post op Xray after thorough debridement, resection of all infected bone with gap and rail fixator in situ; c) 6 month follow up x ray shows mal alignment of middle segment for which it was manipulated and docking site freshened also; d) At 8 months follow up; e) At 15 months follow up with solid union of fracture site so fixator was removed; f) After rail fixator removal; g) clinical photograph of patient after rail fixator removal with full flexion and 1 cm residual shortening so shoe raise given; h) patient standing full weight bearing.

Fig. 2

a) A twenty two years male presented to us infected comminuted fracture of right tibia in proximal half with skin defect and external fixator in situ 4 ½ months after sustaining injury; b) All the infected and devitalized bone and tissues were debrided and flap was applied by plastic surgeons to cover the wound; c) Six weeks after plastic surgery rail fixator was applied and distal corticotomy was done; d) 5 weeks after rail fixator application; e) 7.5 months after rail fixator application; f) After 11 months rail fixator was removed with solid union at docking site; g) clinical photograph of patient with full extension and patient standing partial weight bearing with crutches.