Success Story of Ilizarov in Chronic Non-union of Tibia with 18 Years of Morbidity: A Case Report

Abstract

Introduction: When the fracture fails to heal for more than 12 months, it is called chronic non-union. Surgical intervention becomes mandatory to get this type of fracture healed. We are reporting our results in a case of congenital pseudoarthrosis of the tibia (CPT) having chronic non-union of 18 years duration with superadded infection following attempted surgery, using Ilizarov technology. We shall highlight the problems found during the course of treatment and different strategies to tackle them.

Case presentation: An 18-year-old female, born with CPT of the right tibia with neurofibromatosis, presented as Type 1 infected non-union following three unsuccessful surgeries. She had neurofibromatic nodules all over the body including the face. The leg had multiple active draining sinuses, with evidence of healed sinuses and operating scars, adherent to underlying bone. She had 20 cm of limb shortening. Prolonged morbidity made her socially isolated. Being poor, they could not manage her medical expenses. They started believing that amputation would be a viable option and with that feeling in mind, they approached us. After few sittings of counseling, they somehow agreed to give it a try. After preparing the patient, a radical excision of the infected and dead tissue was done. A 3 ring Ilizarov assembly was mounted as the distal fragment was very small. A corticotomy was done to fill up 10 cm of gap following excision and subsequent limb lengthening. She developed hyporegenerate, pin-tract infections (PTIs) during the course of treatment which were tackled accordingly. She also developed psychological problems due to nature of treatment that was taken care of too. The fracture united and she could start walking unaided. There was no recurrence of infection. The ring was kept in situ for about 700 days.

Conclusion: Chronic non-union associated with neurofibromatosis and infection is a very challenging situation. Radical debridement is the key to prevent recurrence of both. Ilizarov system plays the most significant role in forming regenerate by distraction. Hyporegenerate and PTIs could be tackled meticulously to prevent complications and attain the desired result. The patient could achieve painless unaided walking after the treatment. Probably instilling self-confidence in the patient was one of the most important aspects to sustain such an arduous journey.

Keywords: Chronic non-union; Ilizarov; infected non-union; neurofibromatosis.

Figure 1

Clinical picture of the patient showing neurofibromatic nodules.

Figure 2

Clinical picture showing affected limb with infected sinuses and shortening.

Figure 3

Pre-operative X-ray showing infected non-union right tibia.

Figure 4

X-ray immediately after thorough debridement.

Figure 5

X-ray 10 days after corticotomy.

Figure 6

X-ray showing hyporegenerate at distraction site.

Figure 7

Final X-ray after ring removal.

Figure 8

Final clinical image showing weight-bearing on affected limb.