|Year : 2013 | Volume
| Issue : 1 | Page : 14-19
Treatment of infected non union tibia: A novel technique - lengthening using limb reconstruction system over intramedullary nail
Mahantesh Y Patil, Sumit Mehra
Department of Orthopedics, Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
|Date of Web Publication||28-Mar-2013|
Mahantesh Y Patil
Department of Orthopaedics, Jawaharlal Nehru Medical College, Belgaum, Karnataka
Source of Support: None, Conflict of Interest: None
Background: To assess combination of an intramedullary interlocking (IMIL) nail with limb reconstruction system (LRS) in cases of infected nonunion tibia and to show influence of nail in predicting good outcome. Materials and Methods: From 2009 to 2011, records of 20 patients (17 men and three women) aged 18 to 65 years (mean, 38.4 years) with infected nonunion of the tibia treated with the LRS over IMIL Nail technique were prospectively reviewed. According to Jain et al., patients were classified into five cases of A1, five cases of type A2, seven cases of type B1, and three cases of type B2. All cases underwent LRS and IMIL. Mean amount of target lengthening was 54.65 mm. The mean follow-up was 14 months. Results: Mean amount of tibia lengthening was 51.70 mm. Leg length equalization was achieved in 19 cases (±5). According to modified scoring by Paley et al., 12 patients had excellent results, three patients had good, four patients had fair outcome, and one patient had poor outcome. Mean distraction index was 0.97. Mean maturation index was 2.43. Mean consolidation index was 3.47. Mean healing index was 1.40. One case had proximal locking screw failure. One case developed pre mature consolidation as distraction was started at delayed period due to non-compliance. Two cases developed decreased dorsi flexion of ankle. Two cases required flap surgeries for cover of bone. One case had pin breakage, which had to be exchanged. One case developed re-infection. Conclusion: The advantages of this technique include complete eradication of infective foci, reduced risk of deformity during lengthening, decrease risk of fractures post external fixator removal and reduction of time required for external fixator use thus decreasing healing index: Number of days of external fixation required per centimetre of lengthening.
Keywords: Infected non-union tibia, intramedullary interlocking nail, limb reconstruction system
|How to cite this article:|
Patil MY, Mehra S. Treatment of infected non union tibia: A novel technique - lengthening using limb reconstruction system over intramedullary nail. J Sci Soc 2013;40:14-9
|How to cite this URL:|
Patil MY, Mehra S. Treatment of infected non union tibia: A novel technique - lengthening using limb reconstruction system over intramedullary nail. J Sci Soc [serial online] 2013 [cited 2017 Apr 28];40:14-9. Available from: http://www.jscisociety.com/text.asp?2013/40/1/14/109684
| Introduction|| |
Goals of treatment in infected non-union tibia are to obtain solid bony union, eradication of infection with maximum functional use of extremity. Different modalities of management like extensive debridement and local soft tissue flaps, using antibiotic beads, cancellous bone grafts, allografts vascular fibular grafts have been in use for decades.
Essence is to obtain infection-free environment, and plan to proceed for stabilization and stimulation of healing patterns. These procedures are usually staged requiring one or more procedures and thus prolonging recovery period. They have variable rate of success and are unable to usually accomplish length and stability.
On other hand, Ilizarov and Limb Reconstruction System (LRS)  have been found to show encouraging results as they offer one stage procedure with eradication of infection, correction of length and deformity. A significant modification of these methods is combining an intramedullary interlocking (IMIL) nail with LRS. The advantage of using this method is reduced risk of deformity during lengthening, decreased rate of fractures and deformity post external fixator removal and reduction of time required for external fixator use.
Aim of the study is to show the eradication of infection and influence of IMIL Nail in reducing time needed for external fixator removal, reducing the deformities, and impact on healing index: Number of days of external fixation required per centimetre of lengthening.
| Materials and Methods|| |
Study group: Lengthening over IMIL nail
From 2009 to 2011, records of 20 patients (17 men and three women) aged 18 to 65 years (mean, 34.5 years) with infected nonunion of the tibia treated with the LRS over IMIL Nail technique were followed up. All cases were monitored for one and half years. Sixteen cases occurred after open fractures, one had infection post fasciotomy done due to impending compartment syndrome, and three cases had infection following plate osteosynthesis. Sixteen fractures occurred as result of road traffic accident and four had fall. Thirteen open fracture cases had type II wound and three had type III wounds according to Gustillo Anderson classification [Table 1]. All open fractures except four were initially treated with debridement and external fixator. While one was treated with IMIL Nail after thorough debridement. The mean follow up was 14 months (12-17 months)
Orthofix LRS was used in all cases combined with 8/9 mm IMIL Nails. Location of nonunion was proximal diaphyseal in nine cases and distal diaphyseal in 11 cases. Nonunions were classified according to Jain et al., into five cases of A1, five cases of type A2, seven cases of type B1, and three cases of type B2.
Criteria for evaluation
We modified scoring system of Paley et al.,  [Table 2] for outcome of tibia lengthening procedure on basis of clinical and radiographical criteria. The scores were rated as excellent, good, fair, or poor and were calculated based on the number of points that were assessed for five parameters: Range of motion of ankle, amount of lengthening, gait, pain, and ability to perform daily activities/work. The range of motion of the ankle was determined based on the amount of equinus deformity and the amount of dorsi flexion at the end of treatment or before treatment. Lengthening was assessed by comparing the actual amount of lengthening with the initial goal. Gait was evaluated according to the degree of limp (subjectively assessed on clinical examination) preoperatively compared with postoperatively. The amount of pain was assessed subjectively by the patient before and after treatment, as was the ability to perform activities of daily living and to work. Through the addition and subtraction of point values the patient received a score that was excellent (95-100 points), good (75-94 points), fair (40-74 points), or poor (<40 points) [Table 3].
Operative time, estimated blood loss, and cost of treatment also were also recorded. Radiographs were made monthly throughout the consolidation phase. The maturation phase began at the end of distraction (the limb lengthening phase) and ended when the bone in the distraction gap had healed sufficiently (when three of four cortices were seen to be intact on antero-posterior and lateral radiographs the radiographic consolidation end point). With use of the Ilizarov fixator, lengthening occurs along the mechanical axis of the tibia, whereas lengthening over an intramedullary (IM) nail occurs along the anatomical axis.
Distraction index, maturation index and consolidation index were calculated and evaluated, with respect to the anatomical location, previous operations at the affected site, and age. 
The most important principle of technique was to avoid contact between the IM nail and shanz pins.  The image intensifier was used in the operating room to obtain careful antero-posterior, lateral and oblique views. One problem, which was encountered in the population, was smaller tibial dimension including narrower tibial medullary canals which frequently required the use of an 8 mm diameter IMIL nail.
Step 1: Debridement and osteotomy of infected site
Patients were operated under spinal anesthesia. Preoperatively, [Figure 1] methylene blue was injected into sinuses for complete excision of the sinus tracts. Existing implants were removed, thorough debridement of infected tissue was done and the bone was resected transversely proximal and distal to nonunion site to remove all circumferential defects till punctuate bleeding was noticed. The medullary canal was opened on both sides. Punctate cortical bleeding (paprika sign) was used to determine the completeness of bone debridement.
Step 2: Intramedullary nail insertion
Tibial nail was inserted through a transpatellar incision. Tibia was reamed 1 mm over the planned tibial nail diameter, IM nail was inserted, proximal end of the nail was locked using two medial-to-lateral locking screws.
Step 3: Tibial corticotomy
This metadiaphyseal junction offers superior regenerate for bone formation. Diaphyseal osteotomy was avoided as much as possible. Corticotomy was performed using a ½ cm corticotome [Figure 2].
|Figure 2: Limb reconstruction system with intramedullary interlocking and corticotomy|
Click here to view
Step 4: Application of the limb reconstruction system
Shanz pins of 6 mm were inserted into tibia with two pins above corticotomy site, two pins in the middle segment, and two pins distal to nonunion site and pins were connected using LRS, rails attached with two end clamps and one central clamp connected with compression and distraction device [Figure 2].
Step 5: Postoperative care
Rest and elevation of the leg was given for 1-3 days.
Quadriceps straight-leg raise exercises and knee range of motion were started immediately post-operatively.
Ambulation was started with the patient partial weight-bearing (50%) with crutches or a walker after three days.
Distraction was started on the 8 th day. The distraction rate was 1 mm per day in two phases [Figure 3].
Patients were discharged from hospital on the 14 th postoperative day.
Distraction was stopped when the desired tibial length was achieved [Figure 4].
Step 6: Frame removal
The desired tibial length was usually reached after 1-3 months. LRS was removed during maturation period once maturation period was equal to distraction period [Figure 5].
|Figure 5: After limb reconstruction system removal, once maturation phase was equal to distraction|
Click here to view
Step 7: Follow up
Regular follow up x-rays were obtained every month until the distracted callus had fully matured [Figure 6]. Full weight-bearing without walking aids, running, and jumping was permitted when complete consolidation at the distraction site was seen.
| Results|| |
Mean amount of tibia lengthening was 51.7 mm range (42-67 mm). Leg length equalization was achieved in 19 cases (±5).
Distraction was started at mean 10 days postoperatively. Mean distraction index was 0.97 (0.91-1.05) and mean hospital stay was 14.2 days.
Mean duration of external fixator was 126.6 (104-148) days with mean healing index of 2.24 (2.17-2.53)
The mean maturation index was 2.36 (2.2-2.5).
The mean consolidation index was 3.53 (3.1-3.8).
Operative time and blood loss
Mean operative time was 140 minutes with mean amount of blood loss of 170 ml.
Fourteen patients had excellent, four had good, and two had fair outcome.
One case had proximal locking screw failure-screw had to be exchanged. One case developed pre-mature consolidation as distraction was started at delayed period due to non-compliance-corticotomy had to be reperformed. Two cases required flap surgeries for cover of bone. One case had pin breakage, which had to be exchanged. Two cases developed decreased dorsi flexion of ankle-both cases regained full range after physiotherapy.  One case of infection occurred in our study so implants had to be removed and after thorough debridement and lavage docking was done at fracture site thus resulting in shortening of 3 cm.
According to modified Paley et al., scoring, 12 patients had excellent results, three patients had good, four patients had fair and one patient had poor outcome.
| Discussion|| |
The studies on combined use of Ilizarov external fixator and IMIL Nail have been published by Paley et al.,  in cases of Femur, and Linh et al.,  in tibia. But they were used in cases of shortening with different etiologies, which included congenital,  tumors, post traumatic, bone loss or infective cause. This is original study done in cases of infected nonunion tibia where combined use of LRS and IMIL Nail has been successful.
LRS was used with IMIL Nail to manage length and alignment in infective nonunion tibia. It also helps in diminishing fracture of regenerate, by neutralizing forces on tibia. It also decreases the mal-alignment, which is encountered with use of LRS alone.
Although most cases had no major complaints in their last follow up, three cases had mild limp with slight pain resulting in good outcome, four patients had decreased range of ankle motion up to neutral, with slight pain, mild limp, and reduced activity resulting in fair outcome. One case had developed re-infection thus resulting in implant removal, and had to undergo shortening of 3 cm. Overall, 15 patients had excellent to good outcome, signifying the efficacy of use of LRS along with IMIL nail in cases of infected nonunion tibia.
The most worrisome problem is pin-track infection  leading to deep IM infection during lengthening, a concern that is due to the trauma of nailing after external fixation. Although we did encounter one reinfection despite of adhering to strict asepsis followed in operation theatre, twice daily care of pins and also intra operative care taken so as to avoid contact between pins and nail.
There are few weaknesses in this study. Our study was limited by the lack of match-controlled group, treated with LRS alone. The number of patients is small.
Although the combination of IM nailing and external fixation is technically more demanding than the LRS alone, it has the advantages of a reduction in the duration of external fixation, protection against refracture, and earlier rehabilitation. We believe that these advantages offset the disadvantages of increased cost, increased operative time, and increased blood loss. In conclusion, we believe that our findings demonstrate that tibial lengthening over an IM nail is safe and reliable, and offers advantages compared with the standard method of Ilizarov lengthening/LRS alone. ,,,,
| Conclusion|| |
The advantages of this technique include complete eradication of infective foci, reduced risk of deformity during lengthening, decrease risk of fractures post external fixator removal, and reduction of time required for external fixator use thus decreasing healing index: Number of days of external fixation required per centimetre of lengthening.
| References|| |
|1.||Vijay C, Kumar M, Manjappa CN. Management of open type III a and III b fractures with LRS External fixator. Internet J Forensic Sci 2009;22. |
|2.||Paley D, Herzenberg JE, Paremain G, Bhave A. Femoral lengthening over an intramedullary nail. A matched-case comparison with Ilizarov femoral lengthening. J Bone Joint Surg Am 1997;79:1464-80. |
|3.||Krieg AH, Lenze U, Speth BM, Carol C. Intramedullary leg lengthening with a motorized nail indications, challenges, and outcome in 32 patients. University Children's Hospital, Basel (UKBB), Switzerland. Acta Orthop 2011;82. |
|4.||Stanitski DF, Shahcheraghi H, Nicker DA, Armstrong PF. Results of tibial lengthening with the Ilizarov technique. J Pediatr Orthop 1996;16:168-72. |
|5.||Linh Huy'nh Ba, Feibel RJ. Tibial lengthening over an Intramedullary nail. Tech Orthop 2009;24:279. |
|6.||Park HW, Yang KH, Lee KS, Joo SY, Kwak YH, Kim HW. Tibial lengthening over an intramedullary nail with use of the ilizarov external fixator for idiopathic short stature. J Bone Joint Surg Am 2008;90:1970-8. |
|7.||Paley D. Problems, obstacles, and complications of limb lengthening by Ilizarov technique. Clin Orthop Relat Res 1990;250:81-104. |
|8.||Bassett GS, Morris JR. The use of Ilizarov technique in the correction of lower extremity deformities in children. Orthopedics 1997;20:623-7. |
|9.||Magadum MP, Basavaraj Yadav CM, Phaneesha MS, Ramesh LJ. Acute compression and lengthening by the Ilizarov technique for infected nonunion of the tibia with large bone defects. J Orthop Surg (Hong Kong) 2006;14:273-9. |
|10.||Krishnan A, Pamecha C, Patwa JJ. Modified Ilizarov technique for infected nonunion of the femur: The principle of distraction-compression osteogenesis. J Orthop Surg (Hong Kong) 2006;14:265-72. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3]