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Staged Protocol for the Treatment of Chronic Tibial Shaft Osteomyelitis with Ilizarov’S Technique Followed by the Application of Intramedullary Locked Nail

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Staged Protocol for the Treatment of Chronic Tibial Shaft Osteomyelitis with Ilizarov’S Technique Followed by the Application of Intramedullary Locked Nail n Feature Article Staged Protocol for the Treatment of Chronic Tibial Shaft Osteomyelitis With Ilizarov’s Technique Followed by the Application of Intramedullary Locked Nail CHUN-CHENG LIN, MD; CHUAN-MU CHEN, MD; FANG-YAO CHIU, MD; YU-PIN SU, MD; CHIEN-LIN LIU, MD; TAIN-HSIUNG CHEN, MD abstract Full article available online at Healio.com/Orthopedics. Search: 20121120-23 Open tibial shaft fractures are the most common open fractures, and many complica- tions can occur. During the treatment period, infection leading to osteomyelitis was the most common complication. However, no consensus exists regarding the ideal management for such cases in the literature. The purposes of this retrospective study were to review the treatment of patients with chronic tibial shaft osteomyelitis over the past 14 years who were referred to the authors’ institution and to provide a staged protocol for spontaneous wound healing. The staged protocol included: (1) radical debridement for infected bone and soft tissue; (2) immediate application of Ilizarov’s apparatus for all patients except those needing delayed applica- tion; (3) osteotomy in healthy bone; (4) simultaneous distraction–compression osteogen- esis and histogenesis; (5) additional docking-site bone grafting; and (6) shifting the external fixator to a locked nail when callus formation was visible at the distraction site. Union was achieved in 15 of 16 patients, with an average external fixation time of 4.5 months (range, 3-6 months). No deformity or leg-length discrepancy greater than 1 cm occurred. In the treatment of chronic osteomyelitis, this staged protocol was safe and successful and allowed for union, realignment, reorientation, and leg-length restoration. Regarding the soft tissues, this technique provides a unique type of reconstructive closure for infected wounds. It is suggested that the staged protocol is reliable in providing successful simulta- neous reconstruction for bone and soft tissue defects without flap coverage. Figure: Photograph showing the Ilizarov’s appara- tus with bifocal approach and the extended fixator for forefoot anchorage. Dr Lin is from the Department of Surgery, Taipei Veterans General Hospital Su-Ao Branch, Su-Ao Town, Yi-Lan County, Drs Chen (Chuan-Mu), Chiu, Su, Liu, and Chen (Tain-Hsiung) are from the Department of Orthopedics and Traumatology, Taipei Veterans General Hospital and also the Department of Surgery, National Yang Ming University, and Dr Chen (Chuan-Mu) is also from the Department of Orthopedics, Cheng Hsin General Hospital, Beitou District, Taipei City, Taipei, Taiwan, R.O.C. Drs Lin, Chen (Chuan-Mu), Chiu, Su, Liu, and Chen (Tain-Hsiung) have no relevant financial rela- tionships to disclose. Correspondence should be addressed to: Chuan-Mu Chen, MD, Department of Orthopedics, Cheng Hsin General Hospital, No. 45 Cheng Hsin St, Beitou District, Taipei City 112, Taiwan, R.O.C. (chen_ [email protected]). doi: 10.3928/01477447-20121120-23 DECEMBER 2012 | Volume 35 • Number 12 e1769 n Feature Article ibial diaphyseal fractures are the achieving union in most common open fractures. comminuted frac- TMore than 50% of open fractures tures, correcting in the authors’ institution are classified angular deformity, as high-energy Gustilo-Anderson type III and reconstructing fractures. Many complications can occur, bony defects using including nonunion, malunion, delayed distraction osteo- union, bone and joint deformities, chronic genesis.6-8 This sur- edema, compartment syndrome, limb- gery is performed length discrepancy, infection, and ampu- percutaneously to 1A 1B 1C 1D tation.1-5 minimize soft tissue In the experience of the surgeons of trauma. Advanced the Taipei Veterans General Hospital, it techniques using is difficult to treat the comminuted frac- the Ilizarov method tures in Gustilo-Anderson type III frac- can provide healing tures with only standard intramedullary capacity for large nailing or internal fixation, particularly bone and soft tissue in the setting of large bone and soft tis- defects without the sue defects. Although autogenous bone need for flap cover- grafting may be used to fill bone defects, age and provide an donor-site morbidity and insufficiency ex- alternative to ampu- ist in large segmental defects, in which tation.9 Distraction case the autogenous bone grafting could histogenesis has be performed only as a secondary pro- also been used for 1E 1F 1G 1H cedure. Furthermore, the management skin expansion Figure 1: After previous treatment of plating for open tibial fracture, the of these fractures is complicated by con- around the contrac- patient presented with infection and fracture nonunion. The staged pro- tocol was then applied. Lateral radiograph showing initial status after comitant neurovascular and soft tissue ture joint.10 removal of previous plate (A). Anteroposterior radiograph showing post- injuries, which cause the risks of limb In the current operative status after sequestrectomy, applying Ilizarov’s apparatus, and infection and amputation. In the event of study, infection lead- osteotomy in healthy bone (B). Photograph showing the Ilizarov’s ap- complete bony union, these treatment dif- ing to osteomyelitis paratus with a bifocal approach and the extended fixator for forefoot anchorage (C). Photograph showing the open wound after radical de- ficulties may lead to the functional decline was considered the bridement and then complete wound healing after simultaneous distraction– of limbs with limb-length discrepancy, de- most common com- compression osteogenesis and histogenesis (E). Anteroposterior radio- formities, and joint contracture. plication. However, graph showing visible callus formation at the distraction site, and status Soft tissue damage around the fractures no consensus exists post Harmon’s procedure with posterolateral grafting at the docking site (F). Anteroposterior (G) and lateral (H) radiographs showing bony union and subsequent wound management are of- regarding the ideal at 1-year follow-up. ten the main factors affecting the outcomes management of os- of open tibial fractures. During tibial bone teomyelitis after fixation, early application of either a local treating open tibial shaft fractures in the lit- erage and autogenous cancellous bone muscle flap or a free flap may be the appro- erature. The purposes of the current retro- grafting for the docking site. The external priate treatment, respectively, for the defect spective study were to review the treatment fixator was shifted early to an intramedul- around the proximal two-thirds or the dis- of patients with chronic tibial shaft osteo- lary locked nail when callus formation was tal one-third of the tibia. However, the local myelitis over the past 14 years who were visible at the distraction site. flap can be suboptimal because the rotated referred to the authors’ institution (Taipei muscle often falls in the severe injury zone. Veterans General Hospital) and to provide MATERIALS AND METHODS However, the application of a free flap re- a staged protocol for spontaneous wound Demographic Data quires microsurgery and local blood sup- healing using wet-to-dry dressing followed Between October 1997 and March ply, which may have been compromised by by simultaneous distraction–compression 2012, sixteen patients with chronic os- vascular injuries. osteogenesis or histogenesis of Ilizarov’s teomyelitis and soft tissue loss around the Over the past 3 decades, external fixa- technique to restore the soft tissue defects tibial shaft underwent this protocol at the tion has become a prominent method for and the bony gap without further flap cov- authors’ institution. Prior to staged manage- e1770 ORTHOPEDICS | Healio.com/Orthopedics CHRONIC TIBIAL SHAFT OSTEOMYELITIS | LIN ET AL tis and soft tissue loss around the tibial shaft included: (1) radical debridement for infected bone and soft tissue and the additional insertion of an antibiotic- impregnated cement-rod for 10 days in cases of previously existing septic med- ullary implant; (2) the immediate ap- plication of Ilizarov’s apparatus for all patients except those needing delayed application because of previously exist- ing septic medullary implant; (3) oste- 2A 2B 2C 2D 2E 2F otomy in healthy bone; (4) simultaneous distraction–compression osteogenesis and histogenesis; (5) additional docking-site bone grafting; and (6) shifting the external fixator to a locked nail with a closed tech- nique when callus formation was visible at the distraction site. Vancomycin was used throughout treatment for all patients. Radical Debridement. Performing radical debridement before the Ilizarov’s procedure is necessary. With regard to infected bone, adequate debridement 2G 2H 2I 2J 2K 2L should supply a healthy appearance of the Figure 2: The patient sustained an open segmental tibial shaft fracture with infection and had been treated remaining bone with an opened intramed- with intramedullary locked nail at another institution approximately 3 months before presentation. The ullary canal and bleeding surface, which staged protocol of the clinic was applied. Anteroposterior (A) and lateral (B) radiographs and photograph is best performed under the use of tourni- (C) showing the condition on arriving. Anteroposterior radiograph showing postoperative status after quet. During sequestrectomy, the typical radical debridement, removal of locked nails, sequestrectomy, and residual 12 cm of bone defect (D). Anteroposterior (E) and lateral (F) radiographs showing that bone transport was performed with
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