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 complications 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 application; (3) osteotomy 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 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 simultaneous reconstruction for bone and soft tissue defects without flap coverage. Figure: Photograph showing the Ilizarov’s apparatus 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

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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 protocol 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-

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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 medullary implant; (2) the immediate application of Ilizarov’s apparatus for all patients except those needing delayed application because of previously existing 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 technique 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 a trifocal- bone cut is made perpendicular to the ana- approach. Anteroposterior (left) and lateral (right) radiographs showing visible callus (G). Photograph tomic tibial axis using a power saw cooled taken on arrival at the docking site showing Ilizarov’s apparatus with an extended fixator for forefoot with saline irrigation. Under C-arm fluo- anchorage (H). Anteroposterior (I) and lateral (J) radiographs obtained after removing the external skeletal roscopy, a K-wire is used as a guide for fixator showing intramedullary locked nail and bone consolidation after Harmon’s procedure. Anteropos- terior (K) and lateral (L) radiographs showing bony union at 1-year follow-up. the bone cut. The remaining bone edges require soft tissue coverage to avoid desic- ment, each patient had a complete examina- soft tissue defects after radical debridement cation, secondary necrosis, and osteomy- tion, including electromyography, angiogra- was 8 cm (range, 4-12 cm). The latency elitis. When determining the amount of phy, and triple-film radiographs of the lower period was 7 days, followed by simultane- diseased bone removed, the bone quality limbs. Inclusion criteria were: an absence of ous distraction–compression osteogenesis priority, rather than bone volume, was ad- pin-tract infection when shifting the external and histogenesis after osteotomy in healthy opted. The remaining bone surfaces had fixator to a locked nail and a suitable space bone. A bone defect longer than 6 cm was visible bleeding spots and serosanguinous in the intramedullary canal to accommodate an indicator of trifocal transport. Temporary fluid discharged from the opened intra- a locked nail. Fourteen men with a mean age extended fixator for anchorage of the fore- medullary canal or the multiple pin tracts of 36 years (range, 18-70 years) were select- foot was used in each case to avoid the made on the cancellous bone. The surgi- ed. Ilizarov’s apparatus (Smith & Nephew relative complication of equinus deformity. cal wound was left open, and wet dress- Richards, Memphis, Tennessee) was used Additional bone grafting was performed ing was necessary. Then, the presence of after the removal of previous implants, the around the docking site in all patients. granulation tissue around the proximal or performance radical debridement, or both. distal bone surface ensured the previously Full weight bearing was allowed to enhance Strategies adequate debridement. However, the soft callus maturation during the distraction The staged protocol (Figures 1A-H, tissue defect was ideally fashioned into a stage. The average length of the bone and 2A-L) for treating chronic osteomyeli- basin-like shape, which provided histo-

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genesis a platform to approximate wound each other to avoid deviation during bone tion site, regenerative solid bone existed edges. the Ilizarov’s apparatus was ap- transport and to optimize contact at the on the pathway leading to higher tech- plied immediately following radical de- anticipated docking site. nique demand for intramedullary nailing. bridement. Simultaneous Distraction–compression Under an external fixator for keeping Ilizarov’s Apparatus. To set up the Osteogenesis and Histogenesis. With the the anatomical reduction, a long, rigid Ilizarov’s apparatus, the surgeons placed adjustable rods longitudinally applied be- guide-pin (Rush Pin LLC, Meridian, two 4-mm full pins with central threads tween the rings, simultaneous distraction– Mississippi) with sharp ends was used to (Smith & Nephew Richards), which were compression osteogenesis and histogenesis make a tract break through the regenera- parallel to the joint line under the guid- were administrated 7 days after osteotomy. tive callus. Then, the locking nail (Smith ance of fluoroscopy, through the proxi- Osteogenesis was periodically monitored & Nephew Richards) was introduced mal and distal tibia for stronger connec- during the first postoperative month and af- across the docking site after adequate tions with up- and nethermost rings, re- ter full weight bearing. During the Ilizarov reaming. A locked intramedullary nail spectively. All rings of the Ilizarov’s ap- procedure, monofocal, bifocal, and trifocal was applied after adequate reaming. paratus should be arranged concentrical- approaches were the 3 novel approaches ly. Most of the connections were 1.8-mm chosen for bone and soft tissue transport. Wound Management Principles smooth or olive wires through the tibia, In the monofocal approach, the 2 bony seg- Necrotic and devitalized tissues should perpendicular to the tibial axis, and with ments next to the defect were transported be debrided while preventing exposure of 2 ends fixed on the ring. For each ring toward each other, which caused limb the remaining healthy bone. The wounds block, 1 wire was applied as a reference shortening. An osteotomy was performed should be left accessible, with the leg in on the coronal tibial plane. Then, another outside of the healthy bone injury zone the circle frame. Several self-incremental wire was accordingly applied next to using a bifocal approach (Figure 1B). The adjustments were made on each day. the first wire, forming a transverse ring intercalary segment was then transported Patient involvement and cooperation plane. The clearance between the soft and compressed the defect site (Figures were important while using this method. tissue and the rings was approximately 1C-E). A simultaneous lengthening oc- The self-care of wounds was also essen- 2 fingerbreadths. A tension of 110 kg curred through the corticotomy site, which tial during the transporting phase until was suggested for fixing smooth wires, maintained the limb length. A trifocal ap- closure occurred. In most patients, the whereas 90 kg was suggested for olive proach (tandem procedure), which was wounds were managed with daily nor- wires. An additional 5-mm half-pin was indicated when a bone loss of more than mal saline wet-to-dry dressing during selectively applied in the adaptive site 6 cm occurred (Figure 2D), used 2 length- the transporting phase until closure oc- to enable the ring more stability on the ening osteotomies and compression of the curred. In addition to normal saline, di- plane perpendicular to the tibial axis. defect (Figure 2E). The Ilizarov method of luted H2O2 (about 1:1) in wet gauze as Therefore, setting each ring block should intercalary bone transport was used to treat a disinfectant for treating wounds 3 days have a combination of 2 wires with or tibial bone loss and achieve limb salvage. postoperatively (radical debridement) was without 1 half-pin. All wires and pins Bone Grafting. After the periodic as- used and kept for 2 more weeks. More re- were placed through the safe zone to sessment of regenerated bones, bone mar- cently, a vacuum-assisted closure (VAC) avoid neurovascular structure injury. row injection was indicated in patients with device was used on open wounds during Osteotomy. The subsequent oste- slow maturation of regenerative bone at the the transporting phase. As the transport otomy in healthy bone was suggested 1 2-month follow-up. Additional bone graft- progressed, the granulation tissue was ex- week after applying the external fixator. ing also improved docking site healing af- pected to appear, and the wound size grad- When a short bone segment is left after ter wound closure and eradicated infection ually decreased until the wound healed. an osteotomy in the proximal or distal in all patients. Using Harmon’s11 procedure tibia, extending the circle frame across with posterolateral grafting at the middle Results the knee or ankle joint should be con- and distal tibia was recommended. Union was achieved in 15 of 16 pa- sidered, at least temporarily. In the ex- Intramedullary Locking Nail tients, with an average time to external fix- perience of the surgeons of the Taipei Application. When callus formation was ation of 4.5 months (range, 3-6 months). Veterans General Hospital, the strategy visible at the distraction site, it was con- No deformity or leg-length discrepancy is most commonly used for the distal sidered the appropriate time to apply the greater than 1 cm occurred. Bone marrow tibia. Using the intraoperative olive-wire intramedullary locking nail (Smith & injection to the regenerate site was 15%. reduction technique, the bone defect Nephew Richards). However, when cal- One patient had a recurring infection but edges should be perfectly pointed toward lus formation was visible at the distrac- refused further treatment.

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Discussion cessfully to reconstruct legs with tibial antibiotic therapy. Distraction-area pain An innovative alternative to compen- bone loss and soft tissue defects simul- was the most common report during the sate for bone loss is to transport healthy taneously, was chosen for the current pa- transporting phase. In the patients who bone to the fracture site to bridge the bone tients. This limb-salvage method can be needed lengthening of more than 4 cm, defect.12 The dynamic frame enables grad- used in patients who are not candidates for dermal irritation from wires and screws ual lengthening, deformity correction, flap coverage. Another concern regarding that increased pain happened more fre- and compression of nonunion or delayed the use of this technique was to prevent quently. Otherwise, the increased pain union with minimal invasion. The soft tis- patients from possible failure of flap cov- would be relieved by oral analgesics. sue envelope regenerates around the bone erage. Gradual defect closure was accom- Staged management for chronic tib- transport. The bone transport technique plished, resulting in bone and soft tissue ial shaft osteomyelitis is a top standard. was initially reported as distraction os- healing. Limb lengthening can be per- Staged management for infected tibial teogenesis by Ilizarov,13 and then became formed outside the injury zone in healthy shaft nonunion followed by locked intra- widely used by orthopedic surgeons in the bone and soft tissue. A trifocal approach medullary nailing had been reported by West.6-8 However, this method also has should be considered for defects larger Klemm20 via 3 or 4 stages.In this research, disadvantages, including a prolonged ex- than 6 cm. Technique and frame design the principles of staged management were ternal fixation period.14 advances should help prevent residual de- followed, and the intramedullary locked Regarding soft tissue loss, the early formity. nail provided stable fixation via a closed application of muscle-flap coverage was The priority of reconstructive meth- technique. Insertion of the interlocking often considered a procedure that pro- ods for soft tissue defects is controversial nail at the same time as the external fixa- vided an infection barrier and promoted and may create a dilemma for surgeons tion was supposed to be avoided in previ- healing.15,16 Many have also reported that in determining whether soft tissue trans- ous studies because of concerns of poten- using appropriate soft tissue coverage is port should be used as the last resort only tial infection.25,26 However, early removal necessary for preventing infection and when flap coverage is not available or if of the external fixator and replacement bone desiccation.17-19 Regardless, some it should be used as the priority to avoid by intramedullary nail achieved the same problems remain in the extensive soft possible flap coverage failure. Previous clinical and functional outcome as the tissue injuries and vascular disruption in reports showed that simultaneous bone classic technique with a shorter duration severe tibial fractures.20 Thus, opinions and soft tissue transport could success- of external fixation.27-29 Furthermore, the for flap coverage may be limited. On oc- fully avoid the need for flap coverage.9 suggested adequate time to perform nail- casion, plastic surgeons state that patients The final choice depends on the surgeon’s ing was when callus formation was radio- are not candidates for flap reconstruction preference and the availability of plastic graphically visible at the distraction site due to local soft tissue unavailability, po- surgeons. The treatment time is long, and because the intramedullary implant could tentially poor vascular supply (eg, single patients report pain, especially during the occupy the healing space for osteogenesis. vessel, preexistent procedure of revascu- transporting phase. Potential complications larization, or plaque disease of vessels), include limb-length discrepancy, malalign- Conclusion and systemic comorbidities that make ment and malorientation, joint contracture, In the treatment of chronic osteomyeli- patients intolerant to time-consuming sur- pin-tract problems, nonunion, refracture, tis, the staged protocol proposed by the au- gery. In addition, another flap coverage recurrent infection, and limb loss.13,23,24 thors is safe and successful. The same tech- revision is almost infeasible after previ- Although potential complications ex- niques that were used for all cases allow for ous flap necrosis. With a lack of adequate isted in previous studies, no irreversible union, realignment, reorientation, and leg- wound coverage, many patients may face complication occurred from the proce- length restoration. Regarding the soft tis- inevitable osteomyelitis and amputation. dure during distraction–compression os- sues, this protocol provides a unique type Overall, many methods exist for the teogenesis and histogenesis in the current of reconstructive closure for infected obliteration of the dead space after radi- study. Minor complications were resolved wounds. The cases of tibial open fractures cal debridement for necrotic bone and soft with conservative treatments, whereas with complicated osteomyelitis and soft tissue, including exteriorization, plom- major complications required additional tissue loss in the past 14 years were retro- bage, cancellous bone grafting or bone surgery. Mild pin-tract infections were spectively reviewed, and it is suggested substitutes, transfer of living tissue, and treated by local care and oral antibiot- that the staged protocol is reliable in pro- the simultaneous treatment of bone and ics. For severe pin-tract infections, sur- viding successful reconstruction simulta- soft tissue with Ilizarov’s method.21,22 The gical debridement was performed with neously for bone and soft tissue defects Ilizarov method, which can be used suc- exchanging wire/screw and intravenous without flap coverage.

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