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Treatment of Osteomyelitis and Infected Non-Union of the Femur by a Modified Ilizarov Technique: Follow-Up Study

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Treatment of Osteomyelitis and Infected Non-Union of the Femur by a Modified Ilizarov Technique: Follow-Up Study 42(6):634-641,2001 CLINICAL SCIENCES Treatment of Osteomyelitis and Infected Non-union of the Femur by a Modified Ilizarov Technique: Follow-up Study Vladimir Barbarossa, Branka R. Matkoviæ1, Nikša Vuèiæ2, Miroslav Bielen, Miroslav Gluhiniæ Department of Orthopedics, Holy Ghost General Hospital; 1Zagreb University Faculty of Physical Education; and 2Department of Internal Medicine, Holy Ghost General Hospital, Zagreb, Croatia Aim. To review the results of the management of chronic post-traumatic osteomyelitis and infected non-union with bone defects of femur using the Ilizarov technique with a modified apparatus assembly. Patients and Methods. Thirty patients treated by the Ilizarov method because of chronic fistulous osteomyelitis and in- fected pseudoarthroses of the femur were included in the prospective study between 1989 and 1999. Their mean age was 39.4±14.4 years (range, 25-80 years). The follow-up period lasted for 24 to 126 months. Results. The infection was eradicated in 29 patients before the fixator removal. Excellent bone healing was found in 12, and excellent functional result in 5 out of 30 patients. There was a total of 87 complications in 30 patients. Conclusion. Ilizarov technique is a method of choice in saving the limb with chronic osteomyelitis and infected pseudo- arthrosis. Because of the additional injuries, bone healing in affected limb may be superior to the functional result. Key words: external fixators; femoral fractures; femur; fracture fixation; fractures, ununited; Ilizarov technique; osteogenesis, distraction; osteomyelitis; pseudoarthrosis; war In 1951, G.A. Ilizarov and his colleagues (1) in active use of the affected limb to improve its physio- the Siberian city Kurgan developed the method of dis- logical function, which consequently minimizes the traction osteogenesis for treating acute trauma frac- development of disuse osteoporosis and atrophy of tures. Over the years, the method proved to be so soft tissues. Despite all these advantages, the reports widely applicable and effective that the Association on the use of Ilizarov technique after nonunion and for the Study and Application of the Methods of osteomyelitis of femoral fractures are scarce (10,11). Ilizarov (ASAMI) was established in Lecco, Italy, in We present the results of the treatment by 1982 (2). Further development of the method and de- Ilizarov method in 30 patients with chronic fistulous vices has extended its indications in the treatment of osteomyelitis and infected pseudoarthroses of the fe- trauma fractures and their complications, especially mur. The follow-up period was 2-10 years. to chronic osteomyelitis accompanied by the bone loss, infected nonunion, shortening of extremities, ax- Patients and Methods ial deformation, and joint contracture (1-3). Patients with such diagnoses have usually been treated by a Between 1989 and 1999, 30 patients (24 men and 6 series of different surgical treatments, including women) of the average age of 39.4±14.4 years (range, 25-80 sequestrectomies, drainage, and massive cancellous years) were treated by one of the Ilizarov techniques – the distrac- tion osteogenesis – at the Department of Orthopedics, Holy bone grafts. These techniques are often unsuccessful Ghost General Hospital, Zagreb, Croatia. (4) because the infection is difficult to eradicate due Status of Patients before Ilizarov Treatment to poor vascularization of the bone. In additon, the Thirty patients with either infected femoral nonunion (23 grafts introduce a foreign body, and the resistant bac- patients) or chronic fistulous osteomyelitis (6 patients) and a pa- teria may develop as the result of a long-term antibi- tient with active infection of soft tissues (Table 1) were considered otic administration (5-7). Such patients are the candi- eligible for the treatment with the Ilizarov method. All had al- dates for treatment by the Ilizarov method. ready undergone a long and unsuccessful treatment in other hos- pitals. Twenty-eight patients had been transferred from other hos- Ilizarov method consists of extensive removal of pitals for limb salvage and two patients were treated by other all infected tissues, application of an external fixator, techniques at our Department. and correction through distraction osteogenesis, de- Infected non-union or osteomyelitis developed in four pa- angulation, and compression (3,8,9). The most im- tients after an open fracture, in 12 patients after a closed fracture, portant element of the Ilizarov treatment is distraction and in 14 patients with war wounds (Table 1). In all patients, the fractures of the femur were either diaphy- osteogenesis, which involves bone transport and the seal or metaphyseal, and in 17 patients were multifragmentary. formation of new bone by intramembranous ossifica- For the treatment of original fractures, the patients had undergone tion (9). Distinct advantage of the Ilizarov treatment is 4.4±3.6 surgical procedures on average (range, 1-17) before the 634 www.cmj.hr Barbarossa et al: Modified Ilizarov Technique Croat Med J 2001;42:634-641 Table 1. Relevant clinical data before and after the Ilizarov treatment in 30 patients and descriptive statistic parameters (arithme- tic mean, standard deviation, minimal and maximal value) Time (months) from Previous Amount of Remaining Latency Patient Sex/age Type of Treatment Isolated fracture to Ilizarov operations lengthening dysmetry period No. (years) trauma indicationa bacteriab treatment (n) (cm) (cm) (days) Consolidation 1 F/34 war wound OM MRSA 72 3 12 2.5 10 nonunion 2 M/60 closed fracture INU Pseudomonas 33 5 6.5 2.5 12 nonunion aeruginosa 3 M/35 closed fracture OM MSSA 35 4 4 0 10 normal 4 M/34 closed fracture INU MSSA 22 2 4 0 10 normal 5 F/30 closed fracture INU MRSA 56 8 6 0 12 normal 6 F/34 closed fracture INU MRSA 19 5 2.7 1 9 delayed 7 M/25 open fracture INU MSSA 15 2 7 0 10 normal 8 M/40 war wound INU MSSA 32 7 7 1 8 normal 9 M/26 open fracture INU MRSA 27 3 7 0 7 normal 10 M/32 closed fracture INU MSSA 22 3 2.5 0.5 10 delayed 11 M/32 open fracture INU MRSA 25 2 9 4.5 10 delayed 12 M/34 open fracture OM MSSA 8 2 5 1.5 12 normal 13 F/59 war wound INU Pseudomonas 18 4 4 0 10 normal aeruginosa, Enterococcus 14 M/57 war wound OM MSSA 624 17 2.5 0 15 normal 15 M/30 war wound INU MSSA 28 8 21 1 9 normal 16 M/32 war wound AcOM MRSA 32 2 5 0 10 normal 17 M/30 war wound INU Pseudomonas 26 7 3 0 10 normal aeruginosa Klebsiella 18 M/51 closed fracture INU MRSA 18 5 7 2.5 11 normal 19 M/36 closed fracture INU MSSA 10 10 3.5 0 10 normal 20 M/25 war wound INU MSSA 31 3 3 0 12 normal 21 M/52 war wound INU MSSA 14 1 4 0 10 normal Escherichia 22 M/25 war wound INU 25 2 6.5 3 10 nonunion coli 23 M/40 closed fracture INU MRSA 15 2 17 2.5 9 normal 24 M/56 closed fracture INU MSSA 25 2 5.5 0 10 normal 25 M/69 closed fracture INU MRSA 180 12 - - - nonunion 26 F/41 war wound INU MSSA 6 1 7 1 10 normal 27 M/25 war wound OM MSSA 24 2 6 0 11 normal 28 M/30 war wound INU MRSA 12 2 3 0 14 normal 29 M/28 war wound OM MRSA 12 3 4 0 10 normal 30 F/80 closed fracture INU MRSA 14 3 7 0 11 delayed Mean 39.4 49.3 4.4 6.3 0.8 10.4 SD 14.4 113.0 3.6 4.2 1.2 1.6 Min 25.0 6.0 1.0 2.5 0 7.0 Max 80.0 624.0 17.0 21.0 4.5 15.0 aOM – osteomyelitis, INU – infected non-union, AcOM – active osteomyelitis. bMRSA – methil-resistent staphilococcus aureus, MSSA – methil-sensitive staphilococcus aureus. application of the Ilizarov method. The average number of The advantage of the Schantz screws, particularly in the proximal months elapsed between those surgeries and the treatment at our femur, is that they are better tolerated by the patient. Also, the op- Department was 49.3±113.0 (range, 6-624) (Table 1). In one pa- erative technique is simpler and the surgery time reduced. The tient, the time elapsed was 52 years (624 months), and in another use of the Schantz screws lessens the risk of injury to the relevant one 15 years (180 months). anatomic structures, particularly on medial side of the femur. In Six patients had nonunion without clinical signs of infection addition, infections of the skin and soft tissues resulting from wire and drainage; in 17 patients it was accompanied by signs of infec- fixation on the medial side of the thigh are avoided. The main ad- tion and fistulous drainage. Fistulous drainage with mild signs of vantage of the Schantz screws is that they provide better stability soft tissue inflammation was found in 6 patients with chronic osteomyelitis, whereas active infection of soft tissues, without signs of drainage was noted only in the patient No. 16 (Table 1). All pa- tients had reduced knee and hip function on the injured side. Thir- teen patients had less then 70° knee flexion, and two (patients No. 1 and 25) had a complete extension contracture (Table 1). Expected poor compliance due to psychological disorders, along with a negative attitude toward the frame, were the contra- indications for the application of the Ilizarov method. For these reasons, 2 women were treated with coxofemoral orthosis in- stead of the Ilizarov method.
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