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 infected 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 pseudoarthrosis. 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 distraction 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 hospitals. 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 patients 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. Those women were not included into the study. Ilizarov Apparatus We used the frames for bifocal osteosynthesis, according to preoperative planning (Fig. 1). The traditional Ilizarov apparatus is a circular external fixator that attaches to bone segments with smooth or beaded Kirschner wires of 1.5 or 1.8 mm in diameter, which are placed under tension and oriented in multiple direc- tions and multiple planes. In addition to the rings and wires, the Ilizarov system consists of many multipurpose parts, such as Figure 1. Preoperative scheme of the treatment by Ilizarov hinges, plates, and threaded rods. This original Ilizarov design method. A. Area of the proximal femur marked in grey indi- was used in 4 patients. cates the site of planned resection. The mark in the distal Since 1990, we have applied fixators with our own modifi- part indicates the site of planned cortical osteotomy (corti- cations of fragment stabilization and Schantz screws (12), with cotomy). B. and C. Arrows indicate the direction of the mid- half-pins predominating over the wires as the means of fixation. dle segment transport.

635 Barbarossa et al: Modified Ilizarov Technique Croat Med J 2001;42:634-641

of fragments, which minimizes the risk of nonunion from both During the treatment, the circular frame was applied either the regenerate site and the docking site. before or after the resection of necrotic bone. An intercalated seg- Preoperative Work-up ment of bone, created by corticotomy of either the proximal or distal part of the femoral bone was gradually transported Ilizarov treatment of infected nonunion assumes extensive (0.25-0.5 mm/24 h) together with the soft tissues (Figs. 2-4). removal of radiographically delineated necrotic bone. We some- times underestimated the volume of the bone that had to be re- The correction of anatomic and mechanic axis was done ei- moved because X-ray finding did not correspond with intrao- ther immediately after the necrotic bone resection at the time of perative findings. For that reason, we occasionally used computer frame application, or gradually during the treatment. tomography (CT) and nuclear magnetic resonance (NMR) imag- Latency, or a period of time after a corticotomy when the ing, but encountered the opposite problem. In contrast to roent- initial healing response bridges the cut bone surfaces before initi- genography, when assessed by these techniques the amount of ating the distraction, was 7-15 days (average, 10.4±1.6 days) (Ta- bone that had to be resected was often overestimated. Thus, the ble 1). exact amount of bone for the resection was determined during Antibiotic Treatment the operation, according to the appearance of the tissue. Resec- tion was performed to the bone level that had no circumferential Appropriate antibiotics were administered to all patients, ac- defect. Forage was always done to open up the intramedullary cording to bacteria cultured from the bone and surrounding tissue canal at the level of resection. The “paprika sign” was taken into taken after intraoperative debridement (Table 1). The average time account but was not essential for the level of resection. We did of antibiotic administration was 6 weeks (range, 3-10 weeks) (13). not use methylene blue or other vital dye. An apparatus was constructed according to the preoperative planning, and then sterilized. The preoperative preparation of apparatus spared 60-90 minutes of intraoperative time. Surgical Technique After the resection of necrotic bone, the technique of bone transport was applied in 23 patients with infected pseudoarthroses and in 7 patients with multilocular fistulous osteomyelitis, where the continuity of the femoral bone was not interrupted.

Figure 2. Radiograms of a patient treated by Ilizarov method. A. Before the treatment – the unilateral fixator was applied in the hospital. B. After the surgery – the fixator was replaced by the Ilizarov apparatus. The arrow indicates the Figure 3. Healing of the skin and connective tissue during site of osteotomy. C. Initial stage of bone transport. The ar- the treatment with Ilizarov apparatus of the patient from the row indicates the direction of transport. D. The arrow indi- Fig. 2. A. Half-open method of treatment was used. Infla- cates the contact between transported and target segment. med bone was radically resected and removed, as shown in E. r indicates the regenerated bone in the corticalization central part of the image. B. The wound granulation is visi- state. F. and G. Femoral radiograms after the Ilizarov appa- ble at the time of radiographic evidence of contact between ratus removal; r indicates the length of regenerated bone transported and target segment (see Fig. 2D). C. Scars after during the recanalization. the apparatus removal show the site of pins insertion.

636 Barbarossa et al: Modified Ilizarov Technique Croat Med J 2001;42:634-641

A good result was if the patient was active, but one or two of the other criteria were present. A fair result was if the patient was active, with three or four of the other criteria present. A poor result was if the patient was inactive, regardless of the presence of other criteria. Evaluation of Complications To evaluate complications that occur during and after distraction osteogenesis, the classification according to Paley (15) was used, as follows: A problem is a difficulty in the course of distraction or in the period of consolidation which is fully resolved by the end of the treatment period by non-operative means. An obstacle is a difficulty which arises in the course of distraction or in the period of consolidation that is fully resolved by the end of the treatment period by operative means. A true complication is a difficulty that occurs during distraction or in a period of consolidation, and remains unresolved till the end of the treatment, or remains unresolved after the treatment is completed. Complications are divided into minor and major ones. Minor complications do not prevent the achieve- ment of the goal and can be resolved non-operatively, whereas major complications require a surgical treatment. Permanent complications cannot be solved, frequently prevent the achieve- ment of the goal, and are the leading reason for the failure of treatment.

Results The evaluation of the data obtained was done according to the ASAMI (1,8). The patients were followed-up for 24 to 126 months. Figure 4. Patient from the Fig. 2. Left. Treatment with the The average length of bone regeneration with Ilizarov apparatus in the 7th month. Right. Three months af- cortical structure was 6.3±4.2 cm (range 2.5-21 cm); ter the apparatus removal. 181.7 cm of new bone were obtained altogether in all Side Effects and Complications the patients. At the end of the treatment, total length All the patients were interviewed to obtain pertinent clini- discrepancy of the femoral bone was 26 cm (all pa- cal data. The ASAMI protocol was used to standardize the side ef- tients included). The failure rate was calculated as to- fects and complications (1,8,14). The bone results were deter- tal length discrepancy x 100 / total length of the mined according to four criteria: union, infection, deformity, and achieved regeneration, and it amounted to 12% in leg-length discrepancy. our patients. The bone bridging was followed at the site of the contact of transported and target fragments, as well as at the site of the new Bone Consolidation bone formation. The fracture was considered healed if an X-ray image revealed corticalization, if no clinical signs of motion or In three patients (No. 10, 11, and 30) there were bending of fragments after axial loosening of the construction no signs of consolidation (delayed union) at the site of were found, and if the patient was able to walk without pain, rely- target and transported segments (Table 1). After 20 ing on the operated leg. weeks on average, the frame was changed to unilat- Bone healing was evaluated as follows: eral (Orthofix) and bone bridging was subsequently An excellent bone result was defined as a union without in- obtained. There was a delayed union in a woman (pa- fection, with less than 7° deformity and less than 2.5 cm leg-length inequality. tient No. 6) in whom the fracture occurred at the site A good result was defined as a union, with two out of three of poor regeneration 10 days after the frame removal. criteria for an excellent result present. In her case, subsequent consolidation occurred after A fair result was defined as union, with one of the three cri- immobilization with coxofemoral plaster, with the teria present. loss of 2.7 cm of regenerated length and more than 7° A poor result was a non-union or refracture, without any of varus deviation of the upper leg. the above three criteria fulfilled. Bone consolidation at the site of the regenerate Functional assessment was based on five criteria: (a) observ- did not occur in four patients (No. 1, 2, 22, and 25) able limp, (b) stiffness of knee or hip (loss of >70o of knee flexion, or loss of >15° of extension; loss of >50% hip motion (Table 1). Later consolidation occurred after the use of in comparison with the normal contralateral side), (c) soft tissue coxofemoral plaster in the first three patients but was sympathetic dystrophy, (d) pain that reduced activity or disturbed associated with the loss in the regeneration length. sleep, and (e) inactivity (because of unemployment or an inability to return to daily activities due to the injury). In the fourth patient (No. 25), old age accompanied by osteoporosis, poorly performed corticotomy, The functional result was classified according to the follow- ing criteria: primary instability of the frame, and subsequent infec- An excellent result was if the patient was active, able to ac- tion led to the failure of the treatment. The amputa- complish his/her daily activities, and the other four criteria were tion had to be performed 16 months after the frame absent. was installed.

637 Barbarossa et al: Modified Ilizarov Technique Croat Med J 2001;42:634-641

Cancellous bone grafting was not performed in Complications any of our 30 patients. In 30 patients, there were 87 complications in to- The remaining axial deformities in 13 patients tal (21 problems, 14 obstacles, and 52 true complica- were >7°. In eight patients, femoral shortening was tions). From 52 true complications, 38 were defined >2 cm after the treatment (Table 2). as minor and 14 as major (Table 3). The bone results were excellent in 13 patients, There were no intraoperative complications, good in nine, fair in two, poor in five, and failure (am- such as neurovascular injuries due to the introduction putation) occurred in one patient (Table 2, Fig. 5).

14 Functional Results The functional results were as follows: excellent 12 in five patients, good in 10, fair in eight, poor in six, 10 and a failure occurred in one patient because his leg was amputated (Table 2, Fig. 5). 8

Fifteen patients were not able to come back to 6 their every-day activities or earlier jobs. Limp was ob- 4 servable in 19 patients and less observable in 11 (Ta- Number of patients ble 2). Rigidity was present in 15 patients. Knee 2 flexion was <70°, extensions >15°, and the loss of hip motion was >50% of rate of all motions. In six 0 out of 15 patients, the loss of functions involved both amputation poor fair good excelent joints (knee and hip). Eleven patients had permanent Figure 5. Results of the Ilizarov treatment in 30 patients. stiffness, hypotrophy of soft tissues, and pains at night Bone (open bars) and functional (closed bars) results after (Table 2). the treatment.

Table 2. Bone results, functional results (after fixator removal), and complications in 30 patients treated with distraction osteogenesis Bone result Functional result Complicationsa infection, union limp, rigidity, nonoperative treatment operative treatment Subsequent treatment Case deformity, shortening grade dystrophy, inactivity pain grade with fixator with fixator after fixator removal 1 Nonunion, shortening, poor limp, rigidity (knee), +/-b poor wire site problems wire site problems nonunion, pin track deformity (knee) inactivity infection 2 Nonunion, shortening, poor limp, rigidity (hip+knee), +/- poor none wire site problems nonunion, bowing deformity (hip) inactivity 3 Union excellent limp, - good none none none 4 Union excellent dystrophy +/- good none none none 5 Union excellent limp - good none none none 6 Delayed union, poor limp, rigidity (hip+knee), - poor wire site problems debridement apparatus refracture, pin track deformity inactivity adjustment, axial deviation infection 7 Union, deformity good limp - good none none none 8 Union good limp, rigidity (knee) +/- fair dysesthesia wire site problems edema 9 Union excellent none - excellent none none delayed union 10 Delayed union, poor limp, rigidity (knee), + poor wire site problems debridement, apparatus pain, pin track deformity, shortening inactivity adjustment infection 11 Delayed union, fair limp, rigidity (knee) - fair depression, wire site debridement, apparatus shortening, edema shortening problems adjustment 12 Union, deformity good limp, rigidity (hip+knee), - poor depression, axial deviation rigidity (hip+knee) inactivity 13 Union, shortening good rigidity (knee) - good none none delayed union 14 Delayed union excellent none - excelent none none none 15 Union excellent limp, rigidity (hip+knee) +/- fair none wire site problems rigidity (knee) 16 Union excellent none - excellent none none none 17 Union excellent dystrophy +/- good none none none 18 Union, shortening good limp - good wire site problems none none 19 Union excellent limp - good none none none 20 Union excellent none - excell none none none 21 Union, deformity excellent dystrophy +/- good none none axial deviation 22 Nonunion, shortening, poor limp, rigidity (hip+knee), + poor wire site problems wire site problems nonunion, axial deformity inactivity deviation, pain, pin track infection 23 Union, shortening, fair limp, rigidity (knee) +/- fair none wire site problems none deformity 24 Union, deformity good dystrophy +/- good none none none 25 Nonunion, infection, amputation - - - wire site problems, wire site problems, nonunion, deformity, shortening depression apparatus adjustment amputation 26 Union, bone infection atgood limp, rigidity (knee), - fair dysesthesia none rigidity (knee), edema pin site dystrophy 27 Union excellent none - excellent none none none 28 Union, deformity good limp, rigidity (knee) +/- fair dysesthesia, wire site none rigidity (knee), edema problems 29 Union excellent limp, rigidity (knee), - fair wire site problem none pin track infection dystrophy 30 Union, deformity good limp, rigidity (hip+knee), - fair wire site problem wire site problems, none dystrophy apparatus adjustment aSubheadings refer to the way complications were resolved. bThe patient feels pain, but it does not prevent daily activities.

638 Barbarossa et al: Modified Ilizarov Technique Croat Med J 2001;42:634-641

Table 3. Complications according to ASAMI after fixation removal True complications Complications No. Problems Obstacles minor major Delayed union 4 4 Nonunion (one amputation) 4 4 Remaining dysmetry (>2 cm)a 66 Shortening of regenerate after fixator removal 1 1 Bowing 1 1 Refracture 1 1 Bone infection at pin site 1 1 Rigidity of jointsb 15 11 4 Severe dystrophyc 77 Deformity (axial deviation)d 13 2 9 2 Oedema 4 2 2 Paine 21 1 Wire site problem 14 5 4 5 Debridement 3 3 Apparatus adjustment 5 5 Dysesthesia 3 3 Mental depression 3 3 Total 87 21 14 38 14 aIn 2 patients (No. 2 and 11) dysmetry was treated after apparatus removal by recorticotomy. (Patient numbers are shown in Tables 1 and 2.) bIn 4 patients (No. 12, 15, 26, and 27) arthroscopic synoviolysis of knee and manipulations were performed to restore mobility; others were treated conservatively. cMild dystrophy of muscles was found in all patients. dIn 2 patients (No. 21 and 22) revisions of femoral axes was performed. eIn 2 patients (No. 10 and 22) pain was severe to reduce daily activity and sleep. of wires and Schantz screws. In one patient (No. 26), fenazon, were administered in the beginning of the the residual inflammation was evident, occurring treatment, regularly or on demand. In several cases, around the place where a Kirschner wire was in- pentazocine was given on the day of operation and the serted, and not at the site of non-union. first postoperative day. The stretching of fragments was Skin inflammation of various degrees around frequently reduced to eliminate the intensity of pains. wires or pins was present in all patients. Local anti- In five patients, pains at night were even registered septics were applied, and in several cases antibiotics, over several months after the frame removal. too. Changes and supplements of wires and pins were performed in 10 patients. Discussion A non-union of the regenerate happened in four Conventional methods of non-union treatment patients (No. 1, 2, 22, and 25). After revisional surgi- are successful in cases of non-infected non-unions, in cal treatment with the Ilizarov modified technique, which bone vascular supply and soft tissue integrity consolidation occurred in three patients (No. 1, 2, are not compromized. Repeated surgical procedures, and 22) and amputation was performed in one (No. osteomyelitis, non-union, bone loss, disuse osteopo- 25) (Tables 1 and 2). rosis, muscle dystrophy, impaired arterial circulation, Delayed consolidation of intercalary site was and decreased venous and lymphatic drainage ensue present in three patients. Consolidation was finally when bone fractures do not consolidate. The Ilizarov obtained by the application of a unilateral frame method is the method of choice in these situations (Orthofix), in addition to cortical osteotomy of frag- and can be considered as limb salvage operation. ment edges of 2-5 mm (Table 1). All our patients were operated on several times A woman (patient No. 6) with delayed consoli- before they underwent treatment by the Ilizarov tech- dation suffered a refracture 10 days after the frame re- nique. Bone healing and functional results as asses- moval; the treatment was continued with a coxofe- sed by ASAMI criteria were not well correlated. The moral plaster (Tables 1 and 2). functional results, as a rule, were poorer. After the end of the treatment, axial deviations of The necessary part of a successful Ilizarov treat- ³7° remained in 13 patients because of the bending ment is active involvement and participation of a pa- due to the insufficient stability of fragments. We tient. Patients should be involved in daily adjustment of the apparatus. The cooperation of the physical ther- achieved the improvement of the axis <7° in five pa- apist and a patient is very important, since the patient tients by correcting the frames and adding the wires in must exercise the limb and joints. general or spinal anesthesia (Table 2). The infection appeared to have been success- Slight transient edema was observed in all pa- fully eradicated in all our patients. Amputation had to tients. In four cases the edema was persistent, but it be performed in only one patient (No. 25) because of diminished a year after the frame was removed. the inflammation at the site of corticotomy and proxi- Pain was the most frequent complication during mal pins, although bridging occurred at the docking the period of bone transport and present in all 30 pa- site. There were no signs of inflammation in the tients. It was of the greatest intensity during the first woman with refracture (patient No. 6), either. How- several days after the operation and often occurred ever, since we could not with certainty exclude the during or after walking. Analgesics, usually noramino- possible future reactivation of inflammation, the ab-

639 Barbarossa et al: Modified Ilizarov Technique Croat Med J 2001;42:634-641 sence of inflammatory signs for a minimum of 2 years Bone transport of the femoral bone by intrame- was considered a success. This rule applied to all our dullary nail is very convenient for a patient but its ap- patients. The rate of the successful eradication of in- plication in the case of bone inflammation has not flammatory process after a partial resection of in- been indicated (20,21). fected bone was similar to that reported by Ilizarov et Smrke and Arnez (11) published the results on al (2,3). All our patients started receiving the antibi- 20 patients with extensive bone and soft tissue defects otic treatment on the day of surgery. and posttraumatic osteomyelitis, among whom only Repeated smears from the open wounds were one patient with femoral bone defect was managed usually positive for bacteria up to the docking site. by the Ilizarov method. Both the consolidation of the newly formed bone and Active involvement and participation of the pa- X-rays of the docking sites were less satisfactory than tient is necessary for the successful Ilizarov treatment. the eradication of inflammation. Therefore, in 12 pa- Patients should be involved in daily adjustment of tients, the treatment after the frame removal was con- their apparatus. The cooperation of a physical thera- tinued with coxofemoral cast, and afterwards with pist and patient is also important, since the patient coxofemoral orthoses. In the woman patient No. 6, must exercise the limb and joints. Nearly all of our pa- refracture happened while she was doing her ev- tients were able to stand and walk with partial extrem- ery-day chores at home, and in her case, an orthosis ity loading immediately after the circular frame was was used after the frame removal. Green (16) per- installed. This is considered the most essential part of formed cancellous bone grafting in 43% of bone this method (22). Twenty-one patients were able to transports because he observed the prolonged bridg- do everyday activities while wearing the frame. Early ing at docking site. Ilizarov et al (16) reported the physical therapy significantly contributed to these re- same difficulties, so they refreshed the edges of frag- sults. ments with curettage or minor re-osteotomies, after The long-lasting hospital treatment that accom- the fragments had advanced for 1 cm (12,15,16). panies the application of the Ilizarov method is very In our series, cancellous bone grafting was not expensive. However, in comparison with other treat- applied at all. In three patients (No. 10, 11, and 30), ment modalities (sequestrotomy, bone cement antibi- we performed subcutaneous re-corticotomy of the otic basis – Belfast method, cortical and cancellous fragment around the docking site. Curettage of the bone grafting, transfer of free vascular flaps) the Iliza- ends of fragments and of wound base was performed rov method proved to be cost-effective (9). periodically in all cases with open wounds. Recently, there were some attempts of reducing By retrospective review of roentgenograms, we the period of treatment for leg lengthening with some calculated bone regeneration index (total time in days adaptations of the Ilizarov method. Shevtsov et al (23) necessary for the corticalization of each centimeter of described the results of a technique associating multi- the newly formed bone). The speed of corticalization ple segment lengthening, automatic high-frequency was of 30-40 days per cm (0.25-0.33 mm/day). This lengthening, and stimulation of bone regeneration by finding was similar to the results of distraction osteo- extemporaneous compression at the end of traction. genesis without non-union or bone inflammation They reported shorter treatment periods and very sat- (2,3,17). isfactory anatomic and functional outcomes. Al- though our study showed the efficacy of the Ilizarov Kuftiryev and Meshkov, according to Paley (18), method in limb salvation, prospective studies are nec- reported 147 bridgings in 154 bone defects of femo- essary to further evaluate this mode of treatment. ral bone, with a failure rate of 4.5%, and elimination of bone inflammation in 41 out of 45 cases (91%). In our patients, the outcome of bone consolida- References tion was better than the functional results. Neverthe- 1 Ilizarov GA, Kaplunov AG, Degtiarev VE, Lediaev VI. less, it should be emphasized that we treated some of Treatment of pseudarthroses and ununited fractures, the most severe cases of bone defects accompanied complicated by purulent infection, by the method of by inflammation in Croatia, 28 of them after a long compression-distraction osteosynthesis [in Russian]. period of treatment in other hospitals. Also, an excel- Ortop Travmatol Protez 1972;33:10-4. lent result of the bone defect treatment accompanied 2 Association for the Study and Application of the by the resolution of inflammation does not guarantee Method of Ilizarov Group: non-union of the femur. In: a good functional result. The functional result de- Bianchi-Maiocchi A, Aronson J, editors. Operative prin- pends primarily on the existing damage of nerves, ciples of Ilizarov. Fracture treatment, non-union, muscles, vessels, joints, and, to a lesser extent, bones. osteomyelitis, lengthening, deformity correction. Balti- more (MD): Williams and Wilkins; 1991. p. 245-62. The treatment of infected non-unions and fistu- 3 Ilizarov GA, Barabash AP, Larionov AA. Experimental lous osteomyelitis of femoral bone solely by the and clinical approval of a method of replacing exten- method of bone transport has rarely been reported. sive defects in the long bones [in Russian]. Ortop Polyzois et al (19) had very similar results using that Travmatol Protez 1983;(4):6-9. method at the upper and lower leg. Urazgil’deev et al 4 Meyer S, Weiland AJ, Willenegger H. The treatment of (10) have recently published the results on 30 patients infected non-union of fractures of long bones. Study of with infected non-union of the femur and 93 shin sixty-four cases with a five to twenty-one-year fol- bones, with infection eradication rate of 95.9%. low-up. J Bone Joint Surg Am 1975;57:836-42.

640 Barbarossa et al: Modified Ilizarov Technique Croat Med J 2001;42:634-641

5 Dietrichson GJ, Stören G. Posterolateral approach – a 16 Green SA. Osteomyelitis. The Ilizarov perspective. back-door to infected tibial shaft fractures. Acta Chir Orthop Clin North Am 1991;22:515-21. Scan 1965;129:471-6. 17 Barbarossa V, Kor´inek K. Limb lengthening. Orthopae- 6 Freeland AE, Mutz SB. Posterior bone-grafting for in- dia et Traumatologia 1991;22:9-18. fected ununited fracture of the tibia. J Bone Joint Surg 18 Paley D, Rumley OT Jr, Kovelman H. The Ilizarov tech- Am 1976;58:653-7. nique: a method to regenerate bone and soft tissue. In: 7 Reckling FW, Waters CH. Treatment of non-unions of Habal M, editor. Advances in plastic and reconstructive fractures of the tibial diaphysis by posterolateral cortical surgery. Chicago (IL): Year Book Medical Publishers; cancellous bone-grafting. J Bone Joint Surg Am 1980; 1990. p. 1-41. 62:936-41. 19 Polyzois D, Papachristou G, Kotsiopoulos K, Plessas S. 8 Dendrinos GK, Kontos S, Lyritsis E. Use of the Ilizarov Treatment of tibial and femoral bone loss by distraction technique for treatment of non-union of the tibia associ- osteogenesis. Acta Orthop Scand 1997;68(Suppl ated with infection. J Bone Joint Surg Am 1995;77: 275):84-8. 835-46. 20 Baumgart R, Betz A, Kessler S, Kettler M, Schweiberer. 9 Aronson J, Rock L. Limb-lengthening, skeletal recon- Possibilities in the reconstruction of bone defects [in struction, and bone transport with the Ilizarov method. J German]. Orthopädie 1994;23:396-403. Bone Joint Surg Am 1997;79:1243-58. 21 Oedekoven G, Jansen D, Raschke M, Claudi BF. The monorail system – bone segment transport over unrea- 10 Urazgil’deev ZI, Roskidailo AS. Treatment of ununited med interlocking nails [in German]. Chirurg 1996;67: fractures and pseudarthrosis of long bones of the lower 1069-79. limbs complicated by osteomyelitis [in Russian]. Khirurgiia (Mosk) 1999;(9):48-54. 22 Kor´inek K, Barbarossa V. Lengthening and spatial correction of limbs. Injury 1993;24 Suppl 2:S62-83. 11 Smrke D, Arnez ZM.Treatment of extensive bone and soft tissue defects of the lower limb by traction and 23 Shevtsov V, Popkov A, Popkov D, Prevot J. Reduction free-flap transfer. Injury 2000;31:153-62. of the period of treatment for leg lengthening. Tech- nique and advantages [in French]. Rev Chir Orthop 12 Catagni MA, Malzev V, Kirienko A. Pseudarthroses of Reparatrice Appar Mot 2001;87:248-56. the femur. In: Bianchi-Maiocchi A, editor. Advances in Ilizarov apparatus assembly. Milan: Medicalplastic srl; 1994. p. 70-4. Received: July 5, 2001 Accepted: October 11, 2001 13 Norden CW, Shaffer M. Treatment of experimental chronic osteomyelitis due to Staphylococcus aureus with vankomycin and rifampin. J Infect Dis 1983;147:352-7. Correspondence to: 14 Melissinos EG, Parks DH. Post-trauma reconstruction Vladimir Barbarossa with free tissue transfer – analysis of 442 consecutive Department of Orthopedics cases. J Trauma 1989;29:1095-102. Holy Ghost General Hospital 15 Paley D. Problems, obstacles, and complications of limb Sveti Duh 64 lengthening by the Ilizarov technique. Clin Orthop 10000 Zagreb, Croatia 1990;(250):81-104. [email protected]

641