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COMBINED RECONSTRUCTION OF SEGMENTARY DEFECTS CAUSED BY CHRONIC OSTEOMYELITIS USING EXTERNAL FIXATOR AND IM NAIL

Author: Dr. Mehmet Kocaoglu
Country: Turkey
E-mail : ebaykal@platogrup.com

One of the revolutionary advances in orthopedic surgery during the last quarter of the 20 th century has been distraction osteogenesis and it's use for limb lengthening, bone defect reconstruction, nonunion treatment and alike, first described by Ilizarov.

The millenium we live in does not only pronounce a shortened treatment time, but also increased patient comfort. Combined techniques utilizing external fixators and intramedullary nails bring together the advantages of both techniques, with a decreased external fixation time by almost 50 percent. Johnson et al. described an acute lengthening technique over intramedullary nails in posttraumatic shortenings. In 1996, Lin et al. reported their results accompanied by an animal study, using classical Ilizarov techniques for corticotomy. Chronologically, Raschke et al. described a combined technique used for bone transport in 1992, Paley et al. reported on femoral lengthenings over intramedullary nails in 1997, and Christiansen published his results on lengthening over intramedullary nails in the tibia in 1999.

Patients & Results:

Between years 2000-2003, 13 (F/M: 5/8) patients' lower extremity bone defects due to chronic osteomyelitis were reconstructed with a combination of intramedullary nailing and external fixator.

The mean age of the patients was 37 (range 18-63) years. Mean follow-up period was 23.7 months (range 7-42). Six of the reconstructed defects were in the tibia, 5 of them were in the femur and two of them were both in the tibia and femur. The mean time in external fixation was 5.8 months (range 4-8). Mean lengthened bone in defects and limb length deficiency was 5.7cm (range 3-9).The external fixation index was 1.01months/cm. Bone assessments results were excellent in 5 patients, good in 3 patients, bad in 3 patients. Functional assessments results were excellent in 6 patients and good in 5 patients. In one patient, because of an infection, the intramedullary nail was removed and a circular ex.fix. was applied. Two patients were offered to remove the intramedullary nail because of minimal drainage.

All patients have been mobilized and physical therapy has been initiated on the first postoperative day. The maximum loss of extension following lengthening was 15 degrees, accompanied by a minimum flexion range of 95 degrees.

M.B., 50 years old female patient with infected proximal tibial nonunion )Leg length discrepancy: 4 centimeters)
X-ray during treatment with the combined technique Left: Before lengthening Right: During lengthening

At the end of the treatment using combined technique, the IM nail has been locked, the length discrepancy has disappeared and the nonunion has consolidated.

Clinical view of the patient at the end of the treatment

In three patients, with their bone defects reconstructed by the combined method, complications have been encountered, necessitating reoperations without changing the treatment course. Two patients treated by bone transport over an intramedullary nail have been debrided twice for low grade infections, but removal of neither the external fixator nor the intramedullary nail has been necessary.

Combined utilization of intramedullary nails and external fixators has been invented, intending to unite the advantages of both implants and refraining from their disadvantages at the same time. This technique has a prolonged operation time ( by 1.5 times), necessitates surgical skill and experience and is contraindicated in patients with growing physes; but it shortens the external fixation time, protects the limb segment from refracture and/or malunion. The added stability of the intramedullary nail eases use of diminished number of K-wires during external fixation, promoting an increased range of joint motion.

As a conclusion, combined use of intramedullary nails and external fixators shortens the external fixation time, thus increasing patient comfort. This combined technique is succesfully used to treat limb length discrepancies, length discrepancies and bone defects, and nonunions.

References :

1. Baumgart R, Betz A, Schweiberer L.: A fully implantable motorized intramedullary nail for limb lengthening and bone transport, Clin.Orthop.No:343,pp 135-143, October 1997.
2. Johnson EE.: Acute lengthening of shortened lower extremities after malunion or nonunion of a fracture. JBJS, Vol:76-A, No:3,pp:379-389, March 1994.
3. Kocaoglu M, Eralp L, Boynuk B, Gögüs A.: Alt ekstermite esitsizliklerinin tedavisinde intramedüller çivi üzerinden uzatmanin erken sonuçlari. Acta Orthop.Traum.Turcica, Vol: 32, No;3, s:185-193, 1998.
4. Kocaoglu M, Eralp L, Çakmak M.: Problems and their solutions encountered during a new method of limb lengthening over an intramedullary nail. 9 th Annual Meeting ASAMI north America, California , February 1999.
5. Kristiansen LP, Steen H.: Lengthening of the tibia over an intramedullary nail, using the Ilizarov external fixator. Major complications and slow consolidation in 9 lengthenings. Acta Orthop. Scand. Vol:70,pp:271-274, June 1999.
6. Lin CC, Huang SC , Liu TK, Chapman MW.: Limb lengthening over an intramedullary nail. An animal study and clinic report. Clin.Orthop. No:330, pp208-216, September 1996.
7. Paley D,Herzenberg J,Paremain G, Bhave A.: Femoral lengthening over an intramedullary nail,JBJS, Vol.79-A,No:10, October 1997.
8. Raschke MJ, Mann JW, Oedekoven G, Claudi BF.: Segmental transport after unreamed intramedullary nailing. Preliminary report of a " Monorail " system. Clin.Orthop. Vol:282, pp:233-240, September 1992.
9. Simpson AHRW, Cole AS, Kenwright J.: Leg lengthening over an intramedullary nail, JBJS, Vol. 81-B,No:6, November 1999.
10. Tsuchiya H, Tomita K, Minematsu K, Mori Y, Asada N, Kitano S.: Limb salvage using distraction osteogenesis. A classification of the technique. JBJS, Vol:79-B, No:3,pp:403-411, May 1997.