Clinical Orthopaedics

Clin Orthop Relat Res and Related Research®

DOI 10.1007/s11999-014-3640-8 A Publication of The Association of Bone and Joint Surgeons®

SYMPOSIUM: AWARD PAPERS FROM TURKISH SOCIETY OF ORTHOPAEDICS AND

TRAUMATOLOGY 2013

Ilizarov Fixator Combined With an Intramedullary Nail for Tibial

Nonunions With Bone Loss: Is It Effective?
Deniz Gulabi MD, Mehmet Erdem MD, Gultekin Sıtkı Cecen MD,
Cem Coskun Avci MD, Necdet Saglam MD, Fevzi Saglam MD

Ó The Association of Bone and Joint Surgeons1 2014

Abstract addition to an intramedullary nail to achieve union, limb

Background Treatment of tibial nonunion with bone loss lengthening, and stability of the regenerated segment.
is extremely difficult. A variety of techniques have been Description of Technique First, the pseudoarthrosis area
described, but each has shortcomings, in particular pro- is resected, and acute compression is continued until bone
longed external fixation time as well as serious contact at the docking site was achieved. Then primary
complications such as nonunion and infection. Accord- grafting is applied to the docking site using a graft har-
ingly, we developed a technique that seeks to reduce these vested from the patient’s iliac bone, and the predrilled nail
complications by using a circular external fixator in holes localized on the middle segment of the tibia are
locked with a free-hand technique. Finally, lengthening is
performed to overcome the leg-length discrepancy with an
external fixator.
Each author certifies that he or she, or a member of his or her Methods Between 2008 and 2011, this technique was used
immediate family, has no funding or commercial associations (eg,
consultancies, stock ownership, equity interest, patent/licensing
to treat five patients with tibial nonunion with bone loss. All
arrangements, etc) that might pose a conflict of interest in connection patients were available for a minimum of a 14-month fol-
with the submitted article. lowup (mean, 30 months; range, 14–58 months). General
All ICMJE Conflict of Interest Forms for authors and Clinical indications for the procedure were age older than 16 years,
Orthopaedics and Related Research1 editors and board members are
on file with the publication and can be viewed on request.
tibial nonunion with bone loss, and the absence of any psy-
Clinical Orthopaedics and Related Research1 neither advocates nor chiatric disorder. We evaluated external fixation time,
endorses the use of any treatment, drug, or device. Readers are external fixation index (defined as the duration of external
encouraged to always seek additional information, including FDA- fixation in months divided by the total amount of bone
approval status, of any drug or device prior to clinical use.
Each author certifies that his or her institution approved the human
transported and/or the amount of lengthening in centime-
protocol for this investigation, that all investigations were conducted ters), and time to union on plain radiographs, clinical results
in conformity with ethical principles of research, and that informed using the Paley bone and functional assessment scores, and
consent for participation in the study was obtained. postoperative complications from chart review.
Results The external fixation time was 4 months (range,
D. Gulabi (&), G. S. Cecen, F. Saglam
Dr Lutfi Kırdar Kartal Training and Research Hospital, Semsi 3–5 months), and the average external fixation index was
Denizer Cad. E5, Yanyol Cevizli Kavsagı Kartal, 0.4 months/cm. The mean time to bone union was 4.6 months
34890 Istanbul, Turkey (range, 3.5–5.5 months). All angles were determined to be in
e-mail: dgulabi@yahoo.com
the normal range. No patients developed refracture or mala-
M. Erdem lignment either on the docking site or the osteotomy site. Paley
Orthopaedic and Traumatology Department, Faculty of bone evaluation results were excellent in all five patients, and
Medicine, Sakarya University, Sakarya, Turkey Paley functional results were excellent in four and good in one.
We observed 10 pin-site infections as minor complications,
C. C. Avci, N. Saglam
Umraniye Training and Research Hospital, Umraniye, Istanbul, and one patient was left with a residual equinus deformity of 5°
Turkey as a major complication according to the Paley classification.

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Conclusions Our technique combining acute shortening placed supine on a radiolucent operating table, and 1 g
and distraction osteogenesis had promising results for the first-generation cephalosporin was intravenously adminis-
treatment of tibial nonunion with bone loss in a small group of tered 30 minutes preoperatively. Custom-made Trigen
patients. However, future studies directly comparing available nails (Smith & Nephew, Memphis, TN, USA) that were
approaches to this difficult problem are required. Because this modified with additional locking holes according to nail
problem is uncommon, these studies will almost certainly thickness and length and a constructed Ilizarov frame
require the cooperation of multiple large participating centers. (Tasarim Med; Topkapi, Istanbul, Turkey) were used; these
Level of Evidence Level IV, therapeutic study. See were prepared from preoperative radiological measure-
Guidelines for Authors for a complete description of levels ments magnified by 100% (Fig. 1). For the surgery, a
of evidence. transverse incision was made in the nonunion site, and after

Introduction

The adverse effects of tibial nonunion on health-related quality

of life are severe [3]. Several treatment methods have been
described, including bone grafting with internal fixation, elec-
trical stimulation, vascularized or nonvascularized transfer of
fibula, the Papineau technique (a type of open bone grafting in
which wounds are packed with cancellous bone with no attempt
at soft tissue coverage), and débridement and resection of the
bone followed by bone transport by Ilizarov [1, 2, 10, 11, 13, 21].
However, all of these techniques have high rates of nonunion,
recurrence of infection, leg-length discrepancy, malalignment,
refracture, and a prolonged treatment period [27].
We therefore describe a technique designed to reduce
these complication rates that combined a circular external
fixator with an intramedullary nail to achieve union, limb
lengthening, and stability of the regenerated segment. Our
technique involves gradual bone transport, which relies on
compression and distraction. A similar technique was
reported by Giebel [12] and popularized by Salis de Gau-
zag et al. [26]. The main differences between the current
technique and those others are the acute shortening of the
pseudoarthrosis site, and then gradual compression with a
2-mm/day period, and primary grafting of the docking site
so that the risk of delayed union or nonunion is minimized.
In this study, five patients with tibial nonunion with bone
loss were treated with this technique of acute shortening and
distraction osteogenesis. We evaluated external fixation
time, external fixation index (defined as the duration of
external fixation in months divided by the total amount of
bone transported and/or the amount of lengthening in cen-
timeters), and time to union on plain radiographs, clinical
results using the Paley bone and functional assessment
scores, and postoperative complications from chart review.

Surgical Technique
Fig. 1 Drawing of an AP and lateral tibia view showing a template
The surgery was carried out on all five patients under over a tibia to determine the length and width of the tibial nail and
general anesthesia without a tourniquet. The patient was also the levels at which the extra locking holes should be predrilled.

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Fig. 2 Treatment of a patient (Patient 5) with chronic osteomyelitis

of the distal part of the tibia with transverse exposure is shown.

débridement of the soft tissue, resection of the devitalized

bone ends was performed until healthy-appearing bone
with open intramedullary canals and bleeding surfaces
Fig. 3 Lateral image intensifier view depicting a clear space between
(paprika sign) was reached (Fig. 2). If the fibula was intact, the Schanz screws and the nail.
resection of the same length was performed at the same
level so that the lengthening could be done. After closure
of the subcutaneous tissue, a 2-cm vertical incision was wires and Schanz screws with the intramedullary nail. At
made over the patellar ligament. A threaded Kirschner wire least 1 mm of free space should exist between the Schanz
was inserted using a patellar ligament splitting approach to screws or Kirschner wires and the intramedullary nail to
localize the entry point of the tibial nail under fluoroscopic prevent medullary infection triggered by a pin-site infec-
control. After the confirmation of the entry point of the tion [15]. To insert half-pins without contact with the nail,
tibial nail, a guidewire was inserted through the medullary the cannulated drill-bit technique described by Paley et al.
canal. The medullary canal was overreamed by 1.5 mm is used [20]. A Kirschner wire is inserted on the cortex of
relative to the diameter of the intramedullary nail to be the tibia, perpendicular to the nail, at the level of the
used to allow sliding of the nail for lengthening. Poller Schanz screw. The location of the wire is confirmed with
interference blocking screws were placed before nail an image intensifier. A hole is reamed over the Kirschner
insertion to reduce the larger diameter of the medullary wire with a 4.8-mm cannulated drill bit. The half-pin is
canal at the metaphyseal level to prevent pendular move- inserted, and the clearance between the nail and the Schanz
ment of the nail. The length of the selected nail was longer screw is confirmed with fluoroscopy (Fig. 3). When
to provide sufficient nail length on both sides of the alignment and configuration were confirmed to be appro-
regenerated bone at the completion of distraction. This priate under fluoroscopy, a 2-cm incision was made
necessitates the use of an intramedullary nail that is longer immediately distal to the tibial tuberosity on the proximal
than the length of the tibia, so care was taken to allow the segment, and a percutaneous osteotomy was made with a
excess nail length to protrude into the suprapatellar region Gigli saw (posterior cortex of the tibia) and bone osteoto-
until distraction is completed, by which time the nail will mes (anterior cortex of the tibia). A 5-cm acute shortening
glide gradually to its correct position. The distal holes of was performed while measuring the filling of the tibialis
the nail were locked and proximal holes of the nail were anterior and tibialis posterior muscles with a sterile
locked on completion of the lengthening period in another Doppler instrument and monitoring capillary circulation
session. (Fig. 4A–B). To prevent subsequent circulatory problems,
The second phase of the bifocal technique was the compression of 2 mm/day was planned to complete the
lengthening procedure. The preoperatively prepared four- remaining shortening on the docking site. The distraction
ring circular external fixator was placed on the tibia, and test was performed with a circular external fixator. Acute
each of the circular rings was held with one Kirschner wire distraction of 2 mm was performed to confirm the com-
and one half-pin, which was placed under fluoroscopy pleteness of the osteotomy under fluoroscopic control. The
vertical to the tibial anatomic axis and parallel to the joint. distraction was then recompressed. Daily compression was
Great care was taken to avoid contact of the Kirschner continued after full bone contact was achieved at the

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 Gulabi et al. Clinical Orthopaedics and Related Research1

Fig. 4A–B A fixator is shown on a 57-year-old man (Patient 4) who of the tibia at postoperative Day 1 showing acute shortening. (B)
had three unsuccessful operations resulting from an open tibial Lateral radiographic image of the tibia at postoperative Day 1
fracture. Resection bone length was 9.5 cm. Acute shortening of the showing acute shortening.
tibia was up to 5 cm at the nonunion site. (A) AP radiographic image

Fig. 5A–C Radiographic images and drawing of the tibia after holes of the nail were locked with a free-hand technique. (B)
autografting of the docking site and the predrilled nail holes localized Postoperative lateral radiograph showing the intramedullary nail and
on the middle segment of the tibia were locked with a free-hand the circular external fixator, bone contact, primary autogenous grafting at
technique. (A) Postoperative AP radiograph showing the intramedullary the docking site, and predrilled holes of the nail were locked. (C) Drawing
nail and the circular external fixator. The bone contact was achieved at the of the lateral tibia showing the bone contact and grafting at the docking
docking site, autogenous bone grafting of the docking site, and predrilled site and locking of the predrilled holes of the nail.

docking site, and compression was stopped if the patient anesthesia; the predrilled nail holes localized on the middle
started to experience pain. segment of the tibia were locked with a free-hand tech-
Next, grafting was applied to the docking site using a nique (Fig. 5A–C). Distraction for lengthening was
graft harvested from the patient’s iliac bones under general initiated after the grafting at the docking side using a rate

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of 1 mm/day divided into four equal increments. Full Patients and Methods
weightbearing with two crutches was started immediately
postoperatively. The patient was discharged with policlinic This study was approved by the local ethical committees of
followups. Patients were asked not to do knee exercises Dr Lutfi Kirdar Kartal Research and Training Hospital.
until the nail reached the subchondral region of the tibia. Between 2008 and 2011, this technique was used to treat
A two-stage operation was carried out for one patient five patients with tibial atrophic nonunion with bone loss.
who had an infection together with pseudoarthrosis and All patients were available for a minimum of a 14-month
bone loss (Cierny-Mader Type 4 [B]) [4]. In the first stage, followup period (mean, 30 months; range, 14–58 months).
the infected pseudoarthrotic area was resected; then a General indications for the procedure were age older than
custom-made, antibiotic-impregnated, polymethylmethac- 16 years, tibial nonunion with bone loss, and no mental or
rylate (a combination of 2.4 g teicoplanin and 40 g psychiatric disorders. All patients were men, the average
polymethylmethacrylate) intramedullary rod was placed in age of the patients at the time of the procedure was
the pseudoarthrotic site and stabilization was achieved with 38 years (range, 28–57 years), and the average bone loss
a unilateral fixator. In the second stage, acute shortening was 8.6 cm (range, 6.5–10.5) (Table 1).
and distraction were performed using the combined tech- The nonunions were the result of closed fractures in two
nique described. In the remaining four patients, all patients and open fractures in three. The average number of
procedures were done during the same operation. previous surgeries was two (range, one to three).
The patients were followed up at 2-week intervals dur-
Table 1. Demographics of the patients
ing lengthening and 4-week intervals during consolidation.
Lengthening was terminated when the desired bone length Patient number Age (years) Sex Side Previous surgeries
was achieved. The Ilizarov frame was removed, and the 1 28 Male Right 1
nail was locked proximally under general anesthesia. Iso- 2 34 Male Right 1
metric quadriceps and knee ROM exercises were then 3 31 Male Right 2
started (Fig. 6A–C). After removal of the external fixator,
4 57 Male Right 3
patients were encouraged to begin full weightbearing
5 41 Male Left 3
without a protective brace.

Fig. 6A–C Radiographic images and drawing of the tibia at Lateral radiograph showing the consolidated lengthening regenerate,
5 months followup showing removal of the circular external fixator; the nail is locked proximally, and union at the docking site. (C)
the proximal holes of the nail were locked with a free-hand technique. Drawing of a lateral tibia image showing union at the docking site, the
(A) AP radiograph showing the consolidated lengthening regenerate, nail locked proximally, and the consolidated lengthening regenerate.
the nail is locked proximally, and union at the docking site. (B)

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Fig. 7A–C Drawing and radiographs of a tibia are shown indicating tibial fracture. AP radiograph of the right tibia showing a broken
the margins of resection as determined on AP and lateral radiographs. intramedullary nail and margin of the resection (black lines). (C)
(A) Drawing of a lateral tibia showing the margins of resection (red Lateral radiograph of the right tibia showing a broken intramedullary
dotted lines). (B) A 57-year-old man (Patient 4) who had tibial nail and margin of the resection (black lines).
nonunion after three unsuccessful operations resulting from an open

Preoperatively, plain AP and lateral radiographs and CT fixation in months divided by the total amount of bone
images were taken of all patients to evaluate the amount of transported and/or the amount of lengthening in centime-
resection of the dead or infected bone (Fig. 7A–C). ters. Radiographic union was defined as the presence of
Doppler ultrasonography was used to decide the vascular callus in three of the four cortices as seen on AP and lateral
status of the involved limb. Atrophic bone resection was radiographs.
performed until good, bleeding bone ends were evident The bone and functional results were evaluated by the
(paprika sign) [29] in the pseudoarthrosis regions of the classification of Paley et al. [19]. For bone results, four
four noninfected cases. criteria were evaluated: union, infection, deformity, and leg-
We evaluated external fixation time, external fixation length discrepancy. An excellent bone result was one with
index (defined as the duration of external fixation in union, no infection, deformity of less than 7°, and length
months divided by the total amount of bone transported discrepancy of less than 2.5 cm in the tibia. A good result
and/or the amount of lengthening in centimeters), and time was union plus any two of the others. A fair result was union
to union on plain radiographs, clinical results using the plus one of the others. A poor result was nonunion or
Paley bone and functional assessment scores, and postop- refracture or none of the others. The functional results were
erative complications from chart review. Conventional based on five criteria: significant limp, equinus rigidity of
radiographs were taken every 2 weeks during the distrac- the ankle, soft tissue dystrophy (skin hypersensitivity,
tion phase and once a month during the consolidation insensitivity of sole, or decubitus), pain, and inactivity
phase. AP and lateral 14 9 17-inch radiographs of the tibia (defined as unemployment because of the leg injury or
were used to determine bone union and consolidation. AP inability to return to daily activities because of the leg
and lateral orthogonal radiographs were used to determine injury). An excellent result was an active individual with
the medial proximal tibial angle, posterior proximal tibial none of the other four criteria; a good result was an active
angle, anterior distal tibial angle, and lateral distal tibial individual with one or two of the other four criteria; and a
angle. All radiographic alignment measurements were fair result was an active individual with three or four of the
completed by an independent orthopaedic surgeon (GB) other criteria or an amputation. An inactive individual was
who was not involved in the study. All radiological mea- considered a poor result regardless of the other criteria.
surements and functional and bone assessment scores were Complications were evaluated according to the Paley
determined at the final followup by the same reviewer. classification [17]. Minor complications were problems
External fixator time was defined as the interval from the that did not require additional surgery, major complications
application of the fixator to removal of the fixator. External were resolved with additional surgery, or where sequelae
fixation index was defined as the duration of external remained unresolved at the end of the treatment period.

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Results and good in one who were operated on as a result of the

tibial nonunion associated with osteomyelitis.
Radiographic Analysis

At latest followup, there was union in the pseudoarthrotic area Complications

in all five patients. The mean external fixation time was
4 months (range, 3–5 months) and the average external fixa- We observed 10 pin-site infections, which were classified
tion index was 0.4 months/cm. The mean time to bone union as minor complications. In three patients (Patients 1, 2, 3),
was 4.6 months (range, 3.5–5.5 months) (Table 2). The the pin-site infections were evaluated as Dahl et al. [6]
average medial proximal tibial angle was 90° (range, 88°–95°), Stage 1 and were successfully treated with wet dressings.
the average posterior proximal tibial angle was 78° (range, In another patient (Patient 4), Dahl Stage 2 infection
77°–79°), the average lateral distal tibial angle was 85° (range, developed at the tips of some of the external fixator pins
78°–90°), and the average anterior distal tibial angle was 80° and Schanz screws. One of the Schanz screws was
(range, 79°–81°). All angles were determined to be in the removed, and the infection at the tip of the remaining pin
normal range (Table 3). No patients developed refracture or was successfully treated with care and dressings. In this
malalignment either on the docking site or the osteotomy site. patient, because the tibialis anterior pulse was absent pre-
operatively, peripheral angiography was administered to
confirm the absence of pulse. Angiography confirmed the
Clinical Analysis: Paley Bone and Function Scores damage of the tibialis anterior resulting from the previous
surgeries. A 2 9 2-cm area of superficial skin necrosis
The bone evaluation results were excellent in all five developed in the postoperative wound site, and secondary
patients, and the functional results were excellent in four healing was achieved with local débridement and close

Table 2. Outcome data on the study patients

Patient number Defect length (cm) Acute shortening (cm; mean ± SD) Lengthening (cm) EFT (months)
and time (days)

1 6.5 5 ± 1.5 (7.5) 7 3.2

2 9 5 ± 4 (20) 10 4.2
3 7.5 5 ± 2.5 (12.5) 8.5 3.5
4 9.5 5 ± 4.5 (22.5) 10 3.8
5 10.5 5 ± 5.5 (27.5) 10.5 4.5

Patient EFI Followup Docking site Docking site Docking site Grafting
number (months/cm) (months) time (days) time (months) union (months)

1 0.5 58 10 0.3 3.5 Yes

2 0.4 34 25 0.8 4.5 Yes
3 0.4 24 18 0.6 4.3 Yes
4 0.4 19 25 0.8 5.5 Yes
5 0.4 14 28 0.9 5 Yes

EFT = external fixation time; EFI = external fixation index.

Table 3. PPTA, MPTA, LDTA, and ADTA of the operated sides, Paley bone, and functional scores of the patients
Patient Bone Functional Last followup PPTA Last followup MPTA Last followup LDTA Last followup ADTA
number score score (range, 77–84) (range, 85–90) (range, 86–92) (range,78–82)

1 Excellent Excellent 78° 88° 86° 79°

2 Excellent Excellent 78° 90° 85° 80°
3 Excellent Excellent 79° 89° 85° 81°
4 Excellent Excellent 77° 95° 78° 80°
5 Excellent Good 79° 88° 90° 80°
PPTA = posterior proximal tibial angle; MPTA = medial proximal tibial angle; LDTA = lateral distal tibial angle; ADTA = anterior distal
tibial angle.

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 Gulabi et al. Clinical Orthopaedics and Related Research1

wound monitoring. Patient 5 (the one whose functional Table 4. Details of bone transport studies
score was good rather than excellent) underwent a reop- Study Mean bone External fixation
eration for chronic osteomyelitis. In this case, one of the loss (cm) index (months/cm)
Schanz screws holding the proximal ring was removed
Cierney and Zorn [5] 6.10 1.6
because of Stage 3 infection, and the infection around the
other pin was treated with dressings. The Paley classifica- Saleh and Rees [25] 4.70 2.04
tion of this patient indicated limited ROM in the ankle and Eralp et al. [10] 7.00 0.45
an equinus deformity. Although this improved with per- Sala et al. [24] (mean ± SD) 8.0 ± 2.6 2.0 ± 0.9
cutaneous achilloplasty and aggressive physiotherapy after El-Rossay [9] 4.90 1.3
fixator removal, the patient was left with a residual equinus Mean study 8.60 0.4
deformity of 5°. This patient developed another compli-
cation during the second postoperative followup period; the
proximal posterior tibial angle approached recurvatum in overcome the problems of shortening, plastic deformation,
an unacceptable manner. The angle was reduced to 79° by angular deformity, and fracture of the regenerated bone.
adding a hinge to the proximal ring and including the Bone apposition on the docking site was achieved in a
supracondylar femur in the fixator system. mean time of 21.2 days (range, 7.5–27.5 days). Compared
None of our patients developed any neurovascular def- with the classic external fixator, this combination technique
icits resulting from acute intraoperative compression or pin has the potential to achieve reductions in the length of use
insertion. Similarly, no neurovascular deficits were of the external fixator, EFI, and the consolidation index. In
observed during the lengthening period. No fat or pul- a study by Cierny and Zorn [5], the EFI was calculated as
monary emboli were seen clinically, and there were no 1.6 months/cm for a mean bone loss of 6.4 cm, Saleh and
cases of intramedullary infection. Rees [25] reported an EFI of 2.04 months/cm for a mean
bone defect of 4.7 cm, Eralp et al. [10] reported EFI as
0.45 months/cm for a mean defect of 7 cm by using the
Discussion combination of external fixator with intramedullary nail,
Sala et al. [24] reported EFI as 2.0 ± 0.9 months/cm for a
Surgery for pseudoarthrosis and nonunion is problematic mean defect of 8.0 ± 2.6 cm using the Taylor Spatial
and difficult, and complications occur frequently. Dealing Frame (Smith & Nephew, Memphis, TN, USA), and El-
with bone loss and tibial nonunion is particularly chal- Rossay [9] reported EFI as 1.3 months/cm for a mean
lenging. Various treatment methods have been reported lengthening of 4.9 cm. In the present study, EFI was cal-
[16, 23, 24, 28], all of which aim to achieve tibial union, culated as 0.4 months/cm, and mean bone loss was 8.6 cm
correct the deformity, cover soft tissue, align the limb, and (Table 4). However, to determine whether indeed these
compensate for orientation and leg-length discrepancy, results are generalizable, comparative trials between our
thus achieving early mobilization and return to daily life approach and other techniques are called for.
for the patient. However, nonunion and infection still are Results were evaluated using the Paley bone and func-
frequently observed [24, 27]. We therefore developed a tional assessment scores [19]. The bone evaluation results
technique that seeks to reduce these complications by using were excellent in all five patients, and the functional results
a circular external fixator in addition to an intramedullary were excellent in four and good in one patient who were
nail to achieve union, limb lengthening, and stability of the operated on as a result of the tibial nonunion associated
regenerated segment. We evaluated external fixation time, with osteomyelitis. All patients in the study group had
external fixation index (EFI), and time to union on plain returned to their preinjury jobs. Using a combination
radiographs, clinical results using Paley bone and func- technique including an Ilizarov and a Taylor Spatial Frame,
tional assessment scores, and postoperative complications Sala et al. [24] reported 10 (83%) patients had excellent
in a small group of patients who underwent this results, and two (17%) were good in terms of bony out-
intervention. comes; functional results were excellent in six (50%), good
This study is a small series, and, like any initial report, it in five (42%), and fair in one (8%). In that series, 12
has some important limitations. First, there could be a patients were treated for postinfectious segmental tibial
component of assessor bias because the surgeon is assess- bone defects. Also using a Taylor Spatial Frame, Rozbruch
ing his own results. Second, there was no comparison et al. [22] found 24 (63%) excellent, 12 (32%) good, and
group to determine the success of the current study; future two (5%) poor bone outcomes and 20 (53%) excellent, 14
studies should do so. (37%) good, two (5%) fair, and two (5%) poor patients
Using an intramedullary nail with an Ilizarov external with functional outcomes according to the Paley classifi-
fixator is the main advantage; it has the potential to cation, but there were 11 persistent nonunions in their study

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 Combined Technique for Tibial Bone Loss

group that were retreated. Using bifocal compression-dis- frame if the desired distraction is more than 10% of the
traction with an Ilizarov-type circular external fixator, Sen total tibial length. In the current study, we had one case
et al. [28] described the results of acute shortening and (Patient 5) with a major complication that was improved by
relengthening in the acute treatment of Grade III open percutaneous achilloplasty and aggressive physiotherapy.
tibial fractures with osteocutaneous loss in 24 patients. The Our technique combining acute shortening and distrac-
bone results in their series were excellent in 21 (88%) and tion osteogenesis successfully treated tibial nonunion with
good in three (12%). The functional results were excellent bone loss in a small group of patients. This technique had
in 19 (79%), good in four (17%), and fair in one (4%) favorable bone union time, external fixator time, EFI, and
patient. However, external fixation time was 7.1 months, clinical results compared with reported parameters in
EFI was 1.4 months/cm, and bone healing time was studies of other approaches mentioned. However, future
7.5 months, which were longer than in the present study. studies directly comparing available approaches to this
Because they did not combine circular external fixator with difficult problem are required. Because this problem is
intramedullary nailing, they did not use primary grafting of uncommon, these studies will almost certainly require the
the docking site. However, to determine whether indeed cooperation of multiple large participating centers.
these results are generalizable, comparative trials between
our approach and other techniques are called for. Acknowledgments We thank Dr Guven Bulut for his radiographic
measurements.
Early removal of the external fixator reduces the risk of
pin-site infection and allows for earlier patient rehabilita-
tion. In a study of 24 patients, Sen et al. [28] found a
complication frequency of 2.08 per patient; other studies References
reported frequencies 2.2 complications per patient [25] and
2.5 complications per patient [7]. In this current study, our 1. Aronson J. Current concepts review: limb lengthening, skeletal
reconstruction bone transport with the Ilizarov method. J Bone
complication rate was 2.6 per patient, but most of the Joint Surg Am. 1997;79:1243–1258.
complications were minor and resolved without additional 2. Atkins RM, Madhavan P, Sudhakar J, Whitwell D. Ipsilateral
surgery. Patient 5, who underwent surgery for chronic vascularized fibular transport for massive defects of the tibia. J
osteomyelitis, was the only patient with a major compli- Bone Joint Surg Br. 1999;81:1035–1040.
3. Brinker MR, Hanus BD, Sen M, O’Connor DP. The devastating
cation, which resolved after additional surgery. Our effects of tibial nonunion on health-related quality of life. J Bone
combined technique has the potential to decrease the EFI Joint Surg Am. 2013;95:2170–2176.
and external fixation time by reducing problems originating 4. Cierny G 3rd, Mader JT, Penninck JJ. A clinical staging system
from the circular external fixator [14, 18]. The use of for adult osteomyelitis. Clin Orthop Relat Res. 2003;414:7–24.
5. Cierny G 3rd, Zorn KE. Segmental tibial defects comparing
intramedullary nailing together with an external fixator conventional and Ilizarov methodology. Clin Orthop Relat Res.
reduced the number of Schanz screws and Kirschner wires 1994;301:118–123.
needed with the fixator. In this combined technique, a 6. Dahl MT, Gulli B, Berg T. Complications of limb lengthening. A
circular external fixator was preferred over a unilateral learning curve. Clin Orthop Relat Res. 1994;301:10–18.
7. Dendrinos GK, Kontos S, Lyritis E. Use of the Ilizarov technique
external fixator to avoid valgus malalignment deformity for treatment of non-union of the tibia associated with infection. J
[14]. Angulations and translations were recorded as a bone Bone Joint Surg Am. 1995;77:835–846.
transport complication. We did not observe any valgus 8. Eldridge JC, Bell DF. Problems with substantial limb lengthen-
deformity resulting from the Ilizarov external fixator. Only ing. Orthop Clin North Am. 1991;22:625–631.
9. El-Rossay MA. Acute shortening and re-lengthening in the
Patient 5 developed a posterior proximal tibial angle management of bone and soft-tissue loss in complicated fractures
problem, which was resolved with an additional ring and a of the tibia. J Bone Joint Surg Br. 2007;89:80–88.
hinge system adapted to the proximal ring. Based on our 10. Eralp L, Kocaoglu M, Rashid H. Reconstruction of segmental
results, we conclude that using an intramedullary nail with bone defects due to chronic osteomyelitis with use of an external
fixator and an intramedullary nail. Surgical technique. J Bone
an external fixator will help minimize angulation and Joint Surg Am. 2007;89:183–195.
malalignment of the regenerated bone segment. The nail 11. Eralp L, Kocaoglu M, Yusof NM, Bulbul M. Distal tibial
was extended from the proximal to the suprapatellar area reconstruction with use of a circular external fixator and an
during the acute shortening period. To preclude skin intramedullary nail. The combined technique. J Bone Joint Surg
Am. 2007;89:2218–2224.
problems in the area of the proximal nail, physical therapy 12. Giebel G. Primary shortening in soft-tissue defects with sub-
for the knee was not started until the nail reached the ideal sequent callotasis in the tibia. Unfallchirurg. 1991;94:401–408.
location; none of the patients exhibited knee ROM loss, 13. Gordon L, Chiu EJ. Treatment of infected nonunions and seg-
anterior knee pain, or skin wounds associated with the nail. mental defects of the tibia with staged microvascular muscle
transplantation and bone grafting. J Bone Joint Surg Am. 1988;
Equinus deformity is a frequently encountered complica- 70:377–386.
tion during bone transport and lengthening [9]. Eldridge 14. Harzenberg JE, Paley D. Tibial lengthening over nails (LON).
and Bell [8] proposed that the foot must be included in the Techniques in Orthopaedics. 1997;12:250–259.

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 Gulabi et al. Clinical Orthopaedics and Related Research1

15. Kocaoglu M, Eralp L, Kilicoglu O, Burc H, Cakmak M. Com- 23. Rozbruch RS, Weitzman AM, Tracey Watson J, Freudigman P,
plications encountered during lengthening over an intramedullary Katz HV, Ilizarov S. Simultaneous treatment of tibial bone and
nail. J Bone Joint Surg Am. 2004;86:2406–2411. soft-tissue defects with the Ilizarov method. J Orthop Trauma.
16. Lowenberg DW, Buntic RF, Buncke GM, Parrett BM. Long term 2006;20:197–205.
results and costs of muscle flap coverage with Ilizarov bone transport 24. Sala F, Thabet AM, Castelli F, Miller AN, Capitani D, Lovisetti
in lower limb salvage. J Orthop Trauma. 2013;27:576–581. G, Talamonti T, Singh S. Bone transport for postinfectious seg-
17. Paley D. Problems, obstacles and complications of limb length- mental tibial bone defects with a combined Ilizarov/Taylor spatial
ening by the Ilizarov technique. Clin Orthop Relat Res. 1990; frame technique. J Orthop Trauma. 2011;25:162–168.
250:81–104. 25. Saleh M, Rees A. Bifocal surgery for deformity and bone loss
18. Paley D. Principles of Deformity Correction. Berlin, Germany: after lowerlimb fractures. comparison of bone-transport and
Springer; 2002. compression-distraction methods. J Bone Joint Surg Br. 1995;
19. Paley D, Catagni MA, Argnani F, Villa A, Benedetti GB, Cat- 77:429–434.
taneo R. Ilizarov treatment of tibial nonunions with bone loss. 26. Salis de Gauzag J, Vidal H, Cahuzac JP. Primary shortening
Clin Orthop Relat Res. 1989;241:146–165. followed by callus distraction for the treatment of a posttraumatic
20. Paley D, Herzenberg JE, Paremain G, Bhave A. Femoral bone defects, case report. J Trauma. 1993;34:461–463.
lengthening over an intramedullary nail. A matched-case com- 27. Sen C, Eralp L, Gunes T, Erdem M, Ozden VE, Kocaoglu M. An
parison with Ilizarov femoral lengthening. J Bone Joint Surg Am. alternative method for the treatment of nonunion of the tibia with
1997;79:1464–1480. bone loss. J Bone Joint Surg Br. 2006;88:783–789.
21. Papineau LJ, Alfageme A, Dolcourt JP, Pilon L. Chronic osteo- 28. Sen C, Kocaoglu M, Eralp L, Gulsen M, Cinar M. Bifocal
myelitis: open excision and grafting after saucerization. Int compression-distraction in the acute treatment of grade III open
Orthop. 1979;3:165–176. tibia fractures with bone and soft-tissue loss: a report of 24 cases.
22. Rozbruch RS, Pugsley JS, Fragomen AT, Ilizarov S. Repair of J Orthop Trauma. 2004;18:150–157.
tibial nonunions and bone defects with the Taylor Spatial Frame. 29. Tetsworth K, Cierny G 3rd. Osteomyelitis debridement tech-
J Orthop Trauma. 2008;22:88–95. niques. Clin Orthop Relat Res. 1999;360:87–96.

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