Distal tibial periarticular nonunions: ankle salvage with bone transport

Limb salvage and functional recovery in infected nonunion of the distal tibia treated with the Ilizarov techniques

Introduction

Treatment of infected nonunion of the distal juxta-articular tibia is a challenge due to a short distal fragment, deformity, thin soft-tissue envelope, and active infection. There is still no consensus on the approach that is able to maximally salvage the limb and ankle function.

Material and methods

Infected juxta-articular nonunion of the distal tibia was managed with two Ilizarov techniques, monofocal compression (MC) used in 12 patients and bifocal compression-distraction (BCD) in 6 patients. The choice of the technique depended on the size of the postresection defect, ≥3 cm or ≤3 cm, respectively. The tactics of functional approach were careful debridement, insertion of wires in the distal fragment so that they do not penetrate the ankle joint, stable fixation, and temporary bridging of the ankle and forefoot. MSCT was used along with regular radiography to assess the union and regeneration. Ankle functions were evaluated with AOFAS ankle-hindfoot score system.

Results

Bone consolidation, infection arrest and ankle function improvement were achieved in all patients. External fixation continued 221.7 ± 15.1 days for MC and 235 ± 25.8 days for BCD. Complications were wound divergence, wire-tract infection, premature consolidation of the fibula, and hypoplastic regeneration in one case. The mean functional AOFAS score after treatment was 90.7 ± 2.5 points in MC and 89.7 ± 1.3 in BCD patients. Residual limb discrepancy after MC ranged 0-4 cm. Bone shortening was compensated in BCD patients.

Conclusion

Limb-salvage and functional approach to the treatment of infected nonunion of the juxta-articular distal tibia with the Ilizarov techniques achieves good outcomes. It provides bone infection arrest, consolidation, defect compensation and significantly improves the ankle joint function.

Combined Orthoplastic Approach in Fracture-Related Infections of the Distal Tibia

This series reports on the treatment of distal tibia (DT) fracture-related infections (FRI) with a combined orthoplastic approach. Thirteen patients were included. In eight patients with extensive bone involvement and in those with a non-healed fracture, the DT was resected (“staged approach”). In five cases, the DT was preserved (“single-stage approach”). A wide debridement was performed, and the cavity was filled with antibiotic-loaded PerOssal beads. All patients had a soft-tissue defect covered by a free vascularized flap (anterolateral thigh perforator flap in eight cases, latissimus dorsi flap in five). At the final follow-up (mean 25 months, range, 13–37), no infection recurrence was observed. In one patient, the persistence of infection was observed, and the patient underwent a repeated debridement. In two cases, a voluminous hematoma was observed. However, none of these complications impacted the final outcome. The successful treatment of FRI depends on proper debridement and obliteration of dead spaces with a flap. Therefore, when dealing with DT FRI, debridement of infected bone and soft tissues must be as radical as required, with no fear of the need for massive reconstructions.

Evaluating physiological progression of chronic tibial osteomyelitis using infrared thermography

Purpose

Medical infrared thermography (IRT) was used as a complementary means for the clinical evaluation of musculoskeletal trauma and progression of chronic tibial osteomyelitis.

Methods

Twenty-two adult patients with a medical diagnosis of chronic tibial osteomyelitis were followed up by IRT performed along with standard radiography. Thermal data of the affected limb were compared with those of the healthy contralateral limb based on the thermal profile of the lower limbs as per the medical thermography guideline (32 °C). Data were acquired in the following regions of the lower limb: proximal tibia, diaphysis, and distal tibia, using a FLIR infrared camera, and data were processed using MATLAB®.

Results

For patients with active infections, an increase in the average temperature of the affected limb above + 1.0 °C was observed when compared with the temperature of the contralateral. The wound region of the patients showed an increased temperature (32.3 °C) compared with the temperature of the contralateral (31.4 °C). In contrast, in latent infections, the thermal differences were small, generally below 0.3 °C, and thus were within the threshold of normality. In contrast, in areas diagnosed with reduced blood supply, the affected limb showed an average temperature up to − 5.7 °C below normal. Additionally, the initial temperature range (26.5 to 34.5 °C) decreased during the treatment to 29.8 to 34.1 °C, indicating a convergence toward normality.

Conclusion

IRT has significant potential as a complementary imaging modality in the follow-up of patients with bone lesions with a diagnosis of osteomyelitis as it does not use ionizing radiation, thus allowing repetitive use as desired. Thermal images show important physiological information related to vascularization necessary for bone repair, as well as provide a good indication of the boundary of the infected area, adjacent to the trauma, which is useful for positioning the radiography equipment. However, it should be noted that IRT cannot replace other medical imaging techniques, as it provides information about the skin and cannot directly evaluate the interior of the body.

Calcaneogenesis: the use of tibial bone transport for treatment of massively infected hindfoot defects

Massive hindfoot defects which result after se- questrectomy of chronic osteomyelitis (COM) or Trauma or after tumors resection is a real challenge to the treating surgeons with either amputation or other reconstructive plastic procedures as the only available options, Calcaneal osteomyelitis is a major cause with classical surgical management to cure the infection has limited success in preservation of the hindfoot shape, function, and mechanical stability. The surgical procedure reported with the use of the Ilizarov apparatus for partial or total calcaneal OM is aimed to preserve the Hindfoot.

Materials and Methods

We retrospectively reviewed 10 patients which were treated by radical debridement of the infected area, Ilizarov frame application and arthrodesis with bone reconstruction by the Ilizarov apparatus using tibial transport for Hindfoot salvage. The mean age at presentation was 33.5 years (range; 24-57) and the mean follow-up was 5.1 years (range; 2-12).Patients clinical and radiographic data were assessed according to the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle- Hindfoot score.

Results

The mean preoperative American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score was 48.3(range; 38-86) while the mean postoperative (AOFAS) was 58.5 (range; 45-73) , p value < 0.01 . Clinically all patients had anatomically stable feet with deformity correction and no signs of infection recurrence.

Conclusion

The use of Ilizarov distal tibial bone transport to fill massive hindfoot defects proved to be a reliable method for elimination of infection and reconstruction of large defects without the need for bony or soft tissue plastic procedures. The technique also has the ability to produce a rigid limb fixation following debridement and to fill in massive hindfoot defects due to other etiologies as well.

Analysis of bone transport for ankle arthrodesis as a limb salvage procedure for the treatment of septic pilon fracture nonunion

Septic nonunion of the pilon region with ankle joint infection is challenging for orthopedic surgeons to treat and is associated with a high risk of limb loss. Therefore, the aim of this study was to evaluate the effectiveness of bone transport for ankle arthrodesis in salvaging the limp after septic ankle destruction of the pilon region. We conducted a single-center, retrospective study including 21 patients treated for septic pilon nonunion with accompanying septic ankle destruction via Ilizarov bone transport between 2004 and 2018. In all cases, the complete excision of the nonunion and the resection of the ankle joint were carried out, followed by treating the bone and joint defect with a bone transport into the ankle arthrodesis. In 12/21 patients an additional flap transfer was required due to an accompanying soft tissue lesion. The overall healing and failure rate, final alignment and complications were recorded by the patients’ medical files. The bone-related and functional results were evaluated according to the Association for the Study and Application of Methods of Ilizarov (ASAMI) scoring system and a modified American Orthopedic Foot and Ankle Society (AOFAS) scale. After a mean follow-up of 30.9 ± 15.7 months (range 12–63 months), complete bone and soft tissue healing occurred in 18/21 patients (85.7%). The patients had excellent (5), good (7), fair (4), and poor (3) results based on the ASAMI functional score. Regarding bone stock, 6 patients had excellent, 7 good, and 6 fair results. The modified AOFAS score reached 60.6 ± 18 points (range, 29–86). In total, 33 minor complications and 28 major complications occurred during the study period. In 2 cases, a proximal lower leg amputation was performed due to a persistent infection and free flap necrosis with a large soft tissue defect, whereas in one case, persistent nonunion on the docking side was treated with a carbon orthosis because the patient refused to undergo an additional surgery. Bone transport for ankle arthrodesis offers the possibility of limb salvage after septic ankle destruction of the pilon region, with acceptable bony and functional results. However, a high number of complications and surgical revisions are associated with the treatment of this severe complication after pilon fracture.

Chronic Osteomyelitis of the tibia and ankle treated with Limb Salvage Reconstruction

Introduction: To confirm the success of our limb salvage treatment protocol and determine what factors are predictive of success versus failure in limb salvage techniques for patients with chronic osteomyelitis of the tibia and ankle.

Methods: Retrospective case series analyzing factors and outcomes in patients who underwent limb salvage techniques for chronic osteomyelitis of tibia or ankle. Main outcome measurements included infection controlled without the need for amputation or chronic antibiotic suppression and union of infected non-unions.

Results: Mean follow-up was 3.9 years. Out of the sixty-seven patients (mean age: 51.4 years) treated for chronic osteomyelitis, fifty-four had an associated non-union. Sixty-one patients (91.0%) had their infection controlled by limb salvage. Five ultimately required amputation and one remained on daily chronic antibiotics. Diabetics complicated with neuropathy and increasing numbers of limb salvage surgeries were associated with a significantly higher failure rate. Forty-eight out of fifty-four patients (88.9%) also had successful healing of their infected non-union. Diabetes and need for more limb salvage surgeries were also found to have a significantly higher failure rate.

Conclusions: Limb salvage is a reliable and successful treatment for patients with chronic osteomyelitis and infected non-unions of the lower extremities. Diabetic neuropathy is a risk factor that impedes success.

Level of Evidence: Prognostic Level IV.

Distal tibial distraction osteogenesis-an alternative approach to addressing limb length discrepancy with concurrent hindfoot and ankle reconstruction

Background

Limb length discrepancy (LLD) in the setting of concurrent hindfoot and ankle deformity poses an added level of complexity to the reconstructive surgeon. Regardless of etiology, a clinically significant LLD poses additional challenges without a forthright and validated solution. The purpose of the current study is to determine whether reconstructive hindfoot and ankle surgery with concurrent lengthening through a distal tibial corticotomy is comparable to other treatment alternatives in the literature.

Patients and methods

A retrospective review of hindfoot and ankle deformity correction utilizing Ilizarov circular external fixation with concurrent distal tibial distraction osteogenesis from July 2009 to September 2014 was conducted.

Results

This study included 19 patients with a mean age of 47.47 ± 13.36 years with a mean follow up of 576.13 ± 341.89 days. The mean preoperative LLD was 2.70 ± 1.22 cm and the mean operatively induced LLD was 2.53 ± 0.59 cm. The mean latency period was 9.33 ± 3.47 days and distraction rate was 0.55 ± 0.16 mm/day. The mean distraction length was 2.14 ± 0.83 cm and mean duration of external fixation was 146.42 ± 58.69 days. The time to union of all hindfoot and ankle fusions was 121.00 ± 25.66 days with an overall fusion rate of 85.71%.

Conclusions

The successful treatment of hindfoot and ankle deformity correction in the setting of LLD using the technique of a distal tibial corticotomy and distraction osteogenesis is reported and illustrates an additional treatment technique with comparable measured outcomes to those previously described. We urge that each patient presentation be evaluated with consideration of all described approaches and associated literature to determine the current best reconstructive approach as future studies may validate or replace the accepted options at present.

Ankle Salvage Following Nonunion of Distal Tibia Fractures

BACKGROUND

Nonunions of the distal tibia in close proximity to the ankle joint can be a challenge to treat. The purpose of this study was to evaluate radiographic and clinical outcomes of patients who underwent ankle-sparing bone transport for periarticular distal tibial nonunions.

METHODS

Twenty-one patients underwent ankle-sparing bone transport between January 2006 and July 2016. The mean age of the patients was 48.6 years, and 71% (15/21) were male. Patients were followed for an average of 14.6 months (range, 10.6-17.7 months), with an average of 8.6 months in-frame. Thirteen of 21 patients had infected nonunions. Primary endpoints included time to union and American Orthopaedic Foot & Ankle Society (AOFAS) score.

RESULTS

All fractures achieved union. Mean time to union was 37.4 weeks. Mean AOFAS score was 86.3 points (range, 37-100). A score of 37 was observed in 1 patient with preexisting Charcot foot. Radiographic evaluation at 6 months revealed a mean lateral distal tibial angle of 89.2 degrees and a mean anterior distal tibial angle of 76 degrees. Leg length discrepancy was less than 1.2 cm in all patients. Superficial pin infection was observed in 7 patients, and operative wound infection at the level of bone resection was observed in 3 patients.

CONCLUSION

The ankle-sparing bone transport technique was an effective alternative to bone graft and arthrodesis for the treatment of periarticular nonunions of the distal tibia and was safe for use in patients with infected nonunions in close proximity to the ankle joint.

LEVEL OF EVIDENCE

Level IV, case series.

Prophylactic Postoperative Antibiotics May Not Reduce Pin Site Infections After External Fixation

BACKGROUND

Pin infection continues to be a nuisance when using definitive external fixation. Prophylactic antibiotic treatment has been proposed in an effort to decrease pin complications.

QUESTIONS/PURPOSES

We performed a prospective, randomized, single-blinded study to answer the following questions: (1) what was the effect of a 10-day course of oral prophylactic antibiotics administered immediately after external fixation surgery on the incidence of a subsequent pin infection, (2) what was the effect on the severity of a subsequent pin infection, and (3) what was the effect on the timing of a subsequent pin infection?

METHODS

Patients were randomized into antibiotic treatment and control groups, and incidence, severity, and time of onset of pin infection were recorded.

RESULTS

The incidence of pin infection for the entire cohort during the 90-day observation period was 46/58 (79%) without a statistically significant difference (p = 0.106). There was no statistical difference found (p = 0.512) in pin infection severity. There was no significant difference in the time of onset of infection between the two groups from the date of surgery (p = 0.553).

CONCLUSIONS

Our randomized data do not suggest that oral antibiotics alter the incidence, timing, or severity of pin infection. This study does not support the use of prophylactic oral antibiotics in healthy patients.

Surgical management of infected non-unions: An update

Infected non-union is a devastating complication post fracture fixation. While its incidence is small, its management is lengthy, challenging and costly. Complex reconstruction surgery is often required with unpredictable outcomes despite the significant advances that have been made in diagnostics, surgical techniques and antibiotic protocols. In this article we present recent approaches to the surgical treatment of this condition.

Treatment of hypertrophic distal tibia nonunion and early malunion with callus distraction

BACKGROUND

Hypertrophic nonunions and early malunions of pilon and distal tibia fractures result in complex, challenging to treat deformities. Callus distraction histiogenesis is an option for their management, allowing for the simultaneous correction of multiplanar deformity and limb length discrepancy.

METHODS

A single-surgeon, retrospective case series was performed. Eight patients (6 males and 2 females) who were treated with callus distraction from 1991 to 2011 were reviewed. Six of 8 patients had varus deformities (range, 8-19 degrees) and 2 patients had valgus deformities (both 16 degrees) of the distal tibia metaphysis. Six of 8 had apex anterior deformities (range, 2-21 degrees) and 2 had apex posterior deformity (range, 9-20 degrees). An Ilizarov fixator or Taylor Spatial Frame (Smith & Nephew, Memphis, TN) was used to distract the nonunion or early malunion to correct alignment and shortening. Preoperative and postoperative radiographic outcomes, limb alignment, and ankle-hindfoot scores were reviewed.

RESULTS

Union was achieved in all patients at a mean of 5.8 months (range, 4.1-7.6 months). The 3 patients treated with an Ilizarov-type fixator had deformity correction to within 5 degrees of neutral in 1 plane and to within 10 degrees in the other plane. All 5 patients treated with a Taylor Spatial Frame had correction to within 5 degrees of neutral alignment in both coronal and sagittal planes. There were 2 complications requiring reoperation and 1 persistent limb length discrepancy (2 cm) after treatment. Median AOFAS ankle-hindfoot score was 82.5 (range, 53-90) at an average follow-up of 30.4 months (range, 8-92).

CONCLUSIONS

Callus distraction histiogenesis was a minimally invasive technique that can successfully treat patients with hypertrophic nonunion and early malunion of the distal tibia. We believe the application of a computer-assisted 6-axis frame to correct the deformity improved the correction of these multiplanar deformities.

LEVEL OF EVIDENCE

Level IV, case series.