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Reconstruction of Segmental Bone Defects Due to Chronic Osteomyelitis with Use of an External Fixator and an Intramedullary Nail

¹ Department of Orthopaedics and Traumatology, Istanbul Medical School, Istanbul University, Çapa, 34390, Istanbul, Turkey. E-mail address for L. Eralp: yeralp{at}superonline.com
² Department of Surgery, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan
³ Department of Orthopedics and Traumatology, Gaziosmanpasa University, 1830 Tokat, Turkey

Investigation performed at the Department of Orthopaedics and Traumatology, Istanbul Medical School, Istanbul University, Istanbul, Turkey

The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Methods: Thirteen patients who ranged in age from eighteen to sixty-three years underwent radical débridement to treat a nonunion associated with chronic osteomyelitis of the tibia (seven patients) and femur (six patients). The lesions were classified, according to the Cierny-Mader classification system, as type IVA (nine) and type IVB (four). The resulting segmental defects and any limb-length discrepancy were then reconstructed with use of distraction osteogenesis over an intramedullary nail. Two patients required a local gastrocnemius flap. Free nonvascularized fibular grafts were added to the distraction site for augmentation of a femoral defect at the time of external fixator removal and locking of the nail in two patients. At the time of the latest follow-up, functional and radiographic results were evaluated with use of the criteria of Paley et al.

Results: The mean size of the defect was 10 cm (range, 6 to 13 cm) in the femur and 7 cm (range, 5 to 10 cm) in the tibia. The mean external fixator index was 13.5 days per centimeter, the consolidation index was 31.7 days/cm, and the mean time to union at the docking site was nine months (range, five to sixteen months). At a mean follow-up of 47.3 months, eleven of the thirteen patients had an excellent result in terms of both bone and functional assessment. There were two recurrences of infection necessitating nail removal. These patients underwent revision with an Ilizarov fixator. Subsequently, the infection was controlled and the nonunions healed.

Conclusions: This combined method may prove to be an improvement on the classic techniques for the treatment of a nonunion of a long bone associated with chronic osteomyelitis, in terms of external fixation period and consolidation index. The earlier removal of the external fixator is associated with increased patient comfort, a decreased complication rate, and a convenient and rapid rehabilitation.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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Reconstruction of Segmental Bone Defects Due to Chronic Osteomyelitis with Use of an External Fixator and an Intramedullary Nail. Surgical Technique

Levent Eralp, Mehmet Kocaoglu, and Haroon Rashid
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				L. Eralp and M. Kocaoglu Distal Tibial Reconstruction with Use of a Circular External Fixator and an Intramedullary Nail. Surgical Technique J. Bone Joint Surg. Am., October 1, 2008; 90(Supplement_2_Part_2): 181 - 194. [Abstract] [Full Text] [PDF]

				L. Eralp, M. Kocaoglu, N. M. Yusof, and M. Bulbul Distal Tibial Reconstruction with Use of a Circular External Fixator and an Intramedullary Nail. The Combined Technique J. Bone Joint Surg. Am., October 1, 2007; 89(10): 2218 - 2224. [Abstract] [Full Text] [PDF]

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