The Journal of Bone and Joint Surgery (American). 2007;89:183-195.
doi:10.2106/JBJS.G.00306
© 2007 The Journal of Bone and Joint Surgery, Inc.
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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, MD1, Mehmet Kocaoglu, MD1 and Haroon Rashid, MD1

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

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

The original scientific article in which the surgical technique was presented was published in JBJS Vol. 88-A, pp. 2137-45, October 2006

DISCLOSURE: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received 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, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

The line drawings in this article are the work of Joanne Haderer Müller of Haderer & Müller (biomedart{at}haderermuller.com).

BACKGROUND: Callus distraction over an intramedullary nail is a rarely used technique for the reconstruction of intercalary defects of the femur and tibia after radical débridement of chronic osteomyelitic foci. The aim of this study was to summarize our experience with distraction osteogenesis performed with an external fixator combined with an intramedullary nail for the treatment of bone defects and limb-shortening resulting from radical débridement of chronic osteomyelitis.

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/cm, 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.

ORIGINAL ABSTRACT CITATION: "Reconstruction of Segmental Bone Defects Due to Chronic Osteomyelitis with Use of an External Fixator and an Intramedullary Nail" (2006;88:2137-45).


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Related articles in JBJS:

Reconstruction of Segmental Bone Defects Due to Chronic Osteomyelitis with Use of an External Fixator and an Intramedullary Nail
Mehmet Kocaoglu, Levent Eralp, Haroon ur Rashid, Cengiz Sen, and Kerem Bilsel
JBJS 2006 88: 2137-2145. [Abstract] [Full Text]  



Letters to the Editor:

Read all Letters to the Editor

Surgical treatment of chronic osteomyelitis of long bones - our experience
Cedomir S Vucetic, et al.
JBJS Online, 5 Dec 2007 [Full text]