Use of Ilizarov and MIPPO techniques in the treatment of a 20-year infected nonunion of the tibia: a case report

doi:10.21203/rs.3.rs-3221615/v1

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Case Report

Use of Ilizarov and MIPPO techniques in the treatment of a 20-year infected nonunion of the tibia: a case report

https://doi.org/10.21203/rs.3.rs-3221615/v1

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Introduction: The management of infected nonunion has always been an orthopedic challenge, and it is more difficult to treat it if it is accompanied by shortening and angulation deformity.

Case report: we present a case of osteomyelitis and infected nonunion of the right tibia with right lower extremity shortening and angular deformities. The Ilizarov technique was applied to treat large segmental bone defects with deformities via simultaneous lengthening of the free bone segment and the broken distal tibia.

Conclusion: Use of the Ilizarov technique in combination with MIPPO can effectively treat bone deformities caused by infected nonunion while reducing the duration of external fixation, protecting against refracture and allowing for early rehabilitation.

Tibial infected nonunion

Ilizarov technique

MIPPO

Infected nonunion, generally defined as a failure of fracture healing in the setting of persistent fracture site infection for 6–8 months, is among the most challenging orthopedic conditions to manage. Infected nonunion patients suffer multiple physiological, psychological and economic difficulties that seriously impact quality of life[1, 2]. While treatment of osteomyelitis is difficult, successful repair of large segmental bone defects – mainly formed due to debridement and infection management strategies – is even more challenging. At present, the Ilizarov technique is the strategy of choice for clinical management of bone deformities. However, its use generally requires multiple procedures to gradually restore limb function[3]. As such, a relatively long duration of treatment increases the risk of complications and significantly affects patient quality of life[4].

Use of a less invasive stabilization system (LISS) has been recommended for tibial fracture fixation due to excellent mechanical features[5]. Minimally invasive percutaneous plate osteosynthesis (MIPPO), meanwhile, can protect the fractured segment of a bone and mostly preserve its blood supply, thus providing a biological environment most conducive for nonunion healing[6–8]. Importantly, the course of external fixation can be significantly reduced by introducing a LISS at the start of osteodistraction.

Here, we detail an infected nonunion case where bone deformities were treated using the Ilizarov technique along with MIPPO. Most notably, this patient suffered infected nonunion of the right tibia complicated by progressing deformities of the right lower limb for 20 years. Management involved monolateral external fixator use to extend the segments of the broken distal tibia and the free bone simultaneously; a LISS was introduced via MIPPO to minimize duration of monolateral external fixation. As external fixation was converted into internal fixation as soon as possible, patient quality of life was significantly improved.

A 42-year-old man presented to our department with recurrent right tibial abscess formation and worsening deformity over a course of 20 years after surgery for right tibiofibular fracture. The patient underwent open reduction and internal fixation with a tibial plate for management of a tibial fracture after a comminuted fracture of the right tibia and fibula. The plate was removed and two screws were installed one year postoperatively due to a broken tibial plate (the medical history was unclear). Since the surgery 20 years prior, the patient complained that the right lower limb gradually turned inward and became limp, and that as the extremity shortened and muscles contracted, ambulation became difficult. Indeed, the patient’s deformed right lower limb was noted to be shorter than the left by 2 cm. Moreover, a discharging sinus tract was noted anterior to the tibia, suggesting the need for antibiotic treatment. After appropriately examining the patient, the diagnoses of osteomyelitis, infected nonunion of the right tibia and deformity of the right lower limb were made in-hospital due to edema about the anterior aspect of the right lower limb and a presence of two purulent skin lacerations. Although the patient reported having suffered diabetes for many years, systematic management had not been adhered to. Physical examination and lower extremity CT angiography confirmed normal neurovascular status. The patient reported no history of other illnesses and denied a family medical history remarkable for inherited conditions. The flow chart detailing this patient’s diagnosis and treatment is shown in Fig. 1.

Our treatment process was divided into four stages, namely stage I (treatment of tibial osteomyelitis); stage II (distraction osteogenesis for lower limb lengthening until defect disappearance); stage III (bone grafting and fixation); and stage IV (regular follow-up until approximately 2 years after completion of external fixation). The patient underwent three operations in total.

Preoperative X-rays revealed discontinuity in the middle right tibial shaft, discontinuous callus formation at the broken segment of the bone, and valgus deformity with compensated thickening of the fibula. Two screws remained. Preoperative three-dimensional CT (3D-CT) imaging revealed dead bone and cavity formation at the broken segment (Fig. 2). Osteomyelitis imaging, along with clinical findings, confirmed osteomyelitis of the tibia. Consequently, radical debridement and reconstruction were strongly recommended; the patient consented.

The first stage of surgery: radical debridement and introduction of an antibiotic-loaded cement spacer

The patient was positioned supine on a radiolucent operating table. A pad was placed under the patient’s ipsilateral buttock to prevent his leg from externally rotating; the surgical team did not need to hold his leg throughout the procedure. A pneumatic tourniquet was applied to the patient’s thigh and the leg was placed on another pad. Under spinal anesthesia, radical debridement of bone and soft tissue was performed until the “paprika sign” was noted. The length of the bone defect reached 7 cm after radical debridement. A tigecycline- and vancomycin-impregnated poly(methyl methacrylate) (PMMA) cement spacer was used to fill the defect. The bone was stabilized via external fixation. As antibiotic therapy follows culture and sensitivity findings, the growth of Enterococcus faecalis in samples obtained from the patient’s tibial lesions indicated use of tigecycline and vancomycin. Non-weight-bearing mobilization was initiated on the first postoperative day. Although this surgery did not correct the limb deformity, follow-up cultures confirmed successful eradication of Enterococcus faecalis. The external fixator was removed 2.5 months postoperatively in preparation for the next stage of treatment (Fig. 3).

The second stage of surgery: corticotomy and distraction osteogenesis

After treating the patient's tibial osteomyelitis, the second stage of his treatment was conducted 3 months after the prior (first) operation. This stage of surgical treatment included spacer removal and fibular osteotomy. The bone was stabilized using an LISS applied via MIPPO. A monolateral external fixator was applied to the anteromedial tibial surface and a corticotomy was performed at the proximal tibia. The corticotomy was performed at least 8-10 cm above the bone defect using a Gigli saw (Fig. 4).

Bone distraction was initiated seven days after osteotomy at an average rate of 1 mm/d (0.25 mm per time; four times per day). X-ray images were taken monthly to monitor the progress of bone distraction and defect union. At the same time, passive functional exercises were initiated for the knees and ankles. Distraction of the free bone and distal broken tibial segments was initiated at the same parameters. After 20 days of extension, the right tibia lengthened by 2 cm, at which time both lower limbs became equal in length. Distraction of the distal tibial segment was terminated while the free bone segment continued to be extended distally (Fig. 5).

The third stage of surgery: fixation of the distal broken tibia and the free bone segment; bone grafting at the docking site.

This stage of treatment was initiated upon conclusion of bone distraction. The prior incision was used to align the free bone segment and fix it to the LISS with screws (two and three screws were used to fix the free bone segment and the distal broken tibia, respectively). The monolateral external fixator was removed. Cancellous bone from the ipsilateral iliac crest was removed and grafted at the docking site.

This operation accomplished correction of the external rotation deformity as well as bone grafting.

Outcomes and follow-up

On the first post-graft day, the patient began continuous passive range-of-motion exercises under the guidance of an orthopedic surgeon. X-ray imaging revealed a satisfactory right lower limb force line and reliable fixation of the LISS. Although imaging of the docking site was unclear, bone grafting was noted. Touch weight-bearing was suggested for the first six post-graft weeks, after which protected weight-bearing was permitted. Radiographs 6 months post-graft revealed satisfactory bone consolidation and bridging union (Fig. 6). No re-fractures or infectious inflammation at final 22-month follow-up were noted. Good lower limb alignment and complete bone structure plasticity were also noted; by this time the patient had achieved good limb function (i.e. an acceptable 0°-100° range of knee motion was achieved).

The patient’s satisfaction was assessed using the visual analog scale (VAS). His VAS score of three suggested the presence of mild-to-moderate pain. When the patient could weight-bear painlessly without the brace and bridging callus was noted at three cortices on radiography, union was confirmed. The duration time of external fixator use (EFT) was recorded and defined as days from initial fixator application until removal. The external fixation index (EFI) was calculated by dividing the EFT duration (days) by the lengthening achieved (cm)[9]. The length of free bone segment distraction was 9 cm throughout the transport process (Fig. 7). The EFT was 246 days while the EFI was 27.3 days/cm. According to Paley score criteria[2], our patient had an excellent outcome.

Infected nonunion has always been a major orthopedic challenge. Control of infection is the premise of treating infected nonunion. As osteomyelitis leads to bone destruction, graft resorption and treatment failure are likely complications in this setting. In this case, infection control was achieved via radical debridement and introduction of antibiotic-impregnated PMMA into the defect. The PMMA served to occupy the site of the bone defect and prevent fibrosis, maintain tibial stability and release antibiotics[10, 11]. Although antibiotics are selected according to culture and sensitivity testing data, extensive debridement of infected sites often results in segmental defects and presents management challenges[12]. The patient in this study developed a 7-cm long bone defect after radical debridement as the gap in bone tissue expanded.

Bone defect reconstruction mainly involves bone transport, induced membrane and vascularized bone graft techniques[13–15]. Although these techniques can successfully repair bone defects, the induced membrane technique and vascularized bone grafting could not have been used to manage limb shortening in our patient. As such, we adopted Ilizarov’s method to simultaneously repair the bone defect and correct the limb shortening deformity. The Ilizarov principle is based upon the law of tension-stress[2, 10, 16], which states that continuous slow traction promotes regeneration of biological tissues.

Classical distraction osteogenesis mainly consists of four phases (i.e. corticotomy and latent, distraction, consolidation and bone graft phases)[17]. Considering the characteristics of our patient’s limb shortening deformity, we approached the distraction phase in two steps. The first step attenuated limb shortening by 2 cm. We used the Ilizarov technique to simultaneously extend the free bone and distal broken tibial segments. Extension was initiated 7 days postoperatively[18] at a rate of 1 mm/d. After 20 days, when the length of both lower limbs equalized, the distance between the free bone and distal broken tibial segments was still 7 cm. To repair the 7-cm bone defect, our second step involved free bone segment lengthening utilizing the classical bone transport technique. The final free bone segment distraction length in this case was 9 cm. As the consolidation phase is usually twice as long as the distraction phase in children and three or four times as long in adults[17], adhering to a standard surgical plan would have taken 3.5 months to achieve our aforementioned results (taking one month to equalize lower limb length and about 2.5 months to repair the remaining 7-cm defect at a rate of 1 mm/d). Our patient, however, suffered from poor bone mineralization and it took 8 months to completely repair his bone defect. Even so, the time was less than what would have been required for a 9-cm extension using only external fixation. Furthermore, as our patient was a diabetic whose blood glucose was not monitored, a pro-inflammatory microenvironment at defect sites with resultant pathology of bone metabolism remained a risk[19, 20]. This pathophysiological factor likely prolonged the duration of consolidation during bone segment distraction.

Studies have shown that as duration of external fixator use increases, so does the incidence of complications including pin tract infection, arthralgia, general discomfort and refracture[21]. In order to reduce the duration of external fixation, classic Ilizarov apparatuses have been improved upon in recent years, and monolateral frames have become more attractive due to higher comfort levels and functional outcomes[22]. At the conclusion of distraction, monolateral external fixator placement duration is shortened via LISS fixation using MIPPO and removal of the external fixator, thus reducing the incidence of complications and improving patient quality of life. Here, due to poor bone mineralization, external fixation was employed for 8 months, and no complications occurred.

The use of the LISS significantly shortens the time required for external fixation. In our patient, LISS placement and fixation were achieved by applying a minimally invasive technique. Importantly, LISS is known to work after the conclusion of bone distraction in this case. Here, LISS and monolateral external fixation were introduced at the same time. Theoretically, we had two options regarding timing of LISS fixation. On one hand, the LISS could be fixed when the distal broken end of the tibia was distracted to the length of the bone contralaterally, but early fixation was abandoned to facilitate later correction of the external rotation deformity caused by the second stage of surgery. On the other hand, LISS placement and fixation could have been completed simultaneously at the conclusion of bone distraction. However, follow-up findings revealed that the LISS was placed in advance, no skin and soft tissue collapse or soft tissue impaction into the fracture space occurred in the bone defect area, which deserves further observation and study.

Retrospective analysis of our treatment process revealed that management strategy was not without shortcomings. First, the external rotation deformity was not noted in a timely manner after the second stage of surgery, which delayed distal broken tibial fixation and affected early functional exercise initiation. Second, after monolateral frame removal, we immediately performed bone grafting at the docking site and clamped the distal space through the original needle track; this may have caused autologous infection. Third, as numerous screws were used in managing the proximal tibia, LISS screws may have affected monolateral external fixator screw placement. Interference between the drill bit and screw may also have occurred during drilling.

In summary, this case underscores that combined use of the Ilizarov and MIPPO techniques can effectively treat tibial infected nonunion with deformities, significantly shorten duration of external fixation, improve patient quality of life and facilitate early rehabilitation.

Acknowledgments

None.

Author contributions

All authors consent to publication. ZN had main responsibility for writing the paper. GR was responsible for postoperative follow-up and generating images. GR, DW and YC revised the article and conducted scientific evaluation. All authors read and approved the final manuscript.

Funding

This study was supported by Graduate Innovation Fund of Jilin University (41902142235A, 4190214223Q0)；The 13th Five-Year Plan of Science and Technology Research of Jilin Provincial Education Department (JJKH20180108KJ).

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors have no conficts of interest to declare that are relevant to the content of this article.

Ethical approval and consent to participate

The study was conducted in accordance with principles outlined in the Declaration of Helsinki and was approved by the Ethics Committee of the Second Hospital of Jilin University. The patient provided written informed consent for study participation. Data anonymity was maintained for privacy purposes.

Consent for publication

Written informed consent has been obtained from the patient for publication of this case report and any accompanying images.

Li J, Li M, Wang W, Li B, Liu L. Evolution and Development of Ilizarov Technique in the Treatment of Infected Long Bone Nonunion with or without Bone Defects. Orthop Surg. 2022;14(5):824–30.
Xu K, Fu X, Li YM, Wang CG, Li ZJ. A treatment for large defects of the tibia caused by infected nonunion: Ilizarov method with bone segment extension. Ir J Med Sci. 2014;183(3):423–8.
Lu Y, Wang Q, Ren C, Li M, Li Z, Zhang K, Huang Q, Ma T. Proximal versus distal bone transport for the management of large segmental tibial defect: a clinical case series. Sci Rep. 2023;13(1):3883.
Oh CW, Apivatthakakul T, Oh JK, Kim JW, Lee HJ, Kyung HS, Baek SG, Jung GH. Bone transport with an external fixator and a locking plate for segmental tibial defects. Bone Joint J 2013, 95–b(12):1667–1672.
Devkota P, Manandhar HK, Khadka PB, Mainali LP, Khan JA, Acharya BM, Pradhan NS, Shrestha SK. Less invasive stabilization system for the management of proximal tibia fractures. Eur J Orthop Surg Traumatol. 2014;24(6):993–8.
He GC, Wang HS, Wang QF, Chen ZH, Cai XH. Effect of minimally invasive percutaneous plates versus interlocking intramedullary nailing in tibial shaft treatment for fractures in adults: a meta-analysis. Clin (Sao Paulo). 2014;69(4):234–40.
Sitnik AA, Beletsky AV. Minimally invasive percutaneous plate fixation of tibia fractures: results in 80 patients. Clin Orthop Relat Res. 2013;471(9):2783–9.
Cai Y, Duan J, Fang L, Xu S, Zhang L. [Effect of three-dimensional printing-assisted minimally invasive plate osteosynthesis on anti-malrotation for different types of tibial fractures]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2019;33(12):1510–5.
Wang H, Wei X, Liu P, Fu YH, Wang PF, Cong YX, Zhang BF, Li Z, Lei JL, Zhang K, et al. Quality of life and complications at the different stages of bone transport for treatment infected nonunion of the tibia. Med (Baltim). 2017;96(45):e8569.
Song HR, Cho SH, Koo KH, Jeong ST, Park YJ, Ko JH. Tibial bone defects treated by internal bone transport using the Ilizarov method. Int Orthop. 1998;22(5):293–7.
Février A, Boursot C, Tannugi KC. Osteomyelitis and Gentamicin-PMMA Chains. Clin Nucl Med. 2022;47(11):e708–9.
Keating JF, Simpson AH, Robinson CM. The management of fractures with bone loss. J Bone Joint Surg Br. 2005;87(2):142–50.
McNally M, Ferguson J, Kugan R, Stubbs D. Ilizarov Treatment Protocols in the Management of Infected Nonunion of the Tibia. J Orthop Trauma. 2017;31(Suppl 5):47–s54.
Lavía KF, Boccolini HS, Hernández RA. Reconstruction of a tibial diaphyseal bone defect using the Masquelet technique. A case report. Trauma Case Rep. 2022;42:100728.
Hou SM, Sun JS, Liu TK. Management of bony defects in open grade III fractures. J Formos Med Assoc. 1992;91(3):315–22.
Papakostidis C, Bhandari M, Giannoudis PV. Distraction osteogenesis in the treatment of long bone defects of the lower limbs EFFECTIVENESS, COMPLICATIONS AND CLINICAL RESULTS; A SYSTEMATIC REVIEW AND META-ANALYSIS. Bone & Joint Journal. 2013;95B(12):1673–80.
Apivatthakakul T, Arpornchayanon O. Minimally invasive plate osteosynthesis (MIPO) combined with distraction osteogenesis in the treatment of bone defects. A new technique of bone transport: a report of two cases. Injury. 2002;33(5):460–5.
Kim H, Lee SK, Kim KJ, Ahn JH, Choy WS, Kim YI, Koo JY. Tibial lengthening using a reamed type intramedullary nail and an Ilizarov external fixator. Int Orthop. 2009;33(3):835–41.
Li D, Chen K, Tang H, Hu S, Xin L, Jing X, He Q, Wang S, Song J, Mei L, et al. A Logic-Based Diagnostic and Therapeutic Hydrogel with Multistimuli Responsiveness to Orchestrate Diabetic Bone Regeneration. Adv Mater. 2022;34(11):e2108430.
Xu Z, Qi X, Bao M, Zhou T, Shi J, Xu Z, Zhou M, Boccaccini AR, Zheng K, Jiang X. Biomineralization inspired 3D printed bioactive glass nanocomposite scaffolds orchestrate diabetic bone regeneration by remodeling micromilieu. Bioact Mater. 2023;25:239–55.
Gupta S, Malhotra A, Mittal N, Garg SK, Jindal R, Kansay R. The management of infected nonunion of tibia with a segmental defect using simultaneous fixation with a monorail fixator and a locked plate. Bone Joint J 2018, 100–b(8):1094–1099.
Bhardwaj R, Singh J, Kapila R, Boparai RS. Comparision of Ilizarov Ring Fixator and Rail Fixator in Infected Nonunion of Long Bones: A Retrospective Followup Study. Indian J Orthop. 2019;53(1):82–8.

No competing interests reported.

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Use of Ilizarov and MIPPO techniques in the treatment of a 20-year infected nonunion of the tibia: a case report

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