The Ilizarov method is recommended by a number of authors for treating nonunion of the tibia, as it is highly effective in achieving bone union, treatment of a possible infection, correcting limb length discrepancy and axial misalignment, and eliminating joint contractures [1–5, 7–12, 14–18, 22].
There are various recommended treatment strategies of nonunions of the tibia employing the Ilizarov method [2–5, 7–14, 16–22]. Good treatment outcomes have been demonstrated with the use of various treatment strategies [2–8, 11, 12, 13, 15–19, 22]. These include: fixation alone [9, 12, 14, 15, 17]; fixation and compression [7, 19]; fixation, segmental resection, and bone transport [2, 4, 6, 12, 16, 17, 19, 20, 22]; and fixation, resection, and compression with bone transport [5, 7, 8, 10, 11, 18, 19, 22]. Eralp observed good treatment outcomes in infected nonunions of the tibia treated by means of either combined fixation and compression or combined fixation, resection, and compression with bone transport [7]. However, various surgical techniques and treatment strategies may affect the outcomes in ways that are not known at this time. McNally et al. assessed the effect of four different treatment strategies and techniques used in infected pseudarthrosis of the tibia on treatment outcomes in 79 patients [19]. These strategies and techniques were: monofocal distraction, monofocal compression, bifocal compression/distraction, and bone transport [19]. Post-treatment infection recurrence was observed in three patients from the monofocal compression subgroup. Primary bone union rates were the lowest (73.7%) in the monofocal compression subgroup and the highest in the bifocal compression/distraction (93.8%) and monofocal distraction (96.2%) subgroups. The authors concluded by advising against the use of monofocal compression in the treatment of pseudarthrosis of the tibia [19].
Yin et al. conducted a meta-analysis of 590 patients treated for infected femoral or crural nonunions via the Ilizarov method [1]. A total of 24 studies were analyzed revealing the treatment helped achieve bone union in 97.8% of patients with infected nonunions of the tibia [1]. Peng et al. assessed the treatment outcomes in 58 patients with infected nonunions of the tibia managed via Ilizarov bone transport combined with an antibiotic-loaded cement spacer. Bone union was achieved in 100% of patients [2]. Schoenleber et al. evaluated 8 patients with nonunions of the distal tibia treated with ring fixators, all of whom achieved bone union [3]. Zhang et al. reported bone union in 100% of the 25 patients with infected nonunions of the tibia treated with the Ilizarov method [4]. Abuomira et al assessed 55 patients with nonunions of the tibia, including some cases of false-joint infection, treated with ring fixators. Bone union was achieved in 89% of patients [5]. Baruah reported bone union in 98% of 50 patients with infected nonunions of the tibia [6]. Eralp evaluated the effects of employing ring fixators in 13 patients with infected nonunions of the tibia; bone union was achieved in 92.3% of patients [7]. Hosny and Shawky reported bone union in all of the 11 assessed patients with infected nonunions of the tibia treated with the Ilizarov method [8]. Khan observed bone union in 87.5% of 24 patients with infected nonunions of the tibia treated with the Ilizarov method [9]. Madhusudhan et al. demonstrated bone union in 81.8% of 22 patients with infected nonunions of the tibia treated via an Ilizarov fixator [10]. Magadum et al. assessed treatment outcomes following the use of an Ilizarov fixator in 25 patients with infected nonunions of the tibia. Bone union was observed in 96% of those patients [11]. Meleppuram reported bone union in all of the 42 evaluated patients with infected nonunions of the tibia treated with the Ilizarov method [12]. Sahu reported bone union in all of the 60 patients treated with the Ilizarov method [13]. Sanders evaluated 19 patients with nonunions of the tibia treated with the use of the Ilizarov method and achieved bone union in 84.2% of patients [14]. Shahid reported bone union in 100% of the 12 infected tibial nonunions patients treated with the Ilizarov method [15]. Wang at al. achieved bone union in all of their 15 patients with infected nonunions of the tibia treated with ring fixators [16]. Wani et al. assessed treatment outcomes following the use of the Ilizarov method in 26 patients with infected nonunions of the tibia and achieved union in 100% of cases [17]. Yin reported bone union in all 65 patients with infected nonunions of the tibia treated with the Ilizarov method [18]. McNally et al. analyzed the effect of using various surgical techniques and strategies on treatment outcomes in 79 patients with infected pseudarthrosis of the tibia treated with an Ilizarov fixator [19]. Depending on the employed treatment strategy and surgical technique primary bone union was achieved in a range from 73.7–96.2% of patients, with a refracture rate of 31.6% in one of the subgroups [19]. Dróżdż et al. achieved bone union in 86% of 54 patients with infected nonunions of the tibia treated with the Ilizarov method [20]. Marsh et al. assessed the treatment outcomes of the Ilizarov method employed in 46 patients with nonunions of the tibia. Bone union was reported in 87% of those patients [21].
Our study demonstrated bone union in 100% of patients, which is an outcome comparable to, or even slightly better than, those reported in literature [1–21]. The treatment strategy and surgical technique showed no effect on the proportion of patients who achieved bone union in the individual subgroups.
There have been no studies assessing the number of complications depending on the employed treatment strategy and surgical technique. The group of patients evaluated by Peng developed 0.67 complications per patient [2]. Schoenleber reported a mean of 0.875 complications per patient [3]. The study population evaluated by Zhang developed 0.2 complications per patient [4]. The mean number of complications per patient reported by Abuomira was 1.2 [5]. Eralp reported 1.38 complications per patient [7]. Hosny and Shawky encountered 1.27 complications per patient [8]. Madhusudhan reported a mean of 2.01 complications per patient [10]. The study population evaluated by Meleppuram developed a mean of 1.6 complications per patient [12]. Wani et al. reported 2.27 complications per patient [17].
Our study population, depending on the subgroup, developed anywhere from 0.25 to 0.47 complications per patient, which is a slightly better result than those reported in literature, which range from 0.67 to 2.27 [2, 3, 4, 16]. The employed treatment strategies and surgical techniques were observed to have no effect on the mean number of complications per patient.
There are no available reports from studies assessing the duration of treatment with an external fixator stratified by different treatment strategies and surgical techniques. Overall, the mean duration of treatment ranges from 5.8 months to 13.5 months [2, 3, 4, 5, 6, 8, 9, 13, 16]. These figures are similar to ours. We observed no effect of the evaluated treatment strategies or surgical techniques on Ilizarov treatment duration.
ASAMI bone scores reported by Abuomira were 51% excellent, 33% good, 9% fair, and 7% poor [5]. Khan observed 25% excellent, 58.3% good, 4.2% fair, and 12.5% poor ASAMI bone scores [9]. Meleppuram achieved 60% excellent, 15% good, and 25% fair ASAMI bone scores [12]. None of the authors cited here assessed the ASAMI bone scores stratified by the employed treatment strategy and surgical technique.
The treatment strategies and surgical techniques employed in our evaluated patient population yielded no significant differences in the resulting ASAMI bone scores.
The ASAMI functional scores reported by Abuomira were 45% excellent, 38% good, 9% fair, and 7% poor [5]. Khan observed 33.3% excellent, 50% good, 8.35% fair, and 8.35% poor ASAMI functional scores [9]. Meleppuram reported 55% excellent, 30% good, 5% fair, and 10% poor ASAMI functional scores [12]. The relevant literature contains no studies assessing ASAMI functional scores stratified by the employed surgical technique and treatment strategy.
In our study, treatment strategy was observed to have no effect on the ASAMI functional score. However, when it comes to surgical techniques, the patients who underwent closed fixation achieved significantly higher ASAMI functional scores than the open-fixation patients. This may be a result of better soft-tissue and surgical-wound healing.
We are aware of the fact that treatment of infected and aseptic pseudarthroses may produce different outcomes. Unfortunately, there is a scarcity of papers addressing aseptic pseudarthrosis treatment in the available relevant literature. Our study is one of the first ones to analyze the available techniques and strategies employed in treating pseudarthroses with an Ilizarov fixator.
The available literature reports inform us that the mean length of hospital stay for treating patients with nonunions of the tibia with an external fixator ranges from 5 to 105 days [4, 13, 17]. These statistics are slightly worse than those achieved in our study. We observed no effect of the employed surgical technique or treatment strategy on the length of hospital stay.
Bone transport is a more complex procedure than that of employing compression/distraction. There may be problems with achieving good contact of bone ends and ensuring bone union at the docking site; moreover, more complications may develop, and the duration of treatment may be longer [5]. Open fixation procedures in patients with nonunions are more complex than closed fixation. Continued compression is more bothersome for nonunions patients than neutral fixation without compression.
We observed better ASAMI functional score outcomes in the patients who underwent closed fixation than in the open fixation group.
The different surgical techniques had no effect on the number of complications, rates of bone union, length of hospital stay, duration of Ilizarov treatment, or ASAMI bone scores.
The different treatment strategies had no effect on the number of complications, rates of bone union, rates of bone union, length of hospital stay, duration of Ilizarov treatment, ASAMI bone scores, or ASAMI functional scores.
Multicenter, randomized studies are needed in order to compose the guidelines for the treatment of aseptic pseudarthroses of the tibia. Nonetheless, our study can be considered an attempt to assess various techniques and strategies in the treatment of tibial nonunion and present our team’s experiences.
For managing nonunions of the tibia we recommend the technique of closed fixation without continued compression.
Nonetheless, the use of the Ilizarov method in the treatment of nonunions of the tibia yields good outcomes irrespective of the employed surgical technique or treatment strategy.