Outcome of limb reconstruction system in tibial infected non-union and open tibial diaphysial fracture with bone loss

Abstract

Introduction

Incidence of open fractures of the long bones is increasing due to the increase in road traffic accidents (RTA) which leads to an increased incidence of complex non-unions of long bones. Patients are usually operated many times for fracture fixation (and healing) or to eradicate infection, which causes soft tissue scarring and devitalization of any surviving bone.

Objective

In this study, we assess the outcome of the Limb reconstruction system in tibial infected non-union and open tibial diaphyseal fracture with bone loss.

Method

It is a prospective study conducted on 15 patients and patients included in this study having compound fractures of shaft tibia with bone loss classified by Gustilo-Anderson open fracture classification. With the defect in the distal tibia, proximal corticotomy 1.5 cm distal to the last screw in the proximal clamp and proximal to distal transports were done and vice versa. All patients were evaluated with the ASAMI scoring system into bone results and functional results.

Results

In the majority of patients, the injury was caused by road traffic accidents 80% of cases. Out of 15 cases, 2 belong to the upper 3rd, 9 cases belong to the middle 3rd and 4 cases belong to the lower 3rd of shaft tibia. The union time ranges from 4 to 11 months but the maximum union was achieved in 7–9 months in 8 (53.33%). Pin tract infection was reported in two (13.33%) patients who became better with regular dressing. Ankle stiffness was present in one case (6.67%), most probably due to improper physiotherapy.

According to ASAMI Criteria excellent radiological results were present in 11 (73.33%) cases, good results were found in 4 (26.67) cases and excellent functional results were observed in 7 cases (46.67%) and good results were found in 8 (53.33%) cases. Infection was cured in all patients and did not recur till the last follow-up.

Conclusions

Advantages of rail fixator include less invasive surgery, early weight-bearing, less infection, less blood loss, prevention of diffuse osteoporosis and atrophy, preservation of limb function, no need for bone grafting, correction of deformity during the process of healing, thus no need for a second surgery. Non-union, bone defect, and deformity can be corrected simultaneously. Hence, we recommend the use of this system (rail fixator) especially for infected non-union of long bones and compound fractures with bone loss.

1. Introduction

Incidence of open fractures of the long bones is increasing due to an increase in road traffic accidents (RTA) which leads to increase in the incidence of complex non-unions like infected nonunion. Infected nonunion is defined as a state of failure of union and persistent infection for 6–8 months. Infected non-union of long bones causes a great functional and financial challenge to patients. Usually patients are operated several times for fixation of fracture and also to eradicate infection of bones, which causes soft tissue scarring and devitalization of surviving bone. The presence of long-term infections causes the deformity, limb length variations, stiff joints, osteoporosis, and atrophy of soft tissue. So, it is one of the most dangerous and challenging orthopedic situations to manage. The suffering of patients is so severe in some cases that amputation may be one of the treatment opinions to save the lives of patients. The treatment is usually prolonged in most cases and requires multiple surgeries that lead to disability and social stigma.¹

Thus, open tibial fractures, with infected non-unions require proper soft tissue covering, bone reconstruction and eradication of infection for a functional extremity. The surgical options for the treatment of bone loss include bone transport, vascularized fibula graft, and induced membrane.² The best way to stabilize such a fracture is the application of external fixators. They should not only stabilize the fracture but should also take a cyclic loading for routine activities.

Vascularized fibula graft has certain limitations like highly demanding surgical technique, risk of vascular failure, graft failure; and donor site morbidity.³ Bone transport with Ilizarov has been widely used for the treatment of bone loss.^{4, 5, 6} Disadvantages of Ilizarov fixator are that it causes difficulty in clothing, bulkier than LRS, pain due to tensioned olive wires and more risk of neurovascular damage.⁷ Limb reconstruction system is less bulky than Ilizarov and has better compliance than Ilizarov, easy to apply with the additional advantage of allowing dynamization which is an important concept in the treatment of non-union.⁸

In our study, we evaluate the outcomes of the Limb reconstruction system (LRS) in tibial infected non-union and open tibial diaphyseal fracture with bone loss.

2. Material and methods

It is a prospective study which was conducted on 15 patients and patients having compound fractures of shaft tibia with following inclusion and exclusion criteria.

2.1. Inclusion criteria

1. Bone loss classified by Gustilo- Anderson open fracture classification.

2. Infectednon united fracture of shaft tibia which requires resection of infected bone, classified by Paley’s system of classification.⁹

2.2. Exclusion criteria

• 1.Patients with Closed fractures of tibial diaphysis
• 2.Pathological fractures
• 3.Tibia fractures with intraarticular extension
• 4.Compound diaphyseal fractures of tibia without bone loss

Patients were evaluated with a radiograph of limb AP and Lateral views. The criteria taken for infected nonunion was a minimum period of 9 months after injury with no union or no signs of union seen in two radiographs 3 months apart with discharging sinus.

Limb reconstruction system was applied in all patients after the excision of sinuses and removal of infected or dead bone. With the defect in the distal tibia, proximal corticotomy of 1.5 cm distal to the last screw in the proximal clamp and proximal to distal transport was done and vice versa for proximal tibia. Distraction was started after7 days at the rate of 0.25 mm/6 hourly daily means 1 mm in 24 h. Followup X rays were done at immediate post-operative, 3 weeks, and further at 4 week’s interval till fracture union. Union was confirmed on Xray and after the union, LRS was removed and after removal patellar tendon bearing cast (PTB cast) was applied for 6–8 wks. The patient was further followed for the next three months after the union.

All patients were assessed by using of ASAMI scoring system¹⁰ into bone results (Table 1)and functional results (Table 2).

Table 1.

Bone results.

Excellent	Union, no infection, deformity<7°, limb length discrepancy<2.5 cm
Good	Union + any two of the following: no infection, deformity<7°, limb length discrepancy<2.5 cm
Fair	Union + only one of the following: no infection, deformity<7°, limb length discrepancy<2.5 cm
Poor	Non-union/re-fracture/union + infection + deformity>7° + limb length discrepancy>2.5 cm

Table 2.

Functional results.

Excellent	Active, no limp, minimum stiffness (loss of <15°knee extension/<15° dorsiflexion of ankle), no reflex sympathetic dystrophy, insignificant pain
Good	Active with one or two of the following: Limp, stiffness, RSD, significant pain.
Fair	Active with three or all of the following: Limp, stiffness, RSD, significant pain
Poor	Inactive (unemployment or inability to return to daily activities because of injury)
Failure	Amputation

3. Results

In our study, there were 12 male patients (80%) and 3 female patients (20%). The majority of injuries were caused by a road traffic accident. Out of 15 cases, 2 cases of fracture upper 3rd tibia, 9 cases of fracture middle 3rd tibia, and 4 cases of fracture lower 3rd tibia.

Time between trauma and operation varied from 1 week to 15 months. The majority of cases were operated between 9 and 12 months. The delay in treatment was because they presented late and were treated by various methods elsewhere. The union time was between 4 and 11 months but the maximum union was achieved in 7–9 months in 8 (53.33%).

Pin tract infection was a complication and reported in two (13.33%) patients which became a cure with regular pin tract dressing. One patient (6.67%) had complaint of pin loosening which needed exchanging of a pin. The other patient (6.67%) had developed early consolidation at corticotomy site because of late distraction in a non-compliant patient. In this case, we did re-corticotomy and distraction was started again after 1 week. Ankle stiffness was present in 1 (6.67%) case which was due to improper physiotherapy. Minimal angulation was found in one patient only.

Other complications like fat embolism, postoperative pulmonary embolism, hemorrhage, deep vein thrombosis was not observed in our series, there was no case associated with neurovascular complications in our series.

According to ASAMI Criteria excellent radiological results were present in 11 (73.33%) cases, good results were present in 4 (26.67) cases and excellent functional results were observed in 7 cases (46.67%) and good results were observed in 8 (53.33%) cases. Infection was cured in all patients and did not recur till the last follow-up.

4. Discussion

Non-union of fracture is itself a critical condition, but it becomes worst when it is associated with infection. Infection requires aggressive treatment like debridement, implant removal, and the use of higher antibiotics. External fixation is more beneficial in infected non-union because of the colonization of organisms on implants used for internal fixation. External fixators span the infected area, so increase the chance of healing. The only drawback of external fixation is the discomfort of the patient.

Limb reconstruction system (LRS) is a uniplanar fixator that allows dynamization if required. The basic principle of LRS is distraction osteogenesis same as the principle of Ilizarov ring fixator. It is less bulky than Ilizarov. The application of LRS is easier than the Ilizarov and short learning curve. It provides mechanically strong and rigid fixation. The sliding clamps allow a change in stiffness of fixation thus fracture can be controlled precisely. But unlike Ilizarov, the correction of three-dimensional deformities are very difficult with the LRS system. The basic principle of distraction osteogenesis is that bone and soft tissue can be made to generate new bone. Not only is the new bone generated from the host bone, but it does so in an organized fashion by means of Intra-membranous bone formation in the form of trabecular orientation in the direction of distraction.

In our study, there were 15 cases treated by LRS and it was found that compound fracture was common in male 12 (80%) because they are more active parts of the society. Compared to a study by Patil et al.¹¹ had 95% union rate by application of Ilizarov fixator and Hashmi et al.¹² had 90% union rates with the use of rail fixators, Seenappa et al.¹³ had 89.2% union with the use of rail fixators, in our study union was achieved in all cases. In the study done by Vijay C, and Mahendra Kumar KL et al.¹⁴ on the management of open tibia fractures with rail fixators, overall 90% of the fractures united well, excellent to good results were seen in 72% cases, fair in 18%, and poor in 10% cases and in the study performed by Naveen Wani, KhurshidKangoo et al. on role of Ilizarov fixator in the definitive management of open tibia fracture excellent results were seen in 80% of cases, good in16.7% and fair in 3.3% of cases, comparable results were found in our study with excellent radiological results were present in 11 (73.33%) cases, good results were found in 4 (26.67) cases and excellent functional results were observed in 7 cases (46.67%) and good results were found in 8 (53.33%) cases and none of our cases had soft tissue interposition and none of our cases required re-surgery.

Patients are encouraged for weight-bearing and advised to move all the joints to the full range of motion. Full weight-bearing helps in fracture healing. The aim of treatment in an infected non-union is full functional limbs with no deformity and obviously with no residual infection.

Advantages of rail fixator include less invasive surgery, early weight-bearing, less infection, less blood loss, prevention of diffuse osteoporosis and atrophy, preservation of limb function, no need for bone grafting, correction of deformity during the process of healing, thus no need of second surgery. Non-union, bone defect, and deformity can be corrected simultaneously. Hence, we recommend the use of this system, especially for infected nonunion of long bones and compound fractures with bone loss. Successful outcome mostly depends on the compliance of patients, care of pin tract infection, physiotherapy to prevent joint stiffness and mobilization.

Limitations of the study was the small sample size and there is no control group in our study.

5. Conclusion

Prevention is better than cure for infected non-union patients. Treatment of infected nonunion is a great task. It needs very aggressive management by the surgeon and a lot of patience from the patient side. After implant removal, and wound debridement we can apply a ring fixator like Illizarov or rail fixator means LRS. Advantages of rail fixator include less invasive surgery, less bulky implant, early weight-bearing, less infection, less blood loss, prevention of diffuse osteoporosis and atrophy, preservation of limb function, no need for bone grafting, correction of deformity during the process of healing, thus no need of second surgery. Non-union, bone defect and deformity can be corrected simultaneously. Hence, we recommend the use of this system (Limb reconstruction system) especially for infected nonunion of long bones and compound fractures with bone loss.