Ilizarov external fixation without bone graft for atrophic femoral shaft nonunion_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

GUO Baofeng ¹ , ZHAO Wei ¹ , XU Zhiyang ¹ , WU Hongfei ¹ , CHEN Lei ¹ ,  QIN Sihe ^1,2

1. Department of Orthopaedics, ChuiYangLiu Hospital Affiliated to Tsinghua University, Beijing, 100022, P.R.China;
2. Department of Orthopaedics, Rehabilitation Hospital of the National Research Center for Rehabilitation Technical Aids, Beijing, 100176, P.R.China;

Corresponding author：

QIN Sihe, Email: qinsihe@163.com

Keywords：

Ilizarov external fixation technique; femoral shaft fracture; atrophic nonunion

DOI：

10.7507/1002-1892.201902076

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Objective To explore the effectiveness of Ilizarov external fixation without bone graft in the treatment of atrophic femoral shaft nonunion. Methods The clinical data of 12 patients with atrophic femoral shaft nonunion admitted between October 2010 and January 2017 were retrospectively analyzed. There were 8 males and 4 females, aged from 24 to 61 years, with an average age of 41.7 years. The nonunion sites located in the middle and upper femur in 7 cases and in the distal femur or supracondylar in 5 cases. The disease duration ranged from 1 to 9 years, with an average of 3.7 years. Previous operations ranged from 1 to 9 times, with an average of 2.8 times. The original fixator was removed, the fracture end of nonunion was debrided, and Ilizarov external fixator was installed. In patients with the length of bone defect less than 4 cm, direct compression fixation was performed during operation; in patients with limb shortening more than 2.5 cm, proximal femoral osteotomy and bone lengthening components were required to prepare limb lengthening after operation; all patients did not receive bone graft. The wearing time of external fixator, clinical bone healing time of nonunion fracture end, and complications were recorded. The effectiveness was evaluated by Paley’s nonunion evaluation criteria. Results All patients were followed up 24-50 months, with an average of 30 months. Bony union was achieved in all 12 cases with a healing time of 6.0-23.5 months (mean, 11.5 months). The wearing time of external fixator ranged from 7 to 25 months, with an average of 13.5 months. At last follow-up, according to Paley’s nonunion evaluation criteria, the results were excellent in 6 cases, good in 4 cases, and fair in 2 cases, with an excellent and good rate of 83.3%. Sagittal angulation deformity of femur more than 7° occurred in 4 cases, with no significant effect on knee extension function, and no special treatment such as osteotomy was performed. Two patients had shorter limbs (>2.5 cm) after operation and were replaced by high shoes; 4 patients with trans-knee fixation lost knee joint mobility of 10-30° after operation; 10 cases of needle tract infection occurred, of which 4 cases with infection and loosening of fixed needle were replaced and re-fixed after needle extraction, the remaining 6 cases of infection without loosening of fixed needle were controlled by local dressing change, needle nursing, and oral cephalosporin anti-inflammatory drugs. No complications such as deep infection and vascular nerve injury occurred. Conclusion Ilizarov external fixation has a high healing rate for atrophic femoral shaft nonunion, which is relatively minimally invasive and can avoid bone grafting. Its preliminary effectiveness is exact, and it is also effective for patients who have experienced multiple failed operations. It is necessary to pay attention to the nursing and rehabilitation training after external fixation.

Citation： GUO Baofeng, ZHAO Wei, XU Zhiyang, WU Hongfei, CHEN Lei, QIN Sihe. Ilizarov external fixation without bone graft for atrophic femoral shaft nonunion. Chinese Journal of Reparative and Reconstructive Surgery, 2019, 33(8): 940-946. doi: 10.7507/1002-1892.201902076 Copy

1.	Court-Brown CM, Heckman JD, McQueen MM, et al. Rockwood and Green’s Fracture in adults. Philadelphia: Wolters Kluwer Health, 2015: 2216-2221.
2.	Hak DJ, Fitzpatrick D, Bishop JA, et al. Delayed union and nonunions: epidemiology, clinical issues, and financial aspects. Injury, 2014, 45(Suppl 2): S3-S7.
3.	Babhulkar S, Pande K, Babhulkar S. Nonunion of the diaphysis of long bones. Clin Orthop Relat Res, 2005, (431): 50-56.
4.	Jain A, Kumar S, Aggarwal AN, et al. Augmentation of bone healing in delayed and atrophic nonunion of fractures of long bones by partially decalcified bone allograft (decal bone). Indian J Orthop, 2015, 49(6): 637-642.
5.	Sala F, Talamonti T, Agus MA. Tetrafocal leg reconstruction using combined Ilizarov/TSF technique. Musculoskelet Surg, 2011, 95(2): 151-155.
6.	Paley D, Catagni MA, Argnani F, et al. Ilizarov treatment of tibial nonunions with bone loss. Clin Orthop Relat Res, 1989, (241): 146-165.
7.	Reed AA, Joyner CJ, Brownlow HC, et al. Human atrophic fracture non-unions are not avascular. J Orthop Res, 2002, 20(3): 593-599.
8.	Brownlow HC, Reed A, Simpson AH. The vascularity of atrophic non-unions. Injury, 2002, 33(2): 145-150.
9.	曾炳芳, 康庆林. 四肢骨不连外科学. 北京: 人民军医出版社, 2010: 92-111.
10.	Hak DJ, Lee SS, Goulet JA. Success of exchange reamed intramedullary nailing for femoral shaft nonunion or delayed union. J Orthop Trauma, 2000, 14(3): 178-182.
11.	Jordan CJ, Goldstein RY, McLaurin TM, et al. The evolution of the Ilizarov technique: part 1: the history of limb lengthening. Bull Hosp Jt Dis (2013), 2013, 71(1): 89-95.
12.	Goldstein RY, Jordan CJ, McLaurin TM, et al. The evolution of the Ilizarov technique: part 2: the principles of distraction osteosynthesis. Bull Hosp Jt Dis (2013), 2013, 71(1): 96-103.
13.	Zhang Q, Zhang W, Zhang Z, et al. Femoral nonunion with segmental bone defect treated by distraction osteogenesis with monolateral external fixation. J Orthop Surg Res, 2017, 12(1): 183.
14.	Zhang Q, Zhang W, Zhang Z, et al. Accordion technique combined with minimally invasive percutaneous decortication for the treatment of bone non-union. Injury, 2017, 48(10): 2270-2275.
15.	黄雷, 赵刚, 王慎东, 等. 短缩一延长肢体治疗胫骨骨缺损合并软组织缺损. 中华创伤骨科杂志, 2007, 9(12): 1115-1119.
16.	Tomić S, Bumbasirević M, Lesić A, et al. Ilizarov frame fixation without bone graft for atrophic humeral shaft nonunion: 28 patients with a minimum 2-year follow-up. J Orthop Trauma, 2007, 21(8): 549-556.
17.	秦泗河, 郭保逢, 焦绍锋, 等. 应用骨外固定技术矫正四肢畸形 8113 例数据分析. 中国修复重建外科杂志, 2018, 32(10): 1241-1248.
18.	葛启航, 万春友, 刘亚北, 等. 胫腓骨开放骨折 Taylor 空间支架外固定术后轴向应力刺激对骨折愈合的影响研究. 中国修复重建外科杂志, 2017, 31(8): 931-935.
19.	Paley D. Problems, obstacles, and complications of limb lengthening by the Ilizarov technique. Clin Orthop Relat Res, 1990, (250): 81-104.

1. Court-Brown CM, Heckman JD, McQueen MM, et al. Rockwood and Green’s Fracture in adults. Philadelphia: Wolters Kluwer Health, 2015: 2216-2221.
2. Hak DJ, Fitzpatrick D, Bishop JA, et al. Delayed union and nonunions: epidemiology, clinical issues, and financial aspects. Injury, 2014, 45(Suppl 2): S3-S7.
3. Babhulkar S, Pande K, Babhulkar S. Nonunion of the diaphysis of long bones. Clin Orthop Relat Res, 2005, (431): 50-56.
4. Jain A, Kumar S, Aggarwal AN, et al. Augmentation of bone healing in delayed and atrophic nonunion of fractures of long bones by partially decalcified bone allograft (decal bone). Indian J Orthop, 2015, 49(6): 637-642.
5. Sala F, Talamonti T, Agus MA. Tetrafocal leg reconstruction using combined Ilizarov/TSF technique. Musculoskelet Surg, 2011, 95(2): 151-155.
6. Paley D, Catagni MA, Argnani F, et al. Ilizarov treatment of tibial nonunions with bone loss. Clin Orthop Relat Res, 1989, (241): 146-165.
7. Reed AA, Joyner CJ, Brownlow HC, et al. Human atrophic fracture non-unions are not avascular. J Orthop Res, 2002, 20(3): 593-599.
8. Brownlow HC, Reed A, Simpson AH. The vascularity of atrophic non-unions. Injury, 2002, 33(2): 145-150.
9. 曾炳芳, 康庆林. 四肢骨不连外科学. 北京: 人民军医出版社, 2010: 92-111.
10. Hak DJ, Lee SS, Goulet JA. Success of exchange reamed intramedullary nailing for femoral shaft nonunion or delayed union. J Orthop Trauma, 2000, 14(3): 178-182.
11. Jordan CJ, Goldstein RY, McLaurin TM, et al. The evolution of the Ilizarov technique: part 1: the history of limb lengthening. Bull Hosp Jt Dis (2013), 2013, 71(1): 89-95.
12. Goldstein RY, Jordan CJ, McLaurin TM, et al. The evolution of the Ilizarov technique: part 2: the principles of distraction osteosynthesis. Bull Hosp Jt Dis (2013), 2013, 71(1): 96-103.
13. Zhang Q, Zhang W, Zhang Z, et al. Femoral nonunion with segmental bone defect treated by distraction osteogenesis with monolateral external fixation. J Orthop Surg Res, 2017, 12(1): 183.
14. Zhang Q, Zhang W, Zhang Z, et al. Accordion technique combined with minimally invasive percutaneous decortication for the treatment of bone non-union. Injury, 2017, 48(10): 2270-2275.
15. 黄雷, 赵刚, 王慎东, 等. 短缩一延长肢体治疗胫骨骨缺损合并软组织缺损. 中华创伤骨科杂志, 2007, 9(12): 1115-1119.
16. Tomić S, Bumbasirević M, Lesić A, et al. Ilizarov frame fixation without bone graft for atrophic humeral shaft nonunion: 28 patients with a minimum 2-year follow-up. J Orthop Trauma, 2007, 21(8): 549-556.
17. 秦泗河, 郭保逢, 焦绍锋, 等. 应用骨外固定技术矫正四肢畸形 8113 例数据分析. 中国修复重建外科杂志, 2018, 32(10): 1241-1248.
18. 葛启航, 万春友, 刘亚北, 等. 胫腓骨开放骨折 Taylor 空间支架外固定术后轴向应力刺激对骨折愈合的影响研究. 中国修复重建外科杂志, 2017, 31(8): 931-935.
19. Paley D. Problems, obstacles, and complications of limb lengthening by the Ilizarov technique. Clin Orthop Relat Res, 1990, (250): 81-104.

Chinese Journal of Reparative and Reconstructive Surgery

Ilizarov external fixation without bone graft for atrophic femoral shaft nonunion

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