F. Erkal Bilen

Correction of complex foot deformities using the Ilizarov external fixator.

There are many drawbacks to using conventional approaches to the treatment of complex foot deformities, like the increased risk of neurovascular injury, soft-tissue injury, and the shortening of the foot. An alternative approach that can eliminate these problems is the Ilizarov method. In the current study, a total of 23 deformed feet in 22 patients were treated using the Ilizarov method. The etiologic factors were burn contracture, poliomyelitis, neglected and relapsed clubfoot, trauma, gun shot injury, meningitis, and leg-length discrepancy (LLD). The average age of the patients was 18.2 (5-50) years. The mean duration of fixator application was 5.1 (2-14) months. We performed corrections without an osteotomy in nine feet and with an osteotomy in 14 feet. Additional bony corrective procedures included three tibial and one femoral osteotomies for lengthening and deformity correction, and one tibiotalar arthrodesis in five separate extremities. At the time of fixator removal, a plantigrade foot was achieved in 21 of the 23 feet by pressure mat analysis. Compared to preoperative status, gait was subjectively improved in all patients. Follow-up time from surgery averaged 25 months (13-38). Pin-tract problems were observed in all cases. Other complications were toe contractures in two feet, metatarsophalangeal subluxation from flexor tendon contractures in one foot, incomplete osteotomy in one foot, residual deformity in two feet, and recurrence of deformity in one foot. Our results indicate that the Ilizarov method is an effective alternative means of correcting complex foot deformities, especially in feet that previously have undergone surgery.

Fixator-Assisted Acute Femoral Deformity Correction and Consecutive Lengthening Over an Intramedullary Nail

BACKGROUND External fixators are being used frequently in standard limb-lengthening and deformity-correction procedures. Lengthening over an intramedullary nail has been a successful technique, and fixator-assisted intramedullary nailing has provided satisfactory results for the correction of selected deformities. We report a combined technique for the treatment of femoral deformities associated with shortening. METHODS Between 1997 and 2005, twenty-eight femora in twenty-five patients with a median age of twenty-seven years underwent reconstruction with an intramedullary nail and a unilateral fixator. The mean amount of shortening was 6.33 cm, and the mean preoperative mechanical axis deviation was 33.86 mm. Deformity correction was performed acutely and secured by the intramedullary nail, which was locked distally, and the same external fixator that was used for the deformity correction was utilized for lengthening. At the end of the distraction period, proximal locking screws were placed in the intramedullary nail and the external fixator was removed. At the time of follow-up, deformity correction and bone healing were assessed clinically and radiographically, complications were noted, and the functional results were assessed. RESULTS The mean duration of follow-up was forty months. The mean duration of the external fixation was 83.29 days, and the mean external fixation index was 14.98 days/cm. The mean amount of lengthening was 6.02 cm. The mean amount of mechanical axis deviation at the end of the treatment was 11.29 mm. The mean bone healing index was 36.66 days/cm. A knee flexion contracture developed in one patient and resolved after intensive rehabilitation. One patient underwent two revisions because of Schanz screw displacement secondary to cortical fracture, and four patients with minor pin-track infections were treated successfully with local wound care and oral antibiotics. CONCLUSIONS While femoral lengthening and deformity correction can be obtained with classic methods for application of an external fixator, the long period of external fixation, patient discomfort, and plastic deformation of the regenerated bone after removal of the fixator are major disadvantages. Two techniques, fixator-assisted nailing and lengthening over an intramedullary nail, were combined in this series. The duration of the external fixation was reduced compared with that required for classic treatment with an external fixator and patient comfort was increased. In addition, the intramedullary nail prevented fracture and deformation of the regenerated bone.

Knee arthrodesis using a unilateral external fixator for the treatment of infectious sequelae

OBJECTIVES We evaluated the results of arthrodesis using a monolateral external fixator for the treatment of septic sequelae of the knee joint. METHODS Eleven patients (4 males, 7 females; mean age 60 years; range 29 to 75 years) underwent arthrodesis using a monolateral external fixator. Indications for arthrodesis were infected total knee prosthesis (n=6), septic arthritis sequelae (n=4), and infected distal femoral tumor prosthesis (n=1). Eight patients had active infection; of these, seven patients initially underwent complete clinical and laboratory eradication of infection with debridement, application of antibiotic-impregnated cement spacer (n=6), and parenteral antibiotics. Resection guides of total knee arthroplasty were used to create wide bleeding femoral and tibial bone surfaces. Biplanar or uniplanar monolateral external fixation was applied for a mean of eight months (range 5 to 12 months). The mean follow-up was 28 months (range 7 to 69 months). Complications were evaluated according to the Paleys classification. RESULTS Fusion was achieved in all the patients. There were no recurrent infections. No remarkable shortening developed following the procedure. All the patients could walk without walking aids, except for one patient who further required lengthening for marked shortening due to previous wide tumor resection. Shortening was 3 cm in one patient with infected total knee prosthesis, while it ranged from 1 cm to 2 cm (mean 1.4 cm) in the remaining patients. Pin tract infections were seen in five patients, all of which were successfully treated with oral antibiotics and local wound care. CONCLUSION Knee arthrodesis using a monolateral external fixator is associated with a high fusion rate and a low complication rate, and provides a more comfortable treatment option compared to a circular external fixator.

Treatment of infected nonunion of the juxta-articular region of the distal tibia

OBJECTIVE The purpose of this study was to summarize our clinical results with distraction osteogenesis for the treatment of infected tibial nonunion around the ankle joint. METHODS Between 1994 and 2009, 13 patients with a mean age of 50 years (range: 27-79 years) underwent tibial reconstruction for the treatment of infected nonunion of the distal tibia, with a mean bone loss of 4.8 cm (range: 1-7 cm). Lengthening over an intramedullary nail as a second procedure was used in 2 patients, bifocal compression and distraction technique in 5 cases, compression with Ilizarov external fixator in 5 cases, and Taylor Spatial Frame (TSF, Smith Nephew, Memphis, TN, USA) in 1 case. At final follow-up, functional and radiographic results were evaluated according to Paleys bone and functional healing criteria. RESULTS Mean duration of follow-up was 36 months. Mean external fixation time was 198 days, and mean external fixation index was 29 days/cm. According to Paleys bone healing criteria, there were 10 excellent, 2 good, and 1 poor result(s); additionally, according to Paleys functional healing criteria, there were 5 excellent, 6 good, and 2 fair results. There were 11 problems, 5 obstacles, and 1 sequel according to Paleys classification of complications. There was 1 persisting nonunion, which underwent revision with a retrograde intramedullary nail. CONCLUSION External fixator and/or combined treatment are effective and reliable methods to treat infected nonunion of the distal tibia. Every patient should be evaluated according to their infection level and bony defects for reconstruction.

Bone Transport Over a Nail for Infected Tibial Nonunion and Bone Defect

Chronic bone infections should be managed similar to neoplasms: all of the infected and nonviable bone and soft tissues are resected, leaving a viable tissue environment for reconstruction. Following such resections, significant bone defects occur and require reconstructive procedures such as grafting or bone transport. 1 Brief Clinical History • A 46-year-old male patient presented to our clinic with purulent discharge and atrophic changes on the skin of his left tibia (Fig. 1). He had undergone three previous unsatisfactory surgical interventions. • Clinically he was suffering from chronic pain, limb length discrepancy causing a limp, and purulent discharge. 2 Preoperative Clinical Photos and Radiographs See Figs. 1, 2, 3, and 4. 3 Preoperative Problem List (a) Bone infection (left tibia) (Cierny-Mader type IVA) (b) Infected nonunion at the mid-diaphyseal level of the tibia (Fig. 2) (c) Varus deformity (Fig. 3) (d) Limb length discrepancy of 2.5 cm (Fig. 4) 4 Treatment Strategy (a) First session (resection and debridement): (i) Resection of the infected nonunion site along with the overlying infected soft tissues (amount of resection 12 cm) (Fig. 5a, b). (ii) Deep tissue samples are obtained for cultures, sensitivities, and Gram staining. *Email: drmehmetkocaoglu@gmail.com Limb Lengthening and Reconstruction Surgery Case Atlas DOI 10.1007/978-3-319-02767-8_173-1 # Springer International Publishing Switzerland 2014