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    • The time to use the distraction osteogenesis apparatus

    2019-05-16

    The time to use the distraction–osteogenesis apparatus in children was suggested to be after infection eradication. We used the Ilizarov apparatus immediately following radical debridement to provide stability and prepare for distraction–compression osteogenesis 1 week later. Circular external fixation is an established method to solve the problem of complex tibial nonunion. There is currently a consensus regarding the superiority of circular-type external fixators over uniplanar fixators for lengthening of complex tibia. However, there was a greater incidence of pain during lengthening, and patient satisfaction was lower in the circular external fixator group in a study comparing circular and uniplanar external fixators. The Ilizarov frame construct is very resistant to torsion and bending, but allows axial MK-571 sodium salt hydrate during physiological loading. In this study, we found a minimal incidence of axis deviation and no refracture at the lengthening site. The Ilizarov technique is a good salvage operation for infected nonunion of the femur. Limb salvage is preferable to prosthesis if the limb is viable and adequately innervate and the patient is mentally and financially committed to saving the limb. The Ilizarov distraction–compression osteogenesis method was modified to adequately resect necrotic and infected bone for both hypertrophic and atrophic nonunion to achieve a satisfactory docking site healing process. The distraction–compression method is simpler and is used to close the defect directly. Previous studies showed that simultaneous bone and soft tissue transport could successfully avoid the need for flap coverage. Healing over soft tissue defects would be simultaneously achieved during the osteogenesis process. Spontaneous wound healing using wet-to-dry dressing facilitates the restoration of soft tissue defects and healing of the bony gap without further flap coverage. Although the treatment time is long and patients report pain, especially during the transporting phase, there were no irreversible complications during the procedure. Although distraction osteogenesis is commonly used for the treatment of infected femoral nonunion with bone defects, it is associated with complications such as stiffness of knee joint, leg discrepancy, pin track infection, wires or pins loosening, deep vein thrombosis, thigh compression by tight ring, and neurovascular injury. In our series, six patients had approximately 11° decrease in ROM at the knee joint. Two patients still had limping gait due to leg discrepancy. Other complications reported by Blum et al were not observed in our series. Hesketh and Ali et al quadricepsplasty methods and their modifications might be possible alternatives to solve the stiff knee. In the Thompson technique, the vastus medialis, vastus lateralis, and vastus intermedius are freed from the rectus femoris through an anterior midline incision. The rectus femoris is then isolated from the rest of the quadriceps mechanism. In the Judet technique, the medial and lateral retinacula, suprapatellar gutter, vastus intermedius, vastus lateralis, and rectus femoris are released step by step to achieve knee ROM. Unfortunately, both methods have associated complications including skin necrosis, wound dehiscence, and extension lag caused by a long incision and extensive surgery, as well as edema of the lower leg and severe pain during the early postoperative period. Moreover, the extensive soft tissue release may also jeopardize bone healing at the docking or distraction sites if these methods are not performed at the appropriate time. In our series, we did not arrange any quadricepsplasty for these six patients. In our opinion, quadricepsplasty might be one possible method to manage the knee stiffness following staged protocols, with some modifications at appropriate times. This staged protocol seems to be a feasible treatment option in cases with large bone defects, and includes additional internal fixation after Ilizarov distraction osteogenesis. Internal fixation after distraction with femoral interlocking nailing ensures good clinical and radiological outcomes. When combined with internal fixation, the lengthy external fixation time, which is poorly tolerated by patients and imposes long-term psychosocial hardships on families, is shortened. The mean external fixator time was 6.8 months in this study, at which time callus formation was radiographically visible at the distraction site. The intramedullary implant occupied the healing space for osteogenesis and reduced the refracture rate after removal of the external frame. Earlier removal of the external fixator is also associated with increased patient comfort, convenient and rapid rehabilitation, and fewer pin-related complications.