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

Fig. 1

Pre-operative clinical picture showing fistula (arrow) and atrophic changes over the skin

Fig. 2

Pre-operative AP X-ray demonstrates nonunion and varus deformity of a left tibia

Fig. 3

Bilateral AP tibial X-ray demonstrating bone loss causing tibial shortening, nonunion, and deformity

Fig. 4

Clinical picture of the patient standing. The tibia vara and shortening are apparent

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.

(iii)

Placement of antibiotic-embedded cement rod inside the medullary canal and filling of the dead space with antibiotic-embedded cement beads (Fig. 6a–c). The rod also provided stability during this stage of the treatment.

(iv)

Six weeks of IV antibiotic therapy according to antibiogram (MRSA) results. The CRP levels should be checked to confirm elimination of the infection.

(b)

Second session(bone transport over IM nail ):

(i)

As a second stage the beads and the cement rod are replaced with an antegrade intramedullary nail, which is locked proximally. A circular external fixator (Ilizarov type) consisted of three rings is applied, and a corticotomy is performed at the proximal tibia (arrow) for lengthening and transport (Fig. 7a, b). Each ring is fixed to the corresponding tibial segment.

(ii)

The middle fragment is transported distally until docking, and further lengthening is obtained until the limb length discrepancy has been eliminated (the middle segment was transported distally by 14.5 cm) (Fig. 8a, b).

(c)

Third session (ex. fix. removal and IM nail locking):

(i)

Only gold members can continue reading. Log In or Register to continue