Orthopedics

Tips & Techniques 

Treatment of Massive Tibial Bone Loss Due to Chronic Draining Osteomyelitis: Fibula Transport Using the Ilizarov Frame

Maurizio A. Catagni, MD; Giulia Ottaviani, MD, PhD; Marco Camagni, MD

Abstract

This article affirms the value of the application of the Ilizarov frame for gradual transport of the ipsilateral fibula to replace massive tibial bone loss following chronic refractory osteomyelitis.

Massive segmental tibial bone loss due to chronic osteomyelitis represents a considerable challenge to the orthopedic surgeon and a limb-threatening situation for the patient, especially if it is resistant to any attempted therapies.

Recently, ipsilateral fibular transfer has been reported to treat a massive tibial bone loss using the Ilizarov device with olive wire traction for gradual transport.1-4 While this technique is gaining increased interest, few reports exist in the literature on the application of the external circular fixator to transfer the ipsilateral fibula for massive bone defect due to chronic osteomyelitis.

Figure 1: Radiograph showing osteomyelitis of the medial and proximal thirds of the tibia. Figure 2: Photograph shows the clinical appearance of the left leg with underlying osteomyelitic tibia. Despite multiple debridements and antibiotic treatments, osteomyelitis persisted and a chronic wound sinus developed. Figure 3: Photograph shows the bone after a 15-cm sequestrectomy of the osteomyelitic tibia.

This article reports a case in which a massive tibial bone defect due to chronic draining osteomyelitis and resistance to previous therapies was addressed by gradual medial transport of the ipsilateral fibula using the Ilizarov frame.

A 26-year-old woman sustained a fall while playing basketball. She underwent anterior cruciate ligament (ACL) reconstruction with carbon fiber. One year later the patient developed an infection of the proximal and medium thirds of the tibia that required removal of the carbon fiber ligament. Secretions from the tibial wound were positive for Staphylococcus aureus, Proteus, and Corynebacterium and had been treated with appropriate antibiotics without success. Despite multiple debridements and antibiotic treatments, osteomyelitis persisted and a chronic wound sinus developed (Figures 1-3).

Figure 4: AP (left) and lateral (right) radiographs show the tibial Ilizarov frame for simultaneous bifocal distraction-compression osteogenesis technique to fill the bone defect. Figure 5: Schematic shows the assembly for trifocal longitudinal tibial transport. Figure 6: Radiograph shows the initial successful results obtained using the Ilizarov method for tibial transport. Figure 7: Radiographs show recurrence of osteomyelitis.

Five years after the initial procedure, the patient refused above-knee amputation and limb salvage reconstruction was attempted using the Ilizarov method. A 15-cm bone sequestrectomy followed by debridement (Figure 3), and osteotomies for trifocal Ilizarov longitudinal transport were successfully performed (Figures 4-6). However, osteomyelitis recurred (Figures 7 and 8) and drainage from the fistula was positive for Pseudomonas aeruginosa. An additional 13 cm of bone sequestrectomy and debridement (Figures 9 and 10) were performed, followed by longitudinal bone transport with the Ilizarov standard technique. The scarcity of the tibial bone regenerate necessitated a gradual fibular transport (Figures 11-13).

Figure 8: The clinical appearance of the recurrent osteomyelitis is shown. Figure 9: An additional bone resection of the tibia was performed because of recurrence of osteomyelitis. Figure 10: The large resection of the osteomyelitic tibia is shown.

Indication for fibular transport in this patient was a scarce bone regenerate obtained with the standard Ilizarov technique to replace the massive tibial loss, as well as recurrence of osteomyelitis (Figures 11 and 12).

Figure 11: Schematic shows an Ilizarov assembly for gradual medial fibular transport to address the scarcity of the bone regenerate. Olive wires were used. The olives were placed on the lateral aspect of the middle segment of the ipsilateral fibula to perform transport.

We retrospectively reviewed the medical records and radiographs of the patient. Details such as patient age, length of the tibial segment involved, time to union, necessity for additional procedures, and complications were recorded. …

This article affirms the value of the application of the Ilizarov frame for gradual transport of the ipsilateral fibula to replace massive tibial bone loss following chronic refractory osteomyelitis.

Massive segmental tibial bone loss due to chronic osteomyelitis represents a considerable challenge to the orthopedic surgeon and a limb-threatening situation for the patient, especially if it is resistant to any attempted therapies.

Recently, ipsilateral fibular transfer has been reported to treat a massive tibial bone loss using the Ilizarov device with olive wire traction for gradual transport.1-4 While this technique is gaining increased interest, few reports exist in the literature on the application of the external circular fixator to transfer the ipsilateral fibula for massive bone defect due to chronic osteomyelitis.

Figure 1: Radiograph showing osteomyelitis of the medial and proximal thirds of the tibia

Figure 2: Photograph shows the clinical appearance of the left leg with underlying osteomyelitic tibia

Figure 3: Photograph shows the bone after a 15-cm sequestrectomy of the osteomyelitic tibia

Figure 1: Radiograph showing osteomyelitis of the medial and proximal thirds of the tibia. Figure 2: Photograph shows the clinical appearance of the left leg with underlying osteomyelitic tibia. Despite multiple debridements and antibiotic treatments, osteomyelitis persisted and a chronic wound sinus developed. Figure 3: Photograph shows the bone after a 15-cm sequestrectomy of the osteomyelitic tibia.

This article reports a case in which a massive tibial bone defect due to chronic draining osteomyelitis and resistance to previous therapies was addressed by gradual medial transport of the ipsilateral fibula using the Ilizarov frame.

Case Report

A 26-year-old woman sustained a fall while playing basketball. She underwent anterior cruciate ligament (ACL) reconstruction with carbon fiber. One year later the patient developed an infection of the proximal and medium thirds of the tibia that required removal of the carbon fiber ligament. Secretions from the tibial wound were positive for Staphylococcus aureus, Proteus, and Corynebacterium and had been treated with appropriate antibiotics without success. Despite multiple debridements and antibiotic treatments, osteomyelitis persisted and a chronic wound sinus developed (Figures 1-3).

Figure 4: Tibial Ilizarov frame for simultaneous bifocal distraction-compression osteogenesis technique to fill the bone defect

Figure 5: Schematic shows the assembly for trifocal longitudinal tibial transport

Figure 6: Radiograph shows the initial successful results obtained using the Ilizarov method for tibial transport

Figure 7: Radiographs show recurrence of osteomyelitis

Figure 4: AP (left) and lateral (right) radiographs show the tibial Ilizarov frame for simultaneous bifocal distraction-compression osteogenesis technique to fill the bone defect. Figure 5: Schematic shows the assembly for trifocal longitudinal tibial transport. Figure 6: Radiograph shows the initial successful results obtained using the Ilizarov method for tibial transport. Figure 7: Radiographs show recurrence of osteomyelitis.

Five years after the initial procedure, the patient refused above-knee amputation and limb salvage reconstruction was attempted using the Ilizarov method. A 15-cm bone sequestrectomy followed by debridement (Figure 3), and osteotomies for trifocal Ilizarov longitudinal transport were successfully performed (Figures 4-6). However, osteomyelitis recurred (Figures 7 and 8) and drainage from the fistula was positive for Pseudomonas aeruginosa. An additional 13 cm of bone sequestrectomy and debridement (Figures 9 and 10) were performed, followed by longitudinal bone transport with the Ilizarov standard technique. The scarcity of the tibial bone regenerate necessitated a gradual fibular transport (Figures 11-13).

Figure 8: The clinical appearance of the recurrent osteomyelitis

Figure 9: An additional bone resection of the tibia was performed because of recurrence of osteomyelitis

Figure 10: The large resection of the osteomyelitic tibia

Figure 8: The clinical appearance of the recurrent osteomyelitis is shown. Figure 9: An additional bone resection of the tibia was performed because of recurrence of osteomyelitis. Figure 10: The large resection of the osteomyelitic tibia is shown.

Materials and Methods

Indication for fibular transport in this patient was a scarce bone regenerate obtained with the standard Ilizarov technique to replace the massive tibial loss, as well as recurrence of osteomyelitis (Figures 11 and 12).

 

Figure 11: Lizarov assembly for gradual medial fibular transport

 

Figure 11: Schematic shows an Ilizarov assembly for gradual medial fibular transport to address the scarcity of the bone regenerate. Olive wires were used. The olives were placed on the lateral aspect of the middle segment of the ipsilateral fibula to perform transport.

We retrospectively reviewed the medical records and radiographs of the patient. Details such as patient age, length of the tibial segment involved, time to union, necessity for additional procedures, and complications were recorded.

The patient was treated by the first author (M.A.C.) with a technique for gradual, ipsilateral fibular transport using a stable external fixator based on Ilizarov principles.5,6 The pre-assembled Ilizarov frame for ipsilateral fibular transport consisted of 4 rings (Figures 11-13). Proximal and distal fibular osteotomies were performed to allow medial translation of the central portion of the fibula. Olive wires with the olives placed on the lateral aspect of the ipsilateral fibula were used to perform medial fibular translation, as previously described1,2 (Figures 11 and 12).

Early knee and ankle motion were encouraged postoperatively as tolerated. Pin care started on postoperative day 1 with hydrogen peroxide and betadine. The patient was discharged with the instruction of biweekly pin site care.7 Seven days postoperatively, the fibular transport was begun at the rate of ¼ mm four times daily. Radiographs and clinical evaluations were conducted every 30 to 40 days.

The patient remained ambulatory throughout the treatment (Figure 13) and once consolidation was confirmed clinically and radiologically, the frame was dynamized and then removed in our clinic without anesthesia. A cast then was applied for two months.

Results

The Ilizarov ring fixation time to achieve fibular transport and bone union was 11 months. The patient underwent additional multiple bone cleanings and debridement with insertion of antibiotic beads for infection recurrence (Figure 14). Full replacement of tibial bone loss using the fibular transport was obtained (Figures 15 and 16).

Hypertrophy of the transported fibula accompanied by full weight bearing and excellent joint motion were achieved. At 5-year follow-up the patient was walking unaided and was free of infection (Figures 17-19).

Figure 12: Radiographs show the Ilizarov frame for fibula medial transport

Figure 13: The patient is shown wearing the Ilizarov frame during treatment

Figure 14: Osteomyelitis complicated the distal regenerate bone

Figure 12: AP (left) and lateral (right) radiographs show the Ilizarov frame for fibula medial transport. Figure 13: The patient is shown wearing the Ilizarov frame during treatment. Figure 14: Osteomyelitis complicated the distal regenerate bone and was treated with antibiotic beads.

Discussion

The eradication of chronic osteomyelitis is a difficult problem in orthopedic surgery, despite advances in surgical techniques and antibiotic specificity. Its outcome can be devastating, resulting in amputation. The decision to undergo a limb-salvage procedure is difficult and multifaceted.8 Limb salvage options using the Ilizarov frame for massive bone loss are technically demanding, and are time consuming for the patient and the surgeon.9 Amputation often is considered the simplest surgical solution, although it is not always acceptable to patients and their relatives in the current health climate.9-11 Additionally, despite studies showing that the initial hospitalization costs are considerably less for amputation than for limb salvage,10 Williams 12 has shown that the long-term cost of amputation is considerably more than for a successful Ilizarov reconstruction. The training and experience of the attending surgeons also may influence the decision to amputate versus reconstruct a severely infected leg.

Figure 15: Schematic shows replacement of the massive tibial bone loss by the transported fibula successfully consolidated with the tibia

Figure 16: Radiographs show the transported fibula successfully consolidated with the tibia

Figure 15: Schematic shows replacement of the massive tibial bone loss by the transported fibula successfully consolidated with the tibia. Figure 16: Radiographs show the transported fibula successfully consolidated with the tibia.

Massive tibial bone loss can be treated with microsurgical transport of vascularized bone such as rib,13 iliac crest,14 fibula,15 and allograft reconstruction.16 Each of these methods is effective depending on the circumstance, however they have drawbacks including the possibility of donor site morbidity, deep infection, peroneal nerve injury, and ankle instability on the contralateral previously unaffected limb.17 They may be at a high risk of failure as infection, rejection, fractures and nonunion all have been described with these techniques.18

Figure 17: Clinical photograph shows the patient during full weight bearing

Figure 18: Patient’s ability to plantarflex the ankle shortly after frame removal

Figure 19: Patient’s ability to dorsiflex the ankle and to flex the knee

Figure 17: Clinical photograph shows the patient during full weight bearing. Figure 18: Patient's ability to plantarflex the ankle shortly after frame removal. Figure 19: Patient's ability to dorsiflex the ankle and to flex the knee.

We reported the application of the Ilizarov frame for ipsilateral medial fibular transport to address massive tibial bone loss in 7 trauma-related cases. This technique provided limb salvage with hypertrophy of the transported fibula accompanied by full weight bearing and satisfactory joint motion in all cases.2 Patients were eligible for medial fibular transport if the massive tibial loss or the bad condition of the residual bone increased the likelihood that insufficient regeneration could be obtained with Ilizarov tibial lengthening to replace extensive or total tibial bone loss. Another indication was if it would support mechanical strength of the lengthened tibia. Medial fibular transport also was applied in cases of infected pseudarthrosis; medial transport was not excluded in fractured fibula or in patients with a traumatic lesion of the external popliteal sciatic nerve.2 The recurrence of osteomyelitis in this patient, accompanied by minimal regenerated bone (Figures 7-12) led us to attempt the fibular transport.

Ilizarov methods are technically demanding and complications including neurovascular injury, infection, muscular damage, articular injury, deep venous thrombosis, refractures, deformities, and scar problems may occur even in experienced hands.19,20 However, based on our results, the Ilizarov method for ipsilateral fibular gradual transport is a proven limb salvage method in cases of massive tibial bone loss following chronic osteomyelitis. Amputation should therefore be avoided as in the case herein reported, especially considering that this patient is walking without assistance and is satisfied with the results. Our results confirms the validity of this technique for ipsilateral fibula transport which, as previously reported,2 has the advantages of avoiding surgery on the contralateral limb while allowing early weight bearing attributed to the stability of the Ilizarov frame.

This case is unique because of: 1) the onset of chronic draining osteomyelitis following ACL reconstruction surgery with carbon fiber, 2) persistence of osteomyelitic infection that was not fully eradicated after 15 cm of bone resection and application of the bifocal Ilizarov technique for longitudinal transport, 4) application of an Ilizarov frame for gradual ipsilateral transport of the fibula to replace 13 cm of additional bone resection, and 5) good radiological, clinical, and functional results.

This article affirms the value of the application of the Ilizarov frame for gradual transport of the ipsilateral fibula to replace massive tibial bone loss following chronic refractory osteomyelitis. This technique is not without difficulties and requires significant dedication from the patient and the surgeons.

References

  1. Catagni MA. Treatment of tibial nonunions. In: Bianchi Maiocchi A, ed. Treatment of Fractures, Nonunions and Bone Loss of the Tibia with the Ilizarov Method. Milan, Italy: Il Quadratino; 1998:97-158.
  2. Catagni MA, Camagni M, Ottaviani G. Medial fibula transport with the Ilizarov frame to treat massive tibial bone loss. Clin Orthop Relat Res. 2006; 448:208-216.
  3. Kim HS, Jahng JS, Han DY, Park HW, Chun CH. Immediate ipsilateral fibular transfer in a large tibial defect using a ring fixator. A case report. Int Orthop. 1998; 22:321-324.
  4. Atkins RM, Madhavan P, Sudhakar J, Whitwell D. Ipsilateral vascularised fibular transport for massive defects of the tibia. J Bone Joint Surg Br. 1999; 81:1035-1040.
  5. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues, I: The influence of stability of fixation and soft-tissue preservation. Clin Orthop Relat Res. 1989; 238:249-281.
  6. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues, II: The influence of the rate and frequency of distraction. Clin Orthop Relat Res. 1989; 239:263-285.
  7. Catagni MA, Ottaviani G, Combi A, Elhence A. External circular fixation: a comparison of infection rates between wires and conical tapered half-pins with threads outside or inside the skin. J Trauma. 2006; 61:1186-1191.
  8. Siegel HJ, Patzakis MJ, Holtom PD, Sherman R, Shepherd L. Limb salvage for chronic tibial osteomyelitis:an outcomes study. J Trauma. 2000; 48:484-489.
  9. Ottaviani G, Randelli P, Catagni MA. Segmental cement extraction system (SEG-CES) and the Ilizarov method in limb salvage procedure after total knee cemented prosthesis removal in a former osteosarcoma patient. Knee Surg Sports Traumatol Arthrosc. 2005; 13:557-563.
  10. Bondurant FJ, Cotler HB, Buckle R, Miller-Crotchett P, Browner BD. The medical and economic impact of severely injured lower extremities. J Trauma. 1988; 28:1270-1273.
  11. Hansen ST Jr. Overview of the severely traumatized lower limb. Reconstruction versus amputation. Clin Orthop Relat Res. 1989; 243:17-19.
  12. Williams MO. Long-term cost comparison of major limb salvage using Ilizarov method versus amputation. Clin Orthop Relat Res. 1994; 301:156-158.
  13. Ueng SW, Chuang DC, Cheng SL, Shih CH. Management of large infected tibial defects with radical debridement and staged double-rib composite free transfer. J Trauma. 1996; 40:345-350.
  14. Eisenschenk A, Dihlmann SW, Weber U. Indications, results and complications in connection with free vascularized bone transplants for extremity preservation. Chir Organi Mov. 1993; 78:207-212.
  15. Atkins RM, Madhavan P, Sudhakar J, Whitwell D. Ipsilateral vascularised fibular transport for massive defects of the tibia. J Bone Joint Surg Br. 1999; 81:1035-1040.
  16. Myerson MS, Neufeld SK, Uribe J. Fresh-frozen structural allografts in the foot and ankle. J Bone Joint Surg Am. 2005; 87:113-120.
  17. Morsi E. Tibial reconstruction using a non-vascularised fibular transfer. Int Orthop. 2002; 26:377-380.
  18. Mankin HJ, Hornicek FJ, Raskin KA. Infection in massive bone allografts. Clin Orthop Relat Res. 2005; 432:210-216.
  19. Catagni MA, Lovisetti L, Guerreschi F, Combi A, Ottaviani G. Cosmetic bilateral leg lengthening:experience of 54 cases. J Bone Joint Surg Br. 2005; 87:1402-1405.
  20. Cattaneo R, Catagni M, Johnson EE. The treatment of infected nonunions and segmental defects of the tibia by the methods of Ilizarov. Clin Orthop Relat Res. 1992; 280:143-152.

Authors

Drs Catagni and Camagni are from the Department of Orthopedics and Ilizarov Unit, “Alessandro Manzoni” Hospital, Lecco; and Dr Ottaviani is from the Institute of Pathology, University of Milan, Italy.

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

Correspondence should be addressed to: Maurizio A. Catagni, MD, Dept of Orthopedics and Ilizarov Unit, “Alessandro Manzoni” Hospital, Via dell’Eremo 9/11, 23900 Lecco, Italy.

10.3928/01477447-20070801-19

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