J Ayub Med Coll Abbottabad 2007; 19(3)

EVALUATION OF MANAGEMENT OF TIBIAL NON-UNION DEFECT

WITH ILIZAROV FIXATOR
Farmanullah, Muhammad Shoaib Khan* & Syed Muhammad Awais**
City Hospital, Peshawar, Orthopedic Department, Ayub Teaching Hospital, Abbottabad*, Mayo Hospital, Lahore**

Background: Tibial bone defect lead to limb shortening and functional deficit and needs proper
treatment. There are various treatment modalities for bone defect in long bone to restore length
and function of the limb, i.e. bone grafting, vascularised bone graft, allograft and bone transport.
Bone transport can be done through fixators (uniplaner or ring) and intramedullary nail system.
This study was conducted on management of tibial non-union with Illizarov external fixator.
METHOD: This descriptive study was performed on 58 patients in Agency Headquarter Hospital,
Bajawar and Lady Reading Hospital, Peshawar, from January 2000 to January 2006. Patients of
either gender with age between 9 to 58 years, having nonunion (clean and infected nonunion) in
tibia with defect of 2 to 7cm due to trauma or firearm injury were included in the study. These
patients were followed up upto one year. Outcome measures were according to the classification
of Association for the Study and Application of the Method of Ilizarov (ASAMI), which is based
on radiological (defect filling) and clinical (functional) findings. RESULTS: Out of 58 patients,
44 (75%) were male and 14 (25%) were female. Mean age was 30 years (9 to 58 years). 38
(65.52%) patients had infected non-union while 20 (34.48%) had clean non-union. Right tibia was
involved in 32 patients (51.17%) and left was involved in 26 (44.83%) patients. The cause of
initial trauma was road traffic accident in 27 patients (46.55%), firearm injury in 23 patients
(39.65%) and a simple fall in 8 patients (13.79%). The length of average bone defect was 2.90 cm
(200-7.00cm). Radiological results were excellent in 33 (58.89%) patients, good in 12 (20.68%)
patients, fair in 8 (13.79%) patients and poor in 5 (8.62%) patients. The clinical results were
excellent in 33 patients (56.89%), good in 18 patients (31.05%), fair in 4 (6.89%) patients and
poor in 3 patients (5.17%). CONCLUSION: Ilizarov ring fixator is excellent treatment modality
for tibial non-union with a defect, regarding bone union, deformity correction, infection
eradication, limb length achievement and limb function but this needs prolonged learning curve
for fresh orthopedic surgeons.
Key words: Tibia; Nonunion; Bone Transport; Ilizarov fixator
INTRODUCTION of bone and soft tissue regeneration under tensile
Tibia is the most exposed bone in the body and forces and this is called theory of tension stress7-
9
vulnerable to trauma and therefore its fractures . Ilizarov treated non-union and bone defect by
are common among the long bone fractures 1 . this method based on biologic principles. The
Tibia is the common site of non-union in long Ilizarov fixator, while treating non-union or bone
bone fractures2.3 . defect, has the advantages that the chances of
Management of non-union with bony angular or rotational deformities are less and can
defect in long bones is a challenging problem for be easily corrected in case of deformity. This
orthopedic surgeons. There are various device provides good stability and early weight
techniques to fill the defect in long bones, i.e. bearing. The disadvantages are that it is
cancellous bone grafting for small defect 4 , cumbersome, difficulty in dressings of the
vascularised fibular grafts, allografts and wounds, needs expertise & is an expensive
papineau technique of bone grafting5 for larger device. Segmental bone transport or distraction
bone defects. osteogenesis is slow, control and gradual
When the defect is more than 4cm then stretching of the callus to fill the bony gap after
it needs bone transport. Bone transport can be low energy subperiosteal corticotomy. The
done by ring fixators, modified transport can be mono or bifocal.
Arbeitsgemteinschaftfur Osteosynthesefragen This study was designed to assess the
(OA) fixators or specialized intramedullary nails. outcome of bone transport in tibial non-union
The ring fixators, i.e. Ilizarov fixator was with the help of Ilizarov fixators.
developed by Gavriil Abramovich Ilizarov in
MATERIAL AND METHOD
Kurgan, Western Siberia, USSR in 1951 for the
fixation of fractures 6 . Ilizarovs greatest This descriptive study was performed on 58
contribution, however, was pioneering the sense patients in Agency Headquarter Hospital,
Bajawar and Lady Reading Hospital, Peshawar,

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 J Ayub Med Coll Abbottabad 2007; 19(3)

from January 2000 to January 2006. Patients of 58 years). 38 (65.52%) patients had infected
either gender with ages between 9 to 58 years, bone defect (non-union) while 20 (34.48%) had
having nonunion with or without infection with clean bone defect. Right tibia was involved in 32
defect in tibia of 2 to 7cm due to trauma or (51.17%) patients and left was involved in 26
firearm injury were included in the study. (44.83%) patients. The cause of initial trauma
Hybrid Ilizarov fixators of Russian was road traffic accident in 27 (46.55%) patients,
make were used in all cases. All the procedures firearm injuries in 23 (39.65%) patients and
were done under general or spinal anesthesia simple fall in 8 (13.79%) patients. The average
with antibiotic prophylaxis. Proper wound length of bone defect was 2.90 cm (200-7.00cm).
debridement was done in infected non-union Radiological result was excellent in 33 (58.89%),
cases. Antibiotic protocol was followed good in 12 (20.68%), fair in 8 (13.79%) and poor
according to culture and sensitivity when in 5 (8.62%) patients. Clinical result was
required. excellent in 33 (56.89%), good in 18 (31.05%),
The protocol of treatment was based by fair in 4 (6.89%) and poor in 3 (5.17%) patients.
following the principles of Ilizarov and co- There was no case of late osteomyelitis. Limb
workers: length inequality was observed in 2 patients and
1. Preservation of blood supply both to the maximum discrepancy was 9mm while 14
limb as well as the fracture site. patients (87.5%) had no shortening.
2. Preservation of osteogenic tissue There was an average bone defect of
(periosteum, endosteum and marrow). 2.68cm (1.2-7 cm) and the overall success rate
3. Functional activity 1of limb. was 93%. The average bone length achieved was
4. Early mobilization. 2.5 cm (1-7.5 cm). The total duration of
treatment was an average of 138 days (61-276
The hypertrophic non-union was
days).
managed with distraction while the atrophic non-
union was managed under the removal of soft DISCUSSION
tissues; it was approached for establishing first
Management of tibial non-union has been
the compression than distraction at the non-
described by various authors and it is agreed that
union.
various approaches have been adopted by the
After the application of each fixator,
orthopedic surgeons for such challenging issue
radiographs were taken. Accurate measurements
under the medical ethics and as per needs of the
were made of the pin location and pin length.
patients concerned.
Moreover, location of the fixator bars, adequacy
There are different types of fixators used
of fracture reduction and the subsequent duration
for bone transport to fill the bony defects.
of external fixator were noted. All factors were
Ilizarov fixator is most commonly used for bone
correlated with eventual time to union and the
transport. In the study by Paley D et al, 10 25
presence of mal-union. If X-ray showed incorrect
cases of tibial non-union were treated with
positioning of the pin/fragments, immediate
Ilizarov fixators which shows excellent bone
correction was made to avoid later on
results in 18 cases, good in 5 and fair in 2 based
difficulties. Physical therapy was continued
on union, persistent infection in 3 cases,
throughout the treatment duration and pin-site
deformity in 4 and limb shortening in 1 case.
dressings were changed daily. The fracture
Functional results were excellent in 16 cases,
union, complications and functional recoveries
good in 7, fair in 1 and poor in 1 based on return
were also recorded. A policy of early bone
to daily activities, limp in 4 cases, equinus in 5
grafting was followed whenever it was
cases, dystrophy in 4 cases, pain in 4 cases and
considered necessary and it was employed within
amputation for neurogenic pain in 1 case.
10 to 12 weeks of time.
In another study11 on 17 patients with
Patients were followed up for one year.
tibial pseudoarthrosis, 14 cases had full union, 1
Outcome measures were according to the
patient was still using orthosis and 3 patients
classification of ASAMI, which is based on
were in need of re-operation with bone
radiological (defect filling) and clinical
transplantation. Mean time of treatment was 5.2
(functional) findings.
months (2-11.5 months) while the overall
RESULTS treatment time was 9.8 months (3-19 months). In
this study the Ilizarov method of treatment of
Out of 58 patients, 44 (75%) were male and 14
pseudoarthrosis had a good stimulation of
(25%) were female. Mean age was 30 years (9 to
healing but experience with fixator system and

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 J Ayub Med Coll Abbottabad 2007; 19(3)

aggressive treatment of various minor 4. Edwards CC, Simmons SC, Browner BD, Weigel MC.
Severe open tibial fractures. Results treating 202
complications are essential for successful
injuries with external fixation. Clin Orthop Relat Res
outcome. 1988; 230:98-115.
Our study shows comparable results 5. Tucker HL, Kendra JC, Kinnebrew TE. Tibial defects.
with international literature. Reconstruction using the method of Ilizarov as an
alternative. Orthop Clin North Am 1990;21(4):629-37.
CONCLUSION 6. Ilizarov GA: The principles of Ilizarov method. Bull
Hosp Joint Dis Orthop Inst 1988; 48(1):1 -11.
Ilizarov ring fixator is excellent treatment 7. Ilizarov GA: The tension stress effect on the genesis
modality for tibial non-union with a defect, and growth of tissues: Part I. The influence of stability
of fixation and soft tissue preservation. Clin Orthop
regarding bone union, deformity correction, Relat Res 1989;238:249-81.
infection eradication, limb length achievement 8. Ilizarov GA: The tension stress effect on the genesis
and limb function but this needs prolonged and growth of tissues: Part II. The influence of the rate
learning curve for fresh orthopedic surgeons. and frequency of distraction. Clin Orthop Relat Res
1989;239:263-85.
REFERENCES 9. Paley D Current techniques of limb lengthening. J
Pediatr Orthop 1988;8(1):73-92.
1. Nicoll EA. Fractures of the tibial shaft. A survey of 705 10. Paley D Catagni MA, Argnani F, Villa A, Benedetti
cases. J. Bone Joint Surg Br 1964; 46:373-87. GB, Cattaneo R. Ilizarov treatment of tibial non-unions
2. Ellis H. The speed of healing after fract ure of the tibial with bone loss. Clin Orthop Relat Res 1989; 241:146-
shaft. J. Bone Joint Surg Br 1958; 40-B(1): 42-6. 65.
3. Bauer GC, Edwards P, Widmark PH. Shaft fractures of 11. Andersen LR, Johannsen HG, Ernst C, Weeth ER.
the tibia. Etiology of poor results in a consecutive series Tibial Pseudoarthrosis. Treatment using the Ilizarov
of 173 fractures. Acta Chir Scand 1962;124:386-95. technique. Ugeskr Laeger 1996; 158(16):2237-40.

Address for correspondence: Dr. Farmanullah, Orthopaedic Surgeon, City Hospital,

Kohat Road, Peshawar, Postal address: 4-A Murad plaza University road, Peshawar.
Phone: 0302-5536642, 091-541189

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