|Year : 2015 | Volume
| Issue : 1 | Page : 21-28
Infected lower tibial nonunions without bone grafting - Reliable union using the Ilizarov technique
Milind M Chaudhary, Saurabh Jain, Vigneshwaran Pragadeeswaran, Pratik H Lakhani
Centre for Ilizarov Techniques, Akola, Maharashtra, India
|Date of Submission||21-Oct-2015|
|Date of Acceptance||26-Oct-2015|
|Date of Web Publication||5-Nov-2015|
Milind M Chaudhary
Centre for Ilizarov Techniques, Akola, Maharashtra
Source of Support: None, Conflict of Interest: None
Aims: To retrospectively study infected distal tibial nonunions which have deformity, bone gaps and a small size of distal fragment for union and eradication of infection using staged Ilizarov treatment.
Patients and Methods: Thirty seven distal infected tibial nonunions were treated over 11 years. Twelve presented without active discharge and were treated with Ilizarov fixator. Twenty five presented with draining infection and were treated with debridement, Antibiotic Cement Coated (ACC) rods and beads. Five healed without further intervention. Twenty were treated by Ilizarov fixator secondarily. Monofocal compression was used in 16 patients. Ten had a bone transport to fill gaps of 2 to 17.3 cm. Six had bifocal simultaneous treatment. Twenty three had a foot frame applied for stability. None had Iliac Crest bone grafting to achieve union at Nonunion site. Bone Marrow aspirate was injected in 5 patients to hasten union.
Results: Five patients united without application of fixator. Twenty nine of 32 nonunions healed with first application of Ilizarov fixator. Three needed repeat fixation to achieve 100% union. Infection was eradicated in all patients. Thirteen (40%) were excellent, 14 good (43%), two were fair and three poor by ASAMI criteria. Mean ex-fix duration was 393.4 days (132-720). Mean 7.6 cm length was achieved in the regenerate.
Conclusions: Infected Distal tibial nonunions have a small distal fragment, deformity, bone gap causing difficulties in treatment. Debridement, ACC beads and rods and Ilizarov fixator reliably achieves union and eradicates infection. Residual deformity and prolonged fixator duration were the main problems in our series.
Keywords: Bone grafting, bone transport, distal tibial nonunion, Ilizarov fixator, infected nonunion, monofocal compression
|How to cite this article:|
Chaudhary MM, Jain S, Pragadeeswaran V, Lakhani PH. Infected lower tibial nonunions without bone grafting - Reliable union using the Ilizarov technique. J Limb Lengthen Reconstr 2015;1:21-8
|How to cite this URL:|
Chaudhary MM, Jain S, Pragadeeswaran V, Lakhani PH. Infected lower tibial nonunions without bone grafting - Reliable union using the Ilizarov technique. J Limb Lengthen Reconstr [serial online] 2015 [cited 2019 Mar 26];1:21-8. Available from: http://www.jlimblengthrecon.org/text.asp?2015/1/1/21/168745
| Introduction|| |
Nonunions of the distal tibia are difficult to treat due to infection, bone loss, poor soft tissue cover, shortening, and deformity.  Inadequate fixation of a small fragment makes achieving union very difficult. Literature on this subject is scarce with very few series exclusively describing treatment of infected nonunions of distal tibia. Staged management of infection and secondary definitive Ilizarov fixator treatment to achieve union was done without the use of iliac crest bone grafts. We also present an algorithm for dealing with this condition.
| Patients and Methods|| |
Thirty-seven patients with a distal tibial infected nonunion, treated by the Ilizarov fixator over 11 years are retrospectively reviewed in this study. Only patients with distal tibial nonunions with infection, with a distal fragment lesser than 10 cm were included in the study. Patients with aseptic nonunion or with the distal fragment more than 10 cm were excluded.
Mean age of the patients was 37.6 years (12-77). Thirty- one were males and six were females. Twenty had a right- sided and 17 had a left lower tibial nonunion. Mean size of distal fragment was 5.2 cm (0-9.2). Active infection, drainage, or a large open wound was seen in 25 patients. Twelve presented without active infection, but with a definite history of infection, treated with implant removal, debridement, and antibiotics.
The 25 patients with active drainage and infection were primarily treated with debridement and antibiotic cement- coated (ACC) rod or beads to eradicate the infection. Infection in the proximal fragment was treated with reaming and an ACC rod. Vancomycin was used in all patients. Oral or parenteral antibiotics were then added after culture reports were obtained. Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella pneumoniae, Escherichia coli, Methicillin-resistant S. aureus were some of the common causative organisms isolated. Blood cultures were not performed. After wound culture and sensitivity results were obtained, appropriate antibiotics were started. A cast/brace was applied for stability. They were reviewed at 6 weeks. Infection was eradicated in 20 of these patients and blood counts, sedimentation rate, and C-reactive protein (CRP) levels returned to normal. Five of these 25 patients showed early signs of clinical and radiological healing. Hence, treatment in a cast was continued, and these patients healed without further intervention by an average of 14 weeks (12-19).
Twenty patients had a second look debridement, removal of ACC rods and beads, and definitive second stage treatment with Ilizarov fixator at an average of 8 weeks (6-13). Four of these patients had multiple debridements to eradicate the infection, all of them after application of the Ilizarov fixator. The treatment modality was changed from neutral fixation to bone transport after the infection healed.
Twelve patients who presented with dormant infection without clinical or laboratory signs of active infection were started with definitive treatment with the Ilizarov fixator. We present an algorithm, which describes our approach to these patients [Figure 1].
|Figure 1: Algorithm for treating infected distal tibial nonunions with a small distal fragment|
Click here to view
32 of 37 patients were, thus, treated with the Ilizarov fixator and are the subjects of this study.
All patients had 2 or 3 wires that fixed the distal tibia and fibula and had one or two titanium half pins if the bone stock was good and if the fragment was large enough. The distal fragment was smaller than 5 cm in 23 of the 32 patients and hence a foot frame was applied to enhance stability. The foot frame had 3-4 wires and a calcaneal half pin for fixation.
Sixteen patients had monofocal compression to achieve union without any proximal corticotomy. A proximal corticotomy was done in 16 patients (9 after drill-holes and 7 with a Gigli wire saw).
All patients had shortening ranging from 0.8 cm to 3.9 cm with mean preoperative shortening of 2.5 cm. Mean preoperative bone gap was 8.7 cm (0.8 cm to 17.3 cm) in 9 patients.
A fibulectomy was done at middle-lower third junction. Bifocal simultaneous compression-distraction was done in 6 patients with a minimal gap. Ten patients had shortening and/or bone loss and had bifocal consecutive compression-distraction (Bone Transport).
We did not perform acute compression of more than 2 cm at the nonunion site as has been described by several authors. ,
We did not perform iliac crest bone grafting in any patient. Bone marrow aspiration from posterior iliac crest and injection into the nonunion site were performed in 5 patients on 2-5 occasions. These were performed 16-20 weeks after fixator application.
A second application of external fixation was needed in 5 patients due to a re-fracture. In three of these five, the re-fracture was due to inadequate healing and in 2 patients it was due to a fresh traumatic episode.
The mean follow-up in our series was 43 months (6 months - 10.5 years).
| Results|| |
Union was assessed as per the ASAMI criteria for bony outcome. 
All 37 patients united. Five patients united without application of the Ilizarov external fixator. 29 of the 32 (90.6%) united with a single application of the Ilizarov and the remaining 3 united firmly after a second application of the Ilizarov apparatus.
Excellent results were seen in 13 patients (41%), good in 14 (43%), fair in 2 (7%), and poor in 3 (9%) patients.
Mean external fixation duration for all patients was 393.4 days (132-720). Mean duration for monofocal compression was 269.3 days (132-435) [Figure 2]. Mean duration for patients with bifocal simultaneous compression-distraction was 526.6 days (350-826). Mean duration for patients with bone transport was 514 days (321-721) [Figure 3].
|Figure 2: (a) Infected lower tibial nonunion. Discharge and deformity. (b) Small distal fragment. Antibiotic cement-coated beads and rod inserted after debridement and reaming. (c) Hybrid Ilizarov fixator without foot frame fixation. Procurvatum deformity being corrected. (d) Anterior-posterior X-ray after union. Mild valgus <7°. (e) Postoperative lateral X-ray showing sound union and no deformity. (f) Sound union, no infection|
Click here to view
|Figure 3: (a) Severely infected nonunion lower tibia. 8 months duration. (b) Foul smelling discharge, inadequate fi xator, nonweight bearing. (c) Debridement with beads at nonunion site. Reaming of canal and antibiotic cement-coated rod inserted. (d) Ilizarov fi xator applied. Twodebridements done. Antibiotic cement block inserted. (e) Bone transport modality chosen as it is most reliable. Gigli saw corticotomy done proximally. Hypertrophic regenerate with one episode of premature consolidation. (f) Sound union. No deformity and limb length discrepancy. Spontaneousfusion at ankle joint. (g) Minimal functional deesability despite ankle fusion. Good union and eradication of infection despite poor soft tissue cover|
Click here to view
Mean regenerate length of 7.6 cm (2-17.3) was achieved in 16 patients. Equal limb length was achieved postoperatively in 12 patients. 15 had shortening ranging from 0.8 to 2.5 cm. Only 5 patients had persistent shortening of more than 2.5 cm.
Three patients who were re-operated for an early re-fracture were considered to have a poor result. In two of these, union occurred with application of Ilizarov by monofocal compression only, whereas the 3 rd patient also needed a proximal corticotomy.
Spontaneous or intended ankle fusion occurred in 10 of our patients. Most remaining patients had some loss of ankle range of motion (ROM).
The mean preoperative valgus deformity of 13.8° (10-18.1°) seen in 6 patients preoperatively was corrected to 11.3° (3-31.2°) postoperatively. Five patients had residual valgus angulation >7°.
Mean preoperative varus deformity of 17° (11.4-30°) seen in 7 patients preoperatively was corrected to 11.7° (5-20.3°) postoperatively, with more than 7° deformity persisting in 6 patients. Five patients developed varus deformity anew, out of which 3 patients were ones who healed with antibiotic beads or rod.
The mean procurvatum deformity of 17.1° (8-25°) seen in 5 patients preoperatively was changed to 19° (5-34°) postoperatively, with 4 patients having more than 7°.
The mean recurvatum deformity of 20° (15-30°) seen in 3 patients preoperatively was corrected to 13.4° (5-22°) postoperatively, with 7 patients having more than 7°.
These 14 patients with a residual deformity >7° were considered as good results. Two patients had residual shortening >2.5 cm and hence they were considered as fair results. The 3 patients who needed a re-fixation due to inadequate healing were considered as poor results, despite eradication of infection, sound union, and absence of large deformities.
| Discussion|| |
Distal tibial nonunions are complicated by infection due to poor vascularity and thin soft tissue cover. Paucity of muscle envelope, high energy trauma, and multiple surgeries increase this risk.  With the databases available to us, we were able to find 16 retrospective case series exclusively dealing with distal tibial nonunions [Table 1]. They describe a total of 194 patients. Only 13 series include infected distal tibial nonunions. Only one series by Stasikelis et al.  exclusively dealt with the treatment of infected distal nonunions containing a total of 6 patients. While our study does not have a new message, it represents the largest specific series.
Debridement, reaming, and addition of antibiotic-coated cement rods and beads are accepted methods of eradication of infection. , We used the hand-rolled method of creating beads on the table and silicone tube method of creating the ACC rod. Removal of the beads/rods gives a second opportunity to perform debridement and to confirm eradication of infection. The first surgery improves the nitrogen balance, nutritional and immune status of the patient, and also allows them to start walking, bearing partial weight in a cast or a brace. Infection was eradicated and healing had progressed in 5 casess. We removed the beads/rods and persisted with casting or bracing to achieve union without further treatment in these patients.
Nonunion of distal third is associated with bone loss, shortening, deformity, all of which add to the difficulties of achieving union.  The Ilizarov fixator is ideally suited to perform all these tasks and served as the definitive treatment. In the 32 patients we studied, 8 patients presented with bone loss, with a mean loss of 8.7 cm (0.8 cm - 17.3). Preoperatively, large deformities were seen with varus: 17° (n = 7), valgus: 13.8° (n = 6), recurvatum: 20° (n = 3), or procurvatum: 17.11° (n = 5). Hence, due to the large deformities and small fragments, the difficulty level in our series was very high.
Twenty seven (84%) patients in our series had excellent and good bony results(ASAMI score). Union was achieved and infection eradicated in all our patients without bone grafting. 14 patients were downgraded to good because of residual deformities >7°. Three patients had a re- fracture and were considered as poor results (9%). Results cannot be graded as excellent or good, if bone grafting is done according to the ASAMI score.  Bone grafting We was not performed because many patients had previous grafting surgeries and their donor sites were exhausted. Poor soft tissue cover over the nonunion site would not have accommodated the bone grafts in many patients. Prolonged fixator duration in our series highlights the need for additional biological stimulus for union. Ilizarov proposed that gradual sustained compression transformed the fibrous tissue and sclerotic bone ends and union can be achieved without bone grafting.  Compression was applied in a direction perpendicular to the nonunion surfaces in patients with oblique nonunion surfaces.
Schottel et al.,  Schoenleber and Hutson,  Paley et al.,  Katsenis et al.,  Stasikelis et al.,  and Lonner et al.,  all have treated the infected nonunions of distal third tibia with Ilizarov fixator. Reed and Mormino  and Richmond et al.  have used plates or intramedullary nails for the fixation in distal tibial nonunion with a history of prior infection. Eralp et al.  described debridement and combined treatment with a nail and circular external fixation, in which they had a recurrence of infection in 2/13 patients (15%), which needed to be salvaged by the Ilizarov fixator.
We feel uncomfortable with the usage of internal fixation to achieve union after prior infection. Though complete blood counts, sedimentation rates, and CRP levels do help in determining if the infection has been cured, a repeat internal fixation device implantation is at a higher risk of developing infection again. Zimmerli et al.  showed that the number of microorganisms necessary to cause infection in the presence of metallic implants reduces by 10 4 . Deterioration in the patients' nutritional or immunological status is likely to increase the chances of repeat infection. Grading of quantitative severity of bony infection is not yet published. The Cierny Mader classification grades all infected nonunions as Grade IV A or IV B based on immune status.  Hence, this would not help to grade the severity of infection. Calori et al .  in their classification of the nonunion severity score have not further differentiated the grade of infection, merely grading it as uninfected, dormant, or active. We feel safer using the Ilizarov external fixator in patients with diabetes, anemia, poor nutritional status or poor skin cover, rather than risking internal fixation again.
External fixation lowered the need for higher antibiotics and helped reduced cost of treatment. Stable fixation of small distal fragments is difficult to perform by either locking plates or rods. Osteoporosis of the bony ends reduces the stability of internal fixation.
Fixation of the smallest of distal fragments is possible with three or four Ilizarov wires attached to a single ring for stability. Stability of fixation is enhanced dramatically by a foot frame which we used in 23 of the 32 cases (71.8%). Union in 90% of cases after first application, and in 100% eventually, validates the efficacy of the Ilizarov fixator.
Ankle stiffness was common at start of treatment in most patients with distal tibial nonunions. Movement was further compromised by cast/brace application for 6- 8 weeks. Immobilization of the ankle in the foot frame adds to the stiffness. Spontaneous ankle fusion was seen at the end of treatment in 10 of our patients.
Mean lengthening of 7.6 cm (2-17.3) was achieved. Lengthening occured without augmentation or rescue of the regenerate in all patients.
Excellent results in 14 patients(43%) were downgraded to good in our series despite union and eradication of infection because of residual deformity larger than 7°. deformity correction difficult. Metal connections, bolts, etc., hamper proper x-ray visualization of the nonunion site despite the use of carbon fiber rings. Multiaxial deformites need several montage changes in the Ilizarov fixator and small errors must have added up in our correction to leave the persistent deformities.
The Taylor Spatial Frame 27 (TSF) fixator ensures that no secondary deformities develop during the treatment but was not used in this series. Nonunions with small fragments should have the TSF  fixator to ensure proper axial alignment. Partial defect of the bony ends at the nonunion are also responsible for the deformities. Anteromedial quadrant defects lead to varus recurvatum deformity. Posterior defects lead to a procurvatum deformity.
Partial or complete loss of ankle movement and residual deformity must have resulted in functional disability in many of our patients. Focusing on infection control, union and bony results without evaluating functional outcomes is a major weakness of our study.
Using the nonunion severity score of Calori  to grade its severity. This would have added perspective on the difficulty of the presenting problem.
Kugan  achieved 96% union in 48 hind foot arthrodesis of which 30 cases were infected. Reducing treatment duration in nonunions with gaps was achieved by Sen  by acute compression and then lengthening. They studied 17 patients of whom 11 were infected. Nonunion location in tibia was not described. All united in a mean time of 6 months, but 4/11 (36%) required bone grafting at docking site. Reduced treatment time was achieved with higher morbidity of bone grafting and resection of a large segment of the fibula. Acute compression does give faster union, albeit at a risk of neurovascular compromise and needs careful monitoring. Fibrosis and poor soft tissue conditions prevailed in most of our patients treated by bone transport. We would attempt this method in future cases to reduce fixator duration.
Abdel-Ghani et al.  described the treatment of nonunions following tumor excision. Bose et al.  studied the role of a multidisciplinary team in the management of infected nonunions. In the 44 infected nonunions they 3 described, there is no clear mention of how many were in the distal third.
Help from plastic surgical and infection specialists, nutritionists would be most helpful in tackling the myriad problems. Patil  emphasized the cost implications to the healthcare system for treatment of infected nonunions. Self- paying patients are advised to resume work while in fixator. Gainful employment helps in healing and keeping their spirits high.
Johnson  and Papanagiotou  have used BMP for augmentation of union with varied success rates. BMP is not economically feasible for many of our patients. Bone marrow aspiration and injection (without concentration or centrifugation or density gradient separation) along with platelet concentrates were used in five patients. Hernigou et al.  described concentration of bone marrow aspirate using cell separators to achieve critical concentration of mesenchymal stem cells. Hatzokos used the less expensive alternatives  of bone marrow aspirate combined with demineralized bone matrix do reduce time to healing at the docking site.
To conclude, lower tibial infected nonunions are very difficult to manage and present with problems of infection, deformity, recalcitrant nonunions or bony gaps, small distal fragment, and difficulties in achieving adequate fixation. Staged treatment to control infection and later Ilizarov fixation allowed us to achieve 100% union. Prolonged external fixation duration and residual deformities are problems that we need to solve.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Tarkin IS, Siska PA, Zelle BA. Soft tissue and biomechanical challenges encountered with the management of distal tibia nonunions. Orthop Clin North Am 2010;41:119-26.
El-Rosasy MA. Acute shortening and re-lengthening in the management of bone and soft-tissue loss in complicated fractures of the tibia. J Bone Joint Surg Br 2007;89:80-8.
Mahaluxmivala J, Nadarajah R, Allen PW, Hill RA. Ilizarov external fixator: Acute shortening and lengthening versus bone transport in the management of tibial non-unions. Injury 2005;36:662-8.
Paley D, Catagni MA, Argnani F, Villa A, Benedetti GB, Cattaneo R. Ilizarov treatment of tibial nonunions with bone loss. Clin Orthop Relat Res 1989;241:146-65.
Eralp L, Kocaoglu M, Yusof NM, Bulbul M. Distal tibial reconstruction with use of a circular external fixatorandanintramedullarynail.The combined technique. J Bone Joint Surg Am 2007;89:2218-24.
Reed LK, Mormino MA. Functional outcome after blade plate reconstruction of distal tibia metaphyseal nonunions: A study of 11 cases. J Orthop Trauma 2004;18:81-6.
Chin KR, Nagarkatti DG, Miranda MA, Santoro VM, Baumgaertner MR, Jupiter JB. Salvage of distal tibia metaphyseal nonunions with the 90 degrees cannulated blade plate. Clin Orthop Relat Res 2003;409:241-9.
Richmond J, Colleran K, Borens O, Kloen P, Helfet DL. Nonunions of the distal tibia treated by reamed intramedullary nailing. J Orthop Trauma 2004;18:603-10.
Schottel PC, Muthusamy S, Rozbruch SR. Distal tibial periarticular nonunions: Ankle salvage with bone transport. J Orthop Trauma 2014;28:e146-52.
Cavadas PC, Landin L. Treatment of recalcitrant distal tibial nonunion using the descending genicular corticoperiosteal free flap. J Trauma 2008;64:144-50.
Wu CC, Shih CH. Distal tibial nonunion treated by intramedullary reaming with external immobilization. J Orthop Trauma 1996;10:45-9.
Johnson EE, Urist MR, Finerman GA. Distal metaphyseal tibial nonunion. Deformity and bone loss treated by open reduction, internal fi xation, and human bone morphogenetic protein (hBMP). Clin Orthop Relat Res 1990; 250:234-40.
Marsh JL, Rattay RE, Dulaney T. Results of ankle arthrodesis for treatment of supramalleolar nonunion and ankle arthrosis. Foot Ankle Int 1997;18:138-43.
Schoenleber SJ, Hutson JJ Jr. Treatment of hypertrophic distal tibia nonunion and early malunion with callus distraction. Foot Ankle Int 2015;36:400-7.
Paley D, Lamm BM, Katsenis D, Bhave A, Herzenberg JE. Treatment of malunion and nonunion at the site of an ankle fusion with the Ilizarov apparatus. Surgical technique. J Bone Joint Surg Am 2006;88 Suppl 1 Pt 1:119-34.
Katsenis D, Bhave A, Paley D, Herzenberg JE. Treatment of malunion and nonunion at the site of an ankle fusion with the Ilizarov apparatus. J Bone Joint Surg Am 2005;87:302-9.
Stasikelis PJ, Calhoun JH, Ledbetter BR, Anger DM, Mader JT. Treatment of infected pilon nonunions with small pin fi xators. Foot Ankle 1993;14:373-9.
Lonner JH, Koval KJ, Golyakhovsky V, Frankel VH. Posttraumatic nonunion of the distal tibial metaphysis. Treatment using the Ilizarov circular external fixator.Am J Orthop (Belle Mead NJ) 1 May; Suppl:16-21.
El-Rosasy MA, El-Sallakh SA. Distal tibial hypertrophic nonunion with deformity: Treatment by fi xator-assisted acute deformity correction and LCP fixation.StrategiesTraumaLimbReconstr2013;8:31-5.
Conway J, Mansour J, Kotze K, Specht S, Shabtai L. Antibiotic cement-coated rods: An effective treatment for infected long bones and prosthetic joint nonunions. Bone Joint J 2014;96-B: 1349-54.
Thonse R, Conway JD. Antibiotic cement-coated nails for the treatment of infected nonunions and segmental bone defects. J Bone Joint Surg Am 2008;90 Suppl 4:163-74.
Dendrinos GK, Kontos S, Lyritsis E. Use of the Ilizarov technique for treatment of non-union of the tibia associated with infection. J Bone Joint Surg Am 1995;77:835-46.
Ilizarov GA. Transosseous Osteosynthesis: Theoretical and Clinical Aspects of the Regeneration and Growth of Tissue. 1 st
ed. Berlin: Springer-Verlag; 1992.
Papanagiotou M, Dailiana ZH, Karachalios T, Varitimidis S, Vlychou M, Hantes M, et al. RhBMP-7 for the treatment of nonunion of fractures of long bones. Bone Joint J 2015;97-B: 997-1003.
Zimmerli W, Waldvogel FA, Vaudaux P, Nydegger UE. Pathogenesis of foreign body infection: Description and characteristics of an animal model. J Infect Dis 1982;146:487-97.
Cierny G, Mader JT, Pennick H. A clinical staging system of adult osteomyelitis. Contemp Orthop 1985;10:17-37.
Chaudhary M. Taylor spatial frame-software-controlled fixator for deformity correction-the early Indian experience.Indian J Orthop.2007 Apr;41(2):169-74
Calori GM, Phillips M, Jeetle S, Tagliabue L, Giannoudis PV. Classifi cation of non-union: Need for a new scoring system? Injury 2008;39 Suppl 2:S59-63.
Rozbruch SR, Pugsley JS, Fragomen AT, Ilizarov S. Repair of tibial nonunions and bone defects with the Taylor Spatial Frame. J Orthop Trauma 2008;22:88-95.
Kugan R, Aslam N, Bose D, McNally MA. Outcome of arthrodesis of the hindfoot as a salvage procedure for complex ankle pathology using the Ilizarov technique. Bone Joint J 2013;95-B: 371-7.
Sen C, Eralp L, Gunes T, Erdem M, Ozden VE, Kocaoglu M. An alternative method for the treatment of nonunion of the tibia with bone loss. J Bone Joint Surg Br 2006;88:783-9.
Abdel-Ghani H, Ebeid W, El-Barbary H. Management of combined nonunion and limb-length discrepancy after vascularized fibulargrafting. Bone Joint J 2015;97-B: 814-7.
Bose D, Kugan R, Stubbs D, McNally M. Management of infected nonunion of the long bones by a multidisciplinary team. Bone Joint J 2015;97-B: 814-7.
Patil S, Montgomery R. Management of complex tibial and femoral nonunion using the Ilizarov technique, and its cost implications. J Bone Joint Surg Br 2006;88:928-32.
Hernigou P, Poignard A, Beaujean F, Rouard H. Percutaneous autologous bone-marrow grafting for nonunions. Influence of the number and concentration of progenitor cells. J Bone Joint Surg Am 2005;87:1430-7.
Hatzokos I, Stavridis SI, Iosifidou E, Karataglis D, Christodoulou A. Autologous bone marrow grafting combined with demineralized bone matrix improves consolidation of docking site after distraction osteogenesis. J Bone Joint Surg Am 2011;93:671-8.
[Figure 1], [Figure 2], [Figure 3]