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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 8  |  Issue : 1  |  Page : 24-31

Infected nonunion of the humerus treated by the compression distraction ilizarov technique without radical debridement or bone excision: Case series


1 Department of Orthopedic, Benha University, Banha, Egypt
2 Department of Orthopedic Surgery, Benha Faculty of Medicine, Benha University, Banha, Egypt

Date of Submission15-Apr-2022
Date of Decision19-May-2022
Date of Acceptance19-May-2022
Date of Web Publication30-Jun-2022

Correspondence Address:
Mohammed Anter Meselhy
Department of Orthopedic, Benha University, Kafer El Gazar, Qalyubia, Banha 13511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jllr.jllr_10_22

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  Abstract 


Background: External fixators have been proved to be effective in the treatment of infected nonunion fracture humerus. The current study presents the outcome of treatment of infected nonunion of the humerus by a cyclic compression distraction technique using Ilizarov without radical debridement. Materials and Methods: 32 patients, 19 males and 13 females. The mean age of the patients was 39.72 years (range, 27–54); patients were presented by infected nonunited fracture humerus after an average of 1.9 surgeries (range, 1–4). All patients were treated by removal of the hardware if present without radical debridement or bone resection to avoid bone shortening and to preserve the blood supply of the bone and soft tissue, Ilizarov application with cyclic compression distraction. Results: The mean time of the external fixator application was 179.06 days, and the mean follow-up time was 32.8 months. All patients were united, According to the association for the study and application of the method of the ilizarov scoring system, the functional results were excellent in 8 patients, good in 16, fair in 7, and poor in only 1 patient. The bone results were excellent in 9 patients, good in 16, fair in 5, and poor in 2 patients. The mean post-operative DASH score was 32.43 (range, 10–63), the mean visual analog scale (VAS) score for pain was 3.71 (range: 2–5), while the mean VAS score for satisfaction was 7.41 (range: 6–9). Conclusion: Cyclic compression distraction by Ilizarov without radical debridement had shown a satisfactory outcome in the treatment of infected nonunion humerus. Level of Evidence: IV, A retrospective study.

Keywords: Compression, distraction, humerus, ilizarov, infected nonunion


How to cite this article:
Meselhy MA, Elhammady AS, Hosny GA. Infected nonunion of the humerus treated by the compression distraction ilizarov technique without radical debridement or bone excision: Case series. J Limb Lengthen Reconstr 2022;8:24-31

How to cite this URL:
Meselhy MA, Elhammady AS, Hosny GA. Infected nonunion of the humerus treated by the compression distraction ilizarov technique without radical debridement or bone excision: Case series. J Limb Lengthen Reconstr [serial online] 2022 [cited 2022 Dec 9];8:24-31. Available from: https://www.jlimblengthrecon.org/text.asp?2022/8/1/24/349410




  Introduction Top


Humeral-infected nonunion is a major challenge. Eradication of infection and addressing bony union in the presence of scarred soft tissue is difficult. In addition, multiple operations put financial and psychological burdens on both the surgeon and the patient.[1],[2],[3],[4],[5]

Different external fixators have been used successfully to treat infected humeral nonunion.[1],[2],[3],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15] Ilizarov external fixators have shown superiority to other modalities in the treatment of such cases.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11] However, most reports used radical debridement as a mandatory step in their techniques.

We hypothesized the treatment of infected nonunion of the humerus by a cyclic compression distraction technique using Ilizarov without radical debridement can achieve bone union.


  Materials and Methods Top


This retrospective study was conducted after the approval of the ethical committee of the university (IRB#ORTHO-SURG.24-2011). Inclusion criteria were patients with infected nonunion humerus treated by Ilizarov external fixator. Between March 2012 and May 2017, 32 consecutive patients were enrolled in the current study.

Inclusion criteria included patients with infected nonunion fracture humerus managed by Ilizarov External fixation without radical debridement or bone resection. Nonunion was diagnosed when the fracture failed to progress to union or has little or no potential for further healing without additional intervention.[16] Infection was diagnosed clinically by the presence of active draining sinus in 25 patients and quiescent sinus in 7 patients, and confirmed by isolation of microorganisms from two separate specimens during previous debridement surgery.[17]

There were 19 males (59.4%) and 13 females (40.6%). The mean age of the patients was 39.72 years (range, 27–54). All male patients were smokers. Right side was affected in 19 patients (59.4%), and left side in 13 (40.6%). There were 15 patients with diabetes (46.9%), 11 patients with hypertension (34.3%). Patients were presented by infected nonunited fracture humerus after an average of 1.9 surgeries (range, 1–4) [Table 1].
Table 1: Patients demographic criteria

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Nonunion site was in the proximal third in 7 patients, in the middle third in 13, and in the distal third in 12 patients.

All fractures were closed by the initial trauma. The initial treatment was open reduction and internal fixation (ORIF) by plate and screws in 28 patients (87.6%), 10 of them underwent a second surgery for removal of the hardware before they were presented to our hospital, while 4 patients (12.4%) were treated by intramedullary locked nail. There was no neurological or vascular deficit at the time of presentation in all patients. All patients have signed informed consent.

Surgical technique

Under general anesthesia, patients were positioned in beach chair with the affected limb draped free in case of fixation with interlocking in four patients or in lateral position when the plate was fixed posterior or supine position if the plate was fixed laterally. Removal of implants was performed in 18 patients. Radical debridement or bone resection was not performed. In cases with already removed plate or interlocking nail, no debridement was done. Samples, or swabs from the sinuses were taken and sent for culture and antibiotic sensitivity testing, all patients were operated by the same surgeon.

Under image control, the position of the patient was adjusted to be beach chair in all patients, Ilizarov external fixator was applied. The combined circular and semicircular construct described by Cattaneo et al.[18] was used. A 90° Arch was applied at the level of greater tuberosity and fixed with three half pins 5 mm in diameter in different directions (lateral, postero-lateral and antero-lateral), and at different levels above and below the Arch. A 120° arch was inserted below, fixed to the bone by 5 mm half pins. A dead ring was used instead of the 120° arch in case of nonunion of the proximal third.

Two complete rings or one and half rings were applied at the distal third of the humerus fixed to the bone by 1.8-mm Ilizarov wires and 4- or 5-mm half pins. Wires were tensioned up to 120 kg in complete rings and 80 kg in incomplete rings. The site of nonunion was acutely compressed intraoperatively.

Postoperative care

A postoperative neurovascular examination of the operated limb was performed, postoperative X-rays anteroposterior and lateral views were obtained, medical treatment as injectable antibiotics, nonsteroidal anti-inflammatory drugs, antiedematous drugs were prescribed for the patients during the hospital stay and for 10 days after discharge from the hospital.

On the 2nd day or 3rd day, the patients were discharged from the hospital after teaching the technique of cyclic compression distraction and encouraging them to start range of motion for the elbow and the shoulder,

Patients were followed up in the outpatient clinic, the 1st visit usually was after 1-week postoperative, the patients were demonstrated by the surgeon how to perform compression at the nonunion site by turning the nuts at a rate of 0.5 mm every 12 h for 4 days.

After 4 days of successful compression, the patient came to the outpatient clinic, the process was checked clinically and radiologically, the patient was demonstrated for distraction by turning the nuts 0.5 mm every 12 h in the opposite direction of compression, the patient again came to the clinic for checking of the process achievement [Figure 1].
Figure 1: (a) 45-year-old female with infected nonunion of RT humerus, the fracture was fixed by plate and screws. (a and b) Preoperative plane X-rays showing humerus fixed by plate and screws. (c) Plane X-ray showing acute compression phase at early postoperative. (d) Plane X-ray showing distraction phase during the procedure. (e and f) Plane X-rays show complete union at the fracture site. (g and h) Clinical photos, 3 years follow-up showing range of motion of the shoulder and elbow

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The patient was asked to repeat these phases of gradual compression the gradual distraction, each 4 phases of 2 compression and 2 distraction are called cycle, the patient was asked to perform two successive cycles of gradual compression and distraction which followed by acute compression at the nonunion site which called static phase.

The union progress was then checked every 3 weeks clinically and radiologically till complete bony union was obtained.

If there was no sign of callus formation at the nonunion site 6 weeks after the static phase. The patient was asked to perform another two cycles of gradual compression distraction and acute compression again at the last stage.

Antibiotics were given according to the results of culture and sensitivity for at least 6 weeks and till CRP drop to normal and sinuses close under the supervision of the infection disease team.

The outcome was assessed according to the association for the study and application of the method of the ilizarov (ASAMI) scoring system,[19] DASH scoring system, visual analog scale (VAS) scoring system for pain, and VAS for satisfaction [Table 2]. After union, the Ilizarov fixator was dynamized by gradually removing the connecting rods between the fracture rings. The fixator was then removed under general anesthesia. The patients were instructed to wear a removable humeral brace for the next 3 months.
Table 2: Patients outcome

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Statistical analysis

Statistical comparisons were performed using SPSS (version 13.0; SPSS Inc., Chicago, Illinois). Clinical data were statistically analyzed using the Mann–Whitney U-test for quantitative data of the term of union time, alignment, DASH score, and VAS with the significance level set with P < 0.05. Because the sample size was determined by the available data that met the inclusion and exclusion criteria at a single institution during the time of study, a sample size calculation was not performed.


  Results Top


The bacteriological culture revealed the presence of Staphylococcus aureus in 20 cases including three MRSA infections, Staphylococcus epidermidis in eight cases, and no growth in four of the quiescent nonunion.

The mean time interval between the initial injury and the definitive surgery was 9.16 months (range, 5–17); the mean hospital stay was 4.58 days postoperatively (range: 4–6). The mean time of the external fixator application was 179.06 days (range: 145–231); the mean follow-up time was 32.8 months (range: 19–50).

At the time of fixator removal, union was achieved in all cases [Figure 2] and [Figure 3]. According to radiological assessment and rate of callus formation, seven patients (21.9%) had two cycles of compression distraction, 16 patients (50%) needed three cycles of compression distraction, while nine patients (28.1%) had four cycles of compression distraction.
Figure 2: A 34-year-old male patient with fracture distal third humerus. Infected nonunion was present; the fracture was fixed with plate and screws. (a) Plane X-ray showing fixation of the distal humerus with plate and screws. (b) Plane X-ray showing removal of the plate and screws, application of Ilizarov and the patient was in distraction phase. (c) Plane X-ray showing compression phase. (d) Plane X-ray showing complete bony union after removal of the fixator

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Figure 3: A 28-year-old male, he was presented by infected nonunion of the LT humerus fixed with plate and screws. (a) Preoperative plane X-ray show fracture middle third humerus fixed with plate and screws. (b) Plane X-ray showing compression by Ilizarov at the fracture site after plate removal. (c) Plane X-ray showing distraction phase at the fracture site. (d) Plane X-ray showing bony union after 3 months of cyclic compression distraction technique. (e and f) Plane X-rays showing achievement of bone union after removal of the fixator

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Regarding the ASAMI scoring system, the functional results were excellent in 8 patients (25%), good in 16 (50%), fair in 7 (21.9%), and poor in only 1 patient (3.1%). The bone results were excellent in 9 patients (28.1%), good in 16 (50%), fair in 5 (15.6%), and poor in 2 patients (6.3%).

At the final follow-up, the mean postoperative DASH score was 32.43 (range, 10–63), the mean VAS score for pain was 3.71 (range: 2–5), while the mean VAS score for satisfaction was 7.41 (range: 6–9).

Pin tract infection was the main complication, it was found in14 cases (43.8%); all were of the superficial type that was treated by dressing and oral antibiotics. Discharging sinus persisted in two cases (6.3%) after fixator removal; it was treated by antibiotic according to culture and sensitivity test, and all closed within 3 months of fixator removal.

Radial nerve palsy was recorded in one patient (3.1%) postoperatively and the patient had tendon transfer later. Parasthesia in ulnar nerve distribution was recorded in two patients early postoperatively and it was resolved after the removal of the fixator.

Refracture occurred in two cases (6.3) mainly due to premature removal of the fixator, one of them was treated by re-application of the fixator and the bone was united in 3 months and the other patient preferred to use a humeral brace. Mal-alignment was recorded in one case with 7°varus deformity which was accepted by the patient with no further management.


  Discussion Top


The union rates of humeral fractures are similar after fixation by locked intramedullary nailing and ORIF with plates.[20]

Conventional methods of nonunion management are successful in cases of aseptic humeral diaphyseal shaft nonunions with adequate vascular supply and soft-tissue integrity.[21],[22] Excellent results were reported for reamed exchange nailing, augmentation plating after nailing, and compression plating with bone grafting.[21] In selected oligotrophic humerus nonunions that occurred after locked IM nailing, used a lateral MIPO technique using long 3.5 mm LCPs and achieved bony union with good functional results.[20]

With infection the problem of nonunion becomes more complicated, different methods of treatment were considered to eradicate the infection, achieving bone union, correction of residual deformities, and early limb range of motion.[22]

Because infected nonunion of long bones is a challenge many authors have described several methods for this problem including radical debridement with skin flap, Papineau technique, induced membrane technique with cancellous bone graft or combined cancellous and fibular graft, bone transport using external fixator[6],[7],[19],[23],[24],[25],[26],[27],[28] and vascularized bone graft.[13]

Ilizarov device and techniques have been used in treatment of infected nonunion of long bones with dramatic successful rate in eradication of infection, achieving bone union and ability of deformity correction, corticotomy, and distraction osteogenesis, or compression distraction at the nonunion site enhance the biological environment for fracture healing,[1],[3],[6],[8],[10],[12],[21],[22],[28] long-learning curve, long time of apparatus application, psychologically problems, and external fixation-related complications as pin tract infection, and risk for neurovascular injury.[21],[22]

The concept advocated by Ilizarov as; osteomyelitis burns in the fire of new osteogenesis.[29] It has noticed that the application of this concept in the field of infected humeral nonunion is little; most of the authors had only applied the concept of compression at the fracture site.[2],[3] debridement and compression,[6],[7] or callus distraction for humeral nonunion.[8]

Although radical debridement of the infected site is considered a keystone for infection eradication, it leaves large bone defects restored by corticotomy and distraction osteogenesis which takes a long duration as well as fixator should be left for adequate bony consolidation.[21]

Distraction osteogenesis was described by Ilizarov to initiate a new bone formation in bone lengthening,[30] Ilizarov compression distraction technique allows a bloodless acceleration of new bone formation at the nonunion site.

Several clinical studies reported a satisfactory outcome of this technique with stimulation of bone formation, without sufficient description of the technique.[31],[32] Biomechanical reports had concluded that distraction stimulates new angiogenesis where compression stimulates new osteogenesis and collagen fiber formation and intra-membranous ossification.[31],[33],[34] On the other hand, Ilizarov fixation without radical debridement has been successfully used in the management of infected tibial nonunion in children.[35]

In the current study, we treated 32 patients with infected nonunited humerus by cyclic compression distraction using Ilizarov circular fixator without debridement in 14 cases and minimal debridement with the removal of plate in 18 cases. Union was achieved in all patients in an average of 179.06 days, (range: 145–231), with the satisfactory functional results of the upper limb and few complications, with advantages of preservation of humeral length, bone, and soft-tissue biology.

Few reports have been published reporting management of active infected nonunion of the humerus.[6],[9],[14] Safoury and Atteya[14] reported treatment of two patients out of eight with compression distraction by Ilizarov in postinfection nonunited supracondylar fracture humerus after the infection was subsided completely in addition to autogenous graft. Brinker et al. managed six patients with infected nonunion humerus by one-stage radical debridement, autogenous graft, and gradual compression by Ilizarov for several weeks.[9] To the author's knowledge, this is the first clinical report on the application of the principal of cyclic compression distraction technique without radical debridement in the management of infected humeral nonunion, the same technique was reported successfully in the treatment of infected tibial nonunion.[36] [Table 3] summarizes the current study and some studies reporting the outcome of the management of infected humeral nonunion by Ilizarov fixator.[1],[2],[6],[7],[14]
Table 3: Comparison between the current study and other simolar studies

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The limitations of this study are the retrospective nature, the lack of comparison to the results of other treatment modalities, and the relatively limited number of patients. Further comparative prospective studies are recommended.


  Conclusion Top


Cyclic compression distraction by Ilizarov without radical debridement had shown a satisfactory outcome in the treatment of infected nonunion humerus with satisfactory clinical outcomes and low complication rates.

Compliance with ethical standards

Ethical approval

The study was approved by the ethical committee of the University and was in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

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