AOT Nonunion book sample

René K Marti | Peter Kloen

Concepts and Cases in Nonunion Treatment

Norbert P Haas, President of the AO Foundation

More than 130 case descriptions are included in the unique case part: The core of this collection represents 40 years of personal experience in nonunion treatment of René Marti, demonstrating the principle “technique over technology”. Many of the cases provide long-term follow-ups of up to 20 years. The editors have carefully selected additional cases, contributed by several experts in nonunion treatment.

René K Marti | Peter Kloen

The gold standard for the treatment of nonunions was set by Weber and Čech in the early 1970s. With this new book the Editors René K Marti and Peter Kloen provide a comprehensive update on the state-of-the-art treatment of nonunions.

Concepts and Cases in Nonunion Treatment

“This book will serve as an invaluable aid for any orthopaedic or trauma surgeon who has to deal with the problem of pseudarthrosis.”

René K Marti | Peter Kloen

Concepts and Cases in Nonunion Treatment

The presented guidelines and solutions for the management of nonunions address orthopaedic and trauma surgeons worldwide. There certainly will be alternative ways to treat many cases.

www.aotrauma.org

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Table of contents

Table of contents Foreword (Norbert P Haas)

8

Foreword (René K Marti)

9

Foreword (Peter Kloen)

10

Contributors

11

Introduction (René K Marti)

15

1 Principles

6

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1.1

Evolution of treatment of nonunions

20

1.2 1.2.1 1.2.2 1.2.3 1.2.4

Basic science aspects Normal and impaired fracture healing Pathogenesis and treatment of impaired fracture healing Emerging treatments for fractures and nonunions—growth factors and beyond Nonunion and the application of platelet-leukocyte gel (PLG) and bone morphogenetic protein (BMP)

47 48 56 66

1.3 1.3.1 1.3.2

Nonoperative treatment Pulsed electromagnetic fields in the treatment of nonunions—the Dutch experience Ultrasound in osteotomies and nonunions—basic research

79 80 92

1.4 1.4.1 1.4.2 1.4.3 1.4.4 1.4.5

Bone graft The role of decortication in the treatment of nonunions Autogenous bone grafting in the treatment of nonunions Open cancellous bone graft Bone-graft substitutes Induced membranes—summary

97 98 106 116 122 128

1.5

Infected nonunions

132

74

Concepts and Cases in Nonunion Treatment

René K Marti, Peter Kloen

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Table of contents

2 Cases 2.1

Clavicle

156

2.2

Humerus, proximal

206

2.3

Humerus, shaft

248

2.4

Humerus, distal

290

2.5

Forearm

348

2.6

Pelvis/acetabulum

414

2.7

Femur, neck

452

2.8

Femur, proximal/intertrochanteric

500

2.9

Femur, proximal/subtrochanteric

524

2.10

Femur, shaft

560

2.11

Femur, distal

650

2.12

Tibia, proximal

700

2.13

Tibia, shaft

740

2.14

Tibia, distal/pilon

828

2.15

Ankle

876

2.16

Foot

900

7

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Author

René K Marti

1.5 Infected nonunions

1

Introduction

The diagnostic and therapeutic treatment principles of acute or chronic infections as well as infected nonunions have been well-described by Ochsner et al [1] and Johnson et al [2]. The author would like to summarize his own experience gained over a period of almost 40 years, treating several hundred infected nonunions in all locations of the body and to illustrate the respective treatment principles by corresponding cases.

The main reasons for the occurrence of infected nonunions were open fractures and devascularizing, inadequate plate fixations especially of the lower limb. A special group were the gas gangrene infected defect nonunions after successful limb saving in the hyperbaric oxygen chamber. The author will discuss the infected defect tibial nonunions separately (see 5.5 “Multiple-stage treatment” in this chapter and chapter 2.13 “Tibia, shaft”) because they represent a special case.

These general remarks are valid for all anatomical locations.

2

Classification

Infected nonunions can be classified in the same way as aseptic nonunions, namely: • Hypertrophic • Avital and unstable • Avital with segmental defects It is obvious that this classification does not consider softtissue defects, which play an important role in the treatment of infected nonunions. Therefore, a differentiation of infected nonunions with intact or damaged soft-tissue coverage is of great importance.

The author’s series, dating back to 1973, used the classification of Weber and Čech, but considered every case an individual problem.

3

Preoperative evaluation

Clinical signs of infection like erythema, pain, fever, and swelling are often absent in chronic infections, which have been treated with antibiotics for a long period of time and in which drainage through fistulae limit the infection to a small local area. Drainage can be by single or multiple fistulae up to large soft-tissue defects and even exposed, avascular bone. C-reactive protein (CRP) and erythrocyte sedimentation rate may be elevated. A combination of clinical, laboratory, histopathological, microbiological, and imaging studies are required.

Cooperation with a specialist for infectious diseases is recommended. To detect the microorganism responsible for the infection pre- and intraoperative tissue harvesting from several infected sites is necessary. Superficial culture material (swabs) have a low sensitivity, they may only show the contamination by bacteria not responsible for the chronic infection. Perioperative antibiotic treatment of infected nonunion should be interrupted or not started before tissue specimens have been collected.

In general, standard x-rays provide the necessary information concerning diagnosis and treatment options. Former tomograms are replaced by CT scans to detect sequesters not visible on standard x-rays. An MRI examination may give some more information in regard to the viability of the bone and the infected soft tissues. In future, new imaging techniques will be able to detect avascular bone much more precisely than a scintigram, which had been the basis of the Weber-Čech classification.

Furthermore, there are well-known classifications for adult osteomyelitis by Cierny et al [3] based on location and by May et al concerning posttraumatic osteomyelitis of the tibia [4].

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1 Principles 1.5 Infected nonunions

4

Preoperative planning

Chronic infected nonunions with persistent drainage and sequestra formation are resistant to eradication by long-term antibiotics administration alone—the surgical intervention is the key to successful treatment. Every case has to be analyzed individually; there is no standard procedure that

a

b

f

can be applied to every patient. Standard procedure is the identification of the infective organism, the debridement of all dead infected tissue, the filling of empty space, and the stable fixation. This may be sufficient in presence of a stable implant and a viable soft-tissue environment—otherwise a multiple-stage intervention has to be planned (Fig 1.5-1).

c

g

d Fig 1.5-1a–g Infection treatment in presence of stable implant. a–b Inadequate internal fi xation of a comminuted pilon fracture in a 79-year-old man. c–d Five months postoperatively the medial buttress plate and the lag screw are removed and replaced by a straight DCP 4.5. The lateral avascular cortical fragment is removed and replaced by an impacted bone graft. Note: This intervention was complicated by an infection and soft-tissue necrosis. The plate remains stable, vital granulation tissue is covering necrotic bone and even the proximal part of the plate. e–g Uneventful fracture healing and spontaneous closure of the soft-tissue defect after removal of the plate and superfi cial debridement 6 months after the second intervention.

e

134

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Concepts and Cases in Nonunion Treatment

René K Marti, Peter Kloen

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Author

René K Marti

a

b

c

d

e

h

i

j

f

g

k

Fig 1.5-2a–k Infection in presence of a stable plate fi xation—wait and see. a–c This compression plate fi xation of a transverse femoral fracture in a 16-year-old girl became infected. d–e The general and local signs of infections are under control, the patient is fully mobilized. Sequestration of the femur under the plate but abundant periosteal callus formation. f Removal of the plate and the bone sequester 3 months postoperatively. g Vital bone and soft tissue after debridement. h A Wagner external fi xator protects the debrided femur. Note the bridging callus formation. i Progressive consolidation after 10 weeks of external fi xation, 5.5 months after initial plate fi xation. A lateral cancellous bone graft is added and the Wagner device is removed after 1 more month. Full recovery 6.5 months after the accident. j–k No recurrence of infection and full remodeling of the femur 6 years postoperatively.

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1 Principles 1.5 Infected nonunions

5

Interventions

5.1

One-stage intervention

A one-stage intervention is only possible after meticulous debridement, stable refixation under compression in presence of a sufficient soft-tissue mantle, which allows primary wound closure after drainage. Bone healing will occur even in presence of a persisting infection as demonstrated in the experimental studies by Rittmann et al [5].

c

a

b

Main indications for a one-stage intervention are metaphyseal infected nonunions (Fig 1.5-3) and, in general, nonunions of the femur and humerus in which soft-tissue coverage is intact and primary wound closure is possible (Fig 1.5-4) (see case 2.8.4 “Infected inter- and subtrochanteric nonunion after multiple failed internal fixations” and case 2.9.7 “Multiple failures including low-grade infection in the treatment of a subtrochanteric nonunion”). An additional autogenous bone graft may be added in the same intervention.

e

d Fig 1.5-3a–g Infected nonunion—one-stage intervention. a–b Infected nonunion of the tibia. c Necrotic bone and soft tissue, marked with methylene blue. d Well-vascularized bone and soft tissue upon release of the tourniquet. e External fi xation and open bone graft (see also chapter 1.4.3 “Open cancellous bone graft”). f–g Healing of infection and consolidation of the nonunion.

f

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g

Concepts and Cases in Nonunion Treatment

René K Marti, Peter Kloen

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Author

René K Marti

a

g

b

h

c

d

i

j

e

f

Fig 1.5-4a–j Multiple plate fi xation of an infected humeral shaft nonunion. a–b Comminuted humeral shaft nonunion in a 29-year-old man, treated for 14 months with repeated external fi xation and bone grafts. c–d Remaining segmental nonunion with intact soft-tissue mantle. Signs of pin-tract infections. e–f Situation after standard exposure of the radial nerve, debridement of the infected pin tracts, and stable double plate fi xation of the different nonunions in presence of a manifested infection in the proximal nonunion. The long DCP acts as a splint. Compression of the infected proximal nonunion is achieved with a 90° adolescent condylar blade plate. g–h Wound draining through a fistula for 10 months. Healing of the infection and the nonunions after removal of the plates and local debridement. i–j Remodeling and good functional result 8 years postoperatively.

137

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1 Principles 1.5 Infected nonunions

5.2

Infected wound closure

The closure of infected wounds needs special attention. The author has seen remaining infections around nonresorbable and resorbable suture material. Therefore, he introduced a special suture technique to close infected wounds, especially fracture wounds of the femur and humerus. One single monofilament suture, which allows easy removal, is used to adapt muscle, fascia, subcutaneous tissue, and skin.

These sutures, which can be removed after 8–10 days, do not interfere with the wound drainage. Beside thick redon drains the author frequently used gentamicin beads as drains.

The beads are pulled back in steps and create a circumscripted fistula. Complete eradication of an infection is not always the primary goal since the implant can be removed after healing of the nonunion (see Fig 1.5-6).

Fig 1.5-5 Author’s suture technique for infected wounds (1976).

One monofi lament suture adapts all tissue layers including the skin.

138

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Concepts and Cases in Nonunion Treatment

René K Marti, Peter Kloen

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Author

René K Marti

c

e

f

a

b

d

g

h

i

j

k

Fig 1.5-6a–k a–c One week postinjury: contaminated, comminuted, open fracture of the femoral shaft including the distal femur, the patella, and cruciate ligaments in a 23-year-old man. Good soft-tissue situation after hyperbaric oxygen treatment because of suspected gas gangrene. d–f Two months postinjury: multiple, completely devascularized necrotic bone fragments. Reconstruction of the condylar block. g After debridement of the infected necrotic fragments—stable distal and proximal plate fi xation—according to the principle of a bridge plate. h Rebuilding of the femoral shaft after cancellous bone grafts. i One year postinjury: the remaining low-grade infection leads to a fi stula at the level of the distal femur. No delay of fracture healing occurred and debridement and implant removal could be performed. j–k Remodeled femur 13 years postoperatively, pain-free but rather stiff knee, full working ability, no recurrence of the infection.

Note: Open reduction of the intraarticular fracture is absolutely indicated—further treatment with external fi xation would be an alternative but inconvenient for the patient. The preserved soft-tissue mantle allows debridement and internal fi xation.

139

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1 Principles 1.5 Infected nonunions

Loose implants have to be removed and a more extensive debridement followed by stable fixation is necessary. The resection of avascular bone which is still in contact with vital bone is the most difficult step because revascularization is possible in a well-vascularized environment; an unnecessary bone resection leads to a large defect (Fig 1.5-7).

a

b

c

The body is able to eliminate the infection by increased bone resorption and remodeling of vital areas, but loose avascular fragments act as foreign bodies and have no chance of being resorbed completely—they are sequesters and have to be removed (Fig 1.5-8).

d

e

Fig 1.5-7a–e Careful debridement. Revascularization of a degloved tibia. a–b Debridement and external fi xation of a severe open comminuted lower-leg fracture. 15 cm of the distal tibia are completely degloved (arrows), but could be covered with a vital soft-tissue mantle. Resection of the avascular distal part of the tibia would lead to a huge bone defect. c The arteriogram shows that the vascular supply to the degloved tibia is excellent and allows coverage of the proximal defect with a free fl ap. d Replacement of the external fi xator by two external plates creates optimal stability and allows an easier approach for the free-fl ap coverage. e Uneventful ingrowth of the free fl ap followed by bone grafting and full revascularization of the degloved tibia (see also chapter 1.1 “Evolution of treatment of nonunions”, Fig 1.1-29).

Fig 1.5-8 Typical sequester, marked with methylene blue. It is obvious that antibiotics will not reach the bacteria attached to the dead bone and that bone resorption will not take place because of the absence of blood supply.

140

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Concepts and Cases in Nonunion Treatment

René K Marti, Peter Kloen

4/14/11 3:10:37 PM

Author

René K Marti

Depending on the anatomical location, full stability in a one-stage intervention can also be achieved with an external fixator or with plates as external fixator (see Fig 1.5-6).

Finally, radical resection, shortening, and stable fixation is another alternative. Leg-length equalization can be performed as a second intervention (see case 2.10.12 “Nonunion and shortening of the femoral shaft after external fixation and infection—plate fixation and lengthening”).

5.3

Two-stage intervention

A two-stage intervention in the femoral shaft is indicated when full compression cannot be achieved without significant shortening of the leg. The first stage is debridement followed by external fixation using a unilateral external device. This option allows a possible second debridement and stable fixation with a wave plate or a nail in combination with bone grafting once all signs of infection have disappeared (see case 2.10.2 “Defect nonunion of the femoral shaft” and case 2.13.5 “Infected nonunion of the tibial shaft”).

Again there are alternatives, especially in presence of bone defects. The defect can be filled with gentamicin-PMMA beads or a solid block of antibiotics-loaded bone cement, creating a space for a subsequent bone graft. The space will be lined by an osteogenic membrane, which should not be removed at the time of bone grafting. This technique allows

a

b

c

primary plate or nail fixation after radical debridement but temporary external fixation followed by plate or nail fixation remains a safe option (see chapter 1.4.5 “Induced membranes—summary” and case 2.13.12 “Infected tibial nonunion”).

5.4

Reaming

Special treatment is needed for infections after intramedullary nailing. Both unreamed and reamed intramedullary nailing lead to partial necrosis of the endosteal part of the cortex.

An attempt of periosteal fracture healing by bridging callus formation is likely to occur despite infection as long as fracture fixation remains stable. However, delayed or nonunions may occur. In the 1970s, the author had come to the conclusion that reaming was the method of choice for the treatment of chronic intramedullary infections. Some time later his former coworker Ochsner published long-term results [6].

Reaming performed with a reamer which has a diameter 0.5–1.5 mm larger than the nail diameter until cortical contact occurs, will remove necrotic bone within the diaphysis. The use of sharp reamers is essential. Cooling is important and applying any force should be avoided. A distal opening is created, a lavage is performed and an overflow or irrigationsuction drainage installed for several days (Fig 1.5-9).

d

Fig 1.5-9a–d Reaming of an infected nonunion after nailing. a–b Infection after reamed Küntscher nailing of a transverse tibial fracture with comminution. There is some periosteal callus formation 6 weeks postoperatively. c–d Nonunion consolidates by stimulation of the periosteal callus after overreaming 1 mm and application of an irrigation-suction drainage. Note the opening in the distal tibia for the drainage (arrow). No additional, external fi xation was necessary; cast and brace protection created suffi cient stability.

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1 Principles 1.5 Infected nonunions

An alternative is the insertion of gentamicin beads as a chain, which can be retracted step-by-step within 10 days (Fig 1.5-10).

The author does not recommend further reaming and exchange nailing in the same session and prefers temporary unilateral external fixation in unstable situations and final fixation once all signs of the infection have disappeared.

6

After external fixation invisible pin-tract infections may be present and are a high risk for intramedullary nailing, even after debridement of the pin-tract. Removal of the external fixator and delayed nailing approximately 2 weeks later lower the risk but necessitate an uncomfortable cast fixation.

In the author’s experience primary plate fixation away from the external fixation pins are the safer option, certainly at the femur.

1

5.5

Multiple-stage treatment

Differentiated multiple-stage interventions are necessary in presence of large soft-tissue defects. These are most frequently located in the lower leg and exceptionally at the forearm. The pros and cons of reconstruction of the limb, based on a detailed treatment plan, must be discussed with the patient and relatives. Amputation should be considered if local and patient-related factors indicate that it is a preferred option—especially if the motivation of the patient is missing after an earlier lengthy treatment period.

2 2

The treatment principles are the same as for any infected nonunion, namely: 1. Identification of the infective organism 2. Debridement of dead bone and soft tissues 3. Stable fixation, mainly external 4. Soft-tissue coverage 5. Reconstruction of the bone defect

3 5 7 4 a

b

Fig 1.5-10a–b Reaming of the medullary canal in chronic infection after intramedullary nailing. a Reaming of the medullary canal (1) leaves behind isolated necrotic areas of bone (dark), which are partially sequestrated (2). The original cortex has been surrounded by newly formed periosteal and endosteal bone (light blue). A medullary fi stula has formed (3), which may spread to form a distant abscess (4). The entire medullary canal must be reamed from the proximal to the distal end. b If central reaming is not entirely successful, a lateral window (5) is created. With ample reaming that is supported by the thickened periosteal new bone formation (light blue) all necrotic fragments are removed. An overfl ow drainage without suction (6) is left in place for a few days and a gentamicinPMMA chain (7) for 10 days.

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There are different possibilities for soft-tissue coverage, and reconstruction of the bone defects. Universally used is the stable fixation in general, either with simple external fixation frames or the Ilizarov ring fixator. The use of plates as external fixator can be an elegant method.

Based on the author’s experience with more than 100 infected defect nonunions of the tibia, treatment options can be divided in two periods, namely before and after Ilizarov bone transportation and before and after free-vascularized muscle flaps became available.

Concepts and Cases in Nonunion Treatment

René K Marti, Peter Kloen

4/14/11 3:10:44 PM

Author

René K Marti

5.6

Classical reconstruction

What is now called the classical reconstruction was published

by Weber and Čech in 1973 [7]. The main difference to more recent approaches is the fact that no free flaps were used to cover the soft-tissue defect and Ilizarov bone transportation was not yet known at that time. However, the basic principles earlier mentioned remain the same.

After stable external fixation the debridement of bone and soft tissue can be performed in several steps. At first avascular bone may add stability and can be revascularized but loose, dead fragments have to be removed. Coverage of the open soft-tissue defect with humid gauzes or gentamicin beads will stimulate the formation of vital granulation tissue and even produce an osteogenic membrane. Vacuum dressing (VAC) may be an alternative, especially in smaller soft-tissue defects. Repeated debridement is possible without anesthesia and finally the soft-tissue defect can be covered with skin-mesh grafts. In presence of an intact lateral soft-tissue mantle, the reconstruction of the bone defect can be started before coverage of the medial soft-tissue defect has been completed.

a

d

b

The bone defect is reconstructed with multiple cancellous bone grafts at regular intervals, incorporating the decorticated fibula into the reconstruction (fibula pro tibia). Depending on the location, open bone grafts are an alternative (Fig 1.5-11) (see chapter 1.4.3 “Open cancellous bone graft”).

This classical reconstruction may be old fashioned but remains a reliable treatment option, which can lead to excellent long-term results. This is even valid for patients representing a truely negative selection, namely seven cases with large soft-tissue/bone defects of up to 20 cm after successful hyperbaric oxygen treatment of gas gangrene [8, 9]. Those cases cannot be compared with infected defect nonunions after open fractures, as the damage to skin, subcutaneous tissue, and muscles is much more severe. Nevertheless, after an average follow-up of 16 years they all had no recurrence of an infection, no refractures, and were fully active. The patients had normal knee motion and only limited ankle and foot motion because of the gas gangrene-related muscle necrosis. Restoration of the shape and cosmetic aspect of the tibia could be achieved by splitting the bone street

c

Fig 1.5-11a–d Open bone graft.

After radical debridement the dead cavity at the distal tibia is fi lled with pure, morselized autogenous cancellous bone grafts and covered with gentamicin beads until vital granulation tissue allows skin grafting, or spontaneous closure of the skin defect occurs.

Note: The gentamicin beads, covered with the humid dressing, remain untouched for 1 week.

After removal of the beads the open cancellous bone graft is covered with humid gauzes and wound inspection has to be performed daily. Small pieces of the graft may become necrotic and have to be removed. In general, the underlying cancellous bone is already revascularized. Free-fl ap coverage of such a small soft-tissue defect is also possible but is a much more invasive procedure.

143

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1 Principles 1.5 Infected nonunions

during the repeated lateral bone grafts, translating the bone mass medially (Fig 1.5-12). The skin-mesh grafts partially attached to the reconstructed tibia were transformed into resistant skin and did not cause any problems.

a

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144

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h

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l

Fig 1.5-12a–l Important steps in classical reconstruction of a large bone/soft-tissue defect. a–c Open wound treatment allows a less radical bone debridement. Note the partial revascularization of the proximal tibia. Two free vascularized fl aps would be necessary to cover this defect after radical debridement. d–i Bone reconstruction starts lateral, incorporating the decorticated fi bula. The bone street is split and medialized at the time two more bone grafts are applied. This approach enables giving the reconstructed tibia a normal shape. j–l Clinical result and cosmetic aspect of the lower leg after a 1-year reconstruction.

Concepts and Cases in Nonunion Treatment

René K Marti, Peter Kloen

4/14/11 3:10:50 PM

Author

René K Marti

Pros of the classical reconstruction are the less radical debridement with the possibility of secondary revascularization of the bone still attached to both ends of the defect and the low risk of each intervention, minimizing the loss of bone grafts by a reinfection.

a

b

e

f

Cons are the multiple hospitalizations and the long period of external fixation without full weight bearing. The open wound treatment is reliable but slow.

c

d

Fig 1.5-13a–f Classical reconstruction: important details. a–c Initially, the big necrotic part of the tibia is incorporated within the external fi xation, adds stability, and does not disturb but rather helps in open wound care. The posterior part may even have some osteogenic potential. The shape of the lower leg is preserved by the attachment of the dorsal muscles to the necrotic tibia. Further reconstruction see Fig 1.1-24 in chapter 1.1 “Evolution of treatment of nonunions”. d Coverage of the debrided open wound with gentamicin beads stimulates granulationtissue formation and even osteogenesis. e Attachment and expansion of the intact skin to the external fi xator reduces the softtissue defect. f If ankle function is not restored within days, and in order to avoid equinus contracture of the foot, a transmetatarsal pin connected to the external fi xator should be used.

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1 Principles 1.5 Infected nonunions

5.7

Primary free flap coverage of the soft-tissue defect

The classical treatment of infected tibial nonunions focused on bone reconstruction. Soft-tissue coverage was considered to be of less importance. After 1987 microsurgical interventions became popular at the author’s institution. If large infected soft-tissue defects are covered with a pedicled or a free flap, radical debridement is necessary in order to avoid an infection and the subsequent loss of the transplanted muscle flap. The author does not recommend flap coverage and bone grafting in one intervention because the risk of losing the cancellous bone grafts by an infection is too high.

The defect is filled either with gentamicin beads or a solid PMMA block. Bone grafting or even plate or nail fixation is performed 3–4 weeks after the muscle transfer in order to avoid losing the flap when performing the last stage of the reconstruction. Again because of the infection risk, bone grafting in intervals of 6–8 weeks is safer than a one-step intervention (see case 2.13.6 “Infected tibial nonunion, radical debridement, vascularized flap, and bone grafting”).

Pros of a primary flap coverage are the final soft-tissue quality and the shorter treatment if no problems or complications occur. Other arguments are that a vascularized muscle adds blood supply to the underlying bone graft.

Cons of a primary flap are the much bigger bone defects after a radical debridement and, that big soft-tissue defects may even need two free-vascularized flaps. Microsurgical techniques remain invasive and local- and donor-site problems may occur. Furthermore, it may be a logistical problem, because specialized microsurgeons are needed and not available at every institution.

In conclusion, the orthopaedic surgeon should not forget about the option of a free flap but the plastic surgeon should realize that not every soft-tissue defect needs a free flap— mother nature can be powerful.

5.8

Ilizarov callus distraction and bone transportation

Ilizarov’s contribution to the treatment of defect nonunions by callus distraction was revolutionary. The big advantage is that distraction osteogenesis is associated with an increase in local blood supply, the soft tissues are distracted as well, thereby minimizing the need for additional soft-tissue reconstruction (Fig 1.5-14).

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The open wound treatment allows repetitive debridements if necessary. Main indications are open defect nonunions of the tibia. The author never saw the need for the Ilizarov technique at the femur, where primary shortening and leglength equalization as a second step or temporary fixation with a unilateral external fixator is the better solution, avoiding knee stiffness.

Ilizarov’s original ring fixator allows simultaneous corrections of multiple deformities and optimal alignment of the docking site, but the construct is bulky, needs regular outpatient checkups, and is uncomfortable for the patient. Therefore, the author exclusively used the bone transport external fixator for tibial reconstructions (Fig 1.5-15).

For both bone transportation or lengthening, the secret of the Ilizarov technique is the minimal 1 mm primary distraction or even compression of the osteotomy followed by distraction not exceeding 1 mm a day in three to four steps. The author exclusively used the proximal, in general well-vascularized fragment for bone transportation and never the often degloved distal avascular fragment. Double transportation was never used. Bone transportation by callus distraction is a reliable method but problems and complications may arise.

The corticalization of the distracted callus can be difficult to judge even if the initial ossification is earlier detected with ultrasound than with standard x-rays. Too early a removal of the external fixator may lead to loss of length and secondary deformities.

Nonunions at the docking site are frequent, therefore, in most cases, surgical cleaning of the interposed soft tissues and skin has to be performed, sometimes in combination with decortication and filling of the bone defects with pure cancellous bone grafts. Exceptionally, internal fixation of the docking site is necessary.

Pros of the Ilizarov bone transportation are the simultaneous reconstruction of bone and soft-tissue defects without the need of skin or flap coverage and extensive bone grafting.

This is valid under ideal conditions when no problems occur.

Concepts and Cases in Nonunion Treatment

René K Marti, Peter Kloen

4/14/11 3:11:02 PM

Author

René K Marti

Cons are the fact that the bone transport may be long and cumbersome, requires a commitment by both the patient and the surgeon. The corticalization time can be long with all the problems seen with external fixation. Treatment time can vary between 5 months and 2 years. Callus distraction over an intramedullary nail may reduce the period of external fixation but is itself not without hazards in infected defect nonunions. Different Ilizarov cases are described in chapter 2.13 “Tibia, shaft”.

d

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e Fig 1.5-14a–i Ilizarov callus and soft-tissue transportation. a Primary coverage of this huge softtissue defect would need two free fl aps. b–e Uneventful docking of the transported fragment and full simultaneous coverage of the soft-tissue defect without any additional intervention. f–i Final result 2 years postoperatively.

i

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a

b

c

h

d

e

f

g

Fig 1.5-15a–i a Bone transport external fi xator (modifi cation of the Ilizarov frame). Metaphyseal osteotomy after transfi xation of the proximal and distal tibia. b Segment transportation. c Distal docking. d–g The same external fi xator used unilaterally and mounted anteriorly. h–i Clinical example. Reconstruction of the bone/soft-tissue defect by Ilizarov bone transportation alone.

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i

Concepts and Cases in Nonunion Treatment

René K Marti, Peter Kloen

4/14/11 3:11:09 PM

Author

René K Marti

5.9

Free vascularized bone grafts

For nonunions, the author’s team has rarely used a freevascularized bone graft. In contrast, they used a contralateralvascularized fibula after tibial tumor resection. The final result was good but it often took years until hypertrophy of the transplanted fibula occurred. Also, additional decortication and cancellous bone grafting was often necessary until full loading of the extremity was possible. This functional adaptation might even take longer in a disturbed vascular surrounding of an infected defect nonunion. Even double fibular transplantation could be necessary, accentuating the donor-site problems. Failed vascularized fibula transplantations are shown in case 2.10.5 “Five-year failed treatment of a femoral shaft nonunion” for the femur and in case 2.13.13 “Infected defect nonunion of the tibia— Ilizarov bone transportation after multiple interventions” for the tibia.

A free-vascularized fibula or iliac crest graft may be suitable for humerus and forearm defect nonunions but the autogenous bone grafts also lead to reconstruction of large defects (see case 2.4.3 “Combined humeral shaft and intercondylar nonunion”, case 2.10.2 Defect nonunion of the femoral shaft”, case 2.10.4 “Infected nonunion of the femoral diaphysis with bone defect”, and case 2.10.14 “Infected defect nonunion of the femur—external fixation and bone grafting”).

6

Surgical approach, reconstruction, fixation, and rehabilitation

In general, the surgical approach is given by former incisions or the open wound.

Reconstruction and fixation are described under preoperative planning, and rehabilitation depends on the fixation technique. All treatment principles, pitfalls, and pearls are well-described in the case presentations in the different chapters based on anatomical location.

7

Summary

Treatment of infected nonunions is teamwork. Members of the dedicated team should ideally include an infectious disease specialist, an immunobiologist, a plastic surgeon with microvascular exptertise, and the orthopaedic surgeon.

The multiple available external fixation systems fulfill their function. Personally, the author has been happy with the different AO versions including the old-fashioned Wagner lengthening device, nowadays replaced by the Mephisto system.

The use of plates as external fixator proved to be an excellent tool especially at the forearm and the tibia. No pin-tract infections have been seen, rigid fixation can be achieved with a much less bulky construction, leaving the necessary space for free-flap coverage of large soft-tissue defects.

Bone grafting needs our special attention. Only pure autogenous cancellous bone grafts should be used. These grafts have no primary mechanical but rather a purely biological function. Therefore, the grafts have to be morselized in order to allow quick vascularization, and should not contain any cortical components to reduce the risk of sequestration.

This is especially valid for open cancellous bone grafts, which show rapid ingrowth in a radically debrided, wellvascularized cavity.

The real challenge in the treatment of infected nonunions are the infected defect nonunions of the tibia with an extensive soft-tissue defect. An absolute indication for amputation is only given in presence of critical vascularity or loss of sensibility of the foot. But the indication for a reconstruction needs careful analysis of individual treatment possibilities and should not just depend on the ambition of the surgeon and the motivation of the patient.

Good long-term results can be achieved with all described techniques, classical reconstruction, primary flap coverage followed by bone grafting, and Ilizarov bone transportation.

The decision which treatment is best for a specific patient depends on the local situation, the individual wishes, and the experience of the surgeon.

The author is convinced that small defects of up to 6 cm do not need free-flap coverage or Ilizarov transportation. Here the classical reconstruction remains the author’s method of choice. He is also convinced that distraction osteogenesis is the method of choice for large soft-tissue and bone defects.

The indication for primary free-flap coverage followed by internal fixation and bone grafting lies somewhere in between.

Meticulous analysis and experience is necessary in order to decide whether a one- or multiple-stage intervention is indicated.

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1 Principles 1.5 Infected nonunions

These conclusions are based on the analysis of the author’s results of two series, namely 54 classical reconstructions and 47 primary pedicled or free-flap coverage of the softtissue defect [10, 11]. In the author’s long-term follow-up published by Tulner et al [10] of 20 pedicled and 28 microvascular free flaps, the flap failure rate showed an acceptable 8%. The results of the classical reconstruction did not show any long-term problems in an average followup of 16 years [11].

8

References

1. Ochsner PE, Sirkin MS, Trampuz A (2007) Acute infection. Rüedi TP, Buckley RE, Moran CG (eds), AO Principles of Fracture Management (second expanded edition). Stuttgart New York: Thieme, 521–540.

2. Johnson EE, Buckley RE (2007) Chronic infection and infected nonunion. Rüedi TP, Buckley RE, Moran CG (eds), AO Principles of Fracture Management (second expanded edition). Stuttgart New York: Thieme, 543–555.

3. Cierny G 3rd, Mader JT, Penninck JJ (2003) A clinical staging system for adult osteomylitis. Clin Orthop Relat Res; 414:7–24.

4. May JW, Jupiter JB, Weiland AJ, et al (1989) Clinical classification of post-traumatic tibial osteomyelitis.

J Bone Joint Surg Am; 71(9):1422–1428.

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At institutions that do not have a microsurgical expertise at their disposal, the treating surgeon should be aware that the learning curve of the Ilizarov bone transportation is not long. Most complications can be solved, and the surgeon should also know that the classical reconstruction is still a valid option with excellent long-term results even in large bone/soft-tissue defects.

5. Rittmann WW, Perren SM (1974) Cortical bone healing after internal fi xation and infection; biomechanics and biology.

1st ed. Berlin, Heidelberg, New York: Springer-Verlag.

6. Ochsner PE, Gösele A, Buess P (1990) The value of intramedullary reaming in the treatment of chronic osteomyelitis of long bones. Arch Orthop Trauma Surg; 109(6):341–347.

7. Weber BG, Čech O (1973) [Pseudarthroses: Pathophysiology, biomechanics, therapy, results.] 1st ed.

Bern: Hans Huber. German.

8. Marti RK, Bakker DJ (1988) Secondary reconstruction of defect-infect nonunions and pseudarthroses of the extremities following gas gangrene.

In: Hyperbaric Medicine Proceedings, 2nd Swiss Symposium on Hyperbaric Medicine.

Foundation for Hyperbaric Medicine, Basel. 109–122.

9. Marti RK, Raaymakers E (1978) [Reconstruction of defect-infect pseudarthroses in status after gas gangrene of the lower extremity.]

Unfallheilkunde; 81(4):368–374.

German.

10. Tulner SA, Schaap GR, Strackee SD, et al (2004) Long-term results of multiple-stage treatment for posttraumatic osteomyelits of the tibia.

J Trauma; 56(3):633–642.

11. Marti RK, Besselaar PP, Raaymakers ELFB, et al (1998) [Treatment of infect-defect pseudarthroses of the lower leg, 25 years experience.]

Ned T Orthop; 5:6–15. Dutch

Concepts and Cases in Nonunion Treatment

René K Marti, Peter Kloen

4/14/11 3:11:17 PM

Author

Gerardo Fica

2.6.2 Sacroiliac nonunion after unstable pelvic fracture 1

Case description

A 56-year-old man sustained an unstable pelvic fracture in a work accident. Osteosynthesis was performed with two percutaneous sacroiliac screws after open reduction of the

displaced joint, and placement of an external fixator in the anterior arc of the pelvis.

Fig 2.6.2-1 AP x-ray of pelvis: left sacroiliac luxation, right iliopubic fracture, and pubis diastasis.

Fig 2.6.2-2

CT scan of pelvis shows left sacroiliac luxation.

Fig 2.6.2-3 Osteosynthesis with two percutaneous sacroiliac screws and anterior external fi xation.

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2 Cases

2.6 Pelvis/acetabulum

2.6.2 Sacroiliac nonunion after unstable pelvic fracture

Three months after the osteosynthesis, the x-ray showed loss of the sacroiliac reduction with screw displacement and osteolysis. The screws had to be removed.

One year postinjury, a nonunion and arthrosis of the left sacroiliac joint was diagnosed (x-ray, CT scan) as the result of loss of reduction and insufficient stability in the anterior and posterior arc of the pelvic ring.

Fig 2.6.2-4 Osteosynthesis with two percutaneous sacroiliac screws and anterior external fi xation.

Fig 2.6.2-5

X-ray shows nonunion in the left sacroiliac joint.

Indication

Nonunion in the sacroiliac joint is associated with pain, inability to work and an inability to bear weight.

In this context of symptomatic nonunion and arthrosis in the sacroiliac joint, arthrodesis was selected as the best available treatment option.

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Concepts and Cases in Nonunion Treatment

René K Marti, Peter Kloen

4/14/11 3:32:54 PM

Author

Gerardo Fica

2

Preoperative planning

Equipment

Patient positioning

• • • •

The patient is placed in a prone decubitus position.

Chisels Pelvic reconstruction plate 4.5 Bending pliers Screws

(Size of system, instruments, and implants may vary according to anatomy.)

3

The patient is placed under general anesthesia, and the bilateral sacroiliac zone prepared.

Prophylactic antibiotics and a thrombosis prophylaxis (eg, low-molecular-weight heparin) are administered.

Surgical approach

Both sacroiliac joints are accessed by a bilateral straight and vertical incision. On the left joint, the iliac crest and sacroiliac cartilage are resected. The autogenous bone graft is placed in the joint.

4

Reduction and fixation

The pelvic reconstruction plate 4.5 is placed spanning both sacroiliac joints below the paravertebral muscles and fixed with three screws at each side; on the left side the screws are placed through the joint.

Fig 2.6.2-6 X-ray shows left sacroiliac arthrodesis with pelvic reconstruction plate 4.5, six screws, and autogenous bone graft.

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2 Cases

2.6 Pelvis/acetabulum

2.6.2 Sacroiliac nonunion after unstable pelvic fracture

5

Rehabilitation

Following fixation of the sacroiliac joint, the patient was supervised by a physical therapist for controlled active movements in bed for 3 weeks postoperatively. Partial weight bearing on two crutches was permitted for the first few postoperative months. At 5 months full weight bearing was authorized.

Implant removal

The implant used in the arthrodesis has not been removed.

Fig 2.6.2-7 AP x-ray of pelvis 1 year after the arthrodesis shows complete consolidation of the nonunion.

–

8

Pitfalls

+

Pearls

Fixation

Fixation

The following facts may have contributed to the nonunion and arthrosis of the left sacroiliac joint: insufficient fixation of the sacroiliac joint, poor reduction of the pubic fracture, and pubic diastasis.

The sacroiliac arthrodesis is a good solution for the symptomatic nonunion of this joint.

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Concepts and Cases in Nonunion Treatment

René K Marti, Peter Kloen

4/14/11 3:32:56 PM

Author

Peter Kloen

2.6.3 Pelvic nonunion

1

Case description

A 78-year-old woman was admitted to the medical service for general malaise and weakness. She had suffered a stroke 3 months prior, which left her with left-sided weakness.

She had a complex medical history including atrial fibrillation, chronic urinary tract infection, depression, hyponatremia, and a high erythrocyte sedimentation rate (ESR). During her medical check-up she complained of low-back pain and pain around her symphysis. Six months prior she had sustained a low-energy fall on her hip. Standard pelvic x-rays showed fractures of her pubic rami. The medical service suspected

a

a pathological fracture and performed a needle biopsy which came back negative for malignancy. Only then did the medical service consult the author to see whether her pelvic fracture could be treated. Routine AP pelvis, AP inlet, and AP outlet x-rays suggested a nonunion of both left and right pubic rami. It was difficult to evaluate the sacrum on the standard x-rays. To better evaluate the sacrum a CT was obtained. The CT clearly showed a sacral nonunion through the right sacral foramina (Denis type 2).

b

c c

Fig 2.6.3-1a–c

AP (a), inlet (b), and outlet (c) x-ray views of the pelvis.

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2 Cases

2.6 Pelvis/acetabulum

2.6.3 Pelvic nonunion

Indication

Given her pain the patient was not able to bear weight. It was felt that stabilization of the posterior sacrum might lead to consolidation of at least the posterior components of the pelvic injury. Given her repeated urinary infections it was decided to use a 2-pin external fixator as a tension band anteriorly to minimize the risk of hardware-induced infection.

In addition, given the enormous deformity of the pubic rami it was felt that formal plate osteosynthesis would require a large anterior exposure (eg, Stoppa) with high morbidity.

Fig 2.6.3-2

2

CT scan shows the Denis type 2 sacral nonunion.

Preoperative planning

Ideally, to allow compression across the sacral nonunion both anterior and posterior aspects of the pelvic ring need to be addressed. Given the long-standing urinary tract problems, a large anterior procedure would carry a substantial risk for infection. Posterior fixation of acute sacral fractures is currently done using percutaneous cannulated screws. Other techniques are posterior tension band plating. For sacral and pelvic nonunion only limited data exist in literature.

Most reports combine various techniques to maximize stability and healing potential.

Patient preparation and positioning

The patient is placed prone on the radiolucent table. The lower back and upper thighs are prepped and draped sterile.

Radiographic evaluation is paramount, so the surgeon must always check prior to incision whether the images of interest (inlet, outlet, AP, and lateral) can be obtained.

Equipment

• • • • • • • •

Radiolucent table Cushions for prone positioning 11-hole titanic pelvic reconstruction plate 4.5 4.5 mm standard and locking screws Cannulated large fragment screws External fixator Large pelvic reduction clamp Large plate benders

(Size of system, instruments, and implants may vary according to anatomy.)

Fig 2.6.3-3 The patient is placed prone. A towel roll is wedged under the pelvis to facilitate access to the posterior pelvic ring.

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Concepts and Cases in Nonunion Treatment

René K Marti, Peter Kloen

4/14/11 3:32:58 PM

Author

Peter Kloen

3

Surgical approach

Two incisions are made slightly lateral and parallel to the sacroiliac joints starting at the level of the spina iliaca posterior superior extending down approximately 8 cm. In the most distal aspect of these two incisions the sciatic notch can be palpated. A third incision can be made in the midline over the spinous process of S1 and S2. Through the two outer incisions the gluteal musculature is elevated off the ilium exposing the outer table of the posterior iliac crest.

Spina iliaca posterior superior Spina iliaca posterior inferior

Fig 2.6.3-4a–b

4

Exposure of the outer table of the posterior iliac crest.

Reduction and fixation

Two large cannulated screws are placed over two guide wires that have been placed under radiographic guidance (Fig 2.6.3-5a). Fully threaded screws are used as not to compress the sacral foramina in this Denis type 2 sacral nonunion. Initially, a washer with the first screw is used but the bone quality is so poor that the washer disappears inside the cortex when tightening the screw. The screw and washer are removed and a flattened semitubular plate is used as a washer (Fig 2.6.3-5b). The larger surface area of this modified washer prevents penetration of the outer cortex.

Once radiographic confirmation of good screw positioning is obtained, an 11-hole titanium pelvic reconstruction plate 4.5 is inserted from the right lateral incision towards the left side, spanning over the posterior aspect of the sacrum.

To prevent hardware prominence an opening is created in each posterior crest with an osteotome to insert the plate.

Prior to insertion, the plate is slightly bent on both sides at the level of the posterior crista so that final contouring— once the plate is in place—is facilitated. The plate is pulled

across by pulling on a #5 Ethibond suture (Fig 2.6.3-5c). The (third) midline incision is used to help pass the plate (this incision might not be needed once experience with this technique is gained).

The plate is fixed first on one side after careful molding of the plate to the outer table of the ilium. Locking screws are used to fix the plate. Ideally a locking screw is placed through a hole directly over the crista although this is not always possible given the size and anatomy of the patient. After fixing one side of the plate, the contralateral side of the plate is molded to the outer cortex. Using a large pelvic reduction clamp helps to contour the plate. Here also locking screws are used to fix the plate and ideally a screw is placed down the posterior crista. Wounds are closed over a drain. Next the patient is turned supine and a 2-pin supraacetabular external fixator is placed. The external fixator is preloaded under slight compression to maximize the tension band effect.

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2 Cases

2.6 Pelvis/acetabulum

2.6.3 Pelvic nonunion

a

b

c

e d Fig 2.6.3-5a–e a Intraoperative image intensifi cation shows the two guide wires in place and one fully threaded screw being inserted over a guide wire. b Two screws and a modifi ed washer are now in place. c The pelvic reconstruction plate 4.5 is being inserted by pulling a #5 Ethibond suture. d Molding of the plate to the outer aspect of the ilium. e Final positioning of the posterior fi xation.

a

b

Fig 2.6.3-6a–b a AP pelvis x-ray shows the external fi xation and posterior hardware. b Outlet pelvic x-ray after fi nal fi xation.

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Concepts and Cases in Nonunion Treatment

René K Marti, Peter Kloen

4/14/11 3:33:01 PM

Author

Peter Kloen

5

Rehabilitation

Given her recent stroke, the patient was not able to ambulate with partial weight bearing. Therefore she was mobilized from bed to chair for 4 weeks after which weight bearing was increased to weight bearing as tolerated with an ambulator. X-rays taken at 8 months showed a healed sacral nonunion. All hardware remained intact. Eight months after surgery she was fully ambulatory and reported no further pain.

Implant removal

The external fixator was removed in the outpatient department 6 weeks postoperatively. No pintract infection had developed.

Six years after surgery the patient was doing well although she had suffered additional neurological deficits following another stroke. She was, however, ambulatory without pain.

a

b Fig 2.6.3-7a–c X-rays taken 8 months after surgery show intact hardware and a healed nonunion. The external fi xator had been removed earlier in the outpatient department.

c

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2.6 Pelvis/acetabulum

2.6.3 Pelvic nonunion

a

–

8

b

Pitfalls

Fig 2.6.3-8a–c Patient denied any pain and was fully ambulatory 8 months postoperatively.

c

+

Pearls

Surgical approach

Surgical approach

Only if the dissection is taken too far distally (into the greater sciatic notch) there is risk for neurovascular injury.

After a short learning curve this procedure can be done using a relatively minimally invasive approach.

Reduction

Reduction

An open anatomical anterior reduction was not advisable or possible in this case. Relying only on the posterior fixation would probably be insufficient.

Fixation

A plate that is too long will not allow easy adaptation through a minimally invasive approach.

A plate that is too short will not allow the necessary fixation with at least three screws on each side.

Overly compressing a Denis type 2 (transforaminal) sacral fracture/nonunion can cause neurological deficits.

If anterior fixation is not possible, a supraacetabular external fixator provides a tension band effect.

Fixation

Fully threaded screws should be used not to overly compress the neural foramina in a Denis type 2 sacral injury.

The plate should be prebent at one end to facilitate molding of the plate once in situ.

To minimize the need for later implant removal, the bone blocks on both sides should be removed or a slot to “sink” the plate below the posterior bony prominences should be created.

Transiliac rods have also been used for this purpose but their high compression forces on the lateral cortex of the ilium can cause protrusion of the nut into the bone leading to instability.

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Concepts and Cases in Nonunion Treatment

René K Marti, Peter Kloen

4/14/11 3:33:05 PM

Author

Peter Kloen

2.6.4 Pelvic nonunion after periacetabular osteotomy 1

Case description

A 36-year-old man with bilateral hip dysplasia had undergone successful triple pelvic osteotomy on the left side. Four years later his hip surgeons performed a periacetabular osteotomy on the right side. The posterior sciatic osteotomy was not performed according to standard technique and had fractured so that the posterior column was not intact. Nine months later there was pain and limited ability to bear weight and radiography showed a nonunion of both the anterior as well as the posterior (sciatic) osteotomy. The pubic ramus nonunion

a

was atrophic whereas the ischial nonunion was hypertrophic.

The supraacetabular osteotomy had healed. Eleven months after initial surgery a posterior approach was used to plate (locking compression plate (LCP) 3.5 with nonlocking screws) the ischial nonunion while adding bone graft. After 21 months the nonunion of both the ramus superior and the ischium had not yet healed. As his surgeon had left the department, the patient was referred to the author’s institution for treatment.

b

Fig 2.6.4-1a–b X-rays after triple pelvic osteotomy on left side. Dysplasia of the right hip is seen.

Fig 2.6.4-2 Four years later, after periacetabular osteotomy on right side.

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2 Cases

2.6 Pelvis/acetabulum

2.6.4 Pelvic nonunion after periacetabular osteotomy

a

b

c

d

Fig 2.6.4-3a–d Nine months later there was pain and limited ability to bear weight and radiography showed a nonunion of both the anterior and the posterior (sciatic) osteotomy.

Indication

Although the reorientation of the acetabulum was successful the nonunion of the two osteotomies limited the patient’s activities. The initial attempt at salvaging the nonunion by only plating and grafting the ischial nonunion might have been too limited. As the pelvis is a ring, it might have been better to attack both the anterior as well as the posterior components.

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René K Marti, Peter Kloen

4/14/11 3:33:09 PM

Author

Peter Kloen

a

b Fig 2.6.4-4a–c Showing the initial attempt of salvage when only the ischium was plated. The nonunion persisted.

c

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2 Cases

2.6 Pelvis/acetabulum

2.6.4 Pelvic nonunion after periacetabular osteotomy

2

Preoperative planning

Equipment

Patient preparation and positioning

• • • •

A dual approach was planned to first address the posterior column nonunion of the ischium via a Kocher-Langenbeck approach followed by an anterior (ilioinguinal) approach for superior pubic ramus.

Radiolucent table Pelvic reconstruction plate 3.5 3.5 mm screws Pelvic reduction clamp

(Size of system, instruments, and implants may vary according to anatomy.)

Posterior approach: the patient is positioned in a lateral decubitus position on a beanbag.

Anterior approach: the patient is placed in a supine position after removing the beanbag.

2

Surgical approach

A Kocher-Langenbeck approach is performed. Deep cultures are taken and antibiotics are now administered. There are no obvious signs of infection.

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René K Marti, Peter Kloen

4/14/11 3:33:12 PM

Author

Peter Kloen

3

Reduction and fixation

Previous hardware is removed. A standard steel pelvic reconstruction plate 3.5 is placed posterior after compressing the hypertrophic nonunion with pelvic reduction clamp.

No bone graft is added.

7

6

7

1

1

8

a 4

2 b

3 5

Fig 2.6.4-5a–b Kocher-Langenbeck approach. a Skin incision. b Deep exposure. The sciatic nerve (1) must always be protected. Division of the short external rotator muscles (2) exposes the posterior hip capsule (3). The medial femoral circumfl ex vessels (4) supply the femoral head and are closely related to the quadratus femoris muscle (5). They must be protected by avoiding any dissection of this muscle. This piriformis muscle (6) is cut and the superior gluteal neurovascular bundle (7) must be protected. The gluteus medius muscle (8) is retracted.

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2 Cases

2.6 Pelvis/acetabulum

2.6.4 Pelvic nonunion after periacetabular osteotomy

4

Anterior approach and fixation

The patient was then turned supine after removing the beanbag. An ilioinguinal approach was done according to Letournel.

Fig 2.6.4-6a–d Ilioinguinal approach. a Skin incision. b–c Deep exposure. The ilioinguinal approach creates four anatomical windows (I–IV) to allow access to the anterior column of the acetabulum.

I = Lateral: lateral to the iliopsoas muscle.

II = Middle: between iliopsoas muscle/femoral nerve and external iliac vessels.

III = Medial: between external iliac vessels and spermatic cord.

IV = Median: medial to the spermatic cord.

6

3 a

1 2 3 4 5 6 7

Iliopsoas muscle (detached) Femoral nerve Femoral vein and artery External iliac artery and vein Spermatic cord Lateral femoral cutaneous nerve Inguinal ligament

I

6 1 2 4 7 5 IV

b

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4/14/11 3:33:18 PM

Author

Peter Kloen

Fig 2.6.4-6a–d (cont) Ilioinguinal approach. b–c Deep exposure. The ilioinguinal approach creates four anatomical windows (I–IV) to allow access to the anterior column of the acetabulum.

I = Lateral: lateral to the iliopsoas muscle.

II = Middle: between iliopsoas muscle/femoral nerve and external iliac vessels.

III = Medial: between external iliac vessels and spermatic cord.

IV = Median: medial to the spermatic cord. d Coronal view of hemipelvis. The lateral femoral cutaneous nerve and genitofemoral nerve are also protected.

1 2 3 4 5 6 7

6 7 1 2 3

5

Iliopsoas muscle (detached) Femoral nerve Femoral vein and artery External iliac artery and vein Spermatic cord Lateral femoral cutaneous nerve Inguinal ligament d

2

4 II III 7 5

c

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2 Cases

2.6 Pelvis/acetabulum

2.6.4 Pelvic nonunion after periacetabular osteotomy

In the x-ray it was obvious that the supraacetabular osteotomy had healed. A steel standard pelvic reconstruction plate 3.5 was molded to fit over the nonunion. Bone graft was added from the iliac crest.

5

Rehabilitation

Toe-touch weight bearing for 6 weeks. Postoperatively the patient developed a deep wound infection that required irrigation, debridement, and intravenous antibiotics. All hardware was left in situ. The patient recovered and the

a

nonunion healed without further problems. The patient was most recently contacted 5 years after his last surgery. He was capable of full weight bearing and reported no hip pain.

b Fig 2.6.4-7a–c nonunion.

X-rays 6 months postoperatively showing healed

Implant removal

c

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In case of infection during the healing phase the author often advises patients to have their hardware removed once the bone has consolidated. However, given the complexity of this dual approach removal was not attempted because the patient recovered fully without residual signs of infection.

Concepts and Cases in Nonunion Treatment

René K Marti, Peter Kloen

4/14/11 3:33:45 PM

Author

–

8

Peter Kloen

Pitfalls

+

Pearls

Reduction and fixation

Reduction and fixation

Plating the pubic ramus nonunion necessitated a large approach. A retrograde pubic ramus screw might have been sufficient although this was an atrophic nonunion.

With a posterior and anterior component to the nonunion both should probably have been addressed during the second surgery.

6

Further reading

Altman GT, Altman DT, Routt ML Jr (2000)

Symptomatic hypertrophic pubic ramus nonunion treated with a retrograde medullary screw. J Orthop Trauma; 14(8):582–585.

Ganz R, Klaue K, Vinh TS, et al (1988) A new periacetabular osteotomy for the treatment of hip dysplasias. Technique and preliminary results. Clin Orthop Relat Res; 232:26–36.

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