Infected lower tibial nonunions without bone grafting - Reliable union using the Ilizarov technique

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