1. Ebrahimzadeh Mohammad H. MD
Results and techniques of the treatment of infected nonunion of the long bones, a report of 40 cases
Ebrahimzadeh Mohammad H. MD
Department of Orthopedic surgery
Ghaem Hospital
Mashhad University of Medical Sciences, Mashhad, Iran.

2. Infected nonunion 40 patients; 34 men, 6 women 28 tibia 12 femur
23 (57%) Smoker

3. Infected nonunion infected nonunion of tibia; 28 patients
17 middle third %
8 distal third %
3 proximal third %

4. Infected nonunion infected nonunion of the femur; 12 case
7 distal third %
3 middle third %
2 proximal third %

5. Infected nonunion of the tibia 28 cases
Treatment modalities
Ilizarov apparatus; 21 patients
Plate/ IM rod removal and sequential debridement,…, grafting and plating again; 7 cases

6. Infected nonunion of the femur,12 case
Ilizarov apparatus: 5 cases
Plate/ IM rod removal and sequential debridement,…, grafting and plating again; 4 cases
Plate removal and sequential debridement,…, grafting and girdle stone; 2 cases
Plate removal and sequential debridement,…, grafting and external fixatore, 1 case

7. Ilizarov Results (26 patients)
all patients with Ilizarov apparatus were united and the infection was eradicated finally; 6-30 months
in 4 patients we did rotation flap

8. Ilizarov Results (26 patients)
Complications:
Pin tract infection cases
Knee stiffness
Ankle/foot stiffness
Proneal nerve palsy 3
Refracture

9. Results
Infection was eradicated in 2 Gildelston cases and in one case of them after 4 years of being free of infection,,, the patient is in line for THA.

10. Results
Plate/ IM rod removal and sequential debridement,…, grafting and plating again patients
10 finally successful
1 amputation

11. Results
Plate removal and sequential debridement,…, grafting and external fixatore, 1 case Successful

12. Infected nonunion treatment methods depend on
Type of nonunion; atrophic? Hypertrophic?
Extent of infection
Presence of atrophic skin changes

13. Ilizarov`s concept for infected nonunion:
Osteomylitis burns in the fire of regeneration
Activate biosynthetic process, increasing local resistant to infection

14. Three ways of elimination of infection in Ilizarov method
Controlled osteogenesis, filling of cavities by newly formed tissue
Resection of infected bone and subsequent intercalary bone lengthening
Gradual bone transport of one wall of the cavity

15. Ilizarov Distraction osteogenesis Tension-stress effect
Mechanical induction of new bone formation
Neovascularization
Stimulation of biosynthetic activity
Activation and recruitment of osteoprogenitor cells
Intramembranous ossification

16. Ilizarov`s plan depends on
Size and thickness of bone fragment
Degree and type of displacement
The extent of mobility
Amount and character of scar tissue
Prevalence of purulent process
Characteristics of the individual case

17. Important
Nutritional Index
#WBC
Functional WBC
Stop Smoking

18. Monofocal longitudinal compression
Hypertrophic nonunion
Minimal infection
No sequestrum, smallest sequester left in place, they are assimilated in the process of active osteogenesis
-spontaneous eradication of infection and achievement of union

24. Bifocal Method Atrophic nonunion with diffuse infection and sequestrum
Infected segment should be resected
Creating an intercalary defect

25. Bifocal Method
Acute shortening, opposing ends under compression; 1-2 Cm defect
Poor skin
Big necrotic bone
Numerous fistula

26. Bilocal simultaneous compression-distraction osteosynthesis
Small gap & substantial bone shortening

27. Persistent drainage
And gross motion after
Multiple attempts at
Surgical treatment

28. Followed by proximal
Corticotomy and
Distraction to restore
length
Treatment consisted
Of resection of
Infected bone, acute
Shortening and
External fixation

29. Bilocal consecutive distraction-compression osteosynthesis
Large gap

38. A little Literature Review

39. Acute compression and lengthening by Ilizarov method for infected nonunion of tibia
Magadum MP at al, J of Orthopedic Surgery, 2006;14(3).
27 patient
Complete debridment of nonunion, sequestrectomy, lavage and Ilizarov application
Gap; 10 (6-17)
19 excellent, 5 good, 1 fair, 1 poor,1 above-knee amputation in months.

40. Ilizarov method as a salvage procedure in infected nonunion of the distal femur with bone loss
Saridis A et al JBJS Br. 2006; 8(2).
13 patients; 10 men, 3 women
Radical debridement and Ilizarov application
3.1 previous surgeries
8.3 mean length of defect(3-18)
MEAN external fixator time 309 days
Union and elimination of infection achived in all 13 patients. 8 excellent, 4 good, 1 fair.
1 re-fracture

41. Conclusion
Ilizarov is a golden method for the management of nonunion osteomylitis for both achieving union and eradication of infection, however generous, careful sequential debridement and hardware/dead tissue removal and bone grafting is also an option for some selected cases.