Next, a prospective interventional study aimed at evaluating the effectiveness of the proposed tibial nonunion treatment algorithm was undertaken. Part Two: Part two discusses the rationale for developing the tibial nonunion treatment algorithm.
Introduction
A subsequent prospective interventional study was performed to evaluate the effectiveness of the tibial non-union treatment algorithm. Outline the pathogenesis of tibial non-union and highlight the factors associated with its development.
The Pathogenesis of Tibial Non-union
Many clinical trials have not provided a definitive answer on the effect of NSAIDs on fracture healing.66 Bhattacharyya et al., Burd et al. Effect of smoking on fracture healing and risk of complications in open limb-threatening tibial fractures.
Challenges and Controversies in Defining and Classifying Tibial Non-unions
It is during this period that most of the morbidity associated with non-unions arises. To date, no consensus exists on the definition of non-union and none of the current classifications have proven universally useful.
Tibial Non-union Treated with the TL-Hex: a case report
We report a case of rigid oligotrophic nonunion of the distal tibia successfully treated with monofocal distraction using the new circular external fixator TL-Hex (Orthofix, Verona, Italy). Immature persons require more resources, expensive treatment strategies and a precise understanding of the underlying disease process SAOJ Autumn 2015_Ortopedija Vol3 No. PM Page 44. Treatment of delayed union or nonunion of the tibial stem with partial fibulectomy and the Ilizaro frame.
The hexagonal fixator was a recent modification of the traditional Ilizarov-type fine-wire circular external fixator.29,30 It consists of two rings connected by six oblique struts in an octahedral configuration. In tight nonunions, the ability of the hexapod circular external fixator to provide controlled gradual distraction allows not only the correction of existing deformities, but also the stimulation of new bone formation. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Predictors of nonunion and reoperation in patients with fractures of the tibia: an observational study.
Hexapod External Fixator Closed Distraction in the Management of Stiff
The management of these complex injuries remains one of the most challenging problems facing the orthopedic trauma surgeon.8. We report our results of closed distraction of rigid, hypertrophic, ununited fractures of the tibia with hexapod circular external fixators. Anteroposterior (left) and lateral (right) radiographs of the tibia six months after open fracture showing angulation and nonunion at the fracture site.
In all fractures, leg length was restored to within 1 cm of the contralateral side. Several authors have outlined the principles for the generic ideal treatment of the problem. Our series supports their findings and specifically indicates the value of the hexapod external fixator in the treatment of stiff hypertrophic tibial nonunions.
Accuracy of complex lower extremity deformity correction with external fixation: a comparison of the Taylor Spatial Frame with the Ilizarov ring fixator.
Mechano-biology in the Management of Mobile Atrophic and Oligotrophic Tibial
This algorithm incorporated the treatment strategies that were used successfully during our retrospective audits, with the inclusion of two additional strategies aimed at two less common non-combining subtypes, the so-called mobile hypertrophic "true". The advantage of the proposed treatment algorithm is the suggestion of a specific treatment strategy for each of the four non-fused subtypes. The algorithm also places special emphasis on optimizing host factors that predispose the patient to the formation of non-healing tissue, as well as postoperative functional rehabilitation.
This means that only during definitive surgery without fusion can the final decision on the treatment strategy be made. The implication of getting this wrong was shown in our retrospective series on rigid hypertrophic non-unions. The next chapter evaluates the effectiveness of the tibial non-union treatment algorithm through a prospective interventional study that was undertaken over a one-year period.
During this time, all patients with tibial nonunions were treated according to the algorithm.
Management of Tibial Non-unions: Prospective Evaluation of a Comprehensive
Our proposed treatment algorithm appears to produce high union rates in a diverse group of tibial nonunions. We report the results of the management of non-infected tibial unions treated according to our proposed tibial nonunion treatment algorithm. Between January 2014 and December 2014, all patients who presented with noninfected tibial nonunions were treated according to our proposed tibial nonunion treatment algorithm.
Ilizarov external fixator (Smith & Nephew, Memphis, TN) was used for five, and Truelok external fixator (Orthofix, Verona, Italy) for nine mobile atrophic and oligotrophic nonunions. Hard hypertrophic nonunion was treated with Taylor Space Frame (TSF) (Smith & Nephew, Memphis, TN) in seven and Truelok-Hex (TL-Hex) (Orthofix, Verona, Italy) in 16 cases. Both patients with a nonunion defect were treated with a Truelok external fixator (Orthofix, Verona, Italy).
In conclusion, our proposed treatment algorithm for tibial nonunions appears to produce high rates in a diverse group of tibial nonunions.
Prevention and Management of External Fixator Pin Track Sepsis
It should be emphasized that any strategy to reduce pin site complications begins in the operating room [10]. Twice-daily cleaning of the pin site is continued throughout the duration of external fixation. Although there is no standardized system for classifying pin site infections [5], the Checketts-Otterburn classification is widely used and provides valuable information regarding treatment [35].
We advocate that pin track care be restarted as soon as pin site infection is identified. 2 Redness of the skin, discharge, pain and tenderness in the soft tissue. Improved pin site care and oral antibiotics 3 Grade 2 but no improvement with oral antibiotics. Affected pin or pins recited and external. Gordon JE, Kelly-Hahn J, Carpenter C, Schoenecker PL (2000) Pin site care during external fixation in children: results of a nihilistic approach.
Checketts RG, MacEachern AG, Otterburn M (2000) Pin-track infection and the principles of pin-site care.
Pin Tract Sepsis: Incidence with the use of Circular Fixators in a Limb Reconstruction
Pin site problems remain one of the most common complications in the field of limb reconstructive surgery. Several factors determine the integrity of the bone-pin interface, including the insertion technique, the mechanical forces applied through the frame, and the chosen care protocol for the pin site. Pin site complications can be catastrophic as they can lead to failure of the bone-pin interface and, possibly, osteomyelitis.
Radiographs revealed a small sequestrum in the pin canal that required in-theater debridement of the canal and subsequently healed without incident. These complications could ultimately lead to failure of the bone-pin interface and chronic osteomyelitis. Instability of the external fixator-pin-bone construct leads to pin loosening and infection.3 This infection then further contributes to the deterioration of the bone-pin interface.
These incisions should be as small as possible to facilitate rapid healing of the skin around the pin or wire, thereby creating a bone-pin interface that is sealed from the external environment.
The Effect of HIV Infection on the Incidence and Severity of Circular External
The effect of HIV infection on the incidence and severity of circular external fixator pin sepsis: a retrospective comparison. The effect of HIV infection on the incidence and severity of circular external fixator pin track sepsis: a retrospective comparative study of 229 patients. This retrospective review aims to compare the rate and severity of pin track sepsis in HIV-positive and HIV-negative patients treated with circular external fixators.
It is also currently the only study investigating the effect of HIV infection on the incidence and severity of pin track sepsis using circular external fixators. There was no statistically significant difference in the incidence of pin track sepsis between the three groups (p=0.94). Furthermore, the three groups showed no statistically significant differences in terms of severity of pin track sepsis (p=0.9).
Our results correlate with the findings that there is no correlation between CD4count and severity of pin track infection in HIV-positive patients.
Conclusion
Further, although nonunions are divided into different subtypes, none of these classifications prescribe treatment for specific nonunion subtypes. Our research identified four distinct nonunion subtypes, namely rigid hypertrophic, mobile atrophic/oligotrophic, mobile hypertrophic (true pseudoarthrosis), and defective nonunions. Verifying unionization after nonunion management is difficult to assess and remains a challenge regardless of treatment strategy.
The current research can be considered a proof of concept for the tibial non-union treatment algorithm. The absence of pain at the non-union site is also not an indication that solid union has occurred. The proposed tibial nonunion treatment algorithm appears to produce a predictable, high union rate after a single operation without the need for expensive treatment add-ons.
One of the most important steps in management decision-making is based on the mobility of the non-union side.
Study Protocol
Controversy in precisely defining nonunion has contributed to treatment delays and exacerbated the morbidity commonly associated with nonunion development. Tibial nonunions in particular are common and represent the majority of cases seen in nonunion and reconstruction clinics. A prospective interventional study will be performed to evaluate the outcome of tibial nonunions treated according to the new classification system and treatment protocol.
Another important aspect of non-union management was highlighted, namely the possibility of potential contagion of these non-unions. To design and validate a new strategy for the classification and treatment of nonunion tibia using circular fine wire external fixators. All patients treated for nonunion of the tibial bone between January 2008 and December 2013 will be included.
All consecutive patients with tibial nonunion presenting to the Tumor, Sepsis and Reconstruction Unit will be considered for inclusion.
Ethics Approval
Institutional Approval
Department of Health Approval
