br Acknowledgments This study was supported by a grant from
Acknowledgments This study was supported by a grant from the National Science Council (NSC 98-2314-B-075B-007-MY2).
Introduction Many complications may occur following treatment of femoral shaft open fracture such as nonunion, malunion, delay union, bone defect, bone and joint deformity or stiffness, limb-length discrepancy, and osteomyelitis. Severe chronic osteomyelitis may lead to nonunion and massive skeletal defects caused by procedures such as radical debridement and sequestrectomy. Soft-tissue damage around the fractures and subsequent wound management are other important factors affecting the outcome. A distinct advantage of Ilizarov treatment is the active use of the affected limb to improve its physiological function, which consequently minimizes the development of disuse so much and atrophy of the soft tissue. However, there is no consensus in the literature regarding the ideal management of osteomyelitis after treating open femoral shaft fractures. In this study, we retrospectively reviewed the treatment of patients with chronic femoral shaft osteomyelitis, and provided a staged protocol with spontaneous wound healing using wet-to-dry dressing followed by simultaneous distraction–compression osteogenesis with Ilizarov’s technique to restore soft-tissue defects and the bony gap without further flap coverage for the docking site. The external fixator was shifted early to an intramedullary locked nail when callus formation was visible at the distraction site. The combined technique reduces external fixation time and the consolidation index compared with classic techniques for the treatment of long-bone nonunion associated with chronic osteomyelitis.
Results The mean follow-up after use of the external frame was 87.5 (range, 38–133) months. No patient was lost to follow-up. The mean external fixator time was 6.8 (range, 5–11) months. The mean length of bone and soft tissue defects after radical debridement was 7.5 (range, 6–15) cm. Clinical and radiological union and elimination of infection were achieved in all patients. The most common infective organisms were methicillin-resistant Staphylococcus aureus (MRSA, 4 of 6 patients; Table 1). At the time of the latest follow-up, no patients had neurovascular complications, joint subluxations, or refracture of the regenerated bone. The mean knee range of motion (ROM) before staged protocols and at final follow-up were 64.2±8.6 (range, 60–75)° and 53.3±9.3 (range, 40–65)°, respectively. Limited knee range of motion and loss of range of motion of ∼11° were observed in these six patients following staged protocols (Table 1). The ROM at the affected knee after staged protocols decreased significantly when compared with the preoperative range (Wilcoxon signed rank test, p=0.03). Four patients were able to bear weight fully on the affected leg without a walking aid or brace, and the other two patients suffered from limping due to leg discrepancy (Nos. 2 and 6). They felt no pain or only mild pain when performing their normal activities of daily living. Mean lower leg discrepancy was 1 (range, 0–4) cm. One patient had the complication of a 4-cm residual leg discrepancy due to poor compliance (Table 1).
Discussion Many methods exist for the obliteration of dead space after radical debridement of necrotic bone and soft tissue, including cancellous bone grafting or bone substitutes, transfer of living tissue, and the simultaneous treatment of bone and soft tissue using Ilizarov\'s method. The Ilizarov method is valuable in overcoming the problems of delayed maturation and insecure healing of the docking site. Previous experimental findings and clinical outcomes showed that multilevel defect fragment lengthening could provide sufficient bone formation and reduction of the total osteosynthesis time in one stage, compared with traditional Ilizarov bone transport. In our experience with chronic tibial osteomyelitis, osteotomies of at least two levels were performed in the femoral shaft due to larger defect after radical debridement.