ABSTRACT

Purpose. To evaluate the treatment outcome of the

modified Ilizarov technique in infected nonunion of
the femur.
Methods. Between 1989 and 2002, records of 20
patients with infected nonunion of the femur treated
with the modified Ilizarov technique were retrospectively
reviewed. The modified Ilizarov frame was
fixed after necrectomy of the dead infected bone and
tissues. A proximal or distal corticotomy was performed
following biological principles. For regeneration
of gap, segmental transport was performed in 11
patients with a gap of more than 5 cm; acute docking
followed by lengthening at the corticotomy site was
performed in 9 patients with a gap of smaller than
5 cm. Mobilisation was started early with active participation
of the physical therapist and the patients.
Bone and functional results were measured and
complications were categorised according to the
Association for the Study and Application of the
Method of Ilizarov guidelines.
Results. The mean follow-up period was 62.8 months.
Bony union and eradication of the infection was
Modified Ilizarov technique for infected
nonunion of the femur: the principle of
distraction-compression osteogenesis
A Krishnan, C Pamecha , JJ Patwa
Department of Orthopaedics, Sheth KM School of PG Medicine and Research, Smt NHL
Municipal Medical College,
Ahmedabad, India
Address correspondence and reprint requests to: Dr Jagdish J Patwa, c/o Patwa Nu
rsing Home, 1 Dashaporwad Society, Paldi,
Ahmedabad, 380007, India. E-mail: jjpatwa@yahoo.co.in
Journal of Orthopaedic Surgery 2006;14(3):265-72
achieved in all patients except one who underwent
amputation due to uncontrolled infection. Bone
results were excellent in 13 patients, good in 4, fair in
one, poor in one, and treatment failure (amputation)
in one. Functional results were excellent in 3 patients,
good in 9, fair in 3, poor in 4, and failure in one. A
total of 71 complications occurred: 35 problems, 6
obstacles, and 30 true complications. The mean
healing index was 38.3 day/cm (standard deviation,
1.6 day/cm).
Conclusion. The Ilizarov technique is a good salvage
operation for infected nonunion of the femur. Limb
salvage is preferable to prosthesis if the limb is viable,
adequately innervated and the patient is mentally
and financially committed to save the limb.
Key words: femoral fractures; fixators, external; fractures, ununited;
Ilizarov technique; infection; osteogenesis, distraction
INTRODUCTION
Conventional methods for treating infected nonunion
of the tibia includes external fixation, drainage,
sequestrectomies, and massive cancellous bone
grafting.1 3 They are often unsuccessful due to limita

266 A Krishnan et al. Journal of Orthopaedic Surgery

tions including: quantity of graft available, donor-site
morbidity, poor vascularity, persistence of infection,
and extensive bone defects and deformity. The incidence
of refracture is high. External fixation with
debridement and massive bone grafting for infected
nonunion of the femur has also been reported.4,5
Microvascular composite tissue transfer has given
promising results in the tibia and femur.6 8 Nonetheless,
it has limitations in regaining length and correcting
deformity and requires expertise. Electrical
stimulation has been used in osteogenesis with or
without bone grafting in delayed union or nonunion.
9,10 The results are uniformly poor in patients
with coexisting infection and fracture instability.11 All
these modes of treatment are inadequate for achieving
limb length equality and deformity correction.
In 1951, Ilizarov began to use distraction osteogenesis
to treat acute fractures. Over the years, the
methods and devices have evolved and its indications
have been extended to treat fractures and associated
complications: nonunion, chronic osteomyelitis,
shortened extremity, joint contracture, and deformity.
The Ilizarov technique for infected nonunion consists
of removal of infected tissues and bone, stabilisation
with ring fixators, and regeneration of intercalary
bone defect by distraction osteogenesis, compression
at the nonunion site, and correction of the deformity.
The regenerated bone restores length and eliminates
infection. Disuse osteoporosis and soft-tissue atrophy
is minimised due to early functional loading of the
limb.12 Therefore, the use of Ilizarov technique for
infected nonunion of the tibia is increasingly popular.
13 15 Nonetheless, reports describing large series
of patients with infected nonunion of the femur
treated with the Ilizarov technique are scarce.8,16,17 We
retrospectively reviewed the results of 20 patients
with complicated infected nonunion of the femur
treated by the Ilizarov technique with CatagniCattaneo modification.12 The treatment goal was
bony union and eradication of infection. Potential
complications are the same as with treatments using
fixators or a limb lengthening apparatus, though the
incidence and severity of these complications have
decreased.18,19
MATERIALS AND METHODS
From 1989 to 2002, records of 20 patients (17 men
and 3 women) aged 18 to 65 years (mean, 38.4 years)
with infected nonunion of the femur treated with
the modified Ilizarov technique were retrospectively
reviewed. The causes of injury were traffic accident in
18 patients, a fall from height in one, and gunshot in
one. 13 patients had open and 7 had closed fractures.
Ten patients fractured the lower third of the femoral
shaft, 8 the middle third, and 2 the proximal third. 11
patients had additional injuries (limb fracture, head,
chest, or abdominal injury). In 12 patients the fracture
was comminuted and multifragmentary. All 20
patients had received prior conventional treatments.

The mean period from fracture to Ilizarov treatment

was 9.5 (standard deviation [SD], 6.3; range,
3 24) months. The patients had undergone a mean
of 4.4 (SD, 2; range, 1 9) operations before the Ilizarov
treatment was considered. Nine patients had
undergone fixation previously (plate osteosynthesis=
5, interlocking nail=1, external fixators of the AO
tubular type=3). Three patients had been treated by
traditional bonesetter bandages, 8 by skeletal traction,
6 of whom had open fractures. At presentation,
18 patients had nonunion with active infection and
discharging sinuses; 2 had no signs of active infections,
though quiescent sinuses were present. Hip
and knee functions were severely affected; 10 patients
had knee flexion of <30, 2 up to 50, and the remaining
8 had completely stiff knees.
Patients were thoroughly evaluated and psychologically
assessed. The arduous treatment programme
was explained. Radiographs were taken in at least 2
planes, and sinograms performed in patients with
sinuses (to enable better identification and resection
of the septic focus). A modified Ilizarov frame was
preconstructed using a proximally lateral mounting
apparatus with arches together with single and
multiple pin fixation bolts. Up to 2 rings were used
for the distal fragment and one full ring for the
planned intercalated segment. The proximal construct
was connected to the middle and distal construct
using oblique supports, as well as threaded
and telescopic rods.
Patients were operated under spinal anaesthesia
and the involved leg was placed in traction through
straps and abducted adequately to permit access
to the thigh medially and laterally. Preoperatively
methylene blue was injected into sinuses for complete
excision of the infected and dead tissues. Existing
implants were removed and the bone was resected
transversely to remove all circumferential defects.
The medullary canal was opened on both sides.
Punctate cortical bleeding (paprika sign) was used
to determine the completeness of bone debridement.
The preconstructed sterilised Ilizarov frame was
applied after necrectomy. Rings were fixed to the bone,
distally first, then to the middle and proximal sections
to maintain the mechanical axis of the femur by
keeping the rings parallel to the tibial articular
surface of the knee joint. Moreover, adjustment of

Vol. 14 No. 3, December 2006 Modified Ilizarov technique for infected nonunion o
f the femur 267
the proximal construct after fixation of the middle
and distal rings is easier than the converse sequence.
Full rings of the middle and distal constructs were
reinforced with tensioned 1.8-mm olive wires through
the rings; Schanz screws were applied for additional
stability if required, especially in osteoporotic bone.
To avoid damage to vital structures, olive wires were
inserted according to the level of the femur and
were directly guided by the goniometric atlas of the
Association for the Study and Application of the
Method of Ilizarov (ASAMI).12 The proximal construct
was completed with 3 to 5 bicortical Schanz
screws through pin fixation bolts. The Schanz screws
were 4.5 mm in size and inserted after predrilling
with a 3.2 mm drill bit. The screws were fixed through
the fixation bolts in the arch in a multiplannar way
within the safe corridor of the proximal femur from
30 to 150 laterally (Fig. 1). For bifocal osteosynthesis,
the intercalated segment of bone was created
by corticotomy in the proximal or distal part of the
femur, according to the level of infected nonunion. A
1.5-cm lateral incision was used to obtain a biological
corticotomy/compactotomy. The cortex was subperiosteally
cut with a 5-mm straight osteotome (or
7-mm corticotome) first laterally, then anteriorly
and posteriorly. The corticotomy was completed
medially by twisting the osteotome or by rotating
the frame if necessary. Distal femoral corticotomy
was performed in 7 patients and a proximal femoral
corticotomy in 13. In 4 patients of severe infection,
corticotomy was delayed for 2 weeks to avoid infection
of the site. Intramedullary guide wire was used
in 3 patients to aid the segmental transport and to
prevent its deviation during distraction. All these
patients required more bone to be regenerated
(>8 cm). Intramedullary guide wires (ender nail or
rush nail) were used in these patients prophylactically
to prevent axial deviation, as in 2 of our cases
with >8 cm transport. Severe axial deviation during
distraction necessitated deformity correction with
frame.
Acute docking was performed in 9 patients in
whom the gap was <5 cm, which was followed by
lengthening at the corticotomy site (Fig. 2). Segmental
transport was carried out in the remaining 11
patients (Fig. 3). A latent period of 7 days was planned
in 16 patients, in 4 of whom it was extended to 10 days
(because of suspected inadvertent intramedullary
damage during corticotomy). The rate and rhythm
of distraction was 0.25 mm/6 hours (i.e. 1 mm/day).
Figure 2 Radiographs and photographs of a 33-year-old
man: (a) and (b) the infected nonunion and initial treatment of
fracture with plate. (c) The plate and necrotic bone pieces are
removed. (d) Modified Ilizarov frame fixation with proximal
corticotomy (black arrow) that medially resulted in a spiral
extension during twisting. Acute docking (white arrow) is
performed as the gap was only 5 cm, followed by distraction

at the corticotomy site. (e) Patient mobilising with the frame.

(f) and (g) Excellent bony union achieved at the docking
site (white arrows). (h) The length of the bone regenerated
by lengthening (l). (i) and (j) Good functional result at 110month follow-up.
(a) (b) (c) (d) (e)
(f) (g) (h) (i) (j)
Figure 1 Schematic diagram of the modified Ilizarov
technique for infected nonunion of the femur: (a) the infected
nonunion in the proximal femur is excised (shaded area). The
site of biological corticotomy on the distal femur is marked
(transverse line). (b) The modified Ilizarov construct with the
proximal multiplanner Schanz pin/arch assembly showing
a full ring catching the transport segment and another full
ring catching the distal segment with tensioned transfixing
olive wires. The arrow indicates the direction of transport.
Bone is regenerated at the osteotomy site (line-shaded) and at
the nonunion gap (dot-shaded). (c) Bony union is achieved
at the proximal nonunion site by compression osteogenesis
and bone regeneration at the distal site by distraction
osteogenesis.
(a) (b) (c)

268 A Krishnan et al. Journal of Orthopaedic Surgery

If required, the anatomical and mechanical axes were
corrected at the time of frame application or gradually
during the distraction. Patients were put through a
stringent postoperative protocol with a suitable diet,
active/passive joint mobilisation and strengthening
exercises, systemic antibiotics for 6 weeks according
to culture/sensitivity results, and wound care (repeated
debridement, irrigation, antibiotic instillation,
and dressing changes) until healing was apparent.
Apart from meticulous pin care, the apparatus was
regularly checked for loosening and the wire was retensioned
if required. A physical therapist actively
participated in all stages of the treatment. Radiographs
were taken in 2 planes at 3 weekly intervals
until distraction-compression was complete, and subsequently
at the time of frame removal, at 3 months,
one year, and final follow-up. In case of inadequate
regeneration, distraction was discontinued, reversed,
and re-started at a reduced rate (0.25 mm/12 hours;
Accordian manoeuvre) after a gap of 20 days. Patients
were discharged after having learnt the method of
distraction and so long as wound healing had started.
They were followed up in the out-patient department
weekly, or more often if wound care was required.
Weight bearing with crutches/walker was started as
soon as tolerated. After bifocal osteosynthesis was
accomplished, the frame was left for a variable
period of neutral fixation to complete corticalisation
of the regeneration prior to removal. The apparatus
was dismantled based on radiological and clinical
findings; after new bone had filled the gap from end
to end and there was adequate remodelling of the
circumferential cortex (>75% of the normal diameter).
The distraction and compression stresses were
removed by loosening the connecting rods. If the
patient could tolerate weight bearing without pain
and had a subjective feeling of solidity on the operated
leg, after 3 weeks of dynamisation, the fixator was
removed under the cover of dissociation anaesthesia.
Patients were given a coxofemoral brace for 6 weeks
and physiotherapy was encouraged.
Bone healing, the functional result, and complications
were assessed according to ASAMI.15,16,18 Bone
healing was evaluated based on union, infection, deformity,
and limb length discrepancy as: excellent
union without infection, <7 deformity, and <2.5 cm
limb length inequality; good union with 2 of the
above criteria; fair union with one of the above
criteria; poor nonunion or refracture, and none
of the above criteria fulfilled. Lengthening index
(healing index or regeneration index) was calculated
by dividing the frame-keeping period (days) by the
length of the regenerated bone (cm). It was used to
compare with the indexes in other studies.
The functional result was evaluated according to
5 adverse criteria: (1) observable limp, (2) stiffness of
knee or hip (loss of >70 of knee flexion or >15 of
knee extension), (3) loss of >50% of hip motion when

compared with the normal contralateral side, (4)

severe sympathetic dystrophy, pain that reduced
activity or disturbed sleep, and (5) inactivity (unemployment
or inability to return to daily activities).
Provided the patient was active, the result was
deemed excellent if the other 4 criteria were also
absent, good if one or 2 of the other criteria were
present, and fair if 3 or 4 of them prevailed. The
result was deemed poor if the patient was inactive,
regardless of the other criteria.
Complications that occurred during surgery,
distraction-compression or thereafter were evaluated
according to the Paley working classification18:
1. A problem is a difficulty arising during the
distraction or fixation period and is fully resolved
by the end of the treatment period by nonoperative
means.
2. An obstacle is a difficulty arising during the
distraction or fixation period and is fully resolved
by the end of the treatment period by operative
means.
3. A true complication includes any local or
Figure 3 Radiographs and photographs of a 65-year-old
man: (a) the primary comminuted fracture of the proximal third
femur. (b) Fixation with Jewett nail/plate device with infected
nonunion. (c) Plate was removed and tubular external fixator
was installed. (d) Modified Ilizarov frame fixation with the
gaps created following necrectomy (white arrow) and distal
corticotomy (black arrow). (e) Weight bearing mobilisation
with the apparatus immediate after surgery. (f) Excellent
bony union at the target site (black arrow). (g) The length of
the bone regenerated by segmental transport (l). (h) and (i)
Excellent functional result at 29-month follow-up.
(a) (b) (c) (d) (e)
(f) (g) (h) (i)

Vol. 14 No. 3, December 2006 Modified Ilizarov technique for infected nonunion o
f the femur 269
systemic intra-operative or peri-operative complication,
a difficulty arising during the distraction
or fixation period and remains unresolved at
the end of the treatment period, and any early or
late post-treatment complications. True complications
are further divided into minor and major.
Minor complications are nuisance problems that
leave no significant residual impact on the patient
other than being annoying or delaying treatment
or rehabilitation. They do not prevent achievement
of the treatment goal and can be resolved
non-operatively. Major complications are defined
as requiring surgery and are subdivided into
those that do or do not interfere with achievement
of the original treatment goals.
RESULTS
The bone results, functional results, and complications
of these patients were evaluated. The mean
follow-up period was 63 (SD, 25; range, 29 110)
months. The mean frame-keeping period was 234
(SD, 124; range, 77 446) months. The mean length
of regenerated bone was 6 (SD, 3; range, 2 10.5) cm.
The mean limb length discrepancy was 0.5 (SD, 0.8;
range, 0 2.5) cm. All patients were able to mobilise
(weight-bearing) within a mean of 12 (SD, 7; range,
4 22) days.
Bony union was achieved in all but one patient,
who had an uncontrolled infection and inadequate
bone regeneration. He became impatient and unwilling
to continue treatment, and ultimately had his
limb amputated. Two patients developed delayed
consolidation (poor regeneration), but responded
favourably to the Accordian manoeuvre. One patient
had refracture 2 weeks after frame removal and was
treated with interlocking nails and cancellous bone
grafting. No other patients had bone grafting.
Infection was controlled in all the patients, except
the one whose limb was amputated. Only one patient
had a 2.5-cm shortening after completion of treatment.
Axial deformities of >7 was present in 5 patients.
Three patients in whom an intramedullary guidewire
was used developed no significant deformities. The
mean lengthening index was 38.3 (SD, 1.6; range, 36
42) days/cm.
Four patients were unable to resume their
previous jobs or level of daily activities and 14 had
an observable limp. Major rigidity was present in 11
patients: 7 in the knee only and 4 in both the knee and
hip. Severe dystrophy was present in 7 patients and 2
had occasional intractable night pains.
The bone results were excellent in 13 patients,
good in 4, fair in one, poor in one and treatment failed
(amputation) in one. The functional results were
excellent in 3 patients, good in 9, fair in 3, poor in 4,
and failed in one (Fig. 4).
A total of 71 complications occurred: 35 problems
(2 delayed consolidation, 8 pin-site problems, one

intractable pain, 5 severe oedema, 7 severe dystrophy,

9 loss of appetite/weight, and 3 depression); 6 obstacles
(2 axial deviations, one premature consolidation,
and 3 pin-site problems). 30 of these were designated
to be true complications: 15 minor (6 joint stiffness, 7
axial deviations of <7, and 2 occasional intractable
pain) and 15 major (5 joint stiffness, 5 axial deviations
of >7, one shortening of regeneration, one nonunion/
amputation, one limb length inequality of
>2 cm, one refracture, and one femoral bowing). Of
the 15 major complications, 3 interfered with the
achievement of our original goals: one patient with
uncontrolled infection and nonunion had an amputation;
one with refracture was treated with interlocking
nails and bone grafting; and one had shortening
of 2.5 cm and femoral bowing of 20.
One patient with premature consolidation had a
recorticotomy. Limb length inequality of >2 cm and
femoral bowing of 20 occurred in one patient, in the
plane of knee movement. Axial deformities developed
in 14 patients of whom 2 had corrective apparatus
adjustment for correction; 7 had bony union with <7
of axial deviation and 5 with >7 of axial deviation.
Joint stiffness of varying degrees was present in all
patients, but considerable functional loss was present
in 11 (5 were manipulated under anaesthesia with
little improvement). No patients were subjected to
synoviolysis of the joint. Pin-site problems occurred
in 11 patients: 8 responded well to local care and
antibiotics and 3 required replacement of the wire
Figure 4 Bone and functional results of 20 patients with
infected nonunion of the femur treated with modified Ilizarov
technique.
Failure Poor Fair Good Excellent
0
Bone result
Functional result
2 4 6 8
10
12
14
No. of patients

270 A Krishnan et al. Journal of Orthopaedic Surgery

to maintain stability. Initially, variable oedema was
present in all patients; it persisted during distraction
in only 5 and disappeared before removal of frame.
Dystrophy was evident in 7 patients but gradually
improved. Pain was the most frequent complication
(greatest during the first 4 to 6 weeks), for which
paracetamol and/or tramadol were prescribed. Only
3 patients developed on and off intractable night
pain that resolved around or after frame removal.
Transient loss of appetite and weight occurred in 9
patients. Almost all patients were depressed before
treatment started. After psychotherapy and medications
were given, only 3 remained depressed during
the entire first 6-week period; but all recovered after
being able to stand and walk with the frame. None
developed neurovascular complications.
DISCUSSION
The results of conventional treatment of infected
nonunion of the femur are poor, due to high velocity
primary trauma, multiple surgeries, late presentation,
bone and soft tissue infection, nonunion, bone loss,
osteoporosis, dystrophy, poor vascularity, associated
deformities, and shortening. The Ilizarov technique is
a salvage procedure for these difficulties. According
to Ilizarov, gradual traction on living tissues creates
stress that stimulates and maintains regeneration
and active growth of tissues (bone, muscle, fascia,
tendon, nerve, vessels, skin and its appendages). This
principle is called the law of tension stress .20
The primary objective of the Ilizarov technique
was to eliminate infection by increasing vascularity
of the osteomyelitic centre through biological stimulation
of a corticotomy (osteomyelitis burns in the fire
of regeneration), but infection was not always cured.
Therefore, thorough debridement before distraction
osteogenesis is recommended. Distraction osteogenesis
involves mechanical induction of new
bone formation between bony surfaces that are gradually
pulled apart. After corticotomy, bone transport
entails movements of living bone segments to fill
an intercalary bone defect. The trailing end regenerates
bone by intramembranous ossification and
the leading end fuses with the target bone surface.12
The quality and quantity of the osteogenesis
during distraction depends on the rigidity of bone
fragment fixation, the degree of damage at the time
of corticotomy, and the rate and the rhythm of
distraction.20 The biological response of the tissues to
distraction is intrinsic and thus general body anabolism
should always be positively maintained.12
In case of infected nonunion, after sequestrectomy
and necrectomy, an unintentional gap is created.
The presence of a gap and an infection rules out the
use of internal fixation, leaving only external fixation.
The use of external fixation to treat infected nonunion
of the femur has been previously reported.4,5
The universal-type external fixation requires repeated
bone grafting to fill the gap. It is a cantilever fixation

and not mechanically strong enough to allow mobilisation.

Pin-track problems with larger pins as well
as disuse osteoporosis and refracture are common.
Moreover, it has a limited capacity to correct deformity
and shortening.
The Ilizarov technique can overcome all these
difficulties. Mechanically, the Ilizarov frame construct
is very resistant to torsion and bending but allows
axial compression during physiological loading.12 It
is an established method for treatment of infected
nonunion of tibia,13 15 nonetheless reports on large
series of patients with infected nonunion of the femur
treated by the Ilizarov technique are scarce.8,16,17
Ilizarov used tensioned thin wires that occupy
less space and thus confer lesser pin-track problems.
But placement of wires in proximal segments of the
femur is difficult, less well tolerated, and associated
with frequent complications. ASAMI12 therefore
modified the frame and obtained better overall results
by using a proximal half pin apparatus instead of a
circular frame. We used a similarly modified frame
with Schanz screws through the arch for the proximal
femur. The transfixation tensioned olive wires for
intermediate and distal rings are placed according to
the guidelines of the goniometric atlas on the level of
full rings along the femur. The Schanz screws through
the proximal arch are inserted in the trochanteric and
subtrochanteric region, following the safe corridors
of the proximal femur described by ASAMI.12 For all
practical purpose, this entails avoiding the anteromedial
and posteromedial region of the proximal femur
for pin insertion and starting from the lateral aspect
of the trochanter and subtrochanteric region. The
stability of an assembly is proportional to the number
of rings and the diameter, number, tension, degree of
crossing, and location of the wires along the longitudinal
axis of the bone. Half pin systems of uniplannar
types are prone to cantilever loading, which introduces
angular instability to the osteogenic site. Thus
when using a half pin assembly in the proximal femur,
the arrangement has to be multiplanar. Though the
biomechanics may not be as strong as that of original
Ilizarov apparatus, it serves its purpose well, being
better tolerated and producing fewer complications,
with greater ease of application and shorter operation
time.12,16 Being a deviation from the original Ilizarov
concept of transfixing wires for the proximal femur, it

Vol. 14 No. 3, December 2006 Modified Ilizarov technique for infected nonunion o
f the femur 271
constitutes a hybrid fixator embracing the principle
of 2 external fixation systems (proximal Schanz
screws and distal tensioned wires). The external
tubular system was not used.
The initial damage inflicted at the corticotomy
site determines the quality and quantity of regeneration;
injury to the bone marrow, nutrient artery and
its branches and the periosteal soft tissues should
be minimised during the procedure.20 Latency is the
time period between corticotomy and initiation of
distraction. Short latency affords poor regeneration,
whereas longer latency facilitates early consolidation
and fusion. Depending on the damage during corticotomy,
a latency period of 0 to 14 days is recommended.
12,20 Seven-day latency was prescribed to 16
patients and 10-day latency to 4 suspected of having
sustained damage during corticotomy. Regarding the
latter 4 patients, 2 with poor regeneration responded
favourably to the Accordian manoeuvre. It is important
to minimise damage during corticotomy while
achieving reduction.
During distraction osteogenesis, physiological
bone loading and mobilisation are very important.12
All of our patients were put through weight bearing
and joint mobilisation as soon as possible (mean,
12 days), with active participation of the physical
therapist. The rate and rhythm of distraction was
kept at 0.25 mm/6 hours (1 mm/day) and should
remain within a range of 0.5 to 2 mm/day.12
Planned deformity correction was performed in 4
patients and 2 had their apparatus adjusted during
the course of treatment in order to correct axial
deviation. To increase the stability of the assembly
during bifocal osteosynthesis and reduce the risk of
displacement of bone fragments during transport,
an intramedullary thin central guide wire may be
used and maintained until the moving segments of
bone reach the target site and the target nonunion site
forms callus.12 Larger gap regenerations may develop
axial deviation necessitating apparatus adjustment.
Therefore, from the beginning an intramedullary
wire was used to guide the transport in 3 patients
(for regeneration gaps of 8.7, 10, and 10.5 cm). None
of these 3 patients required apparatus adjustment
for axial deviation during treatment, in contrast to
the 2 patients with large regeneration gaps without
an intramedullary guide wire. Based on our experience
with infected nonunion of the femur, such guide
wires may be recommended for all gaps exceeding
8 cm. The mean healing index of 38 days/cm (SD,
1.6 days/cm) was comparable to other reports on
limb lengthening and infected nonunion of the
femur.16,21
Cancellous bone grafting or refreshing of bone
ends may be required at the site of docking.16,18,19
Nonetheless, bone grafting or refreshing was not
required in our patients except in one with a refracture.

Cancellous bone grafting and refreshing may

reduce the frame-keeping period marginally and thus
enhance healing.
Infection was eliminated and union was achieved
in all patients except one. Refracture occurred in one
patient, possibly due to premature removal of the
frame. One patient developed femoral bowing of 20
and shortening of 2.5 cm. These 3 true major complications
interfered with the achievement of our
treatment goals. Shortening of bone regeneration
after fixator removal can occur, if the regenerated
bone has not corticalised adequately. One patient lost
2.5 cm of regenerated length with bowing. This complication
may be avoided by a suitable radiological
analysis and a guarded approach on the quality of
bone regeneration.
A total of 71 complications occurred with a mean
of 3.6 complications per patient. Complications are
intrinsic to the Ilizarov technique but their frequency
and severity decrease with experience. 85% and 60%
of patients had good-to-excellent bone and functional
results, respectively. The bone result was always
better than the functional result, which is in keeping
with other reports.8,16,18,19 Most patients present late,
having had multiple previous surgeries with major
damage to vessels, nerves, muscles, joints, and bone,
and already having developed a variable amount of
joint stiffness.
Bone transport over an intramedullary nail
gives additional stability and reduces the period of
external fixation and its complications. Nonetheless,
it compromises the endosteal circulation and cannot
be inserted in the presence of active infection; it also
predisposes to necrosis of the moving segment and
recurrence of infection.22,23
Vascularised fibular grafting requires careful
monitoring of the circulation and early intervention
to avoid vascular failure. To improve results, internal
bone transport requires repeated debridements,
bone grafting at the docking site for early union, and
avoidance of stress fractures.8
The duration of external fixation and any associated
complications can be substantially reduced
with the technique of multiple segment lengthening,
automatic high frequency lengthening, and extemporaneous
compression at the end of traction.24
CONCLUSION
Modified Ilizarov technique is a good salvage

272 A Krishnan et al. Journal of Orthopaedic Surgery

REFERENCES
1. Green SA, Dlabal TA. The open bone graft for septic nonunion. Clin Orthop Rel
at Res 1983;180:117 24.
2. Meyer S, Weiland AJ, Willenegger H. The treatment of infected non-union of fr
actures of long bones. Study of sixty-four
cases with a five to twenty-one-year follow-up. J Bone Joint Surg Am 1975;57:836 4
2.
3. Reckling FW, Waters CH 3rd. Treatment of non-unions of fractures of the tibia
l diaphysis by posterolateral cortical cancellous
bone-grafting. J Bone Joint Surg Am 1980;62:936 41.
4. Slatis P, Paavolainen P. External fixation of infected non-union of the femur
. Injury 1985;16:599 604.
5. Barquet A, Silva R, Massaferro J, Dubra A. The AO tubular external fixator in
the treatment of open fractures and infected
non-unions of the shaft of the femur. Injury 1988;19:415 20.
6. Ring D, Jupiter JB, Gan BS, Israeli R, Yaremchuk MJ. Infected non-union of th
e tibia. Clin Orthop Relat Res 1999;369:302
11.
7. Jupiter JB, Bour CJ, May JW Jr. The reconstruction of defects in the femoral
shaft with vascularised transfers of fibular bone.
J Bone Joint Surg Am 1987;69:365 74.
8. Song HR, Kale A, Park HB, Koo KH, Chae DJ, Oh CW, et al. Comparison of intern
al bone transport and vascularized fibular
grafting for femoral bone defects. J Orthop Trauma 2003;17:203 11.
9. Bassett CA, Mitchell SN, Schink MM. Treatment of therapeutically resistant no
n-unions with bone grafts and pulsing
electromagnetic fields. J Bone Joint Surg Am 1982;64:1214 20.
10. Brighton CT, Black J, Friedenberg ZB, Esterhai JL, Day LJ, Connolly JF. A mu
lticenter study of the treatment of non-union
with constant direct current. J Bone Joint Surg Am 1981;63:2 13.
11. Delima DF, Tanna DD. Role of pulsed electromagnetic fields in recalcitrant n
on-unions. J Postgrad Med 1989;35:43 8.
12. Association for the Study and Application of the Method of Ilizarov Group: n
on-union of the femur. In: Bianchi-Maiocchi
A, Aronson J, editors. Operative principles of Ilizarov. Fracture treatment, non
-union, osteomyelitis, lengthening, deformity
correction. Baltimore: Williams and Wilkins; 1991.
13. Aronson J, Johnson E, Harp JH. Local bone transportation for treatment of in
tercalary defects by the Ilizarov technique.
Biomechanical and clinical considerations. Clin Orthop Relat Res 1989;243:71 9.
14. Cattaneo R, Catagni M, Johnson EE. The treatment of infected nonunions and s
egmented defects of the tibia by the methods
of Ilizarov. Clin Orthop Relat Res 1992;280:143 52.
15. Dendrinos GK, Kontos S, Lyritsis E. Use of the Ilizarov technique for treatm
ent of non-union of the tibia associated with
infection. J Bone Joint Surg Am 1995;77:835 46.
16. Barbarossa V, Matkovic BR, Vucic N, Bielen M, Gluhinic M. Treatment of osteo
myelitis and infected non-union of the femur
by a modified Ilizarov technique: follow-up study. Croat Med J 2001:42;634 41.
17. Gualdrini G, Stagni C, Fravisini M, Giunti A. Infected nonunion of the femur
. Chir Organi Mov 2002;87:225 33.
18. Paley D. Problems, obstacles, and complications of limb lengthening by the I
lizarov technique. Clin Orthop Relat Res
1990;250:81 104.
19. Theis JC, Simpson H, Kenwright J. Correction of complex lower limb deformiti
es by the Ilizarov technique: an audit of
complications. J Orthop Surg (Hong Kong) 2000;8:67 71.
20. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues.

In: Transosseous osteosynthesis: theoretical and

clinical aspects of the regeneration and growth of tissue. Berlin: Springer-Verl
ag; 1992:137 256.
21. Dahl MT, Fischer DA. Lower extremity lengthening by Wagner s method and by cal
lus distraction. Orthop Clin North Am
1991;22:643 9.
22. Oedekoven G, Jansen D, Raschke M, Claudi BF. The monorail system--bone segme
nt transport over unreamed interlocking
nails [in German]. Chirurg 1996;67:1069 79.
23. Li G, Berven S, Athanasou NA, Simpson AH. Bone transport over an intramedull
ary nail. A case report with histologic
examination of the regenerated segment. Injury 1999;30:525 34.
24. Shevtsov V, Popkov A, Popkov D, Prevot J. Reduction of the period of treatme
nt for leg lengthening. Technique and
advantages [in French]. Rev Chir Orthop Reparatrice Appar Mot 2001;87:248 56.
operation for infected nonunion of the femur. The
bone results are usually superior to the functional
results. Functional results can be improved by the
early use of the Ilizarov technique. Limb salvage is
always preferable to a prosthesis, so long as the limb
is viable, adequately innervated and the patient
is committed to the financial and psychological
demands of the procedure.