Background
Complex nonunion is defined as established nonunion of at least 6 months’ duration with one of the following criteria: infection, bone defect or shortening of more than 4 cm, deformity, and an attempt to achieve union that failed to heal after at least one supplementary surgical intervention such as bone graft. Internal fixation methods are limited in their ability to deal with infection, bone defect, or shortening, and they involve extensive dissection around the fracture site for realignment of severe deformity. The Ilizarov method of compression distraction is particularly valuable in these complex cases.
Patients and methods
Between January 2004 and December 2010, 52 patients were treated for complex femoral nonunion using Ilizarov circular fixator. A monofocal treatment confined to the nonunion site (simple stabilization of the nonunion with compression and then stimulation of healing by distraction) was used in 23 patients; four of them had infected nonunion. Bifocal compression distraction technique with corticotomy (compression of the nonunion with distraction at the corticotomy) was used in 29 patients; 10 of them were infected.
Results
Bone healing was identified radiologically as callus bridging three cortices in 48 patients after a mean of 6.3 (4–12) months. Twenty patients of 23 treated using the monofocal technique had a mean healing time of 5.6 (4–9) months. Totally, 28 patients of 29 treated with bifocal compression distraction had healing after a mean of 6.8 (4–12) months. Using the criteria proposed by Paley and Maar, 30 patients had excellent functional results, 15 patients had good results, two had fair results, and five had poor results. The bony results were excellent in 35 patients, good in eight, fair in four, and poor in five.
Conclusion
Both monofocal and bifocal compression distraction techniques are effective in the treatment of complex femoral nonunion. Less treatment time is achieved for monofocal cases (mean: 5.6 months). In bifocal cases, acute shortening and lengthening has a much lower treatment time (mean: 5.5 months) compared with bone transport (mean: 9.3 months) and should be used when possible.