The Ilizarov method provides an effective treatment for infected fractures and non-unions, especially those that have failed previous internal fixation attempts. It allows for stabilization, deformity correction, bone lengthening and regeneration through distraction osteogenesis. Key advantages include minimal invasiveness, immediate weight bearing, and stimulation of new bone formation. The document outlines principles, indications, techniques and advantages of the Ilizarov method for managing complex cases of infected non-union.

1. INFECTED FRACTURES, INFIRM PATIENT,
INDOMITABLE SURGEON HANDLING
NONUNION AND INFECTION WITH ILIZAROV
DR. MURUGESH M. KURANI,
Department of Orthopaedics,
KLE ACADEMY OF HIGHER EDUCATION & RESEARCH,
J N Medical College, BELAGAVI.

2. NON UNION
Definition:
9 months elapsed time with no healing progress
for 3 months.
Union is delayed and a fracture has ceased to
show any evidence of healing.
Practically,
A fracture that has no potential to heal without
further Intervention.

3. Nonunion is permanent failure of healing following a
broken bone.
Nonunion is a serious complication of a fracture and may
occur when the fracture moves too much, has a poor
blood supply or gets infected.
Patients who smoke have a higher incidence of
nonunion.
In some cases a pseudo-joint (pseudarthrosis) develops
between the two fragments with cartilage formation and
a joint cavity.

4. BASED ON THE EXTENT OF INFECTION
NON-INFECTED INFECTED
NON-UNION NON-UNION
CLASSIFICATION OF NON UNION

5. PALEY ET AL.CLASSIFICATION OF NON-
UNION
Type A nonunions (<1 cm of
bone loss)
A1, lax (mobile)
A2, stiff (nonmobile)
A2-1, no deformity A2-2,
fixed deformity.
Type B nonunions (>1 cm of
bone loss)
B1, bony defect, no
shortening
B2, shortening, no bony
defect;
B3, bony defect and
shortening.

6. CLASSIFICATION OF INFECTED NON UNION (AO BASED)
NON-DRAINING/
DRY/QUIESCENT
-- nondraining for at least
3 months
-- requires 1 stage
treatment
DRAINING/ACTIVE
--drainig with abscess and
fever
-- Requires 2 stage
treatment
-- stage 2 after a period
of 10-20 days

7. NON INFECTED NON UNION
Causes;
• Excessive motion:
Due to inadequate immobilization
Faulty implants
Loose nails or plates
• Gap b/w fragments:
Soft tissue interposition
Distraction by traction or hardware
Malposition, overriding or displacement of fragments
Loss of bone and soft tissue substance
• Loss of blood supply:
Damage to nutrient vessel
Excessive stripping or injury to periosteum and muscle
Free fragments, severe comminution
Avascularity due to hardware
Peculiar anatomy, eg: # NOF, # SCAPHOID, # TALUS, # DISTAL END TIBIA

9. INFECTED NON UNION
Causes;
• Bone death (sequestrum)
• Osteolysis (gap)
• Loosening of implants (motion)
• Chronic osteomyelitis
• Open fractures
• Post-operative infection in
closed fractures treated with
internal fixation

10. • Systemic Risk Factors
– Malnutrition
– Smoking
– NSAIDs
– Systemic Medical Conditions
like Diabetes, paraplegia.
– Chronic alcoholism.
• Patient Factors
– Non Compliance

11. NON INFECTED NON UNION

12. The most basic requirements for fracture or
fracture non-union healing are:
• 1) mechanical stability,
• 2) an adequate blood supply, and
• 3) bone-to-bone contact.
• The absence of one or more of these factors
predisposes to problems with bone healing
following internal fixation

13. The basic requirements for healing may be
negatively affected by:
1) The severity of the injury,
2) Suboptimal surgical fixation from either a poor
treatment plan or a good treatment plan carried
out poorly, or
3) A combination of the injury severity and the
suboptimal technical performance of the
operative procedure.

14. Examples of such cases include those:
1) that have failed to unite despite multiple well-executed
attempts using internal fixation;
2) with bony fragments that are too small or too numerous for
revision surgery with internal fixation, as is often seen with
periarticular injuries;
3) with an associated bony defect;
4) with osteopenic states where bony purchase can be
problematic with internal fixation, particularly screw
fixation; and
5) with severe irreducible deformity at the site of a stiff
(hypertrophic) non-union.

15. TREATMENT
Variety of treatment options are available,
Revision internal fixation Ilizarov
1.Revision plate and screw fixation
2.Revision intramedullary nail fixation
3.Exchange nailing following failed IM nail fixation

16. INFECTED NON UNION

17. How infection causes non union??
1. Dissection of pus through planes and periosteum-
devascularising th ends
2. Fragmentation and dissolution of fracture
haematoma
3. Inflammatory mediators promotes fibrous tissue
formation
4. If fixation was done then implant failure occurs
destabilization the fragments
5. Increase catabolic response at # ends

18. PATHOGENESIS
OSTEOMYELITIS
thrombosis of blood vessel
of haversian canals
bone sclerosis and dead
bone.
Butterfly fragments become sequestrii,
isolated & devitalized by pus &
INFECTED GRANULATION TISSUE

19. Infection granulation tissue
OSTEOLYIS
GAP NON UNION
Osteolysis occurs around the implants
 loosening  instability of fixation
 nonunion.

20. Why does bone loss occur in certain cases of
osteomyelitis?
• Understand the evolution of osteomyelitis
1. Metaphyseal focus of infection
2. Formation of subperiosteal abscess
3. Periosteum
preserved and forms
involucrum
3. Periosteum destroyed
and forms a gap defect
or non-union

21. What are the problems in gap defects?
• Ongoing infection
• Poor blood supply
• Periosteum itself is destroyed
• No structural support to the limb
• Growth disturbance
• Poor soft tissue cover (original or ongoing infection)

22. INFECTED FRACTURES
– OPEN FRACTURES.
– POST-OPERATIVE INFECTION IN CLOSED
FRACTURES TREATED WITH INTERNAL
FIXATION.

23. • Gustilo type I and II, is a low energy fractures.
• type IIIA: a considerable degree of soft tissue
damage.
• type IIIB: local or a free tissue transfer.
• type IIIC: vascular surgery is mandatory for
salvage of the extremity.
OPEN FRACTURES,
– Gustilo and Anderson in 1976.*
– Gustilo Modification in 1984.**

24. OPEN FRACTURES AND RATE OF INFECTION,
• less than 5 % infection in type I and II
• less than 10 % infection in type IIIA
• 30–50 % infection in type IIIB and IIIC

25. OTHER FACTORS INFLUENCING THE RATE OF
INFECTION,
• The Time Factor
• The Location of the Fracture
• The Host

26. Treatment of Infected non-union…
ERADICATE
INFECTION
ACHIEVE UNION
SOLVE:soft tissue
problem,deformity,joint
stiffness
GOAL 1
GOAL 2
GOAL 3

27. NON OPERATIVE TREATMENT
•Indirect intervention
•Weight bearing And external stabilization
•Electrical stimulation
•Ultrasound stimulation
•Extracorporeal shock wave therapy
•Parathyroid hormone
•Gene therapy

28. OPERATIVE
•Plate and screw fixation
•IM nailing
•External fixation
•Arthroplasty
•Amputation
•Arthrodesis
•Fragment excision and resection arthroplasty
•Osteotomy
•Synostosis

29. PRINCIPLE OF SURGICAL
MANAGEMENT,
• Cure infection if present
• Correct Deformity if significant
• Provide stability through
implants
• Add biologic stimulus when
necessary

30. Contaminated implants and devitalized implants
must be removed.
Infection treated:
• Temporary stabilization (external fixation)
• Culture specific antibiotics
• +/- local antibiotic delivery (antibiotic beads)
Secondary stabilization with augmentation of
osteogenesis (cancellous grafting)

31. • ACTIVE TREATMENT:
The objective of the active method is to obtain bony
union early and shorten the period of convalescence
and preserve motion in the adjacent joints.
• POLYMETHYL METHACRYLATE ANTIBIOTIC BEADS:
Heat-stable antibiotics, such as tobramycin and
gentamicin, can be mixed with PMMA and used locally
to achieve 200 times the antibiotic concentration
achieved with intravenous administration.

32. RECONSTRUCTING THE DEFECT
1. Cortical strut (fibula)
a. Non-vascularised
b. Vascularised
2. Distraction osteogenesis (Ilizarov)
3. Induced Membrane formation (Masquelet)
4. Conversion to single bone procedure

33. NON VASCULAR FIBULAR GRAFT

34. INFECTED NON UNION HEALED BY
ANTIBIOTIC ROD / BEADS

36. TREATMENT OF OPEN FRACTURES,
1. Immediate debridement and irrigation, including
repeated debridement and irrigation of type III
fractures at 24–48 h intervals
2. Antibiotic therapy
3. Secure fracture stability
4. Wound coverage, either by delayed primary
closure or by local or free flaps
5. Early cancellous bone grafting
6. Make an early decision on amputation.

37. POST-OPERATIVE INFECTION IN CLOSED
FRACTURES TREATED WITH INTERNAL
FIXATION
• The aim:
– avoid a chronic infection.
– avoid infected pseudoarthrosis.
• Early and late:
– 4 weeks.

38. • Within 4 weeks:
– radical soft tissue debridement, harvesting of
tissue biopsies for culture and wound closure.
– Stable??.
• After 4 weeks:
– The implant should be removed.
– Ext fixation.
– staphylococcus aureus.

39. • A large dead space that needs to be managed
effectively to prevent recurrence of infection.
• The management of the dead space in this
setting includes,
– closed irrigation systems,
– local soft tissue flaps,
– vascularized free flaps,
– a variety of methods for local antibiotic
delivery.

40. ILIZAROV IN NON UNION

41. General guidelines for management
by ILIZAROV TECHNIQUE
strictly adhere to
1. Stability
- Intrinsic (bone ends
at non union site) &
- Extrinsic (frame
stability),
2. Axial alignment,
3. Vascularity &
4. Function

42. PRINCIPLES OF ILIZAROV
Law of tension stress
Distraction osteogenesis
Mechanical induction of new bone formation
Neo-vascularization
Stimulation of biosynthetic activity
Activation and recruitment of osteo-progenitor cells
Intramembranous ossification

43. INDICATIONS
• Limb lengthening.
• Deformity Correction.
• Infected Non-unions.
• Congenital pseudoarthrosis.
• Treatment of Joint Contractures e.g. resistant congenital
talipes equino varus, post burns contractures, post- traumatic
stiffness.
• Fixation of complex fractures.
• Bone transport & Osteomyelitis (treatment of missing
bone in the limb, due to various causes).
• Arthrodesis (fusion or joining of two bones across a joint)
• Peripheral Vascular Disease like Thrombo-angitis
obliterans.

44. DISTRACTION OSTEOGENESIS

45. UNI FOCAL
(compression) BIFOCAL BONE TRANSPORT
Trifocal bone
transport

46. Bone score -
excellent
UNI FOCAL
(compression)

47. BIFOCAL BONE TRANSPORT

48. NEO-VASCULARISATION

50. TRIFOCAL BONE TRANSPORT
TIBIALISATION OF FIBULA

52. NON-UNIONS…



Ilizarov revolutionized the treatment of recalcitrant
nonunions demonstrating that the affected area of the
bone could be removed, the fresh ends "docked" and the
remaining bone lengthened using an external fixator
device.
The time course of healing after such treatment is longer
than normal bone healing.
Usually there are signs of union within 3 months, but the
treatment may continue for many months beyond that.

53. NON INFECTED NON UNION
For certain fractures and fracture non-unions that have
failed internal fixation, the Ilizarov method offers many
advantages. Some of these advantages are that the Ilizarov
method:
1) is primarily percutaneous, minimally invasive, and typically
requires only minimal soft tissue dissection;
2) can promote generation of bony tissue;
3)is versatile;
4) allows for stabilization of small intra-articular or peri-articular
bone fragments;
5) allows for simultaneous bony healing and deformity
correction; and
6) allows for immediate weight bearing and early joint
mobilization.

60. Ilizarov method may be the preferred treatment strategy
following failed internal fixation.
The Ilizarov method offers many advantages for treatment of
fracture or fracture non-union following failed internal fixation.
Several modes of treatment are available with the Ilizarov
method, including mono-focal, acute, or gradual compression
and bone transport (bifocal treatment).
The Ilizarov method provides excellent mechanical stability,
biologic stimulation at the site of bony injury, and the ability to
generate new bone tissue through distraction osteogenesis.

61. INFECTED NON-UNION
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.

62. 


Osteomylitis burns in the fire of regeneration
Activate biosynthetic process, increasing local resistant
to infection.
Three ways to correct infected Non Union:



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.

63. INFECTED NON UNION

64. INFECTED NON UNION

66. OPEN FRACTURE AND BONE LOSS

68. Cases of fracture or fracture nonunion that have
failed internal fixation that respond well to the
Ilizarov method include those:
1) With multiple previous attempts using internal
fixation;
2) With small or numerous bony fragments;
3) With bone infection;
4) With a bony defect;
5) With osteopenic states; and
6) With a stiff (hypertrophic) nonunion associated
with a severe irreducible deformity.

69. ADVANTAGES




No skin incision is made as in a conventional operation.
Incidents of haemorrhage, tissue trauma and infection
are much fewer.
minimally invasive as only wires fix the bones to the
rings and there is very little soft tissue damage.
The Ilizarov fixator is very versatile; the cylindrical shape
of the fixator allows deformities to be corrected
simultaneously in 3 dimensions.
The patient remains mobile throughout the course of the
treatment. Intensive physiotherapy is instituted early; as
a consequence, problems of joint stiffness and
contractures are rare. Further, the patient's stay in the
hospital is considerably reduced.

70. TAKE HOME MESSAGE





Ilizarov is a compression-distraction device that can do
osteogenesis.
Infection Non-union and Congenital deformity corrections
are one of the golden indications.
You can be taller even after 18 yrs with this.
Wearing Ilizarov is not a fancy style. It returns painful
discomfort.
Physiotherapy is essential.