METHODS AND RESULTS IN THE TREATMENT OF A SEPTIC POSTTRAUMATIC NONUNIONS OF FEMUR AND TIBIA

Aim of investigation: Different methods of internal and external fixat ion are used to treat aseptic posttraumatic nonunion of the femur and tibia. The advantages and disadvantages of the different methods will be demonstrated by analysing the clinical course and the outcome of ou r patients. Utilizing these data, a therapeutic concept tailored to th e individual situation is recommended. Methods: Depending on the form of reaction we distinguish between vital and non-vital nonunions. The classification is made according to the clinical course, x-ray-finding s and in special cases the results of scintigraphy. Due to anatomic di fferences in vascularisation and soft tissue coverage nonunion of the femur and the tibia are discussed separately. Stabilisation is achieve d by intramedullary nail, plate or external fixator. As new methods th e internal plate fixator was used for the femur and the Ilizarov ring fixator for the tibia. If there has been a mistake in the choice of th e method of the primary stabilisation a change of method is done. If t he indication for the initial method of stabilisation was correct, the therapy of nonunions is limited to the correction of technical mistak es. Additionally, a biologic stimulation is required for the therapy o f non-vital nonunion. Results: The clinical data of 77 patients treate d from 1985-1993 were analysed retrospectively. Vital nonunions of the femur (11) healed after 9.5 months on the average, those of the tibia (49) after 10 months. The duration of treatment of non-vital nonunion s was much longer and required 20 and 16 months, respectively. The tre atment of two non-vital non-unions of the tibia could not be completed . For the femur only intramedullary nail (4) and plate (8) were used, for the tibia mainly the fixator (43), of these in 18 cases the Ilizar ov-apparatus. Differences in the duration of treatment due to the choi ce of implant could not be recognized. Complications were pin problems (14) and one lesion of the peroneal nerve in the fixator group and su perficial would infection (2), nerve irritation (1) and fracture (1) i n the group treated with intramedullar nailing. Conclusions: Due to th e good soft tissue coverage and vascularisation internal fixation is f avored for the treatment of femoral nonunions. The fixator should only be used if distraction osteogenesis is necessary because of a bony de fect. Due to the problematic soft tissue situation and poorer vascular isation the external fixator is preferred in the treatment of tibial n onunions if a change of method is indicated. For this purpose, we curr ently use predominantly the Ilizarov-apparatus because of its biomecha nical properties and the convincing results. Initial problems with its use could markedly be reduced with growing experience.