Malunion and nonunion of the juxta-articular distal tibial fractures have been widely treated by internal fixation for many years. Over the last few decades gradual correction of the deformity and/or distraction osteogenesis with an external ring fixator have become more popular among orthopedic surgeons. Ilizarov external fixators not only correct greater degrees of deformity with lesser incidence of complications but also correct more complex deformities compared with other methods of internal fixation such as plate and screws.Patients and methods
Between January 2006 and December 2008, 13 patients presented at the Minia University Hospital with malunion or nonunion of distal tibial fractures after failure of initial internal fixation with plates and screws. Removal of the implant, application of an Ilizarov external fixator, and adjustment of the hinges based on either the need for correction of the deformity alone or correction of the deformity and lengthening were performed. All patients were men, with an average age of 34.5 years (range, 16–52 years). The mean follow-up period was more than 24 months (range, 14–29 months). Eight patients presented with malunion and five with nonunion of the distal tibia. Three of the five patients who had nonunion presented to the department with radiological and clinical signs of osteomyelitis. One of them was treated by drainage and removal of the plate at another hospital.Results
Osseous union was achieved in all cases. Only one patient had a residual angular deformity of less than 10°, and two patients had leg-length discrepancy of lesser than 1 cm. The mean amount of tibial lengthening measured at removal of the frame was 1.5 cm. All patients showed marked improvement in both severity and duration of pain. The mean period for which the Ilizarov external fixator was applied was 146 days (range, 87–256 days). There was no recurrence of infection in the three patients who originally presented with osteomyelitis. The functional results were categorized as excellent in four, good in seven, and fair in two patients according to the classification of the Association for the Study and Application of the Method of Ilizarov.Conclusion
Despite the lengthy duration required for the application of the device to achieve reasonable results, gradual correction of the deformity and distraction osteogenesis can be superior alternatives for the treatment of malunion, nonunion, and/or shortening due to failure of internal fixation of distal tibial fractures.