Older patients fare well, avoid amputation after Ilizarov treatment for tibial nonunion

Patients gained 5.3 quality-adjusted life years postop, with a time trade-off.

Issue: April 2007

Patients older than 60 years achieved union and saw statistically significant improvement in outcome measures after undergoing the Ilizarov method for tibial nonunion repair, according to investigators.

Mark R. Brinker, MD
Mark R. Brinker

A total of 23 consecutive patients who averaged 72 years of age underwent Ilizarov treatment by a single surgeon from 1996 to 2003.

“Older patients with amputations are less likely to recover ambulation than younger patients. And the results of amputation in the literature for younger patients cannot be applied to the older population. For these reasons, limb restoration in older patients is essential,” co-investigator Mark R. Brinker, MD, said at the American Academy of Orthopaedic Surgeons 74th Annual Meeting.

Treatment indications

He and his colleague, Daniel P. O’Connor, PhD, evaluated the 23 patients at an average 38 months follow-up.

The study group included 15 women and 8 men. They ranged in age from 61 years to 92 years.

All patients received initial fracture care at another institution, and presented to Brinker at an average 13 months and two prior surgeries since initial injury. All presented with a viable, sensate foot.

“Several had been offered an amputation by other physicians, but none [accepted] this,” Brinker said.

70-year-old man with an infected nonunion
This 70-year-old man presented with an infected nonunion and a deformity below a total knee replacement at 10 months after injury. He underwent one previous surgery.

Patient with active nondraining infection
The patient had an active nondraining infection and the surgeon treated him with a gradual deformity correction, followed by compression.

Images: Brinker MR

Most patients experienced injury in the distal tibia. The indications for Ilizarov treatment in this series were seven infected nonunions, seven with rigid deformity, seven with periarticular oblique plane deformity, and two that had multiple prior failed attempts at internal fixation, he said.

The surgeon treated four patients with gradual compression and 17 with gradual deformity correction and compression. He performed bony transport on two patients who had infected tibial nonunions and segmental defects.

Successful outcomes

The investigators lost three patients to follow-up. Two died of cardiovascular disease at home while still in the Ilizarov frame. The third demanded early removal of the frame and was then lost to follow-up, Brinker said.

All 20 patients who completed treatment and follow-up had successful outcomes, based on four criteria: retention of the involved limb, bony union, full weight-bearing and ambulation, and no clinical signs of infection. Follow-up ranged from 18 months to 61 months.

“Bony union was identified on plain radiographs with three or four cortices … or a CAT scan showing good, broad cross-sectional healing,” Brinker said.

Patients underwent treatment in the Ilizarov frame for an average of 9 months. “There was no difference based on anatomic region, [but] an infected nonunion had a significantly longer treatment time,” Brinker said. “There were no refractures and no patient who required further operative treatment on the tibia following frame removal.”

Measurement scores

The average AAOS Lower Limb score significantly improved from presentation to final follow-up: 39 to 78.1 (P<.001). The average SF-12 Physical Component Scale score also significantly improved from 26.5 points at presentation to 35.3 points at follow-up (P=.027), Brinker said.

As expected, the Brief Pain Inventory reflected a significant decrease in intensity of pain at final follow-up: 3.6/10 at presentation to 0.9/10 at follow-up (P=.001).

Researchers also evaluated patients using the “time trade-off” technique. They asked the patients, “If you are only going to live 10 more years, how many of those years would you be willing to give up in order to live the remaining years in perfect health?”

When asked this question at presentation, the patients were willing to trade an average 5.2 years – more than half of the hypothetical remaining life expectancy. “This shows how severe they perceived their problem to be,” Brinker said. “At final follow-up, they were only willing to trade 1.3 years or 13%. … If you look at their life expectancy tables, on average each patient gained 5.3 quality-adjusted life years.”

Impacts of function

Brinker compared these gained quality-adjusted life years to literature findings on other successful orthopedic surgeries, including total hip arthroplasty (5 quality-adjusted life years gained) and open reduction internal fixation for hip fracture (3 quality-adjusted life years gained).

“Nonunions in older adults are often complicated … by declining health and medical conditions. Maintaining or restoring function is important and has a large effect on quality and length of life,” Brinker said. “Amputations should be reserved for patients with severe medical conditions, which preclude reconstruction.”

Llizarov external fixator
The patient remained in the Ilizarov external fixator frame for just over 7 months.

Llizarov external fixator
Here is another angle of this patient in the Ilizarov frame.

For more information:

Brinker MR, O’Connor DP. Ilizarov treatment of tibial nonunion in older patients. #519. Presented at the American Academy of Orthopaedic Surgeons 74th Annual Meeting. Feb. 14-18, 2007. San Diego.

Mark R. Brinker, MD, Fondren Orthopedic Group, Texas Orthopedic Hospital, 7401 S. Main, Houston, TX 77030; 713-799-2300; mbrinker@houston.rr.com. He indicated that he has a royalty-bearing agreement with Smith & Nephew Orthopaedics, but received no funding for this study.