Acute shortening and re-lengthening (Asrl) in infected non-union of tibia-advantages revisited

Abstract

Introduction: A gap non-union in various conditions has been treated successfully by the Ilizarov method. The gap can be filled up either by an acute shortening and re-lengthening (ASRL) procedure or by an internal bone transport (IBT). We compared the functional and clinical outcome of ASRL and IBT in gap non-unions of the infected tibia. Materials and Methods: A retrospective study was conducted in our department from the data collected in the period between 1997 and 2010. There were 86 cases of infected non-union of the tibia, in patients of the age group 18 to 65 years, with a minimum two-year follow-up. Group A consisted of cases treated by ASRL (n=46), and Group B, of cases by IBT (n=40). The non-union following both open and closed fractures had been treated by plate osteosynthesis, intra-medullary nails and primary Ilizarov fixators. Radical debridement was done and fragments stabilised with ring fixators. The actual bone gap and limb length discrepancy were measured on the operating table after debridement. In ASRL acute docking was done for defects up to 3cm, and subacute docking for bigger gaps. Corticotomy was done once there was no infection and distraction started after a latency of seven days. Dynamisation was followed by the application of a patellar tendon bearing cast for one month after removal of the ring with the clinico-radiological union. Results: The bone loss was 3 to 8cm (4.77±1.43) in Group A and 3 to 9cm (5.31± 1.28) in Group B after thorough debridement. Bony union, eradication of infection and primary soft-tissue healing was 100%, 85% and 78% in Group A and 95%, 60%, 36% in Group B respectively. Non-union at docking site, equinus deformity, false aneurysm, interposition of soft-tissue, transient nerve palsies were seen only in cases treated by IBT. Conclusion: IBT is an established method to manage gap non-union of the tibia. In our study, complications were significantly higher in cases where IBT was employed. We, therefore, recommend ASRL with an established protocol for better results in terms of significantly less lengthening index, eradication of infection, and primary soft tissue healing. ASRL is a useful method to bridge the bone gap by making soft tissue and bone reconstruction easier, eliminating the disadvantages of IBT.