Clinical outcomes of Ilizarov external fixation in the management of infected tibial non-union: an observational study from Bangladesh

Mohammad Mohsin Mia; Muhammad Anwar Hossen; Shahnewas; M. Sahidur Rahman Khan; M. Samsul Arefin; M. Azizur Rahman

doi:10.18203/2320-6012.ijrms20264162

Authors

Mohammad Mohsin Mia Department of Ilizarov & Deformity Correction, National Institute of Traumatology and Orthopedic Rehabilitation (NITOR), Dhaka, Bangladesh
Muhammad Anwar Hossen Department of Ilizarov & Deformity Correction, National Institute of Traumatology and Orthopedic Rehabilitation (NITOR), Dhaka, Bangladesh
Shahnewas Department of Orthopaedic Surgery, National Institute of Traumatology and Orthopedic Rehabilitation (NITOR) Dhaka, Bangladesh
M. Sahidur Rahman Khan Department of Orthopaedics & Traumatology, National Institute of Traumatology and Orthopaedic Rehabilitation (NITOR), Dhaka, Bangladesh
M. Samsul Arefin Department of Orthopaedic Surgery, Kushtia Medical College, Kushtia, Bangladesh
M. Azizur Rahman Department of Orthopaedic Surgery, National Institute of Traumatology and Orthopedic Rehabilitation (NITOR) Dhaka, Bangladesh

DOI:

https://doi.org/10.18203/2320-6012.ijrms20264162

Keywords:

ASAMI, External fixation, Distraction osteogenesis, Fracture-related infection, Ilizarov technique, Infected tibial nonunion

Abstract

Background: Infected tibial nonunion involves persistent infection, impaired bone biology, mechanical instability, and often bone loss or deformity. Ilizarov fixation enables debridement, stable fixation, compression, and bone transport but may require prolonged treatment and carries frequent complications.

Objective: To evaluate union, infection eradication, Association for the Study and Application of Methods of Ilizarov (ASAMI) outcomes, external fixation duration, and complications following Ilizarov treatment of infected tibial nonunion at a tertiary orthopaedic centre in Bangladesh.

Methods: This observational study reviewed 37 adults treated at the Department of Orthopaedic Surgery, National Institute of Traumatology and Orthopaedic Rehabilitation, Dhaka, from 1 July 2022 to 31 July 2025. Radical debridement, individualized Ilizarov fixation, and culture-directed antibiotics were used; bone transport was performed when required. Patients were followed for 12 months, with descriptive analysis based on last follow-up data.

Results: Mean age was 33.7±11.4 years; 28 (75.7%) were men. Initial fractures were open in 25 (67.6%), and 15 (40.5%) had bone defects >2 cm. Union occurred in 34 (91.9%) after 5.8±1.4 months, and infection was eradicated in 33 (89.2%). Excellent/good ASAMI bone and functional outcomes occurred in 30 (81.1%) and 32 (86.5%), respectively. Mean external fixation duration was 7.4±1.5 months. Complications occurred in 28 (75.7%); pin-tract infection affected 16 (43.2%). One patient underwent amputation for persistent infection and sepsis.

Conclusion: Ilizarov treatment achieved high observed union, infection eradication, and favourable ASAMI outcomes, but complications and prolonged frame treatment remained substantial.

References

Tian R, Zheng F, Zhao W, Zhang Y, Yuan J, Zhang B, et al. Prevalence and influencing factors of nonunion in patients with tibial fracture: systematic review and meta-analysis. J Orthop Surg Res. 2020;15(1):377.

Govaert GAM, Kuehl R, Atkins BL, Trampuz A, Morgenstern M, Obremskey WT, et al. Diagnosing fracture-related infection: current concepts and recommendations. J Orthop Trauma. 2020;34(1):8–17.

McNally M, Govaert G, Dudareva M, Morgenstern M, Metsemakers WJ. Definition and diagnosis of fracture-related infection. EFORT Open Rev. 2020;5(10):614–619.

Metsemakers WJ, Morgenstern M, Senneville E, Borens O, Govaert GAM, Onsea J, et al. General treatment principles for fracture-related infection: recommendations from an international expert group. Arch Orthop Trauma Surg. 2020;140(8):1013–27.

Tissingh EK, Marais L, Loro A, Bose D, Ferguson J, Nnadi C, et al. Management of fracture-related infection in low resource settings: how applicable are the current consensus guidelines? EFORT Open Rev. 2022;7(6):422–32.

Aktuglu K, Erol K, Vahabi A. Ilizarov bone transport and treatment of critical-sized tibial bone defects: a narrative review. J Orthop Traumatol. 2019;20(1):22.

Feng D, Zhang Y, Jia H, Xu G, Wu W, Yang F, et al. Complications analysis of Ilizarov bone transport technique in the treatment of tibial bone defects: a retrospective study of 199 cases. BMC Musculoskelet Disord. 2023;24(1):864.

Yin P, Ji Q, Li T, Li J, Li Z, Liu J, et al. A systematic review and meta-analysis of Ilizarov methods in the treatment of infected nonunion of tibia and femur. PLoS One. 2015;10(11):e0141973.

Wakefield SM, Papakostidis C, Giannoudis VP, Mandía-Martínez A, Giannoudis PV. Distraction osteogenesis versus induced membrane technique for infected tibial non-unions with segmental bone loss: a systematic review of the literature and meta-analysis of available studies. Eur J Trauma Emerg Surg. 2024;50(3):705–21.

Piercey JE, Noye N, Muhib MA, Tetsworth K. Single-stage revision of infected tibia nonunion with antibiotic cement-coated intramedullary nail versus Ilizarov methods: a systematic review and meta-analysis. J Limb Lengthening Reconstr. 2025;11(1):1–9.

Madhusudhan TR, Ramesh B, Manjunath KS, Shah HM, Sundaresh DC, Krishnappa N. Outcomes of Ilizarov ring fixation in recalcitrant infected tibial non-unions: a prospective study. J Trauma Manag Outcomes. 2008;2(1):6.

Wani NB, Syed B. Ilizarov ring fixator in the management of infected non-unions of tibia. SICOT J. 2015;1:22.

Fahad S, Habib AA, Awais MB, Umer M, Rashid HU. Infected non-union of tibia treated with Ilizarov external fixator: our experience. Malays Orthop J. 2019;13(1):36–41.

Bakhsh K, Atiq-Ur-Rehman, Zimri FK, Mohammad E, Ahmed W, Saaiq M. Presentation and management outcome of tibial infected non-union with Ilizarov technique. Pak J Med Sci. 2019;35(1):136–40.

Uddin KMB, Khan MR, Chakraborty S, Nath AT, Mahmood SK, Mazher Ali KM. Evaluation of the outcome of Ilizarov external fixator in tibial non-union. Med Today. 2025;37(1):119–22.

Paley D, Catagni MA, Argnani F, Villa A, Benedetti GB, Cattaneo R. Ilizarov treatment of tibial nonunions with bone loss. Clin Orthop Relat Res. 1989;(241):146–65.

Kukreja K, Reyaz S, Kumar MN. Outcome of bone transport using Ilizarov external fixator in infected non-union of tibia with large bone defects: comparison of those with 5–10 cm bone defect with those having ≥11 cm bone defect. Indian J Orthop. 2024;58(4):345–53.

Shields DW, Iliadis AD, Kelly E, Heidari N, Jamal B. Pin-site infection: a systematic review of prevention strategies. Strategies Trauma Limb Reconstr. 2022;17(2):93–104.