Distraction osteogenesis technique using an intramedullary nail and a monolateral external fixator in the reconstruction of massive postosteomyelitis skeletal defects of the femur

Background: Large skeletal defects due to postosteomyelitis are uncommon, and they present a challenging reconstructive problem. The aim of our study was to summarize our experience performing a distraction osteogenesis technique using an intramedullary nail and a monolateral external fixator in the reconstruction of massive postosteomyelitis skeletal defects of the femur. Methods: Between January 1998 and October 2004, 17 patients with massive postosteomyelitis skeletal defects of the femur (11 men and 6 women), underwent the reconstruction procedure. After osteotomy of diaphysis of the femur, we inserted an intramedullary nail into the femur, and we placed a monolateral external fixator with half-pins lateral to the nail. Lengthening was started on the seventh postoperative day at a rate of 1 mm/d. Once we achieved solid bone union, we removed the monolateral external fixator; the intramedullary nail remained for bone consolidation until reconsruction was complete. We assessed the outcomes clinically and radiographically at a mean of 70.3 months postoperatively. Results: At follow-up (mean 70.3, range 14.0-96.0 mo), all the skeletal defects were filled, bone union at docking sites was achieved without bone graft and leg length discrepancies were less than 2.5 cm in all patients. The mean gain in length was 12.9 (range 10.2-18.4) cm. According to Paley and Maar's evaluation criteria, we graded the bone results as excellent for 10 patients, good for 5, fair for 1 and poor for 1. We graded the functional results as excellent for 12 patients, good for 4 and fair for 1. The mean external fixator index was 18.1 d/cm; the consolidation index was 35.7 d/cm. Ten patients experienced pin infection, and 1 patient experienced a recurrence of deep infection. There were no neurologic or vascular injuries. Conclusion: Our study demonstrates that a distraction osteogenesis technique using an intramedullary nail and a monolateral external fixator is a reliable method for the reconstruction of massive postosteomyelitis skeletal defects.