Abstract
Background Infected nonunion of the femur is a complex and disabling condition characterized by persistent infection, bone loss, limb length discrepancy, deformity, and joint stiffness. Management is particularly challenging in patients with multiple previous failed surgeries. The Ilizarov external fixator, based on the principles of distraction osteogenesis, offers a biological and mechanical approach that enables stable fixation, infection control, and simultaneous bone reconstruction. Methods This retrospective observational study was conducted at the National Institute of Traumatology and Orthopaedic Rehabilitation (NITOR), Dhaka, Bangladesh, from July 2019 to July 2024. A total of 34 patients (aged 16-65 years) with infected nonunion of the femur, with or without bone defects, were included. Diagnosis was established based on a combination of clinical (persistent pain, sinus tract, purulent discharge, local inflammatory signs, abnormal mobility), radiological (sequestrum, bone lysis, periosteal reaction, implant loosening), laboratory (elevated erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), leukocytosis), and microbiological findings where available. Radiological nonunion was defined as the absence of healing for at least 6-9 months with no progression over three months. All patients underwent thorough surgical debridement followed by stabilization using the Ilizarov external fixator, with or without corticotomy. Segmental bone transport was performed for bone defects greater than 1.5 cm. Postoperative management included early mobilization, physiotherapy, and culture-guided antibiotic therapy. Outcomes were assessed using the Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria for bone and functional results, and complications were classified according to Paley's classification. Results The mean age of the patients was 36.82±13.48 years, with a predominance of males (91.2%). The mean follow-up duration was 17.79±5.85 months. Bone defects were present in 85.3% of cases, with a mean defect size of 2.84±1.81 cm and a mean limb length discrepancy of 3.85±1.74 cm. Segmental bone transport was performed in 16 patients, achieving a mean regenerate length of 5 cm and a mean lengthening index of 2.47±0.36 cm/month. The mean duration of external fixation was 11.91±2.41 months. Infection control was achieved in all patients based on clinical and laboratory parameters during follow-up. According to the ASAMI criteria, bone results were excellent or good in 94.1% of patients, while functional results were excellent or good in 85.3%. Common complications included pin tract infection, knee stiffness, wire breakage, and docking site nonunion. Conclusion This study suggests that the Ilizarov external fixator is associated with favorable outcomes in the management of infected nonunion of the femur, including high rates of bone union and infection control. However, given the retrospective design and absence of a comparison group, these findings should be interpreted with caution. Functional outcomes may be limited by complications such as joint stiffness, highlighting the need for comprehensive postoperative rehabilitation. Further prospective and comparative studies are required to validate these results.