C. VINAY KUMAR-FDMFJKAS MFJAFL JDAFKLDJFLKSDJFKLDSJ

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1. NON UNIONS FOLLOWING PATHOLOGICAL FRACTURES IN CHRONIC HAEMATOGENOUS OSTEOMYELITIS IN CHILDREN-A COMPREHENSIVE APPROACH BY ILIZAROV METHOD Dr. C. Vinay Kumar Presenter- Post graduate Dr. N. Srinivas Reddy Associate Professor Dr. M. Nagendra Babu , HOD Prathima Institute of Medical Sciences, Karimnagar.

2. HAEMATOGENOUS OSTEOMYELITIS Primary osteomyelitis – nonunions – rare condition * Treatment – different and difficulty . *

3. WHY DIFFERENT / WHY DIFFICULTY Associated with infection – large cavities / sequestrum . Limb length discrepancy. * Deformities Adjacent joint / soft tissue contractures . *

4. EVALUATION Clinical examination X-Ray Haematological MRI / CT Physeal damage assessment Pus for C/S Fitness for anaesthesia / surgery

5. PATIENTS & METHODS Retrospective clinical study 2006-2018 Mean age- 5.06 years min 1½ year max 11 years Mean age of nonunion- 3 years Limb length discrepancy -3 patients Wound exploration – 7 patients but active infection – 4 patients Bone transport – 1 patient Free fibular graft + cancellous bone graft( CBG ) – 3 patients, CBG – 2 – Iliac crest , 1 – upper tibia Average number of surgeries (Primary) 1.75 / patient.

6. TREATMENT Surgical treatment – Ilizarov fixation Counseling

7. ILIZAROV APPLICATION Single / two stage procedure Wound exploration / debridement Mounting the fixator Deformity correction Corticotomy Bone grafting Antibiotic protocol.

8. POST OPERATIVE PHASE Intensive physiotherapy Fixator education- compression / distraction protocol Pin tract care / infections Bone transport Regular followup

9. LONG TERM FOLLOWUP AND TREATMENT Progression of the deformity Limb length discrepancy. Deformity correction and bone transport.

10. COMPLICATIONS & OUTCOME Pin tract infection Failed osteosynthesis Flareup of infection Malunion Limitation of forearm rotation Despite complications osteosynthesis obtained in all the cases.

11. CASE – 1

12. CASE – 2

13. CASE – 3

14. CASE 3

15. CASE – 4

16. CASE – 5

17. DISCUSSION Nonunions – treated at the earliest. Counseling of the patient / parents. Explanation of the clinical situation / treatment methodology /duration of treatment / inherent complications/ multiple surgeries. Long term followup . Late treatment - progressive limb length discrepancy / angular deformities. Nutritional status. Socio-economic aspects of the family. Psychological status of the child.

18. CONCLUSION Ilizarov method is very reliable and effective in these difficult clinical situations, not only because of its efficacy in osteosynthesis but also because of its comprehensive approach to address the associated conditions.

19. REFERENCES Tachdjian’s paediatric orthopaedics , 5 th Edition S Robert Rozbruch & Svetlana ilizarov , Limb lengthening and reconstruction surgery, 2007 Vladimir golyakhobsky , Text book of Ilizarov Surgical techniques-bone correction & lengthening Dror paley , Principles of deformaty correction Dianchi maiocci A, Aronson J, Operative principles of Ilizarov fracture treatment, non union osteomyelitis . Baltimore, Williams and wilkins , 1991.

20. CONFLICT OF INTEREST Informed consent taken from the patient for inclusion in the study Ethical principles of research followed

21. MASTER CHART Serial no. Name Age Gender Age of nonunion Segment involved Limb length discrepancy. Deformity No.Of surgeries Wound debridement Bone transport Bone grafting Fixator time in days Result Comments 1 Xxx 5 yrs M 4 years Tibia 7cm . Tibia vara 2 Not done Done. Distal tibial . Not done 218 Union+/bone transport+ Varus + 2 Xxx 6 yrs M 6 months Femur 3cm . Nil 1 Done Not done Not done 222 Union failed Ilizarov redone united 3 Xxx 11 yrs F 8 years Tibia Nil Procurvatum tibia 1 Not done Nil Not done 268 Union+/deformity Satisfied patient. 4 Xxx 3 yrs M 2 years Femur Nil Nil 1 Done Not done Not done 192 Successful LLD persisted 5 Xxx 4 yrs M 3 years Radius Nil Manus valgus 2 Done. No inf. Not done Fg+cbg 177 Union + deformity- Min. Stiffness 6 Xxx 6 yrs F 3 years Radius Nil Manus valgus 2 Done.No inf. Not done Fg+cbg 224 Union+ defomity - Stiffness min. 7 Xxx 1½ yrs F 6 months Radius Nil Manus valgus 2 Done.No inf. Not done Fg+cbg 118 Union+ deformity- Lost for followup 8 Xxx 4 yrs F 3 years Femur Nil Deformity+ 3 Done. Infection+ Not done Not done 168 Successful Deformity persisted. LLD -Limb Length Discrepancy FG - Fibular Graft CBG - Cancellous Bone Graft