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Background: Ilizarov external fixation has become the treatment of choice for infected non-union of tibia. Varying degrees of bone loss and different strategies of treatment in the published reports make comparing outcomes difficult. This study hopes to bridge this gap in the literature by focussing exclusively on bone transport in patients with bone loss of 5 cm or more. Methodology: This is a prospective case series conducted at a tertiary level orthopaedic speciality hospital. Outcomes are measured by Association of the Study and Application of Method of Ilizarov (ASAMI) bony scores, ASAMI functional scores, Lengthening Index and by assessing complications encountered. Results: There were 49 patients in this study with an average of 9.57 cm bone gap. Among these, 29 patients had a bone gap of 5-10 cm and 20 patients had a bone gap of ≥ 11 cm. According to the ASAMI bony score, 42 patients had excellent or good outcomes with two fair results and five poor results. The ASAMI functional scores were 45 excellent to good outcomes, four fair and no poor results or failures. Fixed flexion deformity of the knee of more than 5°, ankle stiffness and soft tissue interposition were significantly more frequent in those with bone gap of ≥ 11 cm. Trifocal transport and bone grafting at docking significantly improved the lengthening index. Conclusion: Even massive bone defects of 11 cm or more can be reliably healed by bone transport using Ilizarov external fixation, but with a significantly higher rate of complications. Level of evidence: Level IV.
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INTRODUCTION: The GeneXpert® MRSA/SA SSTI (Methicillin Resistant Staphylococcus aureus/S. aureus skin and soft tissue infection) PCR test allows early detection of methicillin resistance in staphylococci. This test was developed for skin infections and has been evaluated for prosthetic joint infections but, to our knowledge, has not been evaluated for hardware infections outside of arthroplasties. Furthermore, we conducted a retrospective study in patients with non-prosthetic osteosynthesis hardware aiming: (1) to identify the diagnostic values of the PCR test compared to conventional cultures and the resulting rate of appropriate antibiotic therapy; (2) to identify the rate of false negative (FN) results; (3) to identify and compare the rates of failure of infectious treatment (FN versus others); (4) to search for risk factors for FN of the PCR test. HYPOTHESIS: The PCR test allowed early and appropriate targeting of antibiotic therapy. MATERIAL AND METHODS: The results of PCR tests and conventional cultures for osteoarticular infections of non-prosthetic hardware over four years (2012-2016) were compared to identify the diagnostic values of using the results of conventional culture as a reference and the rate of appropriate antibiotic therapies. Infectious management failures between the results of the FN group and the others were compared, and variables associated with a FN of the PCR test were identified. RESULTS: The analysis of 419 PCR tests allowed us to establish a sensitivity of 42.86%, a specificity of 96.82%, a positive predictive value of 60% and a negative predictive value of 93.83%. Using the results of the PCR test for the targeting of postoperative antibiotic therapy, it was suitable for staphylococcal coverage in 90.94% (381/419). The rates of patients for whom infectious treatment failed were not significantly different between the FN group and the other patients (20.8% versus 17.7%, respectively; Hazard Ratio=1.12 (95%CI 0.47-2.69, p=0.79)). A skin opening during the initial trauma (p=0.005) and a polymicrobial infection were significantly associated with a risk of FN from the PCR test (p<0.001). CONCLUSION: The PCR test makes it possible to reduce the duration of empirical broad-spectrum antibiotic therapy during the treatment of an infection of osteosynthesis hardware but causes a lack of antibiotic coverage in 9.06% of cases. LEVEL OF EVIDENCE: III; diagnostic case control study.
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Antibiotic impregnated cement coated intramedullary nails (ACCINs) have been used in clinical practice for many years and have been shown to help eradicate infection in tibial osteomyelitis while providing stability. We present a novel technique for preparation using bronchoscopy tubing, as well as technical tips and a review of the literature, for ease of preparation and potential subsequent retrieval.
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Fijación Intramedular de Fracturas , Osteomielitis , Fracturas de la Tibia , Humanos , Antibacterianos , Broncoscopía , Fracturas de la Tibia/cirugía , Clavos Ortopédicos , Osteomielitis/cirugía , Fijación Intramedular de Fracturas/métodos , Cementos para HuesosRESUMEN
Here, we describe the case of an 80-year-old female patient with type II insulin-dependent diabetes mellitus with a left proximal tibia fracture. Open reduction internal fixation was performed using a locking plate. After the surgical site infection, the plate was removed and negative-pressure wound therapy was applied. The bone was covered with a vastus medialis muscle flap, and a split-thickness skin graft and external fixation using an Ilizarov device was performed as the definitive treatment.
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Aim: To highlight the role of the Masquelet technique as a limb salvage procedure for a neuropathic patient presenting with infected non-union of proximal tibia. Background: The management of an infected non-union in neuropathic patients is most challenging; with various treatment options available, the prognosis is often guarded. Case description: A 37-year-old male with chronic polyneuropathy, also possessing a contralateral midfoot Charcot arthropathy secondary to a history of alcohol abuse, developed infection after a proximal tibial osteotomy for a preceding mal-non-union of a proximal tibia fracture. The management included hardware removal, excision of necrotic bone, interim insertion of antibiotic-loaded bone cement followed by an acute shortening and revision of the internal fixation utilising a second surgical incision. Successful bone union and eradication of infection was achieved and maintained after 13 months follow-up. Conclusion: A successful outcome was achieved for an infected non-union of a long bone in a neuropathic patient using the Masquelet technique which was then followed with a second-stage removal of the spacer and shortening. By performing the revision ORIF surgery utilising a different skin incision in the setting of complicated previous surgical scars proved to be a viable technique towards reducing risk of recurrence of infection and a good outcome. Clinical significance: Utilisation of the Masquelet technique and limb shortening in a staged manner for the management of long bone infections in neuropathic patients has not been reported before and may be valuable in such demanding clinical situations. How to cite this article: Mahmoud AN, Watson JT, Horwitz DS. Modified Masquelet Technique and Primary Tibial Metaphyseal Shortening for the Management of Proximal Tibial-infected Non-union in a Patient with Alcohol-induced Neuropathy: A Case Study. Strategies Trauma Limb Reconstr 2023;18(3):181-185.
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PURPOSE: Orthopaedic-related wounds are critical situations calling for care to avoid deep infections and its consequences. The purpose of this study was to evaluate the efficacy of using honey for care of orthopaedic-related wounds with limited resources. PATIENTS AND METHODS: This prospective study included 50 cases with an average age of 38.18 (range 17-63) years with 38 males and 12 females. The most frequent wound location was the leg (41 patients; 82%), then the foot (six patients; 12%), and the ankle in three patients (6%). The aetiologies were open fractures (34 cases; 68%), infected tibial non-unions (nine cases; 18%), and post-operative infections (seven cases; 14%). Exposed tendon was present in three cases. Bone exposure was present in two cases. Deep infection was present in 29 cases (58%). Besides treating the primary cause, a ribbon of gauze soaked with honey was applied to the wounds after thorough saline washing. RESULTS: Wound sizes were variable. All cases showed improvement in all parameters with complete wound healing and full coverage of bone and tendons. Recurrence of deep infection occurred in three cases and treated by debridement. One case needed sequestrectomy of a small exposed tibial cortical fragment. Exposed tendon cases showed superficial necrosis which was treated by simple debridement. Initial mild itching occurred in five patients with spontaneous resolution. CONCLUSION: With treating the underlying aetiology and optimising the patient's general condition, honey was an effective, simple, and affordable method of wound care in different orthopaedic conditions even with exposed bone or tendons.
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Fracturas Abiertas , Miel , Ortopedia , Adolescente , Adulto , Vendajes , Femenino , Fracturas Abiertas/cirugía , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Adulto JovenRESUMEN
The treatment of infected non-unions of the femur and the tibia remains difficult and requires control of the infection and successful bone healing. Antimicrobial coating of intramedullary nails promises both infection control and stabilization for subsequent bone healing. Both results for custom-made and commercially available antimicrobial coating for intramedullary nails have been published in the past mainly consisting of retrospective case series. The purpose of this work is to review the published literature on techniques and clinical outcome of antimicrobial coatings for intramedullary nails for the treatment of infected long bone non-unions. A systematic literature research in Medline, PubMed, Embase and Cochrane Library was performed in accordance to the PRISMA guidelines. Articles reporting on antimicrobial-coated intramedullary nails for the treatment of infected long bone non-unions were eligible for inclusion. In total, 22 publications were found reporting on 506 infected non-unions of the tibia and femur treated with an antimicrobial-coated nail. Most of them consisted of retrospective case series (72.7%). 469 and 37 patients were treated with an individual antibiotic-loaded PMMA-coating and commercially available gentamicin-coating for intramedullary nails, respectively. The overall infection eradication rate was 90.0% (range 68.7-100%) and the bone consolidation rate was 85.5% (range 57.9-100%). Coating specific side effects were not reported. In conclusion, the treatment of infected long bone non-unions with antimicrobial-coated nails is associated with a high infection control and bone consolidation rate and seems to be a reasonable treatment options with minimal side effects. However, scientific quality of the publications is low and randomized controlled trials are needed.
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Clavos Ortopédicos , Fijación Intramedular de Fracturas , Antibacterianos/uso terapéutico , Fijación Intramedular de Fracturas/métodos , Curación de Fractura , Gentamicinas , Humanos , Polimetil Metacrilato , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: The surgical treatment of osteitis or fracture-related infections (FRI) is often associated with large bone defects. The treatment of these defects remains a major challenge in trauma surgery. Within the concept of tissue engineering, the development of various hybrid bone graft substitutes, such as calcium hydroxyapatite with added antibiotics, is continuously progressing. OBJECTIVE: Chances and limitations in the treatment of osteitis with calcium hydroxyapatite containing antibiotics. MATERIAL AND METHODS: Overview of the results of a 2-stage (infection) pseudarthrosis model on rat femurs treated with Cerament® G (Bonesupport, Lund, Schweden). Evaluation of the clinical experiences based on three case examples of osteitis treated with calcium hydroxyapatite containing antibiotics (Cerament® G or Cerament® V). RESULTS: After establishment of a 2stage pseudarthrosis model on the rat femur, the osteoconductive and osteoinductive potential of calcium hydroxyapatite containing antibiotics could be confirmed. In the clinical application, the use of Cerament® G seems to lead to a more favorable outcome in small cavitary defects. The recurrence rates are higher than previously described, especially for larger segmental defects. CONCLUSION: Taking the clinical and experimental results into consideration, a stricter evaluation of the indications for the use of Cerament® G is necessary to achieve the best possible outcome for patients.
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Sustitutos de Huesos , Osteítis , Seudoartrosis , Sepsis , Animales , Antibacterianos/uso terapéutico , Sustitutos de Huesos/farmacología , Durapatita/uso terapéutico , Osteítis/tratamiento farmacológico , Seudoartrosis/tratamiento farmacológico , Ratas , Sepsis/tratamiento farmacológicoRESUMEN
AIM: The present prospective randomized study compared the bone transport technique (BT) and Masquelet technique (MT) in the treatment of infected gap non-union of the tibia. PATIENTS AND METHODS: Total 25 patients with infected gap non-union of the tibia with bone gap upto 6 cm were randomised into BT group (group I, 13 patients) and MT (group II, 12 patients). The mean age was 31.77 years in group I and 39.67 years in group II. The mean intra-operative bone gap was 3.92 cm in group I and 3.79 cm in group II. Monolateral fixator was applied in nine patients each in both groups, while four and three fractures were stabilized with ring fixators in group I and II, respectively. Mean follow-up was 31.62 months and 30.42 months in group I and II, respectively. Bone and functional results were compared using the association for the study and application of the method of Ilizarov (ASAMI) criteria. RESULTS: The average fixator period was 9.42 and 16.33 months in group I and II, respectively (p < 0.001). Union was achieved in 12 (92%) patients and 6 (50%) patients in group I and II, respectively. The functional results were excellent (eight and two), good (four and six), fair (zero and three) and poor (one and one) in group I and II respectively, (p 0.23). The Bone results were excellent, good and poor in nine, three and one patients in group I, and three, three and six patients in group II respectively, (p 0.109). CONCLUSIONS: The functional and bone results were comparable but more reliable in bone transport than the Masquelet technique. The fixator duration and incidence of non-union were higher in MT group. Ilizarov bone transport technique should be preferred in infected non-union of the tibia with bone loss upto 6 cm.
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Fracturas no Consolidadas , Técnica de Ilizarov , Fracturas de la Tibia , Adulto , Fijadores Externos , Curación de Fractura , Fracturas no Consolidadas/cirugía , Humanos , Estudios Prospectivos , Estudios Retrospectivos , Tibia/cirugía , Fracturas de la Tibia/cirugía , Resultado del TratamientoRESUMEN
Infected non-union status post forearm fracture fixation is a challenge to treat and may be associated with unpredictable outcomes. The management of such a case involving a 71-year-old female suffering from Parkinson's disease is reported herein. The patient referred to our unit for a second opinion while she was under consideration for amputation at her local hospital. Utilising the two stage Masquelet technique successful limb salvage and excellent function were achieved.
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INTRODUCTION: When the fracture fails to heal for more than 12 months, it is called chronic non-union. Surgical intervention becomes mandatory to get this type of fracture healed. We are reporting our results in a case of congenital pseudoarthrosis of the tibia (CPT) having chronic non-union of 18 years duration with superadded infection following attempted surgery, using Ilizarov technology. We shall highlight the problems found during the course of treatment and different strategies to tackle them. CASE PRESENTATION: An 18-year-old female, born with CPT of the right tibia with neurofibromatosis, presented as Type 1 infected non-union following three unsuccessful surgeries. She had neurofibromatic nodules all over the body including the face. The leg had multiple active draining sinuses, with evidence of healed sinuses and operating scars, adherent to underlying bone. She had 20 cm of limb shortening. Prolonged morbidity made her socially isolated. Being poor, they could not manage her medical expenses. They started believing that amputation would be a viable option and with that feeling in mind, they approached us. After few sittings of counseling, they somehow agreed to give it a try. After preparing the patient, a radical excision of the infected and dead tissue was done. A 3 ring Ilizarov assembly was mounted as the distal fragment was very small. A corticotomy was done to fill up 10 cm of gap following excision and subsequent limb lengthening. She developed hyporegenerate, pin-tract infections (PTIs) during the course of treatment which were tackled accordingly. She also developed psychological problems due to nature of treatment that was taken care of too. The fracture united and she could start walking unaided. There was no recurrence of infection. The ring was kept in situ for about 700 days. CONCLUSION: Chronic non-union associated with neurofibromatosis and infection is a very challenging situation. Radical debridement is the key to prevent recurrence of both. Ilizarov system plays the most significant role in forming regenerate by distraction. Hyporegenerate and PTIs could be tackled meticulously to prevent complications and attain the desired result. The patient could achieve painless unaided walking after the treatment. Probably instilling self-confidence in the patient was one of the most important aspects to sustain such an arduous journey.
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INTRODUCTION: We hereby present a rare case of proximal fibular head migration associated with Ilizarov technique for infected tibia gap non-union due to follow-up failure in post-operative management during the coronavirus disease (COVID) pandemic. CASE REPORT: A 45-year-old male patient had undergone primary external fixation with wound debridement for a compound tibia shaft fracture Grade 3 A Gustilo class which later on with a healed external wound with a discharging sinus at the fracture site was confirmed to be infected non-union and subsequently managed by Ilizarov ring fixation over an antibiotic coated intramedullary nail and local gentamycin beads after a necrotic bone fragment of around 6 cm was excised. Post-operative protocol of compression and distraction was initiated and the patient educated regarding the same before discharge. As the world over was hit by the COVID pandemic and the lockdown limited all possible movements in our country, the patient could not follow up for monitoring the Ilizarov limb lengthening procedure. He presented to us after 4 months after the relaxation of lockdown with radiological union at the docking site but with a shortening of about 3 cm. Vigorous knee range physiotherapy failed to improve range beyond 90° which prompted us to check X-ray the knee joint and revealed the complication of proximal fibular head migration of 4 cm but with no neurodeficit and currently the patient is being managed with full weight mobilization with the help of crutch and shoe raise and an improved knee range till 100° of flexion with no pain tenderness or any other complaints. CONCLUSION: Having knowledge of this possible rare complication and the need for follow-up and monitoring with the importance of patient education makes practicing orthopedic surgeons equipped to handle and anticipate such undesirable complications.
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INTRODUCTION: Refracture of the tibia after union is a challenging problem for the patients and the surgeons. The purpose of the current study is to present our experience in conservative management of such patients with refracture of infected ununited tibia after successful treatment by Ilizarov external fixator and bone transport. MATERIAL AND METHODS: We reviewed the files of 812 patients with infected ununited tibia who were treated by debridement, corticotomy, and bone transport using Ilizarov methods in our institute between 1997 and 2017. Inclusion criteria were patients with refracture after union and removal of the Ilizarov apparatus. Twenty-two patients with 23 refracture tibia were included in the study. All the 23 tibias were treated conservatively by above knee cast that was converted to Sarmiento below knee cast after early callus formation, except in the case of upper tibial fracture that continued in above knee cast till union. Afterwards, a protective splint was used for additional two months. RESULTS: There were 19 males (86.4%) and three females (13.6%), the mean age of the patients was 38.39 years, the mean time of Ilizarov external fixator application was 10.86 months (range, 6-17), and the mean time of refracture after fixator removal was 2.33 months. Union was achieved in 19 tibias (82.6%), with a mean time of 7.2 months (range, 4-12). Complications included five cases of skin irritation that was treated by large windows in the cast and changing the casts more frequently, three cases developed DVT (deep venous thrombosis), and axial deviation occured in four tibias (17.3%). CONCLUSION: Conservative treatment of refractured tibia after removal of Ilizarov external fixator following treatment of infected non-union tibia by above knee cast is effective in achieving union. However, complications as skin irritation, DVT (deep venous thrombosis), and axial deviation can be anticipated.
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Fracturas no Consolidadas , Técnica de Ilizarov , Fracturas de la Tibia , Fijadores Externos/efectos adversos , Femenino , Curación de Fractura , Humanos , Lactante , Masculino , Tibia/cirugía , Fracturas de la Tibia/diagnóstico por imagen , Fracturas de la Tibia/cirugía , Resultado del TratamientoRESUMEN
OBJECTIVES: To evaluate the results of one stage radical debridement and segmental bone transport with circular fixator in the treatment of infected tibial non-union requiring extensive debridement with an average defect size of 8 cm and distraction length of 9,5 cm. DESIGN: Retrospective study. SETTING: Level I trauma centre at an academic university hospital. PATIENTS: Thirty patients with infected tibial non-union with an average of 2,9 previous failed operations after a mean 12,5 months post-injury were treated consecutively. The mean age was 39,5 years (R:16-68). After radical debridement and irrigation, all patients were treated with segmental bone transport using Ilizarov circular fixator. All patients except 3, managed with an open docking protocol without bone grafting. In 2 patients a planned ankle arthrodesis with transport was done. MAIN OUTCOME MEASUREMENTS: Bone union, resolution of infection, external fixation index (EFI), external fixation time (EFT), bone and functional results for this big defect size. RESULTS: Union and eradication of infection was achieved in all patients. Mean follow-up was 32,5 months (R: 12-72 mo.) The average bone defect after debridement was measured 8.1 cm (R, 6-15). The total distraction length to restore the debridement defect and previous LLD was 9,5 cm (R, 6-15). The mean external fixation time was 13,7 months; the mean external fixation index was 1,49 mo./cm. One non-union, one refracture and one late valgus deformity was managed successfully with plating or nailing and all were healed uneventfully at the completion of the treatment. According to Paley & Maar and Katsenis criteria, the bone results were excellent in 24 and good in 6, functional scores were excellent in 21, good in 7, and fair in 2 patients. Minor complications were 1,36 per patient, major complications were 0,4 per patient and permanent complications were 0,2 per patient in the study group. CONCLUSION: In the management of large post-infectious bone defects requiring an average 9,5 cm distraction; segmental bone transport is safe in terms of union and eradication of infection. The EFI, EFT, complications, bone and functional results do not differ from the other published studies with smaller defect size.
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Técnica de Ilizarov , Fracturas de la Tibia , Adulto , Desbridamiento , Fijadores Externos , Curación de Fractura , Humanos , Estudios Retrospectivos , Tibia , Fracturas de la Tibia/diagnóstico por imagen , Fracturas de la Tibia/cirugía , Resultado del TratamientoRESUMEN
INTRODUCTION: Adequate debridement of necrotic bone is of paramount importance for eradication of infection in chronic osteomyelitis. Currently, no tools are available to detect the exact amount of necrotic bone in order to optimize surgical resection. The aim of the present study was to evaluate the feasibility of an intraoperative illumination method (VELscope®) and the correlation between intraoperative and pathohistological findings in surgically treated chronic fracture related infection patients. METHODS: Ten consecutive patients with chronic fracture related infections of the lower extremity were included into this prospectively performed case series. All patients had to be treated surgically for fracture related infections requiring bony debridement. An intraoperative illumination method (VELscope®) was used to intraoperatively differentiate between viable and necrotic bone. Tissue samples from the identified viable and necrotic bone areas were histopathologically examined and compared to intraoperative findings. RESULTS: In all included patients, the intraoperative illumination was deemed helpful to differentiate between necrotic and viable bone tissues during bony debridement. The histopathological examination of the samples showed good correlation of the intraoperative illumination findings with histopathological signs of necrosis for areas deemed dead and histopathological signs of intact bone for areas deemed vital during illumination. CONCLUSION: The fluorescence-assisted, intraoperative detection of necrotic and viable bone using the VELscope® is an easy-to-use procedure that can help surgeons to optimize intraoperative bone resection in chronic fracture related infections by unmasking viable from necrotic bone tissue. This may help to improve resection techniques and eventually treatment outcome in patients in the future.
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Fracturas Óseas , Osteomielitis , Osteonecrosis , Desbridamiento , Humanos , Imagen Óptica , Osteomielitis/diagnóstico por imagen , Osteomielitis/cirugía , Resultado del TratamientoRESUMEN
Infected non-union of subtrochanteric fractures is challenging to treat. We experienced two cases and had good clinical results. Treatment strategy comprised debridement without hesitation after considering later limb lengthening; insertion of the proximal lateral bone edge spike into the distal bone marrow cavity until achieving medial-side bony contact and holding good alignment to compensate for the medial-side bone loss, according to the modified Dimon method; and internal fixation with an angled plate in the decubitus position. The angle of the angled plate should be directed toward the abundant cancellous bone using preoperative computed tomography. Residual limb shortening after ORIF was improved by limb lengthening.
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OBJECTIVES: Bone defects as a result of infected non-union or chronic osteomyelitis are difficult to manage. The purpose of this study was to present the results of treatment of bone defects of < 6â¯cm due to a previous infected non-union or chronic osteomyelitis with autologous non-vascularized fibular grafts in a 2-stage surgery. PATIENTS AND METHODS: The records of patients who were treated with autologous non-vascularized fibular grafts for bone defects of < 6â¯cm due to a previous infected non-union or chronic osteomyelitis between 2008 and 2013 were retrospectively reviewed. Primary complete bone union was the primary outcome. Time until fracture union, and return to normal daily activities or previous work were recorded. Radiographs were evaluated for graft hypertrophy as well as for stress fracture and other complications. RESULTS: A total of 27 cases were included. The mean length of the bone defects was 4.4â¯cm (range 2 - 6â¯cm). Complete union and healing occurred in 25/27 patients (primary success rate of 92.6%). Non-union was present in two patients with suboptimal soft tissue condition 10 months after surgery, one patient was subsequently treated with a vascularized free fibular graft from the contralateral fibula, and the other patient was treated with distraction osteogenesis, bone union was achieved after the second surgery. Average time to return to normal daily activity after surgery was 7.82 months (6 ~ 11 months). Graft hypertrophy occurred in 15 cases 15/25 (60%) two years post-surgery. There were no other surgical or postoperative complications. CONCLUSIONS: With careful evaluation of soft-tissue condition surrounding bone defect, management of infected bone defects with autologous non-vascularized fibular grafts technique has a high success rate with few complications.
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Autoinjertos/trasplante , Peroné/trasplante , Fracturas no Consolidadas/microbiología , Osteomielitis/cirugía , Adolescente , Adulto , Anciano , Autoinjertos/patología , Trasplante Óseo/efectos adversos , Trasplante Óseo/métodos , Enfermedad Crónica , Femenino , Curación de Fractura/fisiología , Fracturas por Estrés/diagnóstico por imagen , Fracturas por Estrés/epidemiología , Fracturas no Consolidadas/cirugía , Humanos , Hipertrofia/epidemiología , Masculino , Persona de Mediana Edad , Osteomielitis/complicaciones , Osteomielitis/diagnóstico por imagen , Radiografía , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
One of the most challenging complications in trauma surgery is infection after fracture fixation (IAFF). IAFF may result in permanent functional loss or even amputation of the affected limb in patients who may otherwise be expected to achieve complete, uneventful healing. Over the past decades, the problem of implant related bone infections has garnered increasing attention both in the clinical as well as preclinical arenas; however this has primarily been focused upon prosthetic joint infection (PJI), rather than on IAFF. Although IAFF shares many similarities with PJI, there are numerous critical differences in many facets including prevention, diagnosis and treatment. Admittedly, extrapolating data from PJI research to IAFF has been of value to the trauma surgeon, but we should also be aware of the unique challenges posed by IAFF that may not be accounted for in the PJI literature. This review summarizes the clinical approaches towards the diagnosis and treatment of IAFF with an emphasis on the unique aspects of fracture care that distinguish IAFF from PJI. Finally, recent developments in anti-infective technologies that may be particularly suitable or applicable for trauma patients in the future will be briefly discussed.
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Fijación de Fractura/efectos adversos , Fracturas Óseas/cirugía , Osteomielitis/microbiología , Infecciones Relacionadas con Prótesis/microbiología , Antiinfecciosos/uso terapéutico , Biopelículas/efectos de los fármacos , Fracturas Óseas/microbiología , Humanos , Osteomielitis/tratamiento farmacológico , Guías de Práctica Clínica como Asunto , Infecciones Relacionadas con Prótesis/tratamiento farmacológicoRESUMEN
BACKGROUND: Infected non-union is complex and debilitating disorder affecting orthopaedic surgeon and patient in terms of cost and time. Many methods are described in the literature for treatment of infected non-union. Local high concentration of antibiotic and mechanical stability of antibiotic cement impregnated intramedullary nail (ACIIN) proves cost and time effective. Recently it was suggested that ACIIN can achieve both union and infection control in infected non-unions with bone gap less than 4cm. The aim of our study was to investigate this hypothesis and study the outcome of antibiotic cement impregnated intramedullary nail in term of both infection control and osseous union. MATERIALS AND METHODS: We retrospectively studied 21 patients with infected diaphyseal femoral non-union. Inclusion criteria were bone gap less than 4cm after debridement and more than 1 year follow-up of the case. ACIIN prepared using K nail was used as primary procedure after adequate debridement. Infection control and osseous union was judged on the basis of clinical, radiological and haematological parameters. All patients were followed up with an average follow-up of 20.23±3.65 months (range 14-28 months). RESULTS: Infection control was achieved in all 21 patients at end of 12 months follow-up, out of which 16 patients had osseous union and infection control without any secondary procedure. Of the remaining 5 patients: two patients had good infection control but had broken ACCIN due to non-compliance to weight bearing protocol. One patient underwent exchange nailing and plate augmentation whilst the other underwent simple exchange nailing, One more patient who had infection control but had persistent non-union had to undergo exchange nailing and augmented plating to achieve union. One other patient required debridement and implant removal and attained union and fifth patient required two additional debridements to control infection after which the fracture united. Apart from above 5 cases there were two further complications of knee stiffness. CONCLUSION: In infected non-union with bone gap less than 4cm, ACIIN can achieve both infection control and osseous union in significant number of cases. All such cases should be primarily operated with aim to achieve this outcome and use of thicker nail and ensuring proper compliance from patients regarding weight bearing will improve the outcomes.
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Antibacterianos/farmacología , Cementos para Huesos/farmacología , Diáfisis/lesiones , Fracturas del Fémur/cirugía , Fijación Intramedular de Fracturas/métodos , Curación de Fractura/efectos de los fármacos , Fracturas no Consolidadas/cirugía , Infección de la Herida Quirúrgica/tratamiento farmacológico , Adulto , Clavos Ortopédicos , Desbridamiento/métodos , Diáfisis/cirugía , Femenino , Fracturas del Fémur/complicaciones , Fracturas del Fémur/fisiopatología , Estudios de Seguimiento , Curación de Fractura/fisiología , Fracturas no Consolidadas/complicaciones , Fracturas no Consolidadas/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Infección de la Herida Quirúrgica/prevención & control , Resultado del Tratamiento , Adulto JovenRESUMEN
OBJECTIVES: The objectives of the study were to introduce a circumferential bone graft around an absorbable gelatin sponge core using an induced membrane technique, to assess its ability to reduce the required amount of graft and to maintain the bone graft, and to evaluate the clinical outcomes in the management of critical-size bone defects. PATIENTS AND METHODS: Circumferential bone grafting using a staged induced membrane technique for managing critical-size bone defects was performed in 21 patients. Postoperative computed tomography scans were performed 7days after Hemovac drain removal and 3 months after bone grafting. Volumetric measurements of the defect size, gelatin sponge proportion, and amount of grafted bone were performed by two independent observers using three-dimensional (3D) software. RESULTS: The critical-size defects were located at the metadiaphyseal area of 11 tibias, eight femurs, and two humeri. The average defect size was 8.9cm in length and 65.2cm3 in volume. The absorbable gelatin sponge core replaced 21.4% (average) of the defect volume. There was no significant deterioration in the shape of the grafted bone among the serial 3D models. Eighteen patients (86%) were healed radiographically at 9.1 months (average). CONCLUSION: Our study suggests that circumferential bone grafting in association with the induced membrane technique could reduce the required amount of bone graft and adequately maintain graft position and shape, with favourable clinical outcomes.