Surgical treatment outcome after serial debridement of infected nonunion\u2014A retrospective cohort study

Stefanie Kern,Reinhard Schnettler,Nike Walter,Lydia Anastasopoulou,Markus Rupp,Christian Heiss,Volker Alt

doi:10.1007/s00590-021-02930-4

Abstract

PurposeReported outcome after multiple staged surgical treatment of infected nonunion is scarce. We, therefore, asked: (1) What is the clinical outcome in infected nonunion patients after multiple staged revision surgery? (2) Are different pathogens evidenced after surgical treatment in patients who have undergone more or less surgeries?MethodsAll enrolled patients were surgically treated for long bone-infected nonunion between January 2010 and March 2018. Besides patients´ demographics outcome in terms of bony consolidation and major complications defined as death during inward treatment, amputation and recurrence of infection during follow-up of at least 12 months were assessed. Microbiological findings were assessed and compared between two groups with less than five versus five or more surgical revisions.ResultsBone consolidation was achieved in 86% of the patients while complications such as femoral or transtibial amputation, recurrence of infection or even death during inpatient treatment could be evidenced in six patients (14%). In patients who underwent multiple-stage surgery for five or more times, germ changes and repeated germ detection was more common than in patients with less surgeries.ConclusionsSurgical treatment of infected nonunions poses a high burden on the patients with major complications occurring in about 14% of the patients using a multiple staged treatment concept. Future prospective studies comparing outcomes after limited with multiple staged revision surgeries are necessary.

Highlights

Bone and joint infections are one of the most challenging complications in the orthopedic and traumatological field
Following the 2018 international consensus meeting on musculoskeletal infection [15], fracturerelated infections (FRI) was confirmed by the presence of at least one of the following confirmatory criteria: (1) fistula, sinus tract or wound breakdown (2) purulent drainage or presence of pus during surgery, (3) phenotypically indistinguishable organisms identified by culture from at least two separate deep tissue/implant specimens and (4) histopathological findings
Demographics of patients showed that infected nonunions occurred most often in patients with fractures at the tibia/fibula (62%, n = 26) compared with other fracture sites (Table 1)

Summary

Introduction

Bone and joint infections are one of the most challenging complications in the orthopedic and traumatological field. With increasing incidences of arthroplasty procedures revisions for periprosthetic joint infection (PJI) will pose not. The evolution of modern orthopedic and trauma surgery was coined by efforts to avoid and treat bone and joint infections [5]. Winnett Orr described a staged surgical treatment protocol for treatment of osteomyelitis. After exposure of the diseased bone, necrotic parts were to be removed, wounds were left open and gauze put into the wound. Dressings and plaster were changed as less as possible to avoid recurrence of infection [6]. Later in the twentieth century, this initial concept of staged surgical treatment was adapted to revision arthroplasty [7] and prevention of infection in open fractures [8].

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