Infected Nonunion Research Articles

Presentation and outcome of femoral infected non-unions in children and adolescents.

Objectives:To document the presentation of infected non-unions of femur in pediatric and adolescent population and evaluate the outcome of segmental bone transport with the Ilizarov method.Methods:This prospective case series study was carried out over a period of five years, from January 01, 2015 to December 31, 2019. The study included all children and adolescent patients who presented with femoral infected non unions. The study excluded patients above the age of 16 years and those who had pathological fractures secondary to bone pathologies such as cysts, tumors or metabolic bone diseases.Results:Out of 31 patients, 27(87.09%) were males and 4(12.90%) were females. The mean age was 13.48±1.98 years. The underlying mechanisms that lead to the causation of fractures included road traffic accidents (n=23;74.19%), fall from height (n=7;22.58%) and firearm injuries (n=1;3.22%). The bone gaps ranged from 3-5 cm with a mean of 4.00± 0.856 cm. Bone union was achieved among 28(90.32%) patients. Infection was eradicated among 27(87.09%) patients whereas the remaining patients continued to suffer persistent infection. The most common complications included pin tract inflammation/ infection among (n=31;100%) patients and stiffness of knee joint among (n=19;61.29%) patients.Conclusion:Majority of the patients were males, aged 9-16 years. Road traffic accidents were the commonest cause of the fractures. The Ilizarov method of segmental bone transport was effective in treating the majority of infected non-unions.

The Impact of Inadequate Soft-tissue Coverage following Severe Open Tibia Fractures in Tanzania.

Background:Managing lower extremity fractures complicated by large soft-tissue defects is challenging for surgeons in low- and middle-income countries, and long-term quality of life (QOL) for these patients is unclear.Methods:We examined QOL, surgical complications, and longitudinal outcomes in 10 patients with Gustilo-Anderson Classification Type IIIB open tibia fractures seen at an orthopedic institute in Tanzania, from December 2015 to March 2017. Patients completed follow-up at 2-, 6-, 12-, 26-, and 52-week time points, and returned for qualitative interviews at 2.5 years. The primary outcome was QOL, as measured using EuroQoL-5D scores and qualitative semi-structured interview responses. The secondary outcome was rate of complication, as defined by reoperation for deep infection or nonunion.Results:Ten patients enrolled in the study and 7 completed 1-year follow-up. All fractures were caused by road traffic accidents and treated by external fixation. No patients received initial soft-tissue (flap) coverage of the wound. All patients developed an infected nonunion. No patients returned to work at 6 weeks, 3 months, or 6 months. EQ-5D index scores at 1 year were poor (0.71 ± 0.09). Interview themes included ongoing medical complications, loss of employment, reduced income, and difficulty with activities of daily living.Conclusions:Patients in low- and middle-income countries with IIIB open tibia fractures not treated with appropriate soft-tissue coverage experience poor QOL, high complication rates, and severe socioeconomic effects as a result of their injuries. These findings illustrate the need for resources and training to build capacity for extremity soft-tissue reconstruction in LMICs.

Gentamicin-Coated Tibia Nail in Fractures and Nonunion to Reduce Fracture-Related Infections: A Systematic Review.

The incidence of a fracture-related infection (FRI) can reach 30% of open tibia fractures (OTF). The use of antibiotic-coated implants is one of the newest strategies to reduce the risk of infection in orthopedic surgery. The aim of this study was to investigate the efficacy and safety of a gentamicin-coated tibia nail in primary fracture fixation (FF) and revision surgery (RS) of nonunion cases in terms of FRI incidence. We conducted a systematic review according to the PRISMA checklist on Pub-Med, Cochrane, and EMBASE. Of the 32 studies, 8 were included, for a total of 203 patients treated: 114 were FF cases (63% open fractures) and 89 were RS cases, of which 43% were infected nonunion. In the FF group, four FRI were found (3.8%): three OTF (Gustilo-Anderson III) and one closed fracture; bone healing was achieved in 94% of these cases. There were four relapses of infection and one new onset in the RS group; bone healing occurred in 88% of these cases. No side effects were found. There were no significant differences in terms of FRI, nonunion, and healing between the two groups. Gentamicin-coated tibia nail is an effective therapeutic option in the prophylaxis of high-risk fracture infections and in complex nonunion cases.

Wrist arthroplasty for treatment of infected distal radius nonunion using free vascularised proximal fibular bone graft

ObjectiveManagement of infected distal radius nonunion with a bone defect and radiocarpal and distal radio-ulnar joint arthritis is considered an orthopaedic challenge. Although several methods have been described but none provide a satisfactory solution. Free vascularised fibula bone graft constitutes a good option to eradicate the infection, correct the deformity, compensate for the shortening and maintain motion. Material and methodsThis study included 15 cases with infected distal radius nonunion associated with bone defects. Nine cases were males and six were females. The average age of the patient was 20 years (range 8 - 60 years). The right wrist was involved in 10 patients and left was affected in 5 patients. Nine cases resulted from a motor vehicle accident, four cases after a firearm injury and two cases due to falling from a height. The average number of previous surgical procedures was three (range 2 -6). The principle of treatment was debridement, excision of distal radius and trimming of the proximal part of radius back to healthy bleeding bone, inserting the free vascularised proximal fibular bone graft to compensate the defect and fixation of the graft. ResultsThe procedure was successful in 13 of 15 cases. Bone union was achieved at an average of 4 months. No clinical evidence of osteomyelitis or or infection at final follow-up. Pain was completely relieved in all cases. Wrist joint range of motion averaged flexion 50˚, extension 45˚ and handgrip was the same as the normal site. Twelve cases out of 15 returned to their daily activities. ConclusionFree vascularised proximal fibula bone graft is a new indication for the treatment of an infected distal radius nonunion with a bone defect.

Donorsite defect of medial femoral condyle corticoperiostal flap in the treatment of lower limb infected nonunions.

Chronic osteomyelitis is a major challenge in orthopaedic surgery; it is the result of open fracture, periprosthetic infection and septic arthritis. Osteomyelitis leads to fracture nonunion. The treatment of bone infection and infected nonunion consists primarily of the complete removal of infected and avascular bone and soft tissue from the surgical site, followed by local and systemic pathogen-specific antibiotic therapy and temporary stabilisation, but may lead to massive skeletal and soft tissue defects. The use of free or pedicled vascularised bone transfers and callus distraction techniques (bone transport) has been recommended for large bone defects. The aim of this study is to evaluate the results of patients affected by infected non-unions of the lower limbs, treated with a corticoperiosteal flap from the medial femoral condyle and to investigate the donor site morbidity of this flap. The patients were 11 males (average age of 45.6 years), who presented a nonunion of the tibial diaphysis in 7 cases and non-union of femoral diaphysis in 4 cases, treated with free or pedicled corticoperiosteal flap. In all patients, surgical debridement was performed before the flap of infected bone and soft tissues that would not contribute to wound healing. Clinical and radiographic evaluations of the recipient site were performed. Preoperative and postoperative X-ray and MRI scans after the 3-year follow-up of the donor site were performed, in order to observe possible bone restoration and any complications. The patients reported complete clinical and radiographic bone healing in 90.9 % of cases. As regards donor site, there were no differences between the medial femoral donor condyle compared to the contralateral site, due to complete regeneration of donor site bone. MRI investigation showed complete restoration of the donor site with vascularised bone in all patients. Our results suggest that the use of bone flaps for the treatment of infected non-unions is an effective procedure, that must be performed after accurate debridement of the non-union site. The corticoperiosteal flap seems to have few morbidities on the donor site and a high percentage of successful bone healing.

Plasma Fibrinogen as a Diagnostic Marker of Infection in Patients with Nonunions.

BackgroundThe timely and accurate diagnosis of infected nonunion is challenging, and there is a need for more efficient biomarkers. Previous studies have shown that fibrinogen plays an important role in mediating inflammation in bacterial infections and, therefore, could be a valuable biomarker for infected nonunion. The purpose of this study was to evaluate and compare the performance of plasma fibrinogen and other traditional blood markers for the diagnosis of infected nonunion.Materials and MethodsWe retrospectively studied 146 patients who underwent surgery for primary nonunion between January 2018 and January 2020. The patients were divided into those with infected nonunion (n = 55) and those with aseptic nonunion (n = 91). The preoperatively analyzed parameters were plasma fibrinogen, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, and white blood cell (WBC) count. Receiver operating characteristic (ROC) curve analysis was used to assess the sensitivity and specificity of the biomarkers, and Youden’s index was calculated to determine their optimal cut-off values.ResultsThe plasma fibrinogen values were significantly higher (p < 0.001) in the patients with infected nonunion than in those with aseptic nonunion. ROC curve analysis showed that plasma fibrinogen had a high value of area under the curve (0.816), which indicated that it had good diagnostic ability. Further, at the optimal threshold value of 2.75 g/L, plasma fibrinogen had the highest sensitivity (78.2%; 95% CI = 64.6–87.8) and good specificity (82.4%; 95% CI, 72.7–89.3).ConclusionIn comparison to the traditional markers of infection, plasma fibrinogen showed good diagnostic ability for the detection of infected nonunion. It may have potential as a practical and cost-efficient biomarker for the diagnosis of infected nonunion.

Management of femoral head fractures through surgical hip dislocation (SHD): a demanding but safe technique.

Femoral head fractures considered to be rare injuries. Surgical intervention is indicated for major fragment displacement or in the presence of instability. Surgical management can be achieved through either Anterior, posterior, and trans-trochanteric surgical approaches. Surgical hip dislocation (SHD) has been advocated by many authors to be a safe and effective alternative way of management. The aim of this study was to report on the accuracy of fracture reduction, procedure safety, and outcomes of using SHD in the management of femoral head fractures. Between 2011 and 2017, 31 patients presented with femoral head fracture were treated through SHD. At a mean follow-up of 48months, 27 patients were available for the study with a mean age of 33.8years. Patient demographics, clinical evaluation according to modified Harris hip score and modified Merle d'Aubigne and Postel score, radiographic fracture reduction according to Matta's criteria, and any complications were reported. Excellent and good clinical outcomes were reported in 25 (92.6%) and 24 (89%) patients according to the modified Harris hip and modified Merle d'Aubigne and Postel scores, respectively. Anatomic fracture reduction was achieved in 21 (77.8%) patients. Two (7.4%) patients developed AVN, one (3.6%) patient developed hip OA (grade 3 according to Tönnis classification), and five (18.5%) patients developed asymptomatic Brooker stage I heterotopic ossification. No infection or trochanteric flip osteotomy fragment non-union was reported. SHD offers a safe and efficient approach for femoral head fractures management with acceptable clinical outcomes as well as complication rates. Giving the advantage of fully exposing the femoral head and the acetabulum which enables the surgeon to anatomically reduce the fracture and treat any associated injuries, SHD is recommended besides other approaches for the management of femoral head fractures.

Outcome of limb reconstruction system in tibial infected non-union and open tibial diaphysial fracture with bone loss

IntroductionIncidence of open fractures of the long bones is increasing due to the increase in road traffic accidents (RTA) which leads to an increased incidence of complex non-unions of long bones. Patients are usually operated many times for fracture fixation (and healing) or to eradicate infection, which causes soft tissue scarring and devitalization of any surviving bone. ObjectiveIn this study, we assess the outcome of the Limb reconstruction system in tibial infected non-union and open tibial diaphyseal fracture with bone loss. MethodIt is a prospective study conducted on 15 patients and patients included in this study having compound fractures of shaft tibia with bone loss classified by Gustilo-Anderson open fracture classification. With the defect in the distal tibia, proximal corticotomy 1.5 cm distal to the last screw in the proximal clamp and proximal to distal transports were done and vice versa. All patients were evaluated with the ASAMI scoring system into bone results and functional results. ResultsIn the majority of patients, the injury was caused by road traffic accidents 80% of cases. Out of 15 cases, 2 belong to the upper 3rd, 9 cases belong to the middle 3rd and 4 cases belong to the lower 3rd of shaft tibia. The union time ranges from 4 to 11 months but the maximum union was achieved in 7–9 months in 8 (53.33%). Pin tract infection was reported in two (13.33%) patients who became better with regular dressing. Ankle stiffness was present in one case (6.67%), most probably due to improper physiotherapy.According to ASAMI Criteria excellent radiological results were present in 11 (73.33%) cases, good results were found in 4 (26.67) cases and excellent functional results were observed in 7 cases (46.67%) and good results were found in 8 (53.33%) cases. Infection was cured in all patients and did not recur till the last follow-up. ConclusionsAdvantages of rail fixator include less invasive surgery, early weight-bearing, less infection, less blood loss, prevention of diffuse osteoporosis and atrophy, preservation of limb function, no need for bone grafting, correction of deformity during the process of healing, thus no need for a second surgery. Non-union, bone defect, and deformity can be corrected simultaneously. Hence, we recommend the use of this system (rail fixator) especially for infected non-union of long bones and compound fractures with bone loss.

Non-vascularized large free fibular bone graft in post- traumatic and infectious ulnar bone defect: a case report

&lt;p&gt;This reported case is about the successful union of an adult male, having open post traumatic infected nonunion of ulna with a bone loss of ulna around 11 cm. Difficult environment around gap nonunion makes the management more difficult for bone graft to stay there. Repeated debridement and skin courage played the key role in controlling the infection. A calculated risk of putting a non-vascular 12 cm autologous fibular graft fixed with plate and screws and supported with medullary nail was taken and a successful union achieved within 4.5 months. So nonvascular free can be a choice for critical bone defects nonunion in fore bones post traumatic one also.&lt;/p&gt;

Utility of Common Biomarkers for Diagnosing Infection in Nonunion.

To evaluate the diagnostic utility of leukocyte count (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) for distinguishing between septic and aseptic nonunions. A single-gate (cohort) design was used, using 1 set of eligibility criteria applied to a consecutive sample of nonunions. Private quaternary referral center. Inclusion criteria were consecutive patients (≥18 years) with a nonunion requiring surgery that allowed for direct or medullary canal tissue sampling from the nonunion site. The cohort included 204 subjects with 211 nonunions. Blood samples were drawn for laboratory analysis of WBC, ESR, and CRP before surgery. The reference standard used to define infection was the fracture-related infection confirmatory criteria. Measures of diagnostic accuracy were calculated. To assess the additional diagnostic gain of each index lab test while simultaneously considering the others, logistic regression models were fit. The prevalence of infection was 19% (40 of 211 nonunion sites). The positive likelihood ratios (95% confidence interval) for WBC, ESR, and CRP were 1.07 (0.38-3.02), 1.27 (0.88-1.82) and 1.57 (0.94-2.60), respectively. Multivariable modeling adjusted for the effect of preoperative antibiotics showed that WBC (P = 0.42), ESR (P = 0.48), and CRP (P = 0.23) were not significant predictors of infection. In this consecutive sample of 211 nonunions in whom standard clinical practice would be to obtain index lab tests, our findings showed that WBC, ESR, and CRP were not significant predictors of infection. Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Reconstruction of infected nonunion of the distal humerus by Ilizarov external fixator.

Infected nonunion of the distal humerus represents a true challenge as the fragment is usually small and difficult for fixation. The aim of the present study is to assess the results of Ilizarov external fixator in management of infected nonunion of the distal third humerus. Twenty-three patients with infected nonunion of the distal humerus were included in this study. The ages ranged from 19 to 58 years with an average of 35 years. Seventeen cases were males and 6 were females. All patients were treated by radical debridement and application of Ilizarov external fixator in one stage surgery. Bony union was achieved in all cases. Bone graft was required in 12 patients with hypotrophic nonunion. The external fixation time ranged from 4 to 9 months with an average of 5.6 months. Infection was controlled in all cases without recurrence during the period of follow up. The complications included pin tract infection in 7 cases, radial nerve injury in one case, elbow stiffness in 4 cases and refracture after frame removal in one case. Ilizarov external fixator is effective in management of infected nonunion of the distal humerus. The thin tensioned wires produce good grip in the small or osteoporotic bone fragments.

A study on effects of percutaneous bone marrow injection in delayed union and non-union of long bone fractures- observational study

Background: Bone marrow is a good source of osteoprogenitor cells. Being a simple and minimally invasive technique with lesser complications, this study is intended to evaluate the effectiveness of bone marrow injection in delayed union and non-union and thus decrease the period of morbidity for the patients those are likely to go for non-union.Aim and Objectives: The study effects of percutaneous bone marrow injection in delayed union and nonunion of long bone fractures”Materials and Methods: This prospective study was conducted in Pujitha Hospital, Vijayawada over a period of 2 years. We had 34 patients in our series treated by percutaneous bone marrow injection. Based on the amount of initial displacement, communition, soft tissue injury and post op reduction and alignment we graded the cases likely to go in for non-union. Such cases when failed to show expected amount of clinical and radiological union within a certain period we chose them for bone marrow injection. Bone marrow was aspirated from the iliac crest or tibial tuberosity using a bone marrow aspiration needle. Later this marrow aspirate was injected to the fracture site under C -arm guidance. Patients were followed up in the 1st month and then every 3rd month after the procedure and were clinically and radiographically assessed. Cases with pathological fractures, infected non-unions, malignancy and age under 15 years were excluded from our study. The collected data was analysed statistically.Results and Conclusion: We compared our study with other similar studies. We had 72.7% union achieved, another 18.2% showed progression towards healing and 9.1% showed non-progression for union. Union was better when bone marrow injection was given in a case of delayed union as compared to non-union cases. This is a simple, easy and valuable technique to enhance bone healing and this reduced the period of morbidity due to delayed union and non-union.

Treatment of Tibial and Femoral Bone Defects With Bone Transport Over an Intramedullary Nail

To evaluate the results of the bone transport over an intramedullary nail (BTON) technique for the treatment of segmental bone defects. Retrospective review of case series. Level 1 trauma center. We included 40 patients who underwent reconstruction of the lower limb with BTON technique between 2000 and 2018. The technique was performed in the tibial segments in 21 patients and in the femoral segments in 19 patients. The surgical technique was performed in 2 stages for patients with infected nonunion. Infection was eradicated in all patients at the first stage. For the BTON at the second stage, monolateral external fixators and circular external fixators were used for femoral and tibial defects, respectively. In cases of defects without any infection, debridement with a single-stage BTON was performed. Complications as well as radiological and clinical results were evaluated according to the criteria of Paley-Maar. Minor complications occurred in 11 patients: pin site problems (9), cellulitis (1), and skin detachment due to Schanz screw (1). Major complications occurred in 8 patients: docking site nonunion (4), early consolidation and Schanz screw failure (1), knee flexion contracture (1), and ankle equinus contracture (2). Four patients had osteomyelitis as residual sequelae. Bone score was excellent in 27 patients. Excellent functional results were obtained in 31 patients. The BTON technique is associated with low cost because of the short treatment period, low complication risk, and rapid rehabilitation and is not limited by the amount of bone transport. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

To determine efficiency of Ilizarov's circular external fixator in form of the bone outcome and functional outcome in treatment of femoral and tibial nonunions

Aim: planned to assess bone and functional outcome of Ilizarov's circular external fixator in treatment of femoral and tibial nonunion (infected and noninfected both). Material and methods: The present study is clinical prospective type of study conducted at Dr Hardas Singh Orthopaedic Hospital & Superspeciality Research Centre, Amritsar, Punjab. The present study included 15 cases, all managed with Ilizarov circular external fixator for isolated femoral or tibial nonunion after obtaining informed consent, clinical and radiological examination during a period of 24 months. After removal of frame, patient followed up regularly every month and we assessed them for bony and functional outcome. Results: The age of patients in present study was 22 to 55 years with mean age of 39.4 years. There were 3 (20%) femoral and 12 (80%) tibial nonunions that were operated with Ilizarov’s circular external fixator using ilizarov method’s. Road traffic accidents were the most common mode of injury accounting for 11 cases (73.3%). Fourteen patients had undergone fixation previously (plate osteosynthesis = 7, external fixators of the AO tubular type = 7) and one patient had been treated by traditional bonesetter bandages. According to ASAMI guidelines, bone outcome was excellent in 7 cases (46.6%), good in 5 cases (33.3%), fair in 2 (13.3%) cases and poor in 1 case (6.7%). Functional outcome was excellent in 3 cases (20%), good in 11 cases (73.3%), fair in no case and poor in 1 case (6.7%). But no patient required amputation. Conclusion: Ilizarov technique using circular external fixator is a good salvage operation for infected and noninfected nonunion of the femur and tibia both. Functional results can be improved by the early use of the Ilizarov technique.

A new osteoporotic animal model for implant-related infected non-unions after intramedullary fixation of the femur

A new osteoporotic animal model for implant-related infected non-unions after intramedullary fixation of the femur

Vitamin D Deficiency and Outcomes after Ankle Fusion

Category:Ankle Arthritis; Ankle; Basic Sciences/Biologics; HindfootIntroduction/Purpose:Ankle fusions are associated with a complication profile including nonunion with associated poor functional outcomes, chronic pain, and need for reoperation. Local risk factors (bone and soft-tissue loss, infection, ankle and hindfoot deformity, and neuropathy) and systemic risk factors (advanced age, smoking, alcohol abuse, worker’s compensation, noncompliance, obesity, and systemic comorbidities such as diabetes and immunodeficiency) have been shown to be associated with the development of a nonunion following fusion procedures. Vitamin D has an important role in bone healing, and vitamin D deficiency has been proposed as a potential risk factor for the development of non-unions. The purpose of this study is to assess the impact of low vitamin D levels on reoperation rates and the development of nonunions following ankle fusion surgery.Methods:A retrospective chart review of all ankle fusions performed at a major health system from January 2010 to July 2019 was performed. In total, 240 ankle fusions were performed by seven surgeons. All patients who underwent primary fusion procedures were eligible for inclusion in this study. Exclusion criteria included: age less than 18 years; revision surgery; ankle fusion with the use of bulk allograft; ankle fusion performed as part of an oncologic reconstruction; and an absence of recorded vitamin D levels with 12 months of surgery. In total, 47 patients met inclusion criteria and formed the study group. In this group, 29/47 (61.7%) were female and 18/47 (38.3%) were male. Average age was 57.0 +- 12.3 years (range: 18.6 to 75.7). Patients were grouped according to their vitamin D levels as being deficient (<31 ng/ml) or normal (31-80 ng/ml).Results:Prevalence of vitamin D deficiency was 36.2% (17/47) at average of 35.7 ng/ml. In vitamin D deficient subgroup (n=17), average vitamin D level was 16.9 ng/ml. In normal vitamin D subgroup (n=30), average vitamin D was 46.4 ng/ml. Overall, reoperation rate was 21.3% (10/47). Reoperation rate was 35.3% (6/17) in vitamin D deficiency subgroup compared with 13.3% (4/30) reoperation rate in normal vitamin D subgroup (p<0.05). In vitamin D deficient subgroup, 5 procedures for nonunion included: dynamization (n=1), revision fusion (n=1), staged revision (n=2) and amputation (n=1) due to infected nonunion. There was also a symptomatic hardware removal. In normal vitamin D subgroup, reoperation indications included: malunion (n=1), elective dynamization before weightbearing (n=1), and symptomatic hardware removal (n=2). Normal vitamin D subgroup had zero nonunions.Conclusion:In patients undergoing ankle fusion, vitamin D deficiency (< 31 ng/ml) was associated with a reoperation rate over double that of patients with normal vitamin D levels. In the vitamin D deficient subgroup, nearly all reoperations were for nonunion as compared to zero nonunion incidence in those with normal vitamin D levels. These results suggest routine preoperative screening of vitamin D level is indicated as a key component of ankle fusion care. Vitamin D supplementation during the perioperative period may be indicated in regions with low sunlight to improve fusion rates and lower the risk of reoperation.

Treatment of Infected Tibial Non-union: A Systematic Review and Meta-Analysis

Treatment of Infected Tibial Non-union: A Systematic Review and Meta-Analysis

Treatment of infected tibial non-unions using a BMAC and S53P4 BAG combination for reconstruction of segmental bone defects: A clinical case series.

Treatment of infected non-unions of the tibia is a challenging problem. The cornerstones of optimal infected non-union treatment consist of extensive debridement, fracture fixation, antimicrobial therapy and creation of an optimal local biological bone healing environment. The combination of S53P4 bioactive glass (BAG), as osteostimulative antibacterial bone graft substitute, and bone marrow aspirate concentrate (BMAC) for the implantation of mesenchymal stem cells and growth factors might be a promising combination. In this paper, preliminary results of a new treatment algorithm for infected non-unions of the tibia is presented. In this retrospective case series patients with infected non-unions of the tibia are treated according to a new treatment algorithm. Patients are treated with extensive debridement surgery, replacement of the osteosynthesis and implantation of S53P4 BAG and BMAC in a one-stage or two-stage procedure based on non-union severity. Subsequently patients are treated with culture based antibiotic therapy and followed until union and infection eradication. Five patients with an infected non-union were treated, mean age was 55, average NUSS-score was 44 and the average segmental bone defect was 4.6cm. One patient was treated in a one-stage procedure and four patients in a two-stage induced membrane-, or "Masquelet"-procedure. On average, 23 ml S53P4 BAG and 6.2 ml BMAC was implanted. The mean follow-up period was 13.6 months and at the end of follow-up all patients had clinical consolidation with an average RUST-score of 7.8 and complete eradication of infection. These early data on the combined implantation of S53P4 BAG and BMAC in treatment of infected non-unions shows promising results. These fracture healing results and eradication rates resulted in promising functional recovery of the patients. To substantiate these results, larger and higher quality studies should be performed.

Differentially expressed microRNAs as diagnostic biomarkers for infected tibial non-union

BackgroundInfected tibial non-union is a challenging clinical complication of fracture treatment. Improper treatment of infected tibial non-union may result in high treatment costs and a long treatment period, and lead to medical disputes and decreased patient satisfaction. An increasing number of studies have indicated the significant role of microRNAs (miRNAs) in the development and progression of different bone diseases. Therefore, the identification of a specific miRNA expression profile associated with infected tibial non-union is a key step toward establishing a novel strategy for the diagnosis and treatment of infected tibial non-union. MethodsWe utilised a microarray analysis to compare the specific expression of bone tissue miRNA in patients with infected tibial non-union and closed tibial fractures. Quantitative real-time reverse transcription-polymerase chain reaction was performed to validate the microarray results. Receiver operating characteristic (ROC) curve analysis was performed to assess the diagnostic efficacy of the identified regulated miRNA(s) isolated from bone tissue as potential biomarker(s). ResultsMicroarray analysis showed 20 differentially expressed miRNAs. Differential expression of miR-649, miR-29b-3p, miR-498, miR-365a-5p, miR-328-5p, and miR-345-3p was further confirmed in a validation cohort. ROC curve analyses showed an AUC (Areas Under the ROC Curve) of 0.808 (95% confidence interval [CI]: 0.675-0.940), 0.778 (95% CI: 0.634-0.921), 0.769 (95% CI: 0.619-0.919), 0.798 (95% CI: 0.662-0.933), 0.818 (95% CI: 0.690-0.945), 0.839 (95% CI: 0.715-0.963) for miR-649, miR-29b-3p, miR-498, miR-365a-5p, miR-328-5p, and miR-345-3p, respectively. The combined use of three miRNAs (miR-649, miR-328-5p, and miR-345-3p) yielded an overall diagnostic accuracy of AUC = 0.953, indicating a robust diagnostic value. Conclusion: Our findings highlight the role of miR-649, miR-328-5p, and miR-345-3p as novel candidate biomarkers for infected tibial non-union diagnosis, suggesting that these differentially expressed miRNAs could be utilised as novel diagnostic and therapeutic tools to identify infected tibial non-union.

Advantage of antibiotic cement-coated interlocking intramedullary nail (tibia nail/femur nail) over conventionally used antibiotic cement-coated Kuntscher nail in infected nonunion

Background: Open fracture are very prone to chronic infection. The infection of long bones during its process of fracture healing not only delay but may completely abort the fracture healing and leads to nonunion. Infection along with its nonunion is very difficult to treat and a debilitating disorder which bother both the patients and surgeon. However in many studies, this situation is usually managed with multiple steps first to cure the infection before dealing with nonunion. But this is a single step procedure to cure both infection and nonunion simultaneously with intramedullary nail that coated with antibiotic cement. It is difficult to achieves axial and rotational stability along with controlling infection by antibiotic cement-coated Kuntscher nail. This study we have compare the outcome in term of control the infection and treating nonunion and copmplication associated with these. And also the advantage of antibiotic cementcoated interlocking intramedullary nail (tibia nail / femur nail) for achieving good stability. Materials and Methods: In our study we included 20 adult patients all have stablisted infective nonunion and divided into two group according to types of intramedullary nail used. In group A 12 adult patients with infective nonunion of tibia & femur (9 tibia and 3 femur) were managed using antibiotic cementcoated interlocking intramedullary nail (group A)(tibia nail / femure nail) with proximal and distal locking screws. And in group B 8 adult patients with stablised infective nonunion of tibia & femur (7 tibia and 1 femur) were treated using antibiotic cement-coated K-nail. Combination of Antibiotics used are 4gm vancomycin and 3gm clindamycin in 40gm bone cement package. Results: Controlled of infection is 90% (18 out of 20 patients) similar in both. Bony union achieved in 83% (10 out of 12 patients) in group A with average time of union is 6 months. Bony union 62.5% (5 out of 8 patients) in group B with average time of union 8 months. The ad