Treatment Of Infected Tibial Nonunion Research Articles

Diagnostic and therapeutic work-up of infected tibial nonunion

The failure of bone fracture healing is one of the major complications of fracture treatment, especially of the tibia due to its limited soft tissue coverage and high rate of open injuries. Although implant development is constantly progressing and modern surgical techniques are continuously improving, infected tibial nonunion plays adecisive role in terms of its variable clinical presentation. This article provides guidelines for the successful surgical treatment of infected tibial nonunion. Strategies are presented to identify infection as acause of failure of fracture healing and to achieve infection and bone healing. Asignificant amount of tibial nonunions primarily thought to be aseptic ultimately turn out to be infected nonunions. The treatment of infected tibial nonunion requires extensive clinical, radiological and laboratory diagnostics as well as aprofound biomechanical and biological understanding of the bone situation. This is the only way to achieve rapid osseous healing with as few revision interventions as possible.

Comparative study of monolateral and circular fixator in the treatment of infectious tibial nonunion

To compare treatment effect of monolateral and circular external fixator in infectious tibial nonunion and to explore external fixation structure with better osteogenic ability and fewer complications. A retrospective analysis was performed on 150 patients with infectious tibial nonunion admitted from January 2010 to December 2014. Patients who met the inclusion and exclusion criteria were divided into monolateral fixator group and circular fixator group according to the type of external fixation. Demographic and perioperative data of the two groups were collected. New bone quality was assessed by pixels ratio, treatment effect was assessed by complications. Notes for treatment was explored by case analysis. A total of 64 patients with infectious mid-tibial nonunion were included, 26 in monolateral fixator group and 38 in circular fixator group. There was no difference in demographic data between two groups. The pixel ratio of new bone between two groups was from 0.91 to 0.97 with an average of (0.94±0.03), and from 0.93 to 0.97 with an average of(0.95±0.02), respectively, with no statistical significance (P>0.05). The external fixation index was from 34.1 to 50.6 with an average of (42.3±8.3) days /cm in monolateral fixator group and from 44.5 to 56.1 with an average of (45.8±10.3) days/cm in the circular fixator group, and the difference was not statistically significant (P>0.05). There were 7 cases (26.9%) of complications in monolateral fixator group and 5 cases (13.2%) in circular fixator group, the difference was not statistically significant (P>0.05), but 5 cases of foot ptosis in monolateral fixator group and none in circular fixator group. The time of weight bearing in monolateral fixator group was later than that in circular fixator group, and the difference was statistically significant (P<0.05). Monolateral and circular fixators can achieve equivalent bone formation in the treatment of infected tibial nonunion. Circular fixator is recommended for patients with severe osteoporosis or concomitant medical diseases requiring early weight bearing. Hydroxyapatite coated screws are recommended if a monolateral external fixator is selected when the expected enlarged length is long and the fixation time is long and close monitoring of the ankle movement is required to avoid foot droop.

Les pseudarthroses infectées du tibia: évaluation de la méthode d’Ilizarov avec compression distraction sans geste de débridement local

BackgroundThe treatment of infected nonunion requires radical debridement with stable fixation. Sever soft tissue compromise of the nonunion site might interfere with radical debridement. This study discussed the outcome of treatment of infected tibial nonunion with sever soft tissue compromise by a cyclic compression distraction technique using Ilizarov without radical debridement. MethodsThis study comprised 17 patients with unilateral infected tibial nonunion; 10 with diaphyseal and 7 with metaphysial locations. Their mean age was 21.9 years. There were 12 males and 5 females. The right side was affected in 11 patients and the left side in 6 patients. According toGustilo and Anderson classification, all patients were grade III. The mean limb shortening was 1.3cm. All patients were treated initially in another institute by uniplanner external fixator with rotational skin flap done in 11 patients and thiersch graft in 6 patients. One patient had common peroneal nerve affection. Distal circulation was sufficient in all patients. None of our patients had chronic diseases. Two to three cycles of gradual distraction compression were done. Each cycle consisted of distraction, followed by compression, then distraction, and lastly compression. The mean follow up period was 29.35 months. ResultsUnion was achieved in all patients at a mean time of 23.9 weeks. According to Hammer et al.; there were 8 patients with grade 1, and 9 patients with grade 2. According to Johner and Wruhs’ criteria; the outcome was excellent in 6 patients, goodin 3 patients, poor in 4 patients, and fair in 4 patients. Complications had occurred as pin tract infection(47.1%), persistent discharging sinus (5.9%), and valgus ankle deformity (11.8%). Refracture did not occur in any case till the final follow up. ConclusionAlthough debridement is essential in the treatment of infected tibial nonunion, it could harm the limb in severe soft tissue compromise. Cyclic compression distraction by Ilizarov had a satisfactory outcome in the treatment of such cases through enhancement of a biological environment to achieve union. Level of evidenceIV; prospective case series.

Infected Tibial Nonunion: Assessment of compression distraction Ilizarov technique without debridement

BackgroundThe treatment of infected nonunion requires radical debridement with stable fixation. Sever soft tissue compromise of the nonunion site might interfere with radical debridement. This study discussed the outcome of treatment of infected tibial nonunion with sever soft tissue compromise by a cyclic compression distraction technique using Ilizarov without radical debridement. MethodsThis study comprised 17 patients with unilateral infected tibial nonunion; 10 with diaphyseal and 7 with metaphysial locations.Their mean age was 21.9 years. There were 12 males and 5 females. The right side was affected in 11 patients and the left side in 6 patients. According toGustilo and Anderson classification, all patients were grade III. The mean limb shortening was 1.3cm. All patients were treated initially in another institute by uniplanner external fixator with rotational skin flap done in 11 patients and thiersch graft in 6 patients. One patient had common peroneal nerve affection. Distal circulation was sufficient in all patients. None of our patients had chronic diseases. Two to three cycles of gradual distraction compression were done. Each cycle consisted of distraction, followed by compression, then distraction, and lastly compression. The mean follow up period was 29.35 months. ResultsUnion was achieved in all patients at a mean time of 23.9 weeks. According to Hammer et al.; there were 8 patients with grade 1, and 9 patients with grade 2. According to Johner and Wruhs’ criteria; the outcome was excellent in 6 patients, goodin 3 patients, poor in 4 patients, and fair in 4 patients. Complications had occurred as pin tract infection (47.1%), persistent discharging sinus (5.9%), and valgus ankle deformity (11.8%). Refracture did not occur in any case till the final follow up. ConclusionAlthough debridement is essential in the treatment of infected tibial nonunion, it could harm the limb in severe soft tissue compromise. Cyclic compression distraction by Ilizarov had a satisfactory outcome in the treatment of such cases through enhancement of a biological environment to achieve union. Level of evidenceIV; prospective case series.

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

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

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.

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.

Treatment of Infected Tibial Non-Unions with Ilizarov Technique: A Case Series.

Background: The Ilizarov external fixation technique has been widely used for the treatment of long-bone infected non-unions. After surgical infected bone resection, to allow filling of the remaining bone gap, biomaterials with antibacterial properties could be used. The aim of this study was to report outcomes of infected tibial non-unions treated using the Ilizarov technique and antibacterial bioactive glass. Methods: Between April 2009 and December 2014, 26 patients with infected tibial non-unions were treated with the Ilizarov technique and possible use of the bioactive glass, S53P4. The Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria, a clinical and radiographic evaluating tool, was used for assessing the sample. Results: The average age at the start of treatment was 51 years. The mean follow-up time was 113 weeks. According to the ASAMI Functional Scoring System, 10 excellent (38.5%) cases and 12 good (46.1%) values were recorded. According to the ASAMI Radiological System, they were excellent in 16 (61.5%) cases and good in nine (34.6%). Conclusions: Treatment of infected tibial non-unions using the Ilizarov technique was effective in bone segment regeneration. To fill the remaining bone gap, additional bioactive glass S53P4 could be used, allowing a decrease in re-interventions and minimizing complications.

Application of bone transport with unilateral external fixator combined with locked plate internal fixation in treatment of infected tibial nonunion

To summarize the effectiveness of bone transport with unilateral external fixator combined with locked plate internal fixation in treatment of infected tibial nonunion. Between January 2010 and December 2014, 23 patients with infected tibial nonunion were treated with bone transport with unilateral external fixator combined with locked plate internal fixation. There were 19 males and 4 females with an average age of 37.8 years (range, 19-54 years). The mean length of the bone defect was 6.5 cm (range, 5.2-8.1 cm). The number of previous operations ranged from 2 to 4 times, with an average of 2.5 times. The time from injury to this treatment was 7-23 months, with an average of 11.8 months. The time of bone transport, time of the external fixation, fracture healing time, external fixation index, healing index, and complication were recorded; and the Association for the Study and Application of the Methods of Ilizarov (ASAMI) bone healing and function scores were used to evaluate the effectiveness. All patients were followed up 3-6 years with an average of 4.8 years. Wounds and bone defects healed in all patients. No complication such as infection recurrence, nonunion, re-fracture, malunion, iatrogenic nerve paralysis, or stiffness of knee and ankle joints occurred. Five patients had needle infections which were treated by local care and no deep infection occurred. The time of bone transport was 65-120 days (mean, 75.6 days); the time of the external fixation was 75-145 days (mean, 97.8 days); the fracture healing time was 4-17 months (mean, 8.7 months); the external fixation index was 18-28 days/cm (mean, 22.4 days/cm); and the healing index was 31-52 days/cm (mean, 40.2 days/cm). At last follow-up, according to ASAMI criteria, the result of bone healing was excellent in 15 cases and good in 8 cases, and the result of function was excellent in 18 cases and good in 5 cases, all with the excellent and good rate of 100%. For infected tibial nonunion, bone transport with unilateral external fixator combined with locked plate internal fixation can reduce the time of external fixation and related complications, with a satisfactory effectiveness.

Single-stage treatment of infected tibial non-unions and osteomyelitis with bone marrow granulocytes precursors protecting bone graft.

Infected non-unions present a clinical challenge, especially with risk of recurrent infection. Bone marrow contains granulocyte precursors identified in vitro as colony forming units-granulocyte macrophage (CFU-GM) have a prophylactic action against infection. We therefore tested the hypothesis that bone marrow concentrated granulocytes precursors added to a standard bone graft could decrease the risk of recurrence of infection when single-stage treatment of infected tibial non-unions is performed with bone graft. During a single-stage procedure 40 patients with infected tibial non-union received a spongious bone graft supercharged with granulocytes precursors after debridement (study group). A control group (40 patients) was treated in a single stage with local debridement and standard bone graft obtained from the iliac crest. The antibiotic therapy protocol was the same (60days) in the two groups. CFU-GM progenitors were harvested from bone marrow aspirated on the opposite iliac crest of the site where the cancellous bone was obtained. Union (radiographs and CT scan), a recurrence of clinical infection, and need for subsequent surgery were evaluated. Thirty-eight (95%) patients who received graft supercharged with granulocytes precursors achieved successful union without recurrence of infection during the seven-year follow-up versus 28 (70%) control patients; for the control group the mean graft resorption volume was 40%, while no bone graft resorption was found for the study group. Supercharging the cancellous bone graft with bone marrow granulocytes precursors protect the site of infected non-union from recurrence of infection and bone resorption of the graft.

Experiência na fixação de pseudartrose infectada da tíbia com a técnica de Ilizarov – Estudo retrospectivo de 42 casos

ObjectiveThe aim of the study is to evaluate the clinical and functional outcome in treatment of infected tibial nonunion by the Ilizarov method. MethodsThe authors retrospectively analyzed 42 patients with infected tibial nonunion with bone loss; shortening and deformity treated at this institution during the period of February 2012 to April 2015 were included in the study. The results were evaluated according to Association for the Study and Application of the Methods of Ilizarov (ASAMI) criteria. Pin tract infections were assessed by Moore and Dahl score. ResultsBone results were excellent in 60% of patients (n=25), good in 15% (n=6), fair in 25% (n=11), and poor in none. The functional results were excellent in 55% of patients, good in 30%, fair in 5%, and poor in 10%. The most common complication found in this study was pin tract infection. ConclusionIlizarov ring fixator still remains an excellent treatment modality for tibial nonunion, as it addresses the problems associated with the condition, although the procedure is cumbersome.

Management of 30 infected nonunited tibial fractures by Ilizarov external fixator with acute shortening distraction technique with consideration of the causative organism

Background: Long-standing infected nonunion and gap nonunion tibial fractures are difficult to treat and pose a challenging problem to orthopaedic surgeons. They may lead to residual deformity, persistent infection, knee or ankle contracture, and, at worst, can result in a painful and useless limb requiring amputation. Methods: This prospective study involved 30 patients (27 males and three females) with infected tibial nonunions treated by Ilizarov external fixation with acute shortening and distraction. The mean age was 40 yr with an average bone defect of 3.85 cm (range 2.5 cm to 6 cm). The duration of nonunion before treatment ranged from 6 to 48 mo with an average of 14 mo. The average number of prior surgeries was 1.5 (range 1 to 4). Eleven (36.66%) of the 30 patients had overlying soft-tissue compromise. The causative bacteria were identified and treated with the appropriate antibiotic for at least 6 wk (range 6 to 12 wk). Results: Most infected nonunited fractures in this series (86.66%) occurred in the productive age (four in the 3rd, eight in the 4th, nine in the 5th, and 5 in the 6th decades of life) indicating the socioeconomic impact of this severe injury. The time to consolidation ranged from 3.5 mo to 9 mo, with an average of 6 mo. All fractures united except one (3.33%), with 19 (63.27%) and eight (26.64%) patients having an excellent and good result and two (6.66%) patients having a fair result when applying the Association for the Study and Application of the Method of Ilizarov (ASAMI) classification. Functional results per ASAMI were 12 (39.96%), and 14 (46.62%) patients had excellent and good results. Twenty-seven (89.91%) had bony consolidation with complete remission of infection. The most common isolated bacteria were Staphylococcus aureus (10 patients) and Staphylococcus epidermis (four patients). The most common complication was pin track infection which occurred in all patients. All were uneventfully treated with proper wire/pin care and the appropriate antibiotics. Conclusions: Ilizarov fixation with acute shortening distraction technique is a safe and reliable method for treatment of infected tibial nonunion, however, with the potentially devastating complication of vascular injury during acute compression. The amount of acute shortening is done on an individualized basis as we could not identify safe limits for acute shortening. This technique deals with soft-tissue defects that may require treatment and precludes the need for complex microvascular procedures and secondary bone grafting at the fracture site.

Experience in fixation of infected non-union tibia by Ilizarov technique – a retrospective study of 42 cases

ObjectiveThe aim of the study is to evaluate the clinical and functional outcome in treatment of infected tibial nonunion by the Ilizarov method. MethodsThe authors retrospectively analyzed 42 patients with infected tibial nonunion with bone loss; shortening and deformity treated at this institution during the period of February 2012 to April 2015 were included in the study. The results were evaluated according to Association for the Study and Application of the Methods of Ilizarov (ASAMI) criteria. Pin tract infections were assessed by Moore and Dahl score. ResultsBone results were excellent in 60% of patients (n=25), good in 15% (n=6), fair in 25% (n=11), and poor in none. The functional results were excellent in 55% of patients, good in 30%, fair in 5%, and poor in 10%. The most common complication found in this study was pin tract infection. ConclusionIlizarov ring fixator still remains an excellent treatment modality for tibial nonunion, as it addresses the problems associated with the condition, although the procedure is cumbersome.

Treatment of infected nonunion of the juxta-articular region of the distal tibia.

The purpose of this study was to summarize our clinical results with distraction osteogenesis for the treatment of infected tibial nonunion around the ankle joint. Between 1994 and 2009, 13 patients with a mean age of 50 years (range: 27-79 years) underwent tibial reconstruction for the treatment of infected nonunion of the distal tibia, with a mean bone loss of 4.8 cm (range: 1-7 cm). Lengthening over an intramedullary nail as a second procedure was used in 2 patients, bifocal compression and distraction technique in 5 cases, compression with Ilizarov external fixator in 5 cases, and Taylor Spatial Frame (TSF, Smith Nephew, Memphis, TN, USA) in 1 case. At final follow-up, functional and radiographic results were evaluated according to Paley's bone and functional healing criteria. Mean duration of follow-up was 36 months. Mean external fixation time was 198 days, and mean external fixation index was 29 days/cm. According to Paley's bone healing criteria, there were 10 excellent, 2 good, and 1 poor result(s); additionally, according to Paley's functional healing criteria, there were 5 excellent, 6 good, and 2 fair results. There were 11 problems, 5 obstacles, and 1 sequel according to Paley's classification of complications. There was 1 persisting nonunion, which underwent revision with a retrograde intramedullary nail. External fixator and/or combined treatment are effective and reliable methods to treat infected nonunion of the distal tibia. Every patient should be evaluated according to their infection level and bony defects for reconstruction.

Ilizarov External Fixator for Stump Salvage in Infected Nonunions

Infected nonunions are potentially difficult complications to treat in the context of complex tibial fractures. Often, such complications necessitate amputation to prevent further sequelae, such as fulminant sepsis and complete loss of the limb. As such, the eradication of infection, the decision regarding when to amputate, and the length of the residual stump are important factors to optimize patient outcome. The authors present a unique scenario whereby an Ilizarov external fixation device was used to treat an infected tibial nonunion while simultaneously salvaging stump length to enable fitting for a below-knee prostheses. The use of the Ilizarov device can prevent abrupt dissemination of infection, stabilize the fracture, and bridge nonunion gaps. This is augmented by the unique ability of the construct to be periodically readjusted and realigned where needed to permit osteogenesis and proper alignment. The result in this case was complete eradication of infection, with the use of continuous antibiotics as a pharmacological adjunct, union of the tibial fragments, and a below-knee amputation with adequate stump length and prosthetic fit. The success of this treatment strategy was predicated on the above factors, with an emphasis on amputation level and its effect on function. The Ilizarov external fixator is a device that has been widely used to treat limb-length discrepancies, correct deformities, and induce osseous growth in bony nonunion. The authors present the Ilizarov device as a viable option for the treatment of infected tibial nonunions and stump length salvage.

One-stage reconstruction with open bone grafting and vacuum-assisted closure for infected tibial non-union.

IntroductionNon-union of the tibia complicated by osteomyelitis is one of the most challenging problems in orthopaedic surgery. There remains a significant amount of debate and controversy regarding the optimal medical management of infected tibial non-union. There are few articles which have reported the outcomes of treatment for infected non-union of tibia from single-stage reconstruction with open bone grafting plus vacuum-assisted closure (VAC).Material and methodsOur report covers experience between March 2007 and February 2010 of open bone grafting plus VAC in one stage for patients with infected tibial non-union. The time for bone union and wound healing to occur, the duration of hospitalisation, and the rate of resolution of infection were all analysed. The main outcome measures were based on a clinical scoring system that assessed functional ability, range of knee and ankle motion, shortening, infection and pain. Fifteen patients were involved in this study.ResultsAll patients were followed up for an average of 22.6 months (range: 14–42 months). Bone union was achieved in 93.3% (14/15) of patients after a mean of 5.93 months (range: 3–10 months). All wounds healed within an average period of 5 weeks (range: 3–10 weeks), and the function and appearance of all limbs were satisfactory.ConclusionsOpen bone grafting combined with VAC in a one-stage procedure can be a feasible alternative to the treatment of infected tibial non-union, especially for those wounds which are not good candidates for microsurgery; however, further studies are required to confirm the likely benefits.

Fibula and tibia fusion with cancellous allograft vitalised with autologous bone marrow: first results for infected tibial non-union

Autogenous bone grafting has been used in reconstructing bone defects and in stimulating fracture healing, producing high healing rates in the treatment of infected tibial non-unions. A novel therapeutic alternative is now available known as "vitalised allograft", a cancellous bone graft procured from femoral heads from living human donors and "vitalised" through the injection of autologous bone marrow. The aim of this study is to summarise the initial results of the fibula and tibia fusion using vitalised cancellous allograft in the treatment of infected tibial non-unions. We initiated a follow-up of 15 prospective non-randomized patients who received a vitalised allograft in the treatment of infected tibial non-unions in order to produce bony union. The patients included 13 men and 2 women with an average age of 48 years. All patients received a multi-stage surgical approach. After establishing an infection-free environment, allogenic cancellous bone grafting was performed, intended as the final surgical procedure in fibula and tibia fusion. Our follow-up included a clinical and radiographic investigation of the calf in four planes. We analysed union-rate and time required for bony consolidation, as well as recurrent infections, re-fractures, potential graft-resorption, and time needed for graft and bone remodelling. With an average follow-up of 17.1 months, infection control was obtained in 14 of 15 patients, producing an infection arrest rate of 93.3%. Radiographs indicated consolidation in 11 out of 15 cases, with a union rate of 73.3%. Bone union was achieved on average in 17.1 weeks. Fibula and tibia fusion with allogenic cancellous bone grafting, vitalised through autogenic bone marrow, could well become an innovative treatment option for infected tibial non-unions. We need, however, to analyse a higher number of cases over a longer follow-up period in order to assess more accurately recurrent infections and re-fractures.

Contribution to the surgical treatment of infected tibial nonunion

Contribution to the surgical treatment of infected tibial nonunion

Results of vancomycin-impregnated cancellous bone grafting for infected tibial nonunion

Bone grafting plays a critical role in promoting bone healing in infected nonunion, although recurrent infection is of concern. Cancellous bone grafting as an antibiotic delivery system has been reported as an effective method to combat infections. In this study, we report the clinical results of vancomycin-impregnated cancellous bone grafting for the treatment of infected tibial nonunion. Between January 1996 and March 2001, 18 patients with infected tibial nonunion treated with vancomycin-impregnated cancellous bone grafting were available for follow-up. According to the Cierny-Mader classification, all patients belonged to type IVA and IVB osteomyelitis. Adequate debridement, stabilization with external fixation, and staged vancomycin-impregnated cancellous bone grafting were used in all patients. Regular clinical and radiographic follow-ups were conducted. Infection control was obtained in all 18 patients with a 100% infection arrest rate. Bone union was achieved in 13 of 18 patients at an average of 5.8 months. Bone union was obtained subsequently in the remaining five patients after closed nailing in four, and plating and bone grafting in one patient. Radiographs showed good consolidation and hypertrophy of grafted bone at an average follow-up of 48 months. We conclude that vancomycin-impregnated cancellous bone grafting is a safe method for the treatment of infected tibial nonunion.

Treatment of Infected Tibial Nonunions with Debridement, Antibiotic Beads, and the Ilizarov Method

This study of 10 patients presents the early results of a protocol of debridement, antibiotic bead placement, and use of the Ilizarov method with a circular external fixator for treatment of infected nonunions of the tibia in a military population. The nonunions resulted from high-energy fractures in nine cases and an osteotomy in one. The Ilizarov techniques used were transport (five cases), shortening and secondary lengthening (two cases), minimal resection with compression (one case), and resection with bone grafting (two cases). Flap coverage was required for five patients. There were two recurrences of infection (20%) among patients with the most compromised soft tissue. Only 50% of patients were able to perform limited duties while wearing the external fixator. Only four patients returned to active duty; however, three patients from special operations units were able to return to jump status. Six patients underwent medical retirement because of insufficient function, resulting from decreased ankle or knee range of motion and arthrosis or muscle weakness.