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Kitamura T, Murakami K, Watanabe E. Treatment of post-operative infected nonunion distal radius fracture using the Darrach procedure and radioscapholunate fusion with volar locking plate. Trauma Case Rep 2023; 45:100827. [PMID: 37096137 PMCID: PMC10122001 DOI: 10.1016/j.tcr.2023.100827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2023] [Indexed: 04/05/2023] Open
Abstract
There is no established standard treatment for post-operative infected nonunion distal radius fracture with severe damage to the joint surface. Herein, we report a case of post-operative infected nonunion distal radius fracture with severe articular damage, which was treated using a combination of the Darrach procedure and radioscapholunate fusion with a volar locking plate after implant removal and antibiotic treatment. A 61-year-old man underwent internal fixation with a volar locking plate for a distal radius fracture. Repeated post-operative infections caused distal radius nonunion, a bone defect in the lunate fossa of the radius, subluxation of the carpal bones on the palmar and ulnar sides, and significant limitation of rotation. Implant removal and wound debridement were performed to control infection. After oral antibiotic treatment, the Darrach procedure and radioscapholunate fusion with a volar locking plate combined with ulnar head bone grafting were performed. The patient was able to perform his activities of daily living without any problems after the two-stage surgery. This is the first report describing the treatment of post-operative infected nonunion distal radius fracture with severe damage to the radiocarpal and distal radioulnar joints.
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Affiliation(s)
- Takaki Kitamura
- Corresponding author at: Fuji Orthopaedic Hospital, 1-4-23 Nishikicho, Fuji, Shizuoka 417-0045, Japan.
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2
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Masquelet technique for infected distal radius fractures with gaps in paediatric age group. Trauma Case Rep 2022; 37:100568. [PMID: 34977319 PMCID: PMC8683642 DOI: 10.1016/j.tcr.2021.100568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 11/24/2021] [Accepted: 12/04/2021] [Indexed: 11/23/2022] Open
Abstract
The management of infected nonunion with bone loss is always challenging. The Masquelet technique is an excellent option available for us today. However, there are few reports of its use in the paediatric age group and no reports of its use especially in infected distal radius fractures or nonunion. We report on two children with infection and significant bone loss after open fractures of the distal radius which we have treated successfully using a modified Masquelet technique.
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Hoit G, Kain MS, Sparkman JW, Norris BL, Conway JD, Watson JT, Tornetta P, Nauth A. The induced membrane technique for bone defects: Basic science, clinical evidence, and technical tips. OTA Int 2021; 4:e106(1-5). [PMID: 37608856 PMCID: PMC10441675 DOI: 10.1097/oi9.0000000000000106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/09/2020] [Accepted: 12/11/2020] [Indexed: 08/24/2023]
Abstract
The clinical management of large bone defects continues to be a difficult clinical problem to manage for treating surgeons. The induced membrane technique is a commonly employed strategy to manage these complex injuries and achieve bone union. Basic science and clinical evidence continue to expand to address questions related to the biology of the membrane and how interventions may impact clinical outcomes. In this review, we discuss the basic science and clinical evidence for the induced membrane technique as well as provide indications for the procedure and technical tips for performing the induced membrane technique.
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Affiliation(s)
- Graeme Hoit
- Division of Orthopaedic Surgery, University of Toronto, Toronto, ON, Canada
| | - Michael S Kain
- Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Jeremy W Sparkman
- Department of Orthopaedic Surgery, Oklahoma State University, Tulsa, OK
| | - Brent L Norris
- Department of Orthopaedic Surgery, Oklahoma State University, Tulsa, OK
| | - Janet D Conway
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, MD
| | - J Tracy Watson
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Paul Tornetta
- Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Aaron Nauth
- Division of Orthopaedic Surgery, University of Toronto, Toronto, ON, Canada
- Department of Orthopaedic Surgery, St. Michael's Hospital. Toronto ON, Canada
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Ferreira N, Saini AK, Birkholtz FF, Laubscher M. Management of segmental bone defects of the upper limb: a scoping review with data synthesis to inform decision making. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:911-922. [PMID: 33674937 DOI: 10.1007/s00590-021-02887-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 01/26/2021] [Indexed: 12/18/2022]
Abstract
PURPOSE Injuries to the long bones of the upper limb resulting in bone defects are rare but potentially devastating. Literature on the management of these injuries is limited to case reports and small case series. The aim of this study was to collate the most recent published work on the management of upper limb bone defects to assist with evidence based management when confronted with these cases. METHODS Following a preliminary search that confirmed the paucity of literature and lack of comparative trials, a scoping review using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) was conducted. A literature search of major electronic databases was conducted to identify journal articles relating to the management of upper limb long bone defects published between 2010 and 2020. RESULTS A total of 46 publications reporting on the management of 341 patients were reviewed. Structural autograft, bone transport, one-bone forearm and the induced membrane technique were employed in an almost equal number of cases. The implemented strategies showed similar outcomes but different indications and complication profiles were observed. CONCLUSION Contemporary techniques for the management of post-traumatic upper limb bone defects all produce good results. Specific advantages, disadvantages and complications for each modality should be considered when deciding on which management strategy to employ for each specific patient, anatomical location, and defect size.
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Affiliation(s)
- Nando Ferreira
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, 7505, South Africa.
| | - Aaron Kumar Saini
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, 7505, South Africa
| | - Franz Friedrich Birkholtz
- Walk-A-Mile Centre and Department of Orthopaedics, University of Pretoria, Pretoria, 0002, South Africa
| | - Maritz Laubscher
- Orthopaedic Research Unit (ORU), Division of Orthopaedic Surgery, Department of Surgery, University of Cape Town, Cape Town, 7505, South Africa
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Obremskey WT, Metsemakers WJ, Schlatterer DR, Tetsworth K, Egol K, Kates S, McNally M. Musculoskeletal Infection in Orthopaedic Trauma: Assessment of the 2018 International Consensus Meeting on Musculoskeletal Infection. J Bone Joint Surg Am 2020; 102:e44. [PMID: 32118653 DOI: 10.2106/jbjs.19.01070] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Fracture-related infections (FRIs) are among the most common complications following fracture fixation, and they have a huge economic and functional impact on patients. Because consensus guidelines with respect to prevention, diagnosis, and treatment of this major complication are scarce, delegates from different countries gathered in Philadelphia in July 2018 as part of the Second International Consensus Meeting (ICM) on Musculoskeletal Infection. This paper summarizes the discussion and recommendations from that consensus meeting, using the Delphi technique, with a focus on FRIs. A standardized definition that was based on diagnostic criteria was endorsed, which will hopefully improve reporting and research on FRIs in the future. Furthermore, this paper provides a grade of evidence (strong, moderate, limited, or consensus) for strategies and practices that prevent and treat infection. The grade of evidence is based on the quality of evidence as utilized by the American Academy of Orthopaedic Surgeons. The guidelines presented herein focus not only on the appropriate use of antibiotics, but also on practices for the timing of fracture fixation, soft-tissue coverage, and bone defect and hardware management. We hope that this summary as well as the full document by the International Consensus Group are utilized by those who are charged with musculoskeletal care internationally to optimize their management strategies for the prevention and treatment of FRIs.
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Affiliation(s)
- William T Obremskey
- Department of Orthopaedic Trauma, Vanderbilt Medical Center, Nashville, Tennessee
| | | | | | - Kevin Tetsworth
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Orthopaedic Research Centre of Australia, Brisbane, Queensland, Australia.,Macquarie University Hospital, Sydney, New South Wales, Australia
| | - Kenneth Egol
- Department of Orthopedic Surgery, NYU School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
| | - Stephen Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Martin McNally
- Oxford Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
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Mattos D, Ko JH, Iorio ML. Wrist arthrodesis with the medial femoral condyle flap: Outcomes of vascularized bone grafting for osteomyelitis. Microsurgery 2018; 39:32-38. [PMID: 30176071 DOI: 10.1002/micr.30368] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 05/28/2018] [Accepted: 06/20/2018] [Indexed: 11/11/2022]
Abstract
BACKGROUND Osteomyelitis of the wrist is rare but destructive. Subsequent bone defects often require vascularized bone for successful healing. Recent literature has pointed to the successful use of the medial femoral condylar (MFC) flap for difficult non-unions, yet it has not been specifically described for wrist fusion. We present our experience with this technique for limited and complete wrist arthrodesis. PATIENTS AND METHODS We reviewed 4 cases of radiocarpal bone loss from osteomyelitis. All cases utilized debridement of nonviable tissues, and at least 6 weeks of intravenous antibiotics, followed by vascularized bone grafting with a MFC flap. The flap was based on the horizontal periosteal branch of the descending geniculate artery, and utilized to directly bridge the bony defects following resection. RESULTS Three patients healed primarily, and 1 patient required secondary cancellous bone grafting to reach union. One patient required revision of the donor site closure. None of the patients had a recurrence of infection or other complications. Average follow up was 8.5 months after reconstruction. Average time to union was 11.5 weeks. Three patients demonstrated full composite fist, and 1 patient had incomplete finger range of motion following several flexor and extensor tendon grafts. CONCLUSIONS These cases illustrate the use of the MFC in wrist arthrodesis after osteomyelitis defects. In all cases, there was complete union in a short time, no recurrence of infection, and low donor-site morbidity.
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Affiliation(s)
- David Mattos
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jason H Ko
- Division of Plastic and Reconstructive Surgery, Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Matthew L Iorio
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Division of Plastic and Reconstructive Surgery, University of Colorado, Anschutz Medical Center, Aurora, Colorado
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Abstract
The treatment of infected nonunions is difficult. Antibiotic cement-coated (ACC) rods provide stability as well as delivering antibiotics. We conducted a review of 110 infected nonunions treated with ACC rods. Patients were divided into two groups: group A (67 patients) with an infected arthrodesis, and group B (43 patients) with an infected nonunion in a long bone. In group A, infected arthrodesis, the success rate after the first procedure was 38/67 (57%), 29/67 (43%) required further surgery for either control of infection or non-union. At last follow-up, five patients required amputation, representing a limb salvage rate of 62/67 (93%) overall. In all, 29/67 (43%) presented with a bone defect with a mean size of 6.78 cm (2 to 25). Of those with a bone defect, 13/29 (45%) required further surgery and had a mean size of defect of 7.2 cm (3.5 to 25). The cultures were negative in 17/67 (26%) and the most common organism cultured was methicillin-resistant staphylococcus aureus (MRSA) (23/67, (35%)). In group B, long bones nonunion, the success rate after the first procedure was 26/43 (60%), 17/43 (40%) required further surgery for either control of infection or nonunion. The limb salvage rate at last follow-up was 43/43 (100%). A total of 22/43 (51%) had bone defect with a mean size of 4.7 cm (1.5 to 11.5). Of those patients with a bone defect, 93% required further surgery with a mean size of defect of 5.4 cm (3 to 8.5). The cultures were negative in 10/43 (24%) and the most common organism cultured was MRSA, 15/43 (35%). ACC rods are an effective form of treatment for an infected nonunion, with an acceptable rate of complications. Cite this article: Bone Joint J 2014; 96-B:1349–54
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Affiliation(s)
- J. Conway
- International Center for Limb Lengthening,
Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401
West Belvedere Ave, Baltimore, Maryland, 21215, USA
| | - J. Mansour
- International Center for Limb Lengthening,
Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401
West Belvedere Ave, Baltimore, Maryland, 21215, USA
| | - K. Kotze
- International Center for Limb Lengthening,
Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401
West Belvedere Ave, Baltimore, Maryland, 21215, USA
| | - S. Specht
- International Center for Limb Lengthening,
Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401
West Belvedere Ave, Baltimore, Maryland, 21215, USA
| | - L. Shabtai
- International Center for Limb Lengthening,
Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401
West Belvedere Ave, Baltimore, Maryland, 21215, USA
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Allende C, Paz A, Altube G, Boccolini H, Malvarez A, Allende B. Revision with plates of humeral nonunions secondary to failed intramedullary nailing. INTERNATIONAL ORTHOPAEDICS 2014; 38:899-903. [PMID: 24258153 PMCID: PMC3971268 DOI: 10.1007/s00264-013-2180-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 10/30/2013] [Indexed: 11/26/2022]
Abstract
PURPOSE The objective of this study was to evaluate the results achieved after revision with plates of humeral nonunions secondary to failed intramedullary nailing. METHODS We retrospectively evaluated 32 patients with humeral nonunions secondary to failed intramedullary nailing, treated by internal fixation with plates between 1998 and 2012. Nonunions were diaphyseal in 19 cases, they were located in the proximal humeral metaphysis in nine cases, and in the distal humeral metaphysis in four cases. There were 11 atrophic nonunions and 21 oligotrophic nonunions. Initial treatment was performed with static locked nails in 12 cases, nails with expansive locking systems in 11 cases, and using thin elastic nails in nine cases. The nails were placed antegrade in 18 cases and retrograde in 14 cases. Time between initial surgery and revision surgery averaged 14.5 months. In seven diaphyseal nonunions, the intramedullary nail was left in-situ. Bone graft was added in 25 cases. RESULTS Follow-up averaged 35 months. Union was achieved in all cases, after an average of 3.8 months. Disabilities of the Arm, Shoulder and Hand (DASH) score at last follow-up averaged 14 points, and Constant's score averaged 82 points. The analogue scale of pain averaged 0.8 points. Out of seven patients with radial nerve compromise, six recovered completely and one needed tendon transfers. CONCLUSIONS Revision with plates after failed intramedullary humeral nailing achieved union and good predictable objective and subjective results in all cases. Adequate implant selection and meticulous surgical technique are necessary to achieve successful osteosynthesis and bony union.
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Affiliation(s)
- Christian Allende
- Instituto de Cirugía Reconstructiva de los Miembros, Sanatorio Allende, Córdoba, Argentina,
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Application of an antibiotic intramedullary nail in the management of a large metacarpal bone defect. Tech Hand Up Extrem Surg 2013; 17:187-91. [PMID: 24240621 DOI: 10.1097/bth.0b013e3182a21a48] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Contaminated wounds and infected nonunions of the hand are not amenable to primary internal fixation and grafting. Antibiotic-impregnated cement intramedullary nails have been used in the lower extremity in the treatment of these fractures but have not been described in the hand. This technique combines the advantages of local antibiotic delivery with the mechanical stability afforded by an intramedullary nail. We describe an alternative technique for the management of skeletal defects in a contaminated wound bed in the hand using readily available operating room equipment. The antibiotic-impregnated cement intramedullary nail can be placed temporarily until definitive internal fixation and grafting occur.
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Julka A, Ozer K. Infected nonunion of the upper extremity. J Hand Surg Am 2013; 38:2244-6. [PMID: 23770324 DOI: 10.1016/j.jhsa.2013.03.061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 03/28/2013] [Indexed: 02/02/2023]
Affiliation(s)
- Abhishek Julka
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan
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Matthews D, Samdany A, Ahmed SU. An alternative management option for infected non-union of long bone fractures. J Clin Orthop Trauma 2013; 4:43-5. [PMID: 26403775 PMCID: PMC3880517 DOI: 10.1016/j.jcot.2012.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Accepted: 10/09/2012] [Indexed: 11/16/2022] Open
Abstract
Management of infected non-union following fracture of a long bone is a challenge to the orthopaedic surgeon. Several methods of treating these cases have been described.(1-7) Although reports of single stage or multiple stage procedures exist in the literature, general consensus appears to favour a two-stage approach with initial debridement followed by the use of local antibiotic cement in the first stage.(2,5,8) This antibiotic-impregnated cement has been reported in previous papers as placed around an intramedullary nail or via antibiotic cement beads,(4-6,9) Cement beads offer no mechanical stability to the fracture site. Placing cement around an intramedullary device provides added concerns, such as cement nail debonding and the continued presence of metal, which could cause persistence of infection when in contact with endosteal sequestrate. We describe the use of an antibiotic cement nail fashioned by hand intra-operatively around a length of nylon tape. This eliminates the need for further metalwork during the infected stage, thereby reducing the chance of persistent non-union as well as providing some stability across the fracture site.
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