Infected tibial nonunion. Good results after open cancellous bone grafting in 37 cases

Analysis of risk factors for the recurrence of osteomyelitis of the limb after treatment with antibiotic-loaded calcium sulfate and autologous bone graft

Objective

We aimed to evaluate the efficacy of antibiotic-loaded calcium sulfate combined with autologous iliac bone transplantation in the treatment of limb-localized osteomyelitis (Cierny-Mader type III) and analyze the causes and risk factors associated with infection recurrence.

Methods

Clinical data of 163 patients with localized osteomyelitis of the extremities treated with antibiotic-loaded calcium sulfate combined with autologous iliac bone transplantation in Xi'an Honghui Hospital from January 2017 to December 2022 were retrospectively analyzed. All patients were diagnosed with localized osteomyelitis through clinical examination and treated with antibiotic-loaded calcium sulfate combined with autologous iliac bone. Based on the infection recurrence status, the patients were divided into the recurrence group and the non-recurrence group. The clinical data of the two groups were compared using univariate analysis. Subsequently, the distinct datasets were included in the binary logistic regression analysis to determine the risk and protective factors.

Results

This study included 163 eligible patients, with an average age of 51.0 years (standard deviation: 14.9). After 12 months of follow-up, 25 patients (15.3%) experienced infection recurrence and were included in the recurrence group; the remaining 138 patients were included in the non-recurrence group. Among the 25 patients with recurrent infection, 20 required reoperation, four received antibiotic treatment alone, and one refused further treatment. Univariate analysis showed that education level, smoking, hypoproteinemia, open injury-related infection, and combined flap surgery were associated with infection recurrence (p < 0.05). Logistic regression analysis showed that open injury-related infection (odds ratio [OR] = 35.698; 95% confidence interval [CI]: 5.997-212.495; p < 0.001) and combined flap surgery (OR = 41.408; 95% CI: 5.806-295.343; p < 0.001) were independent risk factors for infection recurrence. Meanwhile, high education level (OR = 0.009; 95% CI: 0.001-0.061; p < 0.001) was a protective factor for infection recurrence.

Conclusion

Antibiotic-loaded calcium sulfate combined with autologous iliac bone transplantation is an effective method for treating limb-localized osteomyelitis. Patients without previous combined flap surgery and non-open injury-related infections have a relatively low probability of recurrence of infection after treatment with this surgical method. Additionally, patients with a history of smoking and hypoproteinemia should pay attention to preventing the recurrence of infection after operation. Providing additional guidance and support, particularly in patients with lower education levels and compliance, could contribute to the reduction of infection recurrence.

Papineau-irrigation technique: an alternative treatment of fracture-related infectious soft tissue defects

The original Papineau technique described satisfactory results in treating infection-related pseudarthrosis and chronic osteomyelitis with chronic draining wounds. We described our experience in treating these soft tissue defects using the Papineau-irrigation technique. We retrospectively reviewed the records of patients that were treated with the Papineau-irrigation technique at UZ Leuven, Belgium, between January 2006 and January 2023. All surgical procedures were performed by one senior orthopedic surgeon. There were no exclusion criteria. There was successful healing of the soft tissue defect in 27 out of 32 patients with serial drip irrigation. Additional debridement was often necessary. The Papineau-irrigation technique may provide a useful alternative for treating fracture-related soft tissue defects. In addition, this technique is safe and feasible. Further comparative studies are necessary to validate its efficacy.

Programmed death ligand 1 signals in cancer cells

The paradigm of surface-expressed programmed death ligand 1 (PDL1) signalling to immune cell programmed death 1 (PD1) to inhibit antitumour immunity has helped to develop effective and revolutionary immunotherapies using antibodies blocking these cell-extrinsic interactions. The recent discovery of cancer cell-intrinsic PDL1 signals has broadened understanding of pathologic tumour PDL1 signal consequences that now includes control of tumour growth and survival pathways, stemness, immune effects, DNA damage responses and gene expression regulation. Many such effects are PD1-independent. These insights demonstrate that the prevailing cell-extrinsic PDL1 signalling paradigm is useful, but incomplete in important respects. This Perspective discusses historical and recent advances in understanding cancer cell-intrinsic PDL1 signals, mechanisms for signal controls and important immunopathologic consequences including resistance to cytotoxic agents, targeted small molecules and immunotherapies. Cancer cell-intrinsic PDL1 signals present novel drug discovery targets and also have potential as reliable treatment response biomarkers. Cancer cell-intrinsic PD1 signals and cell-intrinsic PDL1 signals in non-cancer cells are discussed briefly, as are PDL1 signals from soluble and vesicle-bound PDL1 and PDL1 isoforms. We conclude with suggestions for addressing the most pressing challenges and opportunities in this rapidly developing field.

Treatment of Posttraumatic Tibial Diaphyseal Bone Defects: A Systematic Review and Meta-Analysis

OBJECTIVE

To describe evidenced-based treatment options for patients who sustained trauma and/or posttraumatic osteomyelitis of the tibia resulting in diaphyseal bone defects and to compare outcomes between patients treated with nonvascularized bone grafts (NBGs), bone transport (BT), or vascularized bone grafts (VBGs).

DATA SOURCE

The Preferred Reporting Items for Systematic Review and Meta-Analyses of individual participant data and Cochrane guidelines were followed. PubMed, EMBASE, Cochrane Library, Web of Science, Scopus, and CINAHL were searched from inception to June 2020.

STUDY SELECTION

Patients who were ≥18 years, had sustained trauma to the tibia resulting in fracture and/or osteomyelitis with measurable diaphyseal bone defects, and were treated by interventions such as NBGs, BT, or VBGs were eligible. Excluded studies were non-English, reviews, nonreviewed literature, cadavers, animals, unavailable full texts, nondiaphyseal defects, atrophic nonunions, malignancy, and replantations.

DATA EXTRACTION

A total of 108 studies were included with 826 patients. Two reviewers systematically/independently screened titles/abstracts, followed by full texts to ensure quality, accuracy, and consensus among authors for inclusion/exclusion of studies. A third reviewer addressed disagreements if investigators were unable to reach a consensus. Studies were quality assessed using "Methodological Quality and Synthesis of Case Series and Case Reports".

DATA SYNTHESIS

Analyses were performed with IBM SPSS version 25.0 (IBM Corporation, Armonk, NY) and G*Power3.1.9.2.

CONCLUSIONS

NBGs may be considered first line for trauma defect sizes ≤ 10 cm or posttraumatic osteomyelitis defect sizes <5 cm. BT may be considered first line for posttraumatic osteomyelitis defect sizes <5 cm. VBGs may be considered first line for trauma and posttraumatic osteomyelitis defect sizes ≥5 cm.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Early definitive internal fixation for infected nonunion of the lower limb

Background

The management of an infected nonunion of long bones is difficult and challenging. A staged procedure comprising radical debridement followed by definitive internal fixation was favored. However, no standard treatment has been established to determine the appropriate waiting period between initial debridement and definitive internal fixation. We propose a management method that incorporates early definitive internal fixation in infected nonunion of the lower limb.

Methods

Thirty-four patients (28 men and 6 women; mean age 46.09 years; range 25–74 years) with infected nonunion of the tibia or femur were included. Initial infected bone resection and radical debridement were performed in each patient in accordance with the preoperative plans. Definitive surgery was performed 2–3 weeks after the resection (4 weeks after flap surgery was required), and a third surgery was performed to fill the bone defect through bone grafting or transport (three-stage surgery). In cases of unplanned additional surgery, the reason for the requirement was analyzed, and radiological and functional results were investigated in accordance with the Association for the Study and Application of the Method of Ilizarov criteria.

Results

Bone union was achieved in all patients, and treatment was conducted as planned preoperatively in 28 patients (28/34, 82.35%). The mean interval between primary debridement and secondary definitive fixation was 2.76 weeks (range 2–4 weeks). Six unplanned additional surgeries were performed, and the infection relapsed in two cases. The radiological and functional outcomes were good or better in 32 and 31 patients, respectively.

Conclusions

Early definitive surgery can be performed to treat infected nonunion by thorough planning and implementation of radical resection, active response to infection, restoration of defective bones, and soft tissue healing through a systemic approach.

Gastrocnemius muscle flap with vancomycin/gentamicin-calcium sulfate and autogenous iliac bone graft for the phase I treatment of localized osteomyelitis after tibial plateau fracture surgery

Purpose

To investigate the clinical effect of gastrocnemius muscle flaps combined with vancomycin/gentamicin-calcium sulfate combined and autologous iliac bone graft in the phase I treatment of traumatic focal osteomyelitis (Cierny-Mader type III) after tibial plateau fracture surgery.

Methods

From July 2009 to January 2018, 35 patients with localized osteomyelitis (Cierny-Mader type III) who met the inclusion criteria were followed up and treated. All patients were infected after undergoing internal fracture fixation surgery. Among them, 18 cases were plate-exposed, 14 cases were due to sinus tracts, two were due to skin necrosis, and one was bone-exposed. We treated patients with several measures. All cases were then followed up. The follow-up indicators included Hospital for Special Surgery knee scores (HSS), the time of laying drainage pipe, bone healing time, infection control rate, and the incidence of nonunion and other complications.

Results

All patients were followed up for 24–60 months. None of them underwent amputation. For repairing soft tissue defects, 17 cases were covered with a muscle flap using the medial head of gastrocnemius alone, 15 cases were treated with the lateral head of gastrocnemius muscle, and three cases were covered with the combination of the two heads. Compared to the preoperative score, we found that the average HSS improved at the 1-year and 2-year follow-up (54 vs. 86 vs. 87).

Conclusion

Using a gastrocnemius muscle flap combined with vancomycin/gentamicin-calcium sulfate and autogenous iliac bone was an effective method for the phase I treatment of osteomyelitis (Cierny-Mader type III) after tibial plateau fracture surgery. In the primary treatment of focal traumatic osteomyelitis, it can decrease the treatment time, number of surgeries, pain of patients, time of bone healing, postoperative exudation, and infection recurrence rate and increase the healing bone’s strength.

Reconstruction of tibial bone defect in new age using the old age Papineau technique: A case series

Introduction

Despite advances in treatment, chronic osteomyelitis and infected nonunion after trauma remain a challenge to the orthopaedic field. The Papineau technique, firstly described in 1973, is an alternative to treat such conditions in hospitals where microsurgery is not available, making closure of defect using flap is not feasible. We described our experience in treating patients with chronic osteomyelitis and infected non-union of tibial fractures using the Papineau technique.

Methods

We reviewed the records of patients with severe open tibial fractures with bone defects who were treated using the Papineau technique at Cipto Mangunkusumo Hospital, Jakarta, Indonesia during the period of January 2017 to August 2019. Those with diabetes mellitus, severe liver disease, or malignancies were excluded. All surgical procedures were performed by one senior orthopedic surgeon.

Results

A total of four subjects were enrolled in this study. All subjects were male, with a mean age of 29 ± 6.16 years of age. The mean time to granulation tissue was 21.5 ± 1.29 days, and the mean time to union was 6 ± 0 months. There were no complications.

Conclusions

The Papineau technique may provide successful eradication of infection, reconstruction of bone defect, and soft-tissue closure. In addition, this technique is feasible and safe, and it could be performed in small healthcare centres.

•

Cases of chronic osteomyelitis and infected nonunion after trauma remain a challenge.

•

No consensus regarding the best method.

•

In Indonesia studies regarding the use of the Papineau technique never been conducted.

•

The Papineau technique could be performed in small healthcare centres.

Insights into treatment and outcome of fracture-related infection: a systematic literature review

INTRODUCTION

Standardized guidelines for treatment of fracture-related infection (FRI) are lacking. Worldwide many treatment protocols are used with variable success rates. Awareness on the need of standardized, evidence-based guidelines has increased in recent years. This systematic literature review gives an overview of available diagnostic criteria, classifications, treatment protocols, and related outcome measurements for surgically treated FRI patients.

METHODS

A comprehensive search was performed in all scientific literature since 1990. Studies in English that described surgical patient series for treatment of FRI were included. Data were collected on diagnostic criteria for FRI, classifications used, surgical treatments, follow-up protocols, and overall outcome. A systematic review was performed according to the PRISMA statement. Proportions and weighted means were calculated.

RESULTS

The search yielded 2051 studies. Ninety-three studies were suitable for inclusion, describing 3701 patients (3711 fractures) with complex FRI. The population consisted predominantly of male patients (77%), with the tibia being the most commonly affected bone (64%), and a mean of three previous operations per patient. Forty-three (46%) studies described FRI at one specific location. Only one study (1%) used a standardized definition for infection. A total of nine different classifications were used to guide treatment protocols, of which Cierny and Mader was used most often (36%). Eighteen (19%) studies used a one-stage, 50 (54%) a two-stage, and seven (8%) a three-stage surgical treatment protocol. Ten studies (11%) used mixed protocols. Antibiotic protocols varied widely between studies. A multidisciplinary approach was mentioned in only 12 (13%) studies.

CONCLUSIONS

This extensive literature review shows a lack of standardized guidelines with respect to diagnosis and treatment of FRI, which mimics the situation for prosthetic joint infection identified many years ago. Internationally accepted guidelines are urgently required to improve the quality of care for patients suffering from this significant complication.

Treatment of infected non-unions of the femur and tibia in a French referral center for complex bone and joint infections: Outcomes of 55 patients after 2 to 11 years

INTRODUCTION

An infected non-union is a major complication following bone fracture. While bone union can be obtained in 70% to 100% of cases, treatment of osteomyelitis is less predictable, with reported healing rates ranging from 40% to 100%. The primary aim of this study was to assess the success rate of treating infected non-unions of the tibia and femur by a team specializing in complex bone and joint infections.

MATERIAL AND METHODS

This single-center retrospective study included all patients operated between 2002 and 2012 due to an infected non-union of the femur or tibia using standardized surgical methods. The procedure was typically done in two phases: excision of the infected site and stabilization, followed by bone reconstruction after a waiting period. Additional procedures (lavage and/or bone grafting) were performed in some cases. A minimum 6-week course of antibiotic therapy was given. The primary endpoint was successful medical and surgical treatment after a minimum 2 years' follow-up defined as healing of the infection (no local clinical signs of infection, ESR≤20mm and CRP≤10mg/L, no mortality attributed to the infection) and radiological and clinical bone union, with the lower limb spared.

RESULTS

Fifty-five patients (39 men, 16 women) were included with an average age of 37±11 years. There were 40 tibial fractures and 15 femur fractures. A polymicrobial infection was present in 47% of cases. Repeat surgery was required in 56.4% of patients. At an average of 4±2 years from the first surgical procedure, the treatment was successful in 49 patients (89%): 36 tibia (90%) and 13 femur (87%). The mean time to union was 9±4 months. There were six failures: 3 amputations at 5, 6 and 16 months; 1 mechanical and infection-related failure; 2 failed union.

CONCLUSION

This study found that 89% of patients with an infected tibial or femoral non-union treated by a team specialized in complex bone and joint infections using a standardized surgical protocol had bone union and healing of the infection in an average of 9 months.

LEVEL OF EVIDENCE

IV, retrospective study.

Effect of vacuum-assisted closure combined with open bone grafting to promote rabbit bone graft vascularization

Background

Patients with composite bone non-union and soft tissue defects are difficult to treat. Vacuum-assisted closure (VAC) combined with open bone grafting is one of the most effective treatments at present. The aim of the present study was to preliminarily investigate the effect and mechanism of VAC combined with open bone grafting to promote rabbit bone graft vascularization, and to propose a theoretical basis for clinical work.

Material/Methods

Twenty-four New Zealand white rabbits were randomly divided into an experimental and a control group. Allogeneic bones were grafted and banded with the proximal femur with a suture. The experimental group had VAC whereas the control group had normal wound closure. The bone vascularization rate was compared based on X-ray imaging, fluorescent bone labeling (labeled tetracycline hydrochloride and calcein), calcium content in the callus, and expression of fibroblast growth factor-2 (FGF-2) in bone allografts by Western blot analysis at the 4^th, 8^th, and 12^th week after surgery.

Results

At the 4^th, 8^th, and 12^th week after surgery, the results of the tests demonstrated that the callus was larger, contained more calcium (p<0.05), and expressed FGF-2 at higher levels (p<0.05) in the experimental group than in the control group. Fluorescent bone labeling showed the distance between the two fluorescent ribbons was significantly shorter in the control group than in the experimental group at the 8^th and 12^th week after surgery.

Conclusions

VAC combined with open bone grafting promoted rabbit bone graft vascularization.

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

INTRODUCTION

Non-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 METHODS

Our 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.

RESULTS

All 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.

CONCLUSIONS

Open 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.

Attaining tibiofibular union using an inter-tibiofibular autograft. A series of 43 cases

INTRODUCTION

This study consisted of a series of 43 patients with lower leg non-union that were treated with an inter-tibiofibular autograft (ITFG).

MATERIAL AND METHODS

After reviewing the surgical technique, the overall theory behind the treatment is described, including stabilization, soft tissue repair, infection control if necessary and then performing a procedure to help achieve bone union.

RESULTS

After an average follow-up of 2 years, all the patients achieved union, but some required additional procedures. Only one patient had a delayed reactivation of the infection, which was successfully treated.

CONCLUSION

A broad set of indications for ITFG are proposed for lower leg non-union cases, in particular non-infected cases.

LEVEL OF EVIDENCE

Level IV. Retrospective study.

Management of combined bone defect and limb-length discrepancy after tibial chronic osteomyelitis

Bone defects and leg shortening due to chronic osteomyelitis are rare yet challenging problems to treat. The aim of this study was to summarize our experience with a distraction osteogenesis technique performed with an external fixator for these conditions. Twenty-three consecutive patients with tibial bone defects and limb-length discrepancy caused by osteomyelitis were treated from January 1994 to January 2009. Thirteen boys and 10 girls had a mean age of 12.2 years (range, 8-16 years). Twenty of the 23 patients (87.0%) had undergone an unsuccessful bone grafting procedure. Mean amount of bone defect was 3.6 cm (range, 1.5-6.2 cm) as measured on plain radiographs. Mean leg-length discrepancy was 4.0 cm (range, 0-8.0 cm). All patients were followed for a mean of 116 months (range, 31-182 months). Mean external fixation index was 48.0 days/cm (range, 40.7-66.5 days/cm). Mean lengthening was 9.3 cm (range, 5.8-12.1 cm). Based on the criteria recommended by Paley et al, 16 bone results were excellent, 6 good, and 1 fair. Fifteen functional results were excellent, 7 good, 1 fair, and 0 poor. This study shows that distraction osteogenesis with an external fixator is an effective treatment for massive postosteomyelitis bone defects and leg shortening.

The use of Papineau technique for the treatment of diabetic and non-diabetic lower extremity pseudoarthrosis and chronic osteomyelitis

The treatment of 31 consecutive adult patients, ages 25–67 years with chronic draining osteomyelitis (12 cases) or infected pseudarthrosis (19 cases) by the Papineau technique was retrospectively reviewed. The initial injury was an open fracture in 24 patients and a closed fracture in 7 patients. In all cases an Ilizarov circular external fixation device was used for the stabilization of the fracture or for bone lengthening. Mean follow-up for the group was 20 months (range, 10 months to 5 years) and there was successful limb salvage in all cases with eradication of infection and bone consolidation was achieved. The Ilizarov circular external fixation was removed at a mean of 18 weeks (range, 14–24 weeks). The mean time to bone union was 5 months (range, 4–10 months). All patients returned to their pre-treatment activity levels or better.

Combined distraction osteogenesis and Papineau technique for an open fracture management of the distal lower extremity

Despite modern surgical techniques and advanced antimicrobial therapy, open lower-extremity fracture management and osteomyelitis remain a challenge for reconstructive surgeons. Posttraumatic composite bone and soft tissue defects are usually the result of high-energy trauma and are often associated with concomitant injuries, therefore making complex reconstruction more difficult. This article presents a case report of an open distal tibial fracture managed by a simultaneous distraction osteogenesis and Papineau technique with a long term follow-up and literature review.

Management of infected femoral nonunions with a single-staged protocol utilizing internal fixation

PURPOSE

There are no reported series that specifically deal with repair of infected nonunions of the femur with revision internal fixation. We sought to determine whether a standardised treatment protocol we have used for 13 patients since 1992 results in a high union rate, resolution of infection, and a good functional outcome.

METHODS

The study cohort included seven male and six female patients who presented to the senior author with an infected nonunion of the shaft of the femur. Eleven patients with a minimum of 2-year follow-up and between the ages of 19 and 75 years (mean 53.2 years) were included and evaluated. All patients underwent a single-staged protocol that includes an antibiotic "holiday", then treating the infected nonunion with surgical debridement and hardware removal, local and systemic antibiotics, revision open reduction and internal fixation, and use of supplemental bone grafting. Great emphasis at the time of surgery is placed upon aggressive debridement, correction of any deformity, and obtaining stable internal fixation. We sought to report our success rate of nonunion repair, number of re-interventions, complication rate, final knee range of motion, and the ability to eradicate the infection using this treatment regimen.

RESULTS

At most recent follow-up (mean 5.6, range 2-12 years), all patients had united and resolved their infections. Ten of the patients healed their nonunions with the fixation placed at the time of initial revision by us. Five patients required re-interventions to ultimately attain fracture union. Four patients had additional bone grafting procedures at the time of antibiotic bead removal. One of these four patients, who was later diagnosed with a nickel allergy, required three subsequent revision open reduction and internal fixations with bone grafting for hardware failure and persistent nonunion. A final patient underwent nail dynamisation with achievement of osseous union. Only one patient had less than 90 degrees of knee flexion, although he previously had an extensor mechanism disruption and had only 15 degrees of flexion noted at the time of initial surgery performed by us.

CONCLUSION

The results of this study indicate that our standard protocol for treatment of infected nonunion of the shaft of the femur is reliable at obtaining fracture union with a good functional result, while resolving infection despite the reliance upon internal fixation.

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

BACKGROUND AND AIMS

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.

PATIENTS AND METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Infected nonunion of the long bones

BACKGROUND

Although definitions vary, infected nonunion has been defined as a state of failure of union and persistence of infection at the fracture site for 6 to 8 months.>). Infected nonunions of the supracondylar region of the femur are uncommon and are mostly due to a severe open fracture with extensive comminution and segmental bone loss or after internal fixation of a comminuted closed fracture. Associated factors include exposed bone devoid of vascularized periosteal coverage for more than 6 weeks, purulent discharge, a positive bacteriological culture from the depth of the wound, and histologic evidence of necrotic bone containing empty lacunae. Soft-tissue loss with multiple sinuses, osteomyelitis, osteopenia, complex deformities with limb-length inequality, stiffness of the adjacent joint, polybacterial multidrug-resistant infection, and smoking all complicate treatment and recovery. Although uncommon in incidence, infected nonunions of the long bones present a great challenge to the orthopaedic surgeon in providing optimal treatment of this entity. To give direction to the optimal strategy, this systematic review was performed.

OBJECTIVE

We aimed to review the highest level of available evidence on the operative management of infected nonunions of the long bones.

Modern papineau technique with vacuum-assisted closure

We describe a contemporary modification of the Papineau technique by implementing a vacuum-assisted closure (V.A.C.(R)) device in lieu of wet-to-dry dressing changes. The method makes use of a protocol similar to that of Papineau and others for the treatment of chronic osteomyelitis. This protocol includes aggressive excisional debridement of infected or necrotic bone, open bone grafting with cancellous autograft, vacuum-assisted wound closure by secondary intent, and eradication of chronic infection with concomitant parenteral antibiotics. A representative case report is included to illustrate the technique.

Infected nonunion of the long bones

The problems in infected nonunion include multiple sinuses, osteomyelitis, bone and soft tissue loss, osteopenia, adjacent joint stiffness, complex deformities, limb-length inequalities, and multidrug-resistant polybacterial infection. Bone gap and active infection are the crucial factors relating to treatment and prognosis. Gaps larger than 4 cm likely cannot be effectively bridged by corticocancellous bone grafting. If the limb has intact distal circulation and sensation, limb salvage and reconstruction generally is preferable to amputation. The fracture generally unites if adequate debridement of the nonunion site is done with fracture stabilization and bone grafting. We reviewed 42 consecutive patients with infected nonunion of the long bones. These patients have been categorized into two groups. Type A is infected nonunion of long bones with nondraining (quiescent) infection, with or without implant in situ; Type B is infected nonunion of long bones with draining (active) infection. Both are classified further into two subtypes: 1) nonunion with a bone gap smaller than 4 cm or 2) nonunion with a bone gap larger than 4 cm. Single-stage debridement and bone grafting with fracture stabilization are the methods of choice for Type A1 infected nonunions. Adequate debridement, fracture stabilization, and second-stage bone grafting gives desirable results in Type B1 infected nonunions. Distraction histiogenesis is the preferred procedure for Type A2 and B2. The autogenous nonvascularized fibular graft, posterolateral bone grafting for the tibia, and centralization of the ulna over distal radial remnant (single bone forearm) may be good treatment options in selected cases.

Radical excision and reconstruction of chronic tibial osteomyelitis with microvascular muscle flaps

We report a series of 21 patients with chronic osteomyelitis of the tibia treated with microvascular muscle flap reconstruction. All patients underwent a radical bone and soft-tissue excision until healthy, well-bleeding tissue was exposed. Six patients required cancellous bone grafting. Latissimus dorsi was used in 14 patients, gracilis in 4, and rectus abdominis in 4. One gracilis flap was lost due to vessel thrombosis and was replaced with a rectus abdominis free flap. Average follow-up was 2.5 years. There was no evidence of clinical infection in 20 patients at follow-up; the bone had healed, the soft-tissue cover was stable, and the laboratory parameters were normal. Bone infection recurred in 1 patient, resulting in a below-knee amputation. The radical excision of infected bone and affected soft tissue and reconstruction with a well-vascularized large free-muscle flap is an excellent solution in most difficult chronically infected cases.

Introduction to adult posttraumatic osteomyelitis of the tibia

The tibia is the most frequent site of an open fracture, and treatment of adult posttraumatic osteomyelitis of the tibia represents a significant clinical problem that has been recognized for centuries. Ancient modalities such as immobilization and debridement are still mainstays of therapy, and recent developments such as the use of antibiotics and muscle transfer have helped to improve outcome. Osteomyelitis is classified based on the Cierny-Mader system to provide prognostic and therapeutic information. Open fractures can be classified by the Gustilo system, again providing prognostic and therapeutic data. Gustilo Type III fractures have a high likelihood of having infection develop. Treatment principles include immobilization, thorough debridement, control of infection through antibiotic use, control of dead space, and soft tissue coverage.