Infected nonunions of long bones of the upper extremity: staged reconstruction using polymethylmethacrylate and bone graft impregnated with antibiotics

This case series evaluates 12 patients presenting posttraumatic infected nonunions affecting long bones of the upper extremity, treated with staged reconstruction using polymethylmethacrylate spacers with antibiotics in the first stage and bone graft impregnated with antibiotics in the definitive surgical procedure. Five nonunions affected the humerus, four the ulna and three the radius. All nonunions were atrophic. Patient’s age averaged 35.9 years. The size of the bony defect averaged 2.8 cm. Time between original trauma and revision surgery averaged 9.6 months. Follow-up averaged 19 months. All nonunions healed after an average of 5 months. DASH score at last follow-up averaged 15 points. Although two surgical procedures are needed, one to cure infection and another to achieve bony union, this approach for posttraumatic infected nonunions of long bones of the upper extremities represents a valid treatment alternative.     

Antibiotic-impregnated cement spacer for bone defects of the forearm and hand

Management of bone loss, particularly in the face of open or contaminated wounds, presents a reconstructive challenge. Polymethylmethacrylate impregnated with antibiotics has been used successfully in the treatment of infected total joint arthroplasty and open fractures. The cement delivers high-dose local concentrations of antibiotics while filling a space. This article presents our use of an antibiotic-impregnated cement spacer for bone loss in the forearm or hand in the face of open or infected wounds. The cement spacer fills a potential space, prevents the involution of the surrounding soft tissue, and delivers appropriate antibiotics. When the spacer is removed, the remaining sheath serves to hold and contain the cancellous bone graft.     

The treatment of infected nonunions and segmental defects of the tibia by the methods of Ilizarov.

Circular external fixation using the Ilizarov apparatus combined with internal bone transport or compression-distraction techniques were used to treat 28 patients with infected nonunions or segmental bone loss of the tibia. There were 22 males and six females with an average age of 34 years (range, 17-58 years). Six of 28 patients had infected tibial nonunions associated with hemicircumferential bone loss. These tibiae were treated by anterior hemicircumferential corticotomy and partial bone fragment internal transport. Fifteen of the remaining 22 patients had an average of 4 cm of segmental bone loss (range, 2-7 cm). Seven patients without shortening or defect had infected nonunions associated with extensive diaphyseal sequestrae. These nonunions were treated by en bloc resection of the diaphyseal shaft and internal bone transport. All patients healed their infected extremities without the addition of cancellous bone graft, microvascular fibular, or soft-tissue grafting. Preoperative shortening was present in 13 of 28 patients. Regenerate new bone formation averaged 6 cm (range, 1.5-22 cm). Postoperative antibiotics were not administered in 21 of 28 patients. In seven patients, antibiotics were given for ten days after en bloc resection of the diaphyseal sequestrae. Equal limb length was maintained in 21 extremities, within 1 cm in five tibiae and less than 3 cm in two tibiae. Functional results were good to excellent in 21, fair in six, and poor in one. The application of Ilizarov techniques to diaphyseal infected nonunions and segmental defects is very encouraging. It may prove to be an excellent technique for future management of resistant diaphyseal infections of bone.     

Antibiotic coated hinged threaded rods in the treatment of infected nonunions and intramedullary long bone infections

IntroductionLocal delivery of high dose antibiotics in the form of antibiotic impregnated polymethyl methacrylate (PMMA) cement beads or coated rods is commonly used in the management of long bone infections. The downsides of antibiotic cement beads for intramedullary long bone infections are associated with difficulty in removal from the medullary canal, bead breakage, and lack of stability. Antibiotic cement-coated smooth flexible guide wires, rods and nails can have complications such as delamination or debonding of the cement. In addition, the current techniques for cement rod insertion have a risk of iatrogenic joint contamination.To improve upon this technique and decrease potential complications, we propose the use of an antibiotic cement-coated hinged threaded rod as a temporary intramedullary spacer. This technique utilizes both an antegrade and retrograde insertion of the threaded rod into the medullary canal through the bony defect site with connection at the hinge to treat intramedullary long bone infections and infected nonunions.Material and MethodsA total of 40 patients were included in the study. The details in making the cement rod were well documented. The shape of cement rod and the integrity of the cement at the time of rod insertion and rod removal were compared to identify any cement debonding or delamination. Potential postoperative complications including iatrogenic joint infection, displacement or breakage of the threaded cement rods, and fracture displacement were all carefully documented. The preliminary biological effect of the initial debridement and antibiotic cement rod placement was determined using the negative conversion rate of intraoperative cultures.ResultsA single antibiotic coated threaded rod was inserted in 18 cases. Two separate antibiotic coated threaded rods were inserted and connected via hinge in 22 cases. There were zero cases of rod breakage and no secondary loss of reduction from antibiotic rod placement to the definitive staged operation. There were zero iatrogenic joint infections. There were zero cases of cement debonding or delamination from the rod. The conversion rate to a negative culture after initial debridement and antibiotic rod placement was 85% (34/40 cases).ConclusionsThe use of an antibiotic coated cement threaded rod with a hinge as an intramedullary spacer provides the benefits of local antibiotic delivery, offers improved construct stability, makes implant removal easier without delamination of the cement mantle, and utilizes the versatility of a hinge to prevent violation of native joints when treating infected nonunions and intramedullary long bone infections.     

Free vascularized fibula grafts in surgery of the upper limb

Twenty patients with intractable diseases in the upper extremity were treated using free vascularized fibula grafts. There were 13 men and seven women. Three patients had traumatic bone defects, five had post-traumatic nonunions, two had congenital pseudoarthroses, seven had defects after tumor resection, and three had other lesions. The reconstructed sites were the humerus in two patients, the radius and/or ulna in 17, and the metacarpal and phalangeal bones in one. The length of the bone defect ranged from 3 to 18 cm (mean: 8.4 cm). Follow-up periods ranged from 6 to 204 months. No patient required additional bone grafts. The mean period required to obtain radiographic bone union was 4.4 months. There were no cases with fractures of the grafted bone, but malunion occurred in four cases. The vascularized fibula graft is indicated in patients with large bone defects or intractable nonunions in the humerus, radius, and/or ulna.     

Treatment of infected nonunion and delayed union of tibia fractures with locking intramedullary nails

Treatment of infected nonunion of tibial fractures has focused on irradicating infection before attempting to secure union. To secure union in the presence of infection in cases not amenable to conventional treatment, intramedullary nailing combined with open wound management was the treatment in 19 fractures of infected tibial nonunions in 18 patients. Eighteen fractures united. Drainage lessened or ceased after union of fractures and/or removal of nails. Only three cases had bone grafts. All were initially Type III open fractures. The majority occurred in motorcycle accidents. Time to union averaged 6.6 months (range, three to 14 months). Fourteen cases (15 tibias) healed without further drainage; four had minimal but persistent drainage. In properly selected cases, the treatment was safe and effective.     

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.     

Iliac vessel injury by a cement spacer: report of a case

The use of antibiotic-impregnated acrylic cement as a bone spacer between the intervals of revision hip arthroplasty for infection has been widely practiced. Vascular injuries caused by the migration of a cement spacer with subsequent erosion of the vessel wall have never been reported. A 67-year-old woman presented with tense swelling over her left lower extremity and hemarthroses of the left hip after implantation of a cement spacer for infected hip arthroplasty. Complete external compression of the external iliac vein and laceration of the iliac artery by the spacer were found. The symptoms were resolved after surgical debridement, removal of the spacer and femoral stem, and repair of the vessel. Cautious placement of a cement spacer in the acetabular fossa accompanied with poor bone stock must be emphasized.     

Infected pseudoarthroses of long tubular bones. (Principles of treatment and results in the material of the University Hospital) (author's transl)]

Based on clinical experiences author takes part for principles in the treatment of infected nonunions of long tubular bones. Main characteristics of his treatment are: Baside an approach saving the blood supply of bone, stable osteosynthesis, sequestrotomy and removal of necrotic tissues (focus elimination) filling in with autologous spongy bone chips the residual bone cavities, in acute stadium the application of PMMA balls as preparatory measure for a following cancellous bone, transplantation. Author comments at the same time on drainage, rinsing and sucking. Selective use of antibiotics may complete the therapy. Data of treatment in 42 cases of infected nonunions are given.     

Management of difficult lower extremity fractures and nonunions

Difficult fractures and nonunions of the lower extremities are defined as compound fractures with soft-tissue loss, segmental bone fractures, and infected nonunions. A variety of methods for managing these defects are presented, including the use of modern fixation techniques and the application of highly vascularized bone and soft tissues. Vascularized bone grafts play a significant role in the treatment of difficult fractures that previously would have required amputation.     

A new technique for removing intramedullary cement

Treatment of infected long bone fractures or nonunions requires stability for bony union, yet retained implants can lead to persistent infection. Antibiotic cement intramedullary nails, in addition to external fixation, are commonly used to deliver intramedullary antibiotics in infected long bone fractures and provide temporary stability. However, the retrieval of these nails can result in debonding of antibiotic cement, which can require significant time and effort to remove. A variety of methods, including intramedullary hooks, reverse curettes, flexible osteotomes, and stacked guide rods, are commonly used to remove cement fragments. When these methods fail to allow access to the entire length of the canal, the Reamer Irrigator Aspirator system (Synthes, Paoli, PA) serves as an effective method for removing retained intramedullary cement. The surgical technique is described, and three cases illustrate the successful use of the Reamer Irrigator Aspirator system for removal of an antibiotic cement intramedullary nail.     

Treatment of nonunion of fractures in the epiphyseal-metaphyseal region of long bones

Twenty-four consecutive patients with fracture nonunion in the metaphyseal-epiphyseal areas of long bones were surgically treated. Average time from injury to treatment of the nonunion was 10 months, and average follow-up time after surgical treatment was 29 months. Eight patients with infected nonunions had initial debridement procedures; three of these patients then had placement of external fixators and bone grafting. The remaining five patients and 13 others were then treated by open reduction and internal fixation alone or with the addition of autogenous cancellous bone grafting. Single or double plates and screws were used. Arthrolysis, joint manipulation, and intensive postsurgical exercises were considered necessary to regain joint function. One patient underwent a hemiarthroplasty, and two others underwent arthrodesis as the initial nonunion treatment. Twenty of the 21 patients not treated by arthrodesis or arthroplasty healed their fractures in an average time of 7 months. Fifty-two percent of the patients achieved good or excellent range of motion (ROM) of the contiguous joint, with 70% of the patients reporting no pain in this joint. These fractures have excellent intrinsic healing capability because they occur in anatomical regions with a normally abundant circulation. We recommend stable fixation, with the need for bone grafting only in defect nonunions, together with intra- and postoperative joint mobilization to obtain a satisfactory functional end result.     

Surgical treatment of the aseptic femoral shaft nonunion

Femoral shaft nonunions is difficult complication and a big challenge for the orthopaedic surgeons. These complications occur after open femoral fractures, comminuted fractures, segmental fractures, the infection, after the inadequate fixed osteosynthesis, the systemic disease, and smokers. The paper presents the results of treatment aseptic femoral shaft nonunion in 18 patients. They were primarily operated by the method of internal compresive plate fixation and external fixation (open fractures). For fixation we used dinamic internal fixator by Mitkovic. All nonunions treated by this method are healed. In patients with atrophic femoral shaft nonunions in addition to fixation was performed and bone grafting. This implant has proved successful in the treatment of femoral shaft nonunion. During the fixation no periostal and intramedullary vascularization damage, which is an important prerequisite for bone healing. Implant enables biological and mechanical conditions for nonunion healing.     

Innovative strategies for the management of long bone infection: a review of the Masquelet technique

Post-traumatic long bone osteomyelitis (PTOM) is a relatively frequent occurrence in patients with severe open fractures and requires treatment to prevent limb-threatening complications. The Masquelet technique represents a length-independent, two-staged reconstruction that involves the induction of a periosteal membrane and use of an antibiotic-impregnated cement spacer for the treatment of segmental bone loss that result from bone infection. In this review, we summarize recent developments regarding the diagnosis and treatment of long bone PTOM, with a special emphasis on the use of the Masquelet technique for reconstruction of wide diaphyseal defects.     

Cement spacer loaded with antibiotics for infected implants of the hip joint

It is difficult to treat infected implants of the hip joints. Such treatment involves immeasurable physical and psychological suffering of the patients. We used antibiotic-impregnated cement spacers in 17 cases of infection after total hip arthroplasty and bipolar arthroplasty with good clinical results. We thoroughly removed any foreign material and formed an antibiotic-impregnated cement spacer into a similar shape as that of the implants. A cement spacer enables high-concentration antibiotics to act on infected sites. Also, it can prevent leg length discrepancy and atrophy of bones or muscles. Although cement spacers have been reported to have problems regarding shape and strength, we achieved good results with a cement spacer mold in the present study. No recurring infection has been found at a mean follow-up period of 3 years and 2 months.     

Therapy of bone and joint changes in renal osteodystrophy in adulthood

The renal osteoarthropathy in patients with chronic renal disease undergoing hemodialysis is characterized by increased bone turnover. This is the consequence of secondary hyperparathyroidism and leads to fibro-osteoclasia and osteomalacia. Mineralization of the atypical bone fibers is diminished and the collagen texture is altered. The biomechanical properties of such bone are reduced, which means that the incidence of fractures is increased and fracture healing seems to be disturbed. Therapy given for renal failure leads to segmental necrosis of the epiphyses. In the growing skeleton longitudinal growth is diminished and deviations in the axes of long bones are often observed. Corrective osteotomies, treatment of fractures and artificial joint replacements are therefore necessary in patients with renal failure. Observations recorded in 13 patients (aged 16-67 years) with chronic renal insufficiency who underwent 21 surgical interventions and were followed up for 6 years have led to formulation of the following general recommendations. Corrective osteotomies should only be performed when they are absolutely essential; the rate of nonunions is very high. The same is true for fixation of fractures with plates and nails. When joint replacements are inserted because of segmental necrosis and fractures the course is almost the same as in patients without renal osteoarthropathy when bone cement is used for fixation.     

Staged bone grafting following placement of an antibiotic spacer block for the management of segmental long bone defects

Segmental long bone defects resulting from injury or surgical intervention are difficult problems to manage. Amputation, external fixators, vascularized fibular grafts, acute limb shortening, and various quantities of allograft and autograft have historically been the mainstays of treatment. Recently, the use of osteoinductive substances such as recombinant bone morphogenic proteins, and osteoconductive scaffolds such as calcium phosphate have found use in the treatment of these clinical situations. More recently, Masquelet described the use of a cement spacer placed within the osseous void followed by staged bone grafting within the induced biomembrane formed around the spacer as a potential treatment strategy to manage these large defects.This article describes a series of 11 patients for which we used this technique of staged bone grafting following placement of an antibiotic spacer to successfully manage osseous long bone defects ranging from 4 to 15 cm. The limbs were stabilized and aligned at the time of initial spacer placement with a plate and screw construct, intramedullary nail, or fine wire fixator. Osteoinductive substances including bone morphogenic protein-2 and platelet rich concentrate were used in addition to allograft to improve bony healing. In our series, osseous consolidation and full weight bearing was achieved in 10 of 11 patients. Two patients developed heterotopic ossification. There was 1 non-union and 1 infection, which occurred in the same patient. Staged bone grafting within an induced biomembrane created after the use of a cement spacer is a reasonable option in the management of both acute and delayed segmental long bone defects.     

Tibial Nonunion: Treatment Alternatives

Because the spectrum of injuries to the tibia is so great, no single method of treatment is applicable to all nonunions. Therefore, it is important for surgeons who treat tibial nonunions to be skilled in several different methods of treatment. In patients with significant deformities, electrical stimulation, isolated fibular osteotomy, and bone grafts alone are unsatisfactory treatment options. In aseptic nonunions, the use of intramedullary nailing or compression plating appears to have many advantages. In previously closed and selected grade I and grade II open fractures, reamed intramedullary nailing is a safe and effective method of treatment. Because of the risk of infection, reamed nailing is not recommended after external fixation of open fractures. In these cases as well as others, the authors prefer plate osteosynthesis. With few exceptions, the plate should be placed, under tension, on the convex side of the tibia. Used in this fashion, the plate can assist in correction of any deformity and can also provide stable internal fixation. Half-pin external fixation is used primarily in the management of infected fractures. Ilizarov and other small-wire circular fixators have proved effective in treating complex-composite deformities associated with sepsis, bone loss, shortening, angulation, or malrotation. Amputation may be warranted if a functional limb cannot be achieved.     

Infectious morbidity in extremity fractures

To review infectious morbidity in extremity fractures, 265 patients with 280 open fractures and 573 patients with closed fractures requiring open reduction and internal fixation (ORIF) were reviewed. Among open fractures, 32 (11%) became infected. Significantly fewer infections occurred in open fractures secondary to gunshot wounds (p less than 0.01) and in the upper extremity regardless of cause (p less than 0.05). Preventive preoperative antibiotics did not appear to affect infection rates. Open fracture infections were consistently with hospital-acquired organisms, and these were consistently resistant to the preventive antibiotic employed. Closed fractures had only 18 (3%) infections after ORIF. Preoperative antibiotics did reduce infection rates compared to rates in patients with no preoperative systemic antibiotics (p less than 0.05). Pathogens in ORIF patients showed a greater preponderance of Staphylococci. In conclusion, preventive antibiotics were only effective in the prevention of infection in the ORIF patients. Open fracture patients consistently develop infections with hospital-acquired pathogens, suggesting that contamination after hospitalization rather than at the time of injury is a major factor.     

Double-barrel free fibula flap for treatment of infected nonunion of both forearm bones

Free vascularized bone transfer is a viable treatment option for extensive bony defects greater than 6 to 8 cm involving scarred, poorly vascularized, or infected recipient beds, such as in chronically infected nonunion of the radius and ulna treated with a double-barrel free fibula flap. Both patients reported here experienced bony union with significant resolution of their symptoms. Although range of motion improved following an aggressive physical therapy regimen, pronation was adversely affected. Chronic infected nonunions or nonunions from radionecrosis involving large segmental defects of both forearm bones are a truly unique challenge and must be treated aggressively to ensure any useful long term function of the injured limb.