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.     

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.     

髓内针加自体骨髓移植治疗四肢长骨骨不连

目的 探讨四肢长骨骨不连的治疗方法。方法 13例骨不连中有肱骨5例,股骨4例,胫骨3例,尺骨1例,采用带锁(自锁)髓内针固定,自体髂骨植骨和骨折端自体骨髓移植治疗。结果所有病例经8～14个月随访,均在5～10个月内愈合,功能恢复良好,优良率达76.92％。结论 本手术采用带锁(自锁)髓内针固定坚强;自体骨髓移植可补充成骨基质、骨生长因子和骨祖细胞,有促进骨折愈合的作用。     

Metastatic fractures of long bones

Summary Forty-two patients with a total of 52 metastatic fractures of long bones were analysed retrospectively with regard to the type of treatment, complications, general mobility and survival. Endoprosthetic replacement appeared to be better than osteosynthesis in the proximal femur, and this method should also be considered in pathological fractures of the distal femur. Nailing is indicated in fractures of the shafts of long bones in the lower limb, and also in the humerus. Osteosynthesis with a plate has only limited indications. Cement should be added to an osteosynthesis or replacement of a pathological fracture in order to achieve immediate stability. On the whole, the life expectancy of these patients has improved; five in our series lived for more than 6 years after the treatment of their metastases. The method of surgical treatment therefore needs more consideration.

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Résumé Analyse rétrospective de quarante deux patients présentant en tout 52 fractures métastatiques des os longs, en fonction du type de traitement, des complications, de la mobilité globale et de la survie. Le remplacement prothétique semble meilleur que l'ostéosynthèse pour l'extrémité supéireure du fémur et cette méthode de traitement peut également être envisagée pour les fractures pathologiques de l'extrémité distale. L'enclouage est indiqué dans les fractures diaphysaires du membre inférieur, et aussi de l'humérus. L'ostéosynthèse par plaque n'a que des indications restreintes. Du ciment peut être ajouté à l'ostéosynthèse ou au remplacement prothétique afin d'obtenir d'emblée la stabilisation de la fracture. Dans l'ensemble, l'espérance de vie de ces malades a augmenté; cinq dans notre serie sont encore en vie plus de six ans après le traitement de leurs métastases. Le traitement chirurgical mérite donc de plus en plus d'être pris en considération.

     

Birth fractures of long bones

A case of traumatic separation of the proximal humeral epiphysis in a newborn is described. Three other cases of birth fractures of long bones have been taken care of in our hospital during 1980-89, when the frequency of birth fractures of long bones was 0.02%. The causes and diagnostic problems of these fractures are discussed.     

Treatment of open fractures and dislocations of hand long bones

Efficiency of different fixation methods of open fractures and dislocations of hand tubular bones on the basis of treatment experience of 206 patients has been investigated in clinical conditions. Immobilization with a plaster bandage, osteosynthesis and transarticulation fixation by wires, osteosynthesis by external fixation apparatus were used. An analysis of long-term results of treatment of 128 patients demonstrated that fixation of damaged bones and joints by the external fixation apparatus is the most effective one.     

Multiple diaphyseal fractures of the long bones

The author analyses the treatment of 107 injured patients with 148 double and 203 single diaphyseal fractures of long bones of various localization. Special attention has been paid to double fractures in the light of experimental studies carried out by the author in which a number of formerly unknown regularities of blood supply of the fragments has been revealed, which stipulates the peculiarities of the therapeutic tactics. Indications for various methods of treatment with regard to the classification groups are stated. Long-term results are given.     

Treatment of fractures of long tubular bones associated with cranio-cerebral injuries

Based on an analysis of treatment of 166 patients with fractures of long tubular bones associated with cranio-cerebral trauma the authors discuss tactics of treatment of injuries of the locomotor apparatus. In patients with critical cranio-cerebral traumas at the early period of trauma disease of the brain fractures should be treated by sparing methods, Ilizarov's apparatus included. The operations on the bones should be performed on indications not earlier than 3-4 weeks after trauma.