One-stage open cancellous bone grafting of infected fracture and nonunion

Nineteen patients with either infected fractures or nonunions were managed by a one-stage protocol consisting of thorough debridement of the septic focus, followed by stabilization with an external fixator or a cast and fresh autogenous cancellous bone grafting; the wound was then left open. Nineteen fractures were healed and free of infection at an average of 3.5 years follow-up. Some considerations, including debridement, stabilization, bone grafting, and wound coverage, are discussed. Received for publication on Dec. 11, 1997; accepted on June 17, 1998     

Management of infected tibial intramedullary nailing using an organized treatment protocol

Twenty cases of osteomyelitis following intramedullary nailing of the tibial shaft fracture were managed with a prospective treatment protocol comprising intramedullary reaming debridement, antibiotic-bead depot, external skeletal fixation, microvascular muscle flap and early cancellous bone grafting. The follow-up period ranged from 25 to 48 months (average, 34.3 months). Pseudomonas aeruginosa (37.5%) and staphylococcus aureus (20.8%) were the organisms most commonly involved. There were 8 united and 12 ununited fractures after reaming debridement surgery. Nineteen infections were initially arrested by one debridement. One infection was arrested by two sequential debridements. All 12 ununited fractures were stabilized by Hoffmann unilateral external fixation until the fracture healed. The time spent in external fixation ranged from 3 to 7 months (average, 5.2 months). Early cancellous bone grafting was successfully accomplished for 9 ununited fractures with major debridement bone loss. The average union time of the 9 fractures with bone grafting was 7.2 months (range, from 6 to 8 months). We believe that this treatment protocol gives a predictable and rapid recovery. The complications were infection recurrence in two cases at the old tibial shaft fracture sites, minor pin tract infection of Hoffmann external fixators in two cases, and stiffness in two ankles and one knee.     

The treatment of open femoral fractures with bone loss

The results of the treatment of 31 open femoral fractures (29 patients) with significant bone loss in a single trauma unit were reviewed. A protocol of early soft-tissue and bony debridement was followed by skeletal stabilisation using a locked intramedullary nail or a dynamic condylar plate for diaphyseal and metaphyseal fractures respectively. Soft-tissue closure was obtained within 48 hours then followed, if required, by elective bone grafting with or without exchange nailing. The mean time to union was 51 weeks (20 to 156). The time to union and functional outcome were largely dependent upon the location and extent of the bone loss. It was achieved more rapidly in fractures with wedge defects than in those with segmental bone loss. Fractures with metaphyseal defects healed more rapidly than those of comparable size in the diaphysis. Complications were more common in fractures with greater bone loss, and included stiffness of the knee, malunion and limb-length discrepancy. Based on our findings, we have produced an algorithm for the treatment of these injuries. We conclude that satisfactory results can be achieved in most femoral fractures with bone loss using initial debridement and skeletal stabilisation to maintain length, with further procedures as required.     

Unilateral external fixation until healing with the dynamic axial fixator for severe open tibial fractures

One hundred one cases of open tibia fractures were treated until healing with a unilateral external fixation device that permits fracture site compression with weight bearing. There were 38 type II and 63 type III (24 IIIA, 33 IIIB, six IIIC) open fractures. A standard protocol was followed including irrigation and debridement and, when necessary, flap coverage (19 cases) and bone grafting (31 cases). Fixators were applied at the first debridement and removed when the fracture was healed. All patients were permitted early partial weight bearing and progressed to full weight bearing with fixator dynamization. Ninety-six cases healed in the fixator (12-50 weeks; average, 24.6). Three of the five failures were associated with screw complications. Five patients required screw changes and 29 required oral antibiotic therapy for screw complications. Ninety-five percent of healed cases had angulation of less than 10 degrees (in any plane). There were only six fracture site infections during the course of treatment. Dynamic axial fixation may be applied at the first debridement and be used until healing in severe open tibia fractures. Change of the fixator to another treatment method is not required.     

Effect of repeated irrigation and debridement on fracture healing in an animal model.

The initial management of open fractures often requires repeated irrigation and debridement of the open wound and stabilization of the fracture. However, washing out the fracture hematoma could delay the early healing process of stable fractures. Because delayed union and non-union are serious complications, the effect of repeated irrigation and debridement on the fracture healing process was investigated. Twenty-four rabbits received unilateral, transverse. mid-tibial open osteotomies with a 3 mm gap. The osteotomy site was thoroughly irrigated and stabilized with double-bar external fixators. The osteotomy sites in the study groups underwent repeat irrigation and debridement on either the third day (Group II), the fourth day (Group III), or consecutively on the first and second days (Group IV) after the index procedure. The bone healing was assessed with weekly radiographs and peripheral quantitative computerized tomographs. In Group I (control), all osteotomies healed radiographically before the tenth week. In Group II, five out of six osteotomies healed radiographically before the tenth week. In Group III, only two of five osteotomies healed before the tenth week. In Group IV, none of the osteotomies had healed by week fifteen. All of the non-healed osteotomies exhibited atrophic non-unions at fifteen weeks. Compared to the control group at the tenth week, the average bone mineral content at the osteotomy site and the area of high mineral density callus (> or = 890 mg/cm3) were significantly lower in Groups III (63%, p = 0.002 and 95%, p = 0.05, respectively) and IV (99%, p < 0.001 and 100%, p = 0.05, respectively). The results of this study suggest that repeated irrigation and debridement, associated with persistent rigid immobilization, may contribute to the development of delayed unions or atrophic non-unions.     

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.     

Assessment of bone viability in patients with osteomyelitis: preliminary clinical experience with laser Doppler flowmetry.

The intraoperative determination of bone viability is of fundamental importance in the surgical management of osteomyelitis. Recurrent infection will result from inadequate debridement, whereas reconstructive problems will be magnified by overzealous resections. The purpose of this article is to report the use of laser Doppler flowmetry (LDF) as a surgical adjunct allowing quantitative determination of bone viability in patients with osteomyelitis. Twenty-five patients with osteomyelitis underwent surgical debridement using LDF to assist with the intraoperative identification of necrotic bone and have been observed for at least 6 months. The LDF probe is placed directly on the bone and the output signal is channeled into an oscilloscope that calculates and displays the mean value of the signal in millivolts (mV). All patients underwent radical surgical debridement, including hardware removal if present and resection of nonviable bone. Bone debridement was continued when possible until LDF measurements in excess of 100 mV were obtained. Information regarding bone vascularity obtained with the LDF had a direct influence on the extent of bone debridement in all cases. The patients have been observed for an average of 16 months. No complications were associated with the use of LDF. All readings were pulsatile. Five patients had recurrence of infection. The average LDF reading following debridement for patients with recurrent infection was 72 mV, compared to 107 mV for patients without recurrence (p less than or equal to 0.025). All fractures were healed, although some required supplemental surgical management, including bone grafting or external fixation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Immediate autografting of bone in open fractures with bone loss of the hand: a preliminary report. Case reports.

Three patients with open fractures of the hand associated with bone loss were treated within four to six hours of injury by corticocancellous bone grafting and soft tissue coverage after meticulous debridement, copious irrigation of the wounds, and broad-spectrum antibiotics given intravenously. Long term follow-up was uneventful and showed that the graft had taken and healed well with early and full restoration of function and a good cosmetic result. Immediate corticocancellous bone grafting of an injured hand could be used in selected cases with well-debrided, surgically clean wounds as long as there is a rich blood supply. Adequate bone fixation, soft tissue coverage, and broad-spectrum antibiotics given intravenously will remove the risk of infection. Hand architecture is corrected while wound contracture and secondary deformity are avoided. Both patients' discomfort and hospital costs are considerably reduced.     

抗生素骨水泥珠链结合外固定架治疗感染性骨折不愈合

目的：探讨抗生素骨水泥珠链植入结合外固定架固定治疗感染性骨折不愈合的疗效。,方法：回顾分析22例感染性骨折不愈合患者,男20例,女2例;年龄21±74岁,平均（34．7±11．6）岁。骨折部位：股骨粗隆间3例、股骨干6例、股骨髁上2例、胫骨干9例、肱骨干2例。治疗过程分为3个步骤：先取出内固定物,清创后植入抗生素骨水泥珠链,Ⅰ期闭合伤口;1周后再次清创,更换抗生素骨水泥珠链,行外固定架固定;3个月后取出抗生素骨水泥珠链,取髂骨植骨。结果：随访15～28个月,平均（19．98±4．16）个月。1例胫骨干骨折和1例股骨粗隆问骨折患者分别于植骨术后2、3个月感染复发,其余20例患者感染控制良好。22例患者骨折全部愈合,愈合时间为植骨术后8-24周,平均（15．09±4．13）周。结论：彻底清创、抗生素骨水泥珠链植入结合外固定架固定及Ⅱ期植骨是治疗感染性骨折不愈合简单而有效的方法、     

带锁髓内钉治疗下肢骨折的并发症及防治

目的：探讨带锁髓内钉治疗下肢长管状骨骨折的并发症原因，提出防治措施。方法：回顾性分析1998年3月-2004年5月用带锁髓内钉治疗的下肢长管状骨骨折101例，发生并发症共19例。锁钉放置失败3例，正确连接或更新瞄准器；术中新骨折2例，更换或辅以其他内固定；感染2例，足量应用敏感抗生素，创口引流、冲洗；延迟愈合2例，变静力为动力固定；骨不连1例，行拔钉、扩髓、换钉、植骨；再骨折4例，二次手术或制动；锁钉断裂、退出4例，未处置；肢体短缩1例，未处置。结果：锁钉放置失败、术中新骨折、延迟愈合、骨不连、术后再骨折、感染，共14例，均骨愈合。锁钉的断裂、退出4例，未影响骨愈合。肢体短缩1例，未影响骨愈合及正常生活。结论：运用带锁髓内钉治疗下肢长管状骨骨折严格掌握适应证及遵循静力和动力固定原则、彻底清创，是减少并发症的有效措施。     

Treatment of Chronic Osteomyelitis by Free Grafts of Cancellous Autologous Bone Tissue: A Preliminary Report

Chronic osteomyelitis was treated by free grafts of autologous bone tissue in 13 consecutive patients aged 18 to 81 years. In all patients the osteomyelitis was located in the leg, and Staphylococcus aureus was the causative organism. Seven had an infected non-union. The duration of the osteomyelitis varied from less than 1 year to 75 years. Surgical debridement and grafting of cancellous and cortical cancellous bone were performed at the one operation. The osteomyelitis healed after a single operation in all patients but one, who needed three operations before the infection was eradicated. In one patient a second bone grafting operation was necessary before weight-bearing could be allowed. Although the number of patients is small, the results agree well with larger series published recently. Grafting of autologous bone tissue seems to be a very valuable method of treatment for chronic osteomyelitis.     

Pedestrian tibial injuries

From August 1980 through May 1984, 102 adult pedestrian patients with 130 tibial fractures were admitted to the Shock Trauma Center of the Maryland Institute for Emergency Medical Services Systems. We reviewed their records for admission status, procedures performed, and results: 32 patients who died, underwent primary amputation, or were lost to followup were excluded, leaving 70 patients with 86 tibial fractures as the base study group. We grouped the data by year of admission and analyzed it in terms of the effects of changes in the treatment protocol on results, specifically the time to union. For the first year, the existing treatment protocol included: antibiotics, debridement and irrigation with a bulb syringe, stabilization according to wound size and surgeon preference, split-thickness skin graft, and bone grafting in response to delayed or nonunion. The average time to union for Grade III fractures was 58.39 weeks; average time overall was 53.95 weeks. In the fourth year, the altered treatment protocol included: antibiotics, debridement and jet lavage, scheduled rebridement, external fixation for open fractures, judicious use of open reduction/internal fixation for closed fractures, early free flap soft-tissue coverage, and early bone grafting by history and fracture pattern. The average time to union for Grade III fractures was 37.65 weeks; average time overall was 34.46 weeks. From the first to the fourth year, time to union for Grade III fractures decreased by 64.5% and time to union overall decreased by 63.9%. We feel the decrease is a direct result of early bone grafting, the fixator construct used, and judicious use of open reduction/internal fixation.     

骨搬移术中植入硫酸钙对促进对合端愈合的效果观察

目的:探讨骨搬移术中植入硫酸钙能否促进对合端自然愈合的临床疗效.方法:回顾性分析2013年1月至2018年1月采用骨搬移和硫酸钙植入治疗的27例创伤性慢性骨髓炎患者,其中男23例,女4例;年龄20～61(44.30±10.00)岁;病程3～86(13.26±16.47)个月;骨折内固定术后创伤性慢性骨髓炎16例,开放性...     

前后入路一期病灶清除植骨融合内固定治疗胸腰椎脊柱结核

目的探讨胸腰椎脊柱结核通过前后手术入路行病灶清除一期椎间植骨融合、内固定的治疗疗效。方法回顾性分析2006年1月至2011年1月,采用前后路手术入路行病灶清除一期椎间自体髂骨植骨融合、内固定的手术方式治疗胸腰椎脊柱结核患者32例。术前正规抗结核治疗3～5周,其中术中彻底清除病灶组织,对骨质破坏缺损采用自体髂骨植骨同时行前路钉板或钉棒系统内固定21例。采用前路病灶清除自体髂骨植骨后路椎弓内固定系统内固定11例。术后卧床6～8周,继续正规抗结核治疗9～18个月。结果本组32例患者均获得随访,随访时间6～24个月,1例患者出现切口不愈合,其他患者手术切口均一期愈合。术后摄X线片提示植骨及内固定位置良好,Cobb′s角平均14.30°。均获骨性融合,融合时间4～7个月。无内固定松动、脱落、断裂,愈合后Cobb′s角平均15.2°,无明显矫正角度丢失。术前、术后后凸角度的差异有统计学意义(P<0.05),脊髓功能恢复良好。其中合并神经损害20例,按Frankel分级,C级3例中有1例恢复至D级,1例恢复至E级,1例分级无明显变化,D级17例中有12例恢复至E级,5例分级无明显变化。无复发病例。结论前后手术入路病灶清除一期植骨融合、内固定治疗胸腰椎脊柱结核,椎体前方病灶清除、椎管减压彻底,植骨量大,结合有效内固定避免植骨块松动、脱出,植骨融合率高并有效矫正脊柱后凸畸形。     

Immediate internal fixation of high-energy open forearm fractures

Eighteen patients with Gustilo and Anderson Grade III A (7), III B (8) or III C (3) open diaphyseal forearm fractures were treated with a protocol consisting of extensive primary debridement, immediate open reduction, dynamic compression plate fixation, and vascular repair when indicated. This was followed by routine redebridement at 24 to 48-h intervals until wound status allowed completion of soft tissue reconstruction. Bone grafting was performed at 8 to 10 weeks following obtainment of a closed soft tissue envelope for injuries with extensive comminution or bone loss (5 patients, 7 fractures). Subsequent procedures such as tendon transfers, scar revision, joint arthrodesis, or secondary nerve reconstruction were required in 8 of 18 patients. Minor complications related to delayed wound healing occurred in 3 individuals (15%). One deep infection of a fractured radius occurred in a patient with a floating elbow and failed free flap. Salvage with debridement, retention of hardware, and a second free flap resulted in fracture union. One patient required a second bone graft to obtain union of a segmental forearm defect. Amputation was performed in one patient following failed forearm replantation with greater than 8 h warm ischemia time. Immediate debridement and plate fixation of Grade III forearm fractures performed in conjunction with aggressive soft tissue management provided good or excellent results in 12 patients (66%) and is an acceptable treatment alternative in these difficult injuries.     

应用Orthofix重建外固定架治疗骨缺损

目的 总结应用Orthofix重建外固定架分别利用骨运输术、一期清创 短缩肢体 截骨延长技术以及一期清创 短缩肢体 二期截骨延长技术治疗26例骨缺损的经验，探索肢体安全短缩的限度。方法 在患肢上安放Orthofix重建外固定架。对17例胫骨和2例股骨骨缺损5～22cm者行骨运输术。对5例胫骨干骨缺损小于5cm合并皮肤缺损及感染者和1例股骨干骨缺损4cm合并感染者行一期清创 短缩肢体 延长技术进行治疗。对2例胫骨缺损5cm和1例股骨干骨缺损4cm者合并感染的患者采用先一期清创 部分短缩肢体，术后继续短缩肢体，二期截骨延长恢复肢体的长度。截骨术后10～14d开始延长，每天4次，每天延长1mm。16例胫骨和2例股骨在远、近缺损端相遇后于骨缺损端行清创术和自体骨植骨术。结果 平均随访13个月。骨缺损均得以重建，患肢肢体长度完全恢复，骨折愈合，无感染复发。在5例使用一期清创 短缩 延长法的胫骨缺损和1例行一期短缩 延长法的股骨缺损患者中，3例胫骨和1例股骨短缩至4cm时出现血管危象，立即恢复1cm长度后肢体远端血运恢复。术后第3天开始继续短缩肢体，每天4mm，每天4次。1例术后出现腓总神经麻痹，术后2个月恢复。4例胫骨缺损患者诉膝部疼痛。3例胫骨缺损患者出现马蹄内翻足。2例胫骨缺损患者出现下胫腓分离。结论 应用Orthofix重建外固定架进行骨运输是治疗骨缺损的有效方法，谨慎使用短缩 延长技术。对于软组织有损伤的肢体一期短缩不应超过3cm，可以于术后第2天开始继续短缩，每天短缩4mm，每天4次，每次1mm。     

Early prophylactic autogenous bone grafting in type III open tibial fractures

The authors report the results achieved in patients with type III open tibial fractures who underwent primary autogenous bone grafting at the time of debridement and skeletal stabilisation. Twenty patients with a mean age of 35.8 years (range, 24-55) were treated between 1996 and 1999. Eight fractures were type IIIA, 11 were type IIIB, and 1 was type IIIC. At the index procedure, wound debridement, external fixation and autogenous bone grafting with bone coverage were achieved. The mean follow-up period was 46 months (range, 34-55). The mean time to fixator removal was 21 weeks (range, 14-35), and the mean time to union was 28 weeks (range, 19-45). Skin coverage was achieved by a myocutaneous flap in 2 patients, late primary closure in 4, and split skin grafting in 14. One (5%) of the patients experienced delayed union, and 1 (5%) developed infection. In tibial type III open fractures, skin coverage may be delayed, using the surrounding soft tissue to cover any exposed bone after thorough débridement and wound cleansing. Primary prophylactic bone grafting performed at the same time reduces the rate of delayed union, shortens the time to union, and does not increase the infection rate.     

Management of Periprosthetic Femur Fractures With Severe Bone Loss Using Impaction Bone Grafting Technique

We present a technique of femoral impaction grafting used for the treatment of periprosthetic femur fractures with severe bone loss after total hip arthroplasty. Seven patients with femoral fractures with compromise of the femoral isthmus were treated with femoral component revision using the impaction grafting bone technique. The average age was 64 years (range, 44-72 years), and 2 patients required mesh augmentation at the time of surgery. The average follow-up for this group of patients was 56 months (range, 39-92 months). Radiographic evaluation revealed healed fractures in all patients and no evidence of implant loosening at a mean of 56 months (range, 39-92 months). There were no cases of infections or dislocations in this series. Impaction grafting technique can be useful in the treatment of periprosthetic femur fractures when bone loss and canal geometry preclude the use of fully coated femoral components.     

开放植骨治疗感染性骨折不愈合

目的介绍开放植骨治疗感染性骨折不愈合的手术方法,总结疗效,探讨提高治疗成功率的因素。方法126例感染性骨折不愈合或骨缺损患者,男98例,女28例;年龄15～71岁,平均35岁。胫骨骨折96例,股骨骨折12例,肱骨骨折5例,尺骨骨折6例,桡骨骨折2例,尺桡骨双骨折5例。骨缺损1.5～6.5cm,平均3.5cm。患处彻底清创,切除失活的软组织和骨组织,直至骨折端点状出血。对于轻度骨质疏松、稳定性骨折且预期病程短者可使用双臂单边单平面外固定架;对于明显骨质疏松、不稳定性骨折和(或)预期病程长者使用单臂双平面外固定架;对于严重骨质疏松者,使用单臂双平面外固定架固定并辅以石膏托外固定;邻近关节骨折,可考虑跨关节外固定架和(或)石膏固定。一期或择期植入带皮质的自体松质骨骨条,直径<5mm,开放伤口。术后严格无菌换药。静脉滴注敏感抗生素,平均用药11d。结果平均随访2.4年(8个月～4.5年)。术后平均8周移植骨质表面覆盖肉芽组织,14例于术后5周行游离植皮闭合创面,112例于术后平均10周瘢痕自行愈合。123例骨折于术后平均7个月愈合,9个月去除外固定;3例骨折未愈合。4例出现窦道,2例感染复发。结论开放植骨术是治疗感染性骨折不愈合和骨缺损的简单、积极而有效的方法。与传统方法相比,疗程缩短,手术次数减少。感染并非植骨     

儿童足踝部开放性损伤的处理

 目的 探讨儿童足踝部开放性损伤的特点、治疗方法及临床疗效。方法 回顾性分析2004年2月至2010年6月收治的35例足踝部损伤的病历资料,男22例,女13例;年龄3~14岁,平均8.4岁。交通伤28例,利器切割及机器辗绞伤7例。左18例,右17例,均为单侧;前中足5例,后足及踝部30例。其中合并骨折30例。按照Gustilo分型,Ⅰ型5例、Ⅱ型8例、Ⅲ型22例。Ⅰ型、Ⅱ型及早期收治的10例Ⅲ型病例在急诊行清创缝合或(和)骨折复位内固定术+皮瓣移植术;后期收治的12例Ⅲ型病例一期行清创、闭式负压引流术+石膏外固定或克氏针临时固定,二期行骨折复位(伴或不伴植骨)内固定+皮瓣移植术。结果 30例患儿获得随访,随访时间6~89个月,平均38.7月。2例Ⅱ型患儿术后伤口皮肤局部坏死,行植皮术愈合;10例Ⅲ型患儿一期行急诊手术,手术次数2~6次,平均3.6次;创面愈合时间3~15周,平均8.3周。1例出现慢性骨髓炎,窦道残留,经多次病灶清除植骨后痊愈; 2例足踝及小腿外侧肌肉坏死行皮瓣移植,术后3年因瘢痕组织挛缩出现足踝部内翻畸形,行外固定架矫形后正常行走。12例行分期治疗的Ⅲ型患儿皮瓣均存活,色泽及弹性良好,愈合时间3~8周,平均6.8周。伴发足踝部骨折者骨折愈合良好。按Maryland标准评分[1],优17 足、良9足、中3例、差1例,优良率为86.7%。结论 儿童足踝部创伤以车祸伤为多见;按损伤程度分级分期治疗可取得较好临床疗效。