The role of low-grade infection in the pathogenesis of apparently aseptic tibial shaft nonunion |
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| Institution: | 1. Department of Trauma Surgery, BG Unfallklinik Murnau, Murnau, Germany;2. Institute for Biomechanics, Paracelsus Medical University, Salzburg, Austria;3. Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany;4. Department of Trauma Surgery, University Hospital Zurich, Zurich, Switzerland;1. Department of Emergency Medicine, Mackay Memorial Hospital, Taipei, Taiwan;2. Department of Linguistics, Indiana University, Bloomington, IN, USA;3. Prehospital Emergency Care Center, Mackay Memorial Hospital, Taipei, Taiwan;4. Department of Emergency Medicine, Seoul National University College of Medicine and Hospital, Seoul, South Korea;5. Faculty of Medicine, Universiti Teknologi MARA, Shah Alam, Malaysia;6. Department of Emergency Medicine, National Taiwan University Hospital, Yunlin Branch, Douliu City, Taiwan;7. Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan;1. Department of Orthopedics, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu 610041, People''s Republic of China;2. Department of Orthopaedics, Chongqing General Hospital, Chongqing 400021, People''s Republic of China;3. Department of Radiology, Chongqing Traditional Chinese Medicine Hospital, Chongqing 400022, People''s Republic of China;1. Department of Orthopaedic Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, China;2. Department of Traumatology, Surgical Division, University Medical Centre, Ljubljana, Slovenia;1. Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India;2. Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India;3. Department of Orthopedics, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India;4. Mahatma Gandhi Mission Medical College, Aurangabad, India;5. Department of Orthopedics, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India;1. Department of Orthopaedics and Traumatology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey;2. Department of Orthopaedics and Traumatology, Istanbul Research and Training Hospital University of Health Sciences, Istanbul, Turkey |
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| Abstract: | PurposeAim of this study was to determine the rate of low-grade infection in patients with primarily as aseptic categorized tibial shaft nonunion and lack of clinical signs of infection.MethodsIn a retrospective study between 2006 and 2013, all patients who underwent revision surgery for treatment of tibial shaft nonunion without clinical evidence of infection were assessed. Bacterial cultures harvested during nonunion revision, C-reactive protein (CRP) and/or white blood cell (WBC) values at hospital admission, outcome, and epidemiological data were analyzed.ResultsIn 88 patients with tibial shaft nonunion without any clinical signs of infection, bacterial samples remained negative in 51 patients. In 37 patients, microbiological diagnostic studies after long-term culturing demonstrated positive bacterial cultures whereas after short-term culturing for 2 days only 17 positive cultures were observed. In 12 cases a mixed culture with 2.3 different bacteria on average was detected. Among patients with negative bacterial cultures bone healing was achieved after 13.2 months. Nonunion with positive bacterial cultures required 19 (range 2-42) months until osseous healing (p = 0.009). Furthermore, nonunion with positive bacterial cultures require statistically more surgical revisions to achieve healing (2.9 ± 0.5 vs. 1.3 ± 0.1 additional procedure; (p = 0.003). Hematological studies carried out before surgical intervention did not demonstrate significant differences in CRP values (negative vs. positive cultures: 0.3 (range 0.3-2.8) mg/dl vs. 0.5 (range 0.3-5.7) mg/dl (p = 0.181) and in WBC values (negative vs. positive cultures: 7.4 (range 3.5-11.9) /nl vs. 7.3 (range 3.7-11.1) /nl (p = 0.723). Limitations of this study may include the varying amount of the at least four samples for microbiological diagnostics as well as the circumstance that for diagnosing low-grade infection swabs and tissue samples were included in this evaluation as being equivalent.ConclusionThe pathogenesis of nonunion may originate from low-grade infection even in patients without clinical signs of infection. In addition, nonunion with positive bacterial cultures require statistically more surgical revisions to achieve healing. Therefore, during any revision surgery, multiple bacterial samples are intended to be harvested for long-term culturing. Particularly, in tibial shaft nonunion following Gustilo-Anderson type III open fractures, low-grade infection should be suspected.Trial registration numberDRKS00014657.Date of registration04/26/2018 retrospectively registered |
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