Extract
Open fractures are associated with an increased risk of infection and
healing complications. Management of open fractures is based on the following
principles: assessment of the patient, classification of the injury,
antibiotic therapy, débridement and wound management, fracture
stabilization, early bone-grafting, and supplemental procedures to achieve
healing.
Open fractures are associated with an increased risk of infection and
healing complications. Management of open fractures is based on the following
principles: assessment of the patient, classification of the injury,
antibiotic therapy, débridement and wound management, fracture
stabilization, early bone-grafting, and supplemental procedures to achieve
healing.
Open fractures are usually the result of high-energy trauma and should
alert the treating physician to the possibility of associated injuries.
Therefore, detailed evaluation and appropriate resuscitation of the patient
are necessary. The neurovascular status of the injured extremity should be
carefully assessed, and the development of compartment syndrome should not be
overlooked1. The
soft-tissue injury should be evaluated to determine the size and location of
the wound, the degree of muscle damage, and the presence of contamination.
The Gustilo and Anderson classification
system2, which was
subsequently modified by Gustilo et
al.3, is used widely
to grade open fractures. In this system, type I indicates a puncture wound of
=1 cm with minimal contamination or muscle crushing. Type II indicates a
laceration of >1 cm in length with moderate soft-tissue damage and
crushing; bone coverage is adequate and comminution is minimal. A type-IIIA
open fracture involves extensive soft-tissue damage, often due to a
high-energy injury with a severe crushing component. Massively contaminated
wounds and severely comminuted or segmental fractures are included in this
subtype. Soft-tissue coverage of the bone is adequate. Type IIIB indicates
extensive soft-tissue damage with periosteal stripping and bone exposure,
usually with severe contamination and bone comminution. Flap coverage is
required to provide soft-tissue coverage. A type-IIIC fracture is associated
with an arterial injury requiring repair.
The reliability of this classification has been questioned. In a study in
which orthopaedic surgeons had been asked to classify open fractures of the
tibia on the basis of videotaped case presentations, the average agreement
among the observers was 60% overall, which was deemed to be moderate to
poor4. Therefore,
classification of the open fracture should be done only in the operating room,
after wound exploration and débridement. The degree of contamination
and soft-tissue crushing are important factors in the classification of an
open fracture, but they may be mistakenly overlooked in a wound of small
size.
As most open fractures are contaminated with microorganisms, antibiotics
are used not for prophylaxis but rather to treat wound contamination. To
prevent a clinical infection, immediate antibiotic administration, wound
débridement, soft-tissue coverage, and fracture stabilization are
necessary. Tetanus prophylaxis may be necessary, depending on the patient's
immunization status. The risk of a clinical infection depends on the severity
of the injury and ranges from 0% to 2% for type-I open fractures, 2% to 10%
for type-II, and 10% to 50% for type-III.
The rate of infection of open fractures is associated with the fracture
characteristics, antibiotic therapy variables, and host
parameters5,6.
Infection rates progressively increased from 1.4% (seven of 497) for type-I
open fractures to 3.6% (twenty-five of 695) for type-II open fractures to
22.7% (forty-five of 198) for
type-III5. The
location of the fracture is also important, with the infection rate for open
tibial fractures being twice that for open fractures in other
locations5.
The administration of antibiotics before débridement decreased the
infection rate (two of eighty-four fractures) compared with that found when no
antibiotics had been given (eleven of seventy-nine
fractures)7. The
antibiotics should cover both gram-positive and gram-negative organisms, and
they should be given as soon as possible, preferably within three hours after
the injury5. The
duration of antibiotic therapy, the time between the injury and the surgery,
and the type of wound closure do not seem to be significant
variables5,8.
Even though the infection rates associated with primary and secondary
closure are the same, gas gangrene may occur after primary closure of wounds
contaminated with clostridial organisms. The partial closure technique, in
which the traumatic wound is left open and the surgical extension of the wound
is closed (Figs. 1-A,
1-B,
1-C,
1-D and 1-E,
1-F and 1-G), is recommended
for type-I and II open
fractures9.
The usefulness of cultures of wound specimens is controversial, since they
often fail to identify the organism that subsequently causes the
infection10-12.
Cultures of wound specimens obtained prior to wound débridement are no
longer recommended because of their poor predictive value. However, the
results of cultures of post-débridement specimens and sensitivity
testing may help in the selection of the best agents for subsequent procedures
or in the treatment of an early infection.
Although some authors have recommended cephalosporin as a single agent for
patients with a type-I or II open fracture, the antibiotic therapy should
target both the gram-positive and the gram-negative pathogens contaminating
the wound13. A
commonly used regimen consists of a first-generation cephalosporin (e.g.,
cefazolin), which is active against gram-positive organisms, combined with an
aminoglycoside (e.g., gentamicin or tobramycin), which is active against
gram-negative organisms. Substitutes for aminoglycosides include
quinolones10,
aztreonam, third-generation cephalosporins, or other antibiotics with
gram-negative coverage. Systemic administration of aminoglycosides may not be
necessary if aminoglycoside-impregnated beads are used for local antibiotic
delivery.
Clostridial myonecrosis (gas gangrene) is a particular concern when an
injury is contaminated with anaerobic organisms (e.g., farm injuries) or there
is a vascular injury that may create conditions of ischemia and low oxygen
tension14.
Therefore, in such cases, ampicillin or penicillin should be added to the
antibiotic regimen to provide coverage against anaerobes.
Antibiotic administration should be started promptly, as a delay of more
than three hours has been shown to increase the risk of
infection5. The
recommended duration of therapy is three
days5,13,15.
An additional three days of administration of antibiotics—selected on
the basis of the results of initial cultures—is recommended for
subsequent surgical procedures, such as wound coverage and bone-grafting.
Local therapy with antibiotic-impregnated polymethylmethacrylate cement has
been used as an adjunct to systemic antibiotic therapy in the treatment of
open fractures (Figs. 2-A and
2-B) and has been shown to
reduce the infection rate. Ostermann et
al.16 reported an
infection rate of 3.7% in a group that received combined treatment with both
systemic antibiotics and antibiotic beads. This rate was considerably lower
than the 12% infection rate associated with open fractures treated with
systemic antibiotics alone.
The polymethylmethacrylate powder is mixed with the antibiotic in powder
form, is polymerized, and then is formed into beads, which are incorporated on
a 24-gauge wire; usually 3.6 g of tobramycin is mixed with 40 g of
polymethylmethacrylate
cement17.
Aminoglycosides are common choices for the antibiotic because of their broad
spectrum of activity, heat stability, and low allergenicity. Vancomycin is not
recommended as an initial agent because of concerns of overuse leading to
development of resistant microorganisms.
The bead-pouch technique achieves a high local concentration of
antibiotics; minimizes systemic toxicity; and seals the wound from the
external environment with a semipermeable barrier, thereby preventing
secondary contamination by nosocomial pathogens and at the same time
maintaining an aerobic wound environment.
Open fractures are always associated with a soft-tissue injury, and they
can be thought of as a soft-tissue injury that includes a fracture. The
management of both the bone and the soft tissues is the major determinant of
fracture-healing and functional restoration of the traumatized extremity. An
integrated approach, the so-called orthoplastic approach, takes into account
the importance of early and definitive treatment of both aspects of the
injury18. Important
issues related to management of the fracture include when to provide coverage,
how coverage should be provided, who should provide coverage, and where
coverage should be provided.
Mechanisms of injury include electrical burns, crushing, avulsion, blasts,
and degloving19.
Management of these injuries requires an understanding of the personalities of
soft-tissue injuries, which helps to guide decision-making. For example,
soft-tissue degloving, which is frequently seen in deceleration injuries,
particularly in elderly individuals, often results in avulsion of perforating
vessels to the overlying
skin20. This is
commonly seen in the pelvis, where it is called a Morel-Lavallée
lesion. The same pathological entity is found in the extremities and can
progress to necrosis of the skin envelope with exposure of hardware and
bone21.
It is vital to recognize that, in addition to the variety of mechanisms
that can cause an acute soft-tissue injury, a variety of underlying
morbidities can be associated with an open fracture. These include diabetes
mellitus22,
peripheral vascular disease, collagen vascular disease and chronic venous
insufficiency with underlying venous stasis, immunocompromise, previous
fractures or surgical incisions, and nutritional deficiencies.
Appropriate débridement is
critical23. A
tourniquet should be used during the débridement to distinguish
blood-stained tissue from normal tissue, as local hemorrhage obscures debris
and dirt that must be
removed24. Loop
magnification may be needed. Sharp débridement is essential, and it
should be done in a centripetal fashion. Liberal use of fasciotomies
facilitates wound inspection and releases compromised muscle compartments.
Radical excision of necrotic tissue, as proposed by Godina, should be
performed so that all nonviable tissue including bone is
removed25. The
wound should look healthy and, when there is doubt, all questionable tissue
should be removed.
New techniques for débridement such as use of the Versajet device
(Smith and Nephew, Memphis, Tennessee) have shown the benefit of reducing
tissue loss during initial or second-look procedures. Usually, coverage should
be obtained with one or two formal débridements; if more
débridements are required, then radical débridement has not been
performed.
After débridement, one must decide if the soft-tissue deficiency
associated with the open fracture can be managed by the orthopaedic
traumatologist26.
If not, it is essential that a microvascular surgeon be consulted as soon as
possible. If the local surgical community cannot handle the soft-tissue
problem, then the patient should be referred to another institution as soon as
possible for definitive wound coverage.
Vascularity is the single most important determinant of complications after
an open fracture. Vascularity includes arterial, venous, and lymphatic
conduits. Knowledge of the angiosomes helps the surgeons to avoid improper
placement of incisions and surgical approaches that can further compromise
watershed areas, leading to soft-tissue necrosis following open reduction and
external
fixation27. The
concept of perforators must be understood as
well28. These are
side branches from the main arterial vessels that give rise to skin
angiosomes. Tissue necrosis is the result of compromised perforators and the
watershed areas lying between angiosomes.
Evaluation of the blood supply in skin includes hands-on examination as
well as palpation of pulses and appreciation of temperature differences along
cutaneous surfaces. Skin that has venous discoloration suggests venous
insufficiency, whereas slow refill indicates an arterial-side insufficiency.
Doppler examinations, formal arteriography, digital subtraction arteriography,
and at times venography are important ways to ascertain the vascular status of
an extremity. Without an anterior tibial
artery29,
anterolateral skin territories may be compromised and incisions in this region
should be avoided.
A soft-tissue-closure plan must be formulated during the initial wound
assessment and the initial fixation of fractures. This is not a consecutive
process, nor does planning occur after skeletal fixation. There are multiple
options for the treatment of the wound prior to closure; these include the
placement of antibiotic beads, and recently the wound VAC (vacuum-assisted
closure) (KCI, San Antonio, Texas) has been used as a bridging technique
before definitive coverage takes place several days later. Other techniques
that can be used prior to closure include the application of Epigard
(Parke-Davis, Detroit,
Michigan)27 or
Adaptic gauze (Johnson and Johnson, Raynham, Massachusetts) over the wound,
porcine allograft, or antibiotic beads. The goals of wound coverage are to
prevent desiccation of tissue, optimize antibiotic delivery, optimize patient
comfort, and seal the wound from the external environment. At the same time as
débridement or initial fracture management is performed, tetanus toxoid
prophylaxis, as indicated, and the appropriate antibiotics should be
administered. Incisions that have been used to extend the initial wounds can
be closed to decrease the exposure of deeper
tissues9,30.
Open fractures should never be closed primarily because of the risk of gas
gangrene. While microsurgeons are able to do an immediate free tissue
transfer31, this
method remains controversial. In our opinion, there is no rationale for
performing definitive closur immediately; returning to the operating room in
twenty-four to forty-eight hours is a time-tested method, and the data
reported by Godina do not indicate a difference between wounds closed at the
first operative setting and those closed seventy-two hours
later25.
The majority of open wounds can be covered with split-thickness skin
grafts. Local or regional flaps may involve more morbidity because transposed
skin flaps or muscles may be compromised, particularly in high-energy
injuries, and free tissue transfer may be more reliable. Free tissue transfer
is often the most definitive form of treatment.
Stabilizing the open fracture protects the soft tissues from further injury
by fracture fragments, facilitates the host response to microbes despite the
presence of
implants32,
improves wound care, and allows early motion of adjacent joints and early
mobilization of the patient.
The choice of fracture fixation depends on the bone that is fractured, the
location of the fracture (intra-articular, metaphyseal, or diaphyseal), the
extent of soft-tissue injury and contamination, and the physiologic status of
the patient. Fixation can be definitive or provisional, and techniques include
intramedullary nailing, external fixation, and plate fixation. More than one
technique may be applicable to a specific injury.
Intramedullary nailing is widely used for stabilization of diaphyseal
fractures of the lower
extremity33-35.
External fixation is indicated for fractures associated with extensive
contamination and soft-tissue damage and when there is a need for rapid
fracture stabilization or minimal interference with the patient's physiologic
response to the injury (so-called damage
control)36, as in
the case of a type-IIIC fracture in a multiply injured patient whose condition
is unstable. Plate fixation is indicated for periarticular fractures and for
diaphyseal fractures of the upper extremity.
The method of stabilizing an open tibial diaphyseal fracture is
controversial. Both unreamed intramedullary nailing and external fixation have
been used successfully in the management of open tibial fractures. In two
prospective, randomized studies comparing the two techniques, half-pin
external fixators were associated with malalignment in 31% of the cases, and
with pin-track infection in
50%34, but there
were no differences in fracture-site infection and bone-healing rates between
the two
methods34,35.
The severity of the soft-tissue injury rather than the choice of implant
appeared to be the main factor influencing infection and
bone-healing34. A
meta-analysis of the management of open tibial fractures demonstrated that
unreamed intramedullary nailing reduced the risks of a reoperation, malunion,
and superficial infection compared with the risks associated with external
fixators37.
Intramedullary nailing does not require the same high level of patient
compliance, but an external fixator may be particularly useful for patients
with vascular injury or extensive soft-tissue damage and contamination.
The endosteal blood supply is preserved to a greater degree with unreamed
nailing than it is with reamed
nailing34,35,38-40.
Thus, unreamed nailing may be preferable to reamed nailing for open tibial
fractures, where periosteal vascularity may be already compromised by the
traumatic insult. Reamed nailing, on the other hand, allows insertion of
larger-diameter implants, improves stability at the fracture site, and helps
reduce the implant failure rate. Moreover, the cortical circulation that is
disrupted during reaming is gradually reconstituted, although this may occur
more slowly than it does with unreamed
nailing39.
Reamed nailing of open tibial fractures was compared with unreamed nailing
in two prospective, randomized
studies41,42.
Neither established a significant difference in infection rates (one of forty
and one of twenty-six with unreamed nailing compared with two of forty-five
and one of nineteen with reamed nailing). There were fewer screw failures in
the reamed-nailing group in both studies.
Some complications associated with external fixation are due to the
transition to another form of fixation, and external fixation can be
successfully used as definitive
treatment43-45.
In a prospective study of 101 type-II and III fractures treated with external
fixation, Marsh et al. reported that ninety-six fractures
healed45. There
were six fracture-site infections. Early bone-grafting of fractures with bone
defects treated with external fixation reduces healing
complications46.
Delayed conversion of external fixation to intramedullary nailing can
increase the prevalence of infection to as high as
50%12,47.
On the other hand, Blachut et al. showed that early conversion of the fixator
to a nail (at a mean of seventeen days) in the absence of pin-track infection
was associated with an infection rate of only
5%48. Conversion to
an intramedullary nail can be done safely if the fixator had been in place for
a short period of time and in the absence of pin-track infection. Otherwise,
the fixator should be maintained until the fracture heals.
Reamed intramedullary nailing is the preferred fixation technique for open
diaphyseal femoral fractures, but external fixation for provisional fracture
stabilization is an option in unstable
patients49-51.
Brumback et al. found no infections after the treatment of sixty-two type-I,
II, and IIIA open femoral fractures with reamed intramedullary nailing and
only three infections (11%) after such treatment of twenty-seven type-IIIB
open femoral
fractures33.
Plate fixation is the preferred method of treatment of open forearm and
humeral
fractures52-54.
Intramedullary nailing is an option for open diaphyseal fractures of the
humerus, but there are concerns regarding shoulder pain and stiffness.
External fixation can be useful in the presence of severe soft-tissue injury
and
contamination55,56.
One option for managing open periarticular fractures is provisional
spanning external fixation (with the addition of limited internal fixation
with screws to restore articular congruency in intra-articular fractures) with
plate fixation performed
later57.
Alternatively, these fractures can be treated definitively with use of either
a ring fine-wire fixator (with limited internal fixation if
needed)58,59
or plate
fixation60. The
development of locking plates and minimally invasive osteosynthesis techniques
have shown promise
recently61,62.
Open fractures associated with a vascular injury require special
considerations. The order of fracture fixation and arterial repair is
controversial. Available options include (1) fracture fixation first followed
by arterial
repair63, (2)
arterial repair first followed by fracture
fixation64, and (3)
use of an arterial intraluminal
shunt65.
Decision-making depends on an individualized assessment of the characteristics
of each case in consultation with the vascular surgeon. Important factors to
be considered are the ischemia time that has already elapsed (muscle will not
tolerate ischemia for more than six hours) and the complexity of the fracture
pattern (definitive fixation may be time-consuming).
Bone-grafting can help in fracture repair or the reconstruction of skeletal
defects. The basic types of bone grafts used in fracture treatment are
autogenous cancellous bone, autogenous cortical bone, vascularized
corticocancellous bone, and bone-graft substitutes. Autogenous cancellous bone
is the gold standard for providing osteoconduction, osteoinduction, and
osteogenesis. This bone delivers an osteoconductive matrix made of both
hydroxyapatite and collagen. Furthermore, it delivers an abundance of growth
factors as well as stromal cells to the fracture site. It has the obvious
advantage of histocompatibility and it revascularizes quickly, but it lacks
structural
integrity66. In
1952, Marshall Urist showed that structural integrity becomes normal at
approximately one
year67. The limited
quantity of autogenous cancellous bone available and donor site morbidity are
disadvantages. In order to improve osteocyte survival when obtaining
autogenous cancellous bone, the surgeon should keep the donor cells moist and
chilled in a blood-soaked sponge.
Vascularized corticocancellous grafts provide excellent osteoconduction,
osteoinduction, and stromal cells to the fracture site. These grafts have the
advantage of providing good structural integrity, and they can be used in
defects of >6 cm in size. They usually consist of vascularized fibular or
iliac crest grafts that maintain the viability of the bone cells while not
undergoing extensive resorption; they also provide new blood supply to the
fracture
site68.
Allografts, bone-graft substitutes, ceramics, demineralized bone matrix,
bone marrow, and composite grafts are often used in closed fractures, but they
are less useful in open fractures because of the decreased vascularity and the
contamination often seen in these complex fractures.
The timing of bone-grafting is important, particularly for open fractures.
Bone-grafting is usually not performed at the initial open reduction and
internal fixation procedure, except when the surgeon is dealing with
intraarticular defects. In Gustilo Anderson type-I and II open fractures,
bone-grafting can usually be performed safely at the time of the delayed
primary closure. In type-III fractures, bone-grafting should be performed only
after successful closure, usually at six to nine weeks after the
injury12.
Electrical stimulation of the bone can be accomplished with three clinical
modalities: direct-current stimulation (implanted electrodes); electromagnetic
stimulation by inductive coupling, with time-varying magnetic fields
(non-invasive); and capacitive coupling stimulation with external electrodes
(noninvasive). A double-blinded, randomized clinical study of the use of
pulsed electromagnetic fields on delayed tibial unions demonstrated a 45%
union rate compared with a 14% union rate with use of a placebo
device69. In
another study, involving capacitively coupled electromagnetic fields, Scott
and King reported a 60% success rate at twenty-one weeks compared with a 0%
success rate with a
placebo70. Brighton
et al. compared 167 fractures treated with direct current with fifty-six
treated with capacitively coupled electrical current and with forty-eight
treated with conventional
bone-grafting71.
There were no significant differences among the three groups. As the number of
risk factors such as open fracture, cigarette smoking, and peripheral vascular
disease increased, the healing rate decreased in all three groups in this
unblinded study. Electrical stimulation plays a role in promoting
bone-healing, and probably works as well as conventional bone-grafting, but
its effects are directly affected by the local and systemic host biology, a
situation similar to that seen with bone-grafting.
Over the last fifty years, ultrasound has also been studied in relation to
the stimulation of bone
callus72. In a
prospective, randomized trial of closed and type-I open tibial fractures
treated with low-intensity ultrasound (30 mW/cm2 for twenty minutes
per day), the time to healing was reduced by
24%73,74.
Other studies have also demonstrated
benefits75,76.
In 1965, Urist reported his discovery of bone morphogenetic protein (BMP)
in bone matrix, which is responsible for
osteoinduction77.
Subsequently, sixteen different proteins (BMP-1 through BMP-16) have been
identified in bone matrix. All of these, except BMP-1, are in the family of
transforming growth factor-ß (TGF-ß). Furthermore, all play a role
during embryogenesis and tissue repair in postnatal
life78-84.
It is believed that osteoinduction is mediated by BMP-2 through BMP-7 and
BMP-9, which provide primordial signals for the differentiation of mesenchymal
stem cells into
osteoblasts85.
BMP-2, BMP-6, and BMP-9 have all been shown to be more effective when
pluripotent cells are present.
Clinical research has revealed that recombinant BMP (rhBMP) can be utilized
successfully as a supplemental agent to achieve bone-healing. In the BESTT
study, rhBMP-2 was utilized in an open-fracture
setting86. One
hundred and forty-seven fractures were treated with open reduction and
internal fixation without the use of rh-BMP, while 145 open tibial fractures
were treated with open reduction and internal fixation with the addition of
either 0.75 mg/mL of rhBMP-2 or 1.50 mg/mL of rhBMP-2. The group treated with
1.50 mg/mL of BMP-2 had a 44% reduction in the need for secondary intervention
compared with the control group. A Canadian study of 124 open tibial fractures
randomized either to receive rhBMP-7 or to a control group demonstrated that
rhBMP-7 therapy reduced the need for secondary intervention from 27% to
12%87. In another
study, rhBMP-7 bound to type-1 collagen was compared with conventional
autogenous bone-grafting for the treatment of tibial
nonunions88.
Similar union rates were found, both clinically and radiographically.
In summary, the use of rhBMP therapy as a supplemental procedure to achieve
bone-healing is safe and effective as a treatment of delayed union or nonunion
of fractures and it is probably equivalent to autogenous bone-grafting. There
is no conclusive evidence that the use of rhBMP in fresh fractures will
increase the healing
rate89. Problems
encountered with the use of rhBMP are its short biologic half-life and
difficulties in retaining the product at the fracture site. Often, a large
bolus dose is required, and the release of growth factors is not uniform.
Finally, the high cost of rhBMP is a factor that limits its use.
In the future, gene transfer therapy may be used to deliver growth factors
to the fracture site. Osteogenic proteins can be encoded directly to the
fracture site, allowing a sustained local concentration and dose of growth
factors. Furthermore, endogenous synthesized proteins are more effective than
recombinant synthesized proteins, and the in vivo transfer is minimally
invasive and less expensive than rhBMP therapy. Investigators have utilized a
direct percutaneous gene-delivery technique to enhance the healing of
segmental bone defects in a rat
model90. The
genetically modified osteoprogenitor cells were delivered directly to the
segmental bone defects with a single intralesional injection of adenovirus
carrying BMP-2. At eight weeks, the osseous union rate was 75% in the treated
animals compared with 4% in control animals. The authors showed that a single
percutaneous injection of Ad-BMP-2 can induce healing of critical-size defects
in rats at eight weeks and that the tissue repair is by trabecular bone with
normal mineral content.
Although the use of gene transfer therapy is an exciting possibility for
the future enhancement of fracture-healing, there remain considerable safety
concerns regarding the injection of adenovirus with osteoinduction genes and
the fear of transgenic
expression91.
Management of chronic osteomyelitis with a limb-salvage protocol consists
of débridement, systemic and local antibiotic treatment, skeletal
stabilization, soft-tissue coverage, and bone-grafting and/or reconstructive
procedures for treatment of ununited fractures and existing bone defects.
These principles can be incorporated in a staged protocol, often implemented
by a multidisciplinary team consisting of an orthopaedic surgeon, an
infectious disease specialist, and a microvascular surgeon.
When there is an infection, several factors must be evaluated carefully to
develop a detailed management plan. Imaging studies should be reviewed to
assess the status of bone-healing, the location and extent of cortical and
medullary bone involvement, and the status and integrity of existing implants.
The quality and integrity of the soft-tissue envelope, and the need for flap
coverage, should be evaluated. The neurovascular status of the extremity
should be determined. Cultures and sensitivity tests allow the selection of
appropriate antibiotics for local delivery with antibiotic beads and for
systemic therapy. Subsequent cultures of intraoperative specimens should be
performed, and the results may indicate that a different antibiotic is
required. The medical status of the patient should be assessed to ensure that
it allows the safe execution of a complex reconstructive plan. Interventions,
such as nutritional support and cessation of smoking, will help to optimize
the patient's condition before surgery.
Radical débridement of all nonviable tissue, including skin, soft
tissue, and bone, is necessary. Débridement proceeds until bleeding,
viable tissue is seen at the resection margins, to ensure that all foci of
infection are
removed92,93.
Viable bone is characterized by punctuate bleeding, known as the
"paprika sign." Débridement should not be limited by
concerns about the osseous or soft-tissue defects. Specimens of purulent
fluid, soft tissue, and bone from the affected area should be sent for aerobic
and anaerobic cultures; it is especially important to perform cultures for
mycobacteria and fungi when the patient is immunocompromised or has a chronic
infection92,94.
The wound should be irrigated with a copious amount of saline solution, and
antibiotics may be added to the terminal liter of the irrigation fluid.
The dead space that results from débridement is filled with
physicianmade polymethylmethacrylate antibiotic-impregnated beads. The
pathogen must be susceptible to the eluted antibiotic. If wound closure is not
possible, the wound containing antibiotic beads is sealed with a semipermeable
membrane so that the eluted antibiotic(s) remain in the involved area to
achieve a high local
concentration17.
When a nonunion is associated with infection, subsequent procedures for
wound management and bone-grafting are planned and the beads can be removed at
that time. In the future, biodegradable delivery systems will eliminate the
need for this surgical
removal95.
The type of systemic antibiotic therapy is chosen on the basis of the
results of the preoperative cultures, but it can be modified on the basis of
the results of the intraoperative culture and sensitivity tests.
Administration of antibiotics is a key part of the management, but it will
fail without adequate débridement. Intravenous antibiotics are
generally given for four to six
weeks96. While
antibiotic-resistant organisms are a problem, vancomycin is useful for
oxacillin-resistant Staphylococcus aureus infections, and the
recently introduced antibiotics linezolid and quinupristin/dalfopristin have
been used for oxacillin-resistant Staphylococcus aureus and
vancomycin-resistant enterococcus
infections97.
The decision to retain or remove implants from the site of an infected
fracture must be individualized and depends on the time since the fracture
fixation, bone-healing status, stability provided by the hardware, and
fracture
location92. If the
fracture has healed, the internal fixation device should be removed. When the
fracture has not healed, the internal fixation device should be left in place
as long as it is stabilizing the fracture. Loose hardware that is not
providing stability should be removed. If the fracture has not healed and the
hardware is removed, the fracture should be stabilized with another device;
our preference is to use an external fixator for diaphyseal nonunions of the
tibia and an intramedullary rod for diaphyseal nonunions of the femur.
In cases with an adequate soft-tissue envelope, delayed or primary closure
can be performed depending on the extent of the infection. If soft tissues are
compromised, coverage should be achieved with local or free muscle flaps.
Soft-tissue coverage is usually performed at three to seven days after the
initial
débridement98-100.
The staged coverage allows the treatment of organisms with specific
antibiotics based on the results of cultures of deep-tissue specimens taken
during the first débridement and permits a repeat débridement
prior to flap transfer.
Autogenous iliac crest bone graft can be used to manage bone defects up to
6 cm in size. Bone-grafting techniques for the tibia include anterior,
posterolateral, and free vascularized grafting of the defect
site98,101-103.
Bone-grafting is performed when the soft-tissue envelope has healed, flap
viability has been determined, and infection has been controlled, usually six
to eight weeks after the muscle transfer or when the soft tissues are
healed92. For
anterior tibial defects and most nonunions, the muscle flap is elevated and
the graft is placed at the nonunion or defect site. Posterolateral
bone-grafting is an alternative if infection control has been established (on
the basis of no anterior sequestra and no need for anterior
débridement), there is no anterior defect, and there is no need for a
soft-tissue transfer.
Bone defects longer than 6 cm require specialized reconstructive
procedures, such as vascularized bone-grafting or distraction osteogenesis.
The free vascularized fibular graft is a versatile flap that, in addition to
bone, can include muscle, skin, and
fascia104. It is
particularly useful for combined bone and soft-tissue defects and in patients
opposed to having an external fixator. Distraction osteogenesis is a useful
method for reconstruction of infected bone defects and for correction of
malalignment and large limb-length
discrepancies105.
Limb salvage based on the described principles can be achieved with
eradication of infection and osseous union in 67% to 100% of
cases99,106-109.
Siegel et al. reported that, at a mean of 5.1 years postoperatively, limb
salvage had been accomplished in all of forty-six patients with chronic tibial
osteomyelitis and all but two had clinical and radiographic evidence of
union109.
Thirty-nine patients were able to walk independently, whereas the others used
assistive devices. Thirty-eight of forty-two patients who had been working
were able to return to work within six months after union, and twenty-three of
thirty-seven patients who had been participating in recreational and sports
activities were able to resume those activities. Smoking, advanced age, and
intra-articular involvement were found to adversely affect the outcome.
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the tibia is challenging; however, infection control, osseous union, and a
satisfactory functional outcome can be achieved with use of the aforementioned
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