LOWER LIMB
Management of infected nonunion of the long bones by a multidisciplinary team
D. Bose, R. Kugan, D. Stubbs, M. McNally From Nuffield Orthopaedic Centre, Headington, Oxford, United Kingdom
Infected nonunion of a long bone continues to present difficulties in management. In addition to treating the infection, it is necessary to establish bony stability, encourage fracture union and reconstruct the soft-tissue envelope. We present a series of 67 infected nonunions of a long bone in 66 patients treated in a multidisciplinary unit. The operative treatment of patients suitable for limb salvage was performed as a single procedure. Antibiotic regimes were determined by the results of microbiological culture. At a mean follow-up of 52 months (22 to 97), 59 patients (88%) had an infection-free united fracture in a functioning limb. Seven others required amputation (three as primary treatment, three after late failure of limb salvage and one for recalcitrant pain after union). The initial operation achieved union in 54 (84%) of the salvaged limbs at a mean of nine months (three to 26), with recurrence of infection in 9%. Further surgery in those limbs that remained ununited increased the union rate to 62 (97%) of the 64 limbs treated by limb salvage at final follow-up. The use of internal fixation was associated with a higher risk of recurrent infection than external fixation. Cite this article: Bone Joint J 2015; 97-B:814–17.
D. Bose, MBBS, FRCS, FRCS (Tr&Orth), Consultant in Trauma and Limb Reconstruction Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK. R. Kugan, MSc, FRCS (Tr&Orth), Consultant in Trauma and Orthopaedics Gloucester Royal Infirmary, 8 Meadow Close, Sutton Coldfield B76 2QQ, UK. D. Stubbs, FRCS (Tr&Orth), Consultant in Limb Reconstruction Surgery M. McNally, MD, FRCSEd, FRCS(Orth), Consultant in Limb Reconstruction Surgery, Honorary Senior Clinical Lecturer Oxford University Hospitals NHS Trust, Windmill Road, Oxford OX3 7HE, UK. Correspondence should be sent to Ms D. Bose; e-mail: [email protected] ©2015 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.97B6. 33276 $2.00 Bone Joint J 2015;97-B:814–17. Received 1 March 2014; Accepted after revision 2 February 2015
814
The management of an infected nonunion is challenging for patients and surgeons alike. In addition to the nonunion itself, there may be problems of inadequate soft-tissue cover, bone loss and residual deformity. Improvements in antimicrobial therapy and microvascular tissue transfer,1,2 combined with the use of Ilizarov principles of distraction osteogenesis,3-5 have saved many useful limbs from amputation.6-12 We present a series of 67 infected nonunions of long bones treated using a multidisciplinary approach.
Patients and Methods Between September 1998 and December 2004, we treated a consecutive series of 66 patients with 67 infected nonunions of long bones. There were 53 men and 13 women mean age 41; 17 to 85). A total of 49 fractures involved the tibia, 13 the femur, three the humerus and two the forearm bones. Of these, 44 had suffered an open fracture, 20 a closed fracture and three followed a surgical procedure. Two patients had developed pin-site infections after external fixation. Each patient was assessed by a multidisciplinary team comprising orthopaedic surgeons, plastic surgeons, radiologists and infectious diseases physicians. Three patients had an amputation as their primary procedure,
either at their request or because the limb was not able to be salvaged. Consequently, 64 infected nonunions underwent limb salvage as the primary procedure. The surgical strategy consisted of radical surgical debridement and deep-tissue sampling; dead space management; bony stabilisation; wound closure, either directly or with soft-tissue reconstruction and antibiotic therapy guided by the culture results. All these steps were performed in a single surgical procedure. At least five arbitrary deep tissue samples were taken from each infected nonunion for microscopic examination and at least one for histological examination. Samples were collected using clean instruments for each specimen, and care was taken to avoid contact with the skin to prevent contamination by skin commensals. Bony debridement was achieved by local resection in 35 limbs, segmental resection in 18 and intramedullary reaming in 11. Of the 64 limbs (63 patients) who underwent limb salvage, bony stabilisation was achieved using an Ilizarov external fixator in 54, a monolateral fixator in three and internal fixation in five. Two patients were treated with antibiotics, after biopsy and retention of their fixation, until union was achieved. One patient refused THE BONE & JOINT JOURNAL
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Table I. List of patients who were stabilised by internal fixation Patient
Bony stabilisation
Reason
1 2 3 4 5 6
Tibial nail retained Exchange nailing Femoral nail retained Plating Plating Second stage plating after removal of nail and insertion of gentamicin cement rod Femoral nail
Patient refused external fixation Subtrochanteric femoral fracture unsuitable for external fixation Intertrochanteric femoral fracture unsuitable for external fixation Distal femoral fracture in patient with BMI of 45 Complete segmental excision of humeral nonunion Subtrochanteric femoral fracture unsuitable for external fixation
7
Fracture configuration unsuitable for external stabilisation; elderly patient unsuitable for frame
BMI, body mass index
surgery and the other was deemed unfit for major surgery. Primary skin closure was achieved in 52 limbs; a free muscle flap was required in ten, a local muscle flap in one and a fasciocutaneous flap in one. Bone loss was managed by Ilizarov distraction osteogenesis in 22 (19 bifocal compression–distraction techniques and three bone transports), planned second-stage autologous bone grafting in two, free fibular transfer in one and free scapular transfer (as part of a composite graft) in one. In addition, 16 patients required monofocal Ilizarov techniques (either compression or distraction or a combination of both) to achieve union. The microbiological culture results for six nonunions were not available. Of the remaining 61, 11 revealed no growth and 24 had more than one organism isolated. Methicillinresistant Staphylococcus aureus (MRSA) was isolated from 11, coagulase-negative Staphylococcus (CNS) from 24 and vancomycin-resistant Enterobacter (VRE) from one culture. Histology showed evidence of active infection in the majority of cases, but there were nine inconclusive samples, and six cases showed no evidence of histological infection. Broadspectrum intravenous antibiotics were started intra-operatively after tissue sampling, and a definitive antibiotic plan was formulated in accordance with the culture and sensitivity results obtained from the surgical samples. Antibiotic therapy usually consisted of six weeks of intravenous therapy followed by oral therapy for a minimum of six weeks, or until early signs of radiological bony union were seen. The mean total duration of antibiotic therapy from surgery was 12 weeks (six to 24). Table I lists the patients who had internal fixation, together with the indications for this. Figure 1 illustrates an infected tibial nonunion with implant failure and bone loss after debridement.
Results All 66 patients were followed-up for a minimum of 22 months after operation (mean 52 months; 22 to 97). No patients were lost to follow-up. The three patients (three limbs) treated by primary amputation healed without further infection. Of the 64 limb salvage procedures, 54 achieved bony union with only one operation at a mean of nine months (3 to 26; 92%). Further surgery was required for the other ten limbs that had not achieved union, and a further eight VOL. 97-B, No. 6, JUNE 2015
united with a second operation, resulting in a total of 62 (97%) bony unions at the end of treatment. There were three secondary or late amputations; only one of these was for persistent non-union. The others were for persistent pain and/or infection. Of those patients treated in Ilizarov frames, the mean time in the frame was nine months (3 to 26) and the median was six months (interquartile range 8). The mean time to union in the patients who had internal fixation revised was seven months (6 to 8). At final followup, 59 of the 67 limbs (88%) had an infection-free united fracture with a functioning salvaged limb. Seven patients had an infection-free amputation and one an aseptic fibrous nonunion. The complications in the limb salvage group were as follows: Persistent nonunion. A total of ten patients (16%) had persistent nonunion after their initial treatment. Of these, six were managed by internal fixation, three by a second Ilizarov frame and one by below-knee amputation. Eight of the nine who underwent further surgery went on to union; one of the internally-fixed fractures has a fibrous nonunion. One of the patients with a persistent nonunion who was successfully treated by a second Ilizarov frame later needed internal fixation because of residual deformity, and developed a recurrent infection. Residual deformity. Three patients had a residual deformity at the end of their treatment. One had an acceptable varus deformity after an intertrochanteric fracture. Two were later treated by corrective osteotomy and internal fixation, but both had recurrent infection. Recurrent infection. There were six recurrent infections (9%). In four of these the organisms isolated from the second debridement were different from those isolated in the original procedure. Infection recurred in two of seven patients (29%) who had been stabilised by internal fixation and in two of 57 treated with external fixation (3.5%) at the first operation (p < 0.0001. Two further infections occurred after a corrective osteotomy and internal fixation for residual deformity. Of the six patients with recurrent infection, two were treated by below-knee amputation, three by targeted suppressive antibiotics until union followed by implant removal, and one by local excision and a free muscle flap.
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D. BOSE, R. KUGAN, D. STUBBS, M. MCNALLY
Fig. 1a
Fig. 1b
Fig. 1d
Fig. 1c
Fig. 1e
Fig. 1f
Fig. 1g
a) radiograph showing nonunion of a previously open tibial fracture treated by open reduction and internal fixation and photographs showing b) the breakdown of the medial skin with discharging sinus and c) removal of metalwork, debridement and application of Ilizarov frame for acute compression of the nonunion site and proximal corticotomy for lengthening (bifocal treatment) (soft-tissue cover achieved by free flap) d) photograph of the free flap at ten days, e) photograph of the leg at three months post-operatively, f) AP radiograph after Ilizarov frame removal, and g) lateral radiograph after removal of the Ilizarov frame.
Fractures/deformation. There were two stress fractures after removal of the external fixation, both of which were treated successfully by non-operative means. Three more patients demonstrated deformation of the regenerated bone after removal of the frame: two of these were stabilised by internal fixation and one with a further external fixator. Nonunion at docking site. Three of the 22 patients who underwent distraction osteogenesis required autologous bone grafting of the docking site. In another patient, in whom bifocal bone transport had been undertaken, the docking site united after the introduction of an intramedullary nail. Antibiotic-related problems. Six patients had a significant adverse reaction to their antibiotics, resulting in their treatment being changed or stopped.
Discussion We report a series of patients with an infected nonunion of a long bone which highlights the difficulties in achieving a satisfactory outcome. At the decision-making stage, the general condition of the patient and the presence of any comorbidities were considered when deciding between no treatment, limb salvage
and amputation. If limb salvage was chosen, complete excision of the bacterial biofilm13 is essential in order to prevent persistent or recurrent infection.14 The importance of the complete excision of unhealthy tissue has been emphasised,8,9,14,15 despite Ilizarov’s statement that “the infection burns in the fire of regeneration”.16 Deep tissue sampling needs to be meticulous to avoid contamination with skin commensals. We found that eradication of infection was more predictably achieved by the single surgical procedure than consolidation of the nonunion: this has also been reported by other authors.6,15 However, four of our six recurrent infections followed internal fixation, either at the primary operation or for correction of deformity. Although the numbers in our series are small, the difference was highly significant, suggesting that external fixation may be safer than internal fixation for an infected non-union. We now reserve internal fixation for those patients who refuse, or are deemed unsuitable for, external fixation. The Ilizarov technique of distraction osteogenesis is a satisfactory method of dealing with bone loss or residual bony deformity.6,7,9,15,17-20 In our series, three of 22 regenerated segments deformed after removal of the external fixation, requiring a second procedure. The mean time in an Ilizarov THE BONE & JOINT JOURNAL
MANAGEMENT OF INFECTED NONUNION OF THE LONG BONES BY A MULTIDISCIPLINARY TEAM
frame was nine months, which is comparable with other series of similar patients.17,19 Rozbruch et al20 reported a 71% rate of union after initial treatment, compared with 84% in our series. Three of 22 patients (13.6%) who underwent distraction osteogenesis needed a further procedure to secure union at the docking site as it is not our routine practice to graft the docking site. Lovisetti and Sala21 found that there was no difference between three dissimilar methods of achieving union at the docking site, namely by compression, open or endoscopic procedures. Hatzokos et al22 found that simple compression was inferior to either autologous grafting or a combination of autologous bone marrow and demineralised bone matrix. Soft-tissue reconstruction has long been advocated for defects resulting from trauma or infection.1,23 Restoration of a viable soft-tissue envelope vascularises the recipient site, improves antibiotic delivery, fills the dead space and prevents further contamination.11 The use of a free tissue transfer also allows thorough debridement of dead and infected tissue.8 Our results support the good outcomes achieved by combined orthopaedic and plastic surgery procedures for post-traumatic bone and soft-tissue defects.24,25 Ziran et al26 and Salvana et al27 have reported good outcomes from using a multidisciplinary team approach to treat chronic osteomyelitis. Ziran et al26 compared their outcomes before and after the introduction of a dedicated multidisciplinary team. approach and noted significantly better outcomes with the latter. Such an approach allows each element of the clinical problem to be addressed individually so that the best outcome is achieved. In conclusion, an infected nonunion presents a series of problems, each of which needs to be tackled separately. A multidisciplinary approach can achieve an infection-free, united and functional limb in most patients. As we have demonstrated, both surgeons and patients need to be aware that one in three patients will require further surgery, not only for persistent nonunion, but also for issues such as persistent infection, removal of metalwork, fixation of deformed or fractured regenerates, nonunion of docking sites, and pin-site infections. Supplementary material A table giving details of all infected nonunions treated in this series as well as several radiographs, are available with the online version of this article at www.bjj.boneandjoint.org.uk Author contributions: D. Bose: Data collection, Data analysis, Performed surgeries, Writing paper. R. Kugan: Data collection, Performed surgeries. D. Stubbs: Data collection, Performed surgeries. M. McNally: Data Collection, Data analysis, Performed surgery, Writing paper. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. This article was primary edited by S. P. F. Hughes and first proof edited by A. C. Ross
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References 1. Weiland AJ, Moore JR, Daniel RK. The efficacy of free tissue transfer in the treatment of osteomyelitis. J Bone Joint Surg [Am] 1984;66-A:181–193. 2. Melissinos EG, Parks DH. Post-trauma reconstruction with free tissue transferanalysis of 442 consecutive cases. J Trauma 1989;29:1095–1102. 3. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues. Part I. The influence of stability of fixation and soft-tissue preservation. Clin Orthop Relat Res 1989;238:249–281. 4. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues: part II. The influence of the rate and frequency of distraction. Clin Orthop Relat Res 1989;239:263–285. 5. Papakostidis C, Bhandari M, Giannoudis PV. Distraction osteogenesis in the treatment of long bone defects of the lower limbs: effectiveness, complications and clinical results: a systematic review and meta-analysis. Bone Joint J 2013;95B:1673–1680. 6. Dendrinos GK, Kontos S, Lyritsis E. Use of the Ilizarov technique for treatment of nonunion of the tibia associated with infection. J Bone Joint Surg [Am] 1995;77A:835–846. 7. Maini L, Chadha M, Vishwanath J, et al. The Ilizarov method in infected nonunion of fractures. Injury 2000;31:509–517. 8. Ring D, Jupiter JB, Gan BS, Israeli R, Yaremchuk MJ. Infected nonunion of the tibia. Clin Orthop Relat Res 1999;369:302–311. 9. Cattaneo R, Catagni M, Johnson EE. The treatment of infected nonunions and segmental defects of the tibia by the methods of Ilizarov. Clin Orthop Relat Res 1992;280:143–152. 10. Megas P, Saridis A, Kouzelis A, et al. The treatment of infected nonunion of the tibia following intramedullary nailing by the Ilizarov method. Injury 2010;41:294–299. 11. Bumbasirević M, Tomić S, Lesić A, Milosević I, Atkinson HD. War-related infected tibial nonunion with bone and soft-tissue loss treated with bone transport using the Ilizarov method. Arch Orthop Trauma Surg 2010;130:739–749. 12. McNally M, Nagarajah K. Osteomyelitis. Orthopaedics and Trauma 2010;24:416. 13. Gristina AG, Costerton JW. Bacterial adherence to biomaterials and tissue. The significance of its role in clinical sepsis. J Bone Joint Surg [Am] 1985;67-A:264–273. 14. Patzakis MJ, Zalavras CG. Chronic posttraumatic osteomyelitis and infected nonunion of the tibia: current management concepts. J Am Acad Orthop Surg 2005;13:417–427. 15. Marsh DR, Shah S, Elliott J, Kurdy N. The Ilizarov method in nonunion, malunion and infection of fractures. J Bone Joint Surg [Br] 1997;79-B:273–279. 16. Catagni MA, Giordani M. Treatment of Fractures, Nonunions and Bone Loss of the Tibia with the Ilizarov Method: Including War Injuries and Tumor Resection. Milan: Medicalplastic, 1998:145. 17. Mahaluxmivala J, Nadarajah R, Allen PW, Hill RA. Ilizarov external fixator: acute shortening and lengthening versus bone transport in the management of tibial nonunions. Injury 2005;36:662–668. 18. Patil S, Montgomery R. Management of complex tibial and femoral nonunion using the Ilizarov technique, and its cost implications. J Bone Joint Surg [Br] 2006;88B:928–932. 19. Madhusudhan TR, Ramesh B, Manjunath K, et al. Outcomes of Ilizarov ring fixation in recalcitrant infected tibial nonunions - a prospective study. J Trauma Manag Outcomes 2008;2:6. 20. Rozbruch SR, Pugsley JS, Fragomen AT, Ilizarov S. Repair of tibial nonunions and bone defects with the Taylor Spatial Frame. J Orthop Trauma 2008;22:88–95. 21. Lovisetti G, Sala F. Clinical strategies at the docking site of distraction osteogenesis: are open procedures superior to the simple compression of Ilizarov? Injury 2013;44 (Suppl 1):58–62. 22. Hatzokos I, Stavridis SI, Iosifidou E, Karataglis D, Christodoulou A. Autologous bone marrow grafting combined with demineralized bone matrix improves consolidation of docking site after distraction osteogenesis. J Bone Joint Surg [Am] 2011;93-A:671–678. 23. May JW Jr, Gallico GG III, Lukash FN. Microvascular transfer of free tissue for closure of bone wounds of the distal lower extremity. N Engl J Med 1982;306:253– 257. 24. Yazar S, Lin CH, Wei FC. One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities. Plast Reconstr Surg 2004;114:1457–1466. 25. Chim H, Sontich JK, Kaufman BR. Free tissue transfer with distraction osteogenesis is effective for limb salvage of the infected traumatized lower extremity. Plast Reconstr Surg 2011;127:2364–2372. 26. Ziran BH, Rao N, Hall RA. A dedicated team approach enhances outcomes of osteomyelitis treatment. Clin Orthop Relat Res 2003;414:31–36. 27. Salvana J, Rodner C, Browner BD, et al. Chronic osteomyelitis: results obtained by an integrated team approach to management. Conn Med 2005;69:195–202.
Management of infected nonunion of the long bones by a multidisciplinary team
D. Bose, R. Kugan, D. Stubbs, M. McNally From Nuffield Orthopaedic Centre, Headington, Oxford, United Kingdom
Infected nonunion of a long bone continues to present difficulties in management. In addition to treating the infection, it is necessary to establish bony stability, encourage fracture union and reconstruct the soft-tissue envelope. We present a series of 67 infected nonunions of a long bone in 66 patients treated in a multidisciplinary unit. The operative treatment of patients suitable for limb salvage was performed as a single procedure. Antibiotic regimes were determined by the results of microbiological culture. At a mean follow-up of 52 months (22 to 97), 59 patients (88%) had an infection-free united fracture in a functioning limb. Seven others required amputation (three as primary treatment, three after late failure of limb salvage and one for recalcitrant pain after union). The initial operation achieved union in 54 (84%) of the salvaged limbs at a mean of nine months (three to 26), with recurrence of infection in 9%. Further surgery in those limbs that remained ununited increased the union rate to 62 (97%) of the 64 limbs treated by limb salvage at final follow-up. The use of internal fixation was associated with a higher risk of recurrent infection than external fixation. Cite this article: Bone Joint J 2015; 97-B:814–17.
D. Bose, MBBS, FRCS, FRCS (Tr&Orth), Consultant in Trauma and Limb Reconstruction Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK. R. Kugan, MSc, FRCS (Tr&Orth), Consultant in Trauma and Orthopaedics Gloucester Royal Infirmary, 8 Meadow Close, Sutton Coldfield B76 2QQ, UK. D. Stubbs, FRCS (Tr&Orth), Consultant in Limb Reconstruction Surgery M. McNally, MD, FRCSEd, FRCS(Orth), Consultant in Limb Reconstruction Surgery, Honorary Senior Clinical Lecturer Oxford University Hospitals NHS Trust, Windmill Road, Oxford OX3 7HE, UK. Correspondence should be sent to Ms D. Bose; e-mail: [email protected] ©2015 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.97B6. 33276 $2.00 Bone Joint J 2015;97-B:814–17. Received 1 March 2014; Accepted after revision 2 February 2015
814
The management of an infected nonunion is challenging for patients and surgeons alike. In addition to the nonunion itself, there may be problems of inadequate soft-tissue cover, bone loss and residual deformity. Improvements in antimicrobial therapy and microvascular tissue transfer,1,2 combined with the use of Ilizarov principles of distraction osteogenesis,3-5 have saved many useful limbs from amputation.6-12 We present a series of 67 infected nonunions of long bones treated using a multidisciplinary approach.
Patients and Methods Between September 1998 and December 2004, we treated a consecutive series of 66 patients with 67 infected nonunions of long bones. There were 53 men and 13 women mean age 41; 17 to 85). A total of 49 fractures involved the tibia, 13 the femur, three the humerus and two the forearm bones. Of these, 44 had suffered an open fracture, 20 a closed fracture and three followed a surgical procedure. Two patients had developed pin-site infections after external fixation. Each patient was assessed by a multidisciplinary team comprising orthopaedic surgeons, plastic surgeons, radiologists and infectious diseases physicians. Three patients had an amputation as their primary procedure,
either at their request or because the limb was not able to be salvaged. Consequently, 64 infected nonunions underwent limb salvage as the primary procedure. The surgical strategy consisted of radical surgical debridement and deep-tissue sampling; dead space management; bony stabilisation; wound closure, either directly or with soft-tissue reconstruction and antibiotic therapy guided by the culture results. All these steps were performed in a single surgical procedure. At least five arbitrary deep tissue samples were taken from each infected nonunion for microscopic examination and at least one for histological examination. Samples were collected using clean instruments for each specimen, and care was taken to avoid contact with the skin to prevent contamination by skin commensals. Bony debridement was achieved by local resection in 35 limbs, segmental resection in 18 and intramedullary reaming in 11. Of the 64 limbs (63 patients) who underwent limb salvage, bony stabilisation was achieved using an Ilizarov external fixator in 54, a monolateral fixator in three and internal fixation in five. Two patients were treated with antibiotics, after biopsy and retention of their fixation, until union was achieved. One patient refused THE BONE & JOINT JOURNAL
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Table I. List of patients who were stabilised by internal fixation Patient
Bony stabilisation
Reason
1 2 3 4 5 6
Tibial nail retained Exchange nailing Femoral nail retained Plating Plating Second stage plating after removal of nail and insertion of gentamicin cement rod Femoral nail
Patient refused external fixation Subtrochanteric femoral fracture unsuitable for external fixation Intertrochanteric femoral fracture unsuitable for external fixation Distal femoral fracture in patient with BMI of 45 Complete segmental excision of humeral nonunion Subtrochanteric femoral fracture unsuitable for external fixation
7
Fracture configuration unsuitable for external stabilisation; elderly patient unsuitable for frame
BMI, body mass index
surgery and the other was deemed unfit for major surgery. Primary skin closure was achieved in 52 limbs; a free muscle flap was required in ten, a local muscle flap in one and a fasciocutaneous flap in one. Bone loss was managed by Ilizarov distraction osteogenesis in 22 (19 bifocal compression–distraction techniques and three bone transports), planned second-stage autologous bone grafting in two, free fibular transfer in one and free scapular transfer (as part of a composite graft) in one. In addition, 16 patients required monofocal Ilizarov techniques (either compression or distraction or a combination of both) to achieve union. The microbiological culture results for six nonunions were not available. Of the remaining 61, 11 revealed no growth and 24 had more than one organism isolated. Methicillinresistant Staphylococcus aureus (MRSA) was isolated from 11, coagulase-negative Staphylococcus (CNS) from 24 and vancomycin-resistant Enterobacter (VRE) from one culture. Histology showed evidence of active infection in the majority of cases, but there were nine inconclusive samples, and six cases showed no evidence of histological infection. Broadspectrum intravenous antibiotics were started intra-operatively after tissue sampling, and a definitive antibiotic plan was formulated in accordance with the culture and sensitivity results obtained from the surgical samples. Antibiotic therapy usually consisted of six weeks of intravenous therapy followed by oral therapy for a minimum of six weeks, or until early signs of radiological bony union were seen. The mean total duration of antibiotic therapy from surgery was 12 weeks (six to 24). Table I lists the patients who had internal fixation, together with the indications for this. Figure 1 illustrates an infected tibial nonunion with implant failure and bone loss after debridement.
Results All 66 patients were followed-up for a minimum of 22 months after operation (mean 52 months; 22 to 97). No patients were lost to follow-up. The three patients (three limbs) treated by primary amputation healed without further infection. Of the 64 limb salvage procedures, 54 achieved bony union with only one operation at a mean of nine months (3 to 26; 92%). Further surgery was required for the other ten limbs that had not achieved union, and a further eight VOL. 97-B, No. 6, JUNE 2015
united with a second operation, resulting in a total of 62 (97%) bony unions at the end of treatment. There were three secondary or late amputations; only one of these was for persistent non-union. The others were for persistent pain and/or infection. Of those patients treated in Ilizarov frames, the mean time in the frame was nine months (3 to 26) and the median was six months (interquartile range 8). The mean time to union in the patients who had internal fixation revised was seven months (6 to 8). At final followup, 59 of the 67 limbs (88%) had an infection-free united fracture with a functioning salvaged limb. Seven patients had an infection-free amputation and one an aseptic fibrous nonunion. The complications in the limb salvage group were as follows: Persistent nonunion. A total of ten patients (16%) had persistent nonunion after their initial treatment. Of these, six were managed by internal fixation, three by a second Ilizarov frame and one by below-knee amputation. Eight of the nine who underwent further surgery went on to union; one of the internally-fixed fractures has a fibrous nonunion. One of the patients with a persistent nonunion who was successfully treated by a second Ilizarov frame later needed internal fixation because of residual deformity, and developed a recurrent infection. Residual deformity. Three patients had a residual deformity at the end of their treatment. One had an acceptable varus deformity after an intertrochanteric fracture. Two were later treated by corrective osteotomy and internal fixation, but both had recurrent infection. Recurrent infection. There were six recurrent infections (9%). In four of these the organisms isolated from the second debridement were different from those isolated in the original procedure. Infection recurred in two of seven patients (29%) who had been stabilised by internal fixation and in two of 57 treated with external fixation (3.5%) at the first operation (p < 0.0001. Two further infections occurred after a corrective osteotomy and internal fixation for residual deformity. Of the six patients with recurrent infection, two were treated by below-knee amputation, three by targeted suppressive antibiotics until union followed by implant removal, and one by local excision and a free muscle flap.
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D. BOSE, R. KUGAN, D. STUBBS, M. MCNALLY
Fig. 1a
Fig. 1b
Fig. 1d
Fig. 1c
Fig. 1e
Fig. 1f
Fig. 1g
a) radiograph showing nonunion of a previously open tibial fracture treated by open reduction and internal fixation and photographs showing b) the breakdown of the medial skin with discharging sinus and c) removal of metalwork, debridement and application of Ilizarov frame for acute compression of the nonunion site and proximal corticotomy for lengthening (bifocal treatment) (soft-tissue cover achieved by free flap) d) photograph of the free flap at ten days, e) photograph of the leg at three months post-operatively, f) AP radiograph after Ilizarov frame removal, and g) lateral radiograph after removal of the Ilizarov frame.
Fractures/deformation. There were two stress fractures after removal of the external fixation, both of which were treated successfully by non-operative means. Three more patients demonstrated deformation of the regenerated bone after removal of the frame: two of these were stabilised by internal fixation and one with a further external fixator. Nonunion at docking site. Three of the 22 patients who underwent distraction osteogenesis required autologous bone grafting of the docking site. In another patient, in whom bifocal bone transport had been undertaken, the docking site united after the introduction of an intramedullary nail. Antibiotic-related problems. Six patients had a significant adverse reaction to their antibiotics, resulting in their treatment being changed or stopped.
Discussion We report a series of patients with an infected nonunion of a long bone which highlights the difficulties in achieving a satisfactory outcome. At the decision-making stage, the general condition of the patient and the presence of any comorbidities were considered when deciding between no treatment, limb salvage
and amputation. If limb salvage was chosen, complete excision of the bacterial biofilm13 is essential in order to prevent persistent or recurrent infection.14 The importance of the complete excision of unhealthy tissue has been emphasised,8,9,14,15 despite Ilizarov’s statement that “the infection burns in the fire of regeneration”.16 Deep tissue sampling needs to be meticulous to avoid contamination with skin commensals. We found that eradication of infection was more predictably achieved by the single surgical procedure than consolidation of the nonunion: this has also been reported by other authors.6,15 However, four of our six recurrent infections followed internal fixation, either at the primary operation or for correction of deformity. Although the numbers in our series are small, the difference was highly significant, suggesting that external fixation may be safer than internal fixation for an infected non-union. We now reserve internal fixation for those patients who refuse, or are deemed unsuitable for, external fixation. The Ilizarov technique of distraction osteogenesis is a satisfactory method of dealing with bone loss or residual bony deformity.6,7,9,15,17-20 In our series, three of 22 regenerated segments deformed after removal of the external fixation, requiring a second procedure. The mean time in an Ilizarov THE BONE & JOINT JOURNAL
MANAGEMENT OF INFECTED NONUNION OF THE LONG BONES BY A MULTIDISCIPLINARY TEAM
frame was nine months, which is comparable with other series of similar patients.17,19 Rozbruch et al20 reported a 71% rate of union after initial treatment, compared with 84% in our series. Three of 22 patients (13.6%) who underwent distraction osteogenesis needed a further procedure to secure union at the docking site as it is not our routine practice to graft the docking site. Lovisetti and Sala21 found that there was no difference between three dissimilar methods of achieving union at the docking site, namely by compression, open or endoscopic procedures. Hatzokos et al22 found that simple compression was inferior to either autologous grafting or a combination of autologous bone marrow and demineralised bone matrix. Soft-tissue reconstruction has long been advocated for defects resulting from trauma or infection.1,23 Restoration of a viable soft-tissue envelope vascularises the recipient site, improves antibiotic delivery, fills the dead space and prevents further contamination.11 The use of a free tissue transfer also allows thorough debridement of dead and infected tissue.8 Our results support the good outcomes achieved by combined orthopaedic and plastic surgery procedures for post-traumatic bone and soft-tissue defects.24,25 Ziran et al26 and Salvana et al27 have reported good outcomes from using a multidisciplinary team approach to treat chronic osteomyelitis. Ziran et al26 compared their outcomes before and after the introduction of a dedicated multidisciplinary team. approach and noted significantly better outcomes with the latter. Such an approach allows each element of the clinical problem to be addressed individually so that the best outcome is achieved. In conclusion, an infected nonunion presents a series of problems, each of which needs to be tackled separately. A multidisciplinary approach can achieve an infection-free, united and functional limb in most patients. As we have demonstrated, both surgeons and patients need to be aware that one in three patients will require further surgery, not only for persistent nonunion, but also for issues such as persistent infection, removal of metalwork, fixation of deformed or fractured regenerates, nonunion of docking sites, and pin-site infections. Supplementary material A table giving details of all infected nonunions treated in this series as well as several radiographs, are available with the online version of this article at www.bjj.boneandjoint.org.uk Author contributions: D. Bose: Data collection, Data analysis, Performed surgeries, Writing paper. R. Kugan: Data collection, Performed surgeries. D. Stubbs: Data collection, Performed surgeries. M. McNally: Data Collection, Data analysis, Performed surgery, Writing paper. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. This article was primary edited by S. P. F. Hughes and first proof edited by A. C. Ross
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