SLR - May 2011 - Dr. Pasquale Cancelliere
Reference: Chi Chuan Wu, MD, Single –Staged Surgical Treatment of Infected Nonunion of the Distal Tibia, Journal Orthopedic Trauma, Vol 25, Number 3, March 201,1 pg 156-161
Scientific Literature Review
Reviewed by: Pasquale Cancelliere, DPM, Fellow Reconstructive Foot and Ankle Surgery, Beth Israel Deaconess Medical Center, Clinical Instructor in Surgery, Harvard School of Medicine
Podiatric Relevance:
Infected non unions are not an uncommon complication following distal plating of distal tibial fractures. Internal fixation through plating or intramedullary fixation continues to be the most commonly used technique in reduction and fixation of these fractures. However, deep infection of distal tibial fracture plating ranges from 0% to 15%. Treatment of an infected non union of the tibial shaft is a long and complicated process resulting in increased morbidity and amputation rates.
Methods:
This was a retrospective analysis of 25 consecutive patients who presented with infected non union of the distal tibia after plating from September 2000 to October 2006. Patient ages ranged from 22 to 65 with a male to female ratio of 4:1. The inclusion criteria included: an infected non union of the distal tibia (distal to the tibial isthmus), a plate in situ, and intact ankle space. Exclusion criteria included: non union, non union involving the plafond, or a fused ankle. Surgical technique consisted of radical debridement after removal of retained internal plate. After debridement the fracture was reduced, the IM space was reamed and irrigated with 5000 mL of normal saline. Cancellous bone harvested from the tibia was used to fill any bone defects after debridement after the graft had been saturated with vancomycin and gentamycin. Then, an Ilizarov fixator (Trauma Fix; Paonan Biotech Co, Taipei, Taiwan) was applied. Post-operatively, vancomycin and gentamycin were infused for 24 hours. Early protected weightbearing was initiated to maintain range of motion of knee and ankle
Patients in this series returned after 1 week for suture removal and were then followed up every four to 6 weeks. Fracture union was clinically deemed as the ability to walk without assistive devices, no pain, and radiographic callous bridging the fracture. Follow up ranged from 3.5 to 60 months.
Results:
Three patients were lost to follow up. All of the 22 patients that completed the study obtained successful union. MRSA was the predominant organism cultured from the surgical biopsies. There was no infection recurrence during treatment. All patients had satisfactory knee function, and ankle function increased from 0% to 86% satisfaction. Three patients had below satisfactory rating as a result of intermittent ankle pain and stiffness.
Conclusions:
Successful single stage surgical technique for treatment of infected non unions has rarely been reported in the literature. In this study, the combination of plate removal, aggressive antibiotic irrigation, and external fixation resulted in fracture healing within 6 months with no repeat infections. Also, the saturation of autograft bone with antibiotic represents a very powerful technique as it presents all the advantages of antibiotic cement without many of its complications including removal of the cement and the potential secondary nidus of infection. A limitation of this study was the relatively small sample population size.