Infection caused in open features which leads to failure of unification of bones

1. Approach to Infected Non-
Union
DR. ISHDEEP SINGH OBEROI
PG-2

2. How infection causes non union?
1. Dissection of pus through planes & periosteum devascularizing the
ends
2. Fragmentation & dissolution of fracture haematoma
3. Inflammatory mediators promotes fibrous tissue formation

3. C/F
• Signs of infection
1. Draining sinus
2. Red shiny skin
3. Local temperature & tenderness
• Signs of non union
1. Abnormal mobility
2. Deformity
3. Limb shortening

4. Difficulties associated with Mgx
• Non union usually operated multiple times – results in cicatrisation of
the soft tissue -> avascular environment around the fracture site
• Necrotic bone at non union site
• Lingered immobilization leads to stiff joint
• Development of antibiotic resistance
• Rate of limb length incongruity and malformations
• Erratic degree of soft tissue lost or defects requiring multiple sessions
in reconstruction surgeries.

5. Infected non union of long bones
present difficulties in Mgx
• Aim :
1. Control infection
2. Establish bony stability
3. Encourage union
4. Reconstruct soft tissue envelope

6. Non union
• United states FDA defines “established when a minimum of 9 months
has elapsed since injury and the # shows no visible progressive signs
of healing for 3 months.
• Time frame differs by location &degree of associated soft tissue tissue
injury
• Femoral neck # that has not united with implant failure at 3 months
v/s G.A type 3B open tibia that received appropriate surgical
treatment may not be considered non union after the same 3 months
frame.

7. Biologic Etiologies of Non union
LOCAL :
1. excessive soft tissue
stripping(from injury or
surgeon)
2. Bone loss
3. Vascular injury
4. Radiation
5. Infection
SYSTEMIC :
1. Age
2. Chronic diseases
3. Diabetes mellitus
4. Chronic anemia
5. Metabolic or endocrine abnormalities
6. Malnutrition
7. Medications (steroids, NSAIDs,
antiepileptics
8. Smoking

8. Mechanical Etiologies of Non union
Malreduction Malposition
Malalignment
Distraction
Inappropriate stabilization Too little or insufficient fixation
Too much or too rigid fixation
Inappropriate implant choice
Inappropriate implant position
Technical error(s)

9. CLASSIFICATION OF N/U
• NON INFECTED
• INFECTED

11. Goal for surgery
• At the very least,
• Must get rid of infection

13. Learning objectives
• Clarity in what & how to take out
• How to determine area of resection
• Reasons for considering segmental resection

14. DEBRIDEMENT

15. DEBRIDEMENT – HOW MUCH?

16. How do I know how much bone?
• Xray : all sclerosis is not dead bone
• PET/CT- deliver the radioactive compound to area of infection, 3d
image
• MRI (hematogenous OM)

17. • Before you go in,
make plans to what
appears to be infected
• Area of bone being
eroded
• Xray evidence of
granulation tissue
which is trying to
resorb that bone
• Amount of time can
be told.

18. PET CT

19. METHYLENE BLUE
PUSH INTO SINUS
HOLD GAUZE FOR 4-5MINS
STAINS ALL OF THE TISSUE THAT
WE NEED TO TAKE OUT

20. EXCISE THE SINUS ALONG WITH INFECTED
EDGES

22. CURETTE & OSTEOTOME – FINDING PLANE
B/W INFECTED AND NORMAL
ALL THE BIOFILM
NEEDS TO COME OUT
IN A THOROUGH
FASHION

23. ESSENTIAL TO ASPIRATE AND SEND FOR CULTURE
5-7days prior, IF NOT THEN VANCO/TOBRA TO
CASO4
LEFT WITH GAP
For enhancing local AB :
use bone cement /
stimulant

24. Peri-articular
infections/fragments: extend
across joint for good stable
fixation.

25. Segmental Resection
• Entire segment is infected/nonviable
• Less than 2/3 diameter (unstable)
• But that will leave a GAP!!
Getting rid of infection is the 1st problem
Filling it is the ‘later’ problem

26. Case 1

28. SEQUESTRUM

29. Local antibiotic CaSO4 pellets
LRS fixator

30. Infection settled
gap = 20cm
transport technically
challenging
bone transport
expected fixator time
20 months

31. Vascularized Fibula

32. Fibula inside is a very STABLE construct

33. 4months post removal

34. Summary
• Debridement has to be thorough
• Ways to determine what to take out
Clinical & Imaging
Segmental resection if needed
Getting rid of infection is primary goal
Can’t rid of infection if dead tissue
No harm in staging treatment
Multiple ways to treat gap

35. Case 2
Infected non union distal 1/3rd humerus with implant insitu

36. Pre op xrays

37. Infected non union distal 1/3rd humerus

39. 4months later

40. 7months later

42. Case 3: Infected gap non union tibia
(bone gap >5cm)
7yr old girl

43. Tibialization of fibula done

44. • After 14months

45. After 21 months

46. Case 4
45years
Male
DOI : 8 OCT 2011
RTA
Diaphyseal fracture femur
AO 32B2
Simple

47. LCP done with primary
bone grafting on
13/10/11
Plate broke after 3
months
11/1/12

48. • Replating (LCP) with BG done
• But still didn’t unite

49. • 3rd surgery
• R/G Nailing done
6months after
replating on
25/7/12 by a
private practitioner

50. Pt develops infection with pus discharging sinuses
within 1 month of nailing (increased operative
time? Cause )
6months after nailing 7months after nailing

51. Treatment options?
• 2stage Rx
1. Stage 1: infection elimination,
radical debridement of necrotic
& infected tissue +/- antibiotic
beads/cement
2. Stage 2: reconstruction of bone
and soft tissue (flaps)
a. Autogenous BG
- Cancellous
- Cortical
- Vascularized
b. Allograft
Simultaneous Rx
By Ilizarov technique
Radical debridement
-Bone transport
-Acute shortening, then lengthening
Combination of different methods

52. • Debridement
• Sinus excision
• Antibiotic beads
• Rail rod application 10months after
nailing

53. • Infection controlled
but still non union, at
4 months follow up of
rail fixation

54. Further debridement
Fibular grafting, acute
docking
corticotomy
Rail fixator extension &
change of plane of
fixator

55. Bone Transport

56. Fracture United 4 years of follow-up

57. Functional
Outcome
Infection healed
Acceptable
alignment
2cm shortening
Terminal restriction
of knee movements

58. Eradicate infection
Increase host resistance:
1. Systemic antibiotics
2. Local PMMA beads
3. Optimise systemic conditions(control blood sugars, treatment of
chronic ds, smoking cessation)
Decrease infection load:
1. Through debridement
2. Adequate irrigation
3. Negative suction drain - VAC

59. To achieve union
• Adding biology
1. Aspirated stem cells (with or without expansion)
2. Autogenous cancellous graft
3. Growth factors – platelet derived, recombinant BMPs, gene therapy
External stimuli
-low intensity ultrasound therapy
-electric and electromagnetic therapy

60. • Assess bone defect - <5cm primary
docking
• >5cm internal bone transport
• Temporary cross k wire for
stabilization
• Intramedullary ilizarov wire for bone
transport
• Fibular cuff resection for primary
docking

61. • Through wash
• If we achieve local docking with can do local osteo periosteal
flaps/shingling
• Skin closure
• Proximal or distal corticotomy – multiple drill holes

62. Antibiotic coated nail
• Advantages :
1. Local antibiotic release
2. Single modality for infection control & stabilization
3. Can be done as staged or single stage
4. Heat stable antibiotics : gentamycin, vancomycin, teicoplanin,
cefuroxime.

63. Preparation of K nail

64. Antibiotic sensitivity only from deep cultures
• Duration depend on :
- Duration of infection
- Organism
- Host resistance
- Characterization of antibiotic
->involve infectious diseases specialist

65. Tackling regenerate problems
• Adding bone grafts, BM aspirate, bisphosphonates
• Accordian maneuver
• Adequate mobilization
• Inj Teriparatide

66. Masquelet technique
Originally described by Alian C. Masquelet in 1986 for reconstruction of long bone
defects
Essentially consists of 2 stages:
STAGE 1
1. Identify bone loss, necrotic
bone
2. Removal of necrotic
avascular bone
3. Insertion of cement spacer
PMMA spacer causes a mild foreign body
inflammatory response which induces a think
pseudo-synovial membrane which acts like a
new periosteum.
This membrane is HIGHLY VASCULARIZED and
rich in OSTEOGENIC GROWTH FACTORS.
4-6 weeks post surgery the osteogenic
potential is highest following which stage 2 is
done

67. • STAGE 2
1. Removal of cement spacer and membrane formation
2. Packing the bone graft inside membrane
3. consolidation

68. Bone transport vs Masquelet
BONE TRANSPORT
1. Pin site infections
2. Broken wires
3. Multiple readmission & reoperations
4. Keeping frame for months to years
5. Failure of bone consolidation
6. Non union at docking site
7. Loss of alignment
8. More opd visits
9. Social implications such as clothing limitations
10. ankle stiffness
11.Skin irritation and scarring from wires
Full weight bearing
from day 1
One stage surgery

69. • Masquelet
- 2 staged procedure
- need to harvest large volumes of autologous graft adding donor
site morbidities
- Failure of graft to revascularize and consolidate
- Failure of implant and loss of alignment
- Delayed weight bearing
-No social implications as with frames
-Larger bone defects