infected_non_union in open fractures and it's approaches

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? Dissection of pus through planes & periosteum devascularizing the ends Fragmentation & dissolution of fracture haematoma Inflammatory mediators promotes fibrous tissue formation

3. C/F Signs of infection Draining sinus Red shiny skin Local temperature & tenderness Signs of non union Abnormal mobility Deformity 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 : Control infection Establish bony stability Encourage union 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 : excessive soft tissue stripping(from injury or surgeon) Bone loss Vascular injury Radiation Infection SYSTEMIC : Age Chronic diseases Diabetes mellitus Chronic anemia Metabolic or endocrine abnormalities Malnutrition Medications (steroids, NSAIDs, antiepileptics 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

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

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

12. DEBRIDEMENT

13. DEBRIDEMENT – HOW MUCH?

14. 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)

15. 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.

16. PET CT

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

18. EXCISE THE SINUS ALONG WITH INFECTED EDGES

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

20. 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

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

22. 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 1 st problem Filling it is the ‘later’ problem

23. Case 1

24. SEQUESTRUM

25. Local antibiotic CaSO4 pellets LRS fixator

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

27. Vascularized Fibula

28. Fibula inside is a very STABLE construct

29. 4months post removal

30. 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

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

32. Pre op xrays

33. Infected non union distal 1/3 rd humerus

34. 4months later

35. 7months later

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

37. Tibialization of fibula done

38. After 14months

39. After 21 months

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

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

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

43. 3 rd surgery R/G Nailing done 6months after replating on 25/7/12 by a private practitioner

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

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

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

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

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

49. Bone Transport

50. Fracture United 4 years of follow-up

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

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

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

54. 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

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

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

57. Preparation of K nail

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

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

60. Masquelet technique Originally described by Alian C. Masquelet in 1986 for reconstruction of long bone defects Essentially consists of 2 stages: STAGE 1 Identify bone loss, necrotic bone Removal of necrotic avascular bone 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

61. STAGE 2 Removal of cement spacer and membrane formation Packing the bone graft inside membrane consolidation

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

63. 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