Nonunion long bone. infected nonunion classification diagnosis and management

1. INFECTED NONUNION
Dr arjun kouloth
Orthopaedic resident
Lhmc
newdelhi

2. Nonunion
established when a minimum of 9 months has
elapsed since injury and the fracture shows no
visible progressive signs of healing for 3
months’’(FDA 1986).
A fracture that has no potential to heal without
further intervention.
Non union complicated by local infection at the
fracture site/surrounding tissues( septic non union)

3. pain, deformity, abnormal mobility, chronic discharge
• Open or closed fracture
• nature of injury (high or low energy)
• Bone loss
• Soft tissue injury
• Bone involved and anatomic location
• Nutrition
• Smoking
Patient Evaluation – History of Injury

4. • Diabetes, endocrinopathies, vit D def etc
• Physiologic age – co-morbidities
–Heart disease, COPD, kidney/liver
disease
• Medications : Steroids, Chemotherapy (&
XRT), Antivirals, Anticonvulsants,
Immunosuppressives
• Bone quality, vascular status
• Ambulatory/functional status now and
prior to original injury

5. • Excessive soft tissue stripping
• Open or closed injury
• Number of prior surgical procedures
• H/O drainage or wound healing difficulties
• Prior infection? / Abx used and bacteria
cultured
• Use of NSAIDS ( may masks the signs of
infection)
Surgery related

6. • Appearance of limb
–Color, skin quality, prior incisions, skin grafts
–Erythema or drainage
• Range of motion of all joints
• Pain – location and contributing factors
• Strength, ability to bear weight
• Vascular status and sensation
• Deformity
–Clinically = Length, alignment, And rotation

8. Complicating factor = Infection
• May be obvious
– Open draining wounds
– erythema
– inadequate soft tissue coverage
• Subclinical is more difficult
– High index of suspicion
ESR , CRP
– indicate infection
– baseline values to follow after debridement and
antibiotic therapy

10. UMIAROV’S CLASSIFICATION OF
INFECTED NON-UNION
based on
• the viability of bone ends,
• the presence of limb shortening,
• the presence of bone, and soft tissue defect.

11. UMIAROV’S CLASSIFICATION OF
INFECTED NON-UNION
type 1 nonunion is normotrophic
without shortening
type 2 the nonunion is hypertrophic with
shortening
type 3 Atrophic with shortening
type 4 Atrophic with bone and soft tissue defect (
open #)

12. Mc bone for infected nonunion: TIBIA
(open wound / bone loss / bad soft tissue)
“Of all prognostic factors in tibia fracture
care, that implying the worst prognosis
was infection”
Nicoll EA, CORR 1974

13. Contributing factors
• Contamination
• Inadequate debridement
• Soft tissue loss
• Improper fixation( external/ internal)

14. PROBLEMS
• Infection
• Poor soft tissue
• Bone loss
• Shortening
• deformity

15. Aims
• Eradicate infection
• Get union
• Correct deformity
• Equalisation of length
• Well aligned, healed, painless, and
functional limb.

16. PATHOLOGY
• Compromise of bone and soft tissue vascularity
• Repeated surgeries worsens the vascularity
• Biofilm formaton on implant and devascularised
bone surfaces protects pathogens and may lead to
persistance of infection

17. INFECTION PERSE DOESN’T CAUSE NONUNION
OM
thrombosis of blood vessel of haversian canals
bone sclerosis and dead bone
Butterfly fragments become sequestri, isolated & devitalized
by pus & infection granulation tissue.
Osteolysis
Gap nonunion

18. Investigations
• TLC
• ESR
• CRP
( monitoring the Rx)

19. X rays
• Areas suspicious of infection
• Sequestrum & involucrum
• Periosteal & endosteal new
bone formation
• Cortical irregularities.

20. • Quality of bone
• Type of implant
• Fracture healing status
• Angular alignment

21. SINOGRAM
USG
CT SCAN
Delineating sequestrae and extend of
bony involvement.
Better cortical bone details

22. PET SCAN : to localise the infections
The overall sensitivity and specificity for identifying an
osseous infection were 85.7% and 100%, respectively

23. • Technetium - 99 diphosphonate
– Detects repairable process in bone
• high sensitivity
• Low specific
• Gallium - 67 citrate
– Accumulates at site of inflammation
(not specific)
• Sequential technetium or gallium
scintigraphy
– Only 50-60% accuracy in subclinical
ostoemyelitis
Radionuclide Scanning – Infected Nonunion?

24. Sensitive for : acute osteomyelitis
• but less effective in chronic or subacute bone
infections
• Sensitivity 83-86%, specificity 84-86%
• Technique is superior to technetium and gallium to
identify infection
Nepola JV e.t. al. JBJS 1993
Merkel KD e.t. al. JBJS 1985
Labeled Leukocyte Scan – Infected Nonunion?

25. • Abnormal marrow with
increased signal on T2 and
low signal on T1
• Identify and follow sinus
tacts and sequestrum
MRI – Infected Nonunion?
Mason study- diagnostic sensitivity of 100%,
specificity 63%
To diff. Between bony and soft tissue infection

26. INFECTED NONUNION
• Suspect in all cases of nonunion following
surgical management
• Counsel and discuss the implicatoion prior to the
surgery
• Mandatory to exclude the infection

27. Patient Evaluation – Goals & Expectations
• What are the patient’s goals and needs?
– Household ambulation vs marathon runner
• Pain relief expectations
• Range of motion expectations
– Long standing nonunions may have stiff adjacent
joints
• Risks to neurovascular structures
(radial nerve in humerus nonunion)

28. Management
• Early pathogen identification
• Host alteration
• Surgical methods

29. Early pathogen identification
• Deep tissue specimen for pus c/s

30. Host alteration
LOCAL
• Vascular insufficiency
• Arterial bypass
• Hyperbaric O2
GENERAL
•Nutritional support
•Avoidance of smoking
•Correction of anemia
•Diabetic control
•Antibiotics

31. SURGICAL STRATEGIES
• DEBRIDEMENT
• STABILISATION
• ANTIBIOTIC THERAPY
• DEADSPACE / WOUND MANAGEMNET
• ACHEIVEMENT OF BONY UNION

32. DEBRIDEMENT
• Marginal and devitalised tissue removed( both soft
tissue and bone)
• sinus tract, infected soft tissue, and unhealthy
granulation tissue
• Biopsy and culture from all foci of infection
• Implant removal
• Ream the medullary canal
• Excision of bone is guided by the punctate bleeding
test

33. DEBRIDEMENT

34. • Radical rescection of dead bone and soft tissue
‘’ Dead bone does not unite and does not
get re-vascularised”
• Better to leave cortical bone in doubt of viability
and to do a repeat debridement than to remove
valuable cortex on the 1st treatment that will require
replacement later.

35. STABILISATION
• An appliance that does not cause further
damage
• Stable fixation ( need not be rigid)
• Per se inert and does not promote bacterial
growth
• Internal fixation
• External fixation( MAIN STAY)
CAST
EX FIX
IM NAILING
PLATES

36. Problems with internal fixation
• Persistent infection
• High re-infection rates
• Re-fracture though screw holes
• Shortening not corrected
• Excellent soft tissue cover needed esp. With
plates and screws

37. Excellent soft tissue cover needed esp.
With plates and screws

38. Stabilisation – external fixation
• Minimal damage to soft tissue and bone
• Easy application
• Can be used at any level like long bones like
tibia

39. SURGICAL STRATEGIES
• DEBRIDEMENT
• STABILISATION
• ANTIBIOTIC THERAPY
• DEADSPACE / WOUND MANAGEMNET
• ACHEIVEMENT OF BONY UNION

40. ANTIBIOTIC THERAPY
• Culture specific :
pus/ necrotic material/ bone / granulation tissue
obtained during debridement
• Culture from the sinus : usually commensals
• Broad spectrum(iv/ oral) x 6 weeks
• Local Antibiotic impregnated cement beads
( Culture specific) : Vanco/ genta
• Suction irrigation systems
• Implantable pumbs

42. • Surgical debridement converts an infection with
dead bone to a vascularized tissue (penetrated
better by systemic antibiotics)
• Antibiotic conc. achieved locally is 200 times higher
than with systemic administration.

43. WOUND/DEAD SPACE MANAGEMENT
• PRIMARY CLOSURE
When skin and tissue can be brought together
without tension
WOUND TEMPORISATION
Abx bead pouch tech
Vaccum dressing

44. Defenitive soft tissue coverages
• Delayed primary/ secondary closure
• Split thickness skin grafting
In the absence of infection
Controlled swelling
Adequate soft tissue bed
• Extremity shortening
• Early flap cover( rotationasl/ free flap)

46. SURGICAL STRATEGIES
• DEBRIDEMENT
• STABILISATION
• ANTIBIOTIC THERAPY
• DEADSPACE / WOUND MANAGEMNET
• ACHEIVEMENT OF BONY UNION

47. Bony union
• Attempted when Infection is cleared
• When active infection is quicent
Methods
when Infection is cleared
• INTERNAL FIX
• NAILING? Antibiotic coated
• ? plating
CLINICAL
ESR
CRP
TLC

48. Abx impregnated nails/ rods
• Applicable in infected nails in femur and tibia
• Thorough reaming of medullary canals
• Exchange with interlocking nails after 4- 6
weeks
• Antibiotic coated nails used

49. Abx impregnated nails/ rods
• 50 to 100 % union

50. If with plating and bone grafting
• Soft tissue is intact and there is no infection

51. WHEN ACTIVE INFECTION IS QUICENT
• Internal fixation – high chance of resurgence of
infection
Is there a bone defect or not??
• no bone defect: EX FIX ( circular/unilateral)
• Unifocal ilizarov for bone loss

52. Ilizarov ring fixation
Can be used in situations with or
without bone loss
• Regenerates new bone and
soft tissue
• Shortening deformity can be
corrected
• Can be used in any parts of the
tibia

53. Nonunion with bone defect
• Eradication of infection
• Massive cortico cancellous grafting
• Bone substitute
• Free fibula( vascular/ nonvascular)
• Bone transport

54. Bone transport
• Indication: bone defect / loss
• Ilizarov ex fix> LRS/ HYBRID
• Large defects can be reconstructed
• Distraction histiogenesis
• 1 MM / DAY

55. • Defect filling by newly formed bone
No donor site morbidity
No risk of reactivation of infection
• Provides instant stability
( prevents adjacent joint stiffness)
• Concommitant correction of LLD & deformity
• Soft tissue regeneration
(Less need of flap surgery)

57. Advantages
• Up to 15 – 20 cm defect
can be filled
• Can allow weight bearing
and mobile
• No further tissue damage
• Combined soft tissue
healing
Disadvantages
•Learning curve
•Pin tract infection
•Frame care
•Premature consolidation

58. BONE GRAFT ( union rate 90- 100%)
May be mixed with powdered fibrin and culture
specific antibiotic
• Docking site
• Cavities
Problems related to grafting
•Amount of graft
•Donor site morbidity
•Refracture
•Graft resorption
•Does not address shortening
or deformity

59. Masquelet technique
• Thorough debridement
• Space filled by cement spacer +/- Abx
• Induces membrane formation
Maintains the space of reconstruction
Induces pseudo synovial membrane
Adequate local Abx cover

61. The pseudomembrane
•Avoids the resorption of bone graft
•Promotes revascularisation of the bone graft
•Delivers growth factors( TGF, VEGF, BMP)

62. Free vascularised bone transfer
Rib, fibula, iliac crest.
Up to 20 cm defect can be reconstructed
• Isolation of a segment of contra lateral
fibula with attached nutrient artery and
vein..
• Length of graft should be 4 cm longer
than defect to allow 2 cm overlap at the
proximal and distal ends

63. • No need of prolonged ex fix
• Unites well with host bone
• High incidence of stress fractures 20- 60%

64. Papineau Technique
STAGE I: DEBRIDEMENT
STAGE II: GRAFTING
STAGE III: WOUND COVERAGE
In some cases, spontaneous epithelialization
otherwise
• skin grafts
• myocutaneous flaps
• free flaps requiring microvascular anastomosis

65. AMPUTATION
• Expectation of non functional limb after salvage
• Immuno compromised patient
• Pt not willing/ capable of undergoing multiple surgeries
• Expertise/ facilities not available for treatment and follow
up
• Individualised decision – no hard criteria
• If the limb has intact distal circulation and sensation, limb
salvage and reconstruction generally is preferable to
amputation.

70. • THANKYOU