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Management of Posttraumatic Complications of the lower limb—A 35 Year Experience

This article discusses the management and treatment strategies for posttraumatic complications of the lower limb, including septic bony wounds, aseptic malunions, and nonunions. The importance of wound conditions and terrain in supporting bacteria growth is emphasized, and various classification systems and treatment protocols are explored.

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Management of Posttraumatic Complications of the lower limb—A 35 Year Experience

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  1. Management of Posttraumatic Complications of the lower limb—A 35 Year Experience Jesse B. Jupiter, M.D. Orthopaedic Hand Service Massachusetts General Hospital Boston, Massachusetts

  2. “The lower limb is the pedestal that allows the hand to minister to God’s will.” Hamilton, 1864

  3. 1979--2006 > 450 Patients SEPTIC BONY WOUNDS ASEPTIC MALUNIONS AND NONUNIONS

  4. “The germ is nothing. It is the terrain or environment in which it grows which is everything.” Louis Pasteur

  5. Post-Traumatic Wounds vs.Hematogenous Osteomyelitis “The problem is not the growth of bacteria, as it is in osteomyelitis, but the wound conditions that support bacteria growth.” John Border, M.D.

  6. Chronic Bony Wounds May J, Jupiter J, Gallico G. Treatment of Chronic Bony Wounds. Annals of Surgery 1991 Classification • Type I Cortical bone • Type II Cortical and endosteal bone IIA Stable post surgery IIB Unstable post surgery • Type III Segmental bone loss or nonunion

  7. Significance Wound coverage-flap selection should be based on a number of considerations which complement thorough debridement.

  8. Waldvogel, 1970 NEJM Four to six weeks of parenteral antibiotics is necessary for control of osteomyelitis

  9. Long vs. Short-term Antibiotics Post Debridement of Bony Wounds and Free Tissue Transfer May J, Jupiter J, Karchmer A 1990 T o t a l C a s e s = 4 4 • Long-Term (6 weeks) • 21 patients • 1 recurrence • Short-Term (1 week) • 23 patients • 1 recurrence

  10. JBJS AM 1992

  11. Classification of Traumatic Tibial Osteomyelitis After Surgical Debridement Type 1 Tibia intact not requiring bone graft

  12. 13 year follow-up

  13. Classification of Traumatic Tibial Osteomyelitis After Surgical Debridement Type I Tibia intact not requiring bone graft Type II Tibia intact requires bone graft for structural support

  14. 10 year follow-up

  15. Classification of Traumatic Tibial Osteomyelitis After Surgical Debridement Type I Tibia intact not requiring bone graft Type II Tibia intact requires bone graft for structural support Type III Tibia defect < 6 cm with intact fibula

  16. 8 year followup

  17. Jupiter et al Role of ext fix in treatment of posttraumatic osteomyelitis J Orthop Trauma 1988

  18. May, Gallico, Jupiter, Savage. Free Latissimus dorsi flap with skin graft for treatment of traumatic bony wounds. PRS 1984

  19. Classification of Traumatic Tibial Osteomyelitis After Surgical Debridement Type I Tibia intact not requiring bone graft Type II Tibia intact requires bone graft for structural support Type III Tibia defect < 6 cm with intact fibula Type IV Tibia defect > 6 cm with intact fibula

  20. 12 year follow up

  21. Classification of Traumatic Tibial Osteomyelitis After Surgical Debridement Type I Tibia intact not requiring bone graft Type II Tibia intact requires bone graft for structural support Type III Tibia defect < 6 cm with intact fibula Type IV Tibia defect > 6 cm with intact fibula Type V Tibia defect > 6 cm no usable fibula

  22. Infected Nonunion of the Tibia An Outcome Study Toh C, Jupiter J ClinOrthop 2000

  23. Infected Tibial Nonunion • 37 infected nonunions in 36 patients • 20 male; 16 female • Average age 33 years (12-66 years)

  24. Infected Tibial Nonunion O r i g i n a l I n j u r y • Open fracture 22/37

  25. Infected Tibial Nonunion Level • Proximal 7 • Middle 11 • Distal 19

  26. Infected Tibial Nonunion Average Duration of Infection: 15 Months • 34 active sepsis • 3 quiescent sepsis

  27. Infected Tibial Nonunion Bacteriology • Multiple organisms 23 • Gram positive only 10 • Gram negative 1

  28. Infected Tibial Nonunion Treatment Protocol • Radical debridement • Skeletal stabilization • Soft tissue coverage • Skeletal reconstruction

  29. Infected Tibial Nonunion ClassificationPost-Debridement • Type III 30 • Tibial defect < 6 cm; intact fibula • Type IV 4 • Tibial defect > 6 cm; intact fibula • Type V 3 • Tibial defect > 6 cm; deficient fibula

  30. Skeletal Reconstruction Infected Tibial Nonunion • Anterior cancellous graft 14under flap • Open cancellous graft 7 • Posterolateralcancellous graft 2 • Vascularized fibula 2 • Fibula-pro-tibia 2

  31. Skeletal Reconstruction Open Cancellous Bone Grafting • Indications: • Intact but weakened bone • Limited soft tissue defect • Proximal and distal tibia • Septic arthrodesis • Advantages: • Technically simple • Bone placed at site of defect • Disadvantages: • Requires vascular bed • Delay in wound coverage • Prolonged time until functional loading

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