M R D AVID G OODIER

1. INFECTEDNONUNION MRDAVIDGOODIER

2. Infected Non-union • What is non-union? • How can we tell it’s infected? • How do we prevent it? • How do we treat it?

3. How do we treat this?

4. To avoid this?

5. And now what do we do?

6. Definition of Non-union • US FDA 1986: • “when a minimum of 9 months has elapsed since injury and the fracture shows no visible progressive signs of healing for 3 months” • Defined for testing bone stimulators • Failure of progression of union • Simple idea • Difficult to identify

7. Non-union?

8. Non-union?

9. 9 months post AK47 injury

11. Requirements for union • Some living bone • Lack of movement • Absolute stability? Soudure autogéné • Absolute stability & gap? Atrophic non-union • Micro-movement? Natural Bone Repair • Too much movement? Hypertrophic non-union • Local biological environment • Systemic biological environment

12. The Biological Environment “Union cannot be imposed but may have to be encouraged. Where bone is a plant, with its roots in soft tissues, and when its vascular connections are damaged, it often requires, not the technique of a cabinet maker, but the patient care and understanding of a gardener.” Girdlestone 1932

13. Gathorn Girdlestone

14. Infection affects • The local biological environment • The systemic biological environment • Stability of fixation • loosening of implants • Erosion of bone

15. Systemic Factors Affecting Union • Age • Nutrition • Co-morbidity • e.g. Vascular disease, Diabetes, Head Injury • Medications • e.g. Steroids, NSAIDs • Smoking • Activity

16. Smoking!

17. Cierney Classification • Devised for osteomyelitis • Four parameters: • Condition of the host • Functional impairment • Site of involvement • Extent of bony necrosis • Cierny G 3rd, Mader JT, Penninck JJ. A clinical staging system for adult osteomyelitis. CORR 2003 Sep;(414):7-24.

18. Cierney Host Classification • Type A - normal physiologic, metabolic, and immunologic capabilities • Type B - systemically and/or locally compromised • Type C - morbidity of treatment is worse than that imposed by the disease itself.

19. Cierney Extent of Disease

24. Infected vs Sterile • Not always clear cut • Should always consider there may be infection • If internal fixation was performed, • Was there delayed wound healing? • History of inflammation? • Random use of antibiotics?

25. Infected vs Sterile • Pus pouring out a big clue! • Organism cultured from discharge not necessarily the pathogen • Multiple fracture site biopsies needed • What if it appears sterile? • Biopsy results available too late • Clues from blood markers • Matched labelled isotope scans ?helpful • 99Tc, 151Indium, Gallium, Radiolabelled Cefuroxime

26. MRI • Not helpful in the presence of metalwork • Even if metal removed, still can get signal artifact • ‘Fluid’ in canal visible on T2weighted sequences not always pus • Use of PD sequence may be helpful

27. Prevention • BOAST 4 guidelines • BOA / BAPRAS 2009 • “The patient needs the right surgeon with the right facilities and with minimum delay” • Trauma networks

28. Standards of care • ‘Complex’ open fractures should be treated in specialist centres by a multidisciplinary team • Unless life or limb threatening injury • Vascular injury • Compartment syndrome • Marine or farmyard contamination • Debride & ex-fix

29. Why? • Average DGH serving 250,000 in 1 year: • 30 tibial shaft fractures / year • 25% open • 60 / year if include pilon & plafond • 15% open • ‘Severe open’ (eg Gustilo IIIB etc.) • 2 or 3 / year • Average DGH consultant sees 1 every 2 years

30. Standardised treatment • Initial photo, dressing, splint, Abx, plan • Theatre next trauma list with senior plastic and orthopaedic surgeon • Extend wounds to get to all damaged tissue • Radical debridement. Washout. • Stabilise fracture • Close the skin if possible

31. Initial Operation • If skin not closed, either: • VAC applied to wound • Antibiotic bead pouch • ‘Second Look’ should not be necessary • If further tissue death (notably degloving) • If initially heavily contaminated

32. Antibiotic Bead Pouch

33. Vacuum Assisted Closure

34. Major errors? • Inadequate debridement • Inadequate exposure • Leaving devitalised bone • Delay to closure • Multiple second looks (PUA) • Delay to flap coverage • Over-reliance on ex-fix • Should be able to nail most open tibial fractures

35. Treatment • Can ORIF be retained? • Not if loose • Once biofilm formed will never eradicate infection • Suppress infection until united if progressing • May need multiple biopsies for c&s • Antibiotics 6 weeks; assess markers; further 6 weeks if raised; stop for 3 weeks? • Remove metal at earliest signs of regression

36. Treatment • Can ORIF be replaced? • Tibial non-union with nail • Debride by reaming, washout, revision nailing • Meticulous technique • Long term antibiotics • Remove metalwork as soon as possible

37. Infected Non-union • Usually want to remove all non-viable tissue • All metalwork • All dead soft tissues • All dead bone • How to identify? • Take back to bleeding bone • Preop clues from x-ray, CT, MRI • Bring the ends together & cover them • Regain bone length by The Ilizarov Method

38. Infected Non-union • If no sequestrum or internal fixation • Ex-fix from the beginning • Internal fixation previously removed • Treat as for sterile non-union • If oligotrophic compress • If gap, excise & close by bone transport • If hypertrophic distract or compress

39. Infected, Atrophic non-unionAcute Shortening & Lengthening MRSA infection Offered amputation

42. Excised bone gap acutely closed together

43. Corticotomy Excised bone gap acutely closed together

50. Segmental Transport