Septic Nonunion of the Tibial Shaft with Bone Defect in a Gustilo-anderson Type II Open Fracture
Main Article Content
Abstract
Introduction. Open fractures of the tibial shaft are mostly the result of high-energy trauma, the incidence is 17 to 21 per 100,000 inhabitants, represent 2% of all fractures and 36.7% of all long bone fractures in adults. More than 15% of tibial shaft fractures are classified as open, representing the most common open long bone injuries. The reported incidence of nonunion or delayed union of tibial shaft fractures after intramedullary nailing (IMN) ranges from 16% to 36%. Infection can complicate any stage of the fracture healing process and may contribute to nonunion in up to 38% of cases.
Case: A 64yo female with open fracture of the tibial shaft G-A II, initially treated with external fixators, then 3 internal fixations with IMN were performed at different surgical times due to complication of septic nonunion, managed with local and systemic antibiotics and tissue coverage.
Discussion: Some orthopedic surgeons prioritize bone union as the main treatment goal in septic nonunion and advocate retaining the implant with surgical cleaning and debridement of devitalized tissue, followed by suppressive intravenous antibiotic therapy. Conversely, others consider eradicating the infectious process as the most critical stage of treatment.
Conclusion: Pseudoarthrosis is one of the most devastating problems in orthopedic surgery. We consider it a priority to identify the pathogen associated with the nonunion for specific local and systemic antibiotic therapy associated with aggressive debridement surgery and stable fixation.
Article Details
This work is licensed under a Creative Commons Attribution 4.0 International License.
References
I. Hierholzer C, Friederichs J, Glowalla C, Woltmann A, Bühren V, von Rüden C. Reamed intramedullary exchange nailing in the operative treatment of aseptic tibial shaft nonunion. Int Orthop. 2017;41(8):1647-1653.
doi:10.1007/s00264-016-3317-x .
II. Laigle M, Rony L, Pinet R, Lancigu R, Steiger V, Hubert L. Intramedullary nailing for adult open tibial shaft fractures: An 85-case series. Orthop Traumatol Surg Res. 2019;105(6):1021-1024. doi:10.1016/j.otsr.2019.04.020 .
III. Papakostidis C, Kanakaris NK, Pretel J, Faour O, Morell DJ, Giannoudis PV. Prevalence of complications of open tibial shaft fractures stratified as per the Gustilo–Anderson classification. Injury. 2011;42(12):1408-1415. doi:10.1016/j.injury.2011.10.015 .
IV. Agrawal A, Chauhan VD, Maheshwari RK, Juyal AK. Primary nailing in the open fractures of the tibia: Is it worth? J Clin DiagnRes. 2013;7(6):1125-1130. doi:10.7860/JCDR/2013/5504.3081 .
V. Mills L, Tsang J, Hopper G, Keenan G, Simpson AHRW. The multifactorial aetiology of fracture nonunion and the importance of searching for latent infection. Bone Joint Res. 2016;5(10):512-519. doi:10.1302/2046-3758.510. BJR-2016-0138 .
VI. Rupp M, Kern S, Weber T, Menges TD, Schnettler R, Heiß C, Alt V. Polymicrobial infections and microbial patterns in infected nonunions: A descriptive analysis of 42 cases. BMC Infect Dis. 2020;20:667. doi:10.1186/s12879-020-05386-9
VII. Hackl S, Keppler L, von Rüden C, Friederichs J, Perl M, Hierholzer C. The role of low-grade infection in the pathogenesis of apparently aseptic tibial shaft nonunion. Injury. 2021;52(11):3066-3073. doi:10.1016/j.injury.2021.08.014 .
VIII. Fisher JS, Kazam JJ, Fufa D, Bartolotta RJ. Radiologic evaluation of fracture healing. Skeletal Radiol. 2018;47(11):1513-1527.
doi:10.1007/s00256-018-3051-0.
IX. Simpson H, Tsang STJ. Current treatment of infected nonunion after intramedullary nailing. Injury. 2017;48(suppl1):,S92-S99. Doi:10.1016/j.injury.2017.04.026.
X. Metsemakers WJ, Morgenstern M, McNally MA, Moriarty TF, McFadyen I, Scarborough M, et al. Fracture-related infection: A consensus on definition from an international expert group. Injury.2018;49(3):505-510. doi:10.1016/j.injury.2017.08.040 .
XI. Depypere M, Morgenstern M, Kuehl R, Senneville E, Moriarty TF, Obremskey WT, et al. Pathogenesis and management of fracture-related infection. Clin Microbiol Infect. 2020;26(5):572-578. doi:10.1016/j.cmi.2019.08.006 .
XII. Metsemakers WJ, Morgenstern M, Senneville E, Borens O, Govaert GAM, Onsea J, et al. General treatment principles for fracture-related infection: Recommendations from an international expert group. Arch Orthop Trauma Surg. 2020;140(7):1013-1027.
doi:10.1007/s00402-019-03287-4 .
XIII. Makridis KG, Tosounidis T, Giannoudis PV. Management of infection after intramedullary nailing of long bone fractures: Treatment protocols and outcomes. Open Orthop J. 2013;7:219-226. doi:10.2174/1874325001307010219 .
XIV. Zhang HA, Zhou CH, Meng XQ, Fang J, Qin CH. Intramedullary reaming and irrigation and antibiotic-loaded calcium sulfate implantation for the treatment of infection after intramedullary nailing: A retrospective study of 19 cases. BMC Musculoskelet Disord. 2020;21:710. doi:10.1186/s12891-020-03734-z .
XV. Finelli CA, dos Reis FB, Fernandes HA, Dell’Aquila A, Carvalho R, Miki N, et al. Intramedullary reaming modality for management of postoperative long bone infection: A prospective randomized controlled trial in 44 patients. Patient Saf Surg. 2019;13:39. doi:10.1186/s13037-019-0215-3.
XVI. Tsang STJ, Mills LA, Frantzias J, Baren JP, Keating JF, Simpson AHRW. Exchange nailing for nonunion of diaphyseal fractures of the tibia: Our results and an analysis of the risk factors for failure. Bone Joint J. 2016;98-B(4):534-541. doi:10.1302/0301620X.98B4.34870 .
XVII. McNally M, Govaert G, Dudareva M, Morgenstern M, Metsemakers WJ. Definition and diagnosis of fracture-related infection. EFORT Open Rev. 2020;5(10):614-619.
doi:10.1302/2058-5241.5.190072 .